Every finding on record at Parkview Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) The facility failed to ensure an egress door was adequately secured or Resident #1 was supervised closely enough to prevent her from eloping from the facility on 02/14/2026. The noncompliance was identified as PNC. The IJ began on 02/14/2026 and ended on 02/16/2026. The facility had corrected the noncompliance before the survey began on 02/19/2026. This failure placed residents at risk of injuries due to falls, motor vehicle accidents, or exposure to the elements. Findings included:Record review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vascular dementia with mood disorder (decline in brain function/cognition due to poor blood circulation), generalized anxiety disorder, major depressive disorder, insomnia (trouble sleeping), difficulty walking, unsteadiness on feet, and history of falling. Review of the quarterly MDS assessment dated [DATE] reflected a BIMS score of 6, indicating a severe cognitive impairment. The MDS reflected Resident #1 had not exhibited wandering behaviors in the 7-day lookback period. The MDS reflected she used a wheelchair for ambulation and required substantial assistance, once seated in wheelchair, to wheel at least 150 feet in a corridor or similar space. Review of the care plan for Resident #1 reflected the following with respective dates: 07/22/2025Focus: Impaired physical functioning r/t debility, cognitive impairment. Goal: Will remain well groomed, dressed, and assisted by staff as needed through the next review date. Intervention: Walking - n/a; [NAME] Wheelchair - independent.07/22/2025Focus: I am visually impaired, but has (sic) glasses. Goal: will use appropriate visual devices (i.e., glasses) to promote participation in ADLs and other activities. I have glasses that I use everyday. Intervention: I will be oriented to environment and placement of things in the room.02/15/2026Focus: Resident is at risk for elopement related to cognitive impairment, impaired safety awareness, and ability to ambulate independently, wandering behaviors, elopement risk assessment score as evidenced by HISTORY OF ELOPEMENT EVENT. Goal: WILL NOT WANDER OR ELOPE INTO AN UNSAFE ENVIRONMENT THROUGH NEXT REVIEW DATE. Interventions: 1:1 monitoring as ordered. ELOPEMENT ASSESSMENT PER FACILITY PROTOCOL; NOTIFY MD AS NEEDED. Requested repeat UA. Seeking alternative placement due to increased elopement behaviors. WANDERING/ELOEPMENT: ASSESS FOR UNMET NEEDS (PAIN, HUNGER, TOILETING, BOREDOM). WANDERING/ELOPEMENT: ASSESS FOR ACUTE CHANGES IN CONDITION CONTRIBUTING TOBEHAVIORS (UTI, INFECTION, ANXIETY, FEAR, MEDICATION CHANGES). TREAT UNDERLYING CAUSE IF ABLE. WANDERING/ELOPEMENT: DOCUMENT AND MONITOR BEHAVIORS EVERY SHIFT WHEN ACTIVE EXIT SEEKING BEHAVIORS ARE PRESENT. COMMUNICATE BEHAVIOR CHANGESTO NURSE PROMPTLY. WANDERING/ELOPEMENT: INCREASE MONITORING WHEN RESIDENT DEMONSTRATES NEW OR INCREASED EXIT SEEKING BEHAVIORS AND CANNOT BE REDIRECTED. WANDERING/ELOPEMENT: PROVIDE MEANINGFUL AND ENGAGING ACTIVITES TO REDIRECT RESIDENTWHEN WANDERING/EXIT SEEKING BEHAVIORS ARE PRESENT. WANDERING/ELOPEMENT: PROVIDE REDIRECTION WHEN RESIDENT EXPRESSES DESIRE TO LEAVE. OFFER REASSURANCE AND ORIENTATION AS TOLERATED. Review of progress notes for Resident #1 from 02/10/2026 to 02/19/2026 reflected the following:02/10/2028 (3:58 PM) by RN A Resident with confusion, this evening observed out in hallway and in another residents room, redirection to her room, effective. 02/10/2026 (4:38 PM) by RN A Observed bruise left inner ankle, bruise to RLE, and blanchable redness around right great, RP DON WCN and Hospice notified. No complaint of pain. 02/11/2026 1:47 AM by LPN Q Resident C/O pain to her right inner calf and left inner ankle. Resident has a bruise to right inner calf 3 X 1.5 X 0.1 and bruise to left inner ankle 3.5 X 3 X 0.1. This nurse questioned resident about the bruises and resident does not know how they were received. Notified adon and will notify RP in the AM. 02/13/2026 8:31 AM by DON Nurse spoke with Responsible Party regarding the resident's increased confusion and discussed the possible intervention of relocating the resident closer to the nursing station for closer supervision. (FM) stated that the resident has been in her current room for an extended period and expressed concern that a room change may increase confusion. Nurse explained that staff would assist with reorientation if a move were to occur and that proximity to the nursing station would allow for closer monitoring and assistance. (FM) stated she prefers for the resident to remain in her current room at this time and would like to be involved in any decisions regarding a potential room change. Nurse reassured her that she will be notified of and included in any recommendations prior to implementation. 02/14/2026 (7:00 PM) by LPN C Resident brought to nurses station by a women stating that she found resident outside of facility on the street behind the facility. Reports resident fell out of wheelchair and her and her husband assisted resident back into wheelchair and brought her back into facility. Resident reports that she was looking for her sister. Resident is alert and answering questions per her baseline, reports dizziness and a headache at this time. VS WNL, no s/s of distress noted. skin assessment performed resident noted to have bruising to left ankle and right knee. No skin laceration noted. ROM WNL. Unable to confirm if resident hit her head due to witness story changing andresidents history of dementia and sun downers. Sn reported assessment to NP, orders given to send resident out for further evaluation. Family at residents bedside and aware of situation. DON, ADON and administrator aware. 02/15/2026 (12:24 AM) by LPN C Resident returned from ER. No new orders given. resident is alert and oriented per her baseline, No s/s of distress noted. Assisted into bed x2 assist. Call light within reach, bed in lowest position. 02/15/2026 (5:35 PM) by DON Type of Event : Follow up from elopementVitals : BP 126/78 HR 76 RR 18 Temp 98.2Full Range of Motion Assessment findings (i.e., wnl for resident, or describe abnormal findings) : WNL for residentLevel of Consciousness : Alert and confused. Able to make needs knownDescribe any new injuries or complaints of new pain or enter none: No new pain notedCompliance with Interventions to reduce risk of reoccurrence of event: compliant with Q15 mins checks. Interventions used and able to beredirectedHead to toe skin check findings (note no new findings, changes to initial findings or NO new issues) : No new findingsPain Level : See EMARTreatment for injuries/pain r/t event responding to treatment or resolving : Treatment in place. Appears effectiveProvider notified of new issues identified on assessment- Enter provider name if applicable : N/AName of resident representative notified if applicable : N/ANew orders received/New treatments initiated : N/A 02/15/2026 (07:03) by DON Type of Event : FOLLOW UP FROM ELOPEMENTVitals : BP 143/71 HR 77 RR 18 TEMP 97.1Full Range of Motion Assessment findings (i.e., wnl for resident, or describe abnormal findings) : WNL FOR RESIDENTLevel of Consciousness : ALERT AND CONFUSEDDescribe any new injuries or complaints of new pain or enter none : NO NEW INJURIES/COMPLAINTS NOTEDCompliance with Interventions to reduce risk of reoccurrence of event: COMPLIANT WITH Q 15MINS CHECKS. INTERVENTIONS USEDAND ABLE TO MAKE NEEDS KNOWNHead to toe skin check findings (note no new findings, changes to initial findings or NO new issues): NO NEW FINDINGSPain Level: SEE EMARTreatment for injuries/pain r/t event responding to treatment or resolving: TREATMENTS IN PLACE APPEARS EFFECTIVEProvider notified of new issues identified on assessment- Enter provider name if applicable: N/AName of resident representative notified if applicable: N/ANew orders received/New treatments initiated: NO NEW ORDERS 02/16/2026 (10:57 AM) completed by ADON Name of IDT participating in review: AdministratorDONADONMDSDOR*Event Being Reviewed: Unwitnessed fall*Root Cause Analysis for event: Cognition impairment*Interventions initiated and residents response/compliance with Intervention: Fall assessment, pain assessment, Head to toe assessment,and Neurological assessment*PT/OT involvement if applicable: Receives all therapy services*New Interventions suggested following current IDT review: Purposefully rounding, monitoring bruising, encourage/remind/assist with puttingon shoes properly.*MD and family notification following new Interventions if applicable: Yes 02/16/2026 (5:30 PM) written by DON Staff reports resident continues with exit seeking behaviors, including actively searching for doors. Per staff, resident is adamant that she needs to leave the building. NP contacted regarding 1:1 order. 02/16/2026 (5:32 PM) written by ADM Spoke with (FM) regarding finding alternative placement for resident due to continued exit seeking behaviors. (FM) consented to start the process of searching for potential locked unit placement. 02/16/2026 (10:00 PM) written by LPN P Resident continues on 1:1 d/t elopement. No attempts to leave at this time. Currently in bed. Bed in lowest position and call light within reach. 02/17/2026 (1:54 PM) written by RCS **IDT Follow-up: IDT meet to review the continued need for 1:1 supervision. At the time of review, the resident is not exhibiting active exit seeking behaviors (i.e., attempting to access exits, testing doors, or verbalizing immediate plans to leave the facility). However, the resident continues to demonstrate ongoing confusion. The resident has made statements of going home, which indicates continued potential for elopement risk no active exit seeking behaviors. D/t resident history and cognitive status, the IDT determined that discontinuing 1:1 supervision at this time would present an increased risk for unsafe wandering or elopement. Therefore, 1:1 supervision will remain in place as a preventative safety intervention. Review of results of a urinalysis for Resident #1 collected on 02/15/2026 and received on 02/17/2026 reflected that she was positive for several bacterial species indicating a urinary tract infection. Review of a facility-reported incident investigation initiated on 02/15/2026 and completed on 02/19/2026 reflected the following: Provider Response:Facility immediately ensured all other residents were safe and accounted for. Facility made sure all doors functioned properly. 1 of 10 Doors were found not functioning properly. A CNA was placed on doorwatch until the door was fixed. Resident was assessed with no adverse effects noted. Resident was sent out to the hosptial for further eval. Notifications were made to the family, physician, DON, andadministrator. Elopement risk assessments for all residents were completed with elopement binder and care plans updated. Wander guard system was purchased and pending arrival for installation. Door alarmswere purchased and installed. Outside surroundings near 200 hall door was assessed for any hazards with none noted.Investigation Summary: On 2/14/26 at approximately 3:22 PM the lights in the facility flickered on and off. 9/10 doors were reset and functioning properly. The door on 200 hall near the dining room was not reset or checked. Atapproximately 5:00 pm on 2/14/26, (Resident #1) arrived in the dining room for dinner. She stayed late eating per her baseline. Staff checked on her continuously throughout her time in the dining room. Atapproximately 6:25pm (Resident #1) self propelled from the dining and exited the facility out of the door on 200 hall. At approximately 6:55pm, Resident #1) was returned to the facility by a passerby. Thepasserby stated (Resident #1) was on the street near our trash area. Review of physician orders dated 02/16/2026 reflected one on one continuous monitoring every shift. Review of elopement drills for the facility from November 2025 to February 2026 reflected a missing person drill was conducted on 11/24/25 and signed by 11 staff. Review of a work order history report from 11/22/2025 to 02/17/2026 reflected doors, locks, and alarms were tested with no issues by MAINT D weekly. During an observation and interview on 02/19/2026 at 11:34 AM, an egress door between the dining room and Resident #1's bedroom with a coded alarm, a functioning door closer (aluminum part affixed to the top of the door which pulls the door closed when it is opened and let go), a red light-up button next to the door with the light off, and octagonal alarm attached to the door just above the lock was observed. The door was observed have a delayed-egress with a magnetic lock. During an interview MAINT D stated the magnetic lock deactivated when there was a power outage or the smoke alarm activated so that the door could be used as dictated by the facility's evacuation plan. He stated that all staff had the code to the door and frequently used the door to take the trash to the dumpster, so there was concern staff could exit out the door and not ensure the door closed all the way. He stated they discovered the problem was partially related to the red button on the wall next to the door. He stated he also discovered the door closer was old and did not pull the door closed as designed. He stated before leaving the facility on 02/14/2026, he change the code on that door so nobody could use it until he was able to fix the door closer. He stated he bought the replacement door closer and installed it on 02/15/2026. He stated he received a call the night of 02/14/2026 that there was an elopement, and the door between the dining room and Resident #1's room was disengaged. He stated he came to the facility around 8:00 PM that night and reset all the passcodes for the doors. He stated before he left that night, he made sure all the locks were re-engaged and locked. He stated he checked outside to see if there were any obstacles or debris that might injure a person outside around the facility. He stated the facility added the additional red alarms on 02/16/2026 to be even more cautious. He stated they were waiting on approval for a wander guard system that he and MAINT S would install the system on all doors once it arrived. During an observation and interview on 02/19/2026 at 10:40 AM, Resident #1 was observed seated in her recliner with her FM present. During an interview Resident #1 stated she was fine and did not recall the elopement incident. No visible injuries were observed. During an interview 02/19/2026 at 11:44 AM, CNA I stated she worked the 6 AM-2 PM shift, but picked up evening or overnight shifts sometimes. She stated she was working with CNA L on the evening of 02/14/2026 on the hall Resident #1's resided on. She stated she saw Resident #1 eating in the dining room and told CNA L they would need to take her right to bed when she was done eating, because Resident #1 had a tendency to wander off in the facility if they did not. She stated Resident #1 took a long time to eat and was the last resident in the dining area, drinking her milkshake. CNA I stated CNA L was with Resident #1 at the dinner table, and she (CNA I) was called at 5:45 PM (showed text requesting the assistance at this time) to assist an aide on another hall to change a resident. She stated that took 30 minutes or a little longer, and she continued helping residents get in bed and forgot about Resident #1 for a little while. She stated she found out Resident #1 had eloped after she got back in the facility, and her charge nurse (LPN C) informed her about the door being unsecured. CNA I stated there had been a storm that day (02/14/2026), and the power had gone out for a second. She stated her understanding was the doors came unlocked when that happened. She stated she was not there when that happened, but her charge nurse told her about it to make sure everyone knew about it in case it happened again. CNA I stated she frequently worked with Resident #1, and Resident #1 had tried to go out the door between her room and the dining room at 3:00 AM a day or two prior to the elopement. She said she could not remember the exact day of the incident but she redirected Resident #1. She stated she reported the behavior to the charge nurse but could not remember who the charge nurse was that night. She stated staff was aware Resident #1 liked to roam the halls. She stated she was not aware of exactly what interventions were in Resident #1's care plan prior to the elopement. She stated after the elopement, she received in-services about the following topics: ensuring doors were completely closed, checking for the red light on the door code pad, checking to ensure the red button next to the door by Resident #1's room was not lit, watching for behaviors such as pacing, wandering, exit-seeking, and saying they want to leave and ensuring they are reported to the charge nurse, missing resident procedures, and abuse/neglect. During an interview on 02/19/2026 at 12:26 PM, LPN C stated she had begun her shift at 06:30 PM on Saturday 02/14/2026. She stated she received her verbal report from the outgoing nurse (RN A) and was preparing to begin her rounds when a community member arrived at the facility with Resident #1 in her wheelchair. LPN C stated she understood from the community member that Resident #1 was found on the ground next to her overturned wheelchair on a small side road that led out of the back facility parking lot and out to the main road through town. She stated she sent her aides to immediately begin checking all egress doors for security and went to assess Resident #1 for injuries while also calling Resident #1's FM. LPN C stated she called the ADM and the DON and notified them of the situation. She stated Resident #1 had no obvious injuries or reports of pain, but the community member had stated she might have hit her head, so she called EMS to have her sent out and be assessed at the emergency room. She stated Resident #1 could not tell her what had happened. Resident #1's FM arrived at the facility and went with Resident #1 in the ambulance to the hospital. LPN C stated at that point, she rechecked all egress doors and found that the door between the dining room and Resident #1's room was unsecured. She stated she assigned an aide to stand at the door, and shortly after the MAINT D arrived. She stated the MAINT D reset all the codes in the facility but the door next to Resident #1's room was still not secure. She stated she noticed the button on the wall next to the door was lit and asked the MAINT D what it meant. She stated the MAINT D pressed the button, the light went off, and after that the door was secured. She stated the MAINT D was concerned about the door opener, so he changed the code on the door temporarily so that no one could go in and out unless there were an emergency that caused the lock to automatically release. She stated she was not aware of what else had been done, because she had not been back to the facility since. She stated she did receive a phone call from the DON to take her statement about what happened and to receive an in-service about procedures. She stated the in-service did not include any new information with the exception of the aides seeing every resident each one hour instead of each two hours, and that Resident #1 would be on one-to-one supervision until further notice. She stated she was already familiar with the other processes. She stated they did address the red button next to the door in the in-service. She stated they explained that button was leftover from the facility's now defunct secure unit. LPN C stated she had worked at the facility PRN for two years and worked different shifts, usually on the weekends. She stated she worked evening and overnight shifts as needed and was called in to work frequently. She stated she had noted a mental decline in Resident #1 during the previous months and believed facility management was working with the FM to address the increased need for supervision. During a telephone interview on 02/19/2026 at 12:54 PM, RN B stated he worked during the day on 02/14/2026 when the power blinked out twice during a thunderstorm. He stated the facility was split that day between RN A and him in that he had responsibility for half and she had responsibility for the other half, and he had checked all the doors for security on his side of the facility. He stated he and HA O had divided the task of checking door security that day. He stated he was in charge of a section of the facility that included Resident #1's room. He stated he had not documented his checks of the doors on 02/14/2026. He stated he or HA O would have checked the door between the dining room and Resident #1's room, but he could not recall if he had and did not know for certain if HA O had. He stated he had not been to work since but had received a phone call from the DON with in-service material on securing egress doors, elopement procedures, signs and symptoms of elopement risk, Resident #1 being on one-to-one supervision, and abuse/neglect/exploitation. During a telephone interview on 02/19/2026 at 1:01 PM, LPN D stated he was working as a medication aide the day Resident #1 eloped. He stated he had no idea what happened on the day of the elopement, because he was on the other side of the facility, but after she had returned, he found out about it. He stated he usually worked as the weekend supervisor, so when the power went out that day and the doors demagnetized, he coordinated the effort to reset codes, check all doors, and take a head count of residents. He stated he did not document the effort, and other people helped (RN A, RN B, and HA O) so he did not check every single door himself. He stated after the elopement, he was in-serviced on elopement, exit-seeking/wandering behaviors, checking the doors, and head counts every hour. He stated he was also notified that Resident #1 would be on one-to-one supervision about a day later. Observation on 02/19/2026 at 01:10 AM revealed Resident #1 in a seated exercise activity with the AD and three other residents. There was an additional staff member present providing one-to-one supervision for Resident #1. During a telephone interview on 02/19/2026 at 01:12 PM, HA O stated she was assigned to check doors including the two front doors, hall 100, and hall 200. She stated she looked at the door between the dining room and Resident #1's room but it said Emergency Exit so she was afraid if she checked it the alarm would go off, and the code pad was lit red, so she thought it was secured. She stated she did not know anything at the time about the red button on the wall perpendicular to the door but she was re-educated after the elopement. She stated she was not in the building when the elopement occurred. She stated she was in-serviced on elopement procedures, how to know when someone might elope or the signs such as packing their bags, following family members, pressing on the doors. She stated they were taught if there was a missing resident they would go ask the charge nurse for an assignment of where to look. She stated they received an in-service on abuse and neglect and on how to fully and properly check all doors, including the red button next to that door near Resident #1's room. During an interview on 02/19/2026 at 01:34 PM, CNA J stated she worked the 6 AM-2 PM shift at the facility. She stated she was informed about Resident #1's elopement. She stated she received in-servicing and retraining on what to do if there was a power outage, which was to get an assignment from the charge nurse, and someone would be assigned to each door to go and check manually that it was secured and the alarm would sound if it was opened. She stated they were to perform a headcount every hour on their assigned residents until further notice. She stated they were trained to notice and report if residents were saying wanted to leave or trying to get out, because eventually they would try to get out and especially people with dementia. She stated she knew the residents who were likely to exit-seek, and some of them could not get up on their own any more but others could. She stated Residents #2, 3, 4, and 5 were at risk for elopement and they were also listed in the elopement binders that were housed at each of the two nurse's stations. During an interview on 02/19/2026 at 01:42 pm, CNA K stated she worked 6 AM-2 PM but also picked up 10 PM-6 AM shifts sometimes. She stated she was not present when Resident #1eloped but had worked at the facility for several years. She stated Resident #1 had declined physically and cognitively. CNA K stated Resident #1 would not actively exit-seek but she might say she had been somewhere that she clearly had not been and was confused about her whereabouts and direction. CNA K stated they had an emergency in-service and team meeting on 02/15/2026 where they were retrained on exit seeking behaviors and securing the doors. She stated they learned about procedures for missing residents and general abuse and neglect prevention. She stated they were informed they would be doing residents head counts every hour instead of every two hours. A telephone interview with LPN P was attempted on 02/19/2026 at 1:50 PM. A voicemail was left but not returned. During an interview on 02/19/2026 at 1:52 PM, the PCP stated he had been notified of Resident #1's elopement and had ordered one-to-one supervision. He stated he had not been directly notified about Resident #1's increased wandering behavior prior to the elopement, but as he understood it, the incident happened suddenly. He stated he rarely came to any of his facilities, but other physicians and nurse practitioners visited frequently. He stated the facility was very good about communicating with him. During a telephone interview on 02/19/2026 at 03:17 PM, CNA L stated she had worked with Resident #1 on 02/14/2026. She stated she was employed by a staffing agency and not the facility, but had worked at the facility before. She stated during dinner on 02/14/2026, Resident #1 was at the table finishing her milkshake, and the kitchen staff were present. CNA L stated she was busy and walked through the dining room approximately 6:00 PM and did not see Resident #1. She stated that CNA I had told her they would need to put Resident #1 to bed right away after she finished dinner because Resident #1 liked to wander. CNA L stated the significance of Resident #1 being gone from the dining table did not dawn on her due to being so busy at that hour. She stated she was aware the power had gone out briefly earlier in the day and the door codes had to be reset. CNA L stated she was not aware that the egress door between the dining room and Resident #1's room was unsecured, because she had not been a part of checking the doors for security after the power outage. She stated she found out afterward the door was unsecured when she and the charge nurse went to the door and it swung open and would not latch closed. She stated the charge nurse posted her (CNA L) at the door until someone arrived to fix the problem. She said she thought it was around 8:00 PM when the MAINT D arrived and began working on the door. She stated the ADM and the DON came to the facility that night, and she was instructed to do headcounts of all her residents every hour instead of every two hours. She stated she had not been back to the facility since then. During an interview on 02/19/2026 at 03:56 PM, MA G stated she had worked as the medication aide for Resident #1 on 02/14/2026. She stated Resident #1 had been wandering about the building earlier in the evening, before dinner. She stated she had found Resident #1 on the 400 hall, brought her to dinner, and then gave her medications at 5:56 PM while she was in the dining room by herself, finishing her dinner. She staed she was not aware of anything that happened after that, because she left for the day. She stated the next day, they were called in to a meeting with the ADM and received in-servicing on door checks, door security including how to identify a door that was unsecured, signs that a resident might elope, elopement/missing resident procedures, and abuse/neglect. During an interview on 02/19/2026 at 03:34 PM, CNA P stated she worked the 2 PM-10 PM shift at the facility and had received in-servicing recently related to the elopement of Resident #1. She stated they were told Resident #1 would be on one-to-one supervision and was asked to pick up shifts for that. She stated they were trained on the abuse and neglect procedure, how to notice signs of elopement, what to do if there was a missing resident, resident rights, and door security. During an interview on 02/19/2026 at 04:14 PM, the MAINT S stated he came to the facility after Resident #1's elopement, but the MAINT D was already there, so he left the building. He stated he came back on 02/16/2026 and helped install the octagonal red alarms the facility bought for extra security to the door. He stated he had written out a request for a wander guard system. He said he had the email request but was not sure if the request had been approved by corporate yet. During a telephone interview on 02/19/2026 at 04:23 PM, LPN E stated she worked 6 PM to 6 AM and had received in-servicing a few days prior (did not recall exact date but it was a day or two after the elopement) on elopement procedures, Resident #1 and her exit-seeking and one-to-one supervision, making sure the doors were all secured every shift, rounding on all residents each hour, and abuse/neglect/exploitation. During an interview on 02/19/2026 at 04:25 PM, RN A stated they were checking doors and all residents each hour. She stated she had several in-services and other than one-to-one supervision for Resident #1, it was not new information to her. She stated the information was on elopement procedures, door security, abuse and neglect, and residents who were exhibiting wandering behaviors or were at risk for elopement. During an interview on 02/19/2026 at 04:42 PM, the DON stated she received a call from LPN C that Resident #1 was found by a community member and brought back to the facility on [DATE] after getting out. The DON stated she went to the facility and they checked all the doors and found the one door closest to Resident #1's room was not secure. She stated Resident #1 had been declining cognitively and was not as safety aware as she had been, so the DON had tried to engage the FM in decisions to protect Resident #1's safety. The DON stated she had suggested that Resident #1 be moved closer to the front of the hall where she would be near to the nurse's station instead of at the very end of the hall, but her FM declined that suggestion. She stated this conversation with the FM happened the day before the elopement. She stated Resident #1 had chronic and frequent UTIs and was tested for a UTI the day after the elopement and received a positive result, so that could have also played a part in her unusual behavior. The DON stated the failure was a combination of the malfunctioning egress door and Resident #1's increased cognitive impairment. She stated the RCS had been at the facility all week and had in-serviced her and the ADM on procedures and best practices in a situation like this to make sure it never happened again. She stated Resident #1 was assessed and had no injuries after the incident. She stated they were investing in a wander guard system for the facility and would have Resident #1 on one-to-one supervision at the facility's expense until the wander guard was installed. She stated all residents received updated elopement risk assessments and revised care plans if applicable. She stated Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 each had their care plans updated. She stated she was in-servicing the entire staff and also had materials prepared for agency staff. She stated in-services were on door security, behaviors indicating risk of elopement, head counts once per hour, missing resident procedures, and abuse/neglect/exploitation. Observation and interview on 02/19/2026 at 04:55 PM, revealed a driveway extending from the back of the facility and exiting into the main road. The DON stated Resident #1 was found close to the area of th

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to protect Resident #1 from physical abuse by Resident #2 when Resident #1 and Resident #2 were involved in a resident-to-resident altercation on 11/08/2025. On 11/08/2025, Resident #1 wandered into Resident #2's room. Resident #2 hit Resident #1 resulting in Resident #1 being sent to the hospital on [DATE] and treated for a head injury and scalp laceration and received staples to the posterior scalp. The noncompliance was identified as PNC. The IJ began on 11/08/2025 and ended on 11/08/2025. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk of physical injury and/or psychosocial harm. Findings included:Review of Resident #1's admission record, dated 11/19/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses that included: Alzheimer's disease (a form of dementia that worsens over time), unspecified dementia, unsteadiness of feet, depression, and COVID-19. Review of Resident #1's Quarterly MDS assessment, dated 08/09/2025, reflected a BIMS score of 3 which indicated significant cognitive impairment. Review of Resident #1's care plan, last revised on 11/13/2025, reflected at risk for falls related to Use of Psychoactive Medication, Wandering behavior and Unsteady Gait/Balance with interventions listed as Monitor for restlessness and implement interventions. Also, impaired cognitive function/dementia/thought processes related to Alzheimer's disease; at risk for injury related to wandering behavior, impaired safety awareness with interventions Encourage to stay in common areas of building for observation if needed and redirect back to area of familiarity if disoriented/irritable such as room or activity room; and potential for complication related to diagnosis of depression. Review of Resident #1's physician orders on 11/20/2025 reflected, sertraline for depression, trazadone for insomnia, and buspirone, Depakote tablet, and Ativan (Lorazepam) for anxiety.Review of a NP visit dated 11/05/2025 reflected Resident #1 was seen for an acute visit for agitation and behaviors of urinating in the dining room, making statements he will kill employees; running down the hallways, and increased restlessness. Medications were adjusted at that time. The family agreed to psychiatric to follow up next week if behaviors continue to increase or remain unchanged. Review of Resident #1's progress notes from 10/25/25 to 11/07/25 reflected the resident had a history of aggression with staff, increased wandering, and agitation from. Record review of Resident #1's incident report dated 00/00/00, reflected on 11/08/2025, at 2:51 P.M., Resident #1 wandered into Resident #2's room. Resident #2 admitted pushing Resident #1 to the ground and Resident #1 was observed lying on the floor, with blood on floor. Resident #1 had a head laceration to side and back of head and discoloration to left cheek. Review of Resident #1's hospital Discharge summary dated [DATE] reflected the resident was seen for assault, hit head, head injury, scalp laceration, and received stitches. Per EMS, Resident #1 wandered into the wrong room and was struck in the head by an object and fell. Review of the police report dated 11/08/2025 reflected Resident #1 went into another room and Resident #2 got mad and pushed Resident #1 to the ground. Resident #1 with heavy bleeding from the head. Resident #2 wanted to press charges against Resident #1; however, Resident #1 lacked the culpable mental state to commit a crime. Resident #2 possibly committed assault with serious bodily injury against elderly. Review of the NP visit note dated 11/10/2025 reflected Resident #1 was seen for acute visit for agitation, ER visit and medication adjustments. On 11/08/2025, Resident #1 was punched and fell backwards, hit his head and sustained laceration. Resident #2: Review of Resident #2's admission record, dated 11/20/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had a primary diagnosis of hypertensive emergency (a severe increase in blood pressure that can lead to life-threatening organ damage), along with diagnoses of end stage renal disease, chronic kidney disease, hypertensive encephalopathy (a form of brain dysfunction caused by extremely high blood pressure), depression, cardiomegaly (enlarged heart), and most recently unspecified dementia as of 11/19/2025. Review of Resident #2's admission MDS assessment, dated 10/28/2025, reflected a BIMS score of 11 which indicated moderate cognitive impairment. Under Section E - Behavior: verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days out of a week. Review of Resident #2's care plan, date initiated 11/07/2025, reflected at risk for delirium or acute confusion related to change of condition, change in environment; impaired communication related to hard of hearing; risk of behaviors related to demonstrative physically abusive behaviors, demonstrates verbally abusive behavior.and resident to resident on 11/08/2025; impaired cognition function/thought processes related to memory loss, short term memory loss and at risk behaviors associated with anxiety. Review of Resident #2's doctor orders dated 11/20/2025 reflected an order for Lorazepam 0.5 MG every 6 hours as needed for anxiety. Review of Resident #2's progress notes reflected a history of verbal aggression with staff on 10/28/2025, 11/05/2025, and 11/06/2025. Record review of a progress note date 11/08/2025 at 10:41 AM, written by indicated Resident #2 threatened to hit LVN A member and another resident (Resident #1) that had gone into his room. Staff explained that the other resident has dementia and gets confused - the other resident was redirected away from the resident's room. On 11/08/2025 at 2:51 PM, nurse heard Resident #2 with verbal outburst and cussing and Resident #2 stated, I told them to keep him out of my room. When the nurse looked into Resident #2's room, Resident #1 was observed laying on the floor. Resident #2 was asked if he pushed Resident #1 and Resident #2 stated, Fuck yes I did. Resident #2was escorted out of room, moved to another room, and monitored 1:1 in place. Review of TULIP (an online system used by the Texas Health and Human Services Commission for long-term care licensing, applications, and reporting) facility self-report dated 11/14/2025 reflected Resident #1 wandered into Resident #2's room with his walker. Resident #2 stated that, He (Resident #1) would not leave my room. Staff immediately responded to commotion in Resident #2's room and noted Resident #1 on the floor. Resident #1 stated, He (Resident #2) hit me. Staff immediately separated residents. EMS, police, families, and physicians were all notified. Resident #2 was placed on 1:1 monitoring and moved to a different room. Resident #1's assessment revealed discoloration to the left cheek area, and an open area on right side of scalp and back of head. Resident #1 was sent to the hospital. The facility re-educated staff on facility abuse and neglect policies, resident to resident incidences, and identification/de-escalation of behaviors procedures. The facility investigation findings reported as unfounded. During an interview with the ADM on 11/19/2025 at 9:20 A.M., the ADM stated he did not witness the altercation between Resident #1 and Resident #2. The ADM stated that the incident was unfounded because he did not feel like there was a system failure. Furthermore, Resident #2 stated, He responded in self-defense when he hit Resident #1. The ADM stated that Resident #1 was on the floor and could have fallen, and his injuries could have been sustained by a fall. There were no witnesses. The discoloration of the face would likely be from Resident #2 hitting Resident #1, but the head injury could have come from Resident #1 hitting the edge of the door when he fell. The ADM stated that Resident #2 could be aggressive with staff, but not with residents. The ADM stated that he felt the facility was equipped to handle the behaviors of the residents and did not think there was a risk of having aggressive residents. During an interview and observation with Resident #1 on 11/19/2025 at 11:26 A.M., he was in a wheelchair monitored by staff. Resident #1 was not oriented and was unable to answer questions about the incident. He stated he was a farmer and hurt his head while working. During an interview and observation with Resident #2 on 11/19/2025 at 12:03 PM, Resident #2 was lying in bed. He had his shirt off and a port access in his chest. He recalled the incident with Resident #1 and stated that before the incident occurred, Resident #1 came into his room telling him he needed to put on shoes and come outside. Resident #2 thought Resident #1 was nice at first, but then Resident #1 kept talking, not making sense, and would not leave the room. Resident #2 told Resident #1, If you are looking for trouble, you're in the wrong place. He didn't understand why Resident #1 would not leave his room and felt like he was being threatened. Resident #2 stated, what kind of game is he (Resident #1) playing? I didn't know what was going on. Is he testing me? Resident #1 left the room. Later, Resident #1 came into Resident #2's room with his walker and started getting in his (Resident #2) space. Resident #2 stated he felt threatened by Resident #1 and was scared. Resident #2 thought Resident #1 was posturing and he told Resident #1 to back up. Resident #1 backed up a little and then suddenly lunged towards Resident #2. Resident #2 stated, I hit him in the face. Resident #1 collapsed to the floor. Resident #2 stated he was protecting himself and said he was not sure why Resident #1 would not leave his room after he had warned Resident #1.During an interview on 11/19/2025 at 2:20 PM, a family member for Resident #1 stated that he was aware of the incident with Resident #1. The family member had accompanied Resident #1 to the hospital when it occurred. The family member stated Resident #1 had some change in behaviors within the last 30-60 days. Resident #1 was urinating in the dining room and wandering into another resident's room, which caused the incident. During an interview on 11/19/2025 at 2:28 PM, the NP stated she was familiar with Resident #1. Resident #1 had dementia, which had been worsening, and the NP had several conversations with the RP about having to potentially move Resident #1 to another facility if they could not get his behavior under control. The NP stated on 11/5/2025, the NP saw Resident #1 for worsening behaviors and NP increased Resident #1's medications (Buspar to 10 mg, Lorazepam to 1 m and added Trazadone). The NP had been trying to make a psychiatric referral, but PR had been refusing but finally agreed. The NP talked to the psychiatric NP on 11/19/2025 and Resident #1 will be seen by the psychiatric NP on 11/25/2025 because the NP stated she needed more help in managing Resident #1's behavior and had already done everything within her scope of practice. Resident #1 also had UTIs, which could cause agitation, aggression, and impulsive behaviors. The NP stated there was always a risk of having aggressive residents, but stated Resident #1's aggression was more towards staff than to other residents.During an interview on 11/19/2025 at 3:34 PM, LVN A stated before the incident on 11/08/2025, a CNA told her Resident #1 had wandered into Resident #2's room and Resident #2 got very upset and threatened to hit Resident #1 if he came back into the room. LVN A stated she did not know the name of the CNA but stated they worked on the 400 hallway. LVN A explained to Resident #2 that Resident #1 had dementia and did not know any better. LVN A stated she notified the ADM and DON. LVN A stated that staff tried to keep an eye on Resident #1, but after she went to lunch, she heard yelling, cursing, and Resident #2 was standing out in the hallway. Resident #2 stated he pushed/hit Resident #1 and she observed Resident #1 lying on the floor by the door in Resident #2's room. LVN A stated she did an assessment and Resident #1 had pooled blood underneath him, redness on his face, wound on the head and she put a bandage on it because it was bleeding. LVN A called the DON, the ADM, 9-1-1 and EMS. LVN A had not known or seen Resident #1 to be aggressive with any other residents prior to the incident; only staff. LVN A had been trained in abuse policy, identification and de-escalation of behaviors, and preventing resident-to-resident altercations.During an interview with the DON on 11/19/2025 at 4:55 PM the DON stated she did know who the C.N.A was who had reported to LVN A before the incident when Resident #1 had wandered into Resident #2's room and Resident #2 had threatened to harm Resident #1 if he returned, she said she would need to investigate that. During an interview with the ADM on 11/20/2025 at 9:23 AM, the State Surveyor asked for all documentation related to the incident on 11/08/2025 as there were no statements or interviews in the provider investigation. Review of the police report reflected Resident #3 was listed as a witness. Review of the facility provider investigation reflected an undated witness statement by Resident #3. Resident #3 had reported Resident #1 came in and Resident #2 punched him.hit him. During an interview with Resident #3 on 11/20/2025 at 2:02 PM, Resident #3 stated he used to be Resident #2's roommate and was lying in bed when the incident occurred on 11/08/2025. Resident #1 came into their room and Resident #2 punched him (Resident #1) in the face as hard as he could. Resident #1 fell backwards and might have hit something. Staff immediately responded and took Resident #2 out of the room and a nurse helped Resident #1. The DON was presented with the IJ template at 11/20/2025 at 6:19 PM and it was explained that the IJ was PNC and there was no current immediacy. During an interview with the DON on 11/20/2025 at 6:45 PM, she stated she did not find out the identity of the CNA that talked to LVN A and warned LVN A that Resident #2 had threatened to hit Resident #1. The DON stated she was not aware of the progress note until the State Surveyor pointed it out in Resident #2's chart. The ADM was unable to interview prior to exit as he had left the facility. Review of in-service dated 11/08/2025 reflected abuse policy, identification and de-escalation of behaviors, and preventing resident-to-resident altercations were reviewed with most staff. Review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 reflected, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: b. other residents. Review of facility policy titled Identifying Types of Abuse dated September 2022 reflected, 1. Abuse of any kind against residents is strictly prohibited. 4. Abuse is defined as the willful infliction of injury.with resulting physical harm, pain or mental anguish. Physical Abuse: 1. Physical abuse includes, but is not limited to hitting, slapping, biting, punching, or kicking. Review of facility policy titled Resident Rights dated February 2021 reflected:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards.The facility failed to ensure Resident #1 was free from accidents and hazards, when the facility did not have adequate supervision in place for Resident #1's aggressive and wandering behaviors. On 11/08/2025 at 10:41 AM, Resident #2 threatened to hit Resident #1 because Resident #1 was entering his room. Resident #1 wandered into Resident #2's room on 11/08/2025 at 2:51 PM, and Resident #2 hit Resident #1. Resident #1 was sent to the hospital on [DATE], treated for head injury and scalp laceration, and received staples to the posterior scalp. The noncompliance was identified as PNC. The IJ began on 11/08/2025 and ended on 11/08/2025. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk of injury and hospitalization.Findings included: Review of Resident #1's admission record, dated 11/19/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses that included: Alzheimer's disease (a form of dementia that worsens over time), unspecified dementia, unsteadiness of feet, depression, and COVID-19. Review of Resident #1's Quarterly MDS assessment, dated 08/09/2025, reflected a BIMS score of 3 which indicated significant cognitive impairment. Under section E- Behavior, there were no behaviors listed, except for wandering occurring daily. Review of Resident #1's care plan, last revised on 11/13/2025, reflected at risk for falls related to Use of Psychoactive Medication, Wandering behavior and Unsteady Gait/Balance with interventions listed as Monitor for restlessness and implement interventions. Also, impaired cognitive function/dementia/thought processes related to Alzheimer's disease; at risk for injury related to wandering behavior, impaired safety awareness with interventions Encourage to stay in common areas of building for observation if needed and redirect back to area of familiarity if disoriented/irritable such as room or activity room; and potential for complication related to diagnosis of depression. Review of NP visit dated 11/05/2025 reflected Resident #1 was seen for acute visit for agitation and behaviors of urinating in the dining room, making statements he will kill employees; running down the hallways, and increased restlessness. Medications were adjusted at that time. The family agreed to psychiatric to follow up next week if behaviors continue to increase or remain unchanged. Review of Resident #1's progress notes reflected a history of aggression with staff, increased wandering, and agitation from 10/25/2025 to 11/07/2025. Further review reflected on 11/08/2025, at 2:51 pm, Resident #1 wandered into Resident #2's room. Resident #2 admitted pushing Resident #1 to the ground and Resident #1 was observed lying on the floor, with blood on floor. Review of Resident #1's physician orders on 11/19/2025 reflected sertraline for depression (order date 10/29/2025), trazadone for insomnia (order date 11/05/2025), and buspirone (order date 11/05/2025), Depakote tablet (order date 11/13/2025), and Ativan (Lorazepam) for anxiety (order date 11/20/2025). Record review of Resident #1's incident report dated 00/00/00, reflected on 11/08/2025, at 2:51 P.M., Resident #1 wandered into Resident #2's room. Resident #2 admitted pushing Resident #1 to the ground and Resident #1 was observed lying on the floor, with blood on floor. Resident #1 had a head laceration to side and back of head and discoloration to left cheek.Review of Resident #1's hospital Discharge summary dated [DATE] reflected the resident was seen for assault, hit head, head injury, scalp laceration, and received stitches. Per EMS, Resident #1 wandered into the wrong room and was struck in the head by an object and fell.Resident #2: Review of Resident #2's admission record, dated 11/20/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had a primary diagnosis of hypertensive emergency (a severe increase in blood pressure that can lead to life-threatening organ damage), along with diagnoses of end stage renal disease, chronic kidney disease, hypertensive encephalopathy (a form of brain dysfunction caused by extremely high blood pressure), depression, cardiomegaly (enlarged heart), and most recently unspecified dementia as of 11/19/2025. Review of Resident #2's admission MDS assessment, dated 10/28/2025, reflected a BIMS score of 11 which indicated moderate cognitive impairment. Under Section E - Behavior: verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days out of a week. Review of Resident #2's doctor orders dated 11/20/2025 reflected an order for Lorazepam 0.5 MG every 6 hours as needed for anxiety. Review of Resident #2's care plan, date initiated 11/07/2025, reflected at risk for delirium or acute confusion related to change of condition, change in environment; impaired communication related to hard of hearing; risk of behaviors related to demonstrative physically abusive behaviors, demonstrates verbally abusive behavior.and resident to resident on 11/08/2025; impaired cognition function/thought processes related to memory loss, short term memory loss and at risk behaviors associated with anxiety. Review of Resident #2's progress notes reflected a history of verbal aggression with staff 10/28/2025, 11/05/2025, and 11/06/2025. On 11/08/2025 at 10:41 AM, Resident #2 threatened to hit LVN A and another resident (Resident #1) that had gone in his room. Staff explained that the other resident has dementia and gets confused - the other resident was redirected away from the resident's room. On 11/08/2025 at 2:51 PM, nurse heard Resident #2 with verbal outburst and cussing and Resident #2 stated, I told them to keep him out of my room. When the nurse looked into Resident #2's room, Resident #1 was observed laying on the floor. Resident #2 was asked if he pushed Resident #1 and Resident #2 stated, Fuck yes I did. Resident #2 was escorted out of room, moved to another room, and monitored 1:1 in place. During an interview and observation with Resident #1 on 11/19/2025 at 11:26 A.M., he was in a wheelchair monitored by staff. Resident #1 was not oriented and was unable to answer questions about the incident. He stated he was a farmer and hurt his head while working. Several staff members were in the hallway redirecting him. During an interview with the HA on 11/19/2025 at 11:26 A.M. and 3:21 PM, she stated Resident #1 was being monitored because he wandered into another resident's room and she was told to redirect him. The HA did not witness the incident but did receive abuse in service training and named the ADM as the abuse coordinator. The HA had not received any training regarding monitoring Resident #1 and has not documented the monitoring anywhere. If she had any concerns, she would tell the nurse or DON. During an interview on 11/19/2025 at 2:20 PM, a family member stated that he was aware of the incident with Resident #1. A family member had accompanied Resident #1 to the hospital when it occurred. The family member stated Resident #1 had some change in behaviors within the last 30-60 days. Resident #1 was urinating in the dining room and wandering into another resident's room, which caused the incident. During an interview on 11/19/2025 at 2:28 PM, the NP stated she was familiar with Resident #1. The NP stated that staff were watching Resident #1 to monitor his behaviors. There were no official orders for 1:1 as that was done by the facility. The NP stated that the facility did not have to have a doctor's orders for 1:1 monitoring. The NP did not know when 1:1 started, but stated the DON told her the 1:1 was due to Resident #1 being unpredictable. The NP started residents with dementia that had COVID-19, it caused a change in behavior. Resident #1 also had UTIs, which could cause agitation, aggression, and impulsive behaviors. The NP stated there was always a risk of having aggressive residents, but stated Resident #1's aggression was more towards staff than to other residents. During an interview on 11/19/2025 at 3:14 PM, the DON stated Resident #1 had been on 1:1 since he returned from the hospital and the incident on 11/08/2025. The DON stated that the 1:1 was ordered for Resident #2 by the on-call provider, but they realized Resident #2 did not need it and put the 1:1 on Resident #1 to monitor for increased wandering behaviors after he had COVID-19. The DON stated Resident #1 was not a threat to anyone, but since he had COVID-19, his behaviors had changed. The DON stated there was a hospitality aid that monitored Resident #1 during the day from 7 AM to 4 PM and then another aid that monitored Resident #1 from about 5:45 PM to 10:30 PM. The night nursing staff monitor Resident #1 at night if needed, but they don't have any problems with him after he went to bed at night. The DON stated that all staff were responsible for doing the 1:1 monitoring and she was doing the monitoring now with Resident #1 in her office. During an observation on 11/19/2025 at 3:21 PM, Resident #1 was observed sitting in a wheelchair in the DON's office. He was calm with no concerns observed. He was surrounded by the HA and two treatment nurses. During an interview on 11/19/2025 at 3:34 PM, LVN A stated Resident #1 had been wandering more and going in and out of residents' rooms and appeared more confused. The UA was negative for a UTI, but the NP put him on antibiotics for precaution for UTI. LVN A stated there were multiple acts of aggression towards staff. Resident #1 grabbed the LVN's arms the day prior to the incident. Resident #1 had grabbed the Medication aid's blood pressure cuff and would not give it back. Resident #1 tried to hit LVN A and pushed LVN A. LVN A stated that she called the NP and was given approval to give Resident #1 psychotropic medication. LVN A stated that Resident #1 was put on 1:1 after he returned from the hospital due to him wandering. LVN A stated that when leadership was in the building, they would monitor him, do activities with him, and stay with him in his room. LVN A stated they have a sheet where they document monitoring, but she was not aware of a monitoring sheet for Resident #1 because she had not done 1:1 with resident; she only did frequent rounding. LVN A stated she monitored Resident #1 for aggressive behaviors and wandering and would redirect if he tried to go into another resident's room. During an interview on 11/19/2025 at 4:12 PM, CNA B stated that since the incident on 11/08/2025, Resident #1 was always monitored by staff for behavior and wandering. She had not been asked to monitor Resident #1 and stated that the nurses were responsible for completing the monitoring log. She had not been trained in monitoring Resident #1. On 11/19/2025 at 4:16 PM, surveyor received and reviewed a copy of Resident #1's Frequent Monitoring Record dated 11/10/2025 - 11/19/2025, which reflected Resident #1 was monitored by staff every 30 minutes. During an interview on 11/19/2025 at 4:20 PM, LVN B stated was familiar with Resident #1. Resident #1 had increased agitation and aggression, and wandering in and out of other residents' rooms. LVN B stated that since the incident, Resident #1 had been on 1:1 monitoring and the nurses were responsible for monitoring and documenting in the progress notes. The surveyor showed LVN B the monitoring logs for Resident #1. LVN B stated she did not fill that out; did not know who did but stated that form was used for monitoring. During an interview on 11/19/2025 at 4:55 PM, the DON stated that the hospitality aids do not have access to PCC, so the DON had been filling out the Monitoring sheets for Resident #1. The 1:1 was not official, but it was for his safety. Staff were always with Resident #1 and staff took him into the activity room or other offices to monitor him for behavior and wandering. The DON stated they were trying to determine the root cause of these new wandering behaviors. Resident #1 had never been the aggressor before. The DON stated that she was going to in service all staff about documenting behaviors in PCC, monitoring Resident #1 and ensure the monitoring was document (on forms or in PCC). The DON stated she would get a doctor's order to make the monitoring official. The DON stated that the family was aware of the monitoring, and the facility might have to discharge Resident #1 to a locked facility if they could not determine the cause of his recent decline. The DON stated that Resident #1's care plan was updated about his wandering behavior. The State Surveyor asked about his behaviors of threatening to kill staff, trying to hit LVN A, grabbing hold of hospice aid's arm, grabbing hold of medication aid's cart, trying to stab staff with a fork, urinating on the dining room floor and other examples of behaviors listed in the progress notes. The DON stated those behaviors (aggressive) and the 1:1 monitoring had not been updated in his care plan and needed to be so that staff knew about them. The DON stated she would update the care plan. During an interview with the ADM on 11/19/2025 at 5:06 PM, he stated he would have the DON provide in-service training to all staff about monitoring Resident #1 and filing out the monitoring form or documenting in PCC. The ADM stated he expected to be notified of increased aggression or if Resident #1 hit another resident or staff or any behavior consistent with abuse or neglect. Observations on 11/19/2025 and 11/20/2025 revealed Resident #1 was safe, not aggressive, calm, monitored by staff, and receptive to staff's redirection. During an interview on 11/20/2025 at 8:35 AM, LVN B stated Resident #1 now had a doctor's orders for 1:1 monitoring. LVN B stated she worked 6 AM to 6 PM and had not been in-serviced 11/19/2025 or 11/20/2025 but had received in-service training this month about monitoring Resident #1 and documenting in his progress notes. She had monitored Resident #1 and there had been no behavior. During an interview on 11/20/2025 at 8:38 AM, RN stated she was not sure if Resident #1 was on 1:1 monitoring, but staff were always with him. The RN sat with Resident #1 at breakfast and had him with her in her office on 11/19/2025. The RN had not been in-serviced 11/19/2025 or 11/20/2025 about monitoring Resident #1 or documenting behaviors but had received in-service training about Resident #1 last week on monitoring and documentation. During an interview on 11/20/2025 at 9:52 AM, the DM stated she knew Resident #1 and he had a change in behavior about two weeks ago. She had not been in-serviced about monitoring Resident #1 or documenting behaviors. The DM stated she knew Resident #1 was on 1:1 monitoring due to his behavior (confused, agitated, going in and out of residents' rooms). The DM stated staff were always sitting with Resident #1 at the dining room table, but she did not know how long the 1:1 had been going on. During an interview on 11/20/2025 at 10:05 AM, the SS stated she knew Resident #1 and he had a change in behavior about two weeks ago. Staff must redirect him a lot and staff were always with Resident #1. The SS stated that she had Resident #1 in her office a lot because he had been wandering into other residents' rooms, but she did not know if he had an order for 1:1 monitoring. The SS stated she had been in-serviced on 11/19/2025 regarding monitoring and documenting changes of behaviors in the resident's chart. During an interview on 11/20/2025 at 5:29 PM, CNA D stated he worked with Resident #1. Resident #1 tried to hit staff with his walker in the past. He provided 1:1 monitoring to Resident #1 to prevent wandering into other residents' rooms and would redirect Resident #1. He had received in-service training on monitoring on 11/19/2025, but was not in-service on abuse policy, resident to resident altercations or de-escalation on 11/08/2025 because he was out on leave. He had received that training before and named the ADM as the abuse coordinator. Review of Resident #1's orders as of 11/20/2025 reflected a new order dated 11/19/2025 to begin 11/20/2025: 1:1 monitoring with all activities, document any behaviors in progress noted, and notify provider, the DON, and the ADM every shift for routine monitoring. The DON was presented with the IJ template at 11/20/2025 at 6:19 PM and it was explained that the IJ was PNC and there was no current immediacy. The ADM was not available for interview prior to exit as he had left the facility. Review of facility policy titled Accidents and Supervision dated 05/16/2025, reflected: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s).2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) or risk(s). 4. Monitoring for effectiveness and modifying interventions as necessary. Definitions: Risk refers to any external factor, facility characteristic (e.g. staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident.

Based on observation, interviews, and record reviews; the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to dispose of open stored perishable food products. 2. The facility failed to properly label and date food products in one of two refrigerators and two of four freezers. 3. The facility failed to ensure unknown individual, staff or resident, food products in a bag were labeled and dated in one of two refrigerators. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.Findings include: Observation on 09/02/2025 at 9:05 AM, during a walk-through of the facility kitchen revealed two refrigerators and four freezers. Observation revealed one of the two refrigerators had; two undated and not labeled cut in half deli-meat and cheese sandwiches in the refrigerator, and a bag of 7 undated or not labeled unknown person; resident or staff, yogurts in residents' refrigerator. Observations revealed the two of four freezers had; five undated and not labeled frozen pie crust in the freezer, and there was undated and not labeled open frozen sliced green peppers. In an interview on 09/02/2025 at 9:30 AM, the Dietary Supervisor stated that she observed the food products the Investigator was observing while following Investigator and will throw away the undated or not labeled food products. The Dietary Supervisor stated the bag of 7 undated or not labeled yogurts is unknown; unknown if either a resident or staff, and she will throw it away since it is unknown. Observation on 09/03/2025 at 10:45 AM, revealed during a walk-through of the facility kitchen, there was undated and not labeled open frozen sliced green peppers in one of the four freezers. In an interview on 09/03/2025 at 10:52 AM with CK, she stated the following: she had worked at this facility for a year, but she had been a cook for 30 years. CK stated she had been trained in resident rights such as, if a resident asks for a meal substitution, the residents have the right to have it or receive alternatives for their food preferences. CK stated she had been trained in labeling and dating foods that are in the kitchen. CK stated she last received the labeling and dating training a week ago as well as there are daily reminders from Dietary Supervisor. CK stated all food products in the kitchen needs to be labeled and dated at all times with no exceptions. CK stated all foods that are opened or goes in the pantry, refrigerator, or freezer needs to be labeled and dated. CK stated if there is food that is not labeled or dated in any of the food storage areas, the kitchen staff must throw the food away. CK stated kitchen staff throws the undated or not labeled food away because kitchen staff won't know how long it's been stored for and if it's good for consumption for the residents. CK stated undated or not labeled food can make residents sick if served. CK stated all kitchen staff are responsible for making sure all food is labeled and dated. CK stated all staff double check to make sure each food in the kitchen is labeled and dated. CK stated it was ultimately the Dietary Supervisors responsibility to oversee all foods are labeled and dated. CK stated if residents are served undated or not labeled food from the kitchen, it can cause foodborne pathogens or potentially hospitalize residents. CK stated if residents consume undated or not labeled food from the kitchen, it potentially may have bacteria. CK stated undated or not labeled food can cause an effect on the resident's quality of life overall. In an interview on 09/03/2025 at 11:07 AM with the DA, she stated the following: she had worked at this facility for 3 years. The DA stated she had been trained in resident rights in which residents have all their rights such as, if a resident request a certain food the kitchen staff accommodates the residents right. DA stated she had been trained in labeling and dating food products in the kitchen in which all foods need to be labeled and dated. DA stated kitchen staff put their food in break rooms and not with residents' food. DA stated any food not labeled and dated is to go in the trash regardless of if it was a resident's food or staff members food. DA stated food that is not labeled or dated goes in the trash because the kitchen staff won't know when it was cooked or if it was good to give to residents without them getting sick. DA stated residents can get stomach illness or lead to them going to the hospital if served undated or not labeled foods. DA stated it was the responsibility of the kitchen Cooks and the Dietary Supervisor to make sure all foods are labeled and dated in the kitchen. DA stated it can affect the resident's quality of life and cause a lot of food illnesses if residents consume undated or not labeled foods from the kitchen. In an interview on 09/03/2025 at 11:17 AM with the DS, she stated the following: she has been working at this facility for 13 years and working in the kitchen industry for 20 years. DS stated she had been trained in resident rights. DS stated resident have rights to be accommodated based off their dietary needs. DS stated she had been trained in labeling and dating food in the kitchen. DS stated all food products in the kitchen need to be labeled and dated. DS stated all foods in pantry, refrigerator, and freezer need to be labeled and dated to keep track of the food consumption timeframes and food safety. DS stated any food that expires is to be decomposed and this includes any foods that is not labeled or dated. DS stated undated or not labeled food need to be thrown out and not served to residents. DS stated food not labeled or dated shouldn't be served to residents as the kitchen staff won't know how long it had been stored and if there are bacteria growing that would cause residents to get sick. DS stated its expected that all kitchen staff are in charge of labeling and dating foods that are in the facility kitchen. DS stated it's ultimately the responsibility of the Dietary Supervisor to make sure all food products are labeled and dated at all times. DS stated she threw out the foods that were found yesterday when checking if foods were labeled and dated. DS stated she did not see the undated or not labeled frozen sliced green peppers still remaining in the freezer and will throw it away immediately. DS stated any foods that is not labeled and dated then given to residents will get residents sick such as, diarrhea, vomiting, salmonella, and other potential food borne illness. DS stated it can pose a negative outcome or affect residents' quality of life since the residents have complicated health issues that can not only lead to sickness, but potentially hospitalize or cause a resident to passing away. In an interview on 09/03/2025 at 1:17 PM with the RD, he stated the following: he has been working and overseeing the facility for 2 years. RD stated he has been trained on the topic of residents having preferences in what they are eating. RD stated he has been trained in labeling and dating foods. RD stated he last received training on labeling and dating about two or three months ago. RD stated regardless of if there are food products that are in a refrigerator and its unknown if it is a resident or staff members food, it needs to be tossed out as well as staff shouldn't be storing their foods with resident's foods or if it's a resident's food with no label or dates, it needs to be thrown out. RD stated any and all food that comes in should be labeled and dated. RD stated any food products that are opened should be labeled and dated including foods prepared at the facility. RD stated food products are labeled and dated for safety of the residents, so bacteria won't grow and get residents sick during consumption. RD stated foods must be labeled and dated to know how long the foods can be given to residents and have palatable taste. RD stated the protocol for any food products that aren't labeled and dated is, the food products need to be tossed and thrown away. RD stated he does a full food audit monthly and he visits the kitchen facility three times a month to oversee all foods being labeled and dated. RD stated he educates and in-services the staff along with the Dietary Supervisor in regard to labeling and dating food products. RD stated it's expected that all kitchen staff are responsible for labeling and dating food products in which ultimately, it's the Dietary Supervisors responsibility to check all food products are always labeled and dated. RD stated residents provided undated and not labeled foods can negatively affect a resident and impact the resident's quality of life since residents are fragile, and it can cause food borne illnesses or lead to hospitalization.In an interview on 09/04/2025 at 11:35 AM with the ADMIN, he stated the following: he has been working at the facility for a little over one year. ADMIN stated he has been trained on the State and Federal policies, facility polices, and best practices. ADMIN stated he has been trained in labeling and dating foods. ADMIN stated foods need to be label and dated that come into the facility kitchen. ADMIN stated foods that aren't labeled and dated are to be throw away and any expired food need to be tossed. ADMIN stated he last received training on labeling and dating about a year ago in which he last trained the facility staff was approximately last month during an all staff meeting but doesn't have a documented record of it. ADMIN stated if there is unlabeled or not dated food products that are in a refrigerator and its unknown if it is a resident or staff members food, it needs to be tossed out. ADMIN stated resident and staff foods should be labeled and dated, but shouldn't be stored together, and it needs to be thrown in the trash. ADMIN stated any food products that are opened should be labeled and dated. ADMIN stated its important to label and date food products for resident safety, proper nutrition for residents, and overall food consumption safety for residents. ADMIN stated foods must be labeled and dated to know how long the foods have been stored and shouldn't be given to residents if not labeled and dated, it should be thrown away immediately. ADMIN stated the protocol for any food products that aren't labeled and dated is the food products need to be tossed and thrown away by kitchen staff. ADMIN stated there should be daily monitoring of all foods to be labeled and dated which is the Dietary Supervisors responsibility or a designated individual. ADMIN stated ultimately, it's the responsibility of the Dietary Supervisor, and Administrator to ensure all foods in the facility kitchen remains labeled and dated. ADMIN stated he and Dietary Supervisor does a full food audit monthly and as needed when visiting the facility kitchen to oversee all foods being labeled and dated. ADMIN stated the Dietary Supervisor educates and in-services the kitchen staff about labeling and dating food products as well as this is conducted during all staff meetings. ADMIN stated it's expected that all kitchen staff are responsible for labeling and dating food products to be compliant with State, Federal, and corporate regulations. ADMIN stated it's ultimately, the responsibility of the Administrator to check that all food products are always labeled and dated. ADMIN stated he can't comment if residents being provided undated and not labeled foods can negatively affect a resident and impact the resident's quality of life due to, he can't say from his knowledge what it can to a resident. Record review of facility in-services for Labeling and Dating reflected that trainings were conducted on 07/31/2024, 07/17/2025, and 08/14/2025. Record review of facility Food Receiving and Storage policy with a revised date of October 2017 reflected: Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Record review of facility Date Marking for Food Safety with a revised date of 07/06/2025 reflected: the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 8 residents (Resident #55) reviewed for care plans. The facility failed to ensure that Resident #55's care plan was revised, updated, and individualized to address Resident #55's contracture (a shortening of the muscles, tendons, skin and nearby soft tissues that causes the joints to become very stiff) to his left hand and wrist. This failure placed the resident at risk of not receiving the appropriate care to meet his current needs.Findings included: Record review of Resident #55's admission record, dated 09/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #55 had diagnoses that included: type 2 diabetes mellitus without complications (a condition that affects how the body uses sugar as a fuel), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness or inability to move left side of body due to a blood clot that formed in the brain), and generalized anxiety disorder (a mental health disorder that is characterized by excessive, uncontrollable, and often irrational worry about events or activities). Record review of Resident #55's Quarterly MDS assessment, dated 08/22/2025, reflected a BIMS score of 12 which indicated mild cognitive impairment. Record review of Resident #55's care plan, dated 12/31/2024 and last revised on 08/27/2025, reflected Impaired physical functioning r/t decreased mobility, other paralytic syndrome following cva affective left side. The care plan had no mention of contracture to left hand. (cva - a blood clot in the brain that can cause irreparable disability). During an interview and observation on 09/04/2025 at 09:48 AM, Resident #55 stated the therapy department placed a rolled-up washcloth in his left hand that had a contracture. Observation of Resident #55 revealed Resident #55 had a contracture to the left hand and wrist without any intervention in place at that time. Observation to Resident #55's left hand and wrist revealed no skin breakdown. During an interview on 09/04/2025 at 12:03 PM with the ADON, she stated she was responsible for implementing care plans. She stated the CNAs used care plans to determine the needs for the residents in the facility. The ADON stated if a resident had a contracture to their hand or wrist then the contracture should be care planned so that the CNA was aware of the interventions needed for that resident. The ADON stated, after a brief review of Resident #55's electronic health record, Resident #55 did not have a care plan related to his contracture to the left wrist and left hand. She stated without a care plan for Resident #55's contracture, staff would not know how to adequately care for his contracture, and it could get worse. During an interview on 09/04/2025 at 01:28 PM with MA B, he stated all staff used the care plans to determine to care needed for each resident. MA B stated management was responsible for initiating the care plans for the residents. He stated if a resident had a contracture, then it should be in the care plan. MA B stated if a contracture was not in the care plan, then the contracture could get worse, or the resident could have pain to the contracture site. During an interview on 09/04/2025 at 01:42 PM with LVN A, she stated all staff from all departments use care plans to determine the residents' needs and what staff could do to help the residents. LVN A stated the department heads would meet every morning to discuss any new residents and changes in the current residents and to update care plans. She stated the DON and ADON were responsible for ensuring the care plans were completed appropriately. LVN A stated a contracture should be part of the care plan for the resident. She stated if a contracture was not part of the care plan, then the contracture could get worse, or the resident could get skin breakdown. During an interview on 09/04/2025 at 02:09 PM with the DON, she stated the nurse managers and therapy managers utilize care plans and verbally pass the information to their staff. She stated the care plans were developed by nursing management and were used to ensure staff understood the care, medications, preferences, and devices needed for each resident. The DON stated she expected contractures to be on the care plan. She stated if a contracture was not on the care plan, then they [the resident] may not get the best care that they deserve. During an interview on 09/04/2025 at 02:35 PM with the ADM, he stated every department used care plans as a guide to providing the best care possible to each individual resident that resided at the facility. He stated one of the registered nurses was responsible for initiating care plans, but not sure who. He stated care plans were monitored in the morning meetings with the clinical team for all change of conditions that occurred or new admissions to the facility. The ADM stated if a resident had a contracture, then it should be included in that resident's care plan. He stated he was unsure of how not having the contracture in the care plan could affect the resident because he was not clinical. Record review of facility policy titled, Comprehensive Care Plans, dated 06/01/2025, reflected in part, 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 and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews, 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 8 residents (Resident #46) and 2 of 4 medication carts (400-hall nurses' cart and 100-hall nurses' cart) reviewed for pharmacy services. The facility failed to ensure expired medication, including medication prescribed for Resident #46, were removed from the 100-hall and 400-hall nurses' medication carts. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or contamination from expired supplies.Findings included:Record review of Resident #46's admission record, dated 09/04/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #46 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), Parkinson's disease without dyskinesia (a progressive disorder that affects the nervous system without involuntary movements), and expressive language disorder (a communication disorder that affects a person's ability to express thoughts, ideas, or feelings clearly and effectively).Record review of Resident #46's Quarterly MDS, dated [DATE], reflected a BIMS score was not conducted because resident was rarely/never understood.Record review of Resident #46's order summary, dated 09/04/2025, reflected lorazepam oral tablet 1mg Give 1 tablet by mouth every 2 hours as needed for anxiety, SOB for 14 days.Record review of Resident #46's care plan, dated 07/16/2025, reflected Hospice care related to: end stage neurological disease - senile degeneration of the brain (a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities). Interventions included Administer medication as ordered by physician.Observation on 09/03/2025 at 03:36 PM of the 400-hall nurses' medication cart revealed one tube of hemorrhoidal ointment with an expiration date of 05/2025.During an interview on 09/03/2025 at 03:38 PM, LVN E stated the nurses' medication cart was to be checked weekly on a schedule for expired medications and supplies, though she was unsure of the schedule or who was responsible for checking the carts. LVN E reviewed the hemorrhoidal ointment found in her medication cart and confirmed it was expired. She stated if medication was used on a resident after the medication's expiration date, then the medication may not be as effective and the resident may not receive the intended benefits from the medication, or the resident may have an adverse reaction to the medication.Observation on 09/03/2025 at 04:32 PM of the 100-hall nurses' medication cart revealed one medication card of lorazepam 1mg tab with an expiration date 08/18/2025 prescribed to Resident #46.During an interview on 09/03/2025 at 04:35 PM, LVN F stated she worked for an agency and that was her first day in the facility. She stated she assumed the person responsible for the medication cart was responsible for checking for expired medications, but she was unsure of the frequency. She stated she was unsure of the audit process to ensure expired medications were removed from the medication cart. LVN F stated if medication were administered to the resident past the medication's expiration date, then the medication may not be as effective, or the resident could have an adverse reaction to the medication.During an interview on 09/03/2025 at 04:45 PM, RN G stated the person responsible for the medication cart was responsible for ensuring all expired medications and supplies was removed every shift. She stated nursing management had a process for auditing the medication carts, but she was unaware of the process or frequency. RN G stated if the resident received medication after its expiration date, then the medication may not be as effective, or the medication could make the resident sick.During an interview on 09/04/2025 at 12:03 PM, the ADON stated the nurses and medication aides responsible for the medication carts was responsible for checking for expired medications as they give the medications. She stated there was not a process at that time to ensure expired medications were removed from the medication carts. The ADON stated if medications were administered to the residents past the medication's expiration date, then the medication may not be as effective.During an interview on 09/04/2025 at 01:28 PM, MA B stated the nurses and medication aides that work on the medication cart are responsible for removing expired medications daily from the medication carts. He stated the pharmacy consultant followed up with auditing the medication carts monthly. MA B stated administering medication to residents after the expiration date for the medication was a medication error and the medication may not affect the resident the way it was intended to.During an interview on 09/04/2025 at 01:42 PM, LVN A stated the staff responsible for the medication cart was responsible for checking for expired medications in the cart every shift. She stated the pharmacy consultant ensured all expired medications was removed from the medication carts, but she was unsure of the frequency. LVN A stated, if expired medications were administered to a resident, then the medication may not be as effective.During an interview on 09/04/2025 at 02:09 PM, the DON stated she expected staff responsible for the medication carts to check for expired supplies daily. She stated the pharmacy consultant performed audits monthly to ensure expired medications were removed from the medication carts. The DON stated if expired medications were administered to residents, then the resident would not get the therapeutic dose of the medication.During an interview on 09/04/2025 at 02:35 PM, the ADM stated the staff assigned to the medication cart was responsible for ensuring all expired medications were removed from the medication cart every shift. He stated the pharmacy consultant audited the medication carts monthly to ensure all expired medications had been removed. The ADM stated he was unsure how expired medications could affect a resident because he was not clinical.Record review of the facility's policy titled Pharmacy Services, dated 06/15/2025, reflected: Policy: It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.Compliance Guidelines: 1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. No mention of expired medications in the facility policy. Record review of the facility's policy titled Medication Storage, dated 05/09/2025, reflected: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Policy Explanation and Compliance Guidelines: .8. 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 our Destruction of Unused Drugs Policy.

Based on observation, interviews, and record reviews, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility after a visitor utilized the exit code then held the door open for the resident to walk out on 04/18/25 around 9:52 PM. The temperature outside was a high of 91 degrees and a low of 68. The resident was found over three hours later. She was taken to the hospital for evaluation after 1:30 AM. The noncompliance was identified as PNC. The IJ began on 04/18/24 and ended on 04/21/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for elopements resulting in falls, injuries, dehydration, and hospitalization . Findings included: Review of Resident #1's face sheet, printed 05/07/25, reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses included cerebral infarction due to occlusion or stenosis of small artery (stroke), hypertension (high blood pressure), aphasia following unspecified cerebrovascular disease (difficulty speaking), expressive language disorder (difficulty speaking), and difficulty in walking. Review of Resident #1's admission MDS assessment, dated 04/19/25, Section C (Cognitive Patterns) reflected a BIMS assessment was not completed, nor did staff assess her short-term memory. Section GG (Functional Abilities) reflected she was independent with ADLs including transfers and walking 150 feet. Review of Resident #1's admission assessment and baseline care plan, initiated 04/11/25, reflected the resident was not an elopement risk but was at risk for falls. Review of Resident #1's Elopement Risk Assessment, dated 04/11/25, reflected a 1 which indicated no risk for elopement. Review of Resident #1's psychosocial assessment completed 04/15/25, reflected resident was not very verbal at this time and did not answer many of the questions. Review of Resident #1's progress note, dated 04/19/25 at 2:15 AM, documented by the DON, reflected the following: During a routine round by floor nurse, a resident was reported missing from their room. All staff on duty conducted a thorough search of the entire building but were unable to locate the resident. The DON and Administrator were then called to the building to review the footage and discovered that the resident had been let out of the front door by a family member of another resident. The resident has a local address and several local family friends as emergency contacts. The Administrator contacted the resident's (family member), who resides out of state, to inform her of our findings. The (family member) stated that the resident had informed her that she was visiting a family friend in town. Multiple attempts were made to contact the family friend at their local physical address and via cellular phone. The (city) Police Department was notified for assistance. The DON, Dietary Manager, Administrator, and the (city) Police Department searched various areas, including the facility and the resident's housing address. The resident was located a block away from her home. Due to the resident's disease process, she is occasionally unable to verbally express her needs but can respond to yes or no questions and is aware of her surroundings. The resident was adamant about returning to her home rather than the facility. Once the resident was in the presence of her front door, the DON and Dietary Manager assessed her for any injuries or complications. The resident reported experiencing shortness of breath and consented to allow EMS to conduct a further evaluation. The (city) Police Department requested backup from EMS, and the resident was transported to a hospital for medical attention . Review of Resident #1' progress noted, dated 04/19/25 at 11:39 AM, documented by the DON, reflected the following: During a routine round, a resident was reported missing from their room around 2115. Floor nurse reports that she last time she saw her resting in bed with eyes open around 2015, All staff on duty conducted a thorough search of the entire building but were unable to locate the resident. Around 2251 The DON and Administrator were notified and arrived to building shortly after. They were able to review the camera footage and discovered that the resident had been let out of the front door by a family member of another resident around 2153. Family was notified by the Administrator. Report from floor nurse (name), LVN F. [sic] Review of the facility's investigation reflected the as followed: During routine rounds staff noticed the resident was missing. Staff initiated a search and verified all other residents were accounted for. When staff were unable to locate the resident, facility management were notified at 12:30 AM. Management went to the facility and assisted in the search. The administrator viewed the surveillance video and saw a visitor use a code to open the door, hold the door, and the resident walked out of the building. Family was notified and provided phone numbers and local addresses. The MD was notified. The local police were notified and assisted in the search. The codes to the doors were changed. Staff were interviewed. Staff were in-serviced on elopement, assessing risk of elopement, and codes for the exit alarms. An observation on 05/07/25 at 9:16 AM, revealed a neon pink sign on the inside of the entrance/exit door. The sign reflected, DO NOT ASSIST ANYONE OUT OF FACILITY. The sign was printed in large black font and was posted at eye level. The door had a keypad and required a code to exit the door. Observations on 05/07/25 between 9:16 AM and 3:50 PM, revealed staff entering the code to allow visitors in or out of the facility at the main entrance. The buzzer sounded each time the door was opened. No observations of visitors entering the door code was made. Observations of other entrance doors revealed keypads in place and DO NOT ASSIST ANYONE OUT OF FACILITY signs displayed. An observation on 05/07/25 at 10:00 AM, of the video surveillance from 04/18/25, revealed footage labeled Hall 400. Resident #1 opened her room door and looked into the hallway. She looked to the right, the left, back to the right, then back to the left. She stepped out into the hall and walked out of view of the camera. The resident was wearing long pants and a long-sleeved top. The next camera view was labeled Front Lobby. A person, identified as a family member, not related to Resident #1, was seen walking through the lobby to the front door. Resident #1 was observed as she entered the lobby. She adjusted the strap of her purse over her shoulder. She walked toward the front door. The family member was observed as she entered the code to open the front door. The family member exited the door, turned, and saw Resident #1 walking toward the door. The family member held the door open, and Resident #1 walked out. The next camera view was labeled, Parking Lot. Resident #1 was observed as she walked across the parking lot away from the facility. The time stamp reflected 04/18/25 at 9:52 PM. The video ended when the resident reached the end of the parking lot. A voice message was left 05/07/25 at 10:45 AM, which requested a return call from Resident #1's family member. A return call was not received prior to exit from the facility. During a telephone interview on 05/07/25 at 11:10 AM, an officer from the (city) Police Department provided the location where Resident #1 was picked up by EMS on the morning of 04/19 /25 at 1:45 AM. A mapping website reflected the location was 1.6 miles from the facility. The officer stated he did not participate in the search for the resident because it happened on the night shift. He stated he was able to review the report from the officer who participated in the search. During an interview on 05/07/25 at 1:16 PM, LVN A stated she had received training on elopement recently. The training included identifying risk and preventing elopement. She did not remember the exact date but knew it was after the recent elopement. She stated she did not work the day the resident eloped, and she did not recall any residents with exit-seeking behaviors. She stated if a resident was missing, staff would immediately initiate a search, complete a head count, and notify management immediately. LVN A reported recent training on ANE and named the ADM as the Abuse Coordinator. During an interview on 05/07/25 at 1:19 PM, MA B stated she did not recall ever seeing Resident #1 standing near exit doors or trying to get out of the facility. She stated she had training on ANE and Elopement a few weeks ago. She stated since that training, the door codes had changed, and they were not allowed to give the new code to family members. She stated the family members were understanding once the reason for the change had been explained to them. MA B stated if a resident was missing, they conducted a search, completed a head count, and notified the charge nurse immediately. MA B was able to describe types of abuse and the need to report any abuse immediately. During an interview on 05/07/25 at 1:26 PM, a visiting FM stated staff open the door for her when she entered and exited the facility. She stated she had not been given the code for the doors. She stated it had not been a problem as staff had been available to assist her at each visit. During an interview on 05/07/25 at 1:28 PM, LVN C stated she had recent training on elopement and not giving the door code to visitors. She stated they in-service included training on completing the elopement assessment on admission, frequent rounding, watching for residents exit-seeking, and not giving out the code for the doors. She stated staff assisted family and other visitors in and out of the building. She stated she had received frequent in-services on ANE, spoke to the policy, and named the ADM as the abuse coordinator. During an interview on 05/07/25 at 1:31 PM, the DON stated Resident #1 had been assessed on admission and she was not an elopement risk. She stated the resident was admitted for short term therapy to gain strength after her hospitalization . The DON stated she drove to the facility as soon as she was notified, around 12:30 AM, that the resident was missing . She stated the facility was thoroughly searched and a nurse had searched the perimeter. The administrative staff went out in teams and searched for the resident. She stated she and the dietary manager found Resident #1 near her home. She stated the Resident #1 allowed a partial assessment and the resident made it known that she did not want to return to the facility. The DON stated the resident agreed to go to the hospital to be evaluated after she reported some shortness of breath. She stated the police officer at the scene call for EMS who transported the resident to the hospital. During an interview on 05/07/25 at 2:26 PM, the ADM stated he expected residents were treated with dignity and respect. He stated they tried everything in their power to prevent elopements. He stated he was called just after midnight after the resident was missing. Staff told him they had searched the facility and ensured all other residents were present. He stated, once at the facility, he watched the video and saw the resident had been let out of the building by a visiting family member. He stated a family member of Resident #1 provided addresses for local friends and the resident. The police were notified and assisted in the search. The ADM stated the DON and DM had found the resident about a block from her house. He stated EMS took the resident to the hospital for evaluation. Upon return to the facility, he changed the codes to the doors and staff were instructed not to give the new code to family or visitors. He stated signs were created and placed at each exit. He stated they initiated in-service training on elopement, resident rights, and visitations. The ADM stated they did not have a locked unit and they did not use a Wander guard system. During an interview on 05/07/25 at 3:00 PM, CNA D stated she did not remember Resident #1. She stated she had been trained on Elopement and Resident Rights recently but did not remember the date of the training, about 3 weeks ago. She named the ADM as the abuse coordinator and stated any abuse must be reported immediately. She stated frequent rounding and knowing where the residents were was important to prevent elopement. She stated the door code was not to be given to visitors . Review of an in-service dated 04/19/25 and initiated by RN E then continued by the DON, ADON, and ADM, reflected staff were in-serviced on identifying high risk for elopement, understanding elopement, prevention of elopement, and adding to QAPI. Review of an in-service dated 04/19/25 and initiated by RN E then continued by the DON, ADON, and ADM, reflected staff were in-serviced on Resident Rights. Review of the Ad Hoc QAPI meeting agenda, dated 04/21/25, reflected the ADM, DON, SW, and MD participated. Review of eight resident medical records reflected Elopement Assessments were all current. Residents who had been in the facility more than 90 days had Elopement Assessments completed quarterly. Review of the facility's Elopement Policy, dated Qtr 3, 2018, reflected the following: Staff shall investigate and report all cases of missing residents. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. Review of the facility's Resident Rights Policy, revised February 2021, reflected the following: Employees shall treat all residents with kindness, respect, and dignity. l. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; e. self-determination; p. be informed of, and participate in, his or her care planning and treatment. The noncompliance was identified as PNC. The IJ began on 04/18/24 and ended on 04/21/24. The facility had corrected the noncompliance before the survey began.

Based on interviews and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 3 residents (Resident #1) reviewed for discharge requirements. 1. The facility failed to provide Resident #1's guardian a written discharge notice with appeal information. 2. The facility failed to document interventions attempted to meet Resident #1's needs prior to discharging the resident on 02/23/2025. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. Findings included: Review of Resident #1's face sheet reflected a [AGE] year-old-man admitted on [DATE] with diagnoses of spastic quadriplegic cerebral palsy (severe disorder that affects movement balance and posture, where all four limbs are abnormally stiff and tight), anxiety disorder (group of mental health conditions characterized excessive and persistent worry, fear and nervousness that significantly interfere with daily life), profound intellectual disabilities (condition that involves limitations on intelligence (limitations on intelligence, learning and everyday abilities), unspecified behavioral and emotional disorders, and deaf-nonspeaking. Review of Resident #1's admission MDS dated [DATE] reflected the BIMS assessment was not completed because Resident #1 was not understood. Review reflected Resident #1's cognitive skills for daily decision making was severely impaired. Further review reflected physical behavioral symptoms directed towards others, verbal behavioral symptoms directed at other were not exhibited. Resident #1 had a functional limitation in range of motion on one side for both upper and lower extremities. Resident #1 was total dependence for transfers and required substantial or maximum assistance for most ADLs. Review of Resident #1's care plan date 02/13/2025 reflected Resident #1 was PASRR positive with interventions to encourage and support advocacy efforts to ensure the resident had necessary services provided to promote wellness and functional abilities. Interventions also included to hold scheduled care plan meetings that included resident, family, licensed RN, and LIDDA to discuss changes in condition and resident needs. Care plan dated 02/14/2025 reflected Resident #1 was at risk for impaired psychosocial well-being related to dependent behavior and ineffective coping skills., with interventions that included assess social support systems and community resources and to assist, encourage, and support realistic goals. Review of Resident #1's progress note dated 02/16/2025 reflected Resident #1 was sitting at the dining room table and motioned with his hand for another resident to go by when another resident got next to Resident #1 and was hit in the face as she was passing by. Review of Resident #1's event follow up progress note dated 2/17/2025 by LVN B reflected Resident #1 had compliance with redirection to reduce risk of recurrence of event. Review of Resident #1's event follow up note dated 02/18/2025 reflected the resident to staff event with Resident #1. Resident #1 was compliant with interventions and was removed from situation and environment. Resident #1 was in room after event. Resident #1 became upset and was offered PRN anxiety medication with snack and tolerated medication and snack and was transferred back into bed and slept for remainder of shift. Review of Resident #1's progress note dated 02/18/2025 by the DON reflected Resident was 1:1 for breakfast and swung arms in air at staff. The DON was able to de-escalate the situation and sat with Resident #1 while he ate breakfast. Review of Resident #1's progress notes from 01/31/2025 through 02/23/2025 reflected no additional incidents with staff or residents. The progress notes reflected no documented interventions trialed with Resident #1. Review of Resident #1's physician orders reflected order dated 02/03/2025 for psych consult. Review of Resident #1's medical chart reflected no written discharge notice to guardian/representative. Review also reflected there were no psychiatric/psychological notes or services started for Resident #1. Review of medical chart reflected no documentation from physician regarding facility's inability to meet Resident #1's needs. Review of Resident #1's care conference note dated 01/31/2025 reflected Resident #1 was cooperative and smiled a lot. Resident was able to use left hand to feed himself but did not understand what was being said due to cognition and was deaf in both ears. Review reflected the SW looked for communication pictures to help with communication. Review reflected Resident #1 could be hostile when frustrated and to use patience. Review of hospital referral for Resident #1 dated 01/29/2025 reflected Resident #1 was deaf and did not need ASL, only knew basic signs, and communicated by pointing. The referral reflected facial expressions were important to Resident #1 and if he was not smiled at it may have been perceived as threatening and act out by trying to swing left arm or kick legs. Review reflected Resident did not have strength to cause harm. Review of discharge planning dated 02/05/2025 completed by the SW reflected Resident #1's current admission was anticipated to be long term and the discharge goal was long-term care. The resident/family/guardian concerns regarding discharge plans reflected there was no discharge planned. Review of the discharge planning and summary dated 02/23/2025 reflected resident/representative initiated discharge with reason as necessary for the Resident's welfare and the resident's needs cannot be met in the facility- explain below. Explanation was not included. Discharge summary reflected that Resident #1 was orientated to person and unable to communicate needs. discharged summary reflected yes was selected under resident/representative find current discharge plan acceptable. Discharge summary reflected resident was discharged to another facility. During an interview on 03/03/2025 at 9:36 AM, Resident #1's RP stated that she received a voicemail on 02/21/2025 that Resident #1 was going to be discharged from the facility. The RP stated that she also received a voicemail on 02/23/2025 that Resident #1 had discharged to a sister facility. The RP stated that the facility notified her earlier in the week of an incident but did not mention that Resident #1 was going to be discharged . The RP stated that the facility did not provide any concerns that Resident #1 needed to be discharged . The RP stated that she did not receive a written discharge notice or information about an appeal process. The RP stated that the SW stated that she was not sure why Resident #1 was discharged but stated that he was aggressive. The RP stated she felt blind-sided by the way the discharge was done. She stated that Resident #1 had been at the facility for almost a month, and he was eating and drinking again, and felt that he was starting to adjust. The RP stated Resident #1 has IDD and was deaf and difficult to communicate with. The RP stated that she did not feel the facility tried to work with her or Resident #1 prior to the discharge and if any interventions were put in place due to his behaviors, she was unaware. During an interview on 03/03/2025 at 11:15 AM, CNA C stated when Resident #1 was upset he would throw tantrums and would start to swing his arms. She stated he would sign after and apologize. She stated that he had an impairment on one of his sides and could swing with one arm. She stated that his trigger was his diet, and he did not like a pureed diet. She stated that he would become upset if his food was not sweet. CNA C stated that she felt Resident #1 became overstimulated when there were too many people around. CNA C stated that when he was in the dining room and was upset 3-4 staff would try to intervene and then he would start to swing. CNA C stated she did not recall if there was a specific in-service completed about working with Resident #1 and his needs. During an interview on 03/03/2025 at 11:24 AM, COTA D, she stated Resident #1 was very sweet and that his chart said to smile at him. COTA D stated that he would point, and wave and he was able to point at what he wanted. COTA D stated that he got upset when people were not able to understand what he wanted. COTA D stated that she did not ever see him swinging at people. She said once in the therapy gym he started mumbling because he did not want to participate but was redirected easily. COTA D stated that he was wheelchair bound, deaf, and IDD. She stated that Resident #1 was able to bring his hand to his mouth and feed himself. COTA D stated that Resident #1 knew a bit of sign language and was able to point and grunt to indicate what he wanted. COTA D stated he had an impairment on one side. During an interview on 03/03/2025 at 12:13 PM SW stated that Resident #1's discharge was not initiated by him because he was not able to communicate. She stated that his communication ability was limited, and his sign language was limited. She stated that staff were unable to talk to him other than shaking their head no when he hit staff. The SW stated it was a facility-initiated discharge for Resident #1. The SW stated that the facility reached out to the RP on several occasions and did not hear back from her. The SW stated that messages were left that he was hitting other residents and staff members. The SW stated that Resident #1 was discharged to a sister facility. The SW stated the sister facility was better equipped and more experienced in dealing with residents with these types of behavior. The SW stated the facility thought it would be a better fit for Resident #1. The SW stated she did not document when she spoke with Resident #1's RP or attempted phone calls because nothing was being challenged or disputed and she had nothing to document except that the SW had called the RP. The SW stated that the RP was notified of the discharge the Thursday (02/20/2025) or Friday (02/21/2025) prior to the Sunday (02/23/2025) discharge and was provided the location via voicemail. The SW stated Resident #1's RP was not involved in selecting the location of the discharge because the RP did not call back. The SW stated the most appropriate setting to meet Resident #1's care needs was a facility that was able to find some type of way of communication. The SW stated Resident #1 did not have any way to communicate and would get frustrated. The SW stated that she was whacked by Resident #1 and that there was no warning. The SW stated that a facility that had experience in dealing with residents that had physical violence was the best option for Resident #1. The SW stated that as a team (therapy and SW) Resident #1 was evaluated, and it was determined that he would have benefited from picture cards for the bathroom, food, and medicine. The SW stated that this was communicated with the RP, but the picture cards were not purchased or provided by the RP. The SW stated that this was approximately two weeks prior to Resident #1's discharge. The SW stated that she did not document when she was hit by Resident #1 because she did not log it because she was not injured, and that Resident #1 had challenges. The SW stated she was told he hit other residents and stated it was logged by nursing. The SW stated she felt Resident #1 was more than the facility could handle because he lacked communication abilities. The SW stated that the new facility had experience in dealing with residents with physical aggression issues. She stated that she had not been to the sister facility and the DON would know better. The SW stated that the RP was not provided a written discharge notice but was called. The SW stated she was not aware the RP was provided appeal information. The SW stated nursing also called the RP about Resident #1's discharge. The SW stated interventions for Resident #1 included attempts to communicate with him with hands, such as putting hands up and saying stop, shaking head and saying no. She stated the facility got him in his chair and he was taken outside, and he was involved in activities and a basketball hoop was put on his wall. The SW stated that the facility tried everything they could do. The SW stated that she tried redirecting him and spending time with him and hoped he would adjust better. The SW stated that he was used to being around people and who used sign language. The SW stated she would smile at Resident #1 a lot. The SW stated Resident #1 knew a few signs. The SW stated that number one barrier was communication. The SW stated she did not think Resident #1 was able to comprehend pictures. The SW stated she was not sure if the facility Resident #1 discharged to had the capability to teach him ASL. During an interview on 03/03/2025 at 12:41 PM, SLP E stated that Resident #1 knew very few signs. SLP E stated that Resident #1 would put his open hand to his mouth and decided he wanted to eat this way. SLP E stated Resident #1 became agitated because he had a puree diet and would fight anyone who tried to feed him as he wanted to feed himself. SLP E stated Resident #1 never became aggressive with her and if he became agitated, she would sit across from him and back away and he was okay. SLP E stated he understood expression language but receptive he did not understand. SLP E stated she showed Resident #1 a picture of sandwich and he expressed an overexaggerated yes. SLP E stated Resident #1 understood what was being asked, but he was unable to get his point across. SLP E stated Resident #1 was not able to read. SLP E stated she used basic picture cards, and he was able to respond by shaking he head, no. SLP E stated the best way to communicate with Resident #1 was by utilizing basic one work or two-word prompts such as go eat or let's go. SLP E stated she told the therapy team to speak with three words max, and very slowly. SLP E believed Resident #1 could read lips. SLP E stated she did not provide any in-servicing to care staff on how to communicate with Resident #1. During an interview on 03/03/2025 at 1:00 PM, an anonymous staff member stated that there was too much commotion going on for Resident #1 and stated CNAs would not slow down to work with him. Anonymous staff member stated that CNAs would take him too quickly out of the dining room and did not explain what they were going to do and were too fast paced. During an interview on 03/03/2025 at 1:05 PM, the AD, stated that clinicals were received prior to resident's admission. He stated the DON reviewed all clinicals and told him yes or no to a resident admitting to the facility. The AD stated that clinicals were received prior to Resident #1's admission. The AD stated that he has not been told physical aggression was a barrier to admission and there was nothing that stood out that the facility was unable to accept. The AD stated he remembered he saw the referral for Resident #1 and that he had behaviors at a previous SNF but Resident #1 did not have behaviors in the hospital. The AD stated that the facility was aware of behaviors Resident #1 had at his previous SNF. During an interview on 03/03/2025 at 1:12 PM, CNA F stated that she did not provide care for Resident #1 but saw him in the dining room. She stated that he would wave his arms but did not think he was trying to hit anyone just get someone's attention. During an interview on 03/03/2025 at 1:27 PM, the DOR stated that she tried to use pictures online to communicate with Resident #1. The DOR stated that staff talked with Resident #1's RP and suggested specific picture cards but they were not provided. The DOR stated when Resident #1 first admitted she was told to approach him by smiling and then attempt to provide care or work with him. The DOR stated the most important thing was to go in with a smile. The DOR stated that she, the SW, and the MDS met in general and discussed other ideas on how to communicate with Resident #1. The DOR stated that she verbally told CNAs who provided care to smile and try to simulate the activity they were going to do prior to providing the care to Resident #1, but it was not a formal in-service. During an interview on 03/03/2025 at 1:50 PM, LVN G stated that she saw Resident #1 in the dining room and that he would get frustrated because no one understood him, and he could not verbalize. During an interview on 03/03/2025 at 3:28 PM, LVN B stated that he was familiar with Resident #1. LVN B stated that he tried to find ways to help Resident #1. LVN B stated there was not specific intervention put in place when care was provided for Resident #1. LVN B stated he tried to communicate with Resident #1 with sign and expressions. LVN B stated he felt Resident #1 understood the signs and expressions. LVN B stated Resident #1 could expression when he wanted more food, was thirsty, wanted to watch basketball, and wanted to go to bed. LVN B stated he did not see Resident #1 become aggressive with residents but saw Resident #1 throw his hands at staff. LVN B stated aggressive behaviors should have been documented in the resident's chart. LVN B stated it was important to document behaviors so any interventions that were put in place so other staff would be aware and there would be trail of what was done to help the resident. LVN B stated that it was also important to document conversations or attempted conversations with guardian's or residents' responsible parties so there is a trail and to ensure that staff spoke with the correct individual and other staff were aware of what happened with the resident. During an interview on 03/03/2025 at 4:13 PM, RN H stated she was familiar with Resident #1. She stated that some days he was calm and some days too much noise would upset him. She stated he would squeal, and he knew basic or simple signs like hungry or tired. RN H stated Resident #1 got frustrated if he was not understood right away. RN H stated that when Resident #1 was mad he would swing his arm in a getaway motion. RN H stated when that happened, they would trade off staff and get someone else to care for him. RN H stated as she continued to work with him, she figured out what worked for him and what did not. During an interview on 03/03/2025 at 4:50 PM, the DON stated that she felt the facility could have offered more services for Resident #1's hearing impairment and he could have gotten behavioral support involved. The DON stated that Resident #1 needed extended services that the facility could not do because staff were not trained on PASRR positive aggressive residents. The DON stated prior to Resident #1's admission she did not know if his behaviors were truly aggressive and knew he flailed his arms around. The DON stated he may have had behaviors from being hungry. The DON stated that Resident #1's RP instructed the facility to send him to the ER if his behaviors escalated. The DON stated interventions for Resident #1 were 1:1 care, frequent rounding, removed from dining room as much as possible, and have him eat at a table alone or at nurses' station. The DON stated when Resident #1 finished eating, his behaviors became aggressive as staff tried to remove him from the dining room. The DON stated that she did not believe Resident #1 tried to hit another resident. The DON stated prior to admission they received a report from his RP that his behaviors were good, and he was being discharged from the hospital. The DON stated she reviewed his referral and clinical information and felt it was necessary to give people second changes and she was unsure what caused his behavior in the past. The DON stated there was verbal training provided to keep a positive expression. The DON stated that Resident #1 always moved his arms but did not hit anyone initially. The DON stated she felt that the facility Resident #1 discharged to had a smaller staff to resident ratio and could sit down and meet his needs. The DON stated she believed the facility had a locked unit but was not sure. The DON stated that Resident #1 was referred to psychiatric services, but they come out once or twice a month and he had not been seen. She stated that the NP provided mediation management and PASRR services had not started. The DON stated that staff reached out and left message about the discharge to Resident #1's RP and that the SW also reached out, but the DON did not know if a written discharge notice was provided. She stated that a care plan meeting was not provided with Resident #1's RP prior to discharge because she did not believe it was in the facility's policy to have an emergency care plan meeting prior to discharge. The DON stated she was not sure if interventions were documented anywhere, and it was more verbally communicated. The DON stated that Resident #1 had an immediate discharge when a facility was found that was willing to take him. The DON stated she was unsure if the RP was provided options. The DON stated that she would expect any attempts or conversations with RP to be documented. During an interview on 03/03/2025 at 5:15 PM, the ADM stated that Resident #1's discharge was facility initiated. The ADM stated that Resident #1 hitting staff was what caused his need to discharge. The ADM stated the RP was not involved in picking the facility and stated that staff could not get ahold of the RP. The ADM stated he reached out to the other facility. The ADM stated that the facility was unable to control Resident #1's violent outbursts or anticipate when the next one would be. The ADM could not recall interventions put in place to assist Resident #1 prior to discharge. The ADM stated that DON reviewed clinical information prior to residents' admission to determine capability to care for residents. The ADM stated that he felt like most admissions looked worse on paper and they usually had good outcomes. The ADM stated he did not ask the receiving administrator what the accepting facility could do to meet the needs of Resident #1 and took the administrator's word that the facility was better equipped for handling behavioral needs. The ADM stated he was unsure if PASRR services or behavioral health services had started. The ADM stated the RP was not provided a 30-day discharge notice and he was unsure if the RP was provided a written notice. The ADM stated he expected any interventions that were done to be documented and expected any attempts made to reach out to guardian to be documented. The ADM stated it was important to document so that everyone was on the same page as to what was happening. Review of facility policy titled Transfer or Discharge, Facility-Initiated with revision date of October 2022 reflected once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and requires resident/representative notification and orientation, and documentation as to specified in this policy. Further review reflected documentation of facility-initiated transfer or discharge must include basis for transfer or discharge, specific needs that cannot be met, facility's attempt to meet those needs and the receiving facility's services that are available to meet those needs. Review reflected upon notice of transfer or discharge, the resident will be provided with a statement of his or her right to appeal the transfer, or discharge, including: a. the name, address, email and telephone number of the entity which receives such requests; b. information about how to obtain, complete and submit an appeal form; c. how to get assistance completing the appeal process; and d. the facility bed-hold policy. Review of policy reflected than an appropriate notice was provided to the resident and/or legal representative. Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by a physician: a. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident; or b. The health of the individuals in the facility would otherwise be endangered.

The following acronyms were used: DC A: Dietary [NAME] A DC B: Dietary [NAME] B DM: Dietary Manager DON: Director of Nursing OM: Operations Manager MDS: Minimum Data Set CMS: Centers for Medicare and Medicaid Services PCC: Point Click Care Tag: 812 S/S= F Surveyor Name(s): Steffanie Brand Immediate Supervisor: [NAME] Sill Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety service for 2 of 2 meals observed. The facility failed to ensure that Dietary [NAME] A and Dietary [NAME] B performed proper hand hygiene while preparing food in the kitchen. This failure could place residents at risk of infection or cross contamination. Findings included: On 07/29/2024 at 11:10AM an observation was conducted in the kitchen of the puree process by DC A. DC A completed the chicken puree. DC A had placed the blender in the dishwashing and sanitizing compartment with gloves on. DC A took off her gloves, lifted the trash can lid up, and tossed the gloves in the trash can. DC A did not perform hand hygiene after she tossed her gloves in the trash and when she had grabbed the blender. On 07/29/2024 at 11:15AM an observation was conducted in the kitchen where DC A had performed hand hygiene. DC A washed her hands properly with soap and warm water then turned off the faucet with her clean hand. She then grabbed a paper towel and continued with her kitchen duties. On 07/30/2024 at 11:00AM an observation was conducted in the kitchen of the puree process by DC B. DC B completed the beef tips puree. DC B had placed the blender in the dishwashing and sanitizing compartment with gloves on. DC B took off his gloves, discarded them in the trash can and performed proper hand hygiene with soap and warm water then turned off the faucet with his clean hand . He then grabbed a paper towel and continued with his kitchen duties. On 07/30/2024 at 11:10AM an interview was conducted with DC B regarding the hand hygiene process. DC B described proper hand hygiene as always washing your hands between touching different menu items. DC B stated that a potential negative outcome of not using proper hand hygiene is cross contamination. On 07/30/2024 at 11:20AM an interview was conducted with DC A regarding the hand hygiene process. DC A described proper hand hygiene as 20 seconds of washing the hands under warm to hot water with soap, grab a paper towel to dry your hands, throw the towel away, grab a new paper towel and turn off the faucet . DC A stated that a potential negative outcome of not using proper hand hygiene is salmonella and potentially death. On 07/31/2024 at 10:47AM an interview with Dietary Manager regarding the hand hygiene process in the kitchen. DM described proper hand hygiene as they need to wash their hands with soap, rinse their hands off, and grab a paper towel to turn off the water. DM stated that staff in the kitchen should have gloves on when handling spills and raw foods. DM stated that once they remove the gloves, they should wash their hands before continuing their task. DM stated a potential negative outcome of not performing proper hand hygiene in the kitchen could result in cross contamination. On 07/31/2024 at 01:40 PM an interview was conducted with the DON regarding hand hygiene. DON stated that the policy on handwashing/hand hygiene is it should be performed any time your hands are soiled. DON stated that the steps of performing handwashing/hand hygiene are to turn the faucet on, lather hands with soap, rub vigorously for 20 seconds, rinse with water, grab a paper towel and use the paper towel, after drying your hands, to turn off the faucet. DON stated a potential negative outcome that could come from not performing accurate hand hygiene is infection. On 07/31/2024 at 01:58PM an interview was conducted with the ADM regarding hand hygiene. ADM stated that the policy on handwashing/hand hygiene is to wash your hands as much as possible, between other tasks to reduce cross contamination. ADM stated that the steps that should be taken when performing handwashing/hand hygiene are to rinse, apply soap, scrub for 30 seconds, and dry your hands. ADM stated a potential negative outcome that could occur from not performing accurate handwashing/hand hygiene is infection issues, cross contamination and someone could get sick. Record review of facility provided document titled Handwashing/Hand Hygiene Policy dated August 2019 stated the following: Washing Hands: 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off the faucet. 5. Avoid using hot water because repeated exposure to hot water may increase the risk of dermatitis.

Based on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of its residents for 1 (Resident #1) of three residents reviewed for laboratory services. The facility failed to collect a urine specimen for a UA (urine analysis) for Resident #1 as ordered by the physician on 06/18/24 until 06/26/24. The UA results reflected blood in his urine. This failure could place residents with indwelling urinary catheters at risk of infection, renal failure, urinary tract infections, and pain. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including quadriplegia (the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord), urinary tract infection, and neuromuscular dysfunction of the bladder (muscles in the bladder wall not contracting or relaxing properly). Review of Resident #1's admission MDS assessment, dated 06/24/24, reflected a BIMS of 15, indicating no cognitive impairment. Section H (Bladder and Bowel) reflected he had an indwelling catheter. Review of Resident #1's admission care plan, dated 06/20/24, reflected he had urinary elimination altered due to Neuromuscular Dysfunction of the bladder requiring a foley catheter with an intervention of monitoring for signs and symptoms of a UTI. Review of Resident #1's hospital records, dated 06/05/24, reflected he had been admitted for a UTI with sepsis due to improper insertion with pain. Review of Resident #1's physician order, dated 06/18/24, reflected the type of lab ordered: UA c/s. During an observation and interview on 06/26/24 at 10:20 AM, Resident #1 stated he was concerned because he had a history of UTIs with sepsis and he discussed getting a UA done with the NP a few days ago and it still had not been done. He stated the output in his foley back was dark and it was usually that color when he had a UTI or sepsis. He stated he was extremely worried and hoped something got done soon. This Surveyor observed his foley bag which contained approximately 500 CCs of urine that was a dark amber color. There was sediment around the tubing. During a telephone interview on 06/26/24 at 10:45 AM, Resident #1's NP stated the facility had not gotten back to her with results from the UA that was supposed to have been done on 06/18/24. She stated the resident had a history of repeated UTI's based on poor foley care and he was very paranoid about repeating those incidents. She stated she ordered a UA just to make sure there was no lingering bacteria since he was admitted from the hospital after being treated for a UTI and sepsis. She stated she would have expected for a urine collection to have been done the same day she ordered it. She stated when she saw Resident #1 on 06/18/24 his urine was clear. This Surveyor informed the NP that his urine was now a dark amber color and the NP stated, Oh dear. That is not good. During an observation and interview on 06/26/24 at 11:00 AM, RN A stated she worked on the 100 hall (Resident #1's hall). She opened his EMR and stated she did not see that he had a UA completed during the past week. She stated she reviewed an order for a UA on 06/18/24 but could not recall why a specimen was not collected or sent to the lab. She stated when a UA was ordered, a specimen was normally collected that day and sent to the lab the next morning. She stated when she observed Resident #1's foley bag that morning it looked like it had sediment in it. During an interview on 06/26/24 at 12:22 PM, the DON stated she was not aware before today (06/26/24) that the NP had ordered a UA for Resident #1. She stated she was not aware he was having any signs or symptoms of a UTI. She stated she asked RN A if she remembered getting told to have a UA conducted and she could not recall. She stated she worked with Resident #1 the day prior (06/25/24) and there was not any sediment in the bag nor was his urine odorous. She stated their normal protocol was to collect urine on the day the lab came out to pick up specimen, which was on Tuesdays or Thursdays. She stated they could also order a STAT pick-up. She stated they would be collecting a specimen from Resident #1 that day and it would be a STAT order. She stated the importance of following the NP's orders regarding UA's was to be proactive, to catch any infectious diseases before they could happen, and to stay on top things. Review of the facility's Physician Visits Policy, revised August of 2022, reflected it had nothing regarding following physician orders. Review of the facility's Catheter Care Policy, Revised August of 2022, reflected it had nothing regarding following physician orders for a UA.

Based on interview and record review, the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated for 1 (Resident #1) of 8 residents reviewed for abuse allegations. The facility failed to obtain written statements from staff and the alleged perpetrator of verbal abuse of Resident #1. The facility failed to contact the ombudsman in regard to an allegation of abuse for Resident #1. The facility failed to have the SW assess Resident #1 for emotional trauma after an allegation of abuse. The facility failed to keep Resident #1's family informed of the progress of the investigation. The facility failed to document the investigation completely and thoroughly for Resident #1. The facility failed to assess Resident #1 after an allegation of verbal abuse. These failures placed resident at risk for uninvestigated and continued abuse. Findings included: A record review of Resident #1's face sheet dated 4/16/2024 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, depression, hypertension (high blood pressure), delusional disorder, Alzheimer's disease (type of dementia), lymphedema (localized swelling), anxiety disorder and gastro-esophageal reflux disease (acid reflux). A record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. Resident #1's MDS assessment reflected she had fallen in the last month, and required substantial assistance to partial assistance with toileting, hygiene and dressing. Resident #1's MDS assessment reflected no behavioral symptoms were present. A record review of Resident #1's care plan last revised on 4/15/2024 reflected Staff will treat me with dignity and respect. Resident #1's care plan reflected she had been discharged from the facility and had falls on 3/22/2024, 3/23/2024, 3/24/2024, 3/25/2024, 3/26/2024, 4/01/2024, 4/02/2024 and 4/06/2024. A record review of Resident #1's assessments reflected no skin assessments were completed for Resident #1 on 4/03/2024. A record review of Resident #1's document titled Visit Note Report dated 4/03/2024 reflected the Hospice RN assessed Resident #1's skin, and found no injuries. During an interview on 4/16/2024 at 9:33 a.m., the Hospice RN stated she did not want any retaliation from the DON. During an interview on 4/16/2024 at 9:58 a.m., the Hospice RN stated she was at the facility on 4/03/2024 for another resident's birthday party. The Hospice RN stated the Dietary Manager told her that Resident #1 had fallen so she began to walk from the dining room to the hallway to make a PRN visit since Resident #1 had fallen. The Hospice RN stated the DON had Resident #1 in her wheelchair and said, if you don't do something about this fucking patient, I'm going to stab her in the neck. The Hospice RN stated the DON made a motion with her hand as if she were holding a knife and put her hand up to her own (the DON's) neck. The Hospice RN stated the reason Resident #1 left the facility was because she needed a memory care unit and at the time of the incident on 4/03/2024, they were already looking at alternate placement because Resident #1 had fallen 12-15 times since she was admitted . The Hospice RN stated Resident #1 could not recall what the DON had said because she had advanced Alzheimer's disease. The Hospice RN said when she assessed Resident #1, Resident #1 stated, that's all I wanted, sweetheart. The Hospice RN stated she thought the DON was very frustrated with Resident #1 and that Resident #1 could be a difficult patient, but it was her disease. The Hospice RN stated Resident #1 had the mind of an 18-month-old child, she was regressing and you could tell the Don was irritated or annoyed. The Hospice RN stated she left the facility that day (4/03/2024) in tears because she trusts these people to take care of her residents. The Hospice RN stated if something were to happen to Resident #1, she would never forgive herself for not reporting the incident. The Hospice RN stated the Administrator pulled her in his office and she knew the DON was suspended for 2 days after the incident. The Hospice RN stated she was told there was nothing the facility could do because it was a he said, she said thing. During an interview on 4/16/2024 at 11:09 a.m., the DON stated she started working at the facility in November of 2023. The DON stated Resident #1 was admitted due to having increased falls at home, her dementia was pretty severe upon arrival, she was admitted on hospice and she required extensive to total care when she arrived. The DON stated Resident #1 required lots of care and none of it was affective. The DON stated, this place probably wasn't the best for her and she wasn't a bad patient, she wasn't screaming out all night, but she definitely needed one-on-one care. The DON stated it was a frustrating situation for staff because they did not know how to handle one-on-one care when they had a whole hall. The DON stated, there was nothing wrong with her except for her falling and needing one-on-one care with extra assistance. The DON stated the hospice birthday party was on a Wednesday or Thursday and they had a huge gathering in the dining room. The DON stated Resident #1 was roaming all over the place so we asked hospice for help. The DON stated Resident #1 had fallen on the 200 hall so she picked her up, told the Hospice RN she had a fall and handed off Resident #1 to the Hospice RN so she could do a PRN visit. When asked about her workload that week, the DON stated it was pretty frustrating because she was on the floor working as a med aide and CNA, and she did not have any help. The DON stated, I do get a little frustrated, don't get me wrong but said it was not anything she could not handle. The DON stated, we're always understaffed and said she was the only nurse manager. The DON stated, when people call in, it's frustrating because no one can help me do my job. When asked if in her frustration that day, if she said something by accident that she did not mean, the DON stated, I honestly couldn't tell you and I tried to go back and figure it out. The DON stated, I'm not gonna say nothing came out of my mouth. The DON stated sometimes she should say she would stab herself in the neck and maybe staff heard it and it may have been misinterpreted. The DON stated she would never hurt a resident or take any aggression out on a resident. The DON stated, I'm not going to say I didn't because I don't know what I said at the time in question. The DON stated yeah that threatening to stab a resident in the neck would be considered verbal abuse. The DON stated right that she did not recall what she said. The DON stated she never got that rapport with the Hospice RN, it was nothing against her, and the hospice agency had not been very communicative. The DON stated she was not a firm believer in hospice companies, and she did not feel like hospice companies needed to be in nursing facilities but there were already here. The DON stated if she said she stabbed herself, she was usually joking, and it was not taken seriously. The DON stated she was suspended until Tuesday 4/09/2024 and they did an all staff abuse education. The DON stated she was taking some courses with the Administrator but I haven't started it yet. The DON stated the Administrator told her they would get with corporate on which courses to take. The DON stated she had been trained on abuse, neglect, and exploitation during orientation. The DON stated if residents were verbally threatened, it could be harsh on them, they could fear their lives, and I could see where it could be hurtful for them. An attempt was made on 4/16/2024 at 1:09 p.m. to interview Resident #1's RP, however he was non-interviewable . During an interview on 4/26/2024 at 1:23 p.m., Resident #1's family member stated the facility never contacted family regarding the incident, but she did hear about it. Resident #1's family member stated she had not questioned Resident #1's safety and her reason for discharging from the facility was unrelated to the incident on 4/03/2024. During an interview on 4/16/2024 at 2:14 p.m., the SW stated she was unaware of the incident on 4/03/2024 and had not spoken to Resident #1 regarding it. The SW stated the last time she did safe surveys was at the end of March 2024. During an interview on 4/16/2024 at 3:11 p.m., the Administrator stated he did safe surveys with residents on Resident #1's hall and there was nothing in that area . The Administrator stated the SW met with Resident #1 and corporate wanted a level of discretion to not prove the DON guilty before completing the investigation. The Administrator stated upon learning of the allegation, he joined a group call with hospice while hospice notified Resident #1's family and physician. The Administrator stated corporate made the decision to not discuss it since there was not proof of abuse. The Administrator stated there was no one to interview as a potential witness to the incident on 4/03/2024. The Administrator stated the SW met with Resident #1. The Administrator stated staff, including the DON, were in-serviced on abuse through in-services and computer-based trainings. The Administrator stated he did not know corporate wanted to do specific in-services with the DON. The Administrator stated the incident on 4/03/2024 was he said she said and ultimately, [the DON] said she didn't do it. The Administrator stated he went over professionalism and what was verbal abuse with the DON. The Administrator stated he felt like the Hospice RN feared retaliation. The administrator stated residents were protected from abuse while allegations were being investigated by removing the staff member and said the DON was suspended for 3 or 4 days. The Administrator stated 4/10/2024 was when he finished his investigation of the incident. When asked why the DON returned a day prior to his PIR being submitted, the Administrator stated, I completed it on that Monday (4/08/2024) we did the education. The Administrator stated he did not contact the ombudsman regarding the incident and he did not provide updates to Resident #1's family because she had already moved out of the facility at that point. The Administrator stated himself and his regional VP were responsible for ensuring investigations were through. The Administrator stated a nursing incident report was not completed for the incident on 4/03/2024 because we didn't know who made the allegation for 2-3 days. The Administrator stated, we had them put in the skin assessment. The Administrator stated a potential negative outcome for residents if they were to be verbally abused included depression, fear and anxiety. When asked about the incident, the Administrator stated the DON told him she had not said anything out of the ordinary. A record review of the facility's in-service training dated 4/05/2024 reflected staff were trained on abuse, language in the hallways, verbal abuse and reporting abuse. The sign-in sheet did not reflect the DON's name. A record review of a hospice communication note dated 4/03/2024 reflected the Hospice RN wrote a note for Resident #1 which reflected that when she went to get Resident #1 from the DON, the DON stated, if you don't do something with this fucking patient, I am going to stab her in [the] neck. A record review of the DON's training record reflected she was trained on resident rights, dementia and abuse, neglect and exploitation on 11/01/2023. A record review of the facility's document dated 4/08/2024 reflected the DON was given counseling from the Administrator and provided education on language around staff and residents and professional behavior. A record review of the facility's PIR dated 4/10/2024 reflected yes a statement from the DON was attached, however, no statement was attached. The PIR reflected the following: Agency Immediate Response Staff member [suspended] Nurse assessed resident social worker, admin check in with ms [Resident #1] Family, physician, and admin notified education on abuse, resident to resident encounters working with family and resident to ensure resident feels safe and welcome in facility . Investigation Summary (attach additional sheets as necessary) Form 3613 Page 4 I 03-2023 Following investigation unable to verify accusation. Facility nurse denied making statement and no witnesses present. Education done with staff member on [language] and professionalism in facility. . Investigation Findings Inconclusive Agency Action Post-Investigation continue screening and education for abuse and education with staff on abuse. Staff member able to return to work with education. A record review of safe surveys reflected the Administrator interviewed 4 residents on 4/05/2024 with no reported safety concerns. A record review of the facility's policy titled Resident Rights dated February 2021 reflected the following: Policy Statement Employees shall treat all residents with kindness. respect. and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property. and exploitation; A record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022 reflected the following: All reports of resident abuse (including injuries of unknown origin), neglect. exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source the administrator is responsible for determining what actions (if any) arc needed for the protection of residents. investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly. 8. The following guidelines arc used when conducting interviews: d. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement. 9. The investigator notifies the ombudsman that an abuse investigation is being conducted. The ombudsman is invited to participate in the review process. a. lf the ombudsman declines the invitation to participate in the investigation, that information is noted in the investigation record. b. The ombudsman is notified of the results of the investigation as well as any corrective measures taken. Follow-Up Report 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report. 4. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Corrective Actions 3. Any allegations of abuse are filed in the accused employee's personnel record along with any statement by the employee disputing the allegation, if the employee chooses to make one. A record review of the facility's policy titled Protection of Residents During Abuse Investigations dated April 2021 reflected the following: Policy Statement Residents are protected from harm, retaliation, reprisal, discrimination or coercion during investigations of abuse, neglect, exploitation and misappropriation of resident property. Policy Interpretation and Implementation 5. The victim is evaluated for his or her feelings of safety. If he or she communicates fear, insecurity, etc., measures are taken to alleviate this (e.g., changing the room assignment or providing more supervision).

Based on interview and record review, the facility failed to ensure all residents were free from abuse for 1 (Resident #1) of 8 residents reviewed for verbal abuse. The facility failed to ensure Resident #1 was safe from mistreatment and abuse as evidence by the DON alleging serious life threatening remarks towards Resident #1. This placed residents at risk for abuse that could cause diminished quality of life, psychosocial harm, and/or psychosocial harm. Findings included: A record review of Resident #1's face sheet dated 4/16/2024 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, depression, hypertension (high blood pressure), delusional disorder, Alzheimer's disease (type of dementia), lymphedema (localized swelling), anxiety disorder and gastro-esophageal reflux disease (acid reflux). Resident #1's face sheet reflected she was discharged on [DATE]. A record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. Resident #1's MDS assessment reflected she had fallen in the last month, and required substantial assistance to partial assistance with toileting, hygiene and dressing. Resident #1's MDS assessment reflected no behavioral symptoms were present. A record review of Resident #1's care plan last revised on 4/15/2024 reflected Staff will treat me with dignity and respect. Resident #1's care plan reflected she had been discharged from the facility and had falls on 3/22/2024, 3/23/2024, 3/24/2024, 3/25/2024, 3/26/2024, 4/01/2024, 4/02/2024 and 4/06/2024 . A record review of a hospice communication note dated 4/03/2024 reflected the Hospice RN wrote a note for Resident #1 which reflected that when she went to get Resident #1 from the DON, the DON stated, if you don't do something with this fucking patient, I am going to stab her in [the] neck. During an interview on 4/16/2024 at 9:33 a.m., the Hospice RN stated she did not want any retaliation from the DON. During an interview on 4/16/2024 at 9:58 a.m., the Hospice RN stated she was at the facility on 4/03/2024 for another resident's birthday party. The Hospice RN stated the Dietary Manager told her that Resident #1 had fallen so she began to walk from the dining room to the hallway to make a PRN visit since Resident #1 had fallen. The Hospice RN stated the DON had Resident #1 in her wheelchair and said, if you don't do something about this fucking patient, I'm going to stab her in the neck. The Hospice RN stated the DON made a motion with her hand as if she were holding a knife and put her hand up to her own (the DON's) neck. The Hospice RN stated the reason Resident #1 left the facility was because she needed a memory care unit and at the time of the incident on 4/03/2024, they were already looking at alternate placement because Resident #1 had fallen 12-15 times since she was admitted . The Hospice RN stated Resident #1 could not recall what the DON had said because she had advanced Alzheimer's disease. The Hospice RN said when she assessed Resident #1, Resident #1 stated, that's all I wanted, sweetheart. The Hospice RN stated she thought the DON was very frustrated with Resident #1 and that Resident #1 could be a difficult patient, but it was her disease. The Hospice RN stated Resident #1 had the mind of an 18-month-old child, she was regressing and you could tell the DON was irritated or annoyed. The Hospice RN stated she left the facility that day (4/03/2024) in tears because she trusts these people to take care of her residents. The Hospice RN stated if something were to happen to Resident #1, she would never forgive herself for not reporting the incident. The Hospice RN stated the Administrator pulled her in his office and she knew the DON was suspended for 2 days after the incident. The Hospice RN stated she was told there was nothing the facility could do because it was a he said, she said thing. During an interview on 4/16/2024 at 11:09 a.m., the DON stated she started working at the facility in November of 2023. The DON stated Resident #1 was admitted due to having increased falls at home, her dementia was pretty severe upon arrival, she was admitted on hospice and she required extensive to total care when she arrived. The DON stated Resident #1 required lots of care and none of it was affective. The DON stated, this place probably wasn't the best for her and she wasn't a bad patient, she wasn't screaming out all night, but she definitely needed one-on-one care. The DON stated it was a frustrating situation for staff because they did not know how to handle one-on-one care when they had a whole hall. The DON stated, there was nothing wrong with her except for her falling and needing one-on-one care with extra assistance. The DON stated the hospice birthday party was on a Wednesday or Thursday and they had a huge gathering in the dining room. The DON stated Resident #1 was roaming all over the place so we asked hospice for help. The DON stated Resident #1 had fallen on the 200 hall so she picked her up, told the Hospice RN she had a fall and handed off Resident #1 to the Hospice RN so she could do a PRN visit. The DON stated she had a pretty frustrating workload that week because she was on the floor working as a med aide and CNA, and she did not have any help. The DON stated, I do get a little frustrated, don't get me wrong but said it was not anything she could not handle. The DON stated, we're always understaffed and said she was the only nurse manager. The DON stated, when people call in, it's frustrating because no one can help me do my job. The DON stated, I honestly couldn't tell you if she said something out of frustration or by accident that she did not mean to say and stated, I tried to go back and figure it out. The DON stated, I'm not gonna say nothing came out of my mouth. The DON stated sometimes she should say she would stab herself in the neck and maybe staff heard it and it may have been misinterpreted. The DON stated she would never hurt a resident or take any aggression out on a resident. The DON stated, I'm not going to say I didn't because I don't know what I said at the time in question. The DON stated yeah that threatening to stab a resident in the neck would be considered verbal abuse. The DON stated right that she did not recall what she said. The DON stated she never got that rapport with the Hospice RN, it was nothing against her, and the hospice agency had not been very communicative. The DON stated she was not a firm believer in hospice companies, and she did not feel like hospice companies needed to be in nursing facilities but there were already here. The DON stated if she said she stabbed herself, she was usually joking, and it was not taken seriously. The DON stated she was suspended until Tuesday 4/09/2024 and they did an all staff abuse education. The DON stated she was taking some courses with the Administrator but I haven't started it yet. The DON stated the Administrator told her they would get with corporate on which courses to take. The DON stated she had been trained on abuse, neglect, and exploitation during orientation. The DON stated if residents were verbally threatened, it could be harsh on them, they could fear their lives, and I could see where it could be hurtful for them. During an interview on 4/26/2024 at 1:23 p.m., Resident #1's family member stated the facility never contacted family in regard to the incident, but she did hear about it. Resident #1's family member stated she had not questioned Resident #1's safety and her reason for discharging from the facility was unrelated to the incident on 4/03/2024. During an interview on 4/16/2024 at 2:14 p.m., the SW stated she was unaware of the incident on 4/03/2024 and had not spoken to Resident #1 regarding it. During an interview on 4/16/2024 at 3:11 p.m., the Administrator stated he did safe surveys with residents on Resident #1's hall and there was nothing in that area. The Administrator stated the SW met with Resident #1 and corporate wanted a level of discretion to not prove the DON guilty before completing the investigation. The Administrator stated upon learning of the allegation, he joined a group call with hospice while hospice notified Resident #1's family and physician. The Administrator stated the facility left messages for the medical director but did not hear back. The Administrator stated corporate made the decision to not discuss it since there was not proof of abuse. The Administrator stated he discussed the incident with Resident #1's RP the next day. The Administrator stated the policy on preventing abuse was education on what it was and how to recognize it. The Administrator stated staff, including the DON, were in-serviced on abuse through in-services and computer-based trainings. The Administrator stated he did not know corporate wanted to do specific in-services with the DON. The Administrator stated the incident on 4/03/2024 was he said she said and ultimately, [the DON] said she didn't do it. The Administrator stated he went over professionalism and what was verbal abuse with the DON. The Administrator stated he felt like the Hospice RN feared retaliation. The administrator stated residents were protected from abuse while allegations were being investigated by removing the staff member and said the DON was suspended for 3 or 4 days. When asked why the DON returned a day prior to his PIR being submitted, the Administrator stated, I completed it on that Monday (4/08/2024) we did the education . The Administrator stated a potential negative outcome for residents if they were to be verbally abused included depression, fear and anxiety. When asked about the incident, the Administrator stated the DON told him she had not said anything out of the ordinary. A record review of the facility's in-service training dated 4/05/2024 reflected staff were trained on abuse, language in the hallways, verbal abuse and reporting abuse. The sign-in sheet did not reflect the DON's name. A record review of the DON's training record reflected she was trained on resident rights, dementia and abuse, neglect and exploitation on 11/01/2023. A record review of the facility's training document dated 4/08/2024 reflected the DON was given counseling from the Administrator and provided education on language around staff and residents and professional behavior. A record review of the facility's PIR dated 4/10/2024 reflected yes a statement from the DON was attached, however, no statement was attached. A record review of safe surveys reflected the Administrator interviewed 4 residents on 4/05/2024 with no safety concerns reported A record review of the facility's policy titled Resident Rights dated February 2021 reflected the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property. and exploitation; A record review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 reflected the following: Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental. sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; 3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 7. Implement measures to address factors that may lead to abusive situations, for example: a. adequately prepare staff for caregiving responsibilities; b. provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; c. instruct staff regarding appropriate ways to address interpersonal conflicts; A record review of the facility's policy titled Identifying Types of Abuse dated September 2022 reflected the following: Policy Statement As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Policy Interpretation and Implementation 1. Abuse of any kind against residents is strictly prohibited. . 4. Abuse'' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. a. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. b. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. c. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 5. Abuse toward a resident can occur as: . b. staff-to-resident abuse; or Mental and Verbal Abuse . 2. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. 3. Examples of mental and verbal abuse include. but are not limited to: . d. threatening residents, including but not limited to, depriving a resident of care or withholding a resident from contact with family and friends Psychosocial Outcomes I. Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not be immediately apparent. In addition, the alleged victim may not report abuse due to shame, fear. or retaliation. Other residents may not be able to speak due to a medical condition and/or cognitive impairment (e.g., stroke, coma, Alzheimer's disease), cannot recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse [NAME] occurred.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #1's Naproxen (pain medication) was re-ordered and he subsequently went five days, from 02/01/24 - 02/05/24, without it, causing him to be uncomfortable, in more pain than usual, and having increased Multiple Sclerosis (MS) flare-ups . This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and unnecessary pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including MS (a disease that affects the central nervous system), dementia, radiculopathy (compression of the nerve due to increased pressure that causes numbness, weakness, pain, or tingling) of the lumbar region, polyneuropathy (damage to multiple peripheral nerves), and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment, dated 12/07/23, reflected a BIMS of 15, indicating he was cognitively intact . Section J (Health Conditions) reflected he was on a scheduled pain medication regimen. Review of Resident #1's quarterly care plan, revised 12/21/23, reflected he needed pain management and monitoring with an intervention of administering pain medication as ordered. Review of Resident #1's physician order, dated 09/13/23, reflected Naproxen Oral Tablet 250 MG; give 2 tablets by mouth two times a day for pain. Review of Resident #1's MAR in his EMR, February 2024, reflected he was not administered his scheduled Naproxen from 02/01/24 - 02/05/24. During an observation and interview on 02/05/24 at 9:23 AM, Resident #1 was in bed watching television. When the Surveyor asked him how everything was going, he giggled and his legs started to shake uncontrollably for approximately 15 seconds. He stated he had MS and since he had been without his Naproxen for four days (at that point), it made him have an increase in flare-ups, like his uncontrollable shaking. He stated his Naproxen was also for pain. He stated he was prescribed other pain medication so it was not like he was dying but he had been extremely uncomfortable and in more pain than normal. He stated he was always in pain, but manageable, about a 3/10, but without the Naproxen it was more like a 6-7/10. He stated it made him feel like shit because he was helpless to the situation. He stated the facility knew they had to re-order his medication each month, and why was it so hard to remember? At 9:37 AM, MA A entered the room to administer Resident #1 his morning medication. Resident #1 asked him where his Naproxen was and MA A stated that was his first day back in many days and he had just noticed the medication was not in the cart and had already notified the charge nurse (RN B). He stated he was unsure as to why it had not been reordered. During an interview on 02/05/24 at 11:22 AM, RN B stated she was not aware Resident #1 was out of his Naproxen until MA A had informed her earlier that morning. She stated she had not been notified before then. She stated she had already called the pharmacy and it was supposed to be delivered that day. She stated a negative outcome of not receiving scheduled Naproxen could be an increase in pain. During an interview on 02/05/24 at 12:02 PM, the DON stated she was not aware Resident #1 had been without his Naproxen for multiple days. She stated it was the responsibly of the charge nurse to re-order medications when there was ten days' worth left in the medication cart. She stated a resident going without any medication did not meet her expectations. She stated Resident #1 going without Naproxen for four days could have caused increased pain and muscle spasms due to his diagnosis of MS. She stated Naproxen was the main medication Resident #1 cared about receiving the most. Review of the facility's Pharmacy Services Overview Policy, dated 2001, reflected the following: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. . 4. Residents have sufficient supply of their prescribed medications and received medications (routine, emergency, or as needed) in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for 4 of 5 residents (Residents #7, #4, #31, and #15) reviewed for infection control. 1. MA I failed to use appropriate infection control techniques while administering oral and eye medications to Resident #7. 2. CNA F failed to practice appropriate hand hygiene and infection control techniques during incontinent care for Residents #4, # 31, # 7, and #15. This failure could put residents at risk for infections. Findings included: 1. Record review of the undated Face Sheet for Resident #7 reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (a group of thinking and social symptoms including memory loss and judgement that interfere with daily functioning), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe) and Chronic Pain Syndrome (paint that carries on for longer than 12 weeks despite medication or treatment). Observation on 06/01/2023 at 06:38 AM of MA I who did not sanitize his hands, then placed his fingers inside a water cup and poured water into it. MA I then administered medications to Resident #7 who drank the water out of the contaminated cup. Observation on 06/01/2023 at 7:00 AM of Artificial Tears eye drops administered to Resident # 7 by MA I. MA I administered one drop to the right eye and wiped her eye with a tissue. He administered one drop to the left eye and using the same tissue wiped that eye. Interview on 06/01/2023 at 7:23 AM with MA I who stated by touching the inside of the water cup given to Resident #7 it could cause cross contamination of the cup and water from germs on his hands and then the resident could get sick. He stated by using the same tissue to wipe both eyes, If [Resident #7] has an infection in one eye it could spread it to the other eye. 2. Record review of the undated Face Sheet for Resident # 4 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar) with Hyperglycemia (excess of sugar in the bloodstream), Cognitive Communication deficit (difficulty with thinking and how someone uses language), and Disorder of kidney and ureter (tube from kidney to bladder) unspecified. Record review of the Annual MDS dated [DATE] for Resident # 4 reflected under Section G, Functional Status she was totally dependent for incontinence care with one-person physical assist. Record review of the Care Plan for Resident # 4 dated 10/07/2021 and revised on 03/14/2023 reflected [Resident # 4] has a potential for complications r/t incontinence of bowel/bladder. Goal: will be free from complications r/t incontinence as evidenced by intact skin, no rash or redness to peri area, no s/s of infection daily through next 90-day review. Record review of the undated Face Sheet for Resident # 31 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Hemiplegia (paralysis of one side of the body) and Hemiparesis (partial weakness) following Cerebral Infarction (disrupted blood flow to the brain, deprives brain cells of oxygen and nutrients and can cause parts of brain to die), and Neuromuscular Dysfunction of bladder (lack of bladder control due to a brain, spinal cord or nerve problem). Record review of the quarterly MDS dated [DATE] for Resident # 31 reflected under Section G, Functional Status he required extensive assistance of one-person physical assist for toileting. Record review of the Care Plan for Resident # 31 dated 05/04/20223 and revised on 03/01/2023 reflected Potential for complications r/t frequent incontinence of bowel and always incontinent of bladder. Record review of the undated Face Sheet for Resident # 7 reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction (disrupted blood flow to the brain, deprives brain cells of oxygen and nutrients and can cause parts of brain to die), Irritable Bowel Syndrome (intestinal disorder causing pain in the belly, gas, diarrhea, and constipation) and Constipation. Record review of the quarterly MDS dated [DATE] for Resident # 7 reflected Section G, Functional Status she required extensive assistance of one-person physical assist for toileting. Record review of the Care Plan dated 09/16/2021 for Resident # 7 reflected has a potential for self-care deficit r/t cognitive impairment, need for extensive to total care for most ADLs, and is incontinent of bowel and bladder. Provide peri-care with incontinent episodes. Record review of the undated Face Sheet for Resident # 15 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Amyotrophic Lateral Sclerosis (a nervous system disorder that weakens muscles and impacts physical function), Urinary Tract Infection, Unspecified Kidney Failure (condition in which the kidneys lose the ability to remove waste and balance fluids). Record review of the Care Plan dated 09/23/2021 for Resident # 15 reflected she has self-care deficit r/t musculoskeletal impairment, quadriplegia, Toilet use requires total care of one-two person. Observation on 06/01/23 at 1:29 PM of perineal care performed by CNA F for Resident #4 who had a loose bowel movement. He washed his hands, donned gloves, then performed proper perineal care (cleaning of private areas below the waist) in front. He stated, Lots of residents are having loose watery stools and the nurse know about it. Using the same contaminated gloves, he cleaned her buttocks and threw the dirty linens which had feces on them onto the floor by her bed. Resident #4 had feces on her top, and with the same contaminated gloves on, CNA F removed her top, covered her up, then he opened the curtain with contaminated gloves on, and retrieved another top which he placed on the resident, He then touched the bed controller with the same contaminated gloves on, took the gloves off, did not wash his hands and touched her bedside tray moving it closer to her. He grabbed the unbagged, dirty linen off of the floor and took it out of the room to put into a barrel in the hall. Observation on 6/01/2023 at 1:41 PM, CNA F went into Resident #31's room to place a brief on him as he had taken his own brief off. CNA F had gloves on and placed a new brief on the resident, removed his gloves, did not wash his hands, and took the trash out into the hall and opened the top of barrel and placed trash in it. Observation on 06/01/2023 at 1:45 PM CNA F went into Resident #7's room to perform incontinence care. He sanitized his hands, placed gloves on and performed perineal care correctly to the outer labia area (the inner and outer folds of the vulva, at either side of the vagina). He used several wipes to clean the inner labia but folded them over after they had reached her buttock and picked up some feces and used all of them again to wipe from top to bottom. He removed his gloves, did not wash his hands after this care, then touched the curtain and the resident's call light before he left the room with the trash. Observation on 06/01/2023 at 1:50 PM of CNA F who went into Resident #15's room for incontinence care. He did not place any gloves on and used his bare hands to pull open her brief in the back. He stated her brief was clean. With his contaminated hands, he touched her bed, and controller. He picked up her cup with iced tea in it and assisted her with taking a drink. He then touched the bed controller again, touched the curtain and then sanitized his hands. Interview on 06/01/2023 at 1:55 PM CNA F stated I didn't take my gloves off. I should have washed my hands to get the feces and bacteria off so I wouldn't contaminate anything. If someone else touches what I touched it could spread bacteria. I should have used a different wipe each time when performing perineal care from front to back. Using the same wipe could cause a UTI. When asked why he didn't bag the contaminated linen which was thrown on the floor he asked, Where should I put it.? Interview on 6/02/2023 at 4:10 PM the DON stated staff should always wash their hands before and after resident care and be sure to sanitize between each resident. She stated dirty linens should be rolled up, bagged, then placed in the barrel which should be outside the resident's door. Not following this precaution could spread infections including E-coli (bacteria commonly found in the lower intestine) and ESBL (extended spectrum beta lactamase enzyme found in some strains of bacteria that can't be killed by many of common antibiotics like penicillin's and some cephalosporins. UTIS, cause super infections). Interview on 06/02/2023 at 4:20 PM with the Corporate Consultant who stated the facility had completed reeducation on infection control and handwashing. He stated linens that have feces on them can contaminate the floor and bacteria can be spread. He stated before doing personal care he expects staff to visit with the resident, have their needed supplies ready, wash hands and then don gloves. He further stated between each area of care they should wash their hands and replace their gloves. He stated by staff not using proper infection control techniques, they could spread infection among the staff and other residents. Interview on 06/02/2023 at 4:45 PM the Administrator stated using the same tissue to wipe both of the residents' eyes between administering eye drops could cause infection and cross contamination. She stated her expectation of staff is they do not touch the inside of a water cup during medication pass and if they touch it, then throw it away as that could be an infection control issue. She stated by staff performing personal care then leaving contaminated gloves on and not washing hands it could cause major contamination in the facility and was an infection control issue. Record Review of the facility policy titled Infection Control Guidelines for all Nursing Procedures dated Quarter 3 - 2018 reflected under General Guidelines: 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water for the following conditions: a. Before and after direct contact with residents. c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin. d. After removing gloves. e. After handling items potentially contaminated with blood, body fluids or secretions. 4. d. Before preparing or handling medication. Record review of the facility Policy and Procedure titled Perineal Care dated 2001 and revised February 2018 reflected The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation. Equipment and Supplies 5. Personal protective equipment (e.g., gowns, glove, mask etc., as needed) Steps in the Procedure: 1. Place the equipment on the bedside table. 2. Wash and dry your hands thoroughly. 7. Put on gloves. For a female resident: b. Wash perineal area, wiping from front to back 1. Separate labia and wash area downward from front to back. 2. Continue to wash the perineum from inside outward to the thighs. Rinse perineum thoroughly in the same direction using fresh water and a clean washcloth. Discard disposable items into designated containers. Remove gloves and discard into designated container. [NAME] and dry your hands thoroughly. Reposition the bed covers. Place the call light within easy reach of the resident. Clean the bedside stand. Wash and dry your hands thoroughly. For a female resident: b. Wash perineal area, wiping from front to back. 1. Separate labia and wash area downward from front to back 2. Continue to wash the perineum moving from inside outward toward thighs.

Based on observation, interview and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for one of one kitchens revied for food service safety. Cook J failed to measure the temperature of all food items before serving them to residents. This failure placed residents at risk of foodborne illness. Findings included: An observation on 5/31/2023 at 12:01 p.m. revealed Cook J took the service line temperatures of all foods on the service line before lunch except for the pork and pureed pork items. Observed pureed pork in a steam pan on the steam table and cooked, browned, pork chops in a steam pan which was placed on top of another steam pan-the pork was not on direct heat. During an observation and interview on 5/31/2023 at 12:07 p.m., when asked if there were any alternate food items, Cook J pointed to the pork on the service line. Cook J stated he also had pureed pork for residents on a pureed diet. During an interview on 5/31/2023 at 12:09 p.m., when asked if he was finished taking the temperature of food items, Cook J stated, yes. Cook J had not taken the temperature of the pork and pureed pork items. Observations on 5/31/2023 from 12:20 p.m. - 12:44 p.m. revealed Cook J served pork chops and pureed pork to residents. During an observation and interview on 5/31/2023 at 12:47 p.m., when asked what the temperature was of the pork chop and pureed pork, the Dietary Manager began taking the temperatures of those items. The temperature of the pureed pork was 160 degrees Fahrenheit and the temperature of the pork chop was 120 degrees Fahrenheit. During an observation and interview on 5/31/2023 at 12:50 p.m., the Dietary Manager stated the minimum temperature for serving food depended on the food item. The Dietary Manager stated pork needed to be 160 degrees Fahrenheit. Observed the Dietary Manager pull the pork chop from the steam table and she told Cook J she would heat it up. During an interview on 6/02/2023 at 11:17 a.m., the Dietary Manger stated she had started as a dietary aide and had worked at the facility for nine years. The Dietary Manager stated the facility's policy on taking food temperatures was to take the temperature of food right before serving and in the middle of meal service. The Dietary Manager stated she ensured food was hot enough or cold enough by taking the temperature of food items and that the temperature danger zone was 41-135 degrees Fahrenheit-she said she had this posted throughout the kitchen. The Dietary Manager stated she visually taught staff how to take food temperatures. The Dietary Manager did not explain what she meant by visually. The Dietary Manager stated she expected dietary staff to take the temperature of all food items, including the alternate items, when completing the service line temperatures. When asked why Cook J had not taken the temperature of all items before serving, the Dietary Manager stated, he's probably nervous because it's the first-time having State in the building. The Dietary Manager stated yes that Cook J knew to test the temperature of alternate food items and yes that staff should take the temperature of all food items before serving. The Dietary Manager stated a potential negative resident outcome of failing to take food temperatures before serving included they could get sick. During an interview on 6/02/2023 at 11:37 a.m., the RD stated she would need to check with the Dietary Manager on what the policy was for taking food temperatures. The RD stated she believed dietary staff needed to take food temperatures when food was cooked and at the assembly line before serving. The RD stated yes that dietary staff still needed to take the temperature of all food items even if food items were cooked simultaneously. The RD stated the temperature of alternate food items should be measured before serving as well as all other food items. The RD stated she was not sure how staff were trained on taking food temperatures. The RD stated she did not know if all staff had been trained on taking food temperatures, but she believed dietary staff took some sort of training to be able to work in the kitchen. The RD stated she focused on the clinical side since her company had left the building, so she had kind of pulled back from observing the kitchen full on since it was a different company which managed dietary services. The RD stated she did not monitor the kitchen and that the Dietary Manager oversaw everything. The RD stated the Dietary Manager was responsible for monitoring staff to ensure compliance of food temperatures. The RD stated a potential negative resident outcome of serving food without first measuring the temperature included food poisoning, stomach aches, vomiting and diarrhea. During an interview on 6/02/2023 at 12:44 p.m., the Dietary Manager stated the previous company took all her in-service records so she did not have documentation of the in-services she had completed with staff on taking food temperatures. During an interview on 6/02/2023 at 4:41 p.m., the Administrator stated food temperatures should be taken every meal prior to service and the temperature of all food items should be measured. The Administrator stated dietary staff were typically trained via in-services. The Administrator stated the Dietary Manager and the RD trained dietary staff and that dietary staff had been trained on taking food temperatures. The Administrator stated a potential negative outcome of not taking food temperatures before serving included food poisoning and botulism, stating, there would be negative outcomes with food that's not cooked. A record review of the kitchen's service line checklist dated 5/31/2023 initialed by Cook J reflected Cook J had recorded food temperatures of the main food items (fish, rice and spinach) but not of the alternate food items (pork and pureed pork). A record review of the kitchen's service line checklist dated 6/01/2023 reflected Cook J recorded lunch temperatures for the main food items (BBQ pork, beans, and carrots) but not of the renal pork, renal beans, or BBQ sauce. A record review of the facility's policy titled Food Preparation and Service dated November 2022 reflected the following: Policy Statement Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 1. 'Danger Zone' means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed. 2. 'Potentially Hazardous Food (PHF)' or Time/Temperature Control for Safety (TCS) Food' means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). Examples of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt and cottage cheese. 4. 'Food Distribution' means the processes involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas, etc. When meals arc assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart. Food Preparation, Cooking and Holding Time/Temperatures 1. The 'danger zone' for food temperature is above 41 and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The loner foods remain in the 'danger zone' the greater the risk for grown or harmful pathogens. Therefore, PHF must be maintained at or below 41 F or at or above 135 F. Food Distribution and Services 4. The temperatures of foods held in the steam table are monitored throughout the meal service by food and nutrition staff. A record review of the 2017 Food Code reflected the following: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under [paragraph] (B) and in [paragraph] (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in [paragraph] 3-401.11(B) or reheated as specified in [paragraph] 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; or (2) At 5 C (41 F) or less.

Based on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for 4 of 12 [Resident #41, Resident #12, Resident #31, and Resident #37) residents reviewed for confidentiality of records. The facility failed to protect the private healthcare information of Residents #41, #12, #31 and #37. These failures could affect residents by placing them at risk for loss of privacy and dignity. Findings included: Review of the undated Face Sheet for Resident #41 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of personal history of urinary tract infections and long-term use of antibiotics. Review of the undated Face Sheet for Resident #12 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the undated Face Sheet for Resident #31 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Mood disorder due to known physiological (physical symptoms) condition with depressive features, and Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the undated Face Sheet for Resident #37 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone). Observation on 06/01/2023 at 6:35 AM of MA I's medication cart which was left unattended for approximately two minutes while he went to the nurse's station to check on a medication not in the cart. The unattended cart top revealed an empty Myrbetriq ER 25 mg (bladder control) medication card for Resident #41, an empty Mirtazapine 7.5 mg (anti-depressant) medication card for Resident #12, an empty Sertraline HCL 50 mg (antidepressant) medication card for Resident #31, and an empty Levothyroxine 112 mcg (thyroid hormone replacement) medication card for Resident #37. Interview on 06/01/23 at 07:10 AM with MA I who stated leaving the residents medication cards on top of the cart exposed residents' confidential information and someone might come along and be able to see them. He stated it was a HIPPA violation of resident rights and the night agency LVN had left them on top of the cart. Interview on 06/01/2023 at 7:12 AM with LVN B who stated she had worked a few shifts at the facility and was an agency staff who had just worked the 6 PM to 6 AM shift. She stated by her leaving the medication cards on the top of the cart it exposed confidential patient information. She stated she had received HIPPA training in the past six months but not at the current facility. She further stated it was someone on the shift before her who had left the cards on the cart. When asked why she left the cards out she had no response. Interview on 06/02/2023 at 4:10 PM the DON stated the staff leaving the medication cards on top of the cart was a HIPPA violation and the potential risk was people could see what medication residents were taking. Interview on 06/02/2023 at 4:20 PM the Corporate Consultant stated leaving medication cards on top of the cart is a HIPPA violation. He stated staff needed to tear off the top of the card and place it in the shredder or if the medication needed to be reordered it should have been placed in a locked drawer. He further stated the risk of leaving them exposed on the cart was people could see what medications the residents were taking, for example an antidepressant, or narcotic. Interview on 06/02/2023 at 4:45 PM the Administrator stated her expectation was for staff to destroy used medication cards in the int eh shredder as they were used. She stated it was a HIPPA violation as there was personal information on the medication cards. Record review of a facility policy and procedure titled Resident Rights dated 2001 and revised in December 2016 reflected Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: Privacy and confidentiality.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition for one (Resident #23) of eight residents reviewed for ADLs. The facility failed to ensure Resident #23 was assisted with breakfast and lunch on 6/01/2023. This failure placed residents at risk of not being provided assistance with services when necessary. Findings included: A record review of Resident #23's face sheet dated 6/02/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (brain disorder causing memory and behavioral problems), depression (mood disorder), anemia (blood disorder), cognitive communication deficit (problems communicating), muscle weakness and dysphagia (difficulty swallowing). A record review of Resident #23's MDS assessment dated [DATE] reflected she required supervision and set up help only with eating and drinking. The coding for Supervision in the ADL Self-Performance section reflected residents needed oversight, encouragement or cueing. The ADL Support Provided section reflected One-person physical assist required more support than Setup help only but less support than Two+ persons physical assist. A record review of Resident #23's MDS assessment dated [DATE] reflected she required supervision and a one-person physical assist with eating and drinking. This assessment reflected Resident #23 had a BIMS score of 4, which indicated severely impaired cognition. A record review of Resident #23's care plan last revised on 5/11/2023 reflected she had a physical functioning deficit and required set up assistance with eating. Resident #23's care plan also reflected she had cognitive impairment as evidenced by impaired orientation and Alzheimer's diagnosis. A record review of Resident #23's physician order dated 5/30/2023 reflected she was placed on IV fluids. A record review of Resident #23's weights reflected she lost 3% of her body weight from 2/17/2023 to 5/30/2023, which is not significant weight loss. During an observation and interview on 6/01/2023 at 9:30 a.m., Resident #23 was observed lying in bed with her breakfast tray sitting on her bedside table. The plate was covered, food inside was untouched, and there was spilled milk on the tray. Resident #23 appeared confused, was biting down on her bed sheet, and mumbled no when asked if she was hungry. During an observation and interview on 6/01/2023 at 11:06 a.m., Resident #23 was observed in bed. The ADON was in Resident #23's room along with another nurse and the ADON stated they were going to get Resident #23 up for lunch. During an observation and interview on 6/01/2023 at 2:38 p.m., Resident #23 was observed lying in bed with her lunch tray sitting on her bedside table. The tray of food was covered, food inside was untouched, drinks and dessert covered, and silverware wrapped. When asked if Resident #23 was hungry, she mumbled no but when asked if she wanted her dessert (peaches), she nodded her head up and down. During an interview on 6/01/2023 at 2:59 p.m. Resident #23's family member stated he had observed Resident #23 feeding herself about a month prior and she had some difficulty. During an interview on 6/01/2023 at 3:02 p.m., the Director of Rehab stated Resident #23 had been discharged from therapy in July of 2022 and was last screened for therapy on 4/13/2023. The Director of Rehab confirmed Resident #23 did not currently receive rehab services. During an interview on 6/01/2023 at 3:08 p.m., CNA D stated she worked with an agency and her shift started at 2:00 p.m. that day (6/01/2023). When asked how she knew which residents needed help eating, CNA D stated the CNA leaving would give a report or the nurse would let her know. CNA D stated she was told Resident #23 did not eat lunch that day (6/01/2023). CNA D stated the other agency CNA on duty told her that she had tried to feed Resident #23 lunch but Resident #23 did not eat. When asked if wrapped silverware, covered food, drinks and dessert indicated someone had tried to feed a resident, CNA D stated, no. CNA D stated she had not tried to feed Resident #23, she only heard that Resident did not eat when she arrived on shift at 2:00 p.m. that day (6/01/2023). During an interview on 6/01/2023 at 3:26 p.m., the ADON stated the CNAs who worked that day (6/01/2023) on the 6:00 a.m. - 2:00 p.m. shift included CNA E, CNA F, CNA G, and CNA H. The ADON stated CNA E, CNA G, and CNA H worked with an agency, but CNA F worked full time for the facility. During an interview on 6/01/2023 at 3:28 p.m., LVN A stated that when the nurse practitioner came into the facility, the nurse practitioner had noticed Resident #23 had not been eating and could no longer feed herself. LVN A stated she did not know how long ago that had been, but it was around the time when the nurse practitioner ordered IV fluids for Resident #23. LVN A stated she documented on the 24 hour report that Resident #23 refused her meals that day (6/01/2023) at breakfast and lunch. An observation on 6/01/2023 at 3:30 p.m. revealed LVN A removed Resident #23's untouched lunch tray from her room and delivered it to the kitchen. During an interview on 6/02/2023 at 8:41 a.m., the MDS Nurse stated if a resident's MDS was coded as supervision and one-person physical assist with eating, that meant they may need help with maneuvering the cup to their mouth or moving their arm. The MDS Nurse stated with one-person physical assist, the resident may need supervision to ensure they ate their food. The MDS Nurse stated physical assist might mean staff would need to help residents guide their limbs and with setup assistance, she stated she would expect the lid to be removed from the plate. During an observation and interview on 6/02/2023 at 8:50 a.m., COTA K was observed sitting in the dining room next to Resident #23 and COTA K was physically and verbally cueing Resident #23 to eat breakfast. COTA K stated the Director of Rehab had asked her that morning to conduct a therapy screening on Resident #23 to see if she needed to be picked up for therapy services since Resident #23 had a decline in function. During an interview on 6/02/2023 at 9:43 a.m., CNA H stated she worked with an agency but had worked in that facility for a few months and was familiar with Resident #23. CNA H stated right now, she's total assist in regard to Resident #23. CNA H stated Resident #23 had been like that for a week or two. CNA H stated in the last few weeks, Resident #23 had just stared at her food, so staff had been assisting her. CNA H stated she considered assisting to include placing a cup to a resident's mouth, putting food into their mouth, or putting ga spoon in their hand and assisting their hand. During an interview on 6/02/2023 at 11:03 a.m., the Speech Therapist stated she usually supervised the dining room during meals and was familiar with Resident #23. The Speech Therapist stated she had noticed Resident #23 had declined in the last four to seven days and needed to be fed. When asked how staff knew Resident #23 needed to be fed, the Speech Therapist stated because she would sit in a certain section of the dining room with other residents who needed to be fed. The Speech Therapist stated, a lot of times CNAs will overlook her and stated they did not want to move her to the assisted feeding section of the dining room yet until they knew what was going on. The Speech Therapist stated she told the Director of Rehab the day prior that Resident #23 may require OT services. The Speech Therapist stated one-person physical assist meant someone needed to help her with eating. The Speech Therapist stated she communicated to CNAs two days prior that Resident #23 seemed like she needed more help, but she did not know how information was communicated across nursing staff. The Speech Therapist stated CNAs would not implement it until they moved Resident #23 to the middle table where the other residents who needed assistance with eating sat during meals. The Speech Therapist stated she had seen staff cueing Resident #23, but she had not seen staff physically assisting her and in her opinion, she believed if the MDS were coded as physical assist, that would mean someone sitting down feeding Resident #23. During an interview on 6/02/2023 at 1:30 p.m., CNA E stated she worked the 6:00 a.m. - 2:00 p.m. shift the day prior (6/01/2023) and that was her first day shift at the facility because she usually worked the overnight shift. CNA E stated, I was going to get her up for lunch but she seemed so ., I didn't want her to fall, and they told me to keep checking on her. CNA E stated she was not the one who delivered Resident #23's breakfast and lunch tray. CNA E stated she did walk into Resident #23's room and noticed her lunch was not touched. CNA E stated she asked Resident #23 if she was hungry, but Resident #23 said no. CNA E stated that since Resident #23 pushed away her water cup when offered water, she did not attempt to feed Resident #23 her lunch. CNA E stated, I don't even know if she ate breakfast. CNA E stated she worked for a staffing agency and that morning she received orientation training from the DON. CNA E stated the DON told her that agency staff could not pass trays and that they needed to be in the dining room during meals instead of in the halls. CNA E stated when she saw Resident #23 a month ago, she was not spacing out and did not take two minutes to respond but now she seemed weak and you can tell she was dehydrated so I tried to give her water. CNA E did not explain why Resident #23 appeared dehydrated. CNA E stated CNA H worked the same shift as her on 6/01/2023. During an interview on 6/02/2023 at 1:50 p.m., CNA F stated the facility had rules for CNAs which required them to be in the dining room [ROOM NUMBER] minutes before meals. CNA F stated they would get everyone up that needed assistance and the residents that ate in their rooms did not need assistance with eating. When asked why Resident #23 was not taken out of her room for breakfast and lunch the day prior (6/01/2023), CNA F stated, I think because she had an IV in her arm but he did not know what the conversation was between the nurse and CNA. CNA F stated staff usually would sit down and help Resident #23 eat in the dining room, but he was not sure why no one did that the day prior (6/01/2023). CNA F stated he believed the agency staff did not know residents like the facility staff did and they probably just set down her tray and left without realizing she needed help. CNA F stated if someone had tried to feed Resident #23, he would expect the food to be messed up. When asked if covered cups and wrapped silverware indicated someone had tried to feed Resident #23, CNA F stated, no. During an interview on 6/02/2023 at 2:03 p.m., CNA G stated she did not pass trays in the hall where Resident #23 resided the day prior (6/01/2023) and stated she had not worked the hall where Resident #23 resided. During an interview on 6/02/2023 at 2:08 p.m., CNA H stated she had passed breakfast trays the day prior (6/01/2023) and she did not feed Resident #23 breakfast. CNA H stated she passed half of the trays for lunch the day prior (6/01/2023) and the Speech Therapist had passed Resident #23 her lunch tray. CNA H stated she had not fed Resident #23 lunch the day prior (6/01/2023) and did not know whether or not anyone had fed her. CNA H stated she thought Resident #23 needed help eating and she knew which residents needed help eating based on where they sat in the dining room. CNA H stated Resident #23 was usually in the dining room for meals and when asked why she was not gotten out of bed for breakfast and lunch the day prior (6/01/2023), CNA H stated she did not know and to talk to the aide that worked that hall. During an interview on 6/02/2023 at 3:24 p.m., the DON stated she did not know the facility's policy on ADL care because she was still new. The DON did not say how long she had been there but stated she had DON training on 6/30/2023. The DON stated, you might need to ask the Corporate Consultant. The DON stated when a resident's MDS section G for eating and drinking was coded as supervision and one-person physical assist, she would expect someone to put a fork in their mouth if needed. The DON stated with residents who required physical assistance, they always made sure they sat in the dining room for meals. The DON stated the facility was working on a way for staff to know which tables had residents who required more assistance. The DON stated agency staff remained in the dining room during meals to avoid a mishap with trays. The DON stated this was to prevent trays from getting mixed up, to prevent choking, and ensure resident safety. The DON stated CNA H worked for an agency, but she was allowed to pass trays since she had worked in the building for four to five weeks. When asked how staff knew residents needed help eating if they were in their room during meals, the DON stated they had a group meeting in the morning where they went through the clinicals and stated nurses did little huddles. The DON stated nurses should tell CNAs if residents needed help eating. The DON stated the level of care required was posted inside residents' closets. The DON stated the facility had a choking incident in the past and that was what implemented the no agency on halls rule. When asked what level of care Resident #23 required with eating, the DON stated, from what they told me she can feed herself but this week she's had a rapid decline. The DON stated she had been watching her every day to see how she was doing. The DON stated for physical assist, she would expect the lid cover to be taken off the plate, plate set up, food mixed up, and salt and pepper in food. The DON stated that was her expectation and she was trying to get them up to her expectation. The DON stated she was not sure why Resident #23 was not assisted with getting up for breakfast and lunch the day prior (6/01/2023) but stated she knew Resident #23 was not feeling well. When asked how staff were trained on feeding dependent residents, the DON stated she would have to look and see if it were a competency check or if it was through the Speech Therapist. When asked how staff were trained on feeding residents with Alzheimer's Disease, the DON stated, if they have a low BIMS you're gonna attempt to feed them because you know it's a behavior issue and you should still encourage. The ODN DON stated some residents with dementia liked a lot of salt or sugar. When asked if untouched food, wrapped silverware and covered drinks was considered an attempt to feed a resident, the DON stated, it's an obvious not attempt to feed. The DON stated she monitored staff by going into the dining room at the beginning of meal service to watch them kick off and stated she would go down the halls and do the whip lash to see if residents in their rooms were getting help with eating. When asked if she had done this the day prior (6/01/2023) to check if Resident #23 was being assisted, the DON stated she had not. The DON stated herself and the Administrator were responsible for monitoring staff to ensure compliance of the facility's ADL policy. The ODN DON stated a potential negative resident outcome of not assisting a resident who required help with eating included weight loss, behaviors, UTIs, kidney issues and malnutrition. During an interview on 6/02/2023 at 4:00 p.m., the Corporate Consultant stated the facility's policy on providing ADL assistance with eating depended on what level and he would expect someone to be in the room assisting the resident. The Corporate Consultant stated residents had care cards in their rooms with the level of assistance needed. The Corporate Consultant stated the DON was in charge of ensuring compliance of charge nurses and charge nurses were in charge of CNAs. The Corporate Consultant stated if dependent residents were not helped with eating, it could cause weight loss. An observation on 6/02/2023 at 4:19 p.m. revealed Resident #23's dresser contained sheets of paper posted inside the dresser drawers with information on her code status, ADL care needed, shower days, ambulatory status, and other ADL-specific information-there was no information on her ability to eat with or without assistance. During an interview on 6/02/2023 at 4:25 p.m., the Administrator stated her expectation was to feed residents their entire meal without interruption and she expected them to be setting them up and feeding them. The Administrator stated that a resident with an MDS assessment coded as supervision and one-person physical assist, she expected a CNA to be by the resident to cue them if they needed to be assisted or someone present to feed them if they needed to be fed-she said there needed to be a CNA there. The Administrator stated she talked to staff during meetings all the time about not taking no for an answer when residents with dementia verbally refused meals. The Administrator stated they can't just take no and walk away and stated 99% of the time they could get them to eat something. The Administrator stated she unfortunately could not feed residents since she was not a CNA. The Administrator stated staff had not been trained specifically on feeding resident with dementia but that they had been trained on different techniques to assist with caring for residents with dementia. The Administrator stated staff had been trained on not taking no as a solid as a solid answer. When asked if untouched food, wrapped silverware and covered drinks indicated staff had attempted to feed Resident #23, the Administrator stated, no and stated, until the spoon hits the tray, that's not an attempt. The Administrator stated she would expect staff to offer an alternate or health shake if residents said they were not hungry. When asked how staff were monitored to ensure they were providing sufficient assistance to residents during meals, the Administrator stated through rounds, assessing meal intake, looking at trays, and getting those residents in the dining room. The Administrator stated all staff were responsible for ensuring compliance of the facility's ADL policy. The Administrator stated a potential negative outcome of residents not receive receiving proper assistance with meals included weight loss, increased wound potential and dehydration. A record review of the facility's in-service dated 1/16/2023 reflected nursing staff were trained on the facility's policy on supporting ADLs. A record review of the facility's in-service dated 1/16/2023 reflected nursing staff were trained on assisting residents with meals. A record review of the facility's in-service dated March 2023 reflected all nursing staff were trained by the Administrator on working with patients in a long-term care setting with dementia. A record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting dated 2018 reflected the following: Policy Statement Residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. Dining (meals and snacks) 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: b. Supervision - Oversight, encouragement or cueing provided 3 or more times during the last 7 days. c. Limited Assistance - Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. A record review of the facility's policy titled Dementia - Clinical Protocol dated 2018 reflected the following: Treatment/Management 4. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. a. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. A record review of the facility's policy titled Assistance with Meals dated July 2017 reflected the following: Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation Dining Room Residents: 1. All residents will be encouraged to eat in the dining room. 2. Facility Staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. 4. Residents Confined to Bed: 2. The nursing staff will prepare residents for eating. Resident Requiring Full Assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that: The facility failed to conduct weekly skin assessments, provide showers regularly, and obtain and/or follow physician treatment orders for a rash on Resident #1's left iliac crest (located on the superior and lateral edge of the ilium, very close to the surface of the skin in the hip region), causing increased itchiness and immense pain. These failures placed residents at risk of physical harm, pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, morbid obesity, major depressive disorder, spondylolysis (age-related deterioration of the spine), and chronic pain syndrome. Review of Resident #1's quarterly MDS , dated 03/24/23, reflected a BIMS of 14, indicating she was cognitively intact. Section G (Functional Status) reflected the activity of bathing/showering had not occured over the past seven days and that she required partial/moderate assistance with her ADL's. Section M (Skin Conditions) reflected she had no current skin integrity issues. Review of Resident #1's quarterly care plan, dated 01/05/23, reflected she had potential for altered skin integrity related to altered sensation and poor circulation with an intervention of using powder the facility has available if desirable and inspecting the following areas for pallor (pale skin), redness, and breakdown: elbows, heels, back, hips. The care plan also reflected she was at risk for skin breakdown or infections due to frequent incontinence with an intervention of assessing skin after each episode of incontinence and notifying the nurse if there were any problems. She required extensive assistance with most ADL's due to her potential for self-care deficit related to cognitive impairment, impaired mobility or transfer mobility, and pain. Review of the facility's shower sheets, from 05/01/23 - 05/23/23, reflected no shower sheets for Resident #1. Review of Resident #1's weekly skin assessment, dated 04/25/23 and documented by the TN, reflected she had a fungal rash to her left inguinal fold (left iliac crest). There was no further documentation regarding treatment . Review of Resident #1's weekly skin assessment, dated 05/02/23 and documented by the TN, reflected she had a fungal rash to her left inguinal fold (left iliac crest). There was no further documentation regarding treatment. As of 05/23/23, there had been no other skin assessments conducted. Review of Resident #1's TAR, for May of 2023, reflected a physician's order, dated 06/06/22, for Nystatin Powder 1000000 unit/GM - apply to affected area topically every 12 hours as needed for yeast rash and apply until resolved. From 05/01/23 - 05/23/23, the TAR reflected no documentation that the powder had been applied. During an observation and interview on 05/23/23 at 8:52 AM, Resident #1 was in her room waiting for breakfast. Her skin and hair were greasy. She stated she rarely received a shower and could not remember the last time she received one. She stated it would not do any good to ask for one as the staff always claimed to be too busy. She stated it made her feel dirty, itchy, and she developed rashes under her stomach and in places she sweated a lot. She stated she currently had a rash under her stomach, and it was very rare that powder was ever applied to it. Permission from Resident #1 was received to observe a nurse assess the rash under her stomach. During an interview on 05/23/23 at 10:41 AM, the TN stated he had conducted the weekly skin assessments for Resident #1 on 04/25/23 and 05/02/23, as he was primarily responsible for conducting these assessments for residents with on-going skin integrity issues. He stated he could not give an answer as to why a skin assessment had not been conducted for Resident #1 after 05/02/23. He stated there was an order for a medicated powder to be applied to the area PRN and was looking into why it appeared as it had not been getting applied, according to Resident #1's TAR. He stated he believed he had notified the NP about the rash and believed there was a more current order for treatment and was trying to track it down. During an observation and interview on 05/23/23 at 11:34 AM, the DON assessed the rash under Resident #1's stomach. There were redness/red bumps from her upper left thigh to the bottom of her stomach. The red bumps were inflamed. Resident #1 stated she had it for weeks and it was hurting really bad and felt like it was bleeding, and it took everything she had to not scratch it. During an interview on 05/23/23 at 11:42 AM with the ADM and DON, the ADM stated she knew Resident #1 had a history of getting rashes but was not aware of the current rash. The ADM stated she was surprised because she spoke with Resident #1 daily and it had not been mentioned. The ADM stated the aides utilized shower sheets for documentation, and if there was not a shower sheet, it may not have happened. The DON stated Resident #1's rash was red and inflamed and she would ensure proper orders were in place. She stated rashes occurred when there was a lot of moisture between areas of skin that touched or if showers and incontinent care were not getting done regularly. During an interview on 05/23/23 at 12:56 PM, the ADON stated she had been working the floor as a CNA (and was currently Resident #1's aide) a lot and often provided incontinent care for Resident #1. She stated she changed her brief the day prior, 05/22/23, and there was not any redness under her abdominal fold. She stated if there had been redness, she would have applied the ordered powder. She stated she had just given Resident #1 a shower and noticed redness under her abdominal fold. She stated after showering her, she applied her PRN nystatin powder and notified her NP, requesting a routine order for Nystatin. She stated the NP agreed and a new order was in place. During an interview on 05/23/23 at 1:20 PM, the DON stated it was important for residents to have weekly skin assessments conducted, especially residents with skin integrity issues, to keep an eye on the progression of the skin and for preventative measures. She stated if they were not getting done weekly, wounds could develop and could go untreated. She stated these were the responsibility of the TN. She stated her expectation was that residents were showered at least three times a week, or per their preference . She stated the aides were to complete a shower sheet after each shower. She stated she expected the aides to notify a nurse if any skin integrity issues were identified during showers or incontinent care. She stated it was important for the NP to be notified of any skin integrity issues to ensure the residents' highest level of quality of care, quality of life, and comfort. She stated it was the responsibility of the nurse management team to ensure all those items were being done appropriately. Review of a facility in-service, conducted on 03/27/23 by TN A, reflected all nursing staff were in-serviced on showers - Failure to complete showers will result in disciplinary action. Review of the facility's Activities of Daily Living Policy, dated 2018, reflected the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) Review of the facility's Bladder and Bowel Incontinence Policy, dated 2021, reflected the following: . 8. The staff and physician will identify individuals with complications of existing incontinence, or who are a risk for such complications (e.g. skin maceration or breakdown) A request was made for a policy on skin assessments, but it was not provided prior to exit.

Based on observations, interviews, and record review the facility failed to ensure agency staff were competent and trained in their job responsibilities. The facility failed to provide agency staff with the proper training to care for residents. This failure could place residents identified on a special texture diet at risk for potential harm or danger. On [DATE] at 1:35 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 6:45 PM the facility remained out of compliance at the severity level of actual harm and scope of pattern due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal. Findings include: Observation on [DATE] at 3:00 PM revealed that Resident #1's closet door ADL checklist indicated a puree texture diet. Interview on [DATE] at 2:51 PM Agency CNA A stated they did not receive training about diet textures and verification of meals at the facility. CNA A did not know the location of policies and procedures on diet textures and verification of meals or where they could be found. CNA A stated the charge nurse would provide assignments each day and would answer any questions about his assignment and resident ADL and diet needs. CNA A stated it was important to receive the proper training regarding ADL and diet needs to prevent a resident from serious injuries. Interview on [DATE] at 5:40 PM Agency CNA B stated that the facility did not provide training regarding diet textures and verification of meals. Agency CNA B stated the facility provided a generalized orientation checklist for training and did not believe the facility orientation checklist was an effective training tool to care for residents' needs. Agency CNA B stated the charge nurse gave out assignments daily and would give resident-specific information regarding ADL care and dietary needs. Agency CNA B stated if she had any questions regarding a resident, she would contact the charge nurse. CNA B stated the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA B stated training regarding ADL care and dietary needs was important for the knowledge of residents' needs and to prevent further illness or injuries. Interview on [DATE] at 12:05 PM Agency CNA C stated the facility did not provide any other training other than completing an orientation checklist, that did not include ADL care or dietary needs, and was not an effective training tool. Agency CNA A stated she did not know where she could find policies and procedures related to ADL care and diet textures. Agency CNA A stated the charge nurse gave out assignments daily and if she had questions, she would ask. Agency CNA A stated there was a checklist of the resident's ADLs inside their closet doors and this checklist would guide staff on the care needed for residents. Agency CNA C stated the lack of training regarding ADL care and dietary needs interfered with residents' health and safety. Interview on [DATE] at 12:08 PM Agency LVN A stated that training regarding ADL care and diet textures was not provided to agency staff. Agency LVN A stated the charge nurse provided her with the daily assignments and if she had any questions, she would ask. Agency LVN A stated there was a checklist of ADLs inside the resident's closet doors to help aid in care. Agency LVN A stated he had no knowledge of the location of the policy of procedures regarding ADL care and dietary needs of residents or where to find them. Agency LVN A stated it was important to have the proper training regarding ADL care and dietary needs as it could eventually cause injury or death of a resident. Interview on [DATE] at 12:15 PM Agency CNA D stated the facility did not provide training regarding ADL care and resident dietary needs since their hire date. Agency CNA D stated the nurse in charge provided the daily assignments and answered any questions. Agency CNA D stated they did not know where the policies and procedures regarding ADL care and dietary needs for residents were located. CNA D stated there was a checklist inside the resident's closet door that had a list of ADLs and diet textures for each resident. Agency CNA D stated lack of proper training regarding ADL care and dietary needs could cause further injuries or death. Interview on [DATE] at 12:24 PM Agency CNA E stated the facility did not provide training regarding ADL care and diet textures. Agency CNA E stated a checklist for resident ADLs and dietary textures was located inside the resident closet doors. Agency CNA E stated they did not know the location of the facility policies regarding ADL care and dietary needs. Agency CNA E stated the nurse in charge gave assignments daily and if she had any questions, she would ask the charge nurse. Agency CNA E stated it is important to have training on ADLs and diet textures to help in preventing accidents and hazards. Interview on [DATE] at 1:00 PM DON stated agency staff did not receive additional training regarding ADL care and dietary needs. DON stated if agency staff had questions, they were directed to a charge nurse for an answer. DON stated the agency orientation checklist was acceptable training and if staff needed assistance, they were able to ask the charge nurse. Interview on [DATE] at 3:30 PM Administrator stated before agency staff were hired, they had to complete basic training that did not include ADL care and dietary needs, on their agency's website. Administrator stated the training included basic training of abuse /neglect, emergency evacuations, infection control, bill of rights, and change of conditions. Administrator stated the checklist provided by the facility was sufficient training for the agency and there was no additional training for agency staff regarding ADL care and resident dietary needs. Interview on [DATE] at 3:40 PM DON stated there was no additional training for agency staff regarding ADL care and dietary needs, and the checklist for agency staff was sufficient training. Interview on [DATE] at 5:30 PM Agency CNA F stated there was no facility-instructed training provided for agency workers regarding ADL care and dietary needs. Agency CNA F stated the agency workers were given their assignments by a nurse in charge and if the agency staff had any questions, they would ask him or the nurse in charge. Agency CNA F stated it was important to have training for the health and safety of residents. Interview on [DATE] at 5:50 PM Agency CNA G stated that the agency staff did not get additional training. Agency CNA G stated they reported to the charge nurse for their assignments and would ask any questions they may have. Agency CNA G stated the orientation checklist was not an effective training tool for agency staff regarding ADL care and resident dietary needs. Agency CNA G stated the agency staff utilized the resident ADL closet door checklist posted in resident rooms. Agency CNA G stated without effective training regarding ADL care and dietary needs, residents could have injuries or die. Interview on [DATE] at 6:00 PM RN A stated the agency orientation checklist was a guide but was not an effective training tool for resident ADL care and diet textures. RN A stated agency staff was not getting hands-on training regarding ADL care and diet textures when they start working at facility. RN A stated the facility policy was located online and agency staff was not aware of how to access it. RN A stated the agency staff were given their assignments by the nurse in charge and the nurse would give a rundown on what was needed regarding resident-specific needs. RN A stated the resident closet door ADL checklist provided resident-specific information. RN A stated she had concerns with the agency staff having proper training and the stated lack of training regarding ADL care and diet textures could lead to injuries or possible death. Review of the facility on-the-job training policy dated [DATE] revealed training will be conducted when necessary to assist employees in performing their assigned tasks. Review of the facility orientation policy (undated) revealed the orientation program for newly hired employees, transfers, volunteers, and travel staff stated that an orientation program shall be conducted for all newly hired employees, transfers from other departments, and volunteers. Review of the facility policy regarding on-the-job training dated [DATE] revealed that training will be conducted when necessary to assist employees in performing their assigned tasks. Parkview Nursing and Rehabilitation POR Letter of Abatement for Removal of Immediate Jeopardy [DATE] On [DATE] an abbreviated survey was initiated at Parkview Nursing and Rehab, 1501 S. Main, [NAME], TX . On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. Impact Statement: All residents were identified on [DATE] to have the potential to be affected by this deficient practice. F726 - The facility failed to provide agency staff with the proper training to care for residents. Problem #1 The facility failed to follow the dietary needs of 1 of 4 residents reviewed for the puree diet. The facility failed to verify and follow the residents prescribed modified texture diet. Action Taken/Monitoring: DON/ Designee began in-service on [DATE] in regard to tray distribution and identification to the appropriate resident for all staff including agency prior to the start of their next shift. This has been completed for all current building staff as of [DATE], as well as ongoing for new staff including agency, by monitoring the staff roster in relation to the staff schedule. DON/Designee will ensure that all licensed nursing staff including agency staff have been in-serviced prior to the start of their next shift, by monitoring the staff roster in relation to the staff schedule, to verify that tray cards match the appropriate diet as ordered. This has been completed for all current staff including agency as of [DATE], and ongoing for new staff including agency. DON/Designee will ensure that all staff including agency are in-serviced, started on [DATE] and was completed by [DATE], by monitoring the staff roster in relation to the staff schedule. on where to find the appropriate diet for all residents prior to the start of their next shift. This can be found in each resident's room posted to the inside of their closet door to include photo identification, a binder with the appropriate resident diet is also located in the dining room for staff to access to ensure the appropriate diet is served. Administrator initiated training on tray distribution and identification [DATE] and will ensure that 100% of all staff including agency are in-serviced prior to the start of their next shift by monitoring the staff roster in relation to the staff schedule, to be ongoing with all new staff including agency regarding tray distribution and identification to the appropriate resident. This will be validated daily by monitoring for accuracy x7 days, weekly x3 weeks, then monthly x3 months. Administrator/Designee will ensure that the nursing staff is monitoring the accuracy of the trays to match the ordered diet per each resident by checking a minimum of 10 trays at meal service x7days, beginning [DATE], then weekly x3 weeks, then monthly x 3months. The Administrator/Designee will monitor the training of tray card and identification x7 days, beginning [DATE], then weekly x3 weeks, then monthly x3 months, or until all new staff including agency have been in-serviced. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #2 Interviews with agency staff revealed there is no additional training beyond the checklist provided. Action Taken/Monitoring: The Administrator/Designee will develop and implement an effective training program for all new staff including agency. This training program was developed and initiated beginning on [DATE]. This training has been completed for all agency staff as of [DATE] or the start of their next shift whichever occurs first, and ongoing for new staff including agency by monitoring the staff roster in relation to the staff schedule. This training will include general orientation of the facility to include when and how to report Abuse and Neglect, documentation guidelines include resident identifiers, physician orders including dietary orders, when to complete risk management in regard to incident and accident reports, and abridged policy and procedures for primary care of residents. DON, Nurse Management/ IDT will ensure by monitoring staff roster versus the staff schedule for any new oncoming Agency staff have completed Agency orientation prior to their shift until no more agency is being utilized in facility. The administrator will ensure, by monitoring staff roster versus the staff schedule, that all new staff including agency are trained prior to the start of their next shift, beginning on [DATE] by record review of agency training manual and signed affidavit of receiving a manual x7days, then weekly x3 weeks, then monthly x3 months, or substantial compliance is maintained. The administrator will monitor the training x7 days weekly beginning on [DATE], x3 weeks, then monthly x3 months, or until all new staff have been in-serviced, by record review of agency training manual and signed affidavit of receiving a manual The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #3 No known knowledge of facility policies or the location of policies onsite. Action Taken/Monitoring: Director of Nursing/Designee will in-service and educate all staff including agency staff on where to locate and review policy and procedures prior to the start of their next shift. Policies and Procedures are located at the nursing station as well as in Point Click Care: Home-View All Links-Eduro Central [resident electronic records system], all policies and procedures can be found here by the nursing staff. Education on where to find policies and procedures for staff began on [DATE] and was completed by [DATE] for all current staff including agency. Training will be ongoing for new staff, including agency, to the facility. Don/Designee will monitor all new staff including agency, who come to the facility to ensure their knowledge of the location of the policies and procedures, by record review of agency training manual and signed affidavit of receiving a manual. This will be monitored by Administrator/DON/Designee daily x7days, beginning on [DATE], then weekly x4 weeks, then monthly x3months. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #4 Record review revealed no incident report had been documented on Resident #1 choking incident. Action Taken/Monitoring: DON/Designee will in-service all staff prior to the start of their next shift beginning on appropriate completion of incident reports with identified risk to resident beginning on [DATE], completed on [DATE] or prior to their next scheduled shift whichever occurs first. All current staff including agency will be in-serviced prior to the start of their next shift and will be on-going for new staff including agency. Administrator/DON/Designee will review the accident/incident reports starting on [DATE] and will be an ongoing process to ensure a thorough investigation is completed. Incident and accidents reports will be reviewed, and an investigation will be completed within 72 hours of the incident to include appropriate interventions. This will be reviewed daily during Risk Management Meeting, Monday-Friday. Administrator will ensure, through record review of agency training manual and signed affidavit of receiving a manual that 100% of staff including agency are in-serviced prior to the start of their next shift, beginning on [DATE] and completed for all current staff as of [DATE]. Training will be on-going for new staff, including agency, daily x7days, weekly x3 weeks, then monthly x3 months. Don/Designee will monitor all new staff, including agency, who come to the facility to ensure their knowledge of how and when to complete an incident report by validating the staff roster versus the staff schedule. This will be monitored by Administrator/DON/Designee daily x7days, weekly x3 weeks, then monthly x3months until substantial compliance is achieved beginning on [DATE]. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Involvement of Medical Director The Administrator notified the facility's Medical Directors, of the Immediate Jeopardy tag on [DATE]. The Administrator in collaboration with the Inter-disciplinary team and Medical Director will review and validate the policies and procedures including Accidents and Incidents: Investigations and Reporting; Tray Distribution and Identification; Resident Rights; Emergency Procedure - Choking; Change in a Residents Status or Condition; Activities of Daily Living; Assistance with Meals; and Abuse and Neglect are being followed, as well as meet federal, state, and local regulations, during an ADHOC QAPI meeting held on [DATE]. Involvement of QA On [DATE] an Ad Hoc QAPI meeting will be held with the Medical Director, Administrator, Director of Nursing, and Dietary Director to review and validate the plan of removal. Administrator and Inter-Disciplinary team reviewed policies including: Accidents and Incidents: Investigations and Reporting; Tray Distribution and Identification; Resident Rights; Emergency Procedure - Choking; Change in a Residents Status or Condition; Activities of Daily Living; Assistance with Meals; and Abuse and Neglect of the residents on [DATE], within the facility with appropriate corrections as indicated, and the policy and process to ensure practice is to act upon all allegations as if they are true and accurate until proven otherwise. Who is responsible for the implementation of the process? The Administrator will be responsible for implementation of ensuring the adequate process regarding meeting the nutritional needs of the residents within the facility. The new process/system was started on [DATE]. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on [DATE]. The Surveyor monitored the Plan of Removal on [DATE] as follows: Observations on [DATE] from 12:14 PM - 2:50 PM revealed staff verifying meal tickets to meal trays prior to providing meals to residents. Interview on [DATE] at 2:00 PM ADON stated she verified all residents' diets with ST and all orders/care plans were updated in PCC [ resident electronic records system]. ADON stated she would be getting with Dietary to ensure all diets matched the orders that afternoon. ADON stated RD was scheduled to review all orders the following day. ADON stated she was responsible for diets from the nursing standpoint, and she would continue to work with ST and dietary to ensure orders were updated as needed. ADON stated one person from Administration must be at every meal, checking meal trays, after the nurse verifies meals. Observations on [DATE] between 5:00 PM - 5:15 PM revealed residents to be seated in the dining area waiting for dinner service. Kitchen and nursing staff were observed verifying meals to tickets and placing trays in dining carts. ADON was observed verifying all meals in carts prior to being sent out to resident halls. Interview on [DATE] at 5:05 PM with Agency CNA I, stated she was provided training the previous day by DON regarding policies and procedures related to abuse, neglect, choking, and verification of resident diets and ADLs. Agency CNA I stated she would check the resident's ADL chart posted in residents' closets and ask the charge nurse questions if she was unsure of anything. Interview and observation on [DATE] beginning at 5:20 PM revealed Agency RN to be setting up trays for residents in a resident's room and verifying the meal ticket prior to providing meal trays to residents. Agency RN stated she was in-serviced the previous day by the DON about policies and procedures regarding diets, abuse, neglect, accidents, hazards, and where to find policies and procedures. Interview on [DATE] at 5:25 PM Facility CNA G stated she received recent training from DON about abuse and neglect, policies and procedures related to ADLs, verifying meals, and choking incidents/ accidents. Observations on [DATE] at 5:30 PM revealed three signs posted in the dining room regarding choking, signs of, and procedures for choking. Staff was observed in hallways verifying meals as they pulled trays from meal carts and then brought them into resident rooms. Interview on [DATE] at 5:33 PM DON stated his expectations for verification of meals and procedures and provided an overview of topics covered during recent in-services provided to the staff since IJ was called. DON stated all staff are required to participate in an in-service prior to starting their shift. Review of the following in-services and assignment sheet dated [DATE] revealed all staff working the current shift and previous shift signed and dated in-services. The following in-services were reviewed: Abuse and Neglect dated [DATE] and [DATE], Resident Rights dated [DATE] and [DATE], Tray Distribution and Identification dated [DATE] and [DATE], Emergency Procedure (Choking) dated [DATE] and [DATE], Assistance and Meals dated [DATE] and [DATE], Activities of Daily Living dated [DATE] and [DATE]. Agency Orientation Binder undated was reviewed and it was revealed to include the agency facility orientation checklist and the following facility policies: Tray Identification revised 2007, Abuse/Neglect updated 2021, Emergency Choking 2018, Assistance with Meals revised 2017, and CPR revised ,d+[DATE]. Orientation checklists were noted to be signed and dated by agency staff. Observations on [DATE] at 6:05 PM revealed DON, CNA I and Facility LVN A assisting residents in the dining room with pureed meals. Interview on [DATE] at 6:06 PM Facility LVN A stated it was her first day and was educated on the facility system, charting, how to find orders, and diets and was recently in-serviced by DON on the importance of and how to check meal tickets. Facility LVN A stated she was still getting the hang of things but felt the training was adequate at this point and felt comfortable seeking help, finding policies and procedures, and asking for more education regarding diet textures as needed. Interview on [DATE] at 6:13 PM Agency CMA stated she was recently in-serviced from DON on how to find resident information, how to check ADL information and diet texture posted in resident closets, policies, and choking signs and procedures. Interview and observation on [DATE] beginning at 6:15 PM revealed DON was providing training to Agency LVN C and using Agency Orientation Binder. Agency LVN C stated it was his first day working with the facility and so far, he felt the orientation being provided was easy to understand and understood how to check and verify ADLs and resident diet texture. Administrator, DON, and Corporate Nurse were informed on [DATE] at 6:45 PM that the IJ was removed; however, the facility remained out of compliance at the severity level of actual harm and scope of pattern due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal.

Based on observations, interviews, and record review the facility failed to meet the nutritional menu of a puree diet for 1 (Resident#1) of 4 residents resulting in a choking incident. The facility failed to verify and follow the dietary menu of 1 of 27 residents prescribed a modified textured diet. This failure could place residents identified as having mechanically altered diets at risk for potential death or brain damage due to lack of oxygen from choking. On [DATE] at 1:35 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 6:45 PM the facility remained out of compliance at the severity level of actual harm and scope of isolated due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, high blood pressure, anxiety, [CONDITION(S)] (increased cholesterol), arthritis, abnormalities of gait and mobility, salivary secretion, abnormal posture, muscle weakness(weak) dysphagia (difficulty swallowing), mild malnutrition, and major depressive disorder Review of Resident # 1's care plan undated revealed Resident #1 is at risk for diet alteration related to- regular diet, dysphagia level 1 puree texture, mildly thick (Nectar) 2 consistency diet and nectar thick liquids between meals three times daily. Review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS Score of 0 indicating severe cognitive impairment. Review of Resident #1's progress notes dated [DATE] revealed resident was noted choking on food from the dinner tray. Agency LVN B was able to dislodge food from the mouth and stabilize it. Review of Resident #1's physician order dated [DATE] revealed a regular diet, dysphagia level 1 puree texture, mildly thick (nectar) 2 consistency, fortified meals for all meals, and snacks in between meals. Interview on [DATE] at 2:24 PM DON stated he was not in the facility when the choking incident occurred on [DATE] with Resident #1. DON stated that Agency LVN B (no longer contracted with the facility) was responsible for conducting an investigation of the incident and what caused the resident to receive the wrong textured diet. DON stated the facility incident investigation was not completed by Agency LVN B. DON stated it was Agency LVN B responsibility to ensure it was the incident report was completed. DON stated he failed to verify the incident report and the investigation was completed. Interview on [DATE] at 2:45 PM, ADON stated she was not in the building when the incident with Resident #1 occurred. ADON stated she entered the progress notes regarding the incident. ADON stated when she was called by Agency LVN B, Agency LVN B told her Resident #1 was choking on food and she was able to dislodge food from her mouth and stabilize Resident #1. Interview on [DATE] at 2:51 PM Agency CNA A stated he was in the dining room assisting with other residents when he was redirected by Agency LVN B and was called to assist Resident #1 with feeding. Agency CNA A stated Agency CNA H (no longer contracted with the facility) had already placed the food tray in Resident #1's room. Agency CNA A stated he did not verify the meal tray as he thought it was already verified by Agency CNA H. Agency CNA A stated the meal observed was a regular texture meal of fish and french fries. Agency CNA A stated he had fed the resident a couple of bites of the fish and fries when he noticed Resident #1's lips quivering. Agency CNA A stated he went into the hall to seek assistance and Agency LVN B came in and stuck her fingers in Resident #1 mouth to dislodge the food. Agency CNA A stated he was not provided training on facility-specific policies and procedures, for resident diet orders, and verifying meals and food textures. He stated he did not check Resident #1's closet door checklist for ADLs posted in her room. Agency CNA A stated he did not know the location of the facility policies and procedures for checking dietary orders and textures. Agency CNA A stated the facility's charge nurse would give assignments daily and if he had any questions, he would ask the charge nurse. Observation on [DATE] at 3:00 PM revealed that Resident #1's closet door checklist reflected indicated a diet, puree texture. Interview on [DATE] at 5:40 PM Agency CNA B stated that the facility had not provided training since her start date of employment at the facility on verifying textured diets. Agency CNA B stated the facility's training consisted of being provided with a facility-generalized nonspecific checklist that did not include texture diets and ADL care. Agency CNA B stated a facility checklist was not an effective training tool to care for residents. Agency CNA B stated the charge nurse would give out assignments daily and share information regarding the care of a resident. Agency CNA B stated if she had any questions regarding a resident, she would contact the charge nurse. CNA B stated the treatment of a resident was communicated through the charge nurse and the ADL checklist that included the diet texture was located on the inside door or each resident's closet. CNA B stated training is important for the knowledge of residents' needs and to prevent further illness or injuries. Interview on [DATE] at 12:05 PM Agency CNA C stated the facility did not provide training on verifying textured diets. The only training received was to complete a checklist which she stated was not an effective training tool. Agency CNA C stated she did not know where to find the facility policies and procedures on menus and texture diets. Agency CNA stated the charge nurse would give out her assignment daily and if she had any questions, she would ask the charge nurse. Agency CNA stated there was a checklist of each Resident's ADL needs located inside their closet doors. The lack of training on verifying the residents' diet texture needs could interfere with residents' health and safety. Interview on [DATE] at 12:08 PM Agency LVN A stated the facility did not provide training on verifying textured diets. Agency LVN a stated the charge nurse would make the assignments each shift and if she had any questions her charge nurse would answer them. LVN A stated there is a checklist of ADLs that included the diet texture for each resident. LVN A had no knowledge of the location of the facility's policy and, procedures on menus and verifying textured diets. Agency LVN A stated it was important to have the proper training on resident diets and verification of the texture of the food as it could eventually cause injury or death to a resident. Interview on [DATE] at 12:15 PM Agency CNA D stated the facility did not provide training on verifying textured diets. Agency CNA D stated the nurse in charge would provide the assignment and answer any questions regarding her assignment. CNA D stated she did not know where the policies and procedures regarding resident diet and verification of textured meals were located. CNA D stated that there was a checklist inside each resident's closet door that had a list of ADLs that included the diet texture for each resident. CNA D stated without proper training regarding the verification of modified texture diets this could cause resident injuries or death. Interview on [DATE] at 12:24 PM, Agency CNA E stated the facility did not provide training on verifying textured diets. Agency CNA E stated a checklist for a resident's ADLs to include diet texture was located inside the resident's closet doors. Agency CNA E stated she does not know the location of the facility policies regarding resident textured diets and the verification process. Agency CNA E stated the nurse in charge gives assignments daily and if there were any questions regarding her assignment, she would ask the charge nurse. Agency CNA E stated it was important to have training regarding diets and verification of meals to help in preventing accidents. Interview on [DATE] at 1:00 PM DON stated there was no policy for a CNA-to-CNA tradeoff to share information on resident diet and texture of the meals. DON stated if agency staff had questions, they were directed to a charge nurse for the answers. DON stated there was no additional training when agency staff completed the agency orientation checklist upon hire. DON stated the closet door ADL checklist that includes the diet texture was acceptable for doing the job. DON stated when agency staff had questions, they could seek help from the nurse in charge. Interview on [DATE] at 1:15 PM DON stated it was not clear if Resident #1 was given someone else's tray or if the tray was incorrectly made by kitchen staff. DON stated that an investigation report was not completed for the choking incident on Resident #1. Interview on [DATE] at 1:20 PM DON stated it was the charge nurse's responsibility to start the investigation regarding the choking incident involving Resident #1. DON stated that Agency LVN B placed the incident report in another resident (unnamed) medical record. DON stated he was not able to find the choking incident report for Resident #1. DON stated he dropped the ball in verifying the incorrect charting of the choking incident as it was his job to make sure documentation was accurate. Interview on [DATE] at 3:30 PM Administrator stated before an agency staff was hired, they had to complete basic training identified on their agency's website. Administrator stated these trainings included training on abuse /neglect, emergency evacuations, infection control, bill of rights, and change of conditions. Administrator stated the agency orientation checklist provided by the facility was sufficient training for the agency staff and no additional training was needed for resident ADL and diet texture needs. Interview on [DATE] at 3:40 PM DON stated there was no additional training for agency staff and he believed the agency orientation checklist for agency staff was sufficient training for resident ADL and diet texture needs. Interview on [DATE] at 5:30 PM CNA F stated there was no facility-instructed training provided to agency workers. CNA F stated the agency workers were given their daily assignments by the nurse in charge. CNA F stated if agency staff had any questions the agency staff would ask him or the nurse in charge. CNA F stated it was important to have training regarding verifying resident diet textures for the health and safety of residents. Interview on [DATE] at 5:50 PM CNA G stated that agency staff was not provided additional training on resident diets and verifying meals. CNA G stated staff reported to the charge nurse for their assignment and asked the nursing staff any questions they may have. CNA G stated the agency orientation checklist was not an effective training tool for agency staff and for verifying resident textured diets. CNA G stated agency staff utilized the resident's closet door checklist to complete the resident ADLs and check for their textured diets. CNA G stated without effective training on resident diets and the verification processes injuries or death could occur. Interview on [DATE] at 6:00 PM RN A stated the agency orientation checklist was a guide but was not effective for resident care. RN A stated the agency staff was not getting hands-on training when they came onsite regarding resident diets and verification of meals. RN A stated there was no policy binder on-site, the facility policy was located online, and agency staff was not aware of where to find information specific to resident diets and verification of meals. RN A stated agency staff were given their assignments by the nurse in charge and that nurse gave a rundown on what was needed. RN A stated the resident closet door checklist gave a list of ADLs which included diet texture. RN A stated she had concerns with the agency staff having proper training and the lack of training regarding verifying textured diets could lead to injuries or possible death. Review of facility grievances dated [DATE] revealed Resident #1's family member was concerned that her mother received the wrong food tray with the wrong textured meal. Review of the facility grievance dated [DATE] revealed a written statement from Agency CNA A of Resident #1's choking incident due to wrong meal being provided. Review of the facility agency staff orientation checklist (undated) revealed a checklist for agency nurses to read and follow all treatments/orders as written. The checklist also indicated that agency staff were to complete a risk management report (incident report) for any unusual occurrence and communicate to oncoming nurses. Review of the facility tray identification policy revised in [DATE] revealed nursing staff shall check each food tray for the correct diet before serving the residents. Review of the facility choking policy dated the 3rd quarter of 2018 revealed to call for help but stay with the resident. Report other information in accordance with facility policy and professional standards of practice. No reference on where to find facility policy and professional standards of practice was noted. Review of policy for assisting with impaired resident within room meals policy dated 3rd quarter 2018 to check the tray before serving it to the resident to ensure that it is the correct diet ordered and the food consistency is appropriate to the resident's ability to chew and swallow. Review of the facility staff development program policy dated the 3rd quarter of 2018 revealed all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of the facility's on-the-job training policy dated [DATE] would be conducted when necessary to assist employees in performing their assigned tasks. Review of facility investigation and reporting policy dated 3rd Quarter 2018 revealed if an incident or suspected incident of resident neglect is reported the administrator will assign the investigation to an appropriate individual. A review of the facility orientation policy (undated) revealed the facility orientation program for newly hired employees, transfers, volunteers, and travel staff stated that an orientation program shall be conducted for all newly hired employees, transfers from other departments, and volunteers. Parkview Nursing and Rehabilitation POR Letter of Abatement for Removal of Immediate Jeopardy [DATE] On [DATE] an abbreviated survey was initiated at Parkview Nursing and Rehab, 1501 S. Main, [NAME], TX . On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. Impact Statement: All residents were identified on [DATE] to have the potential to be affected by this deficient practice. F803 - The facility failed to meet the nutritional menu of a puree diet for one resident resulting in a choking incident. Problem #1 The facility failed to follow the dietary needs of 1 of 4 residents reviewed for the puree diet. The facility failed to verify and follow the residents prescribed modified texture diet. Action Taken/Monitoring: DON/ Designee began in-service on [DATE] in regard to tray distribution and identification to the appropriate resident for all staff including agency prior to the start of their next shift. This has been completed for all current building staff as of [DATE], as well as ongoing for new staff including agency, by monitoring the staff roster in relation to the staff schedule. DON/Designee will ensure that all licensed nursing staff including agency staff have been in-serviced prior to the start of their next shift, by monitoring the staff roster in relation to the staff schedule, to verify that tray cards match the appropriate diet as ordered. This has been completed for all current staff including agency as of [DATE], and ongoing for new staff including agency. DON/Designee will ensure that all staff including agency are in-serviced, started on [DATE] and was completed by [DATE], by monitoring the staff roster in relation to the staff schedule. on where to find the appropriate diet for all residents prior to the start of their next shift. This can be found in each resident's room posted to the inside of their closet door to include photo identification, a binder with the appropriate resident diet is also located in the dining room for staff to access to ensure the appropriate diet is served. Administrator initiated training on tray distribution and identification [DATE] and will ensure that 100% of all staff including agency are in-serviced prior to the start of their next shift by monitoring the staff roster in relation to the staff schedule, to be ongoing with all new staff including agency regarding tray distribution and identification to the appropriate resident. This will be validated daily by monitoring for accuracy x7 days, weekly x3 weeks, then monthly x3 months. Administrator/Designee will ensure that the nursing staff is monitoring the accuracy of the trays to match the ordered diet per each resident by checking a minimum of 10 trays at meal service x7days, beginning [DATE], then weekly x3 weeks, then monthly x 3months. The Administrator/Designee will monitor the training of tray card and identification x7 days, beginning [DATE], then weekly x3 weeks, then monthly x3 months, or until all new staff including agency have been in-serviced. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #2 Interviews with agency staff revealed there is no additional training beyond the checklist provided. Action Taken/Monitoring: The Administrator/Designee will develop and implement an effective training program for all new staff including agency. This training program was developed and initiated beginning on [DATE]. This training has been completed for all agency staff as of [DATE] or the start of their next shift whichever occurs first, and ongoing for new staff including agency by monitoring the staff roster in relation to the staff schedule. This training will include general orientation of the facility to include when and how to report Abuse and Neglect, documentation guidelines include resident identifiers, physician orders including dietary orders, when to complete risk management in regard to incident and accident reports, and abridged policy and procedures for primary care of residents. DON, Nurse Management/ IDT will ensure by monitoring staff roster versus the staff schedule for any new oncoming Agency staff have completed Agency orientation prior to their shift until no more agency is being utilized in facility. The administrator will ensure, by monitoring staff roster versus the staff schedule, that all new staff including agency are trained prior to the start of their next shift, beginning on [DATE] by record review of agency training manual and signed affidavit of receiving a manual x7days, then weekly x3 weeks, then monthly x3 months, or substantial compliance is maintained. The administrator will monitor the training x7 days weekly beginning on [DATE], x3 weeks, then monthly x3 months, or until all new staff have been in-serviced, by record review of agency training manual and signed affidavit of receiving a manual The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #3 No known knowledge of facility policies or the location of policies onsite. Action Taken/Monitoring: Director of Nursing/Designee will in-service and educate all staff including agency staff on where to locate and review policy and procedures prior to the start of their next shift. Policies and Procedures are located at the nursing station as well as in Point Click Care: Home-View All Links-Eduro Central [resident electronic records system], all policies and procedures can be found here by the nursing staff. Education on where to find policies and procedures for staff began on [DATE] and was completed by [DATE] for all current staff including agency. Training will be ongoing for new staff, including agency, to the facility. Don/Designee will monitor all new staff including agency, who come to the facility to ensure their knowledge of the location of the policies and procedures, by record review of agency training manual and signed affidavit of receiving a manual. This will be monitored by Administrator/DON/Designee daily x7days, beginning on [DATE], then weekly x4 weeks, then monthly x3months. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #4 Record review revealed no incident report had been documented on Resident #1 choking incident. Action Taken/Monitoring: DON/Designee will in-service all staff prior to the start of their next shift beginning on appropriate completion of incident reports with identified risk to resident beginning on [DATE], completed on [DATE] or prior to their next scheduled shift whichever occurs first. All current staff including agency will be in-serviced prior to the start of their next shift and will be on-going for new staff including agency. Administrator/DON/Designee will review the accident/incident reports starting on [DATE] and will be an ongoing process to ensure a thorough investigation is completed. Incident and accidents reports will be reviewed, and an investigation will be completed within 72 hours of the incident to include appropriate interventions. This will be reviewed daily during Risk Management Meeting, Monday-Friday. Administrator will ensure, through record review of agency training manual and signed affidavit of receiving a manual that 100% of staff including agency are in-serviced prior to the start of their next shift, beginning on [DATE] and completed for all current staff as of [DATE]. Training will be on-going for new staff, including agency, daily x7days, weekly x3 weeks, then monthly x3 months. Don/Designee will monitor all new staff, including agency, who come to the facility to ensure their knowledge of how and when to complete an incident report by validating the staff roster versus the staff schedule. This will be monitored by Administrator/DON/Designee daily x7days, weekly x3 weeks, then monthly x3months until substantial compliance is achieved beginning on [DATE]. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Involvement of Medical Director The Administrator notified the facility's Medical Directors, of the Immediate Jeopardy tag on [DATE]. The Administrator in collaboration with the Inter-disciplinary team and Medical Director will review and validate the policies and procedures including Accidents and Incidents: Investigations and Reporting; Tray Distribution and Identification; Resident Rights; Emergency Procedure - Choking; Change in a Residents Status or Condition; Activities of Daily Living; Assistance with Meals; and Abuse and Neglect are being followed, as well as meet federal, state, and local regulations, during an ADHOC QAPI meeting held on [DATE]. Involvement of QA On [DATE] an Ad Hoc QAPI meeting will be held with the Medical Director, Administrator, Director of Nursing, and Dietary Director to review and validate the plan of removal. Administrator and Inter-Disciplinary team reviewed policies including: Accidents and Incidents: Investigations and Reporting; Tray Distribution and Identification; Resident Rights; Emergency Procedure - Choking; Change in a Residents Status or Condition; Activities of Daily Living; Assistance with Meals; and Abuse and Neglect of the residents on [DATE], within the facility with appropriate corrections as indicated, and the policy and process to ensure practice is to act upon all allegations as if they are true and accurate until proven otherwise. Who is responsible for the implementation of the process? The Administrator will be responsible for implementation of ensuring the adequate process regarding meeting the nutritional needs of the residents within the facility. The new process/system was started on [DATE]. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on [DATE]. The Surveyor monitored the Plan of Removal on [DATE] as follows: Observations on [DATE] from 12:14 PM - 2:50 PM revealed staff verifying meal tickets to meal trays prior to providing meals to residents. Interview on [DATE] at 2:00 PM ADON stated she verified all residents' diets with ST and all orders/care plans were updated in PCC [ resident electronic records system]. ADON stated she would be getting with Dietary to ensure all diets matched the orders that afternoon. ADON stated RD was scheduled to review all orders the following day. ADON stated she was responsible for diets from the nursing standpoint, and she would continue to work with ST and dietary to ensure orders were updated as needed. ADON stated one person from Administration must be at every meal, checking meal trays, after the nurse verifies meals. Observations on [DATE] between 5:00 PM - 5:15 PM revealed residents to be seated in the dining area waiting for dinner service. Kitchen and nursing staff were observed verifying meals to tickets and placing trays in dining carts. ADON was observed verifying all meals in carts prior to being sent out to resident halls. Interview on [DATE] at 5:05 PM with Agency CNA I, stated she was provided training the previous day by DON regarding policies and procedures related to abuse, neglect, choking, and verification of resident diets and ADLs. Agency CNA I stated she would check the resident's ADL chart posted in residents' closets and ask the charge nurse questions if she was unsure of anything. Interview and observation on [DATE] beginning at 5:20 PM revealed Agency RN to be setting up trays for residents in a resident's room and verifying the meal ticket prior to providing meal trays to residents. Agency RN stated she was in-serviced the previous day by the DON about policies and procedures regarding diets, abuse, neglect, accidents, hazards, and where to find policies and procedures. Interview on [DATE] at 5:25 PM Facility CNA G stated she received recent training from DON about abuse and neglect, policies and procedures related to ADLs, verifying meals, and choking incidents/ accidents. Observations on [DATE] at 5:30 PM revealed three signs posted in the dining room regarding choking, signs of, and procedures for choking. Staff was observed in hallways verifying meals as they pulled trays from meal carts and then brought them into resident rooms. Interview on [DATE] at 5:33 PM DON stated his expectations for verification of meals and procedures and provided an overview of topics covered during recent in-services provided to the staff since IJ was called. DON stated all staff are required to participate in an in-service prior to starting their shift. Review of the following in-services and assignment sheet dated [DATE] revealed all staff working the current shift and previous shift signed and dated in-services. The following in-services were reviewed: Abuse and Neglect dated [DATE] and [DATE], Resident Rights dated [DATE] and [DATE], Tray Distribution and Identification dated [DATE] and [DATE], Emergency Procedure (Choking) dated [DATE] and [DATE], Assistance and Meals dated [DATE] and [DATE], Activities of Daily Living dated [DATE] and [DATE]. Agency Orientation Binder undated was reviewed and it was revealed to include the agency facility orientation checklist and the following facility policies: Tray Identification revised 2007, Abuse/Neglect updated 2021, Emergency Choking 2018, Assistance with Meals revised 2017, and CPR revised ,d+[DATE]. Orientation checklists were noted to be signed and dated by agency staff. Observations on [DATE] at 6:05 PM revealed DON, CNA I and Facility LVN A assisting residents in the dining room with pureed meals. Interview on [DATE] at 6:06 PM Facility LVN A stated it was her first day and was educated on the facility system, charting, how to find orders, and diets and was recently in-serviced by DON on the importance of and how to check meal tickets. Facility LVN A stated she was still getting the hang of things but felt the training was adequate at this point and felt comfortable seeking help, finding policies and procedures, and asking for more education regarding diet textures as needed. Interview on [DATE] at 6:13 PM Agency CMA stated she was recently in-serviced from DON on how to find resident information, how to check ADL information and diet texture posted in resident closets, policies, and choking signs and procedures. Interview and observation on [DATE] beginning at 6:15 PM revealed DON was providing training to Agency LVN C and using Agency Orientation Binder. Agency LVN C stated it was his first day working with the facility and so far, he felt the orientation being provided was easy to understand and understood how to check and verify ADLs and resident diet texture. Administrator, DON, and Corporate Nurse were informed on [DATE] at 6:45 PM that the IJ was removed; however, the facility remained out of compliance at the severity level of actual harm and scope of isolated due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal.

Based on record review, interview, and observation, the facility failed to notify a physician of significant change in condition for one (Resident #1) of four residents reviewed. The facility failed to contact the physician immediately after identifying a significant change in condition resulting in Resident #1's leg becoming necrotic. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 7/01/20. While the IJ was removed on 7/03/20, the facility remained out of compliance at a level of actual harm with the potential for more than minimal harm with a scope identified as patterned. This failure could place residents at risk of injury and loss of limb. Findings Included: Review of Resident #1's face sheet reflect that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Care plan, undated, reflected that the resident was care planned for being at risk for skin irritation and skin breakdown because if impaired mobility due to [MEDICAL CONDITION], muscle wasting, [MEDICAL CONDITION] of both legs with an onset date of 2/1/2018. The target for this onset is to have skin remain intact by 90 days and free from skin breakdown/irritation by 90 days. The approach for identified problem/need include weekly skin checks, report [DIAGNOSES REDACTED]. Review of Resident #1's progress note dated 6/2/2020 at 3:37pm, reflected LVN F noted that Resident #1's hospice staff reported red area to left leg when giving the resident a shower. LVN F noted that wound care was notified for assessment but did not identify if they informed the nurse or doctor. In an interview on 6/26/2020 at 1:45 pm, HN stated that on 6/2/2020 the hospice CNAs found Resident #1 with a ted hose on her left leg. HN stated that the hospice CNAs informed a facility nurse that the ted hose was not removed from the night before. HN stated that the ted hose caused a dark red/purple bruise around the left calf. She stated that the red/purple bruised ring was located below the knee on the upper part of left calf. HN stated that on 6/4/2020 a blister was noted on top of the shin area of the bruised ring. HN stated that the FN applied a warm compress to the wound and assessed it to be cold to touch. Stated that the hospice noticed that the blister had popped resulting in a wound on 6/11/2020. HN stated that prior to incident the hospice staff would visit twice a week but because the residents condition changed, they increased the number of visits to three times a week. HN stated that they informed the facility WCN of the wound on 6/11/2020. The HN stated that the wound grew from 5cm on 6/11 /2020 to 15cm by 7cm on 6/14/2020. In an interview on 6/26/2020 at 3:45pm, the DON stated that on 6/2/2020 they identified the resident had a red ring around her left leg from the ted hose. She stated that the red ring changed color and that the blister on the left shin turned into a sore. She stated that the hospice nurses found the ted hose on the resident and that they identified a change in the resident's leg. The DON stated that the facility staff failed to follow physician orders [REDACTED]. In an interview on 6/26/2020 at 4:34pm, LVN A stated that she does not physically check the removal of the ted hose at night. LVN A stated that the CNAs take them off when they change the resident or when they put them to bed. LVN A stated that she reminds them to remove the ted hose but she does not physically check if they do. LVN A stated that was under the impression that the CNAs removed the ted hose on the night of 5/31/2020 and does no recall which CNAs worked that night but that she did sign off on the task as if it was done. LVN A stated that she is not the one who assessed Resident #1's left leg for bruising as a result of the ted hose being left on. LVN A stated that she works a few days a week and the ted hose were left on all day Sunday and found the next day. LVN A stated that she does not recall being trained on monitoring residents with ted hoses, when they should be removed and who was responsible for verifying that ted hoses were removed. Review of Resident #1's Medication Administration Record [REDACTED]. The order start date was 3/16/2020 with a discontinue date of 6/4/2020. The MAR indicated [REDACTED] 6/1/2020 at 8:00 am Ted Hose were put on by HCNA B 6/1/2020 at 8:00 pm Ted Hose were removed by LVN A 6/2/2020 at 8:00 am Ted Hose were not provided by HCNA B 6/2/2020 at 8:00 pm Ted Hose were removed by LVN B 6/3/2020 at 8:00 am Ted Hose were not provided by HCNA B 6/3/2020 at 8:00 pm Ted Hose were removed by LVN C 6/4/2020 at 8:00 am Ted Hose were not provided by HCNA B 6/1/2020 at 8:00 pm Ted Hose were removed by LVN D In an interview on 6/26/2020 at 5:15pm, WCN stated that Resident #1's ted hose was discontinued on 6/01/20, the same day the hose were found to be left on overnight. WCN stated that the Ted hose application and removal were assigned as CNA ADL task and that he physically/visually verifies the task has been done, then signs off on the task. WCN stated that the ted hose left a red ring around Resident #1's leg. WCN stated that Resident #1's left leg was discolored. WCN stated that he did not see a blister on the resident's left shin when the ted hose was removed. He stated that the blister formed within the first week. He stated that the protocol was to notify the physician, hospice, family, and medical director when there was a change in condition and to notify the wound care physician when there was a wound. WCN stated that he started wound care on Resident #1 on 6/13/2020. The WCN stated that he was sent a picture of the wound on 6/11/2020 and provided a copy of the picture. WCN stated that he called the WCP but cannot remember when he called and does not have a fax, or email to show when he called the WCP to assess Resident #1's wound. WCN stated that Resident #1's wound has not been assessed but the WCP. Review of Resident #1's hospice notes dated 6/4/2020 reflected an identified problem with skin integrity alteration due to trauma from compression hose. The goal is noted as managing the skin alteration to reduce complications and free of infection. The skin alteration is noted to be a wound with redness and serosanguineous (contains blood and liquid) drainage. Hospice DR notified facility DON to have the resident's PCP assess the wound. Review of Resident #1's hospice notes dated 6/15/2020 reflected HRN noted that Resident #1's wound on her lower left leg measured 15cm by 7.6cm, noting that the periwound was dark red and/or purple, and unblanchable. Review of Resident #1's progress note dated 6/15/2020 at 12:25pm, WCN entered a wound assessment note for Resident #1's left leg stating that the resident had an arterial ulcer of the left lateral shin and is waiting for treatment orders. Review of Resident #1's hospice notes dated 6/24/2020 reflected that resident #1 had an open wound to the lower left leg, measuring 16cm by 8cm. Hospice RN noted that the wound was dark red, purple and had a foul smell. Review of Resident #1's progress note dated 6/24/2020 at 12:08pm, reflected WCN noted that Resident #1's NP conducted a virtual assessment of the resident's wound and found that the wound was necrotic and would contact the PCP to provide further orders. Review of Resident #1's hospice notes dated 6/26/2020 reflected that Resident #1's left leg was purple, with no pedal pulse palpated. The HN noted that the family was notified of the resident's condition and that she assessed the wound with the facility DON. HN noted that the facility DON was going to contact resident #1's NP for assessment and possible antibiotics. Review of Resident #1's progress notes reflected that the facility nurses did not document daily observation or assessment of resident's legs after failing to remove compression hose on 5/31/2020 resulting in a change in condition. Review of Resident #1's Wound Healing Progress Report dated 6/29/2020, reflect that the wound is located on left lateral shin. The report reflects that wound was discovered on 6/13/2020 and measured 15cm by 6.80cm. The next note and measurement was done on 6/23/2020, the wound grew to 17cm by 14cm. In an interview on 6/29/2020 at 1:23pm, WCN stated that the resident has not seen the wound care doctor and that he put an order in. The WCN stated that Resident #1's NP saw the wound via video conference and relayed the information to her PCP on 6/24/2020. The WCN confirmed that Resident #1's wound on her left leg was necrotic. Observation of Resident #1's left leg on 6/29/2020 at 2:38pm, revealed the resident's wound was seeping through the wrapping/bandage on top of the toe area. The WCN removed the dressing and revealed the purple bruised ring had become necrotic leaving a ring of necrotic flesh around Resident #1's leg. The resident's necrotic wound spread from the top of the shin down to the top of the foot. Further observation revealed that Resident #1's left great toe, second, and third left toe developed necrotic wounds on top of the toe knuckles. In an interview on 6/30/2020 at 10:17am, DON stated that residents with qualifying wounds should be assessed by the WCP. The DON stated that Resident #1's wound should have been assessed by the WCP after the blister popped. The DON stated that the WDN was responsible for contacting the WCP to inform him of residents requiring wound assessments and to follow up with the WCP to ensure residents were seen and that there were wound care orders. In an interview on 7/1/2020 at 8:48am, WCP stated that he first heard of the wound last night (6/30/2020) and came in first thing in the morning. WCP stated that he did not know who the resident was or what the wound looked like, he stated that he got a call and came in to assess the wound. WCP was shown pictures of Resident #1's left leg and stated the wound looks bad and the leg had necrosis and was not good. Review of facility policy and procedure for Anti-Emboli Stockings (Compression Hose) dated 2001 with a revision date of October 2010 reflected that resident Compression Hose should be removed every 8 hours for at least 30 minutes. The assessment guidelines state that the resident's posterior tibial and dorsalis pedis pulse (rate, volume, rhythm), skin color, temperature, skin irritation, open area, presence of [MEDICAL CONDITION] (unilateral and bilateral), distended veins, pain, and/or tenderness of the calf. When applying the Compression Hose the top should be below 1 to 2 inches below the popliteal fossa. The guidelines instruct the facility to document time, date, size, length, and assessment data prior to application and at the time of removal with the name and title of the person who applied or removed the Compression Hose. The guideline instructs staff to report other information in accordance with facility policy and professional standards and practice. Review of facility's Change in a Resident's Condition or Status policy and procedures dated 2001 with a revision date of February 2014 reflected that the nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical condition. The policy states that a significant change of condition is a decline in the resident's status that requires interdisciplinary review and/or revision to the care plan. The Administrator was notified on 7/1/20 at 6:23 p.m. an Immediate Jeopardy situation had been identified due to above failure. The IJ template was provided to the Administrator on 7/1/2020 at 9:50 p.m. The following Plan of Removal was submitted by the administrator on 7/1/2020 at 11:40 p.m. and accepted on 7/2/2020 at 8:00 a.m. Actions Taken/Planned included: Any alteration in skin integrity will be reported to the resident's attending physician and responsible party incorporating the use of Stop and Watch as well as SBAR(completed on 7/1/2020) Wound care Physician will be notified of any wound judged by Wound Care RN as a potential need Physicians' responses will be documented in resident's nurse's notes In the event there is no timely response from the attending physician, or the Wound Care physician, the Medical Director is to be immediately notified. All skin issues are to be reported to Wound Care RN, who can contact Wound Care Physician or Medical Director for assessment and treatment as necessary. To be monitored by DON, Infection Preventionist and/or ADON during morning meeting, chart reviews, review of all Physician order [REDACTED].>Revisions to the Plan of Removal will be made as indicated by review and determined by QAPI team All skin issues to be discussed in weekly Skin and Weights Meeting Resident Care Plans will be updated to reflect skin condition and Physicians Orders The survey team monitored the plan of removal as followed: Review of training records reflect that facility staff to include the DON and WCN received the following training: 6/29/2020 - Reporting Change in Condition 6/29/2020 - Ted Hose application, Removal, Reporting, Documentation 6/29/2020 - Nurse physically check resident legs after application and removal of Ted Hose 7/1/2020 - Neglect/Abuse Review of Ted Hose orders on 7/2/2020 reflect that the FMD updated orders to be in line with facility policy of removing Ted Hose every 8 hours for at least 30 minutes. In an interview on 7/1/2020 at 7:49pm, LVN E stated that the infection control nurse assisted the DON with providing in-services related to the IJ. LVN E stated that she is to notify nurse manager or DON of condition of changes, then physician if immediate assistance is needed. LVN E stated that the Ted hose are to be checked and removed every 8 hours for at least 30 minutes. LVN E stated that the in-services included and covered abuse neglect, who to report to, communication and chain of command, and when to do a self-report. In an interview on 7/1/2020 at 8:30pm, LVN G stated that she received training on Covid, hand washing, abuse neglect, ted hose, communication, making sure they are calling doctors and DON, and family. LVN G stated that they are trained to keep track of when they contact doctors and records, communicating with hospice for continuity of care, and notifying family. In an interview on 7/1/2020 at 8:36pm, LVN B stated that she was trained on communication, ted hose, abuse, neglect, and Covid. She knew to contact doctors of change of condition. She stated that they put in a nurse note to keep track of communications so that you can follow up. She stated that they communicate with hospice for continuity of care especially when there is a change in condition. She stated that the ted hose come off and on 8-hour checks. She stated that they are able to reach out to the medical director team if they are unable to reach a doctor or specialist for assessment and treatment. In an interview on 7/1/2020 at 8:45pm, CNA A stated she was trained in Covid infection controls, abuse, neglect, compression stocking, they need to be put on and taken off per doctors order, make sure they are not too tight, and should be removed every 8 hours. She stated that they report wounds, marks, bruises to DON and charge nurse. There should be communication when there is a change in condition to doctors. She stated that she uses the stop and watch procedure in the event a resident is at risk or suffering a change. In an interview on 7/1/2020 at 8:50pm, CNA B stated that she was trained in Ted hose, Covid, communication when there is a change in condition, and stop and watch. She stated for residents who use ted hoses, she looks for swelling, bruising, and makes sure they were not left on for more than 8 hours. In an interview on 7/1/2020 at 8:57pm, CNA C stated she received training for Covid, abuse, neglect, report change in conditions and skin marks such a bruises to the nurses. She was also received Ted Hose training and what to look for when putting them on and taking them off as well as assessing for bruising, swelling, discoloration and marks. In an interview on 7/1/2020 at 9:04pm, CNA D stated that she works overnight and was trained in Covid, handwashing, how to report change in condition, abuse, neglect, identifying skin conditions and reporting to nurses. She was also trained on assessing residents who wear ted hoses; look for any sores or wrinkles, mark on the ADL sheet when they are put on or removed. The administrator was informed on 7/3/2020 at 11:00 a.m. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of actual harm with the potential for more than minimal harm and a scope identified as patterned.

Based on record review, interview, and observation, the facility failed to identify significant change in condition, inform physician of resident condition, ensure that physician orders [REDACTED].#1) of four residents reviewed. The facility failed to have a process in place to ensure ted hoses were removed after 8 hours and the physician was contacted 14 days after the facility identified that there was a significant change in condition resulting in Resident #1's leg becoming necrotic. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 7/01/20. While the IJ was removed on 7/03/20, the facility remained out of compliance at a level of actual harm with the potential for more than minimal harm with a scope identified as patterned. This failure could place residents with compression hose at risk of injury and loss of limb. Findings Included: Review of Resident #1's face sheet reflect that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Care plan, undated, reflected that the resident was care planned for being at risk for skin irritation and skin breakdown because of impaired mobility due to [MEDICAL CONDITION], muscle wasting, [MEDICAL CONDITION] of both legs with an onset date of 2/1/2018. The target for this onset is to have skin remain intact by 90 days and free from skin breakdown/irritation by 90 days. The approach for identified problem/need include weekly skin checks, report [DIAGNOSES REDACTED]. Review of Resident #1's progress note dated 6/2/2020 at 3:37pm, reflected LVN F noted that Resident #1's hospice staff reported red area to left leg when giving the resident a shower. LVN F noted that wound care was notified for assessment but did not identify if they informed the nurse or doctor. In an interview on 6/26/2020 at 1:45 pm, HN stated that on 6/2/2020 the hospice CNAs found Resident #1 with a ted hose on her left leg. HN stated that the hospice CNAs informed a facility nurse that the ted hose was not removed from the night before. HN stated that the ted hose caused a dark red/purple bruise around the left calf. She stated that the red/purple bruised ring was located below the knee on the upper part of left calf. HN stated that on 6/4/2020 a blister was noted on top of the shin area of the bruised ring. HN stated that the FN applied a warm compress to the wound and assessed it to be cold to touch. Stated that the hospice noticed that the blister had popped resulting in a wound on 6/11/2020. HN stated that prior to incident the hospice staff would visit twice a week but because the residents condition changed, they increased the number of visits to three times a week. HN stated that they informed the facility WCN of the wound on 6/11/2020. The HN stated that the wound grew from 5cm on 6/11 /2020 to 15cm by 7cm on 6/14/2020. In an interview on 6/26/2020 at 3:45pm, the DON stated that facility is in the process of self-reporting Resident #1's incident with the ted hose. The DON stated that on 6/1/2020 they identified the resident had a red ring around her left leg from the ted hose. The DON stated that further review found that the ted hose was left on overnight and was ordered to be removed nightly. She stated that on 6/13/2020 the resident was ordered wound care treatment due to a blister that had formed on the resident's left shin along the line of the ring that turned into a bruise over time. She stated that the red ring changed color and that the blister on the left shin turned into a sore. She stated that the hospice nurses found the ted hose on the resident and that they identified a change in the resident's leg. The DON stated that the facility staff failed to follow physician orders [REDACTED]. In an interview on 6/26/2020 at 4:34pm, LVN A stated that she does not physically check the removal of the ted hose at night. LVN A stated that the CNAs take them off when they change the resident or when they put them to bed. LVN A stated that she reminds them to remove the ted hose but she does not physically check if they do. LVN A stated that was under the impression that the CNAs removed the ted hose on the night of 5/31/2020 and does no recall which CNAs worked that night but that she did sign off on the task as if it was done. LVN A stated that she is not the one who assessed Resident #1's left leg for bruising as a result of the ted hose being left on. LVN A stated that she works a few days a week and the ted hose were left on all day Sunday and found the next day. LVN A stated that she does not recall being trained on monitoring residents with ted hoses, when they should be removed and who was responsible for verifying that ted hoses were removed. Review of Resident #1's Medication Administration Record [REDACTED]. The order start date was 3/16/2020 with a discontinue date of 6/4/2020. The MAR indicated [REDACTED] 6/1/2020 at 8:00 am Ted Hose were put on by HCNA B 6/1/2020 at 8:00 pm Ted Hose were removed by LVN A 6/2/2020 at 8:00 am Ted Hose were not provided by HCNA B 6/2/2020 at 8:00 pm Ted Hose were removed by LVN B 6/3/2020 at 8:00 am Ted Hose were not provided by HCNA B 6/3/2020 at 8:00 pm Ted Hose were removed by LVN C 6/4/2020 at 8:00 am Ted Hose were not provided by HCNA B 6/1/2020 at 8:00 pm Ted Hose were removed by LVN D In an interview on 6/26/2020 at 5:15pm, WCN stated that Resident #1's ted hose was discontinued on 6/01/20, the same day the hose were found to be left on overnight. WCN stated that the Ted hose application and removal were assigned as CNA ADL task and that he physically/visually verifies the task has been done, then signs off on the task. WCN stated that the compression hose left a red ring around Resident #1's leg. WCN stated that Resident #1's left leg was discolored. WCN stated that he did not see a blister on the resident's left shin when the ted hose was removed. He stated that the blister formed within the first week. He stated that the protocol was to notify the physician, hospice, family, and medical director when there was a change in condition and to notify the wound care physician when there was a wound. WCN stated that he started wound care on Resident #1 on 6/13/2020. The WCN stated that he was sent a picture of the wound on 6/11/2020 and provided a copy of the picture. WCN stated that he called the WCP but cannot remember when he called and does not have a fax, or email to show when he called the WCP to assess Resident #1's wound. WCN stated that Resident #1's wound has not been assessed but the WCP. Review of Resident #1's hospice notes dated 6/4/2020 reflected an identified problem with skin integrity alteration due to trauma from compression hose. The goal is noted as managing the skin alteration to reduce complications and free of infection. The skin alteration is noted to be a wound with redness and serosanguineous (contains blood and liquid) drainage. Hospice DR notified facility DON to have the resident's PCP assess the wound. Review of Resident #1's hospice notes dated 6/15/2020 reflected HRN noted that Resident #1's wound on her lower left leg measured 15cm by 7.6cm, noting that the periwound was dark red and/or purple, and unblanchable. Review of Resident #1's progress note dated 6/15/2020 at 12:25pm, WCN entered a wound assessment note for Resident #1's left leg stating that the resident had an arterial ulcer of the left lateral shin and is waiting for treatment orders. Review of Resident #1's progress note dated 6/17/2020 reflected an order to cleanse wound to lower left extremity daily with wound wash, pat dry, and apply [MEDICATION NAME], calcium alginate, army battle dressing and wrap in kerlix to all wounds to lower left extremity, from knee to toes. Review of Resident #1's hospice notes dated 6/17/2020 reflected HRN noted that Resident #1's wound on her lower left leg measured 15cm by 7.6cm, noting that the periwound was dark red and/or purple, and unblanchable. Review of Resident #1's hospice notes dated 6/24/2020 reflected that resident #1 had an open wound to the lower left leg, measuring 16cm by 8cm. Hospice RN noted that the wound was dark red, purple and had a foul smell. Review of Resident #1's progress note dated 6/24/2020 at 12:07pm, reflected WCN noted that the wound continues to deteriorate and measures 17cm by 14 cm. The note reflected that the resident has a history of [MEDICAL CONDITION] and presents with wounds consistent with arterial insufficiency. The WCN noted that he will continue with current intervention. Review of Resident #1's progress note dated 6/24/2020 at 12:08pm, reflected WCN noted that Resident #1's NP conducted a virtual assessment of the resident's wound and found that the wound was necrotic and would contact the PCP to provide further orders. Review of Resident #1's hospice notes dated 6/26/2020 reflected that Resident #1's left leg was purple, with no pedal pulse palpated. The HN noted that the family was notified of the resident's condition and that she assessed the wound with the facility DON. HN noted that the facility DON was going to contact resident #1's NP for assessment and possible antibiotics. Review of Resident #1's progress note dated 6/26/2020 at 9:58am, reflected LVN A noted that a wound care order was submitted to treat Resident #1's left leg. The order was noted as [MEDICATION NAME] 500mg, crush 1 tab and apply to wound daily with each dressing change until resolved. Review of Resident #1's progress notes reflected that the facility nurses did not document daily observation or assessment of resident's legs after failing to remove compression hose on 5/31/2020 resulting in a change in condition. Review of Resident #1's Wound Healing Progress Report dated 6/29/2020, reflect that the wound is located on left lateral shin. The report reflects that wound was discovered on 6/13/2020 and measured 15cm by 6.80cm. The next note and measurement was done on 6/23/2020, the wound grew to 17cm by 14cm. Review of hand written/drawn document provided by WCN on 6/29/2020 reflected that wounds were found on the top of Resident #1's left foot, located and dated as: Identified on 6/26/2020 : Left Great Toe knuckle measuring 1.1cm by 1cm, Left Third Toe knuckle measuring .5cm by .6cm Identified on 6/29/2020: Left Second Toe knuckle measuring .7cm by .7cm with small amount of drainage, Left side of heel on Left foot 1cm by 1cm scab. Observation on 6/26/2020 at 5:26pm, revealed a picture of Resident #1's wound on her left leg. Resident #1's left leg below the knee, towards the top of the calf muscle presented a purple bruise that went around the resident's leg. An indentation of necrotic flesh was found within the bruised ring on top of the left tibialis anterior muscle. The left side of the left shin below the necrotic wound showed a layer of skin was off. The area missing skin spread across the length of Resident #1's leg from the purple bruised ring to the top of the ankle. Observation of Resident # 1 in her room after viewing the picture revealed the resident's left leg was wrapped in a dressing that covered her leg below the knee and completely covered her leg, ankle, foot, and toes. In an interview on 6/29/2020 at 12:44pm, Resident #1's POA stated that the ted hose was left on and it made a sore. In an interview on 6/29/2020 at 1:23pm, WCN stated that the resident has not seen the wound care doctor and that he put an order in. The WCN stated that Resident #1's NP saw the wound via video conference and relayed the information to her PCP on 6/24/2020. The WCN confirmed that Resident #1's wound on her left leg was necrotic. Observation of Resident #1's left leg on 6/29/2020 at 2:38pm, revealed the resident's wound was seeping through the wrapping/bandage on top of the toe area. The WCN removed the dressing and revealed the purple bruised ring had become necrotic leaving a ring of necrotic flesh around Resident #1's leg. The resident's necrotic wound spread from the top of the shin down to the top of the foot. Further observation revealed that Resident #1's left great toe, second, and third left toe developed necrotic wounds on top of the toe knuckles. In an interview on 6/30/2020 at 10:17am, DON stated that residents with qualifying wounds should be assessed by the WCP. The DON stated that Resident #1's wound should have been assessed by the WCP after the blister popped. The DON stated that the WDN was responsible for contacting the WCP to inform him of residents requiring wound assessments and to follow up with the WCP to ensure residents were seen and that there were wound care orders. Interview on 6/30/2020 at 11:23am, HCNA stated they entered Resident #1's room, in the morning on 6/2/2020. The HCNA stated Resident #1 was in bed and they were taking off her gown and her ted hose were still on. The HCNA stated that the ted hose was embedded into Resident #1's skin. The HCNA stated that there was a deep indentation in Resident #1's leg and some discoloration. In an interview on 6/30/2020 at 11:37am, the FMD stated that he did his rounds last week (6/22/2020 through 6/26/2020) and talked to the DON about Resident #1 and that there was a nursing team failure with the ted hose. The FMD stated that the ultrasound showed there were a couple of partial occlusions to the veins that would worsen the injury. He stated that the resident is elderly, frail, has a history of skin failure, and poor protoplasm. He stated that the body had an exaggerated response due to the poor health of the skin. This would not typically happen to anybody else. He stated that there was nothing to do to recover from the injury. The best course of action was to continue with wound care and comfort support. In an interview on 6/30/2020 at 1:24pm, NP stated that she did the visual evaluation on 6/24/2020, the PCP's office received a phone call from facility 6/24/2020 9:44 am stating the hospice MD wanted to see if they could evaluate Residents #1's leg. The NP stated that the PCP office received a call on 6/14/2020 at 10:08am and they responded on the same day at 10:43am. The NP stated the ted hose were discontinued because they were too tight and the resident developed blisters. In an interview on 7/1/2020 at 8:48am, WCP stated that he first heard of the wound last night (6/30/2020) and came in first thing in the morning. WCP stated that he did not know who the resident was or what the wound looked like, he stated that he got a call and came in to assess the wound. WCP was shown pictures of Resident #1's left leg and stated the wound looks bad and the leg had necrosis and was not good. Review of facility policy and procedure for Anti-Emboli Stockings (Compression Hose) dated 2001 with a revision date of October 2010 reflected that resident Compression Hose should be removed every 8 hours for at least 30 minutes. The assessment guidelines state that the resident's posterior tibial and dorsalis pedis pulse (rate, volume, rhythm), skin color, temperature, skin irritation, open area, presence of [MEDICAL CONDITION] (unilateral and bilateral), distended veins, pain, and/or tenderness of the calf. When applying the Compression Hose the top should be below 1 to 2 inches below the popliteal fossa. The guidelines instruct the facility to document time, date, size, length, and assessment data prior to application and at the time of removal with the name and title of the person who applied or removed the Compression Hose. The guideline instructs staff to report other information in accordance with facility policy and professional standards and practice. Review of facility's Change in a Resident's Condition or Status policy and procedures dated 2001 with a revision date of February 2014 reflected that the nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical condition. The policy states that a significant change of condition is a decline in the resident's status that requires interdisciplinary review and/or revision to the care plan. The Administrator was notified on 7/1/20 at 6:23 p.m. an Immediate Jeopardy situation had been identified due to above failure. The IJ template was provided to the Administrator on 7/1/2020 at 9:50 p.m. The following Plan of Removal was submitted by the administrator on 7/1/2020 at 11:40 p.m. and accepted on 7/2/2020 at 8:00 a.m. Actions Taken/Planned included: All orders for TED hose to be evaluated by Physician for continued need All orders for TED hose to follow Policy and Procedure as approved by Preferred Care, Parkview and Medical Director This process to be monitored by DON and or designee weekly and as indicated Revisions to Plan of Removal will be made as indicated, at time of review by QAPI team Interventions will be care planned All of the above in-serviced on 7/1/2020 Residents with orders for TED hose will have TED hose listed on their ADL sheets for CNAs to see Nurses will have a Telephone Order for applying/removing TED hose on the eMAR, and will verify the presence/absence of TED hose before completing their documentation (orders completed 7/1/2020) This will be monitored weekly by the DON and or Assignee Revisions to the Plan of Removal will be made as indicated by review and determined by QAPI team Nursing staff will be In-Serviced and educated on Policy and Procedure in the use of TED hose, and to the possible injury caused by not removing TED hose before bedtime. The above In-Service to be presented by 7/2/2020 to all nursing staff before they start their shifts. Performed by DON, Infection Preventionist and/or ADON The survey team monitored the plan of removal as followed: Review of training records reflect that facility staff to include the DON and WCN received the following training: 6/29/2020 - Reporting Change in Condition 6/29/2020 - Ted Hose application, Removal, Reporting, Documentation 6/29/2020 - Nurse physically check resident legs after application and removal of Ted Hose 7/1/2020 - Neglect/Abuse Review of Ted Hose orders on 7/2/2020 reflect that the FMD updated orders to be in line with facility policy of removing Ted Hose every 8 hours for at least 30 minutes. In an interview on 7/1/2020 at 7:49pm, LVN E stated that the infection control nurse assisted the DON with providing in-services related to the IJ. LVN E stated that she is to notify nurse manager or DON of condition of changes, then physician if immediate assistance is needed. LVN E stated that the Ted hose are to be checked and removed every 8 hours for at least 30 minutes. LVN E stated that the in-services included and covered abuse neglect, who to report to, communication and chain of command, and when to do a self-report. In an interview on 7/1/2020 at 8:30pm, LVN G stated that she received training on Covid, hand washing, abuse neglect, ted hose, communication, making sure they are calling doctors and DON, and family. LVN G stated that they are trained to keep track of when they contact doctors and records, communicating with hospice for continuity of care, and notifying family. In an interview on 7/1/2020 at 8:36pm, LVN B stated that she was trained on communication, ted hose, abuse, neglect, and Covid. She knew to contact doctors of change of condition. She stated that they put in a nurse note to keep track of communications so that you can follow up. She stated that they communicate with hospice for continuity of care especially when there is a change in condition. She stated that the ted hose come off and on 8-hour checks. She stated that they are able to reach out to the medical director team if they are unable to reach a doctor or specialist for assessment and treatment. In an interview on 7/1/2020 at 8:45pm, CNA A stated she was trained in Covid infection controls, abuse, neglect, compression stocking, they need to be put on and taken off per doctors order, make sure they are not too tight, and should be removed every 8 hours. She stated that they report wounds, marks, bruises to DON and charge nurse. There should be communication when there is a change in condition to doctors. She stated that she uses the stop and watch procedure in the event a resident is at risk or suffering a change. In an interview on 7/1/2020 at 8:50pm, CNA B stated that she was trained in Ted hose, Covid, communication when there is a change in condition, and stop and watch. She stated for residents who use ted hoses, she looks for swelling, bruising, and makes sure they were not left on for more than 8 hours. In an interview on 7/1/2020 at 8:57pm, CNA C stated she received training for Covid, abuse, neglect, report change in conditions and skin marks such a bruises to the nurses. She was also received Ted Hose training and what to look for when putting them on and taking them off as well as assessing for bruising, swelling, discoloration and marks. In an interview on 7/1/2020 at 9:04pm, CNA D stated that she works overnight and was trained in Covid, handwashing, how to report change in condition, abuse, neglect, identifying skin conditions and reporting to nurses. She was also trained on assessing residents who wear ted hoses; look for any sores or wrinkles, mark on the ADL sheet when they are put on or removed. Observation on 7/2/2020 at 12:13pm, Resident #2, rm 305A in bed with shorts and shirt on. Resident ted hose appeared to be clean and not restricting or causing indentation on left or right leg. Observation on 7/2/2020 at 12:15pm, Resident #3, rm 300B, resident revealed Ted Hose to investigator, the Ted hose were clean and smooth, no wounds or discoloration at the top of resident Ted Hose on resident skin. The Ted Hose appeared to fit properly. Observation on 7/2/2020 at 12:17pm, Resident #4, B 405A, resident revealed Ted Hose to investigator, the Ted hose were clean and smooth, no wounds or discoloration at the top of resident Ted Hose on resident skin. The Ted Hose appeared to fit properly. Observation on 7/2/2020 at 12:21pm, Resident #5, Rm 401B, resident revealed Ted Hose to investigator, the Ted hose were clean and smooth, no wounds or discoloration at the top of resident Ted Hose on resident skin. The Ted Hose appeared to fit properly. Observation on 7/2/2020 at 12:23pm, Resident #6, Rm405A, resident revealed Ted Hose to investigator, the Ted hose were clean and smooth, no wounds or discoloration at the top of resident Ted Hose on resident skin. The Ted Hose appeared to fit properly. The administrator was informed on 7/3/2020 at 11:00 a.m. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of actual harm with the potential for more than minimal harm and a scope identified as patterned.

Based on observation, interview and record review the facility failed to provide goods and services necessary to avoid physical harm to 1 of 9 residents (Resident #1) reviewed who developed unidentified pressure ulcers. There were 3 of 3 Certified Nurse Aides (CNA S, X, and Y) who cared for Resident #1 who did not identify skin issues and did not report to the charge nurse or treatment nurse. The facility failed to correctly assess and document weekly skin assessments which resulted in Resident #1 having an unstageable pressure wound to his buttock and coccyx area. The wound was not identified until Resident #1 had a temperature requiring a Tylenol suppository. The emergency room identified a wound with Eschar, slough and necrotic tissue extending from the rectal opening to the coccyx and extending outward into buttock tissue measuring 12.0 cm x 10.0 cm x 0.1 cm. There was also abrasions/ and [MEDICAL CONDITION] to the scrotum, an open area to the left ischium, an open area to the right medial thigh and a deep tissue injury to the left lateral heel. None of these areas of skin break down were identified by the facility. The deficient practice to ensure residents did not develop pressure ulcers allowed one (1) residents to have unidentified pressure ulcer development and placed the additional eight (8) residents at risk for not receiving nursing services in a timely manner and developing pressure ulcers. Findings included: Review of Resident #1's facility face sheet reflected Resident #1 was admitted on [DATE]. His admitting [DIAGNOSES REDACTED]. Resident #1 was [AGE] years old and with cognition impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/20/11, under skin conditions, M1200B, skin/ulcer treat: pressure reducing device for bed was checked. M1040Z, Other skin problems: none of the above was checked. M0150 Is resident at risk of developing pressure ulcer was checked. Review of the care plan dated 06/06/11, Resident #1 is a high risk for pressure ulcers. The care plan reflected Resident #1 has "Potential for developing pressure ulcers or other skin breakdown related to decreased mobility and incontinent of bladder and bowel. Approaches include skin checks weekly with bathing, and with care. CNA's to notify nurse of any reddened or broken skin, and nurse will notify physician and family. Skin check by nurse once weekly". Review of the nurses notes, dated 11/05/11 at 2:21 AM, reflected a "nurse aide (CNA S) reported resident has some discoloration to buttocks upon further assessment resident noted to have a large deep tissue injury to the buttocks, L 13 cm W 11 cm area noted to be purple and maroon in color, purple area cool and firm to touch, non-blanchable, small open area on coccyx just inside butt folds 1.5 cm D (deep) resident also was noted to have a Stage II to the area just below anus to perineum areas, small amount of dark red blood noted upon cleaning area, resident also noted to have some open areas to scrotum area, cleaned with wound cleaner and skin barrier cream applied to the area at this time, will notify unit manager, MD and RP in AM will continue to monitor." In an interview on 11/08/11 at 10:30 AM, the Director of Nurses (DON) stated they found the excoriation on Resident #1 on 11/05/11. She stated as soon as it was found staff contacted her. The treatment nurse at that time Licenced Vocation Nurse (LVN) E had only been working about a month as the treatment nurse. She stated he told her that he did not look at Resident #1's skin on 11/04/11 as he had documented. He told her he took the word of a unidentified nurse aide that there was no skin breakdown. Review of the weekly skin assessments for Resident #1 dated from 06/03/11 through 11/04/11, reflected Resident #1 had no skin breakdown. The skin assessment (documented as November 2011) for 11/05/11 entery refers to the nurses notes for further information. Review of the nurse's notes dated 11/05/11 at 5:23 AM reflected "5:30 AM resident in bed has been turned and repositioned from left to right side only due to finding of the decubitus (on Resident #1's) buttocks area. The decubitus was noted to have a foul odor, the area cleaned and skin barrier applied will continue to monitor." Review of the nurses notes, dated 11/05/11 at 4:48 PM, reflected Resident #1 had a change in condition with critical labs results and the phyician was notified. The physician ordered Resident #1 to be sent to a local hospital for evaluation. The resident was noted to have a DTI (deep tissue injury) to the gluteal cleft region with some weeping and excoriation to the scrotal sack. [MEDICATION NAME] was placed on the scrotal sack and groin area and the gluteal cleft area was open to air pending consult for the wound physicians. Alternating pressure relief mattress ordered then canceled once the order was received to send to the emergency department. Observation on 11/08/11 at 12:00 PM at the hospital revealed Resident #1 was in ICU (intensive care unit), comatose, and on a ventilator. Resident #1's wounds were observed. There was red beefy colored tissue to the wound area that was measured by the hospital at 12.0 cm x 10.0 cm x 0.1 cm. There was black Eschar to the bottom of the gluteal folds extending out to encompass both sides of the gluteal fold and the across the crease of the buttock just above the rectal opening. The top of the wound at the coccyx area was fresh beefy colored skin. When the ICU nurse cleaned Resident #1 some of the skin to the coccyx area rolled back on its self. The crease of the buttock had yellow slough with beefy redness along the length of the crease. There were two stage II type open areas underneath the scrotal sack with the lower area having some necrotic tissue. There was an open area to the right inside thigh that appeared to be a tear. The wound was foul smelling and had bloody drainage. In an interview on 11/08/11 at 12:45 PM, the ICU physician stated Resident #1 had severe septic shock, severe dehydration with critical values for sodium, BUN and E-coli urinary tract infection. He stated the septic shock was under control. Resident #1 is still comatose. The physician stated he was not sure but did not think the wound caused [MEDICAL CONDITION]. He stated the wound did not occur over night. In an interview on 11/08/11 at 2:15 PM, the Director of Nurses (DON) stated a there was a treatment nurse completing weekly skin checks at the time of discovering Resident #1's skin issues. She stated at this time the licensed staff is completing the skin checks. She stated when the pressure area to Resident #1 was identified they (DON and nurses) proceeded to do skin checks in the facility. She stated they (her and nurses) did skin checks on the resident who were high risk for skin breakdown first on 11/05/11 and did everyone else on Sunday (11/06/11) and Monday (11/07/11). She stated she did not know who else the nurse (LVN E) did not look at. She stated the nurse aides now have to fill out a QA sheet when they identify anything (any skin issues, tears, bruises etc) and have the nurse sign the sheet before turning it into the Unit Manager. She stated one of the nurse aides (CNA S) stated she told a nurse (LVN G) on Wednesday (10/31/11) that Resident #1's buttocks was red but the nurse stated she was not informed. She stated the staff started a full house skin check on all residents on 11/05/11 and she went personally to check Resident #1's skin. She stated there was no foul odor inside the buttock cheeks and there was a weeping stage II. She stated the former treatment nurses (now a unit manager LVN F) cleaned him up and placed a Foley catheter to protect the wounds from urine. She stated they noticed Resident #1 was warm to touch. She stated she talked with the physician when the critical labs were found and the physician stated to send Resident #1 to the ER room. She stated Resident #1 was put in a gown, and his urine was tea like in color with small sediments like blood clots. She stated they chart weekly on all issues regardless of the residents condition as she does not like charting by exception. She stated he was still eating and his weight had not changed. In an interview on 11/08/11 at 2:40 PM, the DON stated that LVN F was the former treatment nurse and she had no problems when she was the nurse. She stated there was no issues until LVN E took over. She stated she had no documentation of LVN E's training for the treatment nurse position but she trusted LVN F to teach what she knew. She stated she told LVN F to teach LVN E how she does it and she told LVN E to do the treatments the way LVN F did them. She stated she had not monitored to see how LVN E was doing with treatments. In an interview on 11/08/11 at 2:50 PM LVN F stated she was the treatment nurse up till about a month ago. She stated she checked skin weekly on everyone. She stated on 11/05/11, "When they did the skin checks they found little things like a few stage II's. Resident #1 had a large purple deep tissue injury with areas starting to open with weeping bloody drainage from the anus to the coccyx area. When the buttock cheeks were closed together it was red on top of the buttock. When the cheeks were open or separated it was purple with redness around the edges. It was not open but maybe starting to open. When the cheeks were opened the crease area was weeping bloody discharge. He appeared to be uncomfortable with pain. She had already cleaned him up, there was no feces, no odor at that time." In an interview on 11/08/11 at 3:25 PM, nurse aide CNA S stated she took care of Resident #1 on 11/05/11 on the evening shift. She stated his buttock was really red and it looked really bad. She stated she noticed the redness to Resident #1's bottom on Wednesday (11/03/11) during incontinent care. She stated she told nurse (LVN G) on Wednesday (11/03/11) and the nurse told her to apply barrier cream. She stated the Resident was really red on Wednesday when she reported it and the nurse did not look at Resident #1's redness. On Friday (11/05/11) CNA S stated she gave Resident #1 a shower and he was not acting right. She stated he was lethargic and acted like he was in pain when she washed his bottom. He was flinching and grimacing. She stated she wiped up the crease of the buttocks but did not look at it. CNA S stated she has been in-serviced on identifying change in condition after the issue with Resident #1 on 11/05/11. In an interview on 11/08/11 at 3:27 PM, LVN G stated, "No one told me about Resident #1's skin until Saturday 11/05/11." She stated again she did not know about the issue until Saturday 11/05/11. In an interview on 11/09/11 at 1:05 PM CNA Y stated she works with Resident #1 a couple days a week. She stated she does not remember him complaining of pain the last week (week of 11/01/11 through 11/5/11). In an interview on 11/09/11 at 1:10 PM CNA X stated she just started working the day shift. She stated nights already have him up when she comes on and if not she gets Resident #1 up between 6:45/7:15 AM into the geri-chair. She stated he will stay in the geri chair until after lunch. She stated on Thursday 11/03/11 and Friday 11/04/11 she did not see anything on Resident #1 as he was already up. She stated on 11/04/11 she checked on him about 9:00/10:00 AM and he was dry. After lunch he was wet. She stated she did not see anything at that time. She stated when she cleaned Resident #1 after lunch she did not look at his back side. She stated he was wet so she reached his back side from the front and washed him off but did not look at it. She put his brief on from the front and did not look at his bottom. In an interview on 11/09/11 at 1:20 PM the DON stated the former treatment nurse (LVN F) trained LVN E how she did her treatments. The DON stated LVN E had worked as the treatment nurse for 3 weeks to a month when this incident with Resident #1 occurred. She stated the staff verbally tells the treatment nurse or the charge nurse if there were skin issues. She stated the interdisciplinary team meets weekly and weights and skin are discussed with dietary involved. She stated there was no written statement in the policy and procedure saying skin checks were to be completed weekly. She stated it is part of the treatment nurses job description. In an interview on 11/09/11 at 3:05 LVN E stated he was out sick, in the hospital, the week prior to Resident #1 being identified with the skin issue. He stated because he was out the prior week to 11/05/11 (end of October) that week he did not check Resident #1. He stated the week of 11/05/11 he did not check Resident #1 either but took the word of a new nurse aide (unidentified) that Resident #1 had no skin issues. He stated, "Apparently no one else checked him (Resident #1) or other residents while I was in the hospital." He stated someone sent him a picture of Resident #1's wound and he was shocked. LVN E stated the week prior to him going to the hospital Resident #1 skin was fine. He stated he was the treatment nurse as of October 3, 2011. He stated he was given a treatment cart and the treatment book. He was not told what to do. He stated he knew to do the weekly checks from another facility he worked at. He stated you can ask any of the staff if they brought skin issues to my attention I was right on it and took care of it. LVN E stated. "That wound on Resident #1 did not happen overnight. There was a 2 week time lapse - 14 days, 40 shifts and no one brought it to my attention". He stated no one was assigned to do treatment while he was in the hospital and he found dressing that had not been changed while he was gone. The dressings were the same ones he put on". In an interview on 11/09/11 at 3:20 PM the attending physician for Resident #1 stated, "I sure do think it was unavoidable." She stated she was told that day (11/05/11) about Resident #1 having a temperature and she ordered labs to be done. She stated she ordered him to be sent to the hospital because of critical labs. She stated she was told his bottom was red and she told them to put cream on it. She stated she did see him in the hospital and she was shocked at the look of the wound. She stated this wound did not happen overnight. It could have happened in 3-5 days because he sat in a geri-chair all the time. She stated she believes [MEDICAL CONDITION] was from the urinary tract and probably not from the wound. She stated she was not aware of the skin until Saturday morning the 5th and she was shocked when she saw it. In an interview on 11/09/11 at 3:25 PM nurse LVN F stated Resident #1's, "his bottom was purple with redness around the edges with the inside (crease) being deep purple. It looked horrible and I will remember what it looked like for the rest of my life." She stated she told LVN-E how treatments were to be done and to do skin checks weekly. She stated the building is divided into 3 days to get weekly skin checks completed. She did not know LVN-E's schedule. Review of the facility's Procedure for Abuse Prohibition Policy dated 02/17/10 identifies neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Under number 5 (no page number) titled Signs of Actual Physical Neglect included "1. [MEDICAL CONDITION] and dehydration (unexplained weight loss, b. poor hygiene, c. inappropriate clothing (soiled, tattered, poor fitting, lacking, inappropriate for season), decayed teeth e. improper use/administration of medications, f. inadequate provision of care, g. caregiver indifferent to resident's personal care and needs, h. failure to provide privacy and i. leaving someone unattended who needs supervision." The facility census of 73 was provided by the Administrator.

Based on observation, interview and record review the facility failed to implement their written policies and procedures that prohibit abuse/neglect when they failed to to identify pressure sores on 1 of 9 residents reviewed (Resident #1). There were 3 of 3 Certified Nurse Aides (CNA S, X and Y) that did not identify skin issues on Reisdent #1 and notifiy a charge nurse or a treatment nurse. The facility failed to correctly assess and document weekly skin assessments which resulted in Resident #1 having an unstageable pressure wound to his buttock and coccyx area. The wound was not identified until Resident #1 had a temperature requiring a Tylenol suppository. Resident #1 had labs ordered which indicated severe dehydration. When the resident arrived at the hospital he went into [MEDICAL CONDITION] and placed on a vent. The emergency room identified a wound with Eschar, slough and necrotic tissue extending from the rectal opening to the coccyx and extending outward into buttock tissue measuring 12.0 cm x 10.0 cm x 0.1 cm. There was also abrasions and [MEDICAL CONDITION] to the scrotum, an open area to the left ischium, an open area to the right medial thigh and a deep tissue injury to the left lateral heel. None of these areas of skin break down were identified by the facility. The deficient practice to ensure residents did not develop pressure ulcers allowed one (1) resident to have pressure ulcer development and placed the additional eight (8) residents at risk for not receiving nursing services in a timely manner and developing pressure ulcers. Findings included: Review of the facility's Procedure for Abuse Prohibition Policy dated 02/17/10 identifies neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Under number 5 (no page number) titled Signs of Actual Physical Neglect included "1. [MEDICAL CONDITION] and dehydration (unexplained weight loss, b. poor hygiene, c. inappropriate clothing (soiled, tattered, poor fitting, lacking, inappropriate for season), decayed teeth e. improper use/administration of medications, f. inadequate provision of care, g. caregiver indifferent to resident's personal care and needs, h. failure to provide privacy and i. leaving someone unattended who needs supervision." Review of Resident #1's facility face sheet reflected Resident #1 was admitted on [DATE]. His admitting [DIAGNOSES REDACTED]. Resident #1 was [AGE] years old and with cognition impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/20/11, under skin conditions, M1200B, skin/ulcer treat: pressure reducing device for bed was checked. M1040Z, Other skin problems: none of the above was checked. M0150 Is resident at risk of developing pressure ulcer was checked. Review of the care plan dated 06/06/11, Resident #1 is a high risk for pressure ulcers. The care plan reflected Resident #1 has "Potential for developing pressure ulcers or other skin breakdown related to decreased mobility and incontinent of bladder and bowel. Approaches include skin checks weekly with bathing, and with care. CNA's to notify nurse of any reddened or broken skin, and nurse will notify physician and family. Skin check by nurse once weekly". Review of the nurses notes, dated 11/05/11 at 2:21 AM, reflected a "nurse aide (CNA S) reported resident has some discoloration to buttocks upon further assessment resident noted to have a large deep tissue injury to the buttocks, L 13 cm W 11 cm area noted to be purple and maroon in color, purple area cool and firm to touch, non-blanchable, small open area on coccyx just inside butt folds 1.5 cm D (deep) resident also was noted to have a Stage II to the area just below anus to perineum areas, small amount of dark red blood noted upon cleaning area, resident also noted to have some open areas to scrotum area, cleaned with wound cleaner and skin barrier cream applied to the area at this time, will notify unit manager, MD and RP in AM will continue to monitor." In an interview on 11/08/11 at 10:30 AM, the Director of Nurses (DON) stated they found the excoriation on Resident #1 on 11/05/11. She stated as soon as it was found staff contacted her. The treatment nurse at that time Licenced Vocation Nurse (LVN) E had only been working about a month as the treatment nurse. She stated he told her that he did not look at Resident #1's skin on 11/04/11 as he had documented. He told her he took the word of a unidentified nurse aide that there was no skin breakdown. Review of the weekly skin assessments for Resident #1 dated from 06/03/11 through 11/04/11, reflected Resident #1 had no skin breakdown. The skin assessment (documented as November 2011) for 11/05/11 entery refers to the nurses notes for further information. Review of the nurse's notes dated 11/05/11 at 5:23 AM reflected "5:30 AM resident in bed has been turned and repositioned from left to right side only due to finding of the decubitus (on Resident #1's) buttocks area. The decubitus was noted to have a foul odor, the area cleaned and skin barrier applied will continue to monitor." Review of the nurses notes, dated 11/05/11 at 4:48 PM, reflected Resident #1 had a change in condition with critical labs results and the phyician was notified. The physician ordered Resident #1 to be sent to a local hospital for evaluation. The resident was noted to have a DTI (deep tissue injury) to the gluteal cleft region with some weeping and excoriation to the scrotal sack. [MEDICATION NAME] was placed on the scrotal sack and groin area and the gluteal cleft area was open to air pending consult for the wound physicians. Alternating pressure relief mattress ordered then canceled once the order was received to send to the emergency department. Observation on 11/08/11 at 12:00 PM at the hospital revealed Resident #1 was in ICU (intensive care unit), comatose, and on a ventilator. Resident #1's wounds were observed. There was red beefy colored tissue to the wound area that was measured by the hospital at 12.0 cm x 10.0 cm x 0.1 cm. There was black Eschar to the bottom of the gluteal folds extending out to encompass both sides of the gluteal fold and the across the crease of the buttock just above the rectal opening. The top of the wound at the coccyx area was fresh beefy colored skin. When the ICU nurse cleaned Resident #1 some of the skin to the coccyx area rolled back on its self. The crease of the buttock had yellow slough with beefy redness along the length of the crease. There were two stage II type open areas underneath the scrotal sack with the lower area having some necrotic tissue. There was an open area to the right inside thigh that appeared to be a tear. The wound was foul smelling and had bloody drainage. In an interview on 11/08/11 at 12:45 PM, the ICU physician stated Resident #1 had severe septic shock, severe dehydration with critical values for sodium, BUN and E-coli urinary tract infection. He stated the septic shock was under control. Resident #1 is still comatose. The physician stated he was not sure but did not think the wound caused [MEDICAL CONDITION]. He stated the wound did not occur over night. In an interview on 11/08/11 at 2:15 PM, the Director of Nurses (DON) stated a there was a treatment nurse completing weekly skin checks at the time of discovering Resident #1's skin issues. She stated at this time the licensed staff is completing the skin checks. She stated when the pressure area to Resident #1 was identified they (DON and nurses) proceeded to do skin checks in the facility. She stated they (her and nurses) did skin checks on the resident who were high risk for skin breakdown first on 11/05/11 and did everyone else on Sunday (11/06/11) and Monday (11/07/11). She stated she did not know who else the nurse (LVN E) did not look at. She stated the nurse aides now have to fill out a QA sheet when they identify anything (any skin issues, tears, bruises etc) and have the nurse sign the sheet before turning it into the Unit Manager. She stated one of the nurse aides (CNA S) stated she told a nurse (LVN G) on Wednesday (10/31/11) that Resident #1's buttocks was red but the nurse stated she was not informed. She stated the staff started a full house skin check on all residents on 11/05/11 and she went personally to check Resident #1's skin. She stated there was no foul odor inside the buttock cheeks and there was a weeping stage II. She stated the former treatment nurses (now a unit manager LVN F) cleaned him up and placed a Foley catheter to protect the wounds from urine. She stated they noticed Resident #1 was warm to touch. She stated she talked with the physician when the critical labs were found and the physician stated to send Resident #1 to the ER room. She stated Resident #1 was put in a gown, and his urine was tea like in color with small sediments like blood clots. She stated they chart weekly on all issues regardless of the residents condition as she does not like charting by exception. She stated he was still eating and his weight had not changed. In an interview on 11/08/11 at 2:40 PM, the DON stated that LVN F was the former treatment nurse and she had no problems when she was the nurse. She stated there was no issues until LVN E took over. She stated she had no documentation of LVN E's training for the treatment nurse position but she trusted LVN F to teach what she knew. She stated she told LVN F to teach LVN E how she does it and she told LVN E to do the treatments the way LVN F did them. She stated she had not monitored to see how LVN E was doing with treatments. In an interview on 11/08/11 at 2:50 PM LVN F stated she was the treatment nurse up till about a month ago. She stated she checked skin weekly on everyone. She stated on 11/05/11, "When they did the skin checks they found little things like a few stage II's. Resident #1 had a large purple deep tissue injury with areas starting to open with weeping bloody drainage from the anus to the coccyx area. When the buttock cheeks were closed together it was red on top of the buttock. When the cheeks were open or separated it was purple with redness around the edges. It was not open but maybe starting to open. When the cheeks were opened the crease area was weeping bloody discharge. He appeared to be uncomfortable with pain. She had already cleaned him up, there was no feces, no odor at that time." In an interview on 11/08/11 at 3:25 PM, nurse aide CNA S stated she took care of Resident #1 on 11/05/11 on the evening shift. She stated his buttock was really red and it looked really bad. She stated she noticed the redness to Resident #1's bottom on Wednesday (11/03/11) during incontinent care. She stated she told nurse (LVN G) on Wednesday (11/03/11) and the nurse told her to apply barrier cream. She stated the Resident was really red on Wednesday when she reported it and the nurse did not look at Resident #1's redness. On Friday (11/05/11) CNA S stated she gave Resident #1 a shower and he was not acting right. She stated he was lethargic and acted like he was in pain when she washed his bottom. He was flinching and grimacing. She stated she wiped up the crease of the buttocks but did not look at it. CNA S stated she has been in-serviced on identifying change in condition after the issue with Resident #1 on 11/05/11. In an interview on 11/08/11 at 3:27 PM, LVN G stated, "No one told me about Resident #1's skin until Saturday 11/05/11." She stated again she did not know about the issue until Saturday 11/05/11. In an interview on 11/09/11 at 1:05 PM CNA Y stated she works with Resident #1 a couple days a week. She stated she does not remember him complaining of pain the last week (week of 11/01/11 through 11/5/11). In an interview on 11/09/11 at 1:10 PM CNA X stated she just started working the day shift. She stated nights already have him up when she comes on and if not she gets Resident #1 up between 6:45/7:15 AM into the geri-chair. She stated he will stay in the geri chair until after lunch. She stated on Thursday 11/03/11 and Friday 11/04/11 she did not see anything on Resident #1 as he was already up. She stated on 11/04/11 she checked on him about 9:00/10:00 AM and he was dry. After lunch he was wet. She stated she did not see anything at that time. She stated when she cleaned Resident #1 after lunch she did not look at his back side. She stated he was wet so she reached his back side from the front and washed him off but did not look at it. She put his brief on from the front and did not look at his bottom. In an interview on 11/09/11 at 1:20 PM the DON stated the former treatment nurse (LVN F) trained LVN E how she did her treatments. The DON stated LVN E had worked as the treatment nurse for 3 weeks to a month when this incident with Resident #1 occurred. She stated the staff verbally tells the treatment nurse or the charge nurse if there were skin issues. She stated the interdisciplinary team meets weekly and weights and skin are discussed with dietary involved. She stated there was no written statement in the policy and procedure saying skin checks were to be completed weekly. She stated it is part of the treatment nurses job description. In an interview on 11/09/11 at 3:05 LVN E stated he was out sick, in the hospital, the week prior to Resident #1 being identified with the skin issue. He stated because he was out the prior week to 11/05/11 (end of October) that week he did not check Resident #1. He stated the week of 11/05/11 he did not check Resident #1 either but took the word of a new nurse aide (unidentified) that Resident #1 had no skin issues. He stated, "Apparently no one else checked him (Resident #1) or other residents while I was in the hospital." He stated someone sent him a picture of Resident #1's wound and he was shocked. LVN E stated the week prior to him going to the hospital Resident #1 skin was fine. He stated he was the treatment nurse as of October 3, 2011. He stated he was given a treatment cart and the treatment book. He was not told what to do. He stated he knew to do the weekly checks from another facility he worked at. He stated you can ask any of the staff if they brought skin issues to my attention I was right on it and took care of it. LVN E stated. "That wound on Resident #1 did not happen overnight. There was a 2 week time lapse - 14 days, 40 shifts and no one brought it to my attention". He stated no one was assigned to do treatment while he was in the hospital and he found dressing that had not been changed while he was gone. The dressings were the same ones he put on". In an interview on 11/09/11 at 3:20 PM the attending physician for Resident #1 stated, "I sure do think it was unavoidable." She stated she was told that day (11/05/11) about Resident #1 having a temperature and she ordered labs to be done. She stated she ordered him to be sent to the hospital because of critical labs. She stated she was told his bottom was red and she told them to put cream on it. She stated she did see him in the hospital and she was shocked at the look of the wound. She stated this wound did not happen overnight. It could have happened in 3-5 days because he sat in a geri-chair all the time. She stated she believes [MEDICAL CONDITION] was from the urinary tract and probably not from the wound. She stated she was not aware of the skin until Saturday morning the 5th and she was shocked when she saw it. In an interview on 11/09/11 at 3:25 PM nurse LVN F stated Resident #1's, "his bottom was purple with redness around the edges with the inside (crease) being deep purple. It looked horrible and I will remember what it looked like for the rest of my life." She stated she told LVN-E how treatments were to be done and to do skin checks weekly. She stated the building is divided into 3 days to get weekly skin checks completed. She did not know LVN-E's schedule. The facility census of 73 was provided by the Administrator.

Based on observation, interview and record review the facility failed to ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the residents condition demonstrates it is unavoidable for 1of 9 residents reviewed for pressure ulcers (Resident #1). There were 3 of 3 Certified Nurse Aides (CNA S, X and Y) that cared for Resident #1 who did not identify skin issues and notify a licensed nurse or the treatment nurse. The facility failed to correctly assess and document weekly skin assessments which resulted in Resident #1 having an unstageable pressure wound to his buttock and coccyx area. The wound was not identified until Resident #1 had a temperature requiring a Tylenol suppository. Resident #1 had labs ordered which indicated severe dehydration. When the resident arrived at the hospital he went into [MEDICAL CONDITION] and placed on a vent. The emergency room identified a wound with Eschar, slough and necrotic tissue extending from the rectal opening to the coccyx and extending outward into buttock tissue measuring 12.0 cm x 10.0 cm x 0.1 cm. There was also abrasions/ and [MEDICAL CONDITION] to the scrotum, an open area to the left ischium, an open area to the right medial thigh and a deep tissue injury to the left lateral heel. None of these areas of skin break down were identified by the facility. The deficient practice to ensure residents did not develop pressure ulcers allowed one (1) resident to have pressure ulcer development and placed the addition eight (8) residents at risk for not receiving nursing services in a timely manner and developing pressure ulcers. Findings included: Review of Resident #1's facility face sheet reflected Resident #1 was admitted on [DATE]. His admitting [DIAGNOSES REDACTED]. Resident #1 was [AGE] years old and with cognition impairment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/20/11, under skin conditions, M1200B, skin/ulcer treat: pressure reducing device for bed was checked. M1040Z, Other skin problems: none of the above was checked. M0150 Is resident at risk of developing pressure ulcer was checked. Review of the care plan dated 06/06/11, Resident #1 is a high risk for pressure ulcers. The care plan reflected Resident #1 has "Potential for developing pressure ulcers or other skin breakdown related to decreased mobility and incontinent of bladder and bowel. Approaches include skin checks weekly with bathing, and with care. CNA's to notify nurse of any reddened or broken skin, and nurse will notify physician and family. Skin check by nurse once weekly". Review of the nurses notes, dated 11/05/11 at 2:21 AM, reflected a "nurse aide (CNA S) reported resident has some discoloration to buttocks upon further assessment resident noted to have a large deep tissue injury to the buttocks, L 13 cm W 11 cm area noted to be purple and maroon in color, purple area cool and firm to touch, non-blanchable, small open area on coccyx just inside butt folds 1.5 cm D (deep) resident also was noted to have a Stage II to the area just below anus to perineum areas, small amount of dark red blood noted upon cleaning area, resident also noted to have some open areas to scrotum area, cleaned with wound cleaner and skin barrier cream applied to the area at this time, will notify unit manager, MD and RP in AM will continue to monitor." In an interview on 11/08/11 at 10:30 AM, the Director of Nurses (DON) stated they found the excoriation on Resident #1 on 11/05/11. She stated as soon as it was found staff contacted her. The treatment nurse at that time Licenced Vocation Nurse (LVN) E had only been working about a month as the treatment nurse. She stated he told her that he did not look at Resident #1's skin on 11/04/11 as he had documented. He told her he took the word of a unidentified nurse aide that there was no skin breakdown. Review of the weekly skin assessments for Resident #1 dated from 06/03/11 through 11/04/11, reflected Resident #1 had no skin breakdown. The skin assessment (documented as November 2011) for 11/05/11 entery refers to the nurses notes for further information. Review of the nurse's notes dated 11/05/11 at 5:23 AM reflected "5:30 AM resident in bed has been turned and repositioned from left to right side only due to finding of the decubitus (on Resident #1's) buttocks area. The decubitus was noted to have a foul odor, the area cleaned and skin barrier applied will continue to monitor." Review of the nurses notes, dated 11/05/11 at 4:48 PM, reflected Resident #1 had a change in condition with critical labs results and the phyician was notified. The physician ordered Resident #1 to be sent to a local hospital for evaluation. The resident was noted to have a DTI (deep tissue injury) to the gluteal cleft region with some weeping and excoriation to the scrotal sack. [MEDICATION NAME] was placed on the scrotal sack and groin area and the gluteal cleft area was open to air pending consult for the wound physicians. Alternating pressure relief mattress ordered then canceled once the order was received to send to the emergency department. Observation on 11/08/11 at 12:00 PM at the hospital revealed Resident #1 was in ICU (intensive care unit), comatose, and on a ventilator. Resident #1's wounds were observed. There was red beefy colored tissue to the wound area that was measured by the hospital at 12.0 cm x 10.0 cm x 0.1 cm. There was black Eschar to the bottom of the gluteal folds extending out to encompass both sides of the gluteal fold and the across the crease of the buttock just above the rectal opening. The top of the wound at the coccyx area was fresh beefy colored skin. When the ICU nurse cleaned Resident #1 some of the skin to the coccyx area rolled back on its self. The crease of the buttock had yellow slough with beefy redness along the length of the crease. There were two stage II type open areas underneath the scrotal sack with the lower area having some necrotic tissue. There was an open area to the right inside thigh that appeared to be a tear. The wound was foul smelling and had bloody drainage. In an interview on 11/08/11 at 12:45 PM, the ICU physician stated Resident #1 had severe septic shock, severe dehydration with critical values for sodium, BUN and E-coli urinary tract infection. He stated the septic shock was under control. Resident #1 is still comatose. The physician stated he was not sure but did not think the wound caused [MEDICAL CONDITION]. He stated the wound did not occur over night. In an interview on 11/08/11 at 2:15 PM, the Director of Nurses (DON) stated a there was a treatment nurse completing weekly skin checks at the time of discovering Resident #1's skin issues. She stated at this time the licensed staff is completing the skin checks. She stated when the pressure area to Resident #1 was identified they (DON and nurses) proceeded to do skin checks in the facility. She stated they (her and nurses) did skin checks on the resident who were high risk for skin breakdown first on 11/05/11 and did everyone else on Sunday (11/06/11) and Monday (11/07/11). She stated she did not know who else the nurse (LVN E) did not look at. She stated the nurse aides now have to fill out a QA sheet when they identify anything (any skin issues, tears, bruises etc) and have the nurse sign the sheet before turning it into the Unit Manager. She stated one of the nurse aides (CNA S) stated she told a nurse (LVN G) on Wednesday (10/31/11) that Resident #1's buttocks was red but the nurse stated she was not informed. She stated the staff started a full house skin check on all residents on 11/05/11 and she went personally to check Resident #1's skin. She stated there was no foul odor inside the buttock cheeks and there was a weeping stage II. She stated the former treatment nurses (now a unit manager LVN F) cleaned him up and placed a Foley catheter to protect the wounds from urine. She stated they noticed Resident #1 was warm to touch. She stated she talked with the physician when the critical labs were found and the physician stated to send Resident #1 to the ER room. She stated Resident #1 was put in a gown, and his urine was tea like in color with small sediments like blood clots. She stated they chart weekly on all issues regardless of the residents condition as she does not like charting by exception. She stated he was still eating and his weight had not changed. In an interview on 11/08/11 at 2:40 PM, the DON stated that LVN F was the former treatment nurse and she had no problems when she was the nurse. She stated there was no issues until LVN E took over. She stated she had no documentation of LVN E's training for the treatment nurse position but she trusted LVN F to teach what she knew. She stated she told LVN F to teach LVN E how she does it and she told LVN E to do the treatments the way LVN F did them. She stated she had not monitored to see how LVN E was doing with treatments. In an interview on 11/08/11 at 2:50 PM LVN F stated she was the treatment nurse up till about a month ago. She stated she checked skin weekly on everyone. She stated on 11/05/11, "When they did the skin checks they found little things like a few stage II's. Resident #1 had a large purple deep tissue injury with areas starting to open with weeping bloody drainage from the anus to the coccyx area. When the buttock cheeks were closed together it was red on top of the buttock. When the cheeks were open or separated it was purple with redness around the edges. It was not open but maybe starting to open. When the cheeks were opened the crease area was weeping bloody discharge. He appeared to be uncomfortable with pain. She had already cleaned him up, there was no feces, no odor at that time." In an interview on 11/08/11 at 3:25 PM, nurse aide CNA S stated she took care of Resident #1 on 11/05/11 on the evening shift. She stated his buttock was really red and it looked really bad. She stated she noticed the redness to Resident #1's bottom on Wednesday (11/03/11) during incontinent care. She stated she told nurse (LVN G) on Wednesday (11/03/11) and the nurse told her to apply barrier cream. She stated the Resident was really red on Wednesday when she reported it and the nurse did not look at Resident #1's redness. On Friday (11/05/11) CNA S stated she gave Resident #1 a shower and he was not acting right. She stated he was lethargic and acted like he was in pain when she washed his bottom. He was flinching and grimacing. She stated she wiped up the crease of the buttocks but did not look at it. CNA S stated she has been in-serviced on identifying change in condition after the issue with Resident #1 on 11/05/11. In an interview on 11/08/11 at 3:27 PM, LVN G stated, "No one told me about Resident #1's skin until Saturday 11/05/11." She stated again she did not know about the issue until Saturday 11/05/11. In an interview on 11/09/11 at 1:05 PM CNA Y stated she works with Resident #1 a couple days a week. She stated she does not remember him complaining of pain the last week (week of 11/01/11 through 11/5/11). In an interview on 11/09/11 at 1:10 PM CNA X stated she just started working the day shift. She stated nights already have him up when she comes on and if not she gets Resident #1 up between 6:45/7:15 AM into the geri-chair. She stated he will stay in the geri chair until after lunch. She stated on Thursday 11/03/11 and Friday 11/04/11 she did not see anything on Resident #1 as he was already up. She stated on 11/04/11 she checked on him about 9:00/10:00 AM and he was dry. After lunch he was wet. She stated she did not see anything at that time. She stated when she cleaned Resident #1 after lunch she did not look at his back side. She stated he was wet so she reached his back side from the front and washed him off but did not look at it. She put his brief on from the front and did not look at his bottom. In an interview on 11/09/11 at 1:20 PM the DON stated the former treatment nurse (LVN F) trained LVN E how she did her treatments. The DON stated LVN E had worked as the treatment nurse for 3 weeks to a month when this incident with Resident #1 occurred. She stated the staff verbally tells the treatment nurse or the charge nurse if there were skin issues. She stated the interdisciplinary team meets weekly and weights and skin are discussed with dietary involved. She stated there was no written statement in the policy and procedure saying skin checks were to be completed weekly. She stated it is part of the treatment nurses job description. In an interview on 11/09/11 at 3:05 LVN E stated he was out sick, in the hospital, the week prior to Resident #1 being identified with the skin issue. He stated because he was out the prior week to 11/05/11 (end of October) that week he did not check Resident #1. He stated the week of 11/05/11 he did not check Resident #1 either but took the word of a new nurse aide (unidentified) that Resident #1 had no skin issues. He stated, "Apparently no one else checked him (Resident #1) or other residents while I was in the hospital." He stated someone sent him a picture of Resident #1's wound and he was shocked. LVN E stated the week prior to him going to the hospital Resident #1 skin was fine. He stated he was the treatment nurse as of October 3, 2011. He stated he was given a treatment cart and the treatment book. He was not told what to do. He stated he knew to do the weekly checks from another facility he worked at. He stated you can ask any of the staff if they brought skin issues to my attention I was right on it and took care of it. LVN E stated. "That wound on Resident #1 did not happen overnight. There was a 2 week time lapse - 14 days, 40 shifts and no one brought it to my attention". He stated no one was assigned to do treatment while he was in the hospital and he found dressing that had not been changed while he was gone. The dressings were the same ones he put on". In an interview on 11/09/11 at 3:20 PM the attending physician for Resident #1 stated, "I sure do think it was unavoidable." She stated she was told that day (11/05/11) about Resident #1 having a temperature and she ordered labs to be done. She stated she ordered him to be sent to the hospital because of critical labs. She stated she was told his bottom was red and she told them to put cream on it. She stated she did see him in the hospital and she was shocked at the look of the wound. She stated this wound did not happen overnight. It could have happened in 3-5 days because he sat in a geri-chair all the time. She stated she believes [MEDICAL CONDITION] was from the urinary tract and probably not from the wound. She stated she was not aware of the skin until Saturday morning the 5th and she was shocked when she saw it. In an interview on 11/09/11 at 3:25 PM nurse LVN F stated Resident #1's, "his bottom was purple with redness around the edges with the inside (crease) being deep purple. It looked horrible and I will remember what it looked like for the rest of my life." She stated she told LVN-E how treatments were to be done and to do skin checks weekly. She stated the building is divided into 3 days to get weekly skin checks completed. She did not know LVN-E's schedule. The facility census of 73 was provided by the Administrator.

Based on observation, interview and record review the facility failed to ensure 1 of 17 residents receives adequate supervision to prevent accidents when: a. The facility failed to adequately secure Shower Room A ' s (300/400 hall shower room) door to limit access to Resident #22 who has a history of falls. Resident #22 entered Shower Room A on 09/30/2011 which resulted in a fall with a left hip fracture which required surgical repair. Resident #22 was transferred to another facility after her hospitalization . b. The facility failed to do appropriate assessments to determine if any other resident had a willingness to take showers independently. This deficient practice resulted in an Immediate Jeopardy (IJ) on 10/20/2011 at 2:45 PM. While the IJ was removed on 10/21/2011 at 11:45 AM, the facility remained out of compliance at a Severity of Actual Harm that is not an IJ, with a Scope of Isolated due to the lack of time to monitor the Plan of Removal for effectiveness. The deficient practice to ensure adequate supervision allowed Resident #22 to sustain an injury after a fall, and placed 17 residents able to stand unassisted or ambulate independently at risk for injury. Findings include: Review of Resident #22 ' s Medical Record Face Sheet reflected Resident #22 was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #22's Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). The MDS also reflected Resident #22 is able to transfer with one person assistance. Review of Resident #22's Care Plan, dated 07/19/2011, reflected Resident #22 " is at risk for injury R/T (related to) attempts to self-transfer and shower self without staff assistance ". The interventions on the care plan reflected: -Attempt to explain the inappropriateness of behaviors; - Attempt to involve resident in more productive behaviors; -Redirect as often as needed; -Monitor for changes in behaviors; -Provide verbal cues and reminders to have staff assist her with transfers and showers; -redirect and reorient as needed; -Provide verbal cues with each contact to have staff assist her with transfers, ADL ' s and Showering; and -On falling star program. During a telephone interview on 10/19/2011 at 8:40 AM, a relative of Resident #22 stated the resident had a fall on 09/30/2011 after trying to take a shower. Resident # 22 fell in the shower room and broke her hip. Resident # 22 had surgery to repair the hip the day after the fall. The Family requested Resident #22 to be transferred to a different facility after discharge from the hospital. During a telephone interview on 10/20/2011 at 10:35 AM, Resident #22 stated that on 09/30/2011, after she left the dining room she wanted to take a shower and went to the shower room in her wheelchair by herself. She entered the shower room and while transferring from her wheelchair to the shower chair, the shower chair moved and she fell to the floor. She also stated that she did not see any staff to ask for help to take a shower when she was going to the shower room. Record Review of Resident # 22's Emergency Physician Record dated 09/30/2011 reflected an [AGE] year old female admitted to the emergency room with a [DIAGNOSES REDACTED]. Record review of Resident #22 ' s X-Ray reports dated 09/30/2011 reflected a fracture of the left hip and a pubic bone fracture. Record review of the Operative Report from the hospital reflected Resident # 22 had surgery to repair her left hip on 10/01/2011. Review of the Resident Incident Report dated 10/03/2011, reflected the investigation was completed by the facility on 10/03/2011. The Resident Incident report dated 10/03/2011 also reflected Resident #22 has a history of 5 falls over the past 12 months: falls on 06/23/2011, 05/22/2011, 03/08/2011, 02/07/2011 and 10/08/2010. The Incident Report did not include actions to be taken by the facility after the incident on 09/30/2011. The Incident Investigation Report ruled out abuse or neglect. However, because there was no additional interventions and/or policies put in place to keep residents from accessing the shower room, bio hazard room or handicapped bathroom keys, the investigation was not adequately completed. During an interview on 10/21/2011 at 2:20 PM, Certified Nurse Aide (CNA) L stated she did not witness the fall; she was answering a call light at that time. She heard screaming, and then found Resident #22 on the floor in the shower room. She then sent another CNA to get a nurse. During an interview on 10/21/2011 at 2:25 PM, CNA M stated she first heard the screaming and found Resident #22 on the floor in the shower room. She notified the nurse and the nurse came to the shower room. She also stated Resident #22 had opened the shower room door at least one other time. At that time when she witnessed the resident opening the door, she reported the incident to Licensed Vocational Nurse (LVN) B. During an interview on 10/19/2011 at 1:00 PM, LVN A stated one of the CNAs came to get her while I was on break. The CNA stated Resident #22 had fallen in the shower. Resident #22 was observed lying on the floor with her left leg bent and her right leg straight. She was complaining of pain in her left leg and her head. When asked if she could straighten her left leg, she could not straighten it. LVN L called Resident #22 Primary Physician to notify him of the accident; Resident ' s Primary Physician said to send Resident #22 to emergency room (ER). LVN L called 9-1-1 and notified family. During an interview on 10/21/2011 at 2:35 PM, LVN B stated that she was not working on the evening of 09/30/2011, when the fall occurred. She had been told previously that Resident #22 had opened the shower room door before by herself using the key hanging on the door, and attempted to shower herself. LVN B further stated that Resident #22 was counseled after trying to enter the shower room unassisted, Resident was told to make sure she asked for help when she wanted a shower or needed any help. Observations from 10/18/2011 to 10/20/2011 in the facility by the surveyors revealed small round silver key chains with keys attached to retractable strings hanging on the upper right corner of the doors to the two common shower rooms, two biohazard rooms and the two handicap bathrooms. Observations made, during the same time period, of unidentified CNAs entering the Shower Room A and Shower Room B (common shower room on 100/200 hall), by using the keys hanging on the key rings on the doors. During an observation on 10/20/2011 at 11:50 AM revealed the key hanging on the key was attached to a retractable key chain and the key was inserted in the key hole, the door was unlocked. During an observation on 10/20/2011 at 1:20 PM revealed a key attached to the key chain on the door of Shower Room A room in the door lock and the door was ajar. No staff was observed in the hall at that time. During an observation on 10/20/2011 at 1:25 PM revealed Resident #21 was able to stand from her wheelchair and unlock the door to Shower Room A, with the key hanging on the door without assistance, at the request of the surveyors. During an observation on 10/20/2011 at 1:30 PM revealed Resident #23 was able to stand from her wheelchair and open the locked shower room door with the key on the key chain hanging on the door when asked by surveyors. During an interview on 10/19/2011 at 2:30 PM, the Director of Nurses (DON) stated that Resident #22 ' s accident in the Shower Room A happened as reported in the incident report. She was notified of the accident the night it happened and felt the nurse on duty took appropriate actions. During an interview on 10/19/2011 at 2:50 PM, the Administrator stated she was informed of the accident, did an investigation and determined that the accident did not constitute abuse or neglect, and that it was not an injury of unknown origin. She stated the accident was not called into the Department of Aging and Disability Services (DADS). The Administrator also stated that she believes that Resident #22 got into the shower room by using the keys hanging on the door. She stated her the only action taken after Residents #22 ' s accident on 09/30/2011 was the facility ordered non- slip tape for the common shower rooms floor.The adminstrator stated no inservices or any other interventions were done after Resident #22's accident on 09/30/2011. The Administrator also stated that the shower room doors should remain locked at all times. No policy on the shower doors being locked at all times received. During an observation on 10/20/2011 at 11:30 AM revealed the two Bio Hazard Room contained boxes of bio hazard materials in red bio hazard bags, and 3 sharps containers in bio hazard box. Several bottles of unknown chemicals were also stored in the bio hazard room. During an observation on 10/20/2011 at 11:25AM revealed the two handicapped bathrooms had a unlocked doors with access to the adjoining shower rooms. During an interview on 10/21/2011 at 11:00 AM, the Maintenance Director stated the keys have been hanging on the bathrooms, shower rooms and bio hazard rooms for 8 to 9 months. On 10/20/2011 at 2:45 PM, the Administrator was informed that an Immediate Jeopardy existed due to the failure to remove resident accessibility to the common shower rooms (the keys hanging on the shower room doors) and failure to provide adequate supervision to prevent resident injuries. On 10/20/2011 at 3:45 PM, the facility Administrator provided the survey team with a written plan of removal, which reflected the following: 1. Preventative Measures: The facility will remove all keys attached to the shower room doors immediately. The facility will remove all keys attached to the bio hazard room doors immediately. The facility will remove all keys attached to the bathroom doors immediately. Shower rooms, bathrooms, and bio hazard rooms will remain locked at all times. Keys for both shower rooms, bathrooms, and bio hazard rooms will be stored in a designated drawer at the nurses ' station and will be returned to designated drawer after each use. a. Employees will sign out keys at each occurrence 2. Monitoring Shower doors, bathroom doors and bio hazard doors are self locking and will be monitored each shift. Monitoring of doors will be completed by nurses on each shift and kept in 24 hour report book 3. Inservices: Inservice all staff on resident supervision in shower rooms/bathrooms and sign out sheets for shower room keys immediately. Inservice all staff on sign out sheets for bio hazard room keys immediately Inservice all nurses on daily monitoring immediately. The survey team confirmed the facility had started to implement the plan of removal; observed that all keys hanging on the shower rooms, bio hazard rooms, and bathroom doors were removed and placed behind the nurses ' station. The inservices were completed and confirmed by staff interviews and review of the inservice sign in sheets. Review of the facility key sign out sheets and the facility 24 hour report at the nurses ' stations reflected they were being used. The Plan of Removal was accepted on 10/21/2011 at 11:45 AM. While the IJ was removed on 10/21/2011 at 11:45 AM, the facility remained out of compliance due to the lack of time to monitor the Plan of Removal for effectiveness. The CMS 802 dated 10/18/2011 reflected 17 residents able to transfer or ambulate independently.

Based on observation, interview and record review the facility failed to provide services and supervision in accordance with facility policy to prevent neglect for 1 of 23 residents reviewed for falls (Resident #22). Resident #22 had a known history of falls. Staff previously witnessed Resident #22 trying to enter Shower Room A ( 300/400 hall shower room) by using the door key that was attached to a retractable key ring on the door. Resident #22 entered this same shower room on 09/30/2011 and fell while attempting to transfer herself from her wheelchair to the shower chair. This resulted in a fractured pelvis and required surgical repair. Resident 22 transferred to another facility after hospitalization . This deficient practice resulted in an Immediate Jeopardy (IJ) on 10/20/2011 at 2:45 PM. While the IJ was removed on 10/21/2011 at 11:45 AM, the facility remained out of compliance at a Severity of Actual Harm that is not an IJ, with a Scope of Isolated due to the lack of time to monitor the Plan of Removal for effectiveness. The deficient practice to implement their own policy to develop a policy and to ensure adequate supervision allowed Resident #22 to enter Shower Room A, sustain an injury after a fall, and placed 17 residents at risk for falls that can independently transfer or independently ambulate. Findings include: Review of Resident #22 ' s Face Sheet reflected Resident #22 was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #22's Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). The MDS also reflected Resident #22 was able to transfer with one person assistance. Review of Resident #22's Care Plan, dated 07/19/2011, reflected Resident #22 " is at risk for injury R/T (related to) attempts to self-transfer and shower self without staff assistance." The interventions on the care plan reflected: -Attempt to explain the inappropriateness of behaviors; - Attempt to involve resident in more productive behaviors; -Redirect as often as needed; -Monitor for changes in behaviors; -Provide verbal cues and reminders to have staff assist her with transfers and showers; -redirect and reorient as needed; -Provide verbal cues with each contact to have staff assist her with transfers, ADL ' s and Showering; and -On falling star program. During a telephone interview on 10/19/2011 at 8:40 AM, a relative of Resident #22 stated the resident had a fall on 09/30/2011 after attempting to shower herself alone. Resident #22 fell in the shower room, and broke her left hip and pelvis which required surgery. The family requested Resident #22 to be transferred to a different facility after discharge from the hospital. During a telephone interview on 10/20/2011 at 10:35 AM, Resident #22 stated that on 09/30/2011, after she left the dining room she wanted to take a shower and went to the shower room in her wheelchair by herself. She entered the shower room by herself and while transferring from her wheelchair to the shower chair, the shower chair moved and she fell to the floor. She also stated that she did not see any staff to ask for help to take a shower when she was going to the shower room. Review of the Resident Incident Report dated 10/03/2011, reflected the investigation was completed by the facility on 10/03/2011. The Resident Incident report dated 10/03/2011 also reflected Resident #22 has a history of 5 falls over the past 12 months: falls on 06/23/2011, 05/22/2011, 03/08/2011, 02/07/2011 and 10/08/2010. The Incident Report did not include actions to be taken by the facility after the incident on 09/30/2011. The incident investigation report ruled out abuse or neglect. However, because there was no additional interventions and/or policy put into place to keep residents from not accessing the shower room, bio hazard room or handicapped bathroom keys, the investigation was not adequately completed. During an interview on 10/21/2011 at 2:20 PM, Certified Nurse Aide (CNA) L stated she did not witness the fall; she was answering a call light at that time. She heard screaming, and then found Resident #22 on the floor in the shower room. She then sent another CNA to get a nurse. During an interview on 10/21/2011 at 2:25 PM, CNA M stated she first heard the screaming and found Resident #22 on the floor in the shower room. She notified the nurse and the nurse came to the shower room. She also stated she had witnessed Resident #22 unlock and open the shower room door at least one other time. At that time when she witnessed the resident unlocking and opening the door using the key, she stated she reported the incident to Licensed Vocational Nurse (LVN) B. During an interview on 10/21/2011 at 2:35 PM, LVN B stated that she was not working on the evening of 09/30/2011, when the fall occurred. She had been told previously that Resident #22 had opened the shower room door before by herself using the key hanging on the door, and attempted to shower herself. LVN B further stated that Resident #22 was counseled after trying to enter the shower room unassisted the first time; the resident was told to make sure she asked for help when she wanted a shower or needed any help. During an interview on 10/19/2011 at 2:50 PM, the Administrator stated she was informed of the accident and did an investigation that determined that the accident did not constitute abuse or neglect, and that it was not an injury of unknown origin. She stated the accident was not called into the Department of Aging and Disability Services (DADS). The Administrator also stated that she believes that Resident #22 got into the shower room by using the keys hanging on the door. She stated her the only action taken after Residents #22 ' s accident on 09/30/2011 was the facility ordered non- slip tape for the common shower rooms floor. The Administrator stated no inservices or any other interventions were done after Resident #22's accident on 09/30/2011. The Administrator also stated that the shower room doors should remain locked at all times. No policy was provided on the shower doors being locked at all times. Observations from 10/18/2011 to 10/20/2011 in the facility by the surveyors revealed small round silver key chains with keys attached to retractable strings hanging on the upper right corner of the doors to the two common shower rooms, two biohazard rooms and the two handicap bathrooms. Observations made, during the same time period, of unidentified CNAs entering the shower rooms by using the keys hanging on the key rings on the doors. Observation on 10/20/2011 at 11:50 AM revealed the key hanging on the key chain attached to the door of Shower Room A was in the shower room door lock. The shower room door opened easily due to being unlocked when the door handle was turned. No staff were observed in the hall or the shower room at that time Observation on 10/20/2011 at 1:20 PM revealed Shower Room B ' s key (that was attached to the door) was in the keyhole and the door was ajar. No staff were observed in the hall of the shower room or in the shower room at that time. Observation on 10/20/2011 at 1:25 PM revealed Resident #21 was able to stand and unlock the door to Shower Room A, with the key hanging on the door without assistance, at the request of the surveyors. Observation on 10/20/2011 at 1:30 PM revealed Resident #23 was able to stand and open the locked door to Shower Room A with the key on the key chain hanging on the door when asked by surveyors. Review of Facility ' s Abuse and Neglect Policy Section IV Part A. reviewed and updated on 09/2010 reflected " Our abuse prevention/intervention program includes...i) Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect." The policy also reflected in Section IV Part c. #5 " Signs of Actual Physical Neglect... i. leaving someone unattended who needs supervision ... " Further review of the Facility Abuse and Neglect Policy Section IV Part e. reflected " It is the responsibility of our employees, facility consultants, attending physicians... to promptly report any incident of or suspected incident of neglect or resident abuse...to facility management. All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies.... " On 10/20/2011 at 2:45 PM, the Administrator was informed that an Immediate Jeopardy existed due to the failure to remove resident accessibility to the common shower rooms (the keys hanging on the shower room doors) and failure to provide adequate supervision to prevent resident injuries. On 10/20/2011 at 3:45 PM, the facility Administrator provided the survey team with a written plan of removal, which reflected the following: 1. Preventative Measures: The facility will remove all keys attached to the shower room doors immediately. The facility will remove all keys attached to the bio hazard room doors immediately. The facility will remove all keys attached to the bathroom doors immediately. Shower rooms, bathrooms, and bio hazard rooms will remain locked at all times. Keys for both shower rooms, bathrooms, and bio hazard rooms will be stored in a designated drawer at the nurses ' station and will be returned to designated drawer after each use. a. Employees will sign out keys at each occurrence 2. Monitoring Shower doors, bathroom doors and bio hazard doors are self locking and will be monitored each shift. Monitoring of doors will be completed by nurses on each shift and kept in 24 hour report book 3. Inservices: Inservice all staff on resident supervision in shower rooms/bathrooms and sign out sheets for shower room keys immediately. Inservice all staff on sign out sheets for bio hazard room keys immediately Inservice all nurses on daily monitoring immediately. The survey team confirmed the facility had started to implement the plan of removal; observed that all keys hanging on the shower rooms, bio hazard rooms, and bathroom doors were removed and placed behind the nurses ' station. The inservices were completed and confirmed by staff interviews and review of the inservice sign in sheets. Review of the facility key sign out sheets and the facility 24 hour report at the nurses ' stations reflected they were being used. The Plan of Removal was accepted on 10/21/2011 at 11:45 AM. While the IJ was removed on 10/21/2011 at 11:45 AM, the facility remained out of compliance due to the lack of time to monitor the Plan of Removal for effectiveness. The CMS 802 dated 10/18/2011 reflected 17 residents that can independently transfer or independently amubulate.

Based on observation, interview and record review the facility failed to implement their written policy and procedure for abuse/neglect when they failed to identify and report an incident of neglect to the Department of Aging and Disability Services (DADS) for 1 of 23 residents reviewed for abuse/neglect. The facility failed to recognize and report suspected neglect during the investigation of Resident #22 ' s fall with injury on 09/30/2011. This deficient practice resulted in an Immediate Jeopardy (IJ) on 10/20/2011 at 2:45 PM. While the IJ was removed on 10/21/2011 at 11:45 AM, the facility remained out of compliance at a Severity of Actual Harm that is not an IJ, with a Scope of Isolated due to the lack of time to monitor the Plan of Removal for effectiveness. This deficient practice delayed a State Agency investigation, and no policies were put in place surrounding the circumstances of Resident #22 ' s fall and had the potential to affect an additional 17 residents who are able to independently ambulate and/or transfer independently. Findings include: Review of Facility ' s Abuse and Neglect Policy Section IV Part A. reviewed and updated on 09/2010 reflected " Our abuse prevention/intervention program includes...i) Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect." The policy also reflected in Section IV Part c. #5 " Signs of Actual Physical Neglect... i. leaving someone unattended who needs supervision ... "On further review of the Facility Abuse and Neglect Policy Section IV Part e. " It is the responsibility of our employees, facility consultants, attending physicians ... to promptly report any incident of or suspected incident of neglect or resident abuse ...to facility management. All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies...." Review of Resident #22 ' s Face Sheet reflected Resident #22 was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #22's Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). The MDS also reflected Resident #22 is able to transfer with one person assistance. Review of Resident #22's Care Plan, dated 07/19/2011, reflected Resident #22 " is at risk for injury R/T (related to) attempts to self-transfer and shower self without staff assistance ". The interventions on the care plan reflected: -Attempt to explain the inappropriateness of behaviors; - Attempt to involve resident in more productive behaviors; -Redirect as often as needed; -Monitor for changes in behaviors; -Provide verbal cues and reminders to have staff assist her with transfers and showers; -redirect and reorient as needed; -Provide verbal cues with each contact to have staff assist her with transfers, ADL ' s and Showering; and -On falling star program. During a telephone interview on 10/19/2011 at 8:40 AM, a relative of Resident #22 stated the resident had a fall on 09/30/2011 after trying to take a shower. Resident # 22 fell in the shower room and broke her hip. Resident # 22 had surgery to repair the hip the day after the fall. The family requested Resident #22 to be transferred to a different facility after discharge from the hospital. During a telephone interview on 10/20/2011 at 10:35 AM, Resident #22 stated that on 09/30/2011, after she left the dining room she wanted to take a shower and went to the shower room in her wheelchair by herself. She entered the shower room and while transferring from her wheelchair to the shower chair, the shower chair moved and she fell to the floor. She also stated that she did not see any staff to ask for help to take a shower when she was going to the shower room. During an interview on 10/21/2011 at 2:20 PM, Certified Nurse Aide (CNA) L stated she did not witness the fall; she was answering a call light at that time. She heard screaming, and then found Resident #22 on the floor in the shower room. She then sent another CNA to get a nurse. During an interview on 10/21/2011 at 2:25 PM, CNA M stated she first heard the screaming and found Resident #22 on the floor in the shower room. She notified the nurse and the nurse came to the shower room. She also stated Resident #22 had opened the shower room door at least one other time. At that time when she witnessed the resident opening the door, she reported the incident to Licensed Vocational Nurse (LVN) B. During an interview on 10/21/2011 at 2:35 PM, LVN B stated that she was not working on the evening of 09/30/2011, when the fall occurred. She had been told previously that Resident #22 had opened the shower room door before by herself using the key hanging on the door, and attempted to shower herself. LVN B further stated that Resident #22 was counseled after trying to enter the shower room unassisted the first time; the resident was told to make sure she asked for help when she wanted a shower or needed any help. Review of the Resident Incident Report dated 10/03/2011, reflected the investigation was completed by the facility on 10/03/2011. The Resident Incident report dated 10/03/2011 also reflected Resident #22 has a history of 5 falls over the past 12 months: falls on 06/23/2011, 05/22/2011, 03/08/2011, 02/07/2011 and 10/08/2010. The Incident Report did not include actions to be taken by the facility after the incident on 09/30/2011. The incident investigation report ruled out abuse or neglect. However, because there was no additional interventions and/or policy put into place to keep residents from accessing the shower room, bio hazard room or handicapped bathroom keys, the investigation was not adequately completed. During an interview on 10/19/2011 at 2:50 PM, the Administrator stated she was informed of the accident, did an investigation and determined that the accident did not constitute abuse or neglect, and that it was not an injury of unknown origin. She stated the accident was not called into the Department of Aging and Disability Services (DADS). The Administrator also stated that she believes that Resident #22 got into the shower room by using the keys hanging on the door. She stated her the only action taken after Residents #22 ' s accident on 09/30/2011 was the facility ordered non- slip tape for the common shower rooms floor.The Administrator stated no inservices or any other interventions were done after Resident #22's accident on 09/30/2011. The Administrator also stated that the shower room doors should remain locked at all times. There was no policy received on the shower doors being locked at all times. Observations from 10/18/2011 to 10/20/2011 in the facility by the surveyors revealed small round silver key chains with keys attached to retractable strings hanging on the upper right corner of the doors to the two common shower rooms, two biohazard rooms and the two handicap bathrooms. Observations made, during the same time period, of unidentified CNAs entering the Shower Room A and Shower Room B (common shower room on 100/200 hall, by using the keys hanging on the key rings on the doors. During an observation on 10/20/2011 at 11:50 AM of Shower Room A revealed the key hanging on the key was attached to a retractable key chain and the key was inserted in the key hole, the door was unlocked. No staff was observed in the hall at that time. During an observation on 10/20/2011 at 1:20 PM revealed a key attached to the key chain on the door of Shower Room B in the door lock and the door was ajar. No staff was observed in the hall at that time. On 10/20/2011 at 2:45 PM, the Administrator was informed that an Immediate Jeopardy existed due to the failure to remove resident accessibility to the common shower rooms (the keys hanging on the shower room doors) and failure to provide adequate supervision to prevent resident injuries. On 10/20/2011 at 3:45 PM, the facility Administrator provided the survey team with a written plan of removal, which reflected the following: 1. Preventative Measures: The facility will remove all keys attached to the shower room doors immediately. The facility will remove all keys attached to the bio hazard room doors immediately. The facility will remove all keys attached to the bathroom doors immediately. Shower rooms, bathrooms, and bio hazard rooms will remain locked at all times. Keys for both shower rooms, bathrooms, and bio hazard rooms will be stored in a designated drawer at the nurses ' station and will be returned to designated drawer after each use. a. Employees will sign out keys at each occurrence 2. Monitoring Shower doors, bathroom doors and bio hazard doors are self locking and will be monitored each shift. Monitoring of doors will be completed by nurses on each shift and kept in 24 hour report book 3. Inservices: Inservice all staff on resident supervision in shower rooms/bathrooms and sign out sheets for shower room keys immediately. Inservice all staff on sign out sheets for bio hazard room keys immediately Inservice all nurses on daily monitoring immediately. The survey team confirmed the facility had started to implement the plan of removal; observed that all keys hanging on the shower rooms, bio hazard rooms, and bathroom doors were removed and placed behind the nurses ' station. The inservices were completed and confirmed by staff interviews and review of the inservice sign in sheets. Review of the facility key sign out sheets and the facility 24 hour report at the nurses ' stations reflected they were being used. The Plan of Removal was accepted on 10/21/2011 at 11:45 AM. While the IJ was removed on 10/21/2011 at 11:45 AM, the facility remained out of compliance due to the lack of time to monitor the Plan of Removal for effectiveness. The CMS 802 dated 10/18/2011 reflected 17 residents that can independently transfer and ambulate.

Based on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively to attain the highest practicable physical well being for 1 of 23 residents (Resident #22) when: 1. The facility Administrator failed to supervise the facility's direct care staff to ensure Resident #22 was adequately monitored to prevent a fall with an injury. 2. The facility Administrator failed to take appropriate actions to restrict resident access to the common shower rooms (Shower Rooms A and B), the two Bio Hazard Rooms, and the two Handicapped Bathrooms after Resident #22 had a fall with injury on 9/30/11. Resident #22 was found in Shower Room A lying on the floor with complaints of pain to her hip and the back of her head. The keys to the facility ' s two common shower room doors remained accessible to the residents as the keys were on a key ring hanging on the upper left side of the shower room doors, on 10/18/2011. This deficient practice resulted in an Immediate Jeopardy (IJ) on 10/20/2011 at 2:45 PM. While the IJ was removed on 10/21/2011 at 11:45 AM, the facility remained out of compliance at a Severity of Actual Harm with a Scope of Isolated that is not IJ due to the lack of time to monitor the Plan of Removal for effectiveness. The deficient practice that the facility Administration did not ensure adequate supervision, that allowed Resident #22 to sustain an injury after a fall, and placed 17 residents able to stand unassisted or ambulate independently. . Findings include: Review of Resident #22 ' s Medical Record Face Sheet reflected Resident #22 was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #22's Minimum Data Set (MDS), dated [DATE], reflected a Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). The MDS also reflected Resident #22 was able to transfer with one person assistance. Review of Resident #22's Care Plan, dated 07/19/2011, reflected Resident #22 " is at risk for injury R/T (related to) attempts to self-transfer and shower self without staff assistance ". The interventions on the care plan reflected: -Attempt to explain the inappropriateness of behaviors; - Attempt to involve resident in more productive behaviors; -Redirect as often as needed; -Monitor for changes in behaviors; -Provide verbal cues and reminders to have staff assist her with transfers and showers; -redirect and reorient as needed; -Provide verbal cues with each contact to have staff assist her with transfers, ADL ' s and Showering; and -On falling star program. During a telephone interview on 10/19/2011 at 8:40 AM, a relative of Resident #22 stated the resident had a fall on 09/30/2011 after trying to take a shower. Resident # 22 fell in the shower room and broke her hip. Resident # 22 had surgery to repair the hip the day after the fall. The Family requested Resident #22 to be transferred to a different facility after discharge from the hospital. During a telephone interview on 10/20/2011 at 10:35 AM, Resident #22 stated that on 09/30/2011, after she left the dining room she wanted to take a shower and went to the shower room in her wheelchair by herself. She entered the shower room and while transferring from her wheelchair to the shower chair, the shower chair moved and she fell to the floor. She also stated that she did not see any staff to ask for help to take a shower when she was going to the shower room. During an interview on 10/21/2011 at 2:20 PM, Certified Nurse Aide (CNA) L stated she did not witness the fall; she was answering a call light at that time. She heard screaming, and then found Resident #22 on the floor in the shower room. She then sent another CNA to get a nurse. During an interview on 10/21/2011 at 2:25 PM, CNA M stated she first heard the screaming and found Resident #22 on the floor in the shower room. She notified the nurse and the nurse came to the shower room. She also stated Resident #22 had opened the shower room door at least one other time. At that time when she witnessed the resident opening the door, she reported the incident to Licensed Vocational Nurse (LVN) B (300/400 hall Unit Manager). During an interview on 10/19/2011 at 1:00 PM, LVN A stated one of the CNAs came to get her while I was on break. The CNA stated Resident #22 had fallen in the shower. Resident #22 was observed lying on the floor with her left leg bent and her right leg straight. She was complaining of pain in her left leg and her head. When asked if she could straighten her left leg, she could not straighten it. LVN A called Resident #22 Primary Physician to notify him of the accident; Resident ' s Primary Physician said to send Resident #22 to emergency room (ER). LVN A called 9-1-1 and notified family. During an interview on 10/21/2011 at 2:35 PM, LVN B stated that she was not working on the evening of 09/30/2011, when the fall occurred. She had been told previously that Resident #22 had opened the shower room door before by herself using the key hanging on the door, and attempted to shower herself. LVN B further stated that Resident #22 was counseled after trying to enter the shower room unassisted, Resident was told to make sure she asked for help when she wanted a shower or needed any help. Review of the Resident Incident Report dated 10/03/2011, reflected the investigation was completed by the facility on 10/03/2011. The Resident Incident report dated 10/03/2011 also reflected Resident #22 has a history of 5 falls over the past 12 months: falls on 06/23/2011, 05/22/2011, 03/08/2011, 02/07/2011 and 10/08/2010. The Incident Report did not include actions to be taken by the facility after the incident on 09/30/2011. The incident investigation report ruled out abuse or neglect. However, because there was no additional interventions and/or policy put into place to keep residents from not accessing the shower room, bio hazard room or handicapped bathroom keys, the investigation was not adequately completed. Observations from 10/18/2011 to 10/20/2011 in the facility by the surveyors revealed small round silver key chains with keys attached to retractable strings hanging on the upper right corner of the doors to the two common shower rooms, two biohazard rooms and the two handicap bathrooms. Observations made, during the same time period, of unidentified CNAs entering Shower Room A and Shower Room B (common shower room on 100/200 hall, by using the keys hanging on the key rings on the doors. During an interview on 10/21/2011 at 11:00 AM, the Maintenance Director stated the keys have been hanging on the bathrooms, shower rooms and bio hazard rooms for 8 to 9 months. Observation on 10/20/2011 at 11:50 AM revealed the key hanging on the key chain attached to the door of Shower Room A was in the shower room door lock. The shower room opened easily due to being unlocked when the handle was turned. No staff was observed in the hall of the shower room at that time. Observation on 10/20/2011 at 1:20 PM revealed a key attached to the key chain on the door of Shower Room B in the door lock and the door was ajar. No staff was observed in the hall at that time. During an observation on 10/20/2011 at 11:30 AM revealed the two Bio Hazard Room contained boxes of bio hazard materials in red bio hazard bags, and 3 sharps containers in bio hazard box. Several bottles of unknown chemicals were also stored in the bio hazard room. Both Bio Hazard rooms had retractable key chains with a key to unlock the doors attached to the doors. During an observation on 10/20/2011 at 11:25 AM revealed the two Handicapped Bathrooms had a unlocked doors with access to the adjoining shower rooms. Both Handicapped Bathrooms rooms had retractable key chains with a key to unlock the doors attached to the doors. Observation on 10/20/2011 at 1:25 PM revealed Resident #21 was able to stand and unlock the door to Shower Room A, with the key hanging on the door without assistance, at the request of the surveyors. Observation on 10/20/2011 at 1:30 PM revealed Resident #23 was able to stand from her wheelchair and unlock the door to Shower Room A, with the key on the key chain hanging on the door when asked by surveyors. During an interview on 10/19/2011 at 2:30 PM, the Director of Nurses (DON) stated that Resident #22 ' s accident in the shower room happened as reported in the incident report. She was notified of the accident the night it happened and felt the nurse on duty took appropriate actions. During an interview on 10/19/2011 at 2:50 PM, the Administrator stated she was informed of the accident, did an investigation and determined that the accident did not constitute abuse or neglect, and that it was not an injury of unknown origin. She stated the accident was not called into the Department of Aging and Disability Services (DADS). The Administrator also stated that she believes that Resident #22 got into the shower room by using the keys hanging on the door. She stated her the only action taken after Residents #22 ' s accident on 09/30/2011 was the facility ordered non- slip tape for the common shower rooms floor. The Administrator stated no inservices or any other interventions were done after Resident #22's accident on 09/30/2011. The Administrator also stated that the shower room doors should remain locked at all times. No policy on the shower doors being locked at all times received. Review of Facility ' s Abuse and Neglect Policy section IV part A. reviewed and updated on 09/2010 reflected " Our abuse prevention/intervention program includes ... ...i) Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect " . The policy also reflected in section IV part c. #5 " Signs of Actual Physical Neglect: ... i) Leaving someone unattended who needs supervision ... " On further review of the Facility Abuse and Neglect Policy section IV part e. " It is the responsibility of out employees, facility consultants, attending physicians ... to promptly report any incident of or suspected incident of neglect or resident abuse ... ...to facility management. All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies .... " . On 10/20/2011 at 2:45 PM, the Administrator was informed that an Immediate Jeopardy existed due to the failure to remove resident accessibility to the common shower rooms (the keys hanging on the shower room doors) and failure to provide adequate supervision to prevent resident injuries. On 10/20/2011 at 3:45 PM, the facility Administrator provided the survey team with a written plan of removal, which reflected the following: 1. Preventative Measures: The facility will remove all keys attached to the shower room doors immediately. The facility will remove all keys attached to the bio hazard room doors immediately. The facility will remove all keys attached to the bathroom doors immediately. Shower rooms, bathrooms, and bio hazard rooms will remain locked at all times. Keys for both shower rooms, bathrooms, and bio hazard rooms will be stored in a designated drawer at the nurses ' station and will be returned to designated drawer after each use. a. Employees will sign out keys at each occurrence 2. Monitoring Shower doors, bathroom doors and bio hazard doors are self locking and will be monitored each shift. Monitoring of doors will be completed by nurses on each shift and kept in 24 hour report book 3. Inservices: Inservice all staff on resident supervision in shower rooms/bathrooms and sign out sheets for shower room keys immediately. Inservice all staff on sign out sheets for bio hazard room keys immediately Inservice all nurses on daily monitoring immediately. The survey team confirmed the facility had started to implement the plan of removal; observed that all keys hanging on the shower rooms, bio hazard rooms, and bathroom doors were removed and placed behind the nurses ' station. The inservices were completed and confirmed by staff interviews and review of the inservice sign in sheets. Review of the facility key sign out sheets and the facility 24 hour report at the nurses ' stations reflected they were being used. The Plan of Removal was accepted on 10/21/2011 at 11:45 AM. While the IJ was removed on 10/21/2011 at 11:45 AM, the facility remained out of compliance due to the lack of time to monitor the Plan of Removal for effectiveness. The CMS 672 dated 10/18/2011 reflected 17 residents able to transfer or ambulate independently, confirmed by DON.