Every finding on record at Prairie House Living Center

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. for 2 of 7 residents (Residents #1 and #2) reviewed for abuse.The facility failed to report an incident of abuse dated 04/08/2026 between Resident #1 and Resident #2 to the state agency.This could place residents at risk of continued and/or unrecognized abuse, neglect, or exploitation.Findings Included:Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male was admitted to the facility originally on 02/05/2025 with a readmission of 04/22/2026. Diagnoses included but are not limited to dementia in other diseases classified elsewhere, severe, with other behavioral disturbance (decline in cognitive function with behaviors), anxiety, paranoid schizophrenia, and psychotic disorder with delusions. Record review of Resident #1's quarterly MDS, dated [DATE], under Section C- Cognitive Patterns, revealed a BIMs of 04, which indicated the resident has a severe cognitive impairment, reflecting difficulties with memory, orientation, and information recall. Record review of Resident #1's care plan, dated 03/27/2026, revealed Resident #1 focused goals of Resident has a behavior problem as evidenced by: Physical/verbal aggression towards staff and/or other residents. [Resident #1] has a behavior problem as evidenced by: [Resident #1] has been exhibiting physically aggression towards staff/residents.Record review of Resident #1's progress note, dated 04/04/2026 at 12:45 PM, revealed an entry, authored by ADON B, reflected, Resident pushed another resident and almost made her fall down.Resident #2Record review of Resident #2's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses included unspecified dementia, severe, with other behavioral disturbance, mild cognitive impairment, and Alzheimer's disease. Record review of Resident #2 MDS, dated [DATE], did not reveal a BIMS score. Record review of Resident #2's care plan, dated 03/12/2026, revealed focused goals of [Resident #2] has impaired cognition and is at risk for further decline in cognitive and functional abilities related to: unspecified dementia server with other behavioral disturbance. [Resident #2] has a behavior problem as evidenced by: physical behaviors. [Resident #2] also exhibiting rummaging behaviors.Record review of Resident #2's progress notes on 04/08/2026 revealed an authored note by ADON B reflected, Resident was pissed (pushed) by another resident and almost fell down.Record review of an incident report #1812, dated 04/08/2026, revealed a resident-to-resident altercation between Resident #1 and Resident #2 with Resident #1 listed as a perpetrator. Under heading, Incident Description, revealed CNA I witnessed a resident push another resident out of a room and almost pushed her down. The incident report revealed that the incident was not witnessed.In an interview on 06/11/2026 at 9:26 AM, CNA D stated a negative outcome of not reporting abuse, neglect, or exploitation could be the resident could possibly pass away.In an interview on 06/11/2026 at 9:48 AM, HSK E stated a negative outcome of not reporting abuse, neglect, or exploitation could be residents can get hurt and they are not being respected.In an interview on 06/11/2026 at 10:13 AM, LVN F stated a negative outcome of not reporting abuse, neglect, or exploitation could be injuries.In an interview on 06/11/2026 at 10:22 AM, CNA G stated a negative outcome of not reporting abuse, neglect, or exploitation could be the resident could get hurt and we(staff) wouldn't know about it.An interview on 06/11/2026 at 11:45 AM was attempted with Resident #1 in the memory hall. Resident #1 stated he did not remember the incident.In an interview on 06/11/2026 at 11:46 AM, RN C stated he knew about the incident, but he did not work on the day of the incident. RN C stated that it was reported that Resident #1 pushed Resident #2. RN C stated he felt that the incident of Resident #1 and Resident #2 would be reportable. RN C stated he did not know who was notified of the incident. RN C stated that the ADM was the abuse coordinator. RN C stated that a negative outcome could be more things could happen and people could get bolderIn an interview on 06/11/2026 at 11:50 AM, CNA H stated she knew about the incident between Resident #1 and Resident #2. CNA H stated she did not remember when the incident happened but remembered the situation. CNA H reported that Resident #2 went into Resident #1's room, Resident #1 got agitated and pushed her out. CNA H said CNA I was the aide that was working on the day of the incident. CNA H stated that ADM was the abuse coordinator and felt that the incident of Resident #1 pushing Resident #2 was reportable. CNA H stated a negative outcome could be someone could get seriously hurt or even death could result depending on how far it went.In an interview on 06/11/2026 at 2:46 PM, ADON B stated she was in the memory unit where the incident happened on 04/08/2026. ADON B stated the incident happened between Resident #1 and Resident #2. ADON B stated that the incident was reported to the ADM and DON but was unaware if they followed the chain or not. ADON B stated that she felt the incident was reportable even though staff were available to intervene. ADON B stated she was working in the memory unit when the incident happened, and Resident #2 had to grab the rail to keep from falling. ADON B stated the ADM was who reported to the state. ADON B stated she reported the incident to the ADM and DON during the day, and they were notified in person. ADON B stated a negative outcome was the abuse could continue and it could lead to the residents getting hurt.On 06/11/2026 at 2:57 PM, an attempt to speak with CNA I via phone call was unsuccessful.In an interview on 06/11/2026 at 3:22 PM, ADON A revealed she was aware of an incident with Resident #1 where he shoved another resident. ADON A stated that the incident would be reportable. ADON A stated a negative outcome could be the incident can happen again or if it was not thoroughly looked at, they could miss it again. In an interview on 06/11/2026 at 3:42 PM, the DON acknowledged the incident between Resident #1 and Resident #2. The DON stated that Resident #1 did not push Resident #2 down but was trying to get her out of his room and there was no harm. The DON stated if Resident #1 had pushed her down, the incident would be reportable. The DON stated a negative outcome would be abuse could keep happening.In an interview on 06/12/2026 at 11:06 AM, the ADM stated he was made aware of the incident on the memory unit on 04/08/2026. The ADM stated he did not report the incident as Resident #1 did not push or shove Resident #2, he guided her. The ADM stated the incident wasn't abuse. The ADM reported he did investigate but the investigation ended when he determined what shove and pushing meant. The ADM stated a negative outcome was that neglect could be missed and residents could be harmed.Record review of policy titled, Policy and Procedures: Abuse Neglect and Exploitation, dated 10/24/2022, under Policy: Definitions: Abuse, it was stated instances of abuse includes physical abuse. Physical Abuse included but was not limited to hitting, slapping, punching, biting, and kicking. Under heading Policy Explanation and Compliance Guidelines, it stated on line 2- the facility's Abuse Prevention Coordinator is responsible for reporting all allegations or suspected abuse to the state survey agency and other officials in accordance with state law. Under heading VII: Reporting/Response, subsection A, line 1- Reporting allegations involving resident-to-resident altercations involving allegations of abuse. Line 2 stated that reporting of all alleged violations to the ADM and state agency is required immediately, but not later than 2 hours after the allegation is made which includes allegations of Abuse (with or without injury).

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer, and pantry items were properly stored, labeled, and dated.These failures could place residents at risk of food-borne illnesses.Findings included:Observation of the pantry on 02/24/2026 at 9:16 AM, revealed dried onion pieces were observed on the floor and on top of food containers.Observation of the preparation area in the kitchen on 02/24/2026 at 9:20 AM revealed 12 covered bowls containing what appeared to be breakfast cereal, not labeled or dated.Observation of the deep freeze on 02/24/2026 at 9:21 AM revealed 14 cups containing what appeared to be ice cream, not labeled or dated.Observation of Freezer located near pantry on 02/24/2026 at 9:25 AM revealed the following:1 box of what appears to be dinner rolls opened to air, not labeled or dated.1 box of ground beef patties not dated.1 box of seafood patties with visible ice crystals on the patties, not dated.Observation of Refrigerator on 02/24/2026 at 9:30 AM revealed the following:1 box containing seven packages of bologna observed, not dated.1 gallon container of pimento cheese, no open date.1 box containing what appeared to be cheese, not labeled or dated. In an interview on 02/24/2026 at 11:26 AM, the DM stated it was the responsibility of all dietary staff to ensure food items were labeled, dated and stored properly. The DM stated the food could spoil and residents could become sick if not stored correctly. The DM stated she was responsible for ensuring staff complied with labeling and dating requirements.In an interview on 02/24/2026 at 11:26 AM, [NAME] A stated it was everyone's responsibility to label and date food and if this was not happening, residents could get sick. He stated the DM was responsible for ensuring all staff are complying. In an interview on 02/24/2026 2:44 PM, DA G stated it was everyone's responsibility to ensure food items were labeled, dated and covered. DA G stated if food was not labeled or dated then the staff would not know when the food was no longer good, if it was not covered, then residents could get bad food and get sick. The DM was responsible for ensuring all staff are complying. Record review of facility policy, titled Food Storage-Dry Goods dated October 2019, revealed the following information in part.The Dining Services Director or designee ensures that the storage will be neat, arranged for easy identification, and date marked as appropriate. Record review of facility policy, titled Food Storage-Cold dated October 2019, revealed the following information in part.The Dining Services Director/Cook ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable and homelike environment for 1 of 1 facility observed for environment. Failures included a sticky floor in the resident lounge and peeling texture on the ceiling in the main dining room. On the secure unit, there were tables and chairs in need of repair and cleaning as well as dirty ceiling fans and light fixtures and a broken light fixture. These failures could affect residents by placing them in an uncomfortable and unsanitary environment.Findings included: In an observation on 02/24/2026 at 11:45 AM, the Memory care dining area had 2 ceiling fans that were dirty and dust was hanging from fan blades. Light fixtures were dirty with cobwebs all around them. One light fixture above a dining table was cracked and broken. On one chair at a table, the cushion covering was split with cushion coming out. There were 6 out of the 7 tables in the dining area that had stripping on the sides coming off. Chairs in the dining area were dirty and needed cleaning. In an observation on 02/24/2026 at 12:44 PM, dried splotches of orange substance that stuck to shoes were on the floor in the resident activity lounge measuring an area of about 4 square feet. In an observation on 02/24/2026 at 2:56 PM, orange and brown splotches were still in place in the resident activity lounge. In an observation on 02/25/2026 at 6:50 AM, an orange and brown dried sticky substance was still on the floor of the resident activity lounge. In an observation on 02/25/2026 at 10:33 AM, an orange and brown dried sticky substance was still on the floor of the resident activity lounge. In an observation on 02/25/2026 at 11:45 AM, there were 2 areas of ceiling texture hanging down in the main dining room, both areas measuring approximately 2x2 feet over tables. In an observation on 02/25/2026 at 1:36 pm, an orange and brown dried sticky substance was still on the floor of the resident activity lounge. In an observation on 02/26/2026 at 8:53 AM, The memory care dining area still had broken and dirty light fixtures, chairs and tables still in need of repair and cleaning. In an interview on 02/26/2026 at 9:00 AM, HSK I stated that she had been employed almost a year at the facility and that a floor technician cleans the floor and he cleans them every day. In an interview on 02/26/2026 at 9:03 AM, RN H stated that she had worked at the facility for 1 1/2 years but had worked on the memory care unit since August 2025. RN R stated she had not seen the dirt on the ceiling fans before now, and she stated that maintenance and housekeeping had been told about the table edges and the worn and dirty chairs. RN R stated she had not noticed the fans and light fixtures being dirty or the light fixture being broken. She stated that a possible negative outcome for not having these things fixed and cleaned could be a quality-of-life issue for the residents. RN R stated it would bother her if these things were in her home. In an interview on 02/26/2026 at 9:09AM, the MW stated he was aware of the ceiling in the main dining room and he stated staff will be fixing that soon and the MS knew about it also. He stated he knew the chairs needed to be fixed in the memory care unit and he thought housekeeping knew that they were dirty. The MW stated he knew about the light fixture being broken in the memory care unit and the MS was supposed to be fixing that but had no idea about the tables. He stated that a possible negative outcome for having tables broken could be skin tears on residents. The MW stated that the ceiling texture hanging down could fall in residents' food and that all issues were hazards and needed to be fixed. In an interview on 02/26/2026 at 9:40 AM, the DM stated that she was the dietary manager as well as housekeeping and laundry supervisor. She stated she had worked at the facility for 9 years. The DM stated that housekeeping does not climb ladders, so ceiling fans being cleaned were maintenance's responsibility. The DM stated she was not aware of chairs in the memory care unit being dirty, but that she would have housekeepers do that today. She stated that a possible negative outcome could be residents would not have a homelike environment, and they could get sick if things that are dirty fell into their food. In an interview on 02/26/2026 at 9:36 AM, the MS stated he had worked at the facility for 9 years and communication could be better. He stated he was not aware of the issues in the memory care unit with the tables, chairs, and dirty fans and broken light fixture. The MS stated those and the ceiling in the main dining room are going to be fixed by next week and new chairs and tables will be ordered. He stated negative outcomes could be that dust on fans could fall in food, the light fixture could fall, and tables could cause skin tears. In an interview on 02/26/2026 at 9:43 AM, the ADM stated he had been at the facility since September 2025. He stated he had a request sent to corporate for new tables for the memory care unit, as well as new chairs and was aware of the ceiling in the main dining room. He stated the light fixtures, and dirty fans will all be addressed and fixed soon. The ADM stated a possible negative outcome could be residents could get a skin tear and dirt or part of the ceiling could get in resident's food. In an interview on 02/26/2026 at 11:35 AM, HSK J stated that he had worked at the facility for 3 years. He stated it was his job to clean the floors daily but sometimes they are shorthanded and then he was needed to clean rooms. HSK J stated there really was not a possible negative outcome for having sticky and dirty floors. He stated he never knew the floor in the resident lounge was sticky/dirty, no one told him about it and usually if there were sticky/dirty floors, someone would tell him about it. Record review of Resident Rights policy dated 02/23/2016 reflected the following in part: 8. Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (LVN C) of 6 staff observed for infection control and 2 (Resident #8 and #29) of 7 residents observed for infection control. -LVN C did not follow the correct standard precaution procedures. -LVN C did not perform the correct infection control protocols when administering an IV to Resident #29. -CNA L and CNA M did not follow EBP precautions when performing catheter care for Resident #8. This deficient practice has the potential to affect residents by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (LVN C) of 6 staff observed for infection control and 2 (Resident #8 and #29) of 7 residents observed for infection control. -LVN C did not follow the correct standard precaution procedures. -LVN C did not perform the correct infection control protocols when administering an IV to Resident #29. -CNA L and CNA M did not follow EBP precautions when performing catheter care for Resident #8. This deficient practice has the potential to affect residents by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings included: During an observation on 02/25/2026 at 7:00 AM LVN C entered a resident's room to administer medications. The door had a sign for EBP precautions. LVN C placed a gown and gloves but did not tie/secure the gown. LVN C administered the residents' medications and checked where staff had placed his foley catheter on his wheelchair. LVN C removed her PPE, used ABHR, then cleaned her equipment but did not clean the inner portion of the blood pressure cuff. During an observation on 02/25/2026 at 7:29 AM LVN C entered room [ROOM NUMBER] with a sign on the door for contact precautions. LVN C did not put on any PPE. LVN C administered medications, checked the resident's vital signs to include BP, HR, Temp, and O2 sat, and assessed the resident's pedal pulses on both of his legs. Resident #29Record review of Resident #29's admission record dated 02/26/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of osteomyelitis of the vertebrae (a serious, often painful infection of the bone resulting in inflammation of the bone marrow and surrounding tissue). Record review of Resident #29's clinical record revealed his last MDS was an admission/ Medicare 5-day started 02/09/2026 listing him with a BIMS score of 15 indicating he was cognitively intact. The rest of the MDS was in progress and yet to be completed. Record review of Resident #29's Order Summary Report with Active Orders as of 02/26/2026 revealed the following order:- Monitor PICC line insertion site for left upper arm for signs and symptoms of infection every shift for infection prevention. Active 02/24/2026.- Vancomycin HCL Intravenous Solution Reconstituted 1 GM - Use 250ml intravenously every 12 hours for boned and bone marrow infection for 56 days. Active 02/05/2026. Record review of Resident #29's care plan with admission date of 02/02/2026 revealed the following: Focus:- Resident requires Enhanced Barrier Precautions d/t Central or PICC IV-line, active infection with MDROs precautions. Date Initiated: 02/06/2026 Focus:- Intravenous (IV) Therapy: Resident requires intravenous therapy and is at risk for site infiltration, infection, fluid overload, pain, and other potential complications. Resident has Osteomyelitis of the lumbar region. Date Initiated: 02/05/2026. During an observation on 02/25/2026 at 7:42 AM LVN C administer IV vancomycin to Resident #29. LVN C placed PPE to include gown and gloves prior to entry. LVN C did not tie/secure the gown upon entry. LVN C did not wipe his IV/PICC line port with an alcohol rub prior to connecting the IV vancomycin tubing and starting the administration. During an interview on 02/25/2026 at 8:24 AM LVN C reported not cleaning equipment like the IV port and the blood pressure cuff could be an issue, that that portion of the blood pressure cuff is what touches the residents and if it was not cleaned properly then cross contamination of infection could result between residents. LVN C reported she did not wear the appropriate PPE for contact precautions in residents 103's room because she did not touch the resident during his care. LVN C reported the resident in 103 (Resident #93) should have been on EBP precautions and she didn't know why his signage was for contact precautions. LVN C reported that if a resident was on contact precautions a staff member entering that room should put on all the appropriate PPE listed for that precaution. LVN C reported ADON E was the current infection control specialist. LVN C reported that ADON E did all the trainings and the staff were trained on infection control last week. LVN C reported that not securing her gown when she enters a room with precautions can be an issue because the gown can get caught on something and expose the nurse to infection. Resident #8Record review of Resident #8's admission record dated 02/27/2026 revealed a [AGE] year-old female admitted to the facility originally on 03/26/2024 and readmitted on [DATE] with diagnoses to included metabolic encephalopathy (a chemical imbalance in the blood that causes problems in the brain), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), dementia (a group of thinking and social symptoms that interfere with daily functioning), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and incontinence (the involuntary or accidental loss of bladder (urinary) or bowel (fecal) control). Record review of Resident #8's clinical record revealed her last MDS was a quarterly completed 02/11/2026 listing her with a BIMS score of 05 indicating she was severely cognitively impaired, she had a functionality of requiring substantial/maximal assistance with her activities of daily, and she was not listed as having a catheter but was always incontinent. Record review of Resident #8's Order Summary Report with Active Orders as of 02/26/2026 revealed the following order:- Change 16fr 10cc Foley catheter q month. every night shift every 1 month(s) starting on the 12th for 1 day(s). Phone Active 02/12/2026 Record review of Resident #8's care plan with admission date of 01/20/2026 revealed the following: Focus:- Urinary Catheter: Resident has a urinary catheter and is at risk for urinary tract infections and injury. Urinary catheter related to: neurogenic bladder with urine retention. Date Initiated: 02/25/2026. During an observation on 02/25/2026 at 2:36 PM CNA L and CNA M performed catheter care for Resident #8. Neither CNA L nor CNA M placed a gown upon entry to the room, during the care, and post-completion of the care for the EBP precautions that were posted on Resident #8's door. During a group interview on 02/25/2026 at 2:48 PM CNA L and CNA M reported the resident they performed catheter care on did not require EBP precautions. The room was marked for EBP precautions for the roommate that had a wound. CNA L reported they were trained by ADON E a while ago, maybe a couple of months on EBP precautions. CNA M agreed. They were asked what a resident had to have to be placed on EBP precaution and CNA L stated, They are supposed to be on EBP for a catheter so we should have used a gown when we performed her care. Both agreed they should have worn a gown. CNA L reported not wearing a gown could result in the staff getting an infection from the residents or the staff carrying an infection to another resident. During an interview on 02/26/2026 at 09:48 AM ADON E reported she started working for the facility on 02/03/2026, she was currently training to be the infection control preventionist, that the DON was the current infection control preventionist, and she had provided training on 2/25/26 for EBP precautions. ADON E reported the training did cover the different types of precautions to include contact precautions. ADON E reported there are several differences between EBP and Contact Precautions. ADON E reported when asked why some residents were on contact precautions and some residents were on EBP according to signs posted on their doors ADON E stated, That was me. I didn't know they had the EBP precautions sign, and I used the contact precautions sign. I put the wrong sign on the door. ADON E reported the facility did not have any residents on contact precautions. They should have all been listed as EBP precautions. ADON E reported if infection control precautions were not followed correctly then staff could spread infection. During an interview on 02/26/2026 at 10:36 AM the DON reported she expects her staff to be aware of facility practices such as infection control and the differences between contact and EBP precautions and staff should be knowledgeable. The DON reported if staff are not aware of the differences in precautions and how to implement them then residents are at risk of infection. The DON reported that all nursing equipment to include the blood pressure cuff used between residents needs to be cleaned to include all sides to prevent the spread of infection. The DON reported she expects staff to wear a gown and gloves when caring for a resident on EBP precautions such as with a catheter to prevent the spread of infection. Record review of the facility provided sign posted on resident's doors when EBP precautions are determined to be implemented revealed the following:- Enhanced Barrier PrecautionsProviders and Staff must also:Wear gloves and gown for the flowing High-Contact Resident Care Activities:Providing HygieneChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter. Record review of the facility provided sign posted on resident's doors when Contact Precautions are determined to be implemented revealed the following:- Contact PrecautionsProviders and staff must also:Put on gloves before room entry.Discard gloves before room exit. Put on gown before room entry.Discard gown before room exit. Used dedicated or disposable equipmentClean and disinfect reusable equipment before use on another person. Record review of the facility provided policy titled Peripheral Inserted Central Catheter (PICC) Line Flush) revision date 08/12/2014, revealed the following:- Procedure:6. Scrub the injection cap with alcohol or povidone-iodine wipe Record review of the facility provided policy titled Infection Prevention and Control Program revised 11/06/2024, revealed the following:- Policy Explanation and Compliance Guidelines:6. Enhanced Barrier PrecautionsEBP are used in conjunction with standard precaution and expand the use of PPE to donning of gown and gloves during high-contact resident care activities.During high-contact resident care activities:-Providing hygiene-Changing briefs and assisting with toileting.-Device care or use: central line, urinary catheter.Glove and gown prior to the high-contact activity. 10. Equipment Protocolsa. All reuseable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 5 out of 5 residents that received pureed food (Residents #8, # 21, #65, #69, and #85), in that: The facility failed to ensure Residents #8, # 21, #65, #69, and #85 received pureed lemon dessert on 02/24/2026.The facility failed to ensure Residents #8, # 21, #65, #69, #85received pureed bread on 02/25/2026. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. Findings included:Resident #8Record review of Resident #8's Face sheet, dated 02/25/2026, reflected at [AGE] year-old female originally admitted to the facility on [DATE] and with the diagnoses that include but not limited to metabolic encephalopathy (brain dysfunction causing memory loss, confusion), unspecified dementia (loss of cognitive function) and chronic kidney disease (gradual loss of kidney function).Record review of Resident #8's Quarterly MDS Assessment, dated 02/11/2026, indicated a BIMS score of 05 out of 14, reflecting severe impaired cognition. The assessment reflected Resident #8 had a mechanically altered diet (pureed food). Record review of Resident #8's Comprehensive Care Plan, last revised on 11/08/2025 reflected Resident #8 had a puree diet texture, thin liquids with interventions report signs and symptoms of malnutrition. Record review of Resident #8's Active Orders dated 1/20/2026 reflected Resident #8 was on a pureed textured diet.Resident #21Record review of Resident #21's Face sheet, dated 02/25/2026, reflected at [AGE] year-old female originally admitted to the facility on [DATE] with the diagnoses that include but not limited dementia (loss of cognitive function), dysphasia (loss of language), and muscle wasting and atrophy (loss of muscle and strength).Record review of Resident #21's Quarterly MDS Assessment, dated 02/10/2026, indicated a BIMS score of 99 indicating resident was unable to complete the interview. The assessment reflected Resident #21 had a mechanically altered diet (pureed food). Record review of Resident #21's Comprehensive Care Plan, last revised on 12/23/2025 reflected Resident #21 had a mechanical soft diet with interventions to provide, serve diet as ordered. Record review of Resident #21's Active Orders dated 1/06/2026 reflected Resident #21 was on a pureed textured diet. Resident #65Record review of Resident #65's Face sheet, dated 02/25/2026, reflected at [AGE] year-old male originally admitted to the facility on [DATE] with the diagnoses that include but not limited Alzheimer's disease (disorder affecting memory, thinking, behavior), chronic systolic heart failure (weak left ventricle heart) and Parkinson disease with dyskinesia (neurological disorder affecting movement).Record review of Resident #65's Quarterly MDS Assessment, dated 12/18/2026, indicated a BIMS score of 00 indicating resident has severe impaired cognition. The assessment reflected Resident #65 had a mechanically altered diet (pureed food). Record review of Resident #65's Comprehensive Care Plan, last revised on 12/18/2025 reflected Resident #65 had a pureed texture diet with interventions to provide, serve diet as ordered. Record review of Resident #65's Active Orders dated 09/07/2023 reflected Resident #65 was on a pureed textured diet.Resident #69Record review of Resident #69's Face sheet, dated 02/25/2026, reflected at [AGE] year-old male originally admitted to the facility on [DATE] with the diagnoses that include but not limited hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side(partial weakness/paralysis after stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial weakness/paralysis after stroke) and dysphasia (inability to use and understand language).Record review of Resident #69's Quarterly MDS Assessment, dated 11/20/2025, indicated a BIMS score of 07 indicating resident has severe impaired cognition. The assessment reflected Resident #69 had a mechanically altered diet (pureed food). Record review of Resident #69's Comprehensive Care Plan, last revised on 02/15/2026 reflected Resident #69 had a pureed texture diet with interventions to provide, serve diet as ordered. Record review of Resident #69's Active Orders dated 02/15/2026 reflected Resident #69 was on a pureed textured diet. Resident #85Record review of Resident #85's Face sheet, dated 02/25/2026, reflected at [AGE] year-old male admitted to the facility on [DATE] with the diagnoses that include but not limited to unspecified dementia (loss of memory), chronic atrial fibrillation (irregular heartbeat) and essential hypertension (high blood pressure). Record review of Resident #85's Quarterly MDS Assessment, dated 02/14/2026, indicated a BIMS score of 02 out of 15 indicating resident has severe impaired cognition. The assessment reflected Resident #85 had a mechanically altered diet (pureed food). Record review of Resident #85's Comprehensive Care Plan, last revised on 02/15/2026 reflected Resident #85 had a pureed texture diet with interventions to provide, serve diet as ordered. Record review of Resident #85's Active Orders dated 10/29/2025 reflected Resident #85 was on a pureed textured diet. During an observation on 02/24/2026 at 12:00 PM in main dining room the posted menu for the week revealed the lunch menu for 02/24/2026 listed vanilla pudding as the dessert. During an observation on 02/24/2026 at 12:05 PM in the secured dining room, Resident #65, and Resident #21 were observed with a peach-colored dessert on their trays. During an observation on 02/24/2026 at 12:15 PM in the main dining room, Resident #8, Resident #85 and Resident #69 were observed with a peach-colored dessert on their trays. Residents receiving regular diets were observed with a yellow cake type desert on their trays. During an interview and observation on 02/24/2026 at 12:45 PM, the DM stated the residents receiving pureed diets eat pureed fruit better than cake, so peaches were substituted for the lemon bars. The DM stated that not receiving the same menu as other residents could result in negative outcome related to dignity or nutritional intake if caloric values were not equal. The DM did not reference the posted menu which listed vanilla pudding and instead stated that residents were supposed to receive a cookie for dessert, and she substituted the cookie for the lemon bar. The DM opened up the substitution book, and it indicated lemon bars were to be served in place of a cookie for dessert. There was no documentation of a substitution for desserts for residents receiving pureed diet. The DM said the substitution log was for both menus. The DM stated it was her responsibility to ensure the cooks were following the menus. During an observation on 02/25/2026 at 8:10 AM in the main dining room. Resident #85 and Resident #65(no longer in secured unit) were observed eating breakfast. Resident #65 was being assisted by staff. Their trays contained scrambled eggs, sausage, and cream of wheat. The meal ticket located near their plates indicated wheat toast should have also been served. During an observation on 02/25/2026 at 8:11 AM the posted approved menu indicated breakfast was to include scrambled eggs, sausage, cream of wheat and wheat toast. During an interview on 02/25/2026 at 8:16 AM, [NAME] A stated he forgot to puree the toast for the five residents receiving pureed diets. [NAME] A stated it was wrong not to provide the full menu and stated that not providing all menu items could result in residents going hungry. During an interview on 02/25/206 at 9:04 AM, the RD stated she was not aware substitution were being made and indicated that any substitutions should have been approved by her. The RD stated staff would be following the menu as written. The RD stated a potential negative outcome of not following the menu could include residents not receiving the nutritional value required to meet their dietary needs. During an interview 02/25/2026 at 9:10 AM, the DM stated the residents should have had toast on their plate. The DM stated the RD was not aware of the changes and said a possible negative outcome for not following menus would be residents could lose weight, and it was her responsibility to ensure staff was following the menus. Record review of facility policy titled Meal Distribution dated October 2019 reflected the following:Policy statement: It is the center policy that meals are transported to the dining locations.in an accurate manner The Dining Service Director will ensure that all meals are assembled in accordance with individualized diet order, plan of care and preferences.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 1 of 1 facility reviewed for infection control procedures. -staff were unable to implement and maintain appropriate infection control precautions properly when providing resident care. These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to infection, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene.Findings included: During an observation on 02/25/2026 at 7:00 AM LVN C entered room [ROOM NUMBER] (with a sign for EBP on the door) to administer medications. LVN C placed gown for EBP but did not tie/secure the back of her gown, administered the residents' medications, checked the resident's placement of the foley catheter on his wheelchair. LVN C removed her PPE, used ABHR, then cleaned her equipment but did not use her wipe on the inner portion of the blood pressure cuff. During an observation on 02/25/2026 at 7:23 AM room [ROOM NUMBER] and room [ROOM NUMBER] had signs on the doors for contact precautions. room [ROOM NUMBER] had a sign on the door for EBP precautions. During an observation on 02/25/2026 at 7:25 AM LVN C asked ADON E why room [ROOM NUMBER] was on contact precautions and room [ROOM NUMBER] was on EBP precautions. ADON E read both signs and reported that the resident in 102 was on EBP because it was a stricter precaution because that resident had a catheter. During an observation on 02/25/2026 at 7:29 AM LVN C entered room [ROOM NUMBER] with signage for contact precautions with no PPE. LVN C administered medications, checked the residents' vital signs to include BP, HR, Temp, and O2 saturation and assessed the residents' pedal pulses on both of his legs. During an observation 02/25/2026 at 7:42 AM LVN C administer IV vancomycin to the resident in room [ROOM NUMBER] with a sign on the door for contact precautions. LVN C placed PPE to include gown and gloves prior to entry, and she did not tie/secure the gown upon entry. During an interview on 02/25/2026 at 8:24 AM LVN C reported not cleaning her equipment such as the blood pressure cuff could be an issue. LVN C said that portion of the cuff was what touches the residents and if it was not cleaned properly then cross contamination of infection could result between residents. LVN C reported she did not wear the appropriate PPE for contact precautions in residents 103's room because she did not touch the resident during his care. LVN C reported the resident in 103 should have been on EBP precautions and she did not know why his signage was for contact precautions. LVN C reported if a resident was on contact precautions a staff member entering that room should put on all the appropriate PPE listed for that precaution. LVN C reported ADON E was the current infection control specialist, did all the training, and that the staff were trained on infection control last week. LVN C reported that not securing her gown when she enters a room with precautions can be an issue because the gown can get caught on something and expose the nurse to infection. During an observation 02/25/2026 at 2:36 PM of catheter care performed by CNA L and CNA M in room [ROOM NUMBER]. Noted upon entry to the room was a sign for EBP. Neither CNA L nor CNA M placed a gown during the entire catheter care process for EBP. During a group interview on 02/25/2026 at 2:48 PM CNA L and CNA M reported the resident they performed catheter care on did not require EBP precautions. The room was marked for EBP precautions for the roommate that had a wound. CNA L reported they were trained by ADON E a while ago, maybe a couple of months on EBP precautions. CNA M agreed. CNA L stated, Residents are supposed to be on EBP for a catheter so we should have used a gown when we performed her care. Both agreed they should have worn a gown. CNA L reported that not wearing a gown could result in the staff getting an infection from the residents or the staff carrying an infection to another resident. During an interview on 02/26/2026 at 8:54 AM CNA N reported she had been trained on infection control to include the different types of precautions. CNA N's last training was approximately 1 month ago given by ADON E. When asked for the difference between EBP and contact precautions CNA N stated, I'm not sure. CNA N reported an issue with not following the precautions correctly could result in a resident getting an infection and if the staff member were to be sick then they could spread it to the resident. During an interview on 02/26/2026 at 9:05 AM CNA O reported she was trained on infection control to include the different types of precautions and was trained last week by ADON E. CNA O reported the ADON trains the staff in small groups and then has them sign that they have been trained. CNA O reported that if a resident was on contact precautions, then you should use PPE and if a resident was on EBP then you need to wash your hands, use hand sanitizer, basically perform hand hygiene. CNA O reported if the precautions are not followed correctly then a resident could get an infection, COVID, the Flu, a disease and cross contamination could occur. During an interview on 02/26/2026 at 09:48 AM ADON E reported she started working for the facility on 02/03/2026, she was currently training to be the infection control preventionist, that the DON was the current infection control preventionist, and she had provided training on 2/25/26 for EBP precautions. ADON E reported the training did cover the different types of precautions to include contact precautions. ADON E reported there are several differences between EBP and Contact Precautions. ADON E reported when asked why some residents were on contact precautions and some residents were on EBP according to signs posted on their doors ADON E stated, That was me. I didn't know they had the EBP precautions sign, and I used the contact precautions sign. I put the wrong sign on the door. ADON E reported the facility did not have any residents on contact precautions. They should have all been listed as EBP precautions. ADON E reported if infection control precautions were not followed correctly then staff could spread infection. During an interview on 02/26/2026 at 10:36 AM the DON reported she expects her staff to be aware of facility practices such as infection control and the differences between contact and EBP precautions and that staff should be knowledgeable. The DON reported if staff are not aware of the differences in precautions and how to implement them then residents are at risk of infection. The DON reported that all nursing equipment to include the blood pressure cuff used between residents needs to be cleaned to include all sides to prevent the spread of infection. The DON reported she expects staff to wear a gown and gloves when caring for a resident on EBP precautions such as with a catheter to prevent the spread of infection. Record review of the facility provided policy titled Infection Prevention and Control Program revised 11/06/2024, revealed the following:- Policy Explanation and Compliance Guidelines:2. All staff are responsible for following all policies and procedures related to the program.16. Staff education: a. All staff shall receive training.regarding the facility's infection prevention and control program, including policies and procedures related to their job functions. b. All staff are expected to provide care consistent with infection control practices. c. Direct care staff shall demonstrate competence in resident cart procedures established by our facility.

Based on observation, interview, and record review the facility failed to ensure correct installation, use, and maintenance of bedrails for 3 (Resident #27, Resident #29, and Resident #33) of 20 residents reviewed for bedrails.1. The facility failed to ensure Resident #27's bedrails were not loose.2. The facility failed to ensure Resident #29's bedrails were not loose.3. The facility failed to ensure Resident #33's bedrails were not loose.These failures could place residents at risk of injury.Findings Included:1. Record review of Resident #27's admission record dated 02/24/26 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis affecting left non-dominant side (partial paralysis following a stroke), and seizures (uncontrolled electrical disturbance in the brain).Record review of Resident #27's admission MDS with an ARD of 12/27/25 and a completion date of 01/06/26 revealed a BIMS score of 15 which indicated intact cognition. Section GG Functional Abilities revealed she required partial to moderate assistance for toileting, and lower body dressing, transfers, and moving from sitting to lying and vice versa.Record review of Resident #27's care plan completed 12/24/25 revealed no mention of bed rails.Record review of Resident #27's Siderail Education Fact Sheet revealed she signed it on 12/23/25 indicating understanding of the risks of bedrails.Record review of Resident #27's Bed rail Evaluation revealed it was completed on 12/24/25.During an observation on 02/24/26 at 12:01 PM Resident #27 was in her bed with the head of the bed raised to seated position. There were upright bedrails on both sides of her bed. She stated she used the bedrails to move around in her bed. Resident #27 stated the bedrails had been on her bed since she was admitted to the facility. She stated the bedrail on her right side was loose. She demonstrated by turning it. It rotated approximately 30 degrees in either direction. Resident #27 stated the bedrail had just recently started getting loose.2. Record review of Resident #29's admission record dated 02/26/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, metabolic encephalopathy (problems in the brain from chemicals in the blood), adult t-cell lymphoma/leukemia (rare aggressive cancer caused by long term viral infection of HTLV-1 [Human T-lymphotropic virus type 1]) in remission, and osteomyelitis of vertebra lumbar region (rare, serious infection of the spine).Record review of the MDS tab in Resident #29's EHR revealed an admission MDS assessment that was Export Ready. Record review of section C Cognitive Patterns of the admission MDS assessment revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #29's baseline care plan initiated on 02/05/26 revealed no mention of bedrails.Record review of Resident #29's Order Summary Report dated 02/26/26 revealed no mention of bedrails.Record review of Resident #29's Siderail Education Fact Sheet revealed he signed the form indicating understanding of the risks of bedrail usage on 02/05/26.Record review of Resident #29's Bed Rail Assessment Tool revealed he was assessed for bed rail usage as a mobility assist on 02/06/26 and his bedrails were installed on 02/06/26.During an observation and interview on 02/25/26 at 07:30 AM Resident #29 was lying on his back in bed. Bedrails were present on both sides of his bed in the upright position. He stated he used the bedrails to get up from bed. He stated the bedrail on his left was a little loose. He demonstrated by turning the bedrail from side to side. It rotated approximately 30 degrees in either direction.3. Record review of Resident #33's admission record dated 02/26/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, after care following joint replacement surgery, Down Syndrome (genetic condition caused by the presence of an extra copy of chromosome 21 leading to developmental delays and distinct physical features), and repeated falls.Record review of Resident #33's annual MDS assessment completed on 12/31/25 revealed a BIMS score of 3 which indicated severely impaired cognition. Section GG Functional Abilities revealed Resident #33 required substantial/maximal to supervision/touching assistance across all ADLs except for eating where he only required setup or clean-up assistance.Record review of Resident #33's care plan completed on 01/11/26 revealed the following: Bed Mobility: LIMITED X1 PERSON ASSIST - assist rail to both sides of bed to enable increased level of bed mobility function (turning and maintaining side-lying position)Record review of Resident #33's Consent for Bed Rail Use revealed it was signed by his family member on 06/06/23 indicating she understood the risks of bedrails.Record review of Resident #33's most recent Bed Rail Evaluation revealed it was completed on 01/05/26.During an observation on 02/24/26 at 09:41 AM Resident #33 was not in his room. His bed was made and had upright bedrails on both sides. The bed rail on the left side of the bed rotated approximately 30 degrees in both directions.During an observation on 02/25/26 at 01:37 PM Resident #33 was not in his room. His bed was made and had upright bedrails on both sides. The bed rail on the left side of the bed rotated approximately 40 degrees in both directions.A phone call was placed to Resident #33's family member on 02/26/26 at 02:08 PM with no answer or return call.During an interview on 02/26/26 at 09:01 AM LVN C stated MS was responsible for ensuring bedrails were not loose. She stated a resident could be injured if their bedrail was loose.During an interview on 02/26/26 at 09:13 AM ADON B stated MS was responsible for ensuring bedrails were in working order. She stated a resident's safety would be negatively impacted if their bedrail was loose.During an interview on 02/26/26 at 09:32 AM MS stated he inspected all bedrails in the facility monthly to ensure they were in working order. He stated he had a checklist on his computer that prompted him to inspect the bedrails. He stated he did not have any proof of inspecting the bedrails monthly because when he checked the box on the checklist it disappeared and he did not have any paper logs of bedrail inspections. He stated a resident with a loose bedrail could stumble and fall and have no secure grip.During an interview on 02/26/26 at 11:18 AM DON stated MS was responsible for ensuring bedrails were in working order. She stated if a resident had a loose bedrail they could hypothetically be negatively impacted if they were trying to grab it or something and it moved.During an interview on 02/26/26 at 11:27 AM MDS LVN stated a resident would not be able to reposition themselves with a loose bedrail.During an interview on 02/26/26 at 01:20 PM LVN K stated everyone working with a resident should be monitoring bedrails to ensure they were not loose. He stated if a bedrail was loose, Residents could fall and hurt themselves.Record review of facility policy titled Bed Rails and dated 01/22/18 revealed the following: . 2. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails including, but not limited to, the following elements: . f. Inspect bed rails to ensure they have not become still or loosened over time.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 5 (Resident #2, 4, 18, 30, and 83) of 7 residents reviewed for respiratory care. -The facility failed to store the nasal cannulas for Resident #2, 4, 18, and 83 properly. -The facility failed to provide oxygen for Resident #30. These failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings included: Resident #2Record review of Resident #2's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 10/04/2024 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), myocardial infarction (heart attack), and anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's clinical record revealed her last MDS was a quarterly completed 12/09/2025 listing her with a BIMS score of 09 indicating she was moderately cognitively impaired, she had a functionality of requiring partial/moderate assistance with her activities of daily living, and she required oxygen While a Resident. Record review of Resident 2's clinical record revealed a care plan with the admission date of 09/05/2025, which revealed the following:- Oxygen: Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. This is related to COPD (chronic bronchitis or emphysema). Date Initiated: 09/07/2025.Further review revealed there were no interventions for respiratory equipment care to include nasal cannula storage. Record review of Resident #2's Order Summary Report with Active Orders as of 02/26/2026 revealed the following order:- O2 @ _2___ LPM via N/C. Active 02/24/2026- Change O2 tubing and humidifier bottle. every night shift, every Sun. Active 09/05/2025. During an observation on 02/24/2026 at 09:53 AM Resident #2 was sleeping in her wheelchair with the TV on. Resident did not wake to knocking or introduction. Resident #2 had an oxygen concentrator present with the hydration bottle dated 2-22, the concentrator was turned on, and set at 2L/min. Resident #2 was not wearing the O2 and the nasal cannula was on the floor. During an observation on 02/24/2026 at 10:43 AM Resident #2 was not present and the nasal cannula continued to be on the floor. During an observation and an attempted interview on 02/24/2026 at 11:41 AM a CNA was observed leaving Resident #2's room after assisting Resident #2 to the bathroom. Resident #2 was in the bathroom in her wheelchair and stated, I no speak English and smiled. Resident #2's nasal cannula continued to be on the floor. During an observation on 02/24/2026 at 2:06 PM Resident #2 was not in her room but her nasal cannula continued to be on the floor. During an observation on 02/24/2026 at 3:25 PM Resident #2 was not in her room. Her nasal cannula had been moved but continued to be on the floor. During an observation on 02/26/2026 at 8:48 AM Resident #2 was not in her room but her nasal cannula was on the floor in front of her bed between the head of her bed and her recliner. Resident #4Record review of Resident #4's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 09/24/2025 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), aphasia (loss of the ability to understand or express speech caused by brain damage), dysphagia (difficulty or discomfort in swallowing), and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #4's clinical record revealed her last MDS was a quarterly completed 02/02/2026 listing her with a BIMS score of 09 indicating she was moderately cognitively impaired, she had a functionality of requiring substantial/maximal assistance with most of her activities of daily living, and she required oxygen While a Resident. Record review of Resident 4's clinical record revealed a care plan with the admission date of 10/13/2025, which revealed the following:- Focus: Oxygen: Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. Date initiated - 09/26/2025.Further review revealed there were no interventions for respiratory equipment care to include nasal cannula storage. Record review of Resident #4's Order Summary Report with Active Orders as of 02/26/2026 revealed the following order:- O2 @ _2-3____ LPM via N/C. Active 10/14/2025 During an observation on 02/24/2026 at 10:54 AM Resident #4 was not in her room. An O2 concentrator was present with the hydration bottle dated 2-22 and the nasal cannula was on the floor. During an observation on 02/24/2026 at 10:43 AM Resident #4 was not present in the room and her nasal cannula continued to be on the floor. During an observation on 02/24/2026 at 11:41 AM Resident #4 was not present in the room and her nasal cannula continued to be on the floor. During an observation on 02/24/2026 at 2:06 PM Resident #4 was not in her room. A CNA observed exiting the room and reported that Resident #4 was currently at dialysis. Resident #4's nasal cannula continued to be on the floor. During an observation on 02/24/2026 at 3:25 PM Resident #4 was not present and her nasal cannula continued to be on the floor. During an observation and an attempted interview on 02/26/2026 8:48 AM Resident #4 was in her bed eating breakfast with her O2 on via nasal cannula. Resident #4 was awake and alert but did not respond to this surveyors' questions. Resident #4 just started blankly then returned to eating. Noted no date on her nasal cannula tubing and the date on her hydration bottle was still 2-22. Resident #18Record review of Resident #18's clinical record revealed an [AGE] year-old male resident admitted to the facility originally on 07/09/2013 and readmitted on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), paraplegia (paralysis of the legs and lower body), atherosclerotic heart disease (a buildup of fat, cholesterol, and other substances in the artery walls), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Record review of Resident #18's clinical record revealed his last MDS was a quarterly completed 12/17/2025 listing him with a BIMS score of 15 indicating he was cognitively intact, he had a functionality of being setup or clean-up assistance with most of his activities of daily living, and he was marked for not having oxygen therapy due to not needing any oxygen assistance during the required 14 days look back period. Record review of Resident 18's clinical record revealed a care plan with the admission date of 07/13/2020, which revealed the following: Focus: Oxygen - Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. RESIDENT WEARS O2 AT NIGHT. REFUSES HIS C-PAP. Date Initiated: 07/26/2023Further review revealed there were no interventions for respiratory equipment care to include nasal cannula storage. Record review of Resident #18's Order Summary Report with Active Orders as of 02/26/2026 revealed the following order:- O2 @ _2_ LPM via N/C. Notify MD if SpO2 falls below 90% while using O2. Perform resp. assess if O2 applied. Active 10/21/2024 During an observation and interview on 02/24/2026 at 10:08 PM Resident #18 was in his room sitting in his motorized wheelchair. Resident #18 was noted to have an O2 concentrator present that he did not have on and the nasal cannula was on the floor. Resident #18 reported the staff take care of his oxygen to include changing all his equipment last Sunday 2/22/2026. During an observation on 02/24/2026 at 10:43 AM Resident #18 was in his room and continued to have his nasal cannula on the floor. During an observation on 02/24/2026 at 11:41 AM Resident #18 was in his room and continued to have his nasal cannula on the floor. During an observation on 02/24/2026 at 2:06 PM Resident #18 was in his room and continued to have his nasal cannula on the floor. During an observation on 02/24/2026 at 3:25 PM Resident #18 was in his room and continued to have his nasal cannula on the floor. During an observation and interview on 02/26/2026 at 8:17 AM Resident #18 was in the hallway in his electric wheelchair. Resident #18 entered his room where his O2 cannula was noted on the floor. Resident #18 denied his nasal cannula was on the floor, reported that he puts on and takes off his own nasal cannula and demonstrated how he did this. Resident #18 then place the nasal cannula back on the floor. Resident #83Record review of Resident #83's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 09/27/2023 and readmitted on [DATE] with diagnoses to include intracerebral hemorrhage (a life-threatening type of stroke caused by a ruptured blood vessel that bleeds directly into the brain), chronic respiratory failure (a long-term condition that occurs when the body's respiratory system can't exchange oxygen and carbon dioxide properly), dysphasia (difficulty swallowing food or liquids arising from the throat or esophagus), and congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should). Record review of Resident #83's clinical record revealed her last MDS was a quarterly completed 12/30/2025 listing her with a BIMS score of 13 indicating she was cognitively intact, she had a functionality of requiring substantial/maximal assistance with most of her activities of daily living, and she required oxygen While a Resident. Record review of Resident 83's clinical record revealed a care plan with the admission date of 12/27/2025, which revealed the following:- Focus: Oxygen - Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. This is related to acute on chronic respiratory failure with hypoxia and hypercapnia. CHRONIC respiratory FAILURE WITH HYPOXIA illness. Date Initiated: 07/23/2025. Record review of Resident #83's Order Summary Report with Active Orders as of 02/26/2026 revealed the following order:- O2 @ ___3__ LPM via N/C . Active 02/24/2026. During an observation on 02/24/2026 at 09:48 AM Resident #83 was not present in her room. Noted a O2 concentrator present with the hydration bottle dated 2-22 and Resident #83's nasal cannula was laying on the floor. During an observation on 02/24/2026 10:43 AM Resident #83 was not present and the nasal cannula was still on the floor. During an observation on 02/24/2026 11:41 AM Resident #83 was not present, the nasal cannula has been moved to the top of the O2 concentrator but was not stored in a plastic bag. During an observation on 02/24/2026 2:06 PM Resident #83 was present but not wearing her oxygen. Resident #83's nasal cannula was stored on top of the O2 concentrator but was not in a plastic bag. Resident #83 reported no concerns with her care to include her oxygen therapy. During an observation on 02/24/2026 3:25 PM Resident #83 was not present, the nasal cannula was on top of the O2 concentrator but was not stored in a plastic bag During an observation on 02/26/2026 8:16 AM Resident #83 was sleeping peacefully in her bed with her oxygen via her nasal cannula. There was no date on the cannula. Resident #83 did not wake to knocking or introduction. During an interview on 02/26/2026 at 8:54 AM CNA N reported that she was working on the Med Hall/2 Hall, day shift (the hall that Residents #2, 4, 18, and 83 were in). CNA N reported that she made rounds on residents every 2 hours. If the resident was not present, she would make sure the cannula was stored in a bag off the floor. CNA N reported that if the nasal cannula was found on the floor, then she would replace it. CNA N reported that if a nasal cannula that was on the floor was placed on a resident, then that resident would be at risk for infection. During an interview on 02/26/2026 at 9:05 AM CNA O reported that she was working on the Med Hall/2 Hall, day shift (the hall that Residents #2, 4, 18, and 83 were in). CNA O reported that she made rounds every two hours. She reported that if a resident was not in the room she would check to see that the nasal cannula was stored in a bag off the floor. CNA O reported that if the nasal cannula was on the floor, then she would clean it with a wipe and then use the nasal cannula on the resident. CNA O reported that if a cannula was used on a resident that was on the floor, then they could get an infection or get sick. During an interview on 02/26/2026 at 09:48 AM ADON E reported CNA staff were expected to make rounds every two hours, they were expected to check if a resident with oxygen who was not present in the room had their nasal cannula stored in a bag off the floor so the nasal cannula would not be contaminated. ADON E reported a CNA should not put a nasal cannula that was on the floor on a resident because it was contaminated and could give that resident a respiratory infection. During an interview on 02/26/2026 at 10:36 AM the DON reported she expects the CNA's to complete rounds every two hours, nasal cannulas should be stored off the ground in a bag, and if a nasal cannula was found on the floor, then it should be replaced and the charge nurse notified. The DON reported she was not aware they had trained staff on proper nasal cannula storage and if a resident was given a nasal cannula that was on the floor, that resident could develop an infection. During an interview on 02/26/2026 at 10:44 AM the DON reported that the facility does not have a policy on the correct storage of a nasal cannula. Resident #30Record review of Resident #30's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 01/06/2020 and readmitted on [DATE] with diagnoses to include convulsion (a sudden, violent, irregular movement of a limb or of the body caused by involuntary contraction of the muscles and associated especially with brain disorders such as epilepsy), dysphagia (difficulty or discomfort in swallowing), pneumonia (lung inflammation caused by a bacterial or viral infection), multiple fractures of the ribs, and muscle weakness (a lack of muscle strength). Record review of Resident #30's clinical record revealed her last MDS was a quarterly completed 12/26/2025 listing her with a BIMS score of 15 indicating she was cognitively intact, she had a functionality of requiring partial/moderate assistance with activities of daily living, and she required oxygen While a Resident. Record review of Resident 30's clinical record revealed a care plan with the admission date of 04/11/2022, which revealed the following:- Focus: Oxygen - Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. Date Initiated: 09/22/2023.Further review revealed there were no interventions for respiratory equipment care to include nasal cannula storage. Record review of Resident #30's Order Summary Report with Active Orders as of 02/26/2026 revealed the following order:- O2 @ 2 to 3LPM via N/C. Active 09/07/2025. During an observation on 02/24/2026 at 9:41 AM Resident #30 was sitting in a w/c with her oxygen tank on the back of the chair set at 2LPM. Resident #30 stated she gets her oxygen tanks changed regularly and she has had no issues. During an observation on 02/24/2026 at 10:22 AM Resident #30 was observed with the oxygen tank on the back of her wheelchair set at 2LPM, she was wearing her nasal cannula, and the oxygen tank was empty. During an observation on 02/24/2026 at 12:34 PM Resident #30 was in the dining room wearing her nasal cannula with an empty oxygen tank on the back of chair. Resident #30 stated she felt like air was coming in her nasal cannula. Resident #30 did not appear to be in distress. During an interview on 02/24/2026 at 12:36 PM CNA P stated all staff are supposed to check oxygen tanks and a negative outcome for not having O2 tanks checked and full could be O2 levels can go down During an interview on 02/24/2026 at 12:42 PM LVN Q stated it was all nurses' responsibility to check O2 tanks. LVN Q then observed Resident #30's O2 tank and stated it was definitely empty. LVN Q stated the negative outcome of not having a full tank of O2 for a resident could be that resident having poor oxygenation and unresponsiveness Record review of the facility provided policy titled, Oxygen Administration reviewed 01/05/2020, and Oxygen Safety date implemented 02/11/2022, revealed no information concerning ensuring the resident received ordered oxygen therapy or the proper storage of oxygen equipment.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #10, Resident #27, and Resident #62) of 20 residents reviewed for comprehensive care plans.1. The facility failed to include Resident #10's bedrails in her care plan.2. The facility failed to include Resident #27's bedrails in her care plan. Resident #27's care plan noted she was receiving anticoagulant medication when she was not receiving anticoagulant (blood thinning) medication.3. The facility failed to include Resident #62's bedrails in her care plan.These failures could place residents at risk of receiving inaccurate/incomplete care.Findings Included:1. Record review of Resident #10's admission record dated 02/26/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, multiple rib fractures left side, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) mild with agitation, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).Record review of Resident #10's quarterly MDS completed on 01/08/26 revealed a BIMS score of 9 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #10 required set up/clean up assistance to partial/moderate assistance across all ADLs.Record review of Resident #10's care plan completed on 01/13/26 revealed no mention of bed rails.Record review of Resident #10's Siderail Education Fact Sheet revealed Resident #10's family member signed the form on 09/30/25 acknowledging the risks of bedrails.Record review of Resident #10's most recent Bed Rail Assessment Tool revealed her bedrails were installed on 10/01/25 and she was assessed for usage of bedrails on 01/01/26.During an observation on 02/24/26 at 09:49 AM Resident #10 was lying on her back in bed with her eyes closed. She had one upright bedrail on the right side of her bed. The left side of her bed was against the wall.During an observation on 02/24/26 at 12:02 PM Resident #10 was lying on her back in bed with her eyes closed. She had one upright bedrail on the right side of her bed.During an observation on 02/25/26 at 06:54 AM Resident #10 was lying on her back in bed with her eyes closed. She had one upright bedrail on the right side of her bed.2. Record review of Resident #27's admission record dated 02/24/26 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis affecting left non-dominant side (partial paralysis following a stroke), and seizures (uncontrolled electrical disturbance in the brain).Record review of Resident #27's admission MDS with an ARD of 12/27/25 and a completion date of 01/06/26 revealed a BIMS score of 15 which indicated intact cognition. Section GG Functional Abilities revealed she required partial to moderate assistance for toileting, and lower body dressing, transfers, and moving from sitting to lying and vice versa. Section M Medications revealed she was coded as receiving anticoagulant medication.Record review of Resident #27's care plan completed 12/24/25 revealed no mention of bed rails. The care plan revealed the following: [Resident #27] is currently taking an anticoagulant related to Disease process (CVA).Record review of Resident #27's Order Summary Report dated 02/24/26 revealed no anticoagulant medication.Record review of Resident #27's MAR for December of 2025 revealed no anticoagulant medication.Record review of Resident #27's Siderail Education Fact Sheet revealed she signed it on 12/23/25 indicating understanding of the risks of bedrails.Record review of Resident #27's Bed rail Evaluation revealed it was completed on 12/24/25.During an observation on 02/24/26 at 09:47 AM Resident #27 was not in her bed. There were bedrails in the upright position on both sides of the bed.During an observation on 02/24/26 at 09:52 AM Resident #27 was not in her bed. There were bedrails in the upright position on both sides of the bed.During an observation on 02/24/26 at 12:01 PM Resident #27 was in her bed with the head of the bed raised to seated position. There were upright bedrails on both sides of her bed. She stated she used the bedrails to move around in her bed. Resident #27 stated the bedrails had been on her bed since she was admitted to the facility.During an observation on 02/25/26 at 07:10 AM Resident #27 was not in her bed. There were bedrails in the upright position on both sides of her bed.3. Record review of Resident #62's admission record dated 02/26/26 revealed an [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified combined systolic congestive and diastolic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body), and paroxysmal atrial fibrillation (irregular heartbeat).Record review of Resident #62's quarterly MDS assessment completed on 01/28/26 revealed a BIMS score of 9 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #62 ranged from dependent to requiring supervision or touching assistance across all of her ADLs.Record review of Resident #62's care plan completed on 01/23/26 revealed no mention of bed rails.Record review of Resident #62's Siderail Education Fact Sheet revealed she or her family member signed it on 10/24/25 indicating understanding of the risks of bedrails.Record review of Resident #62's Bed Rail Assessment Tool revealed she was assessed for bed rail usage on 01/09/26 and her bed rails were installed on 01/09/26.During an observation on 02/24/26 at 10:35 AM Resident #62 was not in her room. Her bed had upright bedrails on both sides.During an observation and interview on 02/24/26 at 11:57 AM Resident #62 was lying on her back in bed. Her bed had upright bedrails on both sides. She stated she used the bedrails to move around in her bed.During an observation on 02/24/26 at 12:43 PM Resident #62 was lying in bed on her back. The bed had upright bedrails on each side.During an observation on 02/24/26 at 03:06 PM Resident #62 was in her bed on her back with the head of the bed raised to seated position. The bed had upright bedrails on each side.During an observation on 02/25/26 at 07:41 AM Resident #62 was not in her bed. The bed had upright bedrails on each side.During an interview on 02/26/26 at 09:01 AM LVN C stated MDS LVN and a group of other facility staff members were responsible for care plans. She stated an incomplete or inaccurate care plan could result in a resident receiving incomplete or inaccurate care.During an interview on 02/26/26 at 09:11 AM CNA D stated if a resident had an incomplete or inaccurate care plan, they wouldn't get the right care.During an interview on 02/26/26 at 09:13 AM ADON B stated an incomplete or inaccurate care plan could lead to staff not knowing how to care for the resident correctly.During an interview on 02/26/26 at 11:18 AM DON stated MDS LVN was responsible for care plans. She stated if a resident's care plan was inaccurate or incomplete, a new staff member might not know how to care for the resident correctly.During an interview on 02/26/26 at 11:27 AM MDS LVN stated she and a group of facility staff were responsible for completing accurate, complete care plans. She stated an inaccurate or incomplete care plan could impact a resident negatively. She stated the nursing department was responsible for including bed rails in care plans. She stated Resident #27 had anticoagulant medication included in her care plan because she (MDS LVN) mistook an antiplatelet medication for an anticoagulant medication.During an interview on 02/26/26 at 01:20 PM LVN K stated if a resident's bedrails were not included in the care plan the resident would be at risk of injury.Record review of facility policy titled Comprehensive Care Plans and dated 09/04/24 revealed the following: . 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 psychological needs that are identified in the resident's comprehensive assessment. 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.Record review of facility policy titled Bed Rails and dated 01/22/18 revealed the following: . 4. The facility will document in the resident's care plan specific interventions and services for the use of the bed rail .

Based on interviews and record reviews, the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #6) of two residents reviewed in that:The facility failed to identify Resident #6's past trauma, potential triggers and incorporate trauma informed interventions into the resident's care plan. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Record review of Resident #6's Face sheet, dated 02/24/2026, reflected at [AGE] year-old female originally admitted to the facility on [DATE] and with the diagnoses of post-traumatic stress disorder (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) chronic dated 12/11/2024, anxiety disorder ( a condition in which a person has excessive worry and feeling of fear, dread or uneasiness), bipolar disorder, current episode mixed(significant mood changes) and major depressive disorder(feeling of sadness)Record review of Resident #6's Quarterly MDS Assessment, dated 11/20/2025, indicated a BIMS score of 15, reflecting intact cognition. The assessment documented diagnoses of Post Traumatic Stress Disorder (PTSD), anxiety disorder, bipolar disorder and major depressive disorder. Record review of Resident #6's Comprehensive Care Plan, last revised on 11/08/2025 did not include PTSD as a focus area. The care plan failed to identify trauma history, potential triggers, or individualized trauma informed interventions related to her diagnosis of PTSD. Record review of the facility's Comprehensive Trauma Screening, dated 08/27/2024, indicated Resident #6 did not have PTSD. In an interview on 02/25/2026 at 9:00 AM, the DON stated she was unaware Resident #6 had a diagnosis of PTSD and reported she would need to research trauma informed care. The DON stated that failing to recognize PTSD and identify triggers could potentially result in re traumatization. The DON stated the SW was responsible for completing trauma assessments. In an interview on 02/25/2026 at 9:59 AM, the SW stated she was responsible for completing trauma assessments upon admission and when a resident received a diagnosis such as PTSD or experienced any trauma. The SW stated she was unaware that Resident #6 had a diagnosis of PTSD and did not know of any triggers related to the resident. The SW confirmed the only trauma assessment completed for Resident #6 was dated 08/27/2024 and stated no updated assessment had been conducted after the PTSD diagnosis was identified. In an interview on 02/25/2026 at 11:30 AM, ADON E stated she was not aware of any residents having PTSD in the facility. ADON E stated she was not completely sure what trauma informed care entailed. ADON E believed the SW was responsible for conducting trauma assessments but was unsure when residents should be assessed or reassessed. ADON E stated that failure to identify residents with trauma and their potential triggers could result in negative outcomes, including withdrawal or behavioral escalation. ADON E stated trauma related care should be documented in the resident's care plan.In an interview on 02/26/2026 at 8:45 AM, MDS LVN stated she was responsible for ensuring care plans were completed. MDS LVN stated she believed PTSD and any goals or interventions should be in the care plan. In an interview on 02/26/2026 at 9:00 AM LVN F assigned to the hall where Resident #6 resided, stated she was unaware of Resident #6 had a diagnosis of PTSD and did not know of any triggers. LVN F stated lack of awareness of trauma or their triggers could negatively impact and could result in re-traumatization. In an interview and observation on 02/26/2026 at 11:00 AM, Resident #6 was neatly dressed and watching television. Although no acute distress was observed during the brief interaction, she stated a diagnosis of PTSD related to childhood trauma and avoided elaborating further as she changed the subject. In an interview on 02/26/2026, MDS LVN stated that a resident with a diagnosis of PTSD should identify the resident's triggers of PTSD on the resident's care plan. The MDS Coordinator LVN A stated failure to properly care plan a resident for PTSD and triggers could result in a resident being re-traumatized. She stated she was responsible for including PTSD with triggers in resident's care plan. Record review of policy titled Trauma Informed Care dated 10/24/2022 reflected the following:It is the policy of this facility to provide care and services which in addition to meeting professional standards are delivered using approaches which are culturally competent, account for experiences, preferences, and address the needs of trauma survivors by minimizing triggers and or traumatization.Trauma: may include, but are not limited to:Physical, sexual, mental or emotional abuse past or present.Trauma Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma, A trauma informed approach to care delivery recognized the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.

Based on observation, interview, and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #29) of 20 residents reviewed for parenteral fluids.Resident #29 was admitted to the facility on [DATE] with a PICC line without orders for dressing change, flushing, or monitoring for infection of the PICC line until 02/24/26.This failure could place residents at risk of harm due to infection.Findings Included:Record review of Resident #29's admission record dated 02/26/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, metabolic encephalopathy (problems in the brain from chemicals in the blood), adult t-cell lymphoma/leukemia (rare aggressive cancer caused by long term viral infection of HTLV-1 [Human T-lymphotropic virus type 1]) in remission, and osteomyelitis of vertebra lumbar region (rare, serious infection of the spine).Record review of the MDS tab in Resident #29's EHR revealed an admission MDS assessment that was Export Ready. Record review of section C Cognitive Patterns of the admission MDS assessment revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #29's baseline care plan initiated on 02/05/26 revealed the following: . Intravenous (IV) Therapy: [Resident #29] requires intravenous therapy and is at risk for site infiltration, infection, fluid overload, pain, and other potential complications. Resident has Osteomyelitis of the lumbar region . Administer IV therapy/flushes as ordered. Change IV site dressing.according to facility policy. Monitor site for dislodgement, swelling, redness, pain, streaking, and drainage. Report abnormals to the physician.[Resident #29] requires Enhanced Barrier Precautions d/t Central or PICC IV line.Record review of Resident #29's Order Summary Report dated 02/26/26 revealed the following orders and corresponding order start dates:02/24/26 Change transparent dressing to the Midline site as needed for compromised dressing.02/26/26 Change transparent dressing to the Midline site every day shift every Thu for PICC IV ACCESS Measure upper arm circumference and exterior catheter length with each dressing change.02/06/26 Enhanced Barrier Precautions r/t PICC line for infection of bone and bone marrow infection02/24/26 Monitor PICC line insertion site to left upper arm for signs and symptoms of infection every shift for infection prevention02/06/26 cefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM (Ceftriaxone Sodium) Use 2 gram intravenously every 12 hours for infection of bone and bone marrow for 56 Days infuse over 60 minutes02/24/26 Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 10 ml intravenously every morning and at bedtime related to OSTEOMYELITIS OF VERTEBRA, LUMBAR REGION . Flush with 10ml NS before and after medication administration.02/06/26 Vancomycin HCI Intravenous Solution Reconstituted 1 GM (Vancomycin HCI) Use 250 ml intravenously every 12 hours for bone and bone marrow infection for 56 days infuse over 60mins draw vanc and trough (lowest concentration of a drug in the blood stream) before every 4th dose and send results to [physician]Record review of Resident #29's MAR dated 02/24/26 and time stamped 02:42 PM revealed no orders for PICC line dressing change, flushing, or monitoring for infection.Record review of Resident #29's TAR dated 02/26/26 revealed no mention of PICC line dressing change, flushing, or monitoring for infection.During an observation on 02/25/26 at 07:15 AM Resident #29 was lying in bed on his back. His PICC line was partially visible peeking from under the sleeve of his t-shirt on his left arm.During an observation on 02/25/26 at 07:42 AM LVN C flushed Resident #29's PICC line and administered his medication. She stated his PICC line dressing had already been changed. There was no sign of infection.During an interview on 02/26/26 at 09:01 AM LVN C stated any nurse who was certified in PICC line care could provide care for Resident #29's PICC line. She stated LVN K was the wound care nurse, and he was usually responsible for changing Resident #29's PICC line dressing, but certified nurses could do so as well. She stated if a resident did not have orders for PICC line care, flushing, and dressing they could get an infection.During an interview on 02/26/26 at 09:13 AM ADON B stated Resident #29's PICC line dressing was changed by LVN K. She stated if LVN K was not in the facility the nurses would be able to change the PICC line dressing. ADON B stated nurses knew how often to change the dressing due to the physician's order. She stated a possible negative outcome of not having physician orders regarding PICC line care, flushing, and dressing changes was the resident could get an infection.During an interview on 02/26/26 at 11:18 AM DON stated LVN K or the charge nurse on duty was responsible for PICC line care. She stated PICC line dressing should be changed every 7 days. She stated she was looking in Resident #29's chart on 02/24/26 and noticed he did not have any orders for PICC line care, dressing change, or flushing and she put the orders in at that time. She stated not having orders could cause the PICC line dressing not to be changed.During an interview on 02/26/26 at 01:20 PM LVN K stated he and the nurses were responsible for PICC line care. He stated not having physician's orders for PICC line care, flushing, and dressing change could result in the dressing not being change and that could lead to infection.During an interview on 02/26/26 at 01:38 PM Resident #29 stated staff changed the dressing on his PICC line on 02/25/26 and that was the only time it had been changed since his admission.Record review of facility policy titled Peripherally Inserted Central Catheter (PICC) Line Flush and dated 08/12/14 revealed the following: Routine flushing should be performed with the following: Between administration of incompatible medications or solutions . As ordered by the physician . Flush PICC lumens (central hollow channels) according to physician orders . Procedure 1. Review physician order .Record review of facility policy titled PICC Line Transparent Dressing Change and dated 08/12/14 revealed the following: To prevent external infection of the peripheral or central venous catheter . Transparent membrane dressings (no gauze over site) are changed every 7 days and PRN. Document the procedure in the Nurses Notes or initial Treatment Administration Record.Record review of facility policy titled Intravenous Therapy and dated 04/02/24 revealed the following: . The facility will adhere to accepted standards of practice regarding infusion practices. Procedures: Continuous Infusion: 1. Review and verify practitioner's orders for infusion solution . IV Push (RN): 1. Review and verify practitioner's order for infusion solution . Intermittent Medication Infusion: 1. Review and verify practitioner's order for infusion solution.

Based on observations, interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #29) of 20 residents reviewed for care planning.The facility failed to include bedrails in Resident #29's baseline care plan.This failure could place newly admitted residents at risk of not receiving safe, effective, person-centered care.Findings Included:Record review of Resident #29's admission record dated 02/26/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, metabolic encephalopathy (problems in the brain from chemicals in the blood), adult t-cell lymphoma/leukemia (rare aggressive cancer caused by long term viral infection of HTLV-1 [Human T-lymphotropic virus type 1]) in remission, and osteomyelitis of vertebra lumbar region (rare, serious infection of the spine).Record review of the MDS tab in Resident #29's EHR revealed an admission MDS assessment that was Export Ready. Record review of section C Cognitive Patterns of the admission MDS assessment revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #29's baseline care plan initiated on 02/05/26 revealed no mention of bedrails.Record review of Resident #29's Order Summary Report dated 02/26/26 revealed no mention of bedrails.Record review of Resident #29's Siderail Education Fact Sheet revealed he signed the form indicating understanding of the risks of bedrail usage on 02/05/26.Record review of Resident #29's Bed Rail Assessment Tool revealed he was assessed for bed rail usage as a mobility assist on 02/06/26 and his bedrails were installed on 02/06/26.During an observation on 02/24/26 at 09:41 AM Resident #29 was lying in bed on his back. Bedrails were present on both sides of his bed in the upright position. During an observation on 02/24/26 at 12:02 PM Resident #29 was lying on his back in bed with his eyes closed. Bedrails were present on both sides of his bed in the upright position.During an observation on 02/25/26 at 07:15 AM Resident #29 was lying in his bed on his left side. Bedrails were present on both sides of his bed in the upright position.During an observation and interview on 02/25/26 at 07:30 AM Resident #29 was lying on his back in bed. Bedrails were present on both sides of his bed in the upright position. He stated he used the bedrails to get up from bed.During an interview on 02/26/26 at 09:01 AM LVN C stated MDS LVN and a group of other staff members were responsible for care plans. She stated an incomplete or inaccurate care plan could result in a resident receiving incomplete or inaccurate care.During an interview on 02/26/26 at 09:11 AM CNA D stated if a resident had an incomplete or inaccurate care plan, they wouldn't get the right care.During an interview on 02/26/26 at 09:13 AM ADON B stated the nursing department was responsible for baseline care plans. She stated an incomplete or inaccurate care plan could lead to staff not knowing how to care for the resident correctly.During an interview on 02/26/26 at 11:18 AM DON stated MDS LVN was responsible for care plans. She stated if a resident's care plan was inaccurate or incomplete, a new staff member might not know how to care for the resident accurately.During an interview on 02/26/26 at 11:27 AM MDS LVN stated an inaccurate or incomplete care plan could impact a resident negatively. She stated the nursing department was responsible for including bed rails in care plans.During an interview on 02/26/26 at 01:20 PM LVN K stated if a resident's bedrails were not included in the care plan the resident would be at risk of injury.Record review of facility policy titled, Baseline Care Plans and dated 04/02/24 revealed the following: . Resident person-centered baseline care plans are developed and implemented for new admission residents. The baseline care plans include measurable objectives to address the resident's immediate medical, clinical, functional, mental, and psychosocial person-centered needs. The baseline care plans will be developed and implemented from minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission order, admission evaluation/assessments . therapy services . and resident choices.Record review of facility policy titled Bed Rails and dated 01/22/18 revealed the following: . 4. The facility will document in the resident's care plan specific interventions and services for the use of the bed rail .

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #27) of 20 residents reviewed for accuracy of assessment.The facility coded Resident #27 as receiving anticoagulant medication when she did not receive anticoagulant medication.This failure could place residents at risk of receiving unnecessary care/medication.Findings Included:Record review of Resident #27's admission record dated 02/24/26 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis affecting left non-dominant side (partial paralysis following a stroke), and seizures (uncontrolled electrical disturbance in the brain).Record review of Resident #27's admission MDS with an ARD date of 12/27/25 and a completion date of 01/06/26 revealed a BIMS score of 15 which indicated intact cognition. Section N Medications revealed she was coded as receiving anticoagulant (blood thinning) medication.Record review of Resident #27's care plan completed 12/24/25 revealed the following: [Resident #27] is currently taking an anticoagulant related to Disease process (CVA).Record review of Resident #27's Order Summary Report dated 02/24/26 revealed no anticoagulant medication.Record review of Resident #27's MAR for December of 2025 revealed no anticoagulant medication.During an observation on 02/24/26 at 09:52 AM Resident #27 was seated in her wheelchair in the hallway outside of her room. She stated the bruises on her left hand were from taking blood thinners and getting shots.During an interview on 02/26/26 at 09:01 AM LVN C stated MDS LVN was responsible for completing MDS assessments. She stated an inaccurate MDS assessment could have a negative impact on a resident because the MDS assessment determined the resident's care.During an interview on 02/26/26 at 09:13 AM ADON B stated MDS LVN was responsible for completing MDS assessments. She stated an inaccurate MDS assessment could lead to inaccurate resident care.During an interview on 02/26/26 at 11:18 AM DON stated MDS LVN was responsible for completing MDS assessments. She stated an inaccurate MDS assessment could indirectly affect resident care because that is how we (the facility) get paid.During an interview on 02/26/26 at 11:27 AM MDS LVN stated she was responsible for completing MDS assessments. She stated she used the RAI as her policy for completing MDS assessments. MDS LVN stated regarding Resident #27 being coded as receiving anticoagulant medication, That is my error. I thought [brand name for clopidogrel (an antiplatelet medication)] was an anticoagulant. She stated the MDS assessment affects facility funding and an inaccurate MDS assessment could, therefore, indirectly affect resident care.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . SECTION N: MEDICATIONS . Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Coding Instructions Code all high-risk drug class medications according to their pharmacological classification, not how they are being used.

Based on observation, interview, and record review the facility failed to ensure residents had a right to ade a safe, clean, comfortable and homelike environment, which included but not limited to receiving treatment and supports for daily living safety for 1 of 1 resident refrigerators reviewed for resident environment . 1. The facility failed to ensure expired and rotten food was removed from residents refrigerator, located by the main nurses station. 2. The facility failed to ensure residents personal refrigerators maintained sanitary conditions. 3. The facility failed to ensure foods in residents personal refrigerators were labeled and dated. These failures could place residents at risk of contracting foodborne illness and not having their personal food items stored in a sanitary manner. Findings Included: An observation on [DATE] at 2:00 pm of the resident refrigerator located in the hallway by the main nurse's station revealed the following in the freezer: A package of taquitos, open to air, no label or date, ice crystals on the taquitos. A package of opened chicken strips, open to air. 10 frozen breakfast meals with an expiration date of [DATE]. 5 individual ice cream bars, not in original package, no label or date. 1 medium uncovered Sonic Styrofoam cup of a milkshake or ice cream type drink, had no label or date. An observation on [DATE] at 2:05 pm of the main refrigerator revealed the following: 2 plastic bags of salad, no label, with an expiration date of [DATE]. The lettuce was limp and appeared to be slimy. 2 half sandwiches in a resealable plastic bag, no label or date. The bread was soggy, and the sandwich filling was unidentifiable and appeared moldy. Several, small, clear, plastic to go containers of what appears to be tartar sauce, and other condiments had no label or date. Condiments appeared to be dried and crusted inside the cups. During an interview on [DATE] at 02:10 pm, CNA C stated she did not know who was responsible for keeping the refrigerator in order. She stated she had never been told to clean out the refrigerator. She stated that was the resident refrigerator and staff were not supposed to put any personal foods in the refrigerator. She stated she did not know whether any of the food were staff food or not. During an interview on [DATE] at 02:30 pm, the DM stated the nursing staff were responsible for cleaning and maintenance of the resident snack refrigerator. She stated the residents and staff did not tell her or the kitchen staff when foods were brought into the facility, so she and the kitchen employees never knew what was in the refrigerator. She stated the refrigerator was for resident foods and staff were supposed to use the refrigerator. She stated all foods should be labeled and dated as well as secured. She stated all expired foods should be thrown out and the nursing staff was responsible for maintaining the refrigerator. She stated a possible negative outcome of the refrigerator containing rotting or expired food would be residents could be exposed to foodborne illnesses. She stated she was a contract worker for the facility and her supervisor, and the kitchen policies stated the nursing staff was responsible for maintenance of the resident refrigerator. During an interview on [DATE] at 02:35 pm, LVN D stated she did not know who was responsible for keeping the refrigerator in order. She stated she had never been told to clean out the refrigerator. She stated that was the resident refrigerator and staff were not supposed to use the refrigerator for personal food. During an interview on [DATE] at 3:30 pm, RN E stated he was not sure who was responsible for maintenance of the resident refrigerator and had never been told to maintain the refrigerator. He stated he had been told staff were not to put any personal food items in the refrigerator and did not know if there were staff personal food items in the refrigerator. He stated all foods in the refrigerator should be labeled and dated and expired foods should be thrown out. He stated the consequences of having expired foods and unlabeled, undated foods would be residents could be exposed to foodborne illnesses. During an interview on [DATE] at 3:42 pm, ADON B stated she was not sure who was responsible for maintenance of the resident refrigerator and thought it might be housekeeping or dietary services. She stated staff were not to put any personal food items in the refrigerator and did not know if there were staff personal food items in the refrigerator. She stated all foods in the refrigerator should be labeled and dated and expired foods should be thrown out. She stated the consequences of having expired foods and unlabeled, undated foods would be residents could be exposed to foodborne illnesses. Record review of the facility's policy titled Food From Outside Sources and dated [DATE] revealed the following: The task of keeping personal foods stored in a safe and sanitary manner will be the responsibility of the facility staff. Sealed containers must be used. Foods brought in by families and visitors may not enter the food service department, may not be stored in the kitchen, and may not be served by food service personnel. Residents and guests will be encouraged to date restaurant and homemade items and to consume or discard within 7 days. Record review of facility's policy titled Frozen and Refrigerated Foods Storage dated [DATE] revealed the following: 7. Proper labeling of cooked food includes the date placed in the refrigerator and an expiration or use by date . The use by date is 7 days from when the product was opened unless there is a manufacturers use by date 11. All refrigerator and frozen items will be labeled and dated. 14. On a daily basis the Charge Nurse will check unit refrigerators that are used to store any resident foods and /or supplements: and check the temperature is 41 degrees or below, check to make sure all opened foods have use by dates and are properly covered, all items past use by date are discarded and refrigerators are clean.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintained the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 20 residents (Residents #69 and #12) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident # 69's comprehensive care plan addressed the resident's need for a scoop mattress. 2. The facility failed to ensure Resident #12's comprehensive care plan addressed the resident's need for a fall mat. These failures could place residents at risk for not receiving the appropriate care and services needed to maintain optimal health. Finding included: 1. Record review of Resident #69's face sheet, dated 11/13/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #69 had diagnoses which included but not limited to lack of coordination, sequelae of other cerebrovascular disease(paralysis-partial), and seizures. Record review of Resident #69's quarterly MDS Assessment, dated 10/02/2024, reflected Resident #69 had a BIMS of 13 out 15, which indicated he was cognitively intact. Resident #69 required moderate assistance with lying to sitting on the side of the bed and chair to bed transfer. Record review of Resident #69's care plan, dated 10/08/2024, Resident #69 was a risk for falls due to gait/balance problems with interventions of the bed being in the low position and call light in reach, there was no documentation of using a scoop bed relating to Resident #69 risk of falling. No documentation throughout the care plan related to the utilization of a scoop mattress . Record review of Resident #69's Fall Risk Assessment, dated 10/13/2024, reflected Resident #69 was a moderate risk for falling due to decreased muscle coordination. During an observation on 11/12/2024 at 9:30 AM, Resident #69 was lying in his bed asleep, his bed was observed to be contoured with raised edges. During an observation on 11/13/2024 at 8:26 AM, Resident #69 was lying in his bed asleep, his bed was observed to be contoured with raised edges. During an interview/observation on 11/13/2024 at 2:23 PM revealed, Resident #69 was sitting in his motorized chair, Resident #69 had no concerns about his bed. Observation of the bed revealed it was contoured with raised edges . 2. Record review of Resident #12's face sheet, dated 11/13/2024, reflected an [AGE] year-old female who was admitted to the facility 10/01/2021. Resident #12 had diagnoses which included but not limited to unspecified fall, unspecified sequelae of cerebrovascular disease (paralysis-partial) and muscle weakness. Record review of Resident #12's quarterly MDS assessment, dated 10/30/2024, reflected Resident #12's BIMS was 02 out of 15, which indicated she had severe impaired cognition. Record review of Resident #12's care plan, dated 11/06/2024, reflected Resident #12 was at risk for falls related to cognitive impairment, gait/balance problems with interventions of bed being in the low position and call light in reach, no documentation of using a fall mat relating to Resident #12 risk of falling. There was no documentation throughout the care plan related to the utilization of the fall mat. Record review of Resident #12's Fall Risk Assessment, dated 10/08/2024 , reflected Resident #12 was a moderate risk for falling due to loss of balance . During an observation on 11/13/2024 at 10:00 AM, revealed Resident #12 was asleep in her bed, with a fall mat beside the bed. During an interview and observation on 11/13/2024 at 2:31 PM revealed, Resident #12 was in her bed, the fall mat was beside the bed. Resident #12 stated she felt safe with the fall mat near her bed. During an interview on 11/13/2024 at 3:25 PM, LVN G stated a possible negative outcome for not having accurate care plans would be the lack of care for residents. During an interview on 11/13/2024 at 3:45 PM with ADON B revealed the interventions for falls included scoop mattresses and fall mats should be in each resident's care plan. ADON B stated she was responsible for ensuring interventions were documented in the care plans. ADON B said a possible negative outcome for not having interventions in the care plan would be a lack of care of residents. During an interview on 11/14/2024 at 9:01 AM with the ADM, the ADM stated nurses were responsible for ensuring care plans were updated. The ADM stated a possible negative outcome for not having interventions in care plans would be the accuracy of care and care could be missed . Record review of the Care Plans and Care Area Assessments policy, dated 05/06/2024, reflected the following: Care Plan Updates: .The IDT will review the care plans Annually, quarterly, and as needed to ensure all goals and approaches are appropriate . .As acute problems or changes to intervention or goals are identified, an appropriate care plan will be developed or modified by a nursing staff member . Record review of Fall Management System, dated 01/03/2017, reflected the following: It is the policy of this facility that each resident will be assessed to determine his/her risk for fall and a; plan of care implemented based on the resident's assessed needs .

Based on observation, interview and record review the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 20 residents (Resident #45) reviewed for dignity issues. The facility failed to ensure Resident #45's catheter drainage bag was covered and urine in the bag was not visually exposed . This failure could place residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life. Findings included: Record review of Resident #45's faced sheet, dated 11-13-2024, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses which included, but not limited to, acute kidney failure, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms . Record review of Resident #45's Annual MDS dated [DATE] reflected the following: Section C: Resident #45 had a BIMS of 03 out of 15, which indicated he was severely cognitively impaired. Section H; Resident #45 had an indwelling catheter. Record review of Resident #45's physician orders, dated 8-13-2024 , reflected provide catheter care every shift. During an observation on 11-13-2024 at 2:49 PM, revealed catheter care was performed by CNA F on Resident #45, Resident #45's catheter bag had no protective cover and was hanging from the right side of his bed in view of the hallway with his door open. During an observation from the hallway outside of Resident #45's room on 11-13-2024 at 3:26 PM revealed Resident #45 lying in bed asleep. Resident #45's catheter bag was observed hanging from the right side of his bed with no protective cover, there was a small amount of amber liquid was noted in the bag . During an interview on 11-13-2024 at 3:15 PM, LVN D stated all catheter bags should be covered at all times. LVN D stated that a possible negative outcome for not having a bag covered would be a resident could be embarrassed if other residents saw their urine. During an interview on 11-13-2024 at 3:20 PM, CNA F stated all catheter bags should be covered at all times. CNA F stated a possible negative outcome for not having a bag covered would be a dignity issues if other people saw the uncovered bag. During an interview on 11-13-2024 at 3:58 PM, RN E stated he addressed this issue before with his staff and all staff were responsible for ensuring catheter bags were covered because it was a dignity issue. Record review of the facility's provided policy titled, Resident Rights, dated 02-20-2021, reflected the following: .The resident has a right to be treated with respect and dignity, .The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for 2 (Resident #66 and Resident #68) of 5 residents reviewed for respiratory care. 1. The facility failed to obtain orders for Resident #66's oxygen therapy. 2. The facility failed to ensure Resident #68's order for oxygen included the rate (lpm) at which she was to receive oxygen. These failures could affect all residents on oxygen therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: 1. Record review of Resident #66's face sheet printed 11/12/2024 revealed a [AGE] year-old female resident admitted to the facility originally on 9/27/2023 and readmitted on [DATE] with diagnoses to include acute respiratory failure (sudden failure of lungs to deliver oxygen to the body) with hypoxia (low level of oxygen in your body tissue), congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), hypertension(a condition in which the force of the blood against the artery walls is too high), major depressive disorder(a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and cognitive communication deficit(difficulty with thinking and how someone uses language). Record review of Resident #66's clinical record revealed her last MDS was a quarterly completed 11/1/2024 listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring partial/moderate assistance with most of her activities of daily living. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #66 was marked as having oxygen While a Resident. Record review of Resident #66's Physician Orders with active orders for Schedule for [DATE] revealed no orders for oxygen therapy. Record review of Resident #66's clinical record revealed a care plan with the admitted [DATE], with the following care plan: Focus: o Oxygen: Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. Date Initiated: 09/27/2023. Revision on: 03/19/2024 Goal: o Resident will have no signs or symptoms of hypoxia through the next review dates. Date Initiated: 09/27/2023. Target Date: 01/22/2025 Intervention: o Administer oxygen therapy per physician's orders. Date Initiated: 09/27/2023. During an observation on 11/12/24 at 09:35 AM Resident #66 was in her bed sleeping with her oxygen on via nasal canula at 3.5L/min. During an observation and interview on 11/13/24 at 01:37 PM Resident #66 was in her room sitting in her chair with her family member present. Resident #66 was not wearing her oxygen but verified that she used oxygen and that she wore it only at night or when she was sleeping. During an interview on 11/14/24 at 08:20 AM LVN H (the nurse responsible for Resident #66 this shift) verified that Resident #66 was supposed to be on oxygen at night, that she (LVN H) had checked Resident #66's O2 sat this morning at 94% but that she did not verify if Resident #66 was wearing her Oxygen. LVN H reviewed Resident #66's chart and verified that Resident #66 did not have any orders for Oxygen therapy. LVN H then entered Resident #66's room and verified that Resident #66 was wearing Oxygen at 3.5L via a NC. LVN H reported that Resident #66 should have orders for her Oxygen therapy due to oxygen was considered a medication and reported that she would call the physician immediately and get an order. LVN H reported that administering the medication without an order should be a medication error and that it would be a treatment issue for the resident and that it could affect the resident's care. During an interview on 11/14/24 at 08:25 AM when questioned if Resident #66 had orders for her oxygen therapy the DON asked ADON B to check the residents electronic chart. ADON B checked the electronic chart and verified there were no orders for the oxygen therapy. ADON B then called the provider for orders. The DON reported that Resident #66 not having orders for her oxygen therapy was an issue and that it affected quality of care in that the resident would not be getting their medication therapy correctly which definitely could affect the resident negatively. 2. Record review of Resident #68's admission record dated 11/13/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, emphysema (a lung disease which results in shortness of breath), chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), and obstructive sleep apnea (a sleep disorder that causes repeated breathing interruptions during sleep). Record review of Resident #68's quarterly MDS completed on 11/05/24 revealed the following: Section C: Resident #68 had a BIMS of 15 which indicated intact cognition. Section O: Resident #68 was not coded as receiving oxygen therapy. Record review of Resident #68's care plan completed on 09/04/24 revealed oxygen therapy was to be provided as ordered by the physician related to Resident #68's diagnoses of emphysema, chronic obstructive pulmonary disease, and sleep apnea. Record review of Resident #68's active order summary dated 11/13/24 revealed the following orders related to O2: An order with order date of 10/21/24 to Change O2 tubing and humidifier bottle. every night shift every Sun [Sunday] Ensure that tubing is dated when changed. An order with order date of 10/21/24 to Inspect external O2 filter weekly (if present). Clean/change if needed. every night shift every Sun for O2 use. An order with order date of 10/21/24 to Monitor O2 saturation. Apply PRN O2 if SpO2 falls below 90%. Notify the physician if SpO2 falls below 85%. every shift. The active order summary revealed no mention of lpm. Record review of Resident #68's O2 sats from 10/21/24 and 11/12/24 revealed her oxygen was checked 47 times. Of those 47 times she was receiving O2 via NC 38 times. The other 9 times she was breathing room air. Of those 9 times Resident #68's O2 sats were 90% or lower 3 times. Record review of Resident #68's MAR for October and November 2024 revealed the same orders listed above regarding O2 and made no mention of lpm. During an observation on 11/13/24 at 08:22 AM Resident #68 was lying in her bed with her eyes closed receiving O2 via NC at 4.25 lpm. During an observation on 11/13/24 at 01:42 PM Resident #68 was lying in her bed on her left side receiving O2 via NC at 4.25 lpm. On 11/13/24 at 02:23 PM an unsuccessful attempt was made to contact/interview Resident #68's physician who wrote the order for her PRN O2. During an observation on 11/13/24 at 03:12 PM Resident #68 was lying in bed on her right side receiving O2 via NC at 4.25 lpm. During an interview on 11/13/24 at 03:28 PM PC stated an order for oxygen should contain a rate (lpm) because we have to know how fast to run it because it will be different for each resident. During an interview on 11/13/24 at 03:37 PM DON stated nurses were responsible for setting lpms on O2 concentrators for residents receiving oxygen. She stated nurses would know what lpm to set the O2 to by referring to physician's orders. DON was asked for a copy of the facility's standing orders for O2. She stated a resident's quality of care could be negatively impacted by receiving O2 without orders specifying the lpms. She stated a resident could become hypoxic. During an interview on 11/13/24 at 03:38 AM ADON A stated nurses were responsible for setting O2 levels on the O2 concentrators. She stated nurses would refer to physician's orders to find O2 levels. She stated a possible negative outcome of orders that did not specify the level for O2 was a resident might not receive enough O2 which could lead to lethargy or confusion. ADON A stated a possible negative outcome for a resident with COPD receiving oxygen without the level specified by the physician's order was the resident's CO2 levels could increase which would affect everything. During an observation and interview on 11/13/24 at 03:40 PM LVN D stated nurses were responsible for setting O2 levels on O2 concentrators. She stated she would look at the physician's order to determine how high to set the O2 level. LVN D attempted to look at the O2 order for Resident #68 to determine the level for Resident #68's O2. She spent approximately 2 minutes looking at her computer screen and then stated, You are right, I don't see them (lpms) here. She stated most residents start out on 2 lpm of O2 but the order still has to be in there. LVN D stated if she came across an order with no lpms she would start the O2 at 2 lpm and then find out from the physician. During an interview on 11/13/24 at 04:00 PM RN E stated nurses were responsible for setting O2 levels on O2 concentrators. He stated nurses would look at physician's orders to determine the level of lpms. He stated if a resident with COPD was receiving O2 without specified lpms from the physician, It could knock out their respiratory drive. You don't want to see (someone with COPD receiving O2 at rates of) more than a couple of liters. Record review of the facility provided policy titled Oxygen Administration dated 9/12/2014, revealed the following: Procedure: 1. Verify the Physicians Order. 6. Set flow rate Record review of the facility provided policy titled Medication-Treatment Administration and Documentation Guidelines dated 1/9/2014, revealed the following: Process: 2. Verify administration accuracy by checking the medication with the MAR three (3) times. 4. Administer the mediation according to the physician order. 12. Review each MAR and TAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided according to physician orders. 14. Complete a Medication Error Report for medication administration discrepancies.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure items in the freezer, pantry and refrigerator were properly stored, labeled, and dated. The facility failed to ensure items that were expired were disposed of and out of circulation. These failures could place residents at risk of food-borne illness. Findings include: Observation of the deep freeze on [DATE] at 9:24 AM revealed the following: 1. (1) bag of California vegetables had, no manufacturer use by date, sell by date, or best by date and no facility received date documented on the package. 2. (1) bag of stir fry vegetables, had no manufacturer use by date, sell by date, or best by date and no facility received date documented on the package. The vegetables in the bag had a thin layer of ice on them. Observation of the walk-in pantry on [DATE] at 9:34 AM revealed the following: 1. (1) bag of spaghetti opened to the air with no open date. The spaghetti was in a clear storage bin that was not sealed or labeled. 2. (1) bag of macaroni noodles with a hole in the packaging., Macaroni noodles had fallen out in a clear storage bin that was not labeled or sealed. 3. (1) small Ziplock bag with colorful sprinkles were half full and was not labeled or dated. Observation of the standup freezer on [DATE] at 9:43 AM revealed the following: 1. (1) 3-gallon container of open vanilla ice cream had no manufacturer use by date, sell by date, best by date, and no facility received or open date on the package. 2. (1) 3-gallon container of open strawberry ice cream with no manufacturer use by date, sell by date, best by date and no facility received or open date on the package. 3. (1) open box of frozen crab cakes were not sealed and was open to the air was not dated or labeled. Observation of the refrigerator on [DATE] at 9:50 AM revealed the following: 1. (1) clear pitcher of red sauce had no identifying label. 2. (1) expired container of Dessert Sauce with a use by date of [DATE]. 3. (1) expired container of Dessert Sauce with a use by date of [DATE]. Observation and interview on [DATE] at 8:30 AM, revealed the RDS took the bag of California vegetables and looked the bag over in its entirety. The RDS stated she could not find the manufacturer's use by date, sell by date, or best by date or the facility received by date. In an interview on [DATE] at 9:29 AM, the DS stated the negative outcome for not having labeled items in the pantry, refrigerator or freezer could cause residents to get sick and die . In an interview on [DATE] at 11:20 AM, the DA stated if she found an item in the kitchen that wasn't labeled properly or expired, she would throw the item away. DA stated that all staff are responsible for checking labels for expired/labeled foods. The DA stated a possible negative outcome for residents eating expired or unlabeled foods could cause the residents to get sick. Record review of the Frozen and Refrigerated Foods Storage Policy and Procedures, revision date, [DATE], revealed the following: 1. Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered. 2. All refrigerated and frozen items in storage will contain a minimum label of common name and product and dated. 3. All items past use by date are discarded. 4. Packaged frozen items that are opened and not used in their entirety must be properly sealed, label and dated for continued storage. Record review of the Dry Food and Supplies Storage policy and Procedure, revision date [DATE], revealed the following: 1. All opened products must be resealed effectively and properly labeled, dated, and rotated for use. 2. Use by, best by and sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately.

Based on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the medication room) of 3 medication areas reviewed for medication storage. The facility stored 11 medications in the medication room refrigerator that was documented at or below freezing 6 times between 9-13-2023 and 9-22-2023. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: During an observation completed on 09-20-2023 at 08:57 AM of the facility's medication room with ADON B the following medications were noted in the refrigerator: 1-Forteo filled 9-16-2023: noted instructions printed on the medication box not to freeze. 4-Lantaprost filled 8-26-2023: manufacturer storage instructions to store unopened bottle under refrigeration at 36-46 degrees. Tymlos filled 9-11-2023: noted instruction printed on the medication box to store between 36-46 degrees 1-Lantus Solostar filled date of 9-4-2023: manufacturer storage instructions to store under refrigeration at 36-46 degrees. 3-Humalog filled dated of 3-10-2023, 7-4-2023, and 7-30-2023: manufacturer storage instructions to store under refrigeration at 36-46 degrees. 2-Toujeo filled date of 7-30-2023 and 9-4-2023: manufacturer storage instructions do not freeze new pens. Refrigerate pens until expiration dated. 3-Trulicity filled dated of 8-13-2023, 9-2-20203, and 9-7-2023: noted instructions printed on the medication to store between 36-46 degrees In the Nexis kit stored in the refrigerator was the following. 3-Lispro filled 7-18-2023, 8-22-2023, and 9-19-2023: manufacturer storage instructions to store under refrigeration at 36-46 degrees. 1-Aspart with no fill date: manufacturer storage instructions to store under refrigeration at 36-46 degrees. 2-Levemir filled 6-20-2023 and 8-22-2023: manufacturer storage instructions to store under refrigeration at 36-46 degrees. 1-Aspart with no fill date: manufacturer storage instructions to store under refrigeration at 36-46 degrees. 1-Basaglar filled date of 7-18-2023: manufacturer storage instructions to store under refrigeration at 36-46 degrees. -also noted was a sign posted on the refrigerator's door that read temperatures should be between 38-48 degrees. The Temperature Log posted on the upper refrigerator door that read as follows: Refrigerator Med Room: Month-September 2023 Daily Temp Log Refrigerator: Target range 40 degrees Days:13th-30 degrees 14th-30 degrees 15th-30 degrees 17th-32 degrees 18th-32 degrees 20th-32 degrees During an interview on 09-20-2023 at 08:14 AM ADON B reported that if medications were not stored correctly, they would not be effective, that it would affect the effectiveness of the medication. ADON B reported that it would affect a resident condition such as with a diabetic and their insulin not being effective, and their blood sugars could be raised or lowered if their medication had to be adjusted as a result of their blood sugars being affected. During an interview on 09-20-2023 at 11:48 AM the RNC and DON presented the facility policy and CDC guidelines that stated that medications should be stored between 36-46 degrees and reported that the printed information on the refrigerator was incorrect. The RNC reported that she felt the thermometer in the refrigerator was not reading correctly and that the facility was supposed to have a new thermometer but was awaiting approval from corporate to purchase one. RNC reported that she was going to just purchase one today without approval because she felt the refrigerator has been in the proper range and that none of the medications had been stored improperly. The DON reported that she had talked with the PC and that the PC had reported that the medications could be stored safely at lower temperatures and would send an email to verify this. The DON reported that she would print the email for this surveyor. During an interview on 09-21-2023 at 08:27 AM the PC reported that she had spoken to the Tymlos manufacturer and that they reported that Tymlos was safe to store as long as it did not go below 32 degrees no more than 7 days. The PC reported that any insulins exposed to freezing temperatures would need to be discarded. The PC reported that the insulins would not be as effective, and the residents would not receive therapeutic treatment. During an interview on 09-21-2023 at 09:59 AM the DON and RNC were present and the RNC reported that they had noticed that new staff had been documenting the lower temperatures on the refrigerator monitoring and suspected that the new staff may have been doing it incorrectly, that they have replaced the current thermometer with a digital thermometer so it would be easier to read. The RNC reported that they were going to replace all the insulin medications because they could not ensure that they did not freeze and become ineffective. The DON reported that if the medications are not stored correctly, the medications effectiveness will be compromised. The DON reported that all staff have been trained on how to properly store and check medications to include refrigerated medication as to the proper temperatures. The DON reported that the former DON and ADON were responsible for the training of staff. The DON reported that they delegated current training to be the responsibility of the current ADON who started a new training 9-20-2023. Record review of the facility provided printed manufacturer instructions provided by the PC for the medication Tymlos revealed the following: The materials provided may contain information outside of the product labeling approved by the US Food and Drug Administration (FDA). It should not be regarded as a recommendation by Radius of r the us of our product in any manner inconsistent with FDA-approved Prescribing information. Tymlos Storage and Handling: -Before first use, store Tymlos pens in the refrigerator between 36-46 degrees -Do not freeze the Tymlos pen or exposed it to heat. Tymlos allowable temperature excursions during storage and transport Between -4 to 26 degrees: 7 days-Okay for use. Record Review of the facility provided policy titled Storage of Medications effective 9-2018, revealed the following: Temperatures: c. Refrigerated: 36-46 degrees with a thermometer to allow temperature monitoring.

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 7 of 10 anonymous residents reviewed for resident rights. The facility failed to promptly resolve grievances that were addressed in resident council meetings . This failure could place residents at risk of weight loss, as well as experiencing feelings of anger, frustration, and a decreased quality of life. Findings include: Observation on 9/19/2023 at 12:35 PM of anonymous resident in the middle of the dining room at a table by himself, had a trash can sitting beside him. Every few minutes he was observed coughing loudly and spitting into the trash can beside him . During the Resident Council meeting on 9/20/2023 at 9:00 AM five out of the 10 residents who were in attendance commented on how they were frustrated with the man in the dining room who continued to spit into a trash can. Residents stated they would not eat in the dining room because of his spitting ruined their appetite. In an observation on 9/20/23 at 02:20 PM revealed same anonymous resident sitting in the dining room at the middle table during an ice cream social, coughing and spitting into a trash can beside him . Interview with anonymous resident on 9/20/23 at 2:20pm who was exiting the dining room stated the dining room was loud and the man who coughed and spit was disgusting but the staff would not move him or do anything about it. During an interview on 09/20/23 at 11:12 AM the SW stated she was in the resident council meeting last week recording the minutes, and she was aware of the concerns about the man who spits in the trash can in the dining room. She stated that was the resident has the right to be in the dining room as well as the other residents. When asked what was being done about those grievances that were gathered in the resident council meeting, she stated they were given to the Administrator. In an interview with the ADM on 09/20/23 at 11:35 AM the ADM stated she was not aware of any complaints from residents not wanting to eat in the dining room due to the resident who spits. The ADM stated she had not thought about moving the resident away from the middle of the room so it didn't disturb the other residents. In an interview on 9/20/23 at 2:25 PM, LVN B stated he has been assisting in the dining room at breakfast, lunch, and dinner for about a year and was aware of the resident who sat in the middle of the room and spits. LVN B stated the spitting has been an issue with other residents for as long as he had been working in the dining room, and he heard a lot of complaints about the resident. He went on to state the resident used to spit on the floor, which was why there was a trash can there and the resident refused to eat in his room and that the resident doesn't have a physical ailment, just a habit of spitting. LVN B stated a possible negative outcome about the situation would be it could start fights and issues between the residents. Interview with an anonymous resident revealed she ate in the dining room daily and the man who spit in the trashcan was gross and she complained to staff about it. Record review of the resident council minutes revealed a complaint from the meeting minutes on 9/11/2023. The complaint stated, the man at the table that is in the middle of the dining room just keeps spitting. That is gross is he not able to move. The man that keeps spitting and the other guy that spits in a cup and just leaves it on the table, while I am eating . Record review of the facility policy and procedure titled Resident Rights, revised on 2/20/2021, revealed, . a) Voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished; and the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. b) The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 Residents (Resident #2, Resident #3, and Resident #4). - The facility failed to separate COVID positive and presumptive positive residents within the locked unit. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 8-8-2020 at 5:55 PM. While the IJ was lowered on 8-12-2020 at 11:30 AM, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Findings include: During an interview with LVN B on 8-8-2020 at 10:29 AM, she stated that she has symptomatic residents in the locked unit who have not been moved to the COVID unit. LVN B stated that the DON advised her to treat the symptoms of COVID and that no residents will be tested per corporate. LVN B stated that the only way she has found out that her residents are positive is when she sends them to the ER due to symptoms and they test positive at the ER. LVN B then said that the facility is not moving presumptive positive residents to the presumptive unit. She was asked why she thought that was, and she replied that she was just doing what the DON had told her. During an interview on 8-8-2020 at 12:20 PM, DON was asked about when to test a resident for COVID. DON stated that CCRN told her that the facility was a non-testing-based facility. DON stated that she was told to treat symptoms and if anybody gets worse to send them to the hospital. She was asked if residents who were symptomatic should be quarantined. She responded that they should be. She was then asked why residents in the locked unit were not quarantined. She responded that she didn't believe that the residents in the locked unit would be ok to be in a different area. During an observation of the locked unit on 8-8-2020 at 1:42 PM, there were no signs posted on the doors leading into the locked unit stating that anyone was on droplet-precautions, or that there were presumptive positive residents in the unit. Inside the unit, there were no signs posted on any resident doors stating isolation precautions or COVID status. There were no partitions separating presumptive positives or any quarantine measures in place in the locked unit. There was no PPE at hand near any rooms. There were no residents out in the common area. Most residents were seen in their rooms. Residents showed general symptoms of malaise such as lethargy. Some residents appeared asleep while others showed signs of discomfort such as facial grimacing and looking drawn. Coughing and vomiting could be heard from the hallway. During an interview with LVN B on 8-8-2020 at 1:45 PM, LVN B confirmed that Resident #3 was sent to the hospital on 8-5-2020, and in the ER tested positive for COVID. Resident #3's roommate, Resident #2, was not placed on any isolation precautions and later became symptomatic. LVN B stated 3 days after Resident #3 tested positive, Resident #2 was sent to the hospital where she was found to be positive for COVID. LVN B also stated the room was not sanitized after Resident #3 was found to be positive. LVN B stated that Resident #2 was not moved to another room, and that there was no attempt to isolate her. LVN B stated that now the entire unit is not feeling well. She stated that all the residents are eating less the past 2 days and are fatigued, with many of the residents having a cough. LVN B stated that she believed she would be sending more residents, especially Resident #4, to the hospital that day. LVN B stated that she had sent out Resident #2 that morning after taking report at 6:00AM due to signs of COVID 19 (N/V/D, Headache, Lethargy). LVN B was asked to show surveyor Resident #3's and Resident #2's room. There was no warning sign in place stating that a COVID positive or presumptive positive resident was in this room. The room had obviously not been cleaned as evidenced by the dirty laundry and general unkemptness of the room. LVN B was asked and confirmed that Resident #2 was not moved to another room after Resident #3 tested positive for COVID on 8-5-2020. She confirmed that the room was not cleaned. LVN B confirmed that there was no attempt to place Resident #2 on any type of isolation precaution. LVN B then confirmed that Resident #2 had interacted with most other residents in the locked unit after her roommate, Resident #3 tested positive for COVID-19. LVN B was then asked why she did not attempt to place presumptive positive residents on isolation precautions. She stated that she was just following what the DON had told her to do. When asked why the room was not cleaned she stated she was told they had to wait 72 hours after a resident tested positive to clean the room with EPA cleaner that killed COVID. LVN B was then asked if she thought that was safe for the residents, she replied no but she was just doing what she was told. During an observation of the locked unit on 8-8-2020 at 2:30 PM, Resident #4 had no sign on her door stating that she was a presumptive positive resident due to symptoms. During this observation, Resident #4 was leaving the facility via ambulance to be taken to the ER for evaluation due to exhibiting signs and symptoms of COVID-19. During an interview on 8-8-2020 at 3:29 PM, DON was asked if the facility had any mitigation strategies for the locked unit for separating residents who were showing signs of COVID-19. DON confirmed that the facility did not have any mitigation strategies in place to separate presumptive residents from non-presumptive in the locked unit. She confirmed that residents who were exposed to COVID should have been isolated as much as possible in the locked unit and should have been placed on droplet precautions. DON confirmed that there were no signs posted on any resident doors stating the need for isolation, even though some residents were symptomatic. DON confirmed that Resident #3 was sent to the hospital on 8-5-2020 where she was found to be positive for COVID. DON confirmed that her roommate, Resident #2, was not moved out of the room they shared, was not placed on isolation precautions, and did not have their room cleaned after Resident #3 tested positive for COVID. During an interview with the ADM on 8-8-2020 at 5:50 PM, she was asked why there was no effort to separate the presumptive positive cases within the locked unit. ADM stated that they had moved a locked unit resident off the unit and into a COVID positive unit and it had been very difficult for the resident and staff alike. ADM was asked why she did not try and separate presumptive positive residents from healthy residents back in the locked unit itself, and then was asked if she believed that Resident #2 should have been moved to another room at the very least. She responded that they should have moved Resident #2 to a different room and placed her on droplet precautions and confirmed that they did not. She was then asked why there was no attempt to place residents with signs of COVID on isolation precautions. ADM responded that it would have been very hard to keep residents in their rooms but agreed and confirmed that an honest attempt was not made. ADM confirmed that no signs were placed anywhere on the unit alerting anyone to possible COVID exposure. DON also confirmed that Resident #3's room was not cleaned after she was found to be positive for COVID-19. Record review of Resident #2's clinical record revealed an [AGE] year-old female resident admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Record review of Resident #2's MDS, dated [DATE], revealed a BIMS score that could not be assessed. The staff assessed Resident #2 as severely cognitively impaired. Section GG of the MDS revealed that the resident was able to ambulate within the locked unit independently. Record review of Resident #3's clinical record revealed a [AGE] year-old female admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Record review of Resident #3's MDS, dated [DATE], revealed a BIMS score of 5. Section G of the MDS revealed that the resident was able to ambulate with supervision. Record review of Resident #4's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Record review of Resident #4's MDS, dated [DATE], revealed a BIMS score of 6. Section G of the MDS revealed that she was able to ambulate independently in her wheelchair. Record review of facility provided policy titled Surveillance Plan: Infection Control Surveillance COVID-19, dated 1-30-2020, revised 6-2-2020, reflected in part: Fundamental Information Isolation Precautions are implemented for residents with known or suspected COVID-19 in a private room (if available), or other actions taken based on national (e.g., CDC), state, or local health authority recommendations. Patient Placement -Resident that is presumptive or COVID-19 positive will immediately be placed in a Private Room or cohorted (if private room no available) with the door closed in the designated area and implement Droplet/Contact Isolation Precautions. - Any roommates exposed to COVID-19 should be moved to a designated area and monitored for COVID-19 symptoms three times daily for 14 days. Room-sharing might be necessary if there are multiple resident with unknown or suspected COVID-19 in the facility. Infection Control Measures - If the resident has fever or symptoms, implement recommended infection prevention and control measures. Record review of Nursing Facility COVID-19 Response Emergency Rule, not dated, reflected in part: f) A nursing facility must cohort residents based on the residents' COVID-19 status. Record review of facility provided policy titled Surveillance Plan: Infection Control Surveillance COVID-19, dated 1-30-2020, revised 6-2-2020, reflected in part: Signage - Place signs to notify individuals entering the room to talk with nurse prior to room entry - Signage on the use of specific PPE (for staff) posted in appropriate locations in the facility (e.g., outside of a resident's room, wing, or facility-wide) The ADM was notified of the Immediate Jeopardy (IJ) on 8-8-2020 at 5:55 PM. The ADM was emailed a copy of the completed Immediate Jeopardy (IJ) template. ADM verified that she received the template via email. On 8-10-2020 at 10:14 AM the facility provided a plan of removal and it was accepted on 8-10-2020 at 11:30 AM. It documented the following: Plan of Removal Infection Control Prairie House Living Center This plan of removal serves as Prairie House Living Center's response to the Immediate Jeopardy notification the Center received at 5:55 PM on August 8, 2020 from the Texas Department of Aging and Disability related to: - Center failed to follow CMS and CDC guidelines addressing infection control to prevent the development and spread of COVID-19 to prevent the potential spread of COVID-19. - The facility failed to follow CMS guidance for LTC facilities regarding cohorting (positive and negative residents with COVID-19. - The facility failed to ensure isolation/quarantine measures were followed for residents with signs and symptoms or exposure to COVID-19 1. Immediate action(s) taken for the resident(s) found to have been affected include: - On 8/8/2020 all residents were assessed by DON and physician via telehealth for each resident in the TLC unit to determine if any residents were displaying signs and symptoms of COVID-19 - 22 residents were identified as having COVID 19 signs and symptoms. 22 residents from the TLC unit were identified. - 3 residents on the TLC unit were transferred to hospital on [DATE]. - 16 of the 22 residents remained on the TLC unit which was converted into a presumptive unit on 8/8/2020 with all residents in contact-droplet precautions. - On 8/9/2020 RNC validated using the unit assessment form the COVID positive unit and both Presumptive units have dedicated staff. - On 8/8/2020 all other residents in center on south, north, and med hall were assessed by DON and ADON using infection control monitoring tool to determine if any other residents were displaying signs and symptoms of COVID-19. No other residents were identified as having COVID-19 symptoms. This was completed 8/8/2020. - On 8/8/2020 ADM made complete room rounds on TLC unit and all other units to validate that any resident that is displaying signs of COVID-19 were placed in droplet-contact precautions. - On 8/8/2020 ADM made complete room rounds to validate roommate of symptomatic resident was separated and placed in droplet-contact isolation. This was completed on 8/8/2020. - On 8/8/2020 ADM, using a facility census, validated that any resident with COVID-19 symptoms or recently transferred to hospital had resident(s) room clean and sanitized using and EPA grade disinfectant. 2. Action to Prevent Occurrence/Reoccurrence: The following actions were taken to ensure occurrence or reoccurrence of process/system failure that could lead to serious adverse outcome and when those actions were completed. - 1:1 education was completed on 8/8/2020 with ADM and DON via phone with RDO and RNC on relocation and placing in droplet-contact precautions, any resident displaying symptoms of COVID-19 and separating exposed roommates of symptomatic residents and placing in droplet-contact isolation. Post-test was completed. - In service education was started on 8/8/2020 by ADON and DON on S/S of COVID-19 to all staff including CNAs. This education will continue until 100% of all staff is completed. Post-test will be completed to validate knowledge base. Education and Post Tests will be completed on 8/8/2020 and any staff that has not had this education will not be allowed to return to work until this is completed. Post-test was completed. - In service education was started on 8/8/2020 by ADON and DON for all nurses and CNAs on protocol of relocating residents who display S/S of COVID-19, on protocol regarding separating roommates who had potential exposure to residents displaying S/S of COVID-19, or positive for COVID-19. This education will continue until 100% of nurses and CNAs are completed. Post-test will be completed to validate knowledge base. This education and Post Tests will be completed on 8/8/2020 and any staff that has not had this education will not be allowed to return to work until this is completed. - 1:1 education was completed on 8/8/2020 with ADM and DON via phone with RDO and RNC on ensuring that all rooms are cleaned with EPA grade disinfectant after a resident with symptoms of COVID-19/COVID positive/or any exposed resident, is identified and/or relocated to another area in the center. - On 8/9/2020 education was started with all staff including CNAs on ensuring that all rooms are cleaned with EPA grade disinfectant after a resident with symptoms of COVID-19/COVID positive/or any exposed resident, is identified and/or relocated to another area in the center. This education will be completed on 8/9/2020 and any staff that has not had this education will not be allowed to return to work until this is completed. - DON/designee using the QAPI monitoring tool for Infection Control will review infection control monitoring tool daily x 4 weeks to validate that any residents identified with COVID-19 symptoms or had a potential exposure were identified, evaluated, had family and physician notification, placed in droplet-contact precautions, and relocated in center in applicable. - DON/designee using the QAPI monitoring tool for PPE will validate daily x 4 weeks that donning and doffing area are running correctly, and that staff are donning and doffing PPE correctly. - Administrator/designee using the QAPI Environmental monitoring tool will validate daily x 4 weeks that all rooms are cleaned with EPA grade disinfectant after a resident with symptoms of COVID-19/COVID positive/or any exposed resident is identified and/or relocated to another are in the center. - Administrator and DON will daily in morning meeting will review resident assessment tools and identify potential exposure risk, relocating roommates and for continued observations and/or quarantine. - Administrator and DON daily will review unit assignment sheets for COVID unit and both Presumptive units to validate dedicated staff to each unit x 4 weeks. - Administrator and DON will review QAPI monitoring tools daily in morning meeting. - MD was notified on the Immediate Jeopardy 8/8/2020 at 8:05 PM. - This system will be reviewed in QAPI meeting to include the medical director and will be conducted on 8/8/2020 to discuss sustaining compliance. A QAPI meeting will be conducted monthly to monitor compliance. 3. Date facility asserts likelihood for serious harm no longer exist is 8/9/2020. During a visit on 8-11-2020 beginning at 9:15 AM to verify completion of the facility's Plan of Removal, the following observations, interviews and record reviews were completed: Observation of the locked unit revealed all rooms had signs for droplet-contact precautions as well as COVID signs posted on the doors. Each unit in the facility was labeled to tell what type of unit was partitioned off. Both Presumptive units had a donning and doffing area in place. Observed NF staff adherence to PPE donning and doffing techniques. Observed proper handwashing techniques by NF staff. Interviewed 8 staff members to include the DON, ADM, CCRN, 3 LVNS, and 2 CNAs, all of which could identify what type of residents were in each unit. All stated that they had received training on signs and symptoms of COVID-19, cohorting positive or presumptive positive residents, and cleaning infected rooms. Reviewed the assessments completed by the DON, ADON, and ADM. Reviewed the training that was provided the DON and ADM by their corporate office. Record review of training and post-tests for staff were completed. Review revealed that less than half of the staff had been trained on COVID issues. Interview with CCRN revealed a plan to have most of the staff trained within 24 hours. During an interview with CCRN on 8-11-2020 at 3:00 PM, she was asked how she planned on training all staff in a timely manner. She responded that no staff member would be allowed to clock in and work the floor until all training stated on the Plan of Removal had been completed. She stated that all staff currently working the floor had been trained prior to clocking in that morning. On 8-12-2020 at 9:45 AM, CCRN sent an updated list via email of all staff what had been trained according to their Plan of Removal. List revealed that the majority of all staff had been trained and had taken the post-test. Immediate Jeopardy was lifted on 8-12-2020 at 11:30 AM. The facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure Each resident received adequate supervision and assistance devices to prevent accidents; in that: a) Cognitively impaired Resident #1 was a 2 person transfer with right side weakness. This resident was transferred from her bed to a shower chair by CNA #1 alone resulting in a fall that caused resident #1 to fracuture her right hip. It was further noted that the shower chair wheels were unlocked and rolled backwards during the transfer. b) The facility's system failed to prevent transfer related accidents by not training all staff on Care plans and CNA Assignment Sheets inaccurately reflected the resident's current transfer abilities; Assist of 2 instead of 1. The majority of nursing staff were not effectively in-serviced during the most recent in-service related to transfers, 3/14/18 (including CNA #1). Nine of 41 facility CNAs were documented as attending. This problem could result in an increase in resident transfer injuries in the facility. This problem had the potential to affect 69 residents that required assistance of one or two staff in transferring and 6 residents who were dependent on staff for transfers. The findings include: RESIDENT #1 - BACKGROUND Record Review of the Admission Record sheet for Resident #1 revealed that the resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. The resident was [AGE] years old. Review of the clinical record for Resident #1 revealed that she was discharged to the emergency roiagnom on [DATE] and re admitted to the facility on [DATE] due to the fracture of her right hip. She was discharged again to the hospital on [DATE] due to a venous problem. Record Review of the [DIAGNOSES REDACTED].#1 on the current care plan for Resident #1 was as follows, muscle wasting and atrophy, lack of coordination, [MEDICAL CONDITION], disorientation, hypertensive [MEDICAL CONDITION] with Stage 5 [MEDICAL CONDITION] or [MEDICAL CONDITIONS], type 2 diabetes mellitus with diabetic [MEDICAL CONDITION], cerebral infarction, dysphagia, cognitive communication deficit, [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris, heart failure, [MEDICAL CONDITION] reflux disease without esophagitis, [MEDICAL CONDITIONS] unspecified organism, dependence on [MEDICAL TREATMENT], and fracture of unspecified part of neck of right femur, initial encounter for closed fracture (6/22/18). Review of the annual MDS for Resident #1 dated 11/01/17 revealed that the resident had a BIMS score of 3 which indicated that the resident was cognitively impaired. The MDS further documented that the resident experienced inattention that fluctuated. It was further noted on the MDS that the resident functional status was that the resident required extensive assistance of 2 or more staff members for bed mobility and required extensive assistance of one person physical assist with transfers. Further review of the MDS revealed that the resident had muscle wasting and atrophy as a [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Record Review of the quarterly MDS dated [DATE] for Resident #1 revealed that the resident had a BIMS score of 3 which indicated that the resident was cognitively impaired. Further review of the MDS revealed that the resident functional status declined and was extensive assistance with two or more persons for bed mobility and transfers. Additional review of the MDS revealed that she had active [DIAGNOSES REDACTED]. Additional review of the MDS revealed that the resident had [MEDICAL CONDITION], lack of coordination, and disorientation. Both MDSs documented under the section balance during transitions and walking that the resident was not steady and only able to stabilize with staff assistance when moving from seated to standing position and surface-to-surface transfers such as transfers between bed and chair or wheelchair. Also documented on the MDS was that the resident was Mobile by wheelchair. It was further documented that the resident had impairment on both sides of her lower extremities. On 6/28/18 at 8:42 a.m., LVN #1 was asked to describe Resident #1. She stated, Mentally at times she's confused. The resident has a wound on her right toe . She doesn't always know what day it is. She can express needs and wants and can stand and pivot. She can turn herself in bed and could stand with assistance. She transfers with one depending on how tired she is; Especially after [MEDICAL TREATMENT] (she needs more assist to transfer). On 6/28/18 at 9:07 a.m. CNA #2 was asked to describe Resident #1. She stated, She needs assistance to transfer . Her arms and legs on the right-side has weakness. You have to help her with everything on that side. On 6/28/18 at 6:18 p.m. in Hospital #1, Resident #1 was observed in bed dozing. The resident was verbal with some confusion. The residents stated that she remembered the fall with a CNA. The resident was unable to remember any other details of the fall. On 6/28/18 at 2:23 p.m. LVN #3 stated, regarding Resident #1's transfer abilities, Sometimes she is a one person transfer. If it's a [MEDICAL TREATMENT] day it may be 2 .The wound on her right foot is chronic. It's almost healed then it breaks down. Review of the Pain Data Collection Tool for Resident #1 dated 6/ 7 / 18 revealed that this assessment was conducted quarterly and that the resident verbalizes pain which was internal and chronic on her right foot. The frequency of the pain was documented as occasional. Record Review of the Progress Note for Resident #1 dated 4 / 23 / 18 from Physician #1 revealed the following: Reason for appointment . Follow up . History of present illness. Constitutional: patient is elderly . Who has been having pain in both knees, both lower extremities are very hyper sensitive to touch due to [MEDICAL CONDITION] . Assessment. 1 [MEDICAL CONDITION], . 4. [MEDICAL CONDITION] of both knees unspecified [MEDICAL CONDITION] type . Treatment: Continue fall precautions . INVESTIGATION - RESIDENT #1 FALL 6/22/18 Record Review of the incident report for Resident #1 dated 6/22/18 at 3:30 a.m. revealed the following, CNA #1 assisted resident to shower chair before surgery. Resident started to slip and the aide tried to sit resident in shower chair, chair started to roll so aide started to lower resident to the floor. Other aide enter the room and try to help, but the first aid started to slip and the resident landed on top of the aide. Record Review of the Interdisciplinary Post Fall Assessment for Resident #1 dated 6/22/18 revealed the following additional information, Description of fall .Reported that she hit her right hip without pain, abrasion or pain in the hip. Groin area was having discomfort. Which relieved after 45 minutes. Further review of the form revealed the following, Gate balance deficits: right sided weakness . Record Review of the Investigation Follow-Up form dated 6/22/18 for Resident #1 revealed the following, . Summary of Investigation. Resident fall related to shower chair not locked and assist of two CNAs not done . Recommendation/New Interventions gait belt usage. And training, assist x2 cna's, for this resident transfers. On 6/28/18 at 8:42 a.m., LVN #1 was interviewed. LVN #1 was the charge nurse on duty at the time of the incident. She stated, I did not witness the fall. She added CNA #1 came got me and said her and the resident fell together. She said she was getting her up for a shower and her foot was slipping, both started slipping and the aide came in. CNA #1 stated that she did a bear hug on the resident. The resident was saying all she hit was her (Resident #1) hip. She stated that she had pain in her groin. The resident refused to go to the ER because she wanted to go to an appointment that she had scheduled several times. We put her in bed. She picked up her leg. There was no bruising to the area, nothing sticking out. I called (Physician #1). He stated if there was no pain, then monitor and go to the appointment. They gave the resident a bed bath without any complaints of pain. At approximately 4 or 4:45 a.m. they were leaving for the appointment and the resident had no complaints of pain when asked. The daughter said that the resident told her she hit her head. I was surprised she could move it if it was broken. LVN #1 was asked about any work-related concerns she had regarding CNA #1. She stated , The only thing, she needs to get help since she is on the smaller side. I have not had any complaints on her. She may have worked some day shift. She stated, She (CNA #1) is real helpful but probably needs to ask for help more. Record Review of the website www.mayoclinic.org revealed the following documentation, [MEDICAL CONDITION] Symptoms . signs and symptoms of [MEDICAL CONDITION] include . Severe pain in your hip or groin . On 6/28/18 at 9:07 a.m. CNA #2 was interviewed regarding the incident with Resident #1. She stated, I finished up rounds and open Resident #1's door. I saw CNA #1 and Resident #1 about the fall. CNA #1 had the impact of everything since the resident fell on her . On 6/28/18 at 11:23 a.m. CNA #1 was interviewed regarding the incident with Resident #1. She stated, It was approximately 3:00 a.m. and they told me she (Resident #1) needed a shower to go to a procedure. I told the nurse I would do it. I'm the floater . I put the gait belt on as I transferred she (Resident #1) stood. She said, 'I'm slipping.' Her leg went out, right leg. I tried to pull the shower chair, but it was starting rolling backwards. I guess her leg hit it. I lost control. We both fell and lost control. I fell on my hip. I'm not sure she fell on hers. The nurse asked if she, (Resident #1) wanted to go to her appointment. LVN #1 moved the leg. The resident complained of pain in the groin, but seemed OK. We put her in bed and gave a bed bath. She was put in a chair with no complaints of pain. CNA #1 was then asked if she had locked the shower chair wheels during the transfer. She stated, No. She was then asked what shower chair she used. She stated, It was the one in the South shower. The CNA was then asked what training she received regarding transfers to shower chairs prior to the incident. She stated, I was trained to lock the wheels on the shower chair. It was a transfer from the bed to the shower chair. The CNA was further asked about her previous training regarding wheelchair transfers. She stated, I was trained to lock wheelchair wheels. CNA #1 was then asked about Resident #1's transfer abilities. She stated, I saw it (Resident #1 as 2 person assist in transfers) on the paper (CNA Daily Assignment Sheet). She (Resident #1) will say sometimes she can help and we don't need 2 (to transfer her). She told me she would help (assist in the transfer on 6/22/18). I should have said 'No Miss (Resident #1). I'll go get help.' The CNA was then asked if she was aware that the resident had one sided weakness. She stated, Yes. The CNA was asked to describe Resident #1. She stated, .she can turn when you change her. She can hold herself up on the side of the bed. She can occasionally stand up to transfer when we are shorthanded. The CNA was then asked to describe the actual fall during the incident. She stated, I turned and she fell on this side, (top left side of the staff member, on resident's right side), face-to-face. I think she did hit her hip. I limped the rest of the night. They said to go to the ER. I didn't go that evening. I didn't want to leave them short. I came in and went to the ER the next day. On 6/28/18 an observation was made of the South shower and it was noted that a shower chair was present and all 4 wheels were equipped with locks. All 4 wheels were lockable. Record Review of the written statement provided to the surveyor by CNA #1 dated 6/28/18 at 12:30 p.m. revealed the following, My shift started at 6 p.m. the nurse informed me that Miss (Resident #1) needed a shower . as the float I have to help everyone on the floor. So around 3 a.m. I start the shower took the shower chair from the South Hall to her room and forgot to lock it. I sat Miss (Resident #1) up on the side of the bed around her and she said that she was slipping so then I tried to pull her closer to me and tried to pull the shower chair a little closer and it started to roll backwards. We both lost control and we fell . As we were falling CNA #2 came in and tried to catch us but it happened too fast. Miss (Resident #1) fell on my left side of my body and she was facing me so we were face-to-face. I told CNA #2 to stay with Miss (Resident #1) as I went to get the nurse as I was getting up, then I went limping to get the nurse (LVN #1) and explain to her what happened and told her she might have hit her hip I wasn't too sure. As we're walking down into the room when we get there she asked Miss (Resident #1) if she was hurting. She pointed to her groin area only, so then we got her up and on the bed . When they came for her . to leave the nurse asked if she was in any pain and she replied 'No' then she left. I also was aware that Miss (Resident #1) is a two-person transfer. She stated to me not to get help that she could help me. Record Review of the Provider in Investigation Report dated 6 / 22/18 revealed the following additional documentation, Incident Date. 6/22/18 time, 3:30 a.m. Individual resident involved . (Resident #1) Description of the Allegation. the resident landed on top of the aid. Resident reported that she (resident) hit her right hip. Denies pain or abrasion to the hip. Description of Injury. Resident denies pain to right hip after 45 minutes . Description of Assessment. Resident was assessed by LVN. No bruising or abrasion noted . Provider Response. The resident had a procedure that she was scheduled for at the hospital and she refused to go to the ER. They sent her by (transport service) for the appointment in Lubbock. Investigation Summary . When she arrived for her appointment, she began to complain of pain in right hip and was sent to the ER at the time. At 8:30 a.m., resident's daughter notified LVN on duty that the resident was in ER and right hip was broken. Provider Action Taken Post Investigation. Education and in-services are being provided to all staff regarding gait belt use and transfer safety. We are auditing CNA worksheets to match the MDS and care plans to make sure our residents receive the right assistance. Further review of the investigation report attached documents (6/22/18 nurse's notes, CNA #1 facility written Witness Statements taken by LVN #1 and the Administrator) confirmed that the shower chair rolled backwards during the transfer fall and that the resident stated she fell on her right side and hip. Record Review of the Witness Statement form provided as part of the facility investigation report revealed a statement from LVN #2. The statement revealed the following, Witness to description of fall 6:45 p.m. CNA #1 and Administrator demonstrated how the fall happen. CNA stated using gait belt she stood resident up to sit her on the shower chair, the back of residents legs only touch the shower chair, resident lost her balance. CNA attempted to break the fall pulling resident toward her and she lost her balance as well, they both fell to the floor face-to-face, resident landed on her right side of body, CNA landed on her left side of her body, another seeing they walked into the room and stayed with resident and she came to the nurses station to notify the nurse. Record Review of the hospital records for Resident #1 revealed the following documentation, . Cardiology Consultation . History of present illness. Miss (Resident #1) is a [AGE] year old female She was referred to our practice for a non-healing wound to the lower extremity. She underwent diagnostic testing and confirmed that she has [MEDICAL CONDITION]. She was scheduled for abdominal angiogram this morning and while at the nursing home The event of the Fall have been gathered only through the medical records. She is unable to communicate the events that led up to the fall. She presented to the cardiac Service Unit and with complaints of right lower extremity pain. She was directed to the emergency room for further evaluation. It is noted that she has an acute fracture to the right femoral neck . Medical History . Musculoskeletal: [MEDICAL CONDITION] . Physician Documentation. Discharge summary . 6 / 25 / 18 12:46 p.m. admitting [DIAGNOSES REDACTED]. Discharge diagnosis : closed [MEDICATION NAME] fracture of right femur. Procedures right hip repaired 6/22 . 79 F lives in nursing home .with mechanical fall the morning of admission resulting in broken right hip. Ortho asked us to admit for surgery 6 / 23 / 18. Patient was scheduled for .angiogram 6/22 . for non-healing wound on medial right great toe . History [MEDICAL CONDITION] right side deficits / weakness. Patient remarks that her hip is hurting 6/10 pain, Patient also has dementia, [MEDICAL CONDITION] on HD, significant vascular disease . discharge disposition: Residential Care. Problem list: 1. [MEDICAL CONDITION], right . Fracture of unspecified part of neck of right femur, initial encounter for closed fracture . Qualifiers . Fracture of unspecified part of neck of right femur, initial encounter for closed fracture Physician Documentation . Ortho trauma surgery consult . 6 / 22 / 18 7:12 p.m. Reason for consult. Right femoral neck fracture . History of present illness . She does report her right foot hurts. She does report pain with palpation of the right hip. Review of systems. Musculoskeletal: pain - right foot and hip, range-of-motion - pain with range of motion of right hip. Skin. 2 cm by 2 cm wound to the medial aspect of the right foot . Imaging / Diagnostics . Indication: injury trauma. fell at (nursing) home. Comparison: comparison made to 12 / 26 / 17. Findings : there appears to be acute, traumatic, impacted [MEDICAL CONDITION] hip. Impression : there appears to be impacted [MEDICAL CONDITION] femoral neck . On 6/28/18 at 2:00 p.m. the DON was asked what type of training staff were provided regarding transfers from the bed to a wheelchair or shower chair. She stated, They lock the shower chair wheels. They should use a gait belt. They stand and pivot to the shower chair. Record Review at the facility policy label Policy and Procedure, Origination Date: 5 - 2012, Transfer of Residents revealed the following documentation, Policy. Transfers are defined as the act of moving a resident from one surface such as from the bed to the wheelchair or from the wheelchair to the toilet. The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident, to prevent injuries to staff member assisting the resident, and to enable the resident to as independent during the transfer as possible. Fundamental Information. Procedure . always use good body mechanics . transfer residents toward their stronger side . position the wheel chair so that the 2 transfers services form an angle of 45? to 60?. Lock the brakes of the wheel chair and remove or swing the foot pedals out of the way if possible . stand with the feet apart with one foot ahead of the other to improve balance or if necessary blocked the residents knee/knees and foot/feet . assist the resident leaning as far forward as possible. Ensure resident has a good base support at the feet . use a slow, steady motion - not a fast, jerking motion. Record Review at the facility policy labeled Nursing Policy And Procedure Manual, Incident/Accident Reporting and Supervision, Review Date: 5/2005, revision date: 5/5 ; 11/17, revealed the following documentation, Policy. It is the policy of this facility to report and investigate all incidents and accidents that ocurred in the facility or on facility property in a timely manner. Appropriate authorities will be notified in a timely manner for all reportable incidents and accidents. It is the policy of this facility to provide an environment that is free from hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accidents. Fundamental information. Definitions . avoidable accident: means that an accident occurred because the facility fail to correctly identify environmental hazards and individual resident risk of an accident, including the need for supervision; and/or evaluate/analyze the hazards and risk; and/or implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident: and/or monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice . OTHER ISSUES - TRAINING, CARE PLAN/ASSESSMENT, CNA ASSIGNMENT SHEET ~ Inservice Record Review of the most recent in-services related to transfers, prior to the 6/22/18 incident revealed an in-service dated 3/14/18. Review of the In-Service Program Attendance Record dated 3/14/18 with a topic - Transfers revealed there was no documentation that the CNA #1 attended this in service. Further review of the attendance list revealed documentation that only 9 CNAs attended this in-service. Review of the facility list of active employees revealed that the facility currently employed 41 CNAs. Record Review of the In-Service Program Attendance Record dated 12/13/(17)18 revealed a topic - safe transfers using gait belts / preventing injury. Review of this documentation revealed that there was no documentation that CNA #1 had attended this in service. Record Review of the 3/14/18 in-service documents revealed a document labeled Transfer Activities, Responsibility: License Nurse, Nursing Assistant, Restorative Nursing Assistant And Physical Therapy. Purpose. To transfer the resident from bed to chair, toilet or tub safely . General Instructions . 2. Wheelchair breaks must always be locked and foot pedals raised . 4. Obtain help when necessary. Procedure. Transfer From Bed To Wheelchair. 1. Breaks on wheel chair should be locked, foot pedals raised . 2. Obtain assistance of another individual if necessary for safe transfer . Transfer From Bed To Wheelchair (Resident Unable To Assist In) . 2. Obtain assistance of another person for safe transfer . 4. Lock wheels on wheeled vehicle . Transfer Of Dependent Resident (Two Person) From Bed To Wheelchair. 1. Some residents will require the assistance of 2 persons for transfers . 3 .Lock the brakes . During an interview with the DON on 6/28/18 at 8:05 a.m. she was asked what the facility had done since the incident to protect residents. She stated we are doing training for gait belts. We updated her (Resident #1) care plan to say now she's extensive transfer by two. We are doing education and in-services on that. ~ CNA Assignment Sheet - Not updated On 6/28/18 at 11:00 a.m. LVN #3 was asked what was used by CNAs to know what care was required for resident. She stated, Yes, it's the CNA Assignment Sheet. On 6/28/18 at 2:23 p.m. LVN #3 was further asked about the CNA Assignment Sheet she stated, That's the latest they've given me. Record Review the CNA Daily Assignment Sheet revealed that Resident #1 was mobile by a wheelchair and required one person assist for transfers. It further stated that the resident was not a fall risk. This was the document presented by LVN #3 to the Surveyor as the current CNA Daily Assignment Sheet. The date at the bottom of the assignment sheet was 3/12/18. On 7/11/18 at 4:55 p.m. the DON was interviewed. She was then asked where the transfer abilities were documented for the resident. She stated, CNA Assignment Sheet I believe. It's printed off of Care Tracker. We upgraded her to 2 to transfer all the time. I believe it happened when she came back after hospitalization on the (MONTH) 29th, to make sure she was safe. Prior to that some say she was a one to transfer and some say it was 2 to transfer. Some say they can transfer her alone, so we decided to make her a 2-person transfer. The DON was then asked how did CNA's know how many staff are used to transfer a resident, Prior to the incident. She stated, It was pretty much left to the discretion of the CNA. With (CNA #1) being so small she needed 2 with the height difference. On 6/28/18 at 2:00 p.m. When asked about the CNA Assignment Sheet updates the DON stated, I'm not sure how the CNA Assignment Sheets are updated. On 6/28/18 at 2:12 p.m. the ADON #1, who made up the CNA Assignment sheets for the 1st two halls (South and Medicare) was interviewed. She stated, ADON #2 updates them, usually on a weekly basis. They are updated on a daily basis per shift. The nurses have to update it when they come in. They are in a pile. ~ Care Plan/Assessment On 6/28/18 at 2:45 p.m. the DON was asked which care plan was the most current for Resident #1. She stated, The nurses write on them, so the one in the chart is the most current. Record Review of Resident #1's current care plan printed from the computer system on 6/28/18 revealed the following, Focus, ADL'S: resident having ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to history of cerebral infarction, unspecified lack of coordination. Date initiated 11/01/17 revision on: 12/13/2017. Interventions listed for this Focus were, . Transfers: extensive, one person assist . This care plan further stated that the resident had an admission date of [DATE]. Record Review of Resident #1's care plan that was in the residents' clinical chart revealed the same documentation regarding ADL'S with interventions that stated transfers: extensive, one person assist. This care plan was updated 3/26/18. Record Review of the Baseline care plan for Resident #1 dated 6/25/18 revealed that this care plan was blank/not completed and failed to describe any care to be provided to the resident regarding activities of daily living which included bed mobility and transfers. Record Review of the CHR - One click, MDS 3.0 report dated 6/28/18 for Resident #1, Section G ADL revealed that the resident had a score by frequency of 3/3 - extensive assistance with support of two or more staff. Review of the 62 transfers documented between 6/1/18 thru 6/22/18 revealed that 33 of the 62 transfers required extensive assistance of 2 or more staff. Further review of this document revealed that from 6/20/18 through 6/22/18 the resident was dependent in transfers and require two or more staff assistance for 6 of 7 transfers during this time period. The facility had not updated the care plan to reflect the residents current ADL transfer status as documented in the most recent MDS and care tracker documentation. This provided staff with inaccurate resident information. ~ Review of the facility submitted CMS form 672 (Resident Census and Conditions of Residents) dated 5/03/18 confirmed a census of 104. Additional review of this form revealed that there were 69 residents that required assistance of one or two staff in transferring and 6 residents who were dependent on staff for transfers. Review of the facility submitted CMS form 672, resident census and conditions of residence form, dated 6/28/18 revealed that the facility had 69 residents that required assistance of one or two staff in transferring and 6 residents who were dependent on staff for transfers.

Based on observation, record review, and interview, the facility failed to prevent accidents, when residents' alarms, which were incorporated into their fall prevention programs, were not in place and/or were not in working order for five of nine residents (R#1, R#2, R#3, R#4, and R#5) reviewed for falls. 1) R#1, who had an order for [REDACTED]. 2) R#2, who had a history of [REDACTED]. This pad was supposed to be connected to an alarm that would alert staff if he was attempting to roll off his bed. 3.) R#3, who had an order for [REDACTED]. 4.) R#4, who had an order for [REDACTED]. 5.) R#5, who had an order for [REDACTED]. These failures could place all 37 residents with a history of falls at risk for additional falls and injuries. The findings were: Record review of R#1's current Admission Record revealed R#1 was an [AGE] year-old, who was admitted to this facility on 01/22/16. R#1's [DIAGNOSES REDACTED]. Observation of R#1 on 03/14/17 at 1:30 PM indicated R#1 was sitting in her wheelchair with her splint on her left leg. This wheelchair was located in front of the fall mat that was on the floor between the wheelchair and her bed, and her call light was clipped on mattress near her beds headrest. R#1 attempted to reach for her call light but was unable to do so, while she was sitting in her wheelchair. Interview with R#1 on 03/14/17 at 1:30 PM indicated she was wearing a leg splint because fell trying to go to the bathroom. Further interview with R#1 indicated she calls staff all the time, and they don't come. Review of R#1's Minimum Data Set (annual) dated 02/03/17 and MDS (quarterly) dated 12/07/16 indicated R#1 had scored a 5 on her Brief Interview for Mental Status revealing she was severely impaired. These reports indicated R#1, under Activities of Daily Living Assistance, required extensive assistance for bed mobility and transfers with one person physical assist. In addition these reports indicated R#1 utilized a wheelchair for mobility. Review of R#1's Comprehensive Plan of Care dated 10/27/17 identified R#1 as a fall risk, which was due to impaired mobility, cognitive deficits, impaired safety awareness, unsteady gait, and use of psychotropic medications. The evidence used to add fall risk to this plan included history of falls, unable to ambulate without assistance, and due to forgetting to use assistive device. This plan indicated R#1's fall risk would be approached by assessing medications, maintaining record of falls, evaluating for patterns, making sure staff members are aware that resident is at high risk for falls, involving therapy to evaluate as ordered by physician with documented declines, maintaining room and pathways free of clutter, set bed in lowest position with side rails up or down as ordered, bed or personal alarm if appropriate, call light within reach and answer promptly, and encourage resident to utilize call light, educate resident in safety awareness with voiced understanding, fall risk assessment update with all precautions taken, encourage resident to ask for assistance when needed, floor mat, Physical Therapy, and frequent monitoring. This plan identified activities of daily living deficits, which required R#1 have extensive assistance of one person for transfers, toileting, and limited assistance of one person for bed mobility. Record review of R#1's Fall Risk assessment dated [DATE] indicated R#1 scored a 17, and as noted on this report a score of 10 or above represents a high risk for falls. Review of R#1's Incident/Accident Report indicated her fall history as: on 01/05/17 R#1 was found sitting on her bedroom floor, no injuries were noted. This report included additional comments and/or steps taken to prevent recurrence by assisting with one person staff to bathrooms. On 01/07/17 R#1 was found sitting on the floor beside her bed, and R#1 sustained bleeding and swelling to forehead area. This report included additional comments and/or steps taken to prevent recurrence by keeping bed alarm in place, encourage R#1 to call for assistance, and keep floor mat in place. The Interdisciplinary Post-Fall Assessment on 02/25/17 R#1 slipped out of her wheelchair while attempting to self-transfer, and she ended up in a sitting position on her fall mat. The Incident/Accident Report dated 02/26/17 indicated R#1 was found on the floor sitting with a raised area and bruising to forehead. This report included additional comments and/or steps taken to prevent recurrence by toileting every two hours while awake. Review of R#1's Nurse's Notes dated 02/27/17 indicated on 02/26/17 at 11:15 PM R1's roommate yelled out for staff, and that's when staff found R#1 sitting on the floor. R#1 was assessed, and then at 3:35 AM CNA reported that R#1 yelled out in pain as she touched her left leg; therefore, an order was obtained to send R#1 to an emergency room . emergency room 's staff reported to facility's nurse that R#1's CT Scan and X-Ray revealed no fractures, instead she had a left knee sprain; and that R#1 was being returned to facility. R#1 upon arrival to facility had an ace applied as ordered, and neuro checks were initiated. R#1 continue to display signs and symptoms of pain until 03/02/17 when emergency room 's physician reported to facility's nurse that R#1's left patella was fractured on 02/27/17. This report indicated R#1 was in a low bed, safety alarm working, and fall mat placed by bed. Interview with R#6, who is R#1's roommate, on 03/14/17 at 5:15 PM indicated on 02/26/17 she did not see R#1 in her wheelchair, and that's when R#6 checked on R#1 and noticed she was on the floor in their bedroom. Afterwards R#6 yelled out for help, and LVN #5 and CNA #1 responded by assessing R#1, and then later sending R#1 to an emergency room . Further interview with she did not hear R#1's alarm making any sounds, and she is familiar with how R#1's alarm sounds when its activated. Review of R#6's Brief Interview for Mental Status dated 01/31/17 indicted she had scored a 15, which meant she was cognitively intact. Interview with CNA #1 on 3/14/2017 at 4:13 pm indicated she heard R#1's roommate, R#6, yelling for help, and that's when found R#1 sitting on the floor against her bathroom door. CNA #1 indicated she witnessed R#1's bed alarm; however, it was not activated (beeping), when she found R#1, who was crying, on the floor. Interview with LVN#5 on 03/23/17 at 10:05 AM indicated on 02/26/17 R#2 was yelling for help, and that's when she entered R#1's bedroom. In the room LVN #5 found R#1 sitting on the floor, and it looked like she walked away from her bed. LVN #5 could not be for sure that the bed alarm was sounding off, when she found R#1 on the floor. Interview with CNA #2 on 03/14/17 at 4:27 PM indicated it was reported to her that R#1 had fallen on the 6 pm to 6 am shift on 02/26/17. Afterwards CNA on her 6 am to 6 pm shift checked R#1's bedroom and discovered she did not have an alarm on her chair or her bed. Prior to 02/26/17 incident, CNA #2 witnessed R#1 in her bedroom standing up by her wheelchair, and noticed R#1's alarm had not activate (beeped) because it was unplugged. Further interview with CNA #2 indicated this morning, 03/14/17; she noticed R#1's sitting in her wheelchair, and her alarm was missing from her wheelchair. Review of facility's Provider Investigation Report dated 03/02/17 indicated R#1 sustained a fall on 02/16/17 at approximately 11:15 PM. Then at approximately R#1 was sent to emergency roiagnom on [DATE] at approximately 4 AM, and at 6:50 PM emergency room called facility's staff to report no fractures, but did have a knee sprain. On 03/01/17 at 8:20 PM emergency room 's physician reported to facility's staff that on 02/27/16 R#1 did sustain a left patella fracture, and recommended a knee mobilizer. This investigation indicated evidence was confirmed for a fracture, but that facility was not neglectful in this incident. Further review of this report failed to identify that R#1's alarm had not activated (beeping), and failed to confirm if alarm was in place on her bed/wheelchair, when R#1 was found on the floor on 02/26/17. Review of R#1's Order Summary Report dated 03/02/17 and signed by physician indicated bed and chair alarm need to be checked for placement and function on every shift. Review of R#1's treatment record included checking for bed and chair alarm for placement and function every shift (1st shift was 6 am to 6 pm and 2nd shift was 6 pm to 6 am). Each shift was initialed by a staff to indicated bed and chair alarm, and floor mat were in place; even though, it was not working. Record review of R#2's current Admission Record, dated 02/27/17, revealed R#2 was a [AGE] year-old, who was admitted to this facility on 07/05/11, and readmitted on [DATE]. R#2's [DIAGNOSES REDACTED]. Observation of R#2 on 03/14/17 at 10:23 am indicted he had an alarm; however, it was not working due to not having pad under his body while lying in bed. Review of R#2's Minimum Data Set (annual) dated 04/14/16 and MDS (quarterly) dated 12/14/16 indicated he scored a 0 on his Brief Interview for Mental Status revealing he was rarely or never understood. These reports indicated R#2, under Activities of Daily Living Assistance, required extensive assistance for bed mobility and transfers with two person physical assist. In addition these reports indicated R#2 utilized a wheelchair for mobility. Record review of R#2's Fall Risk assessment dated [DATE] indicated he scored a 19, and assessment dated [DATE] indicated he scored a 12, which as noted on this report a score of 10 or above represents a high risk for falls. Review of R#2's Incident/Accident Report indicated his fall history as: on 01/26/17 R#2 was found on the floor mat beside his bed without injuries noted. This report included additional comments and/or steps taken to prevent recurrence were to monitor closely. Review of R#2's Potential for Falls (Baseline Care Plan) updated 01/16/17 identified he was a risk for fall, and the interventions would include low/platform bed, bedside mat, call light within reach, lock brakes on bed and chair before transferring, etc. Review of R#2's SBAR Communication Form dated 02/07/17 indicated he moves a lot while in bed, and safety alarm has been applied. In addition this report indicated review and notification of this had been made with his physician. Review of R#2's Order Summary Report dated and signed by his physician on 03/02/17 indicated orders for safety alarm on wheelchair, and to check safety alarm placement and function on every shift. Review of R#2's Nurse's Notes dated 02/07/17 indicated he rolled out of his bed, but did not sustain an injury. Record review of R#3's current Admission Record indicated she was [AGE] years-old, and was admitted into this facility on 11/05/10, and readmitted [DATE]. This report indicated R#3 was diagnosed with [REDACTED]. Observation of R#3's bed alarm with LVN #3 on 03/15/17 at 4:10 am indicated R#3's, who was lying in his bed, had her bed alarm under her bed, and this alarm was not working. Interview with LVN #3 on 03/15/17 at 7:45 AM confirmed R#3's bed alarm was missing on 03/15/17 at 4:10 am. Record review of R#3's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with LVN #4 indicted recently she witnessed R#5 getting off his bed, and his alarm did not activate (beep). LVN #4 checked this alarm and found the switch had been turned off, and added that R#5 is unable to turn it off himself. Interview with CNA #3 on 03/15/17 at 6 am indicated on her shift, between 6 pm to 6 am, she normally does not check residents' alarms because she does not have time. In addition CNA #3 indicated she was unaware that R#3's alarm was not working on 03/15/17 at 4:10 AM. Record review R#4's current Admission Record indicated she was a [AGE] year-old, who was admitted to this facility on 10/10/2014. This report indicated R#4 was diagnosed with [REDACTED]. Observation on 03/15/2017 at 4:07 AM, R#4, who was lying in her bed, transferred from her bed to her wheelchair; however, this bed alarm did not activate (beep). Record review of R#4's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with R#4 on 03/15/17 at 4:07 am indicated her alarm had not been working for a while. Interview on 03/14/2017 at 4:07 am LVN#6, who checked R#4's alarm, confirmed it was not working. Record review of R#4's Comprehensive Plan of Care dated 10/13/2016 indicated she has an unsteady gate and falls, which would be addressed through a chair alarm and bed alarm. Review of R#5's current Admission Record indicated she was an [AGE] year-old, who was admitted into this facility on 10/11/12, and readmitted [DATE]. This report indicated R#5 was diagnosed with [REDACTED]. Record review of R#5's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with CNA #2 on 03/14/17 at 4:27 PM confirmed R#5's bed alarm was not working, because the pad that is supposed to be under her body and attached to alarm was missing. CNA indicated R#5 is unable to remove her alarm. Interview with CNA #2 on 03/14/17 at 4:27 PM indicated a while back she witnessed a box with pad alarms in the shower area, and she reported this to LVN #1. Interview with LVN #1on 03/14/17 at 5 pm indicated that approximately 2 weeks ago she discovered four alarms with pads stored in a box. Afterwards LVN #1 indicated she checked for missing alarms and found 3 residents without their alarms (R#2, R#3 and a non-sample resident). LVN #1 indicated she reported her findings to LVNs #2 and #3 that residents' alarms were missing, and she suspected somebody was removing them. Further interview with LVN 1 indicated today, 03/14/15, R#2's pad alarm was missing, R#3's bed and chair alarm were missing, and two non-sample residents' alarms were missing from their wheelchair and/or bed. Interview with facility staff #7 on 03/15/17 at 4 PM indicated prior to 03/14/15, Incident/Accident reports and post fall report were found to be incomplete; therefore, interdisciplinary team were not given opportunity to make recommendation for interventions and prevention as needed. Review of facility's policy and procedure for Fall Management System dated 01/03/17, indicated residents who scored a 10 or above on their Fall Risk Assessment may represent high risk for falls. Residents who have falls will have a licensed nurse initiate the Incident/Accident investigation immediately after each fall utilizing the Investigation Follow-up guideline. In addition interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results the licensed nurse will initiate intervention measures as soon as practicable such as a chair alarm. Further review indicated further investigation might by necessary, and the Director of Nursing or designee, Administrator and the Interdisciplinary Team in the clinical meeting will review falls and may modify intervention to reduce the risk of future falls. The facility's undated CMS Roster/Sample Matrix (802) form, dated 01/10/17 indicated there were 28 residents with falls, including 9 residents with fractures. In addition facility provided a list dated 03/15/17, which indicated there were 37 residents with bed and/or wheelchair alarms.

Based on observation, record review, and interview, the facility failed to implement their written policies and procedures to prohibit neglect for five of nine residents (R#1, R#2, R#3, R#4, and R#5) reviewed for neglect. 1) R#1, who had an order for [REDACTED]. 2) R#2, who had a history of [REDACTED]. This pad was supposed to be connected to an alarm that would alert staff if he was attempting to roll off his bed. 3.) R#3, who had an order for [REDACTED]. 4.) R#4, who had an order for [REDACTED]. 5.) R#5, who had an order for [REDACTED]. These failures could place all 37 residents with a history of falls at risk for additional falls and injuries. The findings were: Record review of R#1's current Admission Record revealed R#1 was an [AGE] year-old, who was admitted to this facility on 01/22/16. R#1's [DIAGNOSES REDACTED]. Observation of R#1 on 03/14/17 at 1:30 PM indicated R#1 was sitting in her wheelchair with her splint on her left leg. This wheelchair was located in front of the fall mat that was on the floor between the wheelchair and her bed, and her call light was clipped on mattress near her beds headrest. R#1 attempted to reach for her call light but was unable to do so, while she was sitting in her wheelchair. Interview with R#1 on 03/14/17 at 1:30 PM indicated she was wearing a leg splint because fell trying to go to the bathroom. Further interview with R#1 indicated she calls staff all the time, and they don't come. Review of R#1's Minimum Data Set (annual) dated 02/03/17 and MDS (quarterly) dated 12/07/16 indicated R#1 had scored a 5 on her Brief Interview for Mental Status revealing she was severely impaired. These reports indicated R#1, under Activities of Daily Living Assistance, required extensive assistance for bed mobility and transfers with one person physical assist. In addition these reports indicated R#1 utilized a wheelchair for mobility. Review of R#1's Comprehensive Plan of Care dated 10/27/17 identified R#1 as a fall risk, which was due to impaired mobility, cognitive deficits, impaired safety awareness, unsteady gait, and use of [MEDICAL CONDITION] medications. The evidence used to add fall risk to this plan included history of falls, unable to ambulate without assistance, and due to forgetting to use assistive device. This plan indicated R#1's fall risk would be approached by assessing medications, maintaining record of falls, evaluating for patterns, making sure staff members are aware that resident is at high risk for falls, involving therapy to evaluate as ordered by physician with documented declines, maintaining room and pathways free of clutter, set bed in lowest position with side rails up or down as ordered, bed or personal alarm if appropriate, call light within reach and answer promptly, and encourage resident to utilize call light, educate resident in safety awareness with voiced understanding, fall risk assessment update with all precautions taken, encourage resident to ask for assistance when needed, floor mat, Physical Therapy, and frequent monitoring. This plan identified activities of daily living deficits, which required R#1 have extensive assistance of one person for transfers, toileting, and limited assistance of one person for bed mobility. Record review of R#1's Fall Risk assessment dated [DATE] indicated R#1 scored a 17, and as noted on this report a score of 10 or above represents a high risk for falls. Review of R#1's Incident/Accident Report indicated her fall history as: on 01/05/17 R#1 was found sitting on her bedroom floor, no injuries were noted. This report included additional comments and/or steps taken to prevent recurrence by assisting with one person staff to bathrooms. On 01/07/17 R#1 was found sitting on the floor beside her bed, and R#1 sustained bleeding and swelling to forehead area. This report included additional comments and/or steps taken to prevent recurrence by keeping bed alarm in place, encourage R#1 to call for assistance, and keep floor mat in place. The Interdisciplinary Post-Fall Assessment on 02/25/17 R#1 slipped out of her wheelchair while attempting to self-transfer, and she ended up in a sitting position on her fall mat. The Incident/Accident Report dated 02/26/17 indicated R#1 was found on the floor sitting with a raised area and bruising to forehead. This report included additional comments and/or steps taken to prevent recurrence by toileting every two hours while awake. Review of R#1's Nurse's Notes dated 02/27/17 indicated on 02/26/17 at 11:15 PM R1's roommate yelled out for staff, and that's when staff found R#1 sitting on the floor. R#1 was assessed, and then at 3:35 AM CNA reported that R#1 yelled out in pain as she touched her left leg; therefore, an order was obtained to send R#1 to an emergency room . emergency room 's staff reported to facility's nurse that R#1's CT Scan and X-Ray revealed no fractures, instead she had a left knee sprain; and that R#1 was being returned to facility. R#1 upon arrival to facility had an ace applied as ordered, and neuro checks were initiated. R#1 continue to display signs and symptoms of pain until 03/02/17 when emergency room 's physician reported to facility's nurse that R#1's left patella was fractured on 02/27/17. This report indicated R#1 was in a low bed, safety alarm working, and fall mat placed by bed. Interview with R#6, who is R#1's roommate, on 03/14/17 at 5:15 PM indicated on 02/26/17 she did not see R#1 in her wheelchair, and that's when R#6 checked on R#1 and noticed she was on the floor in their bedroom. Afterwards R#6 yelled out for help, and LVN #5 and CNA #1 responded by assessing R#1, and then later sending R#1 to an emergency room . Further interview with she did not hear R#1's alarm making any sounds, and she is familiar with how R#1's alarm sounds when its activated. Review of R#6's Brief Interview for Mental Status dated 01/31/17 indicted she had scored a 15, which meant she was cognitively intact. Interview with CNA #1 on 3/14/2017 at 4:13 pm indicated she heard R#1's roommate, R#6, yelling for help, and that's when found R#1 sitting on the floor against her bathroom door. CNA #1 indicated she witnessed R#1's bed alarm; however, it was not activated (beeping), when she found R#1, who was crying, on the floor. Interview with LVN#5 on 03/23/17 at 10:05 AM indicated on 02/26/17 R#2 was yelling for help, and that's when she entered R#1's bedroom. In the room LVN #5 found R#1 sitting on the floor, and it looked like she walked away from her bed. LVN #5 could not be for sure that the bed alarm was sounding off, when she found R#1 on the floor. Interview with CNA #2 on 03/14/17 at 4:27 PM indicated it was reported to her that R#1 had fallen on the 6 pm to 6 am shift on 02/26/17. Afterwards CNA on her 6 am to 6 pm shift checked R#1's bedroom and discovered she did not have an alarm on her chair or her bed. Prior to 02/26/17 incident, CNA #2 witnessed R#1 in her bedroom standing up by her wheelchair, and noticed R#1's alarm had not activate (beeped) because it was unplugged. Further interview with CNA #2 indicated this morning, 03/14/17; she noticed R#1's sitting in her wheelchair, and her alarm was missing from her wheelchair. Review of facility's Provider Investigation Report dated 03/02/17 indicated R#1 sustained a fall on 02/16/17 at approximately 11:15 PM. Then at approximately R#1 was sent to emergency roiagnom on [DATE] at approximately 4 AM, and at 6:50 PM emergency room called facility's staff to report no fractures, but did have a knee sprain. On 03/01/17 at 8:20 PM emergency room 's physician reported to facility's staff that on 02/27/16 R#1 did sustain a left patella fracture, and recommended a knee mobilizer. This investigation indicated evidence was confirmed for a fracture, but that facility was not neglectful in this incident. Further review of this report failed to identify that R#1's alarm had not activated (beeping), and failed to confirm if alarm was in place on her bed/wheelchair, when R#1 was found on the floor on 02/26/17. Review of R#1's Order Summary Report dated 03/02/17 and signed by physician indicated bed and chair alarm need to be checked for placement and function on every shift. Review of R#1's treatment record included checking for bed and chair alarm for placement and function every shift (1st shift was 6 am to 6 pm and 2nd shift was 6 pm to 6 am). Each shift was initialed by a staff to indicated bed and chair alarm, and floor mat were in place; even though, it was not working. Record review of R#2's current Admission Record, dated 02/27/17, revealed R#2 was a [AGE] year-old, who was admitted to this facility on 07/05/11, and readmitted on [DATE]. R#2's [DIAGNOSES REDACTED]. Observation of R#2 on 03/14/17 at 10:23 am indicted he had an alarm; however, it was not working due to not having pad under his body while lying in bed. Review of R#2's Minimum Data Set (annual) dated 04/14/16 and MDS (quarterly) dated 12/14/16 indicated he scored a 0 on his Brief Interview for Mental Status revealing he was rarely or never understood. These reports indicated R#2, under Activities of Daily Living Assistance, required extensive assistance for bed mobility and transfers with two person physical assist. In addition these reports indicated R#2 utilized a wheelchair for mobility. Record review of R#2's Fall Risk assessment dated [DATE] indicated he scored a 19, and assessment dated [DATE] indicated he scored a 12, which as noted on this report a score of 10 or above represents a high risk for falls. Review of R#2's Incident/Accident Report indicated his fall history as: on 01/26/17 R#2 was found on the floor mat beside his bed without injuries noted. This report included additional comments and/or steps taken to prevent recurrence were to monitor closely. Review of R#2's Potential for Falls (Baseline Care Plan) updated 01/16/17 identified he was a risk for fall, and the interventions would include low/platform bed, bedside mat, call light within reach, lock brakes on bed and chair before transferring, etc. Review of R#2's SBAR Communication Form dated 02/07/17 indicated he moves a lot while in bed, and safety alarm has been applied. In addition this report indicated review and notification of this had been made with his physician. Review of R#2's Order Summary Report dated and signed by his physician on 03/02/17 indicated orders for safety alarm on wheelchair, and to check safety alarm placement and function on every shift. Review of R#2's Nurse's Notes dated 02/07/17 indicated he rolled out of his bed, but did not sustain an injury. Record review of R#3's current Admission Record indicated she was [AGE] years-old, and was admitted into this facility on 11/05/10, and readmitted [DATE]. This report indicated R#3 was diagnosed with [REDACTED]. Observation of R#3's bed alarm with LVN #3 on 03/15/17 at 4:10 am indicated R#3's, who was lying in his bed, had her bed alarm under her bed, and this alarm was not working. Interview with LVN #3 on 03/15/17 at 7:45 AM confirmed R#3's bed alarm was missing on 03/15/17 at 4:10 am. Record review of R#3's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with LVN #4 indicted recently she witnessed R#5 getting off his bed, and his alarm did not activate (beep). LVN #4 checked this alarm and found the switch had been turned off, and added that R#5 is unable to turn it off himself. Interview with CNA #3 on 03/15/17 at 6 am indicated on her shift, between 6 pm to 6 am, she normally does not check residents' alarms because she does not have time. In addition CNA #3 indicated she was unaware that R#3's alarm was not working on 03/15/17 at 4:10 AM. Record review R#4's current Admission Record indicated she was a [AGE] year-old, who was admitted to this facility on 10/10/2014. This report indicated R#4 was diagnosed with [REDACTED]. Observation on 03/15/2017 at 4:07 AM, R#4, who was lying in her bed, transferred from her bed to her wheelchair; however, this bed alarm did not activate (beep). Record review of R#4's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with R#4 on 03/15/17 at 4:07 am indicated her alarm had not been working for a while. Interview on 03/14/2017 at 4:07 am LVN#6, who checked R#4's alarm, confirmed it was not working. Record review of R#4's Comprehensive Plan of Care dated 10/13/2016 indicated she has an unsteady gate and falls, which would be addressed through a chair alarm and bed alarm. Review of R#5's current Admission Record indicated she was an [AGE] year-old, who was admitted into this facility on 10/11/12, and readmitted [DATE]. This report indicated R#5 was diagnosed with [REDACTED]. Record review of R#5's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with CNA #2 on 03/14/17 at 4:27 PM confirmed R#5's bed alarm was not working, because the pad that is supposed to be under her body and attached to alarm was missing. CNA indicated R#5 is unable to remove her alarm. Interview with CNA #2 on 03/14/17 at 4:27 PM indicated a while back she witnessed a box with pad alarms in the shower area, and she reported this to LVN #1. Interview with LVN #1 on 03/14/17 at 5 pm indicated that approximately 2 weeks ago she discovered four alarms with pads stored in a box. Afterwards LVN #1 indicated she checked for missing alarms and found 3 residents without their alarms (R#2, R#3 and a non-sample resident). LVN #1 indicated she reported her findings to LVNs #2 and #3 that residents' alarms were missing, and she suspected somebody was removing them. Further interview with LVN 1 indicated today, 03/14/15, R#2's pad alarm was missing, R#3's bed and chair alarm were missing, and two non-sample residents' alarms were missing from their wheelchair and/or bed. Interview with facility staff #7 on 03/15/17 at 4 PM indicated prior to 03/14/15, Incident/Accident reports and post fall report were found to be incomplete; therefore, interdisciplinary reviews were not given opportunity to make recommendation for interventions and prevention as needed. In addition care plans were not updated when a change in condition was warranted, such as a fall. Based on interview and record review, the facility failed to ensure each resident was free from neglect, for five of of eight residents (R#1, R#2, R#3, R#4, and R#5) reviewed for neglect. 1) R#1, who had an order for [REDACTED]. 2) R#2, who had a history of [REDACTED]. This pad was supposed to be connected to an alarm that would alert staff if he was attempting to roll off his bed. 3.) R#3, who had an order for [REDACTED]. 4.) R#4, who had an order for [REDACTED]. 5.) R#5, who had an order for [REDACTED].>These failures could place all 37 residents with a history of falls at risk for additional falls and injuries. The findings were: Record review of R#1's current Admission Record revealed R#1 was an [AGE] year-old, who was admitted to this facility on 01/22/16. R#1's [DIAGNOSES REDACTED]. Observation of R#1 on 03/14/17 at 1:30 PM indicated R#1 was sitting in her wheelchair with her splint on her left leg. This wheelchair was located in front of the fall mat that was on the floor between the wheelchair and her bed, and her call light was clipped on mattress near her beds headrest. R#1 attempted to reach for her call light but was unable to do so, while she was sitting in her wheelchair. Interview with R#1 on 03/14/17 at 1:30 PM indicated she was wearing a leg splint because fell trying to go to the bathroom. Further interview with R#1 indicated she calls staff all the time, and they don't come. Review of R#1's Minimum Data Set (annual) dated 02/03/17 and MDS (quarterly) dated 12/07/16 indicated R#1 had scored a 5 on her Brief Interview for Mental Status revealing she was severely impaired. These reports indicated R#1, under Activities of Daily Living Assistance, required extensive assistance for bed mobility and transfers with one person physical assist. In addition these reports indicated R#1 utilized a wheelchair for mobility. Review of R#1's Comprehensive Plan of Care dated 10/27/17 identified R#1 as a fall risk, which was due to impaired mobility, cognitive deficits, impaired safety awareness, unsteady gait, and use of [MEDICAL CONDITION] medications. The evidence used to add fall risk to this plan included history of falls, unable to ambulate without assistance, and due to forgetting to use assistive device. This plan indicated R#1's fall risk would be approached by assessing medications, maintaining record of falls, evaluating for patterns, making sure staff members are aware that resident is at high risk for falls, involving therapy to evaluate as ordered by physician with documented declines, maintaining room and pathways free of clutter, set bed in lowest position with side rails up or down as ordered, bed or personal alarm if appropriate, call light within reach and answer promptly, and encourage resident to utilize call light, educate resident in safety awareness with voiced understanding, fall risk assessment update with all precautions taken, encourage resident to ask for assistance when needed, floor mat, Physical Therapy, and frequent monitoring. This plan identified activities of daily living deficits, which required R#1 have extensive assistance of one person for transfers, toileting, and limited assistance of one person for bed mobility. Record review of R#1's Fall Risk assessment dated [DATE] indicated R#1 scored a 17, and as noted on this report a score of 10 or above represents a high risk for falls. Review of R#1's Incident/Accident Report indicated her fall history as: on 01/05/17 R#1 was found sitting on her bedroom floor, no injuries were noted. This report included additional comments and/or steps taken to prevent recurrence by assisting with one person staff to bathrooms. On 01/07/17 R#1 was found sitting on the floor beside her bed, and R#1 sustained bleeding and swelling to forehead area. This report included additional comments and/or steps taken to prevent recurrence by keeping bed alarm in place, encourage R#1 to call for assistance, and keep floor mat in place. The Interdisciplinary Post-Fall Assessment on 02/25/17 R#1 slipped out of her wheelchair while attempting to self-transfer, and she ended up in a sitting position on her fall mat. The Incident/Accident Report dated 02/26/17 indicated R#1 was found on the floor sitting with a raised area and bruising to forehead. This report included additional comments and/or steps taken to prevent recurrence by toileting every two hours while awake. Review of R#1's Nurse's Notes dated 02/27/17 indicated on 02/26/17 at 11:15 PM R1's roommate yelled out for staff, and that's when staff found R#1 sitting on the floor. R#1 was assessed, and then at 3:35 AM CNA reported that R#1 yelled out in pain as she touched her left leg; therefore, an order was obtained to send R#1 to an emergency room . emergency room 's staff reported to facility's nurse that R#1's CT Scan and X-Ray revealed no fractures, instead she had a left knee sprain; and that R#1 was being returned to facility. R#1 upon arrival to facility had an ace applied as ordered, and neuro checks were initiated. R#1 continue to display signs and symptoms of pain until 03/02/17 when emergency room 's physician reported to facility's nurse that R#1's left patella was fractured on 02/27/17. This report indicated R#1 was in a low bed, safety alarm working, and fall mat placed by bed. Interview with R#6, who is R#1's roommate, on 03/14/17 at 5:15 PM indicated on 02/26/17 she did not see R#1 in her wheelchair, and that's when R#6 checked on R#1 and noticed she was on the floor in their bedroom. Afterwards R#6 yelled out for help, and two R#6 indicated staff (LVN #2 and CNA #1) responded by assessing R#1, and then later sending R#1 to an emergency room . Further interview with she did not hear R#1's alarm making any sounds, and she is familiar with how R#1's alarm sounds when its activated. Review of R#6's Brief Interview for Mental Status dated 01/31/17 indicted she had scored a 15, which meant she was cognitively intact. Interview with CNA #1 on 3/14/2017 at 4:13 pm indicated she heard R#1's roommate, R#6, yelling for help, and that's when found R#1 sitting on the floor against her bathroom door. CNA #1 indicated she witnessed R#1's bed alarm; however, it was not activated (beeping), when she found R#1, who was crying, on the floor. Interview with LVN#5 on 03/23/17 at 10:05 AM indicated on 02/26/17 R#2 was yelling for help, and that's when she entered R#1's bedroom. In the room LVN #5 found R#1 sitting on the floor, and it looked like she walked away from her bed. LVN #5 could not be for sure that the bed alarm was sounding off, when she found R#1 on the floor. Interview with CNA #2 on 03/14/17 at 4:27 PM indicated it was reported to her that R#1 had fallen on the 6 pm to 6 am shift on 02/26/17. Afterwards CNA on her 6 am to 6 pm shift checked R#1's bedroom and discovered she did not have an alarm on her chair or her bed. Prior to 02/26/17 incident, CNA #2 witnessed R#1 in her bedroom standing up by her wheelchair, and noticed R#1's alarm had not activate (beeped) because it was unplugged. Further interview with CNA #2 indicated this morning, 03/14/17; she noticed R#1's sitting in her wheelchair, and her alarm was missing from her wheelchair. Review of facility's Provider Investigation Report dated 03/02/17 indicated R#1 sustained a fall on 02/16/17 at approximately 11:15 PM. Then at approximately R#1 was sent to emergency roiagnom on [DATE] at approximately 4 AM, and at 6:50 PM emergency room called facility's staff to report no fractures, but did have a knee sprain. On 03/01/17 at 8:20 PM emergency room 's physician reported to facility's staff that on 02/27/16 R#1 did sustain a left patella fracture, and recommended a knee mobilizer. This investigation indicated evidence was confirmed for a fracture, but that facility was not neglectful in this incident. Further review of this report failed to identify that R#1's alarm had not activated (beeping), and failed to confirm if alarm was in place on her bed/wheelchair, when R#1 was found on the floor on 02/26/17. Review of R#1's Order Summary Report dated 03/02/17 and signed by physician indicated bed and chair alarm need to be checked for placement and function on every shift. Review of R#1's treatment record included checking for bed and chair alarm for placement and function every shift (1st shift was 6 am to 6 pm and 2nd shift was 6 pm to 6 am). Each shift was initialed by a staff to indicated bed and chair alarm, and floor mat were in place; even though, it was not working. Record review of R#2's current Admission Record, dated 02/27/17, revealed R#2 was a [AGE] year-old, who was admitted to this facility on 07/05/11, and readmitted on [DATE]. R#2's [DIAGNOSES REDACTED]. Observation of R#2 on 03/14/17 at 10:23 am indicted he had an alarm; however, it was not working due to not having pad under his body while lying in bed. Review of R#2's Minimum Data Set (annual) dated 04/14/16 and MDS (quarterly) dated 12/14/16 indicated he scored a 0 on his Brief Interview for Mental Status revealing he was rarely or never understood. These reports indicated R#2, under Activities of Daily Living Assistance, required extensive assistance for bed mobility and transfers with two person physical assist. In addition these reports indicated R#2 utilized a wheelchair for mobility. Record review of R#2's Fall Risk assessment dated [DATE] indicated he scored a 19, and assessment dated [DATE] indicated he scored a 12, which as noted on this report a score of 10 or above represents a high risk for falls. Review of R#2's Incident/Accident Report indicated his fall history as: on 01/26/17 R#2 was found on the floor mat beside his bed without injuries noted. This report included additional comments and/or steps taken to prevent recurrence were to monitor closely. Review of R#2's Potential for Falls (Baseline Care Plan) updated 01/16/17 identified he was a risk for fall, and the interventions would include low/platform bed, bedside mat, call light within reach, lock brakes on bed and chair before transferring, etc. Review of R#2's SBAR Communication Form dated 02/07/17 indicated he moves a lot while in bed, and safety alarm has been applied. In addition this report indicated review and notification of this had been made with his physician. Review of R#2's Order Summary Report dated and signed by his physician on 03/02/17 indicated orders for safety alarm on wheelchair, and to check safety alarm placement and function on every shift. Review of R#2's Nurse's Notes dated 02/07/17 indicated he rolled out of his bed, but did not sustain an injury. Record review of R#3's current Admission Record indicated she was [AGE] years-old, and was admitted into this facility on 11/05/10, and readmitted [DATE]. This report indicated R#3 was diagnosed with [REDACTED]. Observation of R#3's bed alarm with LVN #3 on 03/15/17 at 4:10 am indicated R#3's, who was lying in his bed, had her bed alarm under her bed, and this alarm was not working. Interview with LVN #3 on 03/15/17 at 7:45 AM confirmed R#3's bed alarm was missing on 03/15/17 at 4:10 am. Record review of R#3's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with LVN #4 indicted recently she witnessed R#5 getting off his bed, and his alarm did not activate (beep). LVN #4 checked this alarm and found the switch had been turned off, and added that R#5 is unable to turn it off himself. Interview with CNA #3 on 03/15/17 at 6 am indicated on her shift, between 6 pm to 6 am, she normally does not check residents' alarms because she does not have time. In addition CNA #3 indicated she was unaware that R#3's alarm was not working on 03/15/17 at 4:10 AM. Record review R#4's current Admission Record indicated she was a [AGE] year-old, who was admitted to this facility on 10/10/2014. This report indicated R#4 was diagnosed with [REDACTED]. Observation on 03/15/2017 at 4:07 AM, R#4, who was lying in her bed, transferred from her bed to her wheelchair; however, this bed alarm did not activate (beep). Record review of R#4's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with R#4 on 03/15/17 at 4:07 am indicated her alarm had not been working for a while. Interview on 03/14/2017 at 4:07 am LVN#6, who checked R#4's alarm, confirmed it was not working. Record review of R#4's Comprehensive Plan of Care dated 10/13/2016 indicated she has an unsteady gate and falls, which would be addressed through a chair alarm and bed alarm. Review of R#5's current Admission Record indicated she was an [AGE] year-old, who was admitted into this facility on 10/11/12, and readmitted [DATE]. This report indicated R#5 was diagnosed with [REDACTED]. Record review of R#5's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with CNA #2 on 03/14/17 at 4:27 PM confirmed R#5's bed alarm was not working, because the pad that is supposed to be under her body and attached to alarm was missing. CNA indicated R#5 is unable to remove her alarm. Interview with CNA #2 on 03/14/17 at 4:27 PM indicated a while back she witnessed a box with pad alarms in the shower area, and she reported this to LVN #1. Interview with LVN #1 on 03/14/17 at 5 pm indicated that approximately 2 weeks ago she discovered four alarms with pads stored in a box. Afterwards LVN #1 indicated she checked for missing alarms and found 3 residents without their alarms (R#2, R#3 and a non-sample resident). LVN #1 indicated she reported her findings to LVNs #2 and #3 that residents' alarms were missing, and she suspected somebody was removing them. Further interview with LVN 1 indicated today, 03/14/15, R#2's pad alarm was missing, R#3's bed and chair alarm were missing, and two non-sample residents' alarms were missing from their wheelchair and/or bed. Interview with facility staff #7 on 03/15/17 at 4 PM indicated prior to 03/14/15, Incident/Accident reports and post fall report were found to be incomplete; therefore, interdisciplinary team were not given opportunity to make recommendation for interventions and prevention as needed. Review of facility's Abuse Policy dated 12/05/16 indicated the resident has the right to be free from neglect. The approach would include evaluating and identifying trends, assessing and monitoring of resident with needs, and involving interdisciplinary to determine needs, etc. Review of facility's policy and procedure for F

Based on observation, interview and record review, the facility failed to ensure each resident was free from neglect five of nine residents (R#1, R#2, R#3, R#4, and R#5) reviewed for neglect. 1) R#1, who had an order for [REDACTED]. 2) R#2, who had a history of [REDACTED]. This pad was supposed to be connected to an alarm that would alert staff if he was attempting to roll off his bed. 3.) R#3, who had an order for [REDACTED]. 4.) R#4, who had an order for [REDACTED]. 5.) R#5, who had an order for [REDACTED]. These failures could place all 37 residents with a history of falls at risk for additional falls and injuries. The findings were: Record review of R#1's current Admission Record revealed R#1 was an [AGE] year-old, who was admitted to this facility on 01/22/16. R#1's [DIAGNOSES REDACTED]. Observation of R#1 on 03/14/17 at 1:30 PM indicated R#1 was sitting in her wheelchair with her splint on her left leg. This wheelchair was located in front of the fall mat that was on the floor between the wheelchair and her bed, and her call light was clipped on mattress near her beds headrest. R#1 attempted to reach for her call light but was unable to do so, while she was sitting in her wheelchair. Interview with R#1 on 03/14/17 at 1:30 PM indicated she was wearing a leg splint because she fell trying to go to the bathroom. Further interview with R#1 indicated she calls staff all the time, and they don't come. Review of R#1's Minimum Data Set (annual) dated 02/03/17 and MDS (quarterly) dated 12/07/16 indicated R#1 had scored a 5 on her Brief Interview for Mental Status revealing she was severely impaired. These reports indicated R#1, under Activities of Daily Living Assistance, required extensive assistance for bed mobility and transfers with one person physical assist. In addition these reports indicated R#1 utilized a wheelchair for mobility. Review of R#1's Comprehensive Plan of Care dated 10/27/17 identified R#1 as a fall risk, which was due to impaired mobility, cognitive deficits, impaired safety awareness, unsteady gait, and use of [MEDICAL CONDITION] medications. The evidence used to add fall risk to this plan included history of falls, unable to ambulate without assistance, and due to forgetting to use assistive device. This plan indicated R#1's fall risk would be approached by assessing medications, maintaining record of falls, evaluating for patterns, making sure staff members are aware that resident is at high risk for falls, involving therapy to evaluate as ordered by physician with documented declines, maintaining room and pathways free of clutter, set bed in lowest position with side rails up or down as ordered, bed or personal alarm if appropriate, call light within reach and answer promptly, and encourage resident to utilize call light, educate resident in safety awareness with voiced understanding, fall risk assessment update with all precautions taken, encourage resident to ask for assistance when needed, floor mat, Physical Therapy, and frequent monitoring. This plan identified activities of daily living deficits, which required R#1 have extensive assistance of one person for transfers, toileting, and limited assistance of one person for bed mobility. Record review of R#1's Fall Risk assessment dated [DATE] indicated R#1 scored a 17, and as noted on this report a score of 10 or above represents a high risk for falls. Review of R#1's Incident/Accident Report indicated her fall history as: on 01/05/17 R#1 was found sitting on her bedroom floor, no injuries were noted. This report included additional comments and/or steps taken to prevent recurrence by assisting with one person staff to bathrooms. On 01/07/17 R#1 was found sitting on the floor beside her bed, and R#1 sustained bleeding and swelling to forehead area. This report included additional comments and/or steps taken to prevent recurrence by keeping bed alarm in place, encourage R#1 to call for assistance, and keep floor mat in place. The Interdisciplinary Post-Fall Assessment on 02/25/17 R#1 slipped out of her wheelchair while attempting to self-transfer, and she ended up in a sitting position on her fall mat. The Incident/Accident Report dated 02/26/17 indicated R#1 was found on the floor sitting with a raised area and bruising to forehead. This report included additional comments and/or steps taken to prevent recurrence by toileting every two hours while awake. Review of R#1's Nurse's Notes dated 02/27/17 indicated on 02/26/17 at 11:15 PM R#1's roommate, R#6 yelled out for staff, and that's when staff found R#1 sitting on the floor. R#1 was assessed, and then at 3:35 AM CNA reported that R#1 yelled out in pain as she touched her left leg; therefore, an order was obtained to send R#1 to an emergency room . emergency room 's staff reported to facility's nurse that R#1's CT Scan and X-Ray revealed no fractures, instead she had a left knee sprain; and that R#1 was being returned to facility. R#1 upon arrival to facility had an ace applied as ordered, and neuro checks were initiated. R#1 continue to display signs and symptoms of pain until 03/02/17 when emergency room 's physician reported to facility's nurse that R#1's left patella was fractured on 02/27/17. This report indicated R#1 was in a low bed, safety alarm working, and fall mat placed by bed. Interview with R#6, who is R#1's roommate, on 03/14/17 at 5:15 PM indicated on 02/26/17 she did not see R#1 in her wheelchair, and that's when R#6 checked on R#1 and noticed she was on the floor in their bedroom. Afterwards R#6 yelled out for help, and LVN #5 and CNA #1 responded by assessing R#1, and then later sending R#1 to an emergency room . Further interview with she did not hear R#1's alarm making any sounds, and she is familiar with how R#1's alarm sounds when its activated. Review of R#6's Brief Interview for Mental Status dated 01/31/17 indicted she had scored a 15, which meant she was cognitively intact. Interview with CNA #1 on 3/14/2017 at 4:13 pm indicated she heard R#1's roommate, R#6, yelling for help, and that's when found R#1 sitting on the floor against her bathroom door. CNA #1 indicated she witnessed R#1's bed alarm; however, it was not activated (beeping), when she found R#1, who was crying, on the floor. Interview with LVN#5 on 03/23/17 at 10:05 AM indicated on 02/26/17 R#2 was yelling for help, and that's when she entered R#1's bedroom. In the room LVN #5 found R#1 sitting on the floor, and it looked like she walked away from her bed. LVN #5 could not be for sure that the bed alarm was sounding off, when she found R#1 on the floor. Interview with CNA #2 on 03/14/17 at 4:27 PM indicated it was reported to her that R#1 had fallen on the 6 pm to 6 am shift on 02/26/17. Afterwards CNA on her 6 am to 6 pm shift checked R#1's bedroom and discovered she did not have an alarm on her chair or her bed. Prior to 02/26/17 incident, CNA #2 witnessed R#1 in her bedroom standing up by her wheelchair, and noticed R#1's alarm had not activate (beeped) because it was unplugged. Further interview with CNA #2 indicated this morning, 03/14/17; she noticed R#1's sitting in her wheelchair, and her alarm was missing from her wheelchair. Review of facility's Provider Investigation Report dated 03/02/17 indicated R#1 sustained a fall on 02/16/17 at approximately 11:15 PM. Then at approximately R#1 was sent to emergency roiagnom on [DATE] at approximately 4 AM, and at 6:50 PM emergency room called facility's staff to report no fractures, but did have a knee sprain. On 03/01/17 at 8:20 PM emergency room 's physician reported to facility's staff that on 02/27/16 R#1 did sustain a left patella fracture, and recommended a knee mobilizer. This investigation indicated evidence was confirmed for a fracture, but that facility was not neglectful in this incident. Further review of this report failed to identify that R#1's alarm had not activated (beeping), and failed to confirm if alarm was in place on her bed/wheelchair, when R#1 was found on the floor on 02/26/17. Review of R#1's Order Summary Report dated 03/02/17 and signed by physician indicated bed and chair alarm need to be checked for placement and function on every shift. Review of R#1's treatment record included checking for bed and chair alarm for placement and function every shift (1st shift was 6 am to 6 pm and 2nd shift was 6 pm to 6 am). Each shift was initialed by a staff to indicated bed and chair alarm, and floor mat were in place; even though, it was not working. Record review of R#2's current Admission Record, dated 02/27/17, revealed R#2 was a [AGE] year-old, who was admitted to this facility on 07/05/11, and readmitted on [DATE]. R#2's [DIAGNOSES REDACTED]. Observation of R#2 on 03/14/17 at 10:23 am indicted he had an alarm; however, it was not working due to not having pad under his body while lying in bed. Review of R#2's Minimum Data Set (annual) dated 04/14/16 and MDS (quarterly) dated 12/14/16 indicated he scored a 0 on his Brief Interview for Mental Status revealing he was rarely or never understood. These reports indicated R#2, under Activities of Daily Living Assistance, required extensive assistance for bed mobility and transfers with two person physical assist. In addition these reports indicated R#2 utilized a wheelchair for mobility. Record review of R#2's Fall Risk assessment dated [DATE] indicated he scored a 19, and assessment dated [DATE] indicated he scored a 12, which as noted on this report a score of 10 or above represents a high risk for falls. Review of R#2's Incident/Accident Report indicated his fall history as: on 01/26/17 R#2 was found on the floor mat beside his bed without injuries noted. This report included additional comments and/or steps taken to prevent recurrence were to monitor closely. Review of R#2's Potential for Falls (Baseline Care Plan) updated 01/16/17 identified he was a risk for fall, and the interventions would include low/platform bed, bedside mat, call light within reach, lock brakes on bed and chair before transferring, etc. Review of R#2's SBAR Communication Form dated 02/07/17 indicated he moves a lot while in bed, and safety alarm has been applied. In addition this report indicated review and notification of this had been made with his physician. Review of R#2's Order Summary Report dated and signed by his physician on 03/02/17 indicated orders for safety alarm on wheelchair, and to check safety alarm placement and function on every shift. Review of R#2's Nurse's Notes dated 02/07/17 indicated he rolled out of his bed, but did not sustain an injury. Record review of R#3's current Admission Record indicated she was [AGE] years-old, and was admitted into this facility on 11/05/10, and readmitted [DATE]. This report indicated R#3 was diagnosed with [REDACTED]. Observation of R#3's bed alarm with LVN #3 on 03/15/17 at 4:10 am indicated R#3's, who was lying in his bed, had her bed alarm under her bed, and this alarm was not working. Interview with LVN #3 on 03/15/17 at 7:45 AM confirmed R#3's bed alarm was missing on 03/15/17 at 4:10 am. Record review of R#3's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with LVN #4 indicted recently she witnessed R#5 getting off his bed, and his alarm did not activate (beep). LVN #4 checked this alarm and found the switch had been turned off, and added that R#5 is unable to turn it off himself. Interview with CNA #3 on 03/15/17 at 6 am indicated on her shift, between 6 pm to 6 am, she normally does not check residents' alarms because she does not have time. In addition CNA #3 indicated she was unaware that R#3's alarm was not working on 03/15/17 at 4:10 AM. Record review R#4's current Admission Record indicated she was a [AGE] year-old, who was admitted to this facility on 10/10/2014. This report indicated R#4 was diagnosed with [REDACTED]. Observation on 03/15/2017 at 4:07 AM, R#4, who was lying in her bed, transferred from her bed to her wheelchair; however, this bed alarm did not activate (beep). Record review of R#4's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with R#4 on 03/15/17 at 4:07 am indicated her alarm had not been working for a while. Interview on 03/14/2017 at 4:07 am LVN#6, who checked R#4's alarm, confirmed it was not working. Record review of R#4's Comprehensive Plan of Care dated 10/13/2016 indicated she has an unsteady gate and falls, which would be addressed through a chair alarm and bed alarm. Review of R#5's current Admission Record indicated she was an [AGE] year-old, who was admitted into this facility on 10/11/12, and readmitted [DATE]. This report indicated R#5 was diagnosed with [REDACTED]. Record review of R#5's Order Summary Report for March 2017, indicated she had an order for [REDACTED]. Interview with CNA #2 on 03/14/17 at 4:27 PM confirmed R#5's bed alarm was not working, because the pad that is supposed to be under her body and attached to alarm was missing. CNA indicated R#5 is unable to remove her alarm. Interview with CNA #2 on 03/14/17 at 4:27 PM indicated a while back she witnessed a box with pad alarms in the shower area, and she reported this to LVN #1. Interview with LVN #1 on 03/14/17 at 5 pm indicated that approximately 2 weeks ago she discovered four alarms with pads stored in a box. Afterwards LVN #1 indicated she checked for missing alarms and found 3 residents without their alarms (R#2, R#3 and a non-sample resident). LVN #1 indicated she reported her findings to LVNs #2 and #3 that residents' alarms were missing, and she suspected somebody was removing them. Further interview with LVN 1 indicated today, 03/14/15, R#2's pad alarm was missing, R#3's bed and chair alarm were missing, and two non-sample residents' alarms were missing from their wheelchair and/or bed. Interview with facility staff #7 on 03/15/17 at 4 PM indicated prior to 03/14/15, Incident/Accident reports and post fall report were found to be incomplete; therefore, interdisciplinary team were not given opportunity to make recommendation for interventions and prevention as needed. Review of facility's Abuse Policy dated 12/05/16 indicated the resident has the right to be free from neglect. The approach would include evaluating and identifying trends, assessing and monitoring of resident with needs, and involving interdisciplinary to determine needs, etc. Review of facility's policy and procedure for Fall Management System dated 01/03/17, indicated residents who scored a 10 or above on their Fall Risk Assessment may represent high risk for falls. Residents who have falls will have a licensed nurse initiate the Incident/Accident investigation immediately after each fall utilizing the Investigation Follow-up guideline. In addition interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results the licensed nurse will initiate intervention measures as soon as practicable such as a chair alarm. Further review indicated further investigation might by necessary, and the Director of Nursing or designee, Administrator and the Interdisciplinary Team in the clinical meeting will review falls and may modify intervention to reduce the risk of future falls. The facility's undated CMS Roster/Sample Matrix (802) form, dated 01/10/17 indicated there were 28 residents with falls, including 9 residents with fractures. In addition facility provided a list dated 03/15/17, which indicated there were 37 residents with bed and/or wheelchair alarms.

Based on observation, interviews and record review, it was determined the facility failed to consult the physician and failed to notify the resident's legal representative for changes in condition for 2 of 7 sampled residents (Resident #1 and #7) reviewed for changes in condition as evidenced by: 1. The facility failed to provide the treatment, assessment and physician notification for a pressure sore that worsened to the point of requiring amputation. -Resident #1 was found to have a pin prick hole in the bottom of his left heel but LVN C failed to inform the physician or the family. -The next day, LVN D redressed a 7.5 cm x 6 cm open area to Resident #1's left heel without an order and failed to notify the physician or the family. -Resident #1's physician assessed the open area 3 days after the wound was found but the family was not notified. -Nursing Staff failed to notice a change in Resident #1's wound to his left heel after two separate antibiotic treatments and failed to notify the doctor and family. -Nursing staff failed to notice a foul smell which was worsening and radiating from Resident #1's foot. -Nursing staff failed to ensure Resident #1's physician and family were aware of the worsening of his left heel. As a result, Resident #1 had a necrotic unstageable large decubitus ulcer to his left heel and was sent, per family request, to the hospital with a foul-smelling odor coming out of his left heel, placing Resident #1 at risk for worsening infection, amputation and death. 2. Resident #7's dressing on her left lower leg had not been changed in 8 days. This failure resulted in identification of an Immediate jeopardy (IJ) on 3/23/16. While the IJ was removed on 3/24/16, the facility remained out of compliance at harm at a scope of a pattern due to all active staff were still being in-serviced on notification of physician and family on a change of condition, skin management to identify skin observations, alterations, assessments, documentation guidelines related to skin alterations and the facility was still monitoring the Plan of Removal. This deficient practice affected Resident #1 and had the potential to place all 114 residents at risk for not having their physician consulted or family notified when having a change of condition which could result in not including the family nor the physician in making medical decisions concerning their loved ones. The evidence is as follows: Resident #1 Review of Resident #1's closed clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -An annual MDS resident assessment, dated 1/20/16, documented the resident rarely/never was understood, usually understands others, had short and long term memory problems, severely impaired cognitive skills for daily decision making, required extensive assistance with bed mobility, locomotion in the facility, eating, was totally dependent on two staff for transfers, dressing, toileting and bathing, was totally dependent on one staff for personal hygiene, had limited range of motion of one upper extremity and both lower extremities, used a wheelchair, was incontinent of bladder and bowel, 70 inches tall and 169 pounds, had weight loss but was not on a physician-prescribed weight-loss regimen, was at risk of developing pressure ulcers but did not have any pressure ulcers. -Review of a Care Plan, initiated on 1/20/16 and revised on 3/22/16, documented the following: Resident has [MEDICAL CONDITION]: Intervention - monitor/document/report to MD as needed any signs or symptoms of skin problems related to [MEDICAL CONDITION]: redness, [MEDICAL CONDITION], blistering, itching, burning, bruises, cuts, other [MEDICAL CONDITION]. Resident is currently taking Aspirin 81 mg daily as an anticoagulant related to [MEDICAL CONDITION] and [MEDICAL CONDITION]: Intervention - daily skin inspection. Report abnormalities to the nurse. Resident has potential for pressure ulcer development related to diabetes, incontinence and immobility. Patient developed Stage II on 2/17/16: Intervention - monitor and report to MD as needed changes in skin status: appearance, color, impaired skin. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas and other changes in skin integrity. Report new conditions to the physician. -Physician Telephone Orders documented the following: 2/17/16 - cleanse wound to left heel with wound cleanser, apply hydrogel and cover with non-adherent pad and wrap with [MEDICATION NAME] every day. 2/19/16 - Bactrim by mouth twice a day for 10 days for left heel wound, change dressing on Monday, Wednesday and Friday. 3/4/16 - Keflex 500 mg by mouth three times a day for 10 days for left heel wound. 3/20/16 - send to emergency room for evaluation/treatment for [REDACTED]. During a telephone interview on 3/22/16 at 8:52 a.m., family member #1 stated the facility did not do their job and now their choice is either an above the knee amputation or Hospice. Family member #1 stated, This has all been caused from neglect. Family member #1 stated he was never called about Resident #1's heel; the first time he saw a boot on Resident #1's foot, he asked the nurse about it and she informed him that his father had rubbed his foot on his bed sheet but he was ok. Family member #1 stated his sister was visiting on 3/20/16 and thought her father had pooped on himself because he smelled so bad so she asked the CNAs to clean him up. Family member #1 stated the CNAs told his sister that Resident #1 did not poop in his bed, his foot was what smelled. Family member #1 stated his father's heel was black and smelled something awful and his heel just got worse and worse. During an interview on 3/22/16 at 11:25 a.m., the facility Administrator stated Resident #1's son has some complaints, with one being he was not notified of his father's wound on his foot, but he was aware his father was wearing a boot. The Administrator stated Resident #1's son travels a lot and maybe he missed a message on his phone. Hospital Observations, Interviews and Record Review During an observation in ICU room [ROOM NUMBER] on 3/22/16 at 1:20 p.m., with RN E and RN F, Resident #1 had a small pressure ulcer to the side of his right foot which looked to be a deep tissue injury. Resident #1 left foot was covered with a clean dressing dated 3/22/16 which had a very foul odor. During an interview on 3/22/16 at 1:35 p.m., RN E stated she had taken care of Resident #1 since early on 3/21/16, when he was transferred to ICU. RN E stated Resident #1's left heel pressure ulcer had a very foul smell and was draining when he arrived on the unit. During an interview on 3/22/16 at 1:50 p.m., HNM stated she was aware his wound was really bad and the unstageable ulcer to his left heel smelled bad. During an observation in ICU room [ROOM NUMBER] at 2:15 p.m., with RN E assisting revealed the following: A strong foul smell was radiating out of Resident #1's room as the room was approached. The dressing was off and the unstageable pressure ulcer covered his entire left heel. The outer edges of the ulcer were a bright red, looked slimy and was bleeding. The bottom of his foot was light pink and [MEDICAL CONDITION] (puffy) all the way to the base of his toes. Resident #1 was grimacing in pain as the leg was raised. The attending physician was not interviewed at this time because he was at the end of the hallway talking with Resident #1's family. During a follow-up interview on 3/22/16 at 2:15 p.m., RN E stated the attending physician wanted to get an x-ray of Resident #1's foot to see if the wound has tunneling because the foot looks like it has tunneled all the way to his toes by the way the bottom of his foot looks. Review of hospital records, dated 3/21/16 at 2:39 p.m., which included hospital photos documented Resident #1's left heel pressure ulcer along with measurements, documented the pressure ulcer was 8.63 cm by 6.77 cm. Review of Emergency Department Report, dated 3/20/16 at 8:14 p.m., documented the following: patient presents with foul smelling infected left heel that apparently has been having dressing changes at the nursing home intermittently. Left heel with necrotic unstageable large decubitus ulcer with surrounding [DIAGNOSES REDACTED], purulence and foul smell. NOTE: Pressure Ulcer - also called bedsore, decubitus ulcer, pressure necrosis or pressure sore - an inflammation, sore, or ulcer in the skin over a bony prominence. It results from ischemic [MEDICAL CONDITION] of the tissues caused by prolonged pressure on them. Prevention of pressure ulcers is a cardinal aspect of nurse care. Prompt and continued care of early [MEDICAL CONDITION] can prevent invasion of underlying tissue and promote healing. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page1318 - 1319) Hospital physician progress notes [REDACTED]. The family is discussing the problem with the patient about his diabetic foot with multiple decubitus ulcers infected and poor circulation with significant [MEDICAL CONDITION]. This discussion is about the need to proceed with amputation versus transfer of the patient to hospice services. Nursing Home Nurses Notes documented the following: 2/14/16 - CNAs called nurse to room and noted that resident's left heel was dripping blood. Assessed the heel, it noted a small hole, cleaned wound and applied pressure to stop bleeding. Applied pressure dressing. 2/17/16 - Doctor here and assessed wound. Received order to cleanse wound with wound cleaner, apply hydrogel and cover with non-adherent pad and wrap with [MEDICATION NAME] every day. 2/19/16 - received order for Bactrim DS by mouth twice a day for 10 days and change dressing changes to Monday, Wednesday and Friday. Initial dose given. All documented by LVN C. During an interview on 3/22/16 at 2:50 p.m., LVN C stated she noticed a problem with Resident #1's foot when the aides called her down to his room on 2/14/16 because his foot was bleeding. LVN C stated there was a hole in the bottom of his heel so she cleaned the heel up and held pressure to get the wound to stop bleeding. When asked if she reported the wound on Resident #1's heel to the physician or the family, she stated she did not because she was so busy. She stated Resident #1 received his dressing changes on Monday, Wednesday and Fridays after he got showered. She stated Resident #1 was on antibiotics and to her, his wound did not look like it ever changed much. She stated she did not think Resident #1's foot stunk and no one had reported to her that his foot stunk but she had been having trouble with her allergies. She stated she was surprised how fast Resident #1's wound opened up. During an interview on 3/22/16 at 3:09 p.m., CNA G stated she was the aide who reported Resident #1's foot bleeding to LVN C. CNA G stated she took care of Resident #1 a lot and noticed his foot was starting to smell really bad. When asked when Resident #1's foot started to smell bad, she said around the beginning of March. CNA G stated she did not report the smell to the nurse because she figured the nurse could smell it herself without being told. CNA G stated when she had Resident #1 in the shower; she would clean his foot fast because it smelled so bad. CNA G stated when the nurse would change Resident #1's dressing; she would hold his leg up so the nurse could wrap his foot. During a follow-up interview on 3/22/16 at 3:45 p.m., LVN C stated when she first assessed Resident #1's heel on 2/14/16; the wound was the size of a pin prick. LVN C again stated she did not call the physician or family about the wound to Resident #1's heel. LVN C stated she took good care of Resident #1 but she just did not document like she should have. LVN C stated, I messed up. During an interview on 3/22/16 at 3:50 p.m., CNA H stated when she came back from vacation on 2/27/16; Resident #1 foot was already bandaged and had an inflated boot thing on his foot. CNA H stated she would prop up Resident #1's leg to assist with dressing changes and said, It stunk pretty bad. CNA H stated Resident #1's foot started stinking about two weeks ago. CNA H stated the nurse was doing the dressing changes every other day so she figured she knew Resident #1's foot stunk. During an interview on 3/22/16 at 4:00 p.m., with ADON I, when asked for Resident #1's Treatment Administration Record for February 2016, she stated it could not be found in his chart. Review of the Non-Pressure Skin Condition Report, documented the following: 2/9/16 - skin intact 2/16/16 (first documentation of left heel ulcer) - dressing intact to left heel prior to shower on 2/15/16, open area noted once dressing was removed: 7.5 cm x 6 cm with small amount of serosanguinous exudate, no odor, wound bed with [MEDICATION NAME] tissue and the surrounding skin color was normal. This was documented by LVN D. NOTE: serosanguinous: thin and red; composed of serum and blood. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 1480) Exudate: fluid, cells or other substances that have been slowly exuded, or discharged , from cells or blood vessels through small pores or breaks in cell membranes. Perspiration, pus and serum are sometimes identified as exudates. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 607) During an interview on 3/23/16 at 9:35 a.m., LVN D stated a CNA came to her on 2/15/16 and asked her if she wanted to change the dressing on Resident #1's foot. LVN D stated she was unaware Resident #1 had a dressing on his foot and said to the CNA, What dressing? LVN D stated when she last worked on 2/11/16 (Thursday) Resident #1 did not have any skin issues but when she came back to work on 2/15/16, Resident #1 had skin issues but she was not informed about the dressing change or skin issues from the evening nurse she received report from. LVN D stated she redressed Resident #1's heel on 2/15/16 but failed to document on the Non-Pressure Skin Condition Report until 2/16/16. LVN D stated Resident #1 heel was open with healthy pink tissue. LVN D stated the wound was big and covered the whole bottom of Resident #1's heel. When asked if there was an order for [REDACTED].#1's heel, LVN D stated there were not any orders for dressing changes for Resident #1. LVN D stated she redressed Resident #1's heel because there was dressing on it. When asked when there were no orders for dressing changes to Resident #1's did it raise her suspicion the doctor had not been notified, LVN D stated she thought the doctor had already been notified. LVN D stated she did not write an incident report or an SBAR (Situation, Background, Appearance, Review and notify) for Resident #1's heel because she was too busy as she had several people sick at the same time. LVN D stated she documented on the Non-Pressure Skin Condition Report on 2/16/16 for Resident #1's heel and wrote the measurements on it but she stated she did not contact the physician or the family because she thought the other nurse had already done that. When asked when she did not see any documentation for the previous day on the Non-Pressure Skin Condition Report for Resident #1's heel wound, did that raise a suspicion the physician and family had not been notified; LVN D stated she thought the other nurse had notified the physician and family. LVN D stated there was a day she took the physician to Resident #1's room to see his foot because the wound had an odor and that was when Resident #1's physician ordered antibiotics. LVN D stated she could not remember the day, but Resident #1's son had noticed a dressing on his father's foot and the son asked her a lot of questions about Resident #1's foot. Further review of the Non-Pressure Skin Condition Report documented the following: 2/23/16 - 7 x 6 with serosanguinous exudate with no odor, wound bed with [MEDICATION NAME] tissue which was a normal color. 3/1/16 - Left heel 7 cm x 6 cm - with no other documentation for exudate, odor condition of wound bed or surrounding skin color. Review of the Weekly Pressure Ulcer Healing Record ffor the left heel, with date of onset as 2/15/16, documented the following: 3/14/16 - 7 x 7 with a moderate amount of serosanguinous exudate, a moderate odor was dark red with the surrounding skin dark red/purple, with peripheral tissue [MEDICAL CONDITION]. 3/18/16 - 7 x 7 with a moderate amount of serosanguinous exudate, a moderate odor, wound bed was black/brown (eschar) with surrounding skin dark red/purple and peripheral tissue [MEDICAL CONDITION]. Both notations were documented by LVN D. NOTE: eschar - a scab or dry crust that results from trauma, such as a thermal or chemical burn, infection or excoriating skin disease. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 587) Interview on 3/23/16 at 9:35 a.m., with LVN D, continued: LVN D stated she thought she wrote the wrong date on 3/14/16 because it should be 3/4/16. LVN D stated she had allergies and to her, Resident #1's heel smelled moderately. She stated on 3/18/16 she gave the doctor a call because Resident #1's heel was worse but she did not notify Resident #1's son. LVN D stated she was working on Sunday, 3/20/16, when Resident #1's daughter came to visit. LVN D stated she was in Resident #1's room, checking his blood sugar, when Resident #1's daughter was asking about his foot because his foot smelled so bad. LVN D stated she thought Resident #1's daughter called Resident #1's son and the son called the nursing home and wanted his father sent to the hospital. LVN D stated she wished she would have been more aggressive with the doctor about Resident #1's heel but she was just so busy because she had several people sick at the same time and she had a lot of work to do. LVN D stated there should have been documentation of Resident #1's heel between 3/4/16 and 3/18/16 but confirmed there was no documentation for 3/11/16. During a follow-up interview on 3/23/16 at 10:00 a.m., the Administrator stated Resident #1's son knew his father had a wound and was aware of a boot that Resident #1 was wearing. The Administrator again stated she hoped staff did not leave a message on his phone and he never saw it. The Administrator stated the son's biggest issues was that he was not notified of his father's wound on his heel. The Administrator stated Resident #1's son was in the facility two weeks ago when the son noticed the boot and was asking questions. When informed that interviews with two of her nurses revealed that neither one had notified Resident #1's son of the wound on his heel or of the wound getting worse, the Administrator stated they should have notified the doctor and the family on 2/14/16 but they did not. At this time, she was informed on 2/15/16, when a nurse redressed a wound with no orders for dressing changes and that was significantly worse from the day before, the physician nor the family was notified. The Administrator stated skin assessments were to be conducted weekly. Nurses Notes documented the following: 3/4/16 - physician here making rounds, received new orders: Keflex 500 mg by mouth three times a day for 10 days, Diagnoses: [REDACTED]. PO fluids encouraged and accepted well, dressing to left heel changed, procedure tolerated well. Reflect: Son notified of new order. 3/18/16 - changed dressing to left heel wound, left heel with back/brown eschar, moderate odor noted, moderate amount of exudate, resident completed antibiotics on 3/13/16, physician notified of unstageable wound, states it was unstageable since 3/4/16 when he last saw it, stated it was dark red then blister like, reported to him that it is now black/brown eschar with moderate odor, stated he wants to see it again when he makes round. All documented by LVN D. Nurses Notes documented the following: 3/20/16 - received personal call from Resident #1's son who stated that a family member was visiting from out of town and came by to visit his Dad and she reported to him that there was a bad odor from Resident #1's left heel. Advised son that physician was aware and notified of worsening condition to heel; that he was to come and check in on Friday but was unable to make it in. Son requesting that his father be sent at this time to the emergency room . Physician was advised of above; order given to send to emergency room for evaluation/treatment of [REDACTED]. 3/21/16 - personal call placed to hospital to check on resident's status and they advised me that he was admitted with left heel ulcer, infection. During an interview on 3/23/16 at 2:08 p.m., ADON I stated staff are to do a skin assessment on admission and weekly. ADON I stated on admit, pressure ulcers are identified and then it would be reported to the DON but now that are reported to me or the Weekend Supervisor. ADON I on the Pressure Ulcer sheet, there was a space to check when the dietary department was notified to order Med Plus and a space to check for notification of physician and family. ADON I stated on 2/14/16, the wound on Resident #1's left heel was reported to LVN C but she did not report the wound to the DON, physician or the family but she should have. ADON I stated Resident #1's wound was located on his heel and was not going to get better. ADON I stated when Resident #1's physician ordered dressing changes on 2/17/16 and 2/19/16, LVN C wrote the orders but ADON I never saw the February order so it was not transcribed to the MAR. ADON I stated LVN C got the doctor to sign the dressing change order for Resident #1's heel right after she wrote the order and LVN C put the order directly into the chart but LVN C did not transcribe the dressing change order to the Treatment Record; that was why there was no treatment record of dressing changes for Resident #1 for February. ADON I stated she would not document on a dressing change in nurses notes but would document a change of condition in the nurses notes. ADON I stated she was positive the CNAs would not let the nurse forget to change the dressings on Resident #1's heel after his shower. ADON I stated staff are to fill out an SBAR or an incident report on a change of condition but neither one was done. ADON I stated even on a Physician Telephone Order, there was a place to notify the doctor and family and that was not done. ADON I stated all systems to catch this were missed for Resident #1. Review of Resident #1's physician notes documented the following: 2/26/16 - patient is an elderly male who suffered a shearing trauma to left heel which caused wound and patient's dead skin is sloughing off now. Patient is currently on Bactrim for his left heel wound which is slowly getting better, does not have any drainage. Plan: Continue present wound care with alginate and change the dressing every other day. 3/4/16 - Evaluation of left heel wound [MEDICAL CONDITION]. Patient is an elderly male who had sheared the top skin on the left heel which has developed DTI (Deep Tissue Injury) now with the dark discoloration and some smell and some serosanguinous fluid. Skin: left heel had to have DTI with dark purplish discoloration, also with the superficial skin being sloughed off. There is a small area of an open wound at the very bottom of the heel with serosanguinous fluid and bad smell. Plan: Continue wound care and keep wound clean with wound cleanser and change dressing Monday, Wednesday and Friday. During an interview on 3/23/16 at 3:05 p.m., Resident #1's physician stated the resident does have a lot going on medically and has had a steady decline for the past 8 months. The physician stated he was not notified on 2/14/16 when the wound to Resident #1's heel was initially found. The physician stated a couple of weeks ago, he looked at Resident #1's heel and he thought the wound was getting better because not one notified him that is wasn't. The physician stated he expected the nurses to let him know when a wound was not responding to treatments so it can be changed but he was not notified until Resident #1 was sent to the hospital and now he needs an amputation. The physician stated he was very accessible by phone and did expect nursing staff to call him to let him know any changes so he could change the treatment. The physician stated, The nurses are supposed to be an extension of me but if I don't know, I can't help. They are my eyes and ears. During a follow-up interview on 3/24/16 at 9:15 a.m., LVN D stated on 3/18/16 (Friday), after she called Resident #1's physician about his heel wound, she stated she got real busy and forgot to call the physician again. LVN D stated on 3/19/16 (Saturday), she had a resident who passed away and again, she was real busy and just forgot to call Resident #1's physician again. LVN D stated she was going to call Resident #1's physician on 3/20/16 (Sunday) when she had time but the family called and wanted Resident #1 sent to the hospital so she never got a chance. Resident #7 Review of Resident #7's clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -An MDS resident assessment, dated 2/2/16, documented the resident scored 11 of 15 on a mini mental exam, required extensive assistance with bed mobility, dressing, personal hygiene, toileting and bathing, had limited range of motion for both lower extremities, used a wheelchair for locomotion, was frequently incontinent of bladder, continent of bowel, was 68 inches tall and 134 pounds. -A Physician Telephone Order, dated 3/8/16, documented to cleanse left lower leg with normal saline, pat dry gently with 4x4 gauze, apply triple antibiotic ointment and cover with non-adherent pad and wrap with [MEDICATION NAME] until healed - every day. -Review of Resident #7's Treatment Record for the daily dressing changes documented the dressing was changed in March on the 17th, 18th, 19th, 21st, and 22nd. On March 20th and 23rd, the date was circled which indicated the treatment was not provided. During an observation on 3/24/16 at 9:30 a.m., of LVN J providing wound care to Resident #7 revealed the resident's dressing on her left lower leg was dated 3/16/16 (8 days ago). During an interview on 3/24/16 at 9:45 a.m., LVN J stated she had not changed the dressing recently but had checked on Resident #7's dressing every day and the dressing was clean. LVN J stated, I don't want the facility to be in anymore trouble. The facility's policy and procedure titled Notification of Changes, implemented on 7/13/15, documented the following: to provide guidance on when to communicate acute changes in status to MD, NP and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident ' s legal representative or appropriate family member(s) of the following: 3. A significant change in the physical, mental or psychosocial status of the resident. 4. The need to significantly alter the resident's treatment. Policy Explanation and Compliance Guidelines: 3. In the case of a resident who is incapable of making a decision, the resident should still be notified. Notify the resident's physician. Decisions would be made by the legal representative or appropriate family member(s). 5. The facility documents resident assessment(s), interventions, physician and family notification on SBAR, Nurses Progress Note or Telephone Order Form (physician/family notice) as appropriate. 6. a. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes), the Medical Director will be contacted before the resident will be sent for emergency room evaluation. b. Non Immediate Physician Notification - the physician is notified and there should be a return call within the same day (worsening of symptoms use Immediate Physician Notification steps). Review of the Policy and Procedure for Medication - Treatment Administration and Documentation, revised 2/2/14, documented the following: Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Process: 5. Documented initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. 12. Review each MAR and TAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided according to physician orders. 15. Provide a summary of medication or treatment administration issues to on-coming nurse or CMA during shift to shift report. Review of the policy and procedure for Skin Management, revised 2/1/14, documented the following: Implement/Ongoing Strategy: 2. A weekly skin evaluation is completed by the licensed nurse for those patients identified with moderate to very high skin risk on the Braden Scale and do not have pressure ulcers. Documentation indicating the completion of the skin evaluation is entered on the Treatment Administration Record. 3. A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. 4. The wound nurse or licensed nurse re-assesses/re-evaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the Pressure Ulcer Form. Evaluate: 2. Pressure Ulcer healing is documented using descriptive characteristics of the sound (i.e., depth, width, presence of granulation tissue, exudate) and by using the PUSH Tool a validated pressure ulcer healing tool. 6. If a change in patient condition occurs, such as deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team, family or responsible party and documents follow up in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs. Communications with the physician, patient and family are documented in the clinical record. On 3/23/16 at 4:41 p.m., an IJ was identified and the Administrator and both ADONs were informed of the IJ due to the above failures. On 3/24/16 at 12:15 p.m., the Administrator and both ADONs were informed Plan of Removal was accepted and the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as a pattern as the facility was still monitoring the Plan of Removal. On 3/24/16 at 12:15 p.m., the facility's final Plan of Removal was accepted and contained the following: Plan to Remove Immediate Jeopardy: The plan of removal represents the centers allegation of compliance. This plan of removal serves as the nursing home's response to Immediate Jeopardy notification the center received on 3/23/16 at 4:41 p.m. from the Texas Department of Aging and Disability Services regarding neglect related to Physician notification related to a wound. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 2/14/16, LVN C identified a wound to the left heel of Resident #1. LVN C notified physician on 2/17/16 and obtained an order to treat the left heel. On 2/19/16, LVN C notified p

Based on observation, interview, and record review, it was determined the facility failed to ensure that residents having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 2 of 7 residents reviewed for pressure sores (Resident #1 and Resident #7). 1. The facility failed to provide the treatment, assessment and physician notification for a pressure sore that worsened to the point of requiring possible amputation. -Resident #1 was found to have a pin prick hole in the bottom of his left heel but LVN C failed to inform the physician or the family. -The next day, LVN D redressed a 7.5 cm x 6 cm open area to Resident #1's left heel without an order and failed to notify the physician or the family. -The facility did not have a record of Resident #1 receiving dressing changes from 2/17/16 to 3/2/16 - 13 days. -Nursing Staff failed to notice a change in Resident #1's wound to his left heel after two separate antibiotic treatments and failed to notify the doctor and family. -Nursing staff failed to conduct and document proper assessments for Resident #1's left heel. -Nursing staff failed to notice a foul smell which was worsening and radiating from Resident #1's foot. -Nursing staff failed to ensure Resident #1's physician and family was aware of the worsening of his left heel. As a result, Resident #1 had a necrotic unstageable large decubitus ulcer to his left heel and was sent, per family request, to the hospital with a foul-smelling odor coming out of his left heel, placing Resident #1 at risk for worsening infection, amputation and death. 2. Resident #7's dressing on her left lower leg had not been changed in 8 days. This failure resulted in identification of an Immediate jeopardy (IJ) on 3/23/16. While the IJ was removed on 3/24/16, the facility remained out of compliance for potential for harm at a scope of a pattern due to all active staff were still being in-serviced on notification of physician and family on a change of condition, skin management to identify skin observations, alterations, assessments, documentation guidelines related to skin alterations and the facility was still monitoring the Plan of Removal. This deficient practice could place all 6 residents identified by the facility with pressure ulcers at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, pain, possible amputation and death. The evidence is as follows: Resident #1 Review of Resident #1's closed clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -An annual MDS resident assessment, dated 1/20/16, documented the resident rarely/never was understood, usually understands others, had short and long term memory problems, severely impaired cognitive skills for daily decision making, required extensive assistance with bed mobility, locomotion in the facility, eating, was totally dependent on two staff for transfers, dressing, toileting and bathing, was totally dependent on one staff for personal hygiene, had limited range of motion of one upper extremity and both lower extremities, used a wheelchair, was incontinent of bladder and bowel, 70 inches tall and 169 pounds, had weight loss but was not on a physician-prescribed weight-loss regimen, was at risk of developing pressure ulcers but did not have any pressure ulcers. -Review of a Care Plan, initiated on 1/20/16 and revised on 3/22/16, documented the following: Resident has [MEDICAL CONDITION]: Intervention - monitor/document/report to MD as needed any signs or symptoms of skin problems related to [MEDICAL CONDITION]: redness, [MEDICAL CONDITION], blistering, itching, burning, bruises, cuts, other [MEDICAL CONDITION]. Resident is currently taking Aspirin 81 mg daily as an anticoagulant related to [MEDICAL CONDITION] and [MEDICAL CONDITION]: Intervention - daily skin inspection. Report abnormalities to the nurse. Resident has potential for pressure ulcer development related to diabetes, incontinence and immobility. Patient developed Stage II on 2/17/16: Intervention - monitor and report to MD as needed changes in skin status: appearance, color, impaired skin. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas and other changes in skin integrity. Report new conditions to the physician. -Physician Telephone Orders documented the following: 2/17/16 - cleanse wound to left heel with wound cleanser, apply hydrogel and cover with non-adherent pad and wrap with [MEDICATION NAME] every day. 2/19/16 - Bactrim by mouth twice a day for 10 days for left heel wound, change dressing on Monday, Wednesday and Friday. 3/4/16 - Keflex 500 mg by mouth three times a day for 10 days for left heel wound. 3/20/16 - send to emergency room for evaluation/treatment for [REDACTED]. During a telephone interview on 3/22/16 at 8:52 a.m., family member #1 stated the facility did not do their job and now their choice is either an above the knee amputation or Hospice. Family member #1 stated, This has all been caused from neglect. Family member #1 stated he was never called about Resident #1's heel; the first time he saw a boot on Resident #1's foot, he asked the nurse about it and she informed him that his father had rubbed his foot on his bed sheet but he was ok. Family member #1 stated his sister was visiting on 3/20/16 and thought her father had pooped on himself because he smelled so bad so she asked the CNAs to clean him up. Family member #1 stated the CNAs told his sister that Resident #1 did not poop in his bed, his foot was what smelled. Family member #1 stated his father's heel was black and smelled something awful and his heel just got worse and worse. During an interview on 3/22/16 at 11:25 a.m., the facility Administrator stated Resident #1's son has some complaints, with one being he was not notified of his father's wound on his foot, but he was aware his father was wearing a boot. The Administrator stated Resident #1's son travels a lot and maybe he missed a message on his phone. Hospital Observations, Interviews and Record Review During an observation in ICU room [ROOM NUMBER] on 3/22/16 at 1:20 p.m., with RN E and RN F, Resident #1 had a small pressure ulcer to the side of his right foot looked to be a deep tissue injury. Resident #1 left foot was covered with a clean dressing dated 3/22/16 which had a very foul odor. During an interview on 3/22/16 at 1:35 p.m., RN E stated she had taken care of Resident #1 since early on 3/21/16, when he was transferred to ICU. RN E stated Resident #1's left heel pressure ulcer had a very foul smell and was draining when he arrived on the unit. During an interview on 3/22/16 at 1:50 p.m., HNM stated she was aware his wound was really bad and the unstageable ulcer to his left heel smelled bad. During an observation in ICU room [ROOM NUMBER] at 2:15 p.m., with RN E assisting revealed the following: A strong foul smell was radiating out of Resident #1's room as the room was approached. The dressing was off and the unstageable pressure ulcer covered his entire left heel. The outer edges of the ulcer were a bright red, looked slimy and was bleeding. The bottom of his foot was light pink and [MEDICAL CONDITION] (puffy) all the way to the base of his toes. Resident #1 was grimacing in pain as the leg was raised. The attending physician was not interviewed at this time because he was at the end of the hallway talking with Resident #1's family. During a follow-up interview on 3/22/16 at 2:15 p.m., RN E stated the attending physician wanted to get an x-ray of Resident #1's foot to see if the wound has tunneling because the foot looks like it has tunneled all the way to his toes by the way the bottom of his foot looks. Review of hospital records, dated 3/21/16 at 2:39 p.m., which included hospital photos documented Resident #1's left heel pressure ulcer along with measurements, documented the pressure ulcer was 8.63 cm by 6.77 cm. Review of Emergency Department Report, dated 3/20/16 at 8:14 p.m., documented the following: patient presents with foul smelling infected left heel that apparently has been having dressing changes at the nursing home intermittently. Left heel with necrotic unstageable large decubitus ulcer with surrounding [DIAGNOSES REDACTED], purulence and foul smell. NOTE: Pressure Ulcer - also called bedsore, decubitus ulcer, pressure necrosis or pressure sore - an inflammation, sore, or ulcer in the skin over a bony prominence. It results from ischemic [MEDICAL CONDITION] of the tissues caused by prolonged pressure on them. Prevention of pressure ulcers is a cardinal aspect of nurse care. Prompt and continued care of early [MEDICAL CONDITION] can prevent invasion of underlying tissue and promote healing. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page1318 - 1319) Hospital physician progress notes [REDACTED]. The family is discussing the problem with the patient about his diabetic foot with multiple decubitus ulcers infected and poor circulation with significant [MEDICAL CONDITION]. This discussion is about the need to proceed with amputation versus transfer of the patient to hospice services. Nursing Home Nurses Notes documented the following: 2/14/16 - CNAs called nurse to room and noted that resident's left heel was dripping blood. Assessed the heel, it noted a small hole, cleaned wound and applied pressure to stop bleeding. Applied pressure dressing. 2/17/16 - Doctor here and assessed wound. Received order to cleanse wound with wound cleaner, apply hydrogel and cover with non-adherent pad and wrap with [MEDICATION NAME] every day. 2/19/16 - received order for Bactrim DS by mouth twice a day for 10 days and change dressing changes to Monday, Wednesday and Friday. Initial dose given. All documented by LVN C. During an interview on 3/22/16 at 2:50 p.m., LVN C stated she noticed a problem with Resident #1's foot when the aides called her down to his room on 2/14/16 because his foot was bleeding. LVN C stated there was a hole in the bottom of his heel so she cleaned the heel up and held pressure to get the wound to stop bleeding. When asked if she reported the wound on Resident #1's heel to the physician or the family, she stated she did not because she was so busy. She stated Resident #1 received his dressing changes on Monday, Wednesday and Fridays after he got showered. She stated Resident #1 was on antibiotics and to her, his wound did not look like it ever changed much. She stated she did not think Resident #1's foot stunk and no one had reported to her that his foot stunk but she had been having trouble with her allergies. She stated she was surprised how fast Resident #1's wound opened up. During an interview on 3/22/16 at 3:09 p.m., CNA G stated she was the aide who reported Resident #1's foot bleeding to LVN C. CNA G stated she took care of Resident #1 a lot and noticed his foot was starting to smell really bad. When asked when Resident #1's foot started to smell bad, she said around the beginning of March. CNA G stated she did not report the smell to the nurse because she figured the nurse could smell it herself without being told. CNA G stated when she had Resident #1 in the shower; she would clean his foot fast because it smelled so bad. CNA G stated when the nurse would change Resident #1's dressing; she would hold his leg up so the nurse could wrap his foot. During a follow-up interview on 3/22/16 at 3:45 p.m., LVN C stated when she first assessed Resident #1's heel on 2/14/16; the wound was the size of a pin prick. LVN C again stated she did not call the physician or family about the wound to Resident #1's heel. LVN C stated she took good care of Resident #1 but she just did not document like she should have. LVN C stated, I messed up. During an interview on 3/22/16 at 3:50 p.m., CNA H stated when she came back from vacation on 2/27/16; Resident #1 foot was already bandaged and had an inflated boot thing on his foot. CNA H stated she would prop up Resident #1's leg to assist with dressing changes and said, It stunk pretty bad. CNA H stated Resident #1's foot started stinking about two weeks ago. CNA H stated the nurse was doing the dressing changes every other day so she figured she knew Resident #1's foot stunk. During an interview on 3/22/16 at 4:00 p.m., with ADON I, when asked for Resident #1's Treatment Administration Record for February 2016, she stated it could not be found in his chart. Review of the Non-Pressure Skin Condition Report, documented the following: 2/9/16 - skin intact 2/16/16 (first documentation of left heel ulcer) - dressing intact to left heel prior to shower on 2/15/16, open area noted once dressing was removed: 7.5 cm x 6 cm with small amount of serosanguinous exudate, no odor, wound bed with [MEDICATION NAME] tissue and the surrounding skin color was normal. This was documented by LVN D. NOTE: serosanguinous: thin and red; composed of serum and blood. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 1480) Exudate: fluid, cells or other substances that have been slowly exuded, or discharged , from cells or blood vessels through small pores or breaks in cell membranes. Perspiration, pus and serum are sometimes identified as exudates. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 607) During an interview on 3/23/16 at 9:35 a.m., LVN D stated a CNA came to her on 2/25/16 and asked her if she wanted to change the dressing on Resident #1's foot. LVN D stated she was unaware Resident #1 had a dressing on his foot and said to the CNA, What dressing? LVN D stated when she last worked on 2/11/16 (Thursday) Resident #1 did not have any skin issues but when she came back to work on 2/15/16, Resident #1 had skin issues but she was not informed about the dressing change or skin issues from the evening nurse she received report from. LVN D stated she redressed Resident #1's heel on 2/15/16 but failed to document on the Non-Pressure Skin Condition Report until 2/16/16. LVN D stated Resident #1 heel was open with healthy pink tissue. LVN D stated the wound was big and covered the whole bottom of Resident #1's heel. When asked if there was an order for [REDACTED].#1's heel, LVN D stated there were not any orders for dressing changes for Resident #1. LVN D stated she redressed Resident #1's heel because there was dressing on it. When asked when there were no orders for dressing changes to Resident #1's did it raise her suspicion the doctor had not been notified, LVN D stated she thought the doctor had already been notified. LVN D stated she did not write an incident report or an SBAR (Situation, Background, Appearance, Review and notify) for Resident #1's heel because she was too busy as she had several people sick at the same time. LVN D stated she documented on the Non-Pressure Skin Condition Report on 2/16/16 for Resident #1's heel and wrote the measurements on it but she stated she did not contact the physician or the family because she thought the other nurse had already done that. When asked when she did not see any documentation for the previous day on the Non-Pressure Skin Condition Report for Resident #1's heel wound, did that raise a suspicion the physician and family had not been notified; LVN D stated she thought the other nurse had notified the physician and family. LVN D stated there was a day she took the physician to Resident #1's room to see his foot because the wound had an odor and that was when Resident #1's physician ordered antibiotics. LVN D stated she could not remember the day, but Resident #1's son had noticed a dressing on his father's foot and the son asked her a lot of questions about Resident #1's foot. Further review of the Non-Pressure Skin Condition Report documented the following: 2/23/16 - 7 x 6 with serosanguinous exudate with no odor, wound bed with [MEDICATION NAME] tissue which was a normal color. 3/1/16 - Left heel 7 cm x 6 cm - with no other documentation for exudate, odor condition of wound bed or surrounding skin color. Review of the Weekly Pressure Ulcer Healing Record for the Left Heel, with date of onset as 2/15/16, documented the following: 3/14/16 - 7 x 7 with a moderate amount of serosanguinous exudate, a moderate odor was dark red with the surrounding skin dark red/purple, with peripheral tissue [MEDICAL CONDITION]. 3/18/16 - 7 x 7 with a moderate amount of serosanguinous exudate, a moderate odor, wound bed was black/brown (eschar) with surrounding skin dark red/purple and peripheral tissue [MEDICAL CONDITION]. Both notations were documented by LVN D. NOTE: eschar - a scab or dry crust that results from trauma, such as a thermal or chemical burn, infection or excoriating skin disease. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 587) Interview on 3/23/16 at 9:35 a.m., with LVN D, continued: LVN D stated she thought she wrote the wrong date on 3/14/16 because it should be 3/4/16. LVN D stated she had allergies and to her, Resident #1's heel smelled moderately. She stated on 3/18/16 she gave the doctor a call because Resident #1's heel was worse but she did not notify Resident #1's son. LVN D stated she was working on Sunday, 3/20/16, when Resident #1's daughter came to visit. LVN D stated she was in Resident #1's room, checking his blood sugar, when Resident #1's daughter was asking about his foot because his foot smelled so bad. LVN D stated she thought Resident #1's daughter called Resident #1's son and the son called the nursing home and wanted his father sent to the hospital. LVN D stated she wished she would have been more aggressive with the doctor about Resident #1's heel but she was just so busy because she had several people sick at the same time and she had a lot of work to do. LVN D stated there should have been documentation of Resident #1's heel between 3/4/16 and 3/18/16 but confirmed there was no documentation for 3/11/16. During a follow-up interview on 3/23/16 at 10:00 a.m., the Administrator stated Resident #1's son knew his father had a wound and was aware of a boot that Resident #1 was wearing. The Administrator again stated she hoped staff did not leave a message on his phone and he never saw it. The Administrator stated the son's biggest issues was that he was not notified of his father's wound on his heel. The Administrator stated Resident #1's son was in the facility two weeks ago when the son noticed the boot and was asking questions. When informed that interviews with two of her nurses revealed that neither one had notified Resident #1's son of the wound on his heel or of the wound getting worse, the Administrator stated they should have notified the doctor and the family on 2/14/16 but they did not. At this time, she was informed on 2/15/16, when a nurse redressed a wound with no orders for dressing changes and that was significantly worse from the day before, the physician nor the family was notified. The Administrator stated skin assessments were to be conducted weekly. Nurses Notes documented the following: 3/4/16 - physician here making rounds, received new orders: Keflex 500 mg by mouth three times a day for 10 days, Diagnoses: [REDACTED]. PO fluids encouraged and accepted well, dressing to left heel changed, procedure tolerated well. Reflect: Son notified of new order. 3/18/16 - changed dressing to left heel wound, left heel with back/brown eschar, moderate odor noted, moderate amount of exudate, resident completed antibiotics on 3/13/16, physician notified of unstageable wound, states it was unstageable since 3/4/16 when he last saw it, stated it was dark red then blister like, reported to him that it is now black/brown eschar with moderate odor, stated he wants to see it again when he makes round. All documented by LVN D. Nurses Notes documented the following: 3/20/16 - received personal call from Resident #1's son who stated that a family member was visiting from out of town and came by to visit his Dad and she reported to him that there was a bad odor from Resident #1's left heel. Advised son that physician was aware and notified of worsening condition to heel; that he was to come and check in on Friday but was unable to make it in. Son requesting that his father be sent at this time to the emergency room . Physician was advised of above; order given to send to emergency room for evaluation/treatment of [REDACTED]. 3/21/16 - personal call placed to hospital to check on resident's status and they advised me that he was admitted with left heel ulcer, infection. During an interview on 3/23/16 at 2:08 p.m., ADON I stated staff are to do a skin assessment on admission and weekly. ADON I stated on admit, pressure ulcers are identified and then it would be reported to the DON but now that are reported to me or the Weekend Supervisor. ADON I on the Pressure Ulcer sheet, there was a space to check when the dietary department was notified to order Med Plus and a space to check for notification of physician and family. ADON I stated on 2/14/16, the wound on Resident #1's left heel was reported to LVN C but she did not report the wound to the DON, physician or the family but she should have. ADON I stated Resident #1's wound was located on his heel and was not going to get better. ADON I stated when Resident #1's physician ordered dressing changes on 2/17/16 and 2/19/16, LVN C wrote the orders but ADON I never saw the February order so it was not transcribed to the MAR. ADON I stated LVN C got the doctor to sign the dressing change order for Resident #1's heel right after she wrote the order and LVN C put the order directly into the chart but LVN C did not transcribe the dressing change order to the Treatment Record; that was why there was no treatment record of dressing changes for Resident #1 for February. ADON I stated she would not document on a dressing change in nurses notes but would document a change of condition in the nurses notes. ADON I stated she was positive the CNAs would not let the nurse forget to change the dressings on Resident #1's heel after his shower. ADON I stated staff are to fill out an SBAR or an incident report on a change of condition but neither one was done. ADON I stated even on a Physician Telephone Order, there was a place to notify the doctor and family and that was not done. ADON I stated all systems to catch this were missed for Resident #1. Review of Resident #1's physician notes documented the following: 2/26/16 - patient is an elderly male who suffered a shearing trauma to left heel which caused wound and patient's dead skin is sloughing off now. Patient is currently on Bactrim for his left heel wound which is slowly getting better, does not have any drainage. Plan: Continue present wound care with alginate and change the dressing every other day. 3/4/16 - Evaluation of left heel wound [MEDICAL CONDITION]. Patient is an elderly male who had sheared the top skin on the left heel which has developed DTI (Deep Tissue Injury) now with the dark discoloration and some smell and some serosanguinous fluid. Skin: left heel had to have DTI with dark purplish discoloration, also with the superficial skin being sloughed off. There is a small area of an open wound at the very bottom of the heel with serosanguinous fluid and bad smell. Plan: Continue wound care and keep wound clean with wound cleanser and change dressing Monday, Wednesday and Friday. During an interview on 3/23/16 at 3:05 p.m., Resident #1's physician stated the resident does have a lot going on medically and has had a steady decline for the past 8 months. The physician stated he was not notified on 2/14/16 when the wound to Resident #1's heel was initially found. The physician stated a couple of weeks ago, he looked at Resident #1's heel and he thought the wound was getting better because not one notified him that is wasn't. The physician stated he expected the nurses to let him know when a wound was not responding to treatments so it can be changed but he was not notified until Resident #1 was sent to the hospital and now he needs an amputation. The physician stated he was very accessible by phone and did expect nursing staff to call him to let him know any changes so he could change the treatment. The physician stated, The nurses are supposed to be an extension of me but if I don't know, I can't help. They are my eyes and ears. During a follow-up interview on 3/24/16 at 9:15 a.m., LVN D stated on 3/18/16 (Friday), after she called Resident #1's physician about his heel wound, she stated she got real busy and forgot to call the physician again. LVN D stated on 3/19/16 (Saturday), she had a resident who passed away and again, she was real busy and just forgot to call Resident #1's physician again. LVN D stated she was going to call Resident #1's physician on 3/20/16 (Sunday) when she had time but the family called and wanted Resident #1 sent to the hospital so she never got a chance. Resident #7 Review of Resident #7's clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -An MDS resident assessment, dated 2/2/16, documented the resident scored 11 of 15 on a mini mental exam, required extensive assistance with bed mobility, dressing, personal hygiene, toileting and bathing, had limited range of motion for both lower extremities, used a wheelchair for locomotion, was frequently incontinent of bladder, continent of bowel, was 68 inches tall and 134 pounds. -A Physician Telephone Order, dated 3/8/16, documented to cleanse left lower leg with normal saline, pat dry gently with 4x4 gauze, apply triple antibiotic ointment and cover with non-adherent pad and wrap with [MEDICATION NAME] until healed - every day. -Review of Resident #7's Treatment Record for the daily dressing changes documented the dressing was changed in March on the 17th, 18th, 19th, 21st, and 22nd. On March 20th and 23rd, the date was circled which indicated the treatment was not provided. During an observation on 3/24/16 at 9:30 a.m., of LVN J providing wound care to Resident #7 revealed the resident's dressing on her left lower leg was dated 3/16/16 (8 days ago). During an interview on 3/24/16 at 9:45 a.m., LVN J stated she had not changed the dressing recently but had checked on Resident #7's dressing every day and the dressing was clean. LVN J stated, I don't want the facility to be in anymore trouble. Review of the facility's Abuse/Neglect/Misappropriation Nursing Policy, revised 1/29/15, documented the following: Policy - Residents have the right to be free from abuse, neglect, corporal punishment, misappropriation of property and involuntary seclusion. Definition - Neglect - A deprivation of life ' s necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. Review of the facility's undated Freedom of Abuse Notice to Employees documented the following: Among the rights specified in the federal and state laws, each resident and patient has a right to a dignified existence and to be free from verbal, sexual, physical or mental abuse; corporal punishment; and involuntary seclusion. Abuse includes, but is not limited to: Neglect - the failure of a caregiver to provide the goods and services that are necessary to maintain the health or safety of a resident. Additionally neglect is the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs. Review of the Policy and Procedure for Medication - Treatment Administration and Documentation, revised 2/2/14, documented the following: Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Process: 5. Documented initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. 12. Review each MAR and TAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided according to physician orders. 15. Provide a summary of medication or treatment administration issues to on-coming nurse or CMA during shift to shift report. Review of the policy and procedure for Skin Management, revised 2/1/14, documented the following: Implement/Ongoing Strategy: 2. A weekly skin evaluation is completed by the licensed nurse for those patients identified with moderate to very high skin risk on the Braden Scale and do not have pressure ulcers. Documentation indicating the completion of the skin evaluation is entered on the Treatment Administration Record. 3. A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. 4. The wound nurse or licensed nurse re-assesses/re-evaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the Pressure Ulcer Form. Evaluate: 2. Pressure Ulcer healing is documented using descriptive characteristics of the sound (i.e., depth, width, presence of granulation tissue, exudate) and by using the PUSH Tool a validated pressure ulcer healing tool. 6. If a change in patient condition occurs, such as deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team, family or responsible party and documents follow up in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs. Communications with the physician, patient and family are documented in the clinical record. On 3/23/16 at 4:41 p.m., an IJ was identified and the Administrator and both ADONs were informed of the IJ due to the above failures. On 3/24/16 at 12:15 p.m., the Administrator and both ADONs were informed Plan of Removal was accepted and the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as a pattern as the facility was still monitoring the Plan of Removal. On 3/24/16 at 12:15 p.m., the facility's final Plan of Removal was accepted and contained the following: Plan to Remove Immediate Jeopardy: The plan of removal represents the centers allegation of compliance. This plan of removal serves as the nursing home's response to Immediate Jeopardy notification the center received on 3/23/16 at 4:41 p.m. from the Texas Department of Aging and Disability Services regarding neglect related to Physician notification related to a wound. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 2/14/16, LVN C identified a wound to the left heel of Resident #1. LVN C notified physician on 2/17/16 and obtained an order to treat the left heel. On 2/19/16, LVN C notified physician and he ordered Ba

Based on observation, record review and interviews, it was determined the facility failed to implement their written policies and procedures that prohibit abuse/neglect for 2 of 7 residents (Resident #1 and #7) reviewed. 1. The facility failed to provide the treatment, assessment and physician notification for a pressure sore that worsened to the point of requiring amputation. -Resident #1 was found to have a pin prick hole in the bottom of his left heel but LVN C failed to inform the physician or the family. -The next day, LVN D redressed a 7.5 cm x 6 cm open area to Resident #1's left heel without an order and failed to notify the physician or the family. -The facility did not have a record of Resident #1 receiving dressing changes from 2/17/16 to 3/2/16 - 13 days. -Nursing Staff failed to notice a change in Resident #1's wound to his left heel after two separate antibiotic treatments and failed to notify the doctor or the family. -Nursing staff failed to conduct and document proper assessments for Resident #1's left heel. -Nursing staff failed to notice a foul smell which was worsening and radiating from Resident #1's foot. -Nursing staff failed to ensure Resident #1's physician and family were aware of the worsening of his left heel. As a result, Resident #1 had a necrotic unstageable large decubitus ulcer to his left heel and was sent, per family request, to the hospital with a foul-smelling odor coming out of his left heel, placing Resident #1 at risk for worsening infection, amputation and death. 2. Resident #7's dressing on her left lower leg had not been changed in 8 days. This failure resulted in identification of an Immediate jeopardy (IJ) on 3/23/16. While the IJ was removed on 3/24/16, the facility remained out of compliance at harm at a scope of a pattern due to all active staff were still being in-serviced on notification of physician and family on a change of condition, skin management to identify skin observations, alterations, assessments, documentation guidelines related to skin alterations and the facility was still monitoring the Plan of Removal. Failure to put effective interventions into place and ensure staff knew how to assess and intervene to protect Resident #1 and #7, and 5 other residents with wounds, could place them at risk for developing an infection and worsening of a wound and lack of services. In addition, this failure could put all 114 residents of the facility at risk for mistreatment, abuse and neglect that may result in physical, mental or psychological harm. The evidence is as follows: Review of the facility's Abuse/Neglect/Misappropriation Nursing Policy, revised 1/29/15, documented the following: Policy - Residents have the right to be free from abuse, neglect, corporal punishment, misappropriation of property and involuntary seclusion. Definition - Neglect - A deprivation of life ' s necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. Review of the facility's undated Freedom of Abuse Notice to Employees documented the following: Among the rights specified in the federal and state laws, each resident and patient has a right to a dignified existence and to be free from verbal, sexual, physical or mental abuse; corporal punishment; and involuntary seclusion. Abuse includes, but is not limited to: Neglect - the failure of a caregiver to provide the goods and services that are necessary to maintain the health or safety of a resident. Additionally neglect is the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs. Resident #1 Review of Resident #1's closed clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -An annual MDS resident assessment, dated 1/20/16, documented the resident rarely/never was understood, usually understands others, had short and long term memory problems, severely impaired cognitive skills for daily decision making, required extensive assistance with bed mobility, locomotion in the facility, eating, was totally dependent on two staff for transfers, dressing, toileting and bathing, was totally dependent on one staff for personal hygiene, had limited range of motion of one upper extremity and both lower extremities, used a wheelchair, was incontinent of bladder and bowel, 70 inches tall and 169 pounds, had weight loss but was not on a physician-prescribed weight-loss regimen, was at risk of developing pressure ulcers but did not have any pressure ulcers. -Review of a Care Plan, initiated on 1/20/16 and revised on 3/22/16, documented the following: Resident has [MEDICAL CONDITION]: Intervention - monitor/document/report to MD as needed any signs or symptoms of skin problems related to [MEDICAL CONDITION]: redness, [MEDICAL CONDITION], blistering, itching, burning, bruises, cuts, other [MEDICAL CONDITION]. Resident is currently taking Aspirin 81 mg daily as an anticoagulant related to [MEDICAL CONDITION] and [MEDICAL CONDITION]: Intervention - daily skin inspection. Report abnormalities to the nurse. Resident has potential for pressure ulcer development related to diabetes, incontinence and immobility. Patient developed Stage II on 2/17/16: Intervention - monitor and report to MD as needed changes in skin status: appearance, color, impaired skin. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas and other changes in skin integrity. Report new conditions to the physician. -Physician Telephone Orders documented the following: 2/17/16 - cleanse wound to left heel with wound cleanser, apply hydrogel and cover with non-adherent pad and wrap with [MEDICATION NAME] every day. 2/19/16 - Bactrim by mouth twice a day for 10 days for left heel wound, change dressing on Monday, Wednesday and Friday. 3/4/16 - Keflex 500 mg by mouth three times a day for 10 days for left heel wound. 3/20/16 - send to emergency room for evaluation/treatment for [REDACTED]. During a telephone interview on 3/22/16 at 8:52 a.m., family member #1 stated the facility did not do their job and now their choice is either an above the knee amputation or Hospice. Family member #1 stated, This has all been caused from neglect. Family member #1 stated he was never called about Resident #1's heel; the first time he saw a boot on Resident #1's foot, he asked the nurse about it and she informed him that his father had rubbed his foot on his bed sheet but he was ok. Family member #1 stated his sister was visiting on 3/20/16 and thought her father had pooped on himself because he smelled so bad so she asked the CNAs to clean him up. Family member #1 stated the CNAs told his sister that Resident #1 did not poop in his bed, his foot was what smelled. Family member #1 stated his father's heel was black and smelled something awful and his heel just got worse and worse. During an interview on 3/22/16 at 11:25 a.m., the facility Administrator stated Resident #1's son has some complaints, with one being he was not notified of his father's wound on his foot, but he was aware his father was wearing a boot. The Administrator stated Resident #1's son travels a lot and maybe he missed a message on his phone. Hospital Observations, Interviews and Record Review During an observation in ICU room [ROOM NUMBER] on 3/22/16 at 1:20 p.m., with RN E and RN F, Resident #1 had a small pressure ulcer to the side of his right foot which looked to be a deep tissue injury. Resident #1 left foot was covered with a clean dressing dated 3/22/16 which had a very foul odor. During an interview on 3/22/16 at 1:35 p.m., RN E stated she had taken care of Resident #1 since early on 3/21/16, when he was transferred to ICU. RN E stated Resident #1's left heel pressure ulcer had a very foul smell and was draining when he arrived on the unit. During an interview on 3/22/16 at 1:50 p.m., HNM stated she was aware his wound was really bad and the unstageable ulcer to his left heel smelled bad. During an observation in ICU room [ROOM NUMBER] at 2:15 p.m., with RN E assisting revealed the following: A strong foul smell was radiating out of Resident #1's room as the room was approached. The dressing was off and the unstageable pressure ulcer covered his entire left heel. The outer edges of the ulcer were a bright red, looked slimy and was bleeding. The bottom of his foot was light pink and [MEDICAL CONDITION] (puffy) all the way to the base of his toes. Resident #1 was grimacing in pain as the leg was raised. The attending physician was not interviewed at this time because he was at the end of the hallway talking with Resident #1's family. During a follow-up interview on 3/22/16 at 2:15 p.m., RN E stated the attending physician wanted to get an x-ray of Resident #1's foot to see if the wound has tunneling because the foot looks like it has tunneled all the way to his toes by the way the bottom of his foot looks. Review of hospital records, dated 3/21/16 at 2:39 p.m., which included hospital photos documented Resident #1's left heel pressure ulcer along with measurements, documented the pressure ulcer was 8.63 cm by 6.77 cm. Review of Emergency Department Report, dated 3/20/16 at 8:14 p.m., documented the following: patient presents with foul smelling infected left heel that apparently has been having dressing changes at the nursing home intermittently. Left heel with necrotic unstageable large decubitus ulcer with surrounding [DIAGNOSES REDACTED], purulence and foul smell. NOTE: Pressure Ulcer - also called bedsore, decubitus ulcer, pressure necrosis or pressure sore - an inflammation, sore, or ulcer in the skin over a bony prominence. It results from ischemic [MEDICAL CONDITION] of the tissues caused by prolonged pressure on them. Prevention of pressure ulcers is a cardinal aspect of nurse care. Prompt and continued care of early [MEDICAL CONDITION] can prevent invasion of underlying tissue and promote healing. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page1318 - 1319) Hospital physician progress notes [REDACTED]. The family is discussing the problem with the patient about his diabetic foot with multiple decubitus ulcers infected and poor circulation with significant [MEDICAL CONDITION]. This discussion is about the need to proceed with amputation versus transfer of the patient to hospice services. Nursing Home Nurses Notes documented the following: 2/14/16 - CNAs called nurse to room and noted that resident's left heel was dripping blood. Assessed the heel, it noted a small hole, cleaned wound and applied pressure to stop bleeding. Applied pressure dressing. 2/17/16 - Doctor here and assessed wound. Received order to cleanse wound with wound cleaner, apply hydrogel and cover with non-adherent pad and wrap with [MEDICATION NAME] every day. 2/19/16 - received order for Bactrim DS by mouth twice a day for 10 days and change dressing changes to Monday, Wednesday and Friday. Initial dose given. All documented by LVN C. During an interview on 3/22/16 at 2:50 p.m., LVN C stated she noticed a problem with Resident #1's foot when the aides called her down to his room on 2/14/16 because his foot was bleeding. LVN C stated there was a hole in the bottom of his heel so she cleaned the heel up and held pressure to get the wound to stop bleeding. When asked if she reported the wound on Resident #1's heel to the physician or the family, she stated she did not because she was so busy. She stated Resident #1 received his dressing changes on Monday, Wednesday and Fridays after he got showered. She stated Resident #1 was on antibiotics and to her, his wound did not look like it ever changed much. She stated she did not think Resident #1's foot stunk and no one had reported to her that his foot stunk but she had been having trouble with her allergies. She stated she was surprised how fast Resident #1's wound opened up. During an interview on 3/22/16 at 3:09 p.m., CNA G stated she was the aide who reported Resident #1's foot bleeding to LVN C. CNA G stated she took care of Resident #1 a lot and noticed his foot was starting to smell really bad. When asked when Resident #1's foot started to smell bad, she said around the beginning of March. CNA G stated she did not report the smell to the nurse because she figured the nurse could smell it herself without being told. CNA G stated when she had Resident #1 in the shower; she would clean his foot fast because it smelled so bad. CNA G stated when the nurse would change Resident #1's dressing; she would hold his leg up so the nurse could wrap his foot. During a follow-up interview on 3/22/16 at 3:45 p.m., LVN C stated when she first assessed Resident #1's heel on 2/14/16; the wound was the size of a pin prick. LVN C again stated she did not call the physician or family about the wound to Resident #1's heel. LVN C stated she took good care of Resident #1 but she just did not document like she should have. LVN C stated, I messed up. During an interview on 3/22/16 at 3:50 p.m., CNA H stated when she came back from vacation on 2/27/16; Resident #1 foot was already bandaged and had an inflated boot thing on his foot. CNA H stated she would prop up Resident #1's leg to assist with dressing changes and said, It stunk pretty bad. CNA H stated Resident #1's foot started stinking about two weeks ago. CNA H stated the nurse was doing the dressing changes every other day so she figured she knew Resident #1's foot stunk. During an interview on 3/22/16 at 4:00 p.m., with ADON I, when asked for Resident #1's Treatment Administration Record for February 2016, she stated it could not be found in his chart. Review of the Non-Pressure Skin Condition Report, documented the following: 2/9/16 - skin intact 2/16/16 (first documentation of left heel ulcer) - dressing intact to left heel prior to shower on 2/15/16, open area noted once dressing was removed: 7.5 cm x 6 cm with small amount of serosanguinous exudate, no odor, wound bed with [MEDICATION NAME] tissue and the surrounding skin color was normal. This was documented by LVN D. NOTE: serosanguinous: thin and red; composed of serum and blood. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 1480) Exudate: fluid, cells or other substances that have been slowly exuded, or discharged , from cells or blood vessels through small pores or breaks in cell membranes. Perspiration, pus and serum are sometimes identified as exudates. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 607) During an interview on 3/23/16 at 9:35 a.m., LVN D stated a CNA came to her on 2/15/16 and asked her if she wanted to change the dressing on Resident #1's foot. LVN D stated she was unaware Resident #1 had a dressing on his foot and said to the CNA, What dressing? LVN D stated when she last worked on 2/11/16 (Thursday) Resident #1 did not have any skin issues but when she came back to work on 2/15/16, Resident #1 had skin issues but she was not informed about the dressing change or skin issues from the evening nurse she received report from. LVN D stated she redressed Resident #1's heel on 2/15/16 but failed to document on the Non-Pressure Skin Condition Report until 2/16/16. LVN D stated Resident #1 heel was open with healthy pink tissue. LVN D stated the wound was big and covered the whole bottom of Resident #1's heel. When asked if there was an order for [REDACTED].#1's heel, LVN D stated there were not any orders for dressing changes for Resident #1. LVN D stated she redressed Resident #1's heel because there was dressing on it. When asked when there were no orders for dressing changes to Resident #1's did it raise her suspicion the doctor had not been notified, LVN D stated she thought the doctor had already been notified. LVN D stated she did not write an incident report or an SBAR (Situation, Background, Appearance, Review and notify) for Resident #1's heel because she was too busy as she had several people sick at the same time. LVN D stated she documented on the Non-Pressure Skin Condition Report on 2/16/16 for Resident #1's heel and wrote the measurements on it but she stated she did not contact the physician or the family because she thought the other nurse had already done that. When asked when she did not see any documentation for the previous day on the Non-Pressure Skin Condition Report for Resident #1's heel wound, did that raise a suspicion the physician and family had not been notified; LVN D stated she thought the other nurse had notified the physician and family. LVN D stated there was a day she took the physician to Resident #1's room to see his foot because the wound had an odor and that was when Resident #1's physician ordered antibiotics. LVN D stated she could not remember the day, but Resident #1's son had noticed a dressing on his father's foot and the son asked her a lot of questions about Resident #1's foot. Further review of the Non-Pressure Skin Condition Report documented the following: 2/23/16 - 7 x 6 with serosanguinous exudate with no odor, wound bed with [MEDICATION NAME] tissue which was a normal color. 3/1/16 - Left heel 7 cm x 6 cm - with no other documentation for exudate, odor condition of wound bed or surrounding skin color. Review of the Weekly Pressure Ulcer Healing Record for the left heel, with date of onset as 2/15/16, documented the following: 3/14/16 - 7 x 7 with a moderate amount of serosanguinous exudate, a moderate odor was dark red with the surrounding skin dark red/purple, with peripheral tissue [MEDICAL CONDITION]. 3/18/16 - 7 x 7 with a moderate amount of serosanguinous exudate, a moderate odor, wound bed was black/brown (eschar) with surrounding skin dark red/purple and peripheral tissue [MEDICAL CONDITION]. Both notations were documented by LVN D. NOTE: eschar - a scab or dry crust that results from trauma, such as a thermal or chemical burn, infection or excoriating skin disease. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 587) Interview on 3/23/16 at 9:35 a.m., with LVN D, continued: LVN D stated she thought she wrote the wrong date on 3/14/16 because it should be 3/4/16. LVN D stated she had allergies and to her, Resident #1's heel smelled moderately. She stated on 3/18/16 she gave the doctor a call because Resident #1's heel was worse but she did not notify Resident #1's son. LVN D stated she was working on Sunday, 3/20/16, when Resident #1's daughter came to visit. LVN D stated she was in Resident #1's room, checking his blood sugar, when Resident #1's daughter was asking about his foot because his foot smelled so bad. LVN D stated she thought Resident #1's daughter called Resident #1's son and the son called the nursing home and wanted his father sent to the hospital. LVN D stated she wished she would have been more aggressive with the doctor about Resident #1's heel but she was just so busy because she had several people sick at the same time and she had a lot of work to do. LVN D stated there should have been documentation of Resident #1's heel between 3/4/16 and 3/18/16 but confirmed there was no documentation for 3/11/16. During a follow-up interview on 3/23/16 at 10:00 a.m., the Administrator stated Resident #1's son knew his father had a wound and was aware of a boot that Resident #1 was wearing. The Administrator again stated she hoped staff did not leave a message on his phone and he never saw it. The Administrator stated the son's biggest issues was that he was not notified of his father's wound on his heel. The Administrator stated Resident #1's son was in the facility two weeks ago when the son noticed the boot and was asking questions. When informed that interviews with two of her nurses revealed that neither one had notified Resident #1's son of the wound on his heel or of the wound getting worse, the Administrator stated they should have notified the doctor and the family on 2/14/16 but they did not. At this time, she was informed on 2/15/16, when a nurse redressed a wound with no orders for dressing changes and that was significantly worse from the day before, the physician nor the family was notified. The Administrator stated skin assessments were to be conducted weekly. Nurses Notes documented the following: 3/4/16 - physician here making rounds, received new orders: Keflex 500 mg by mouth three times a day for 10 days, Diagnoses: [REDACTED]. PO fluids encouraged and accepted well, dressing to left heel changed, procedure tolerated well. Reflect: Son notified of new order. 3/18/16 - changed dressing to left heel wound, left heel with back/brown eschar, moderate odor noted, moderate amount of exudate, resident completed antibiotics on 3/13/16, physician notified of unstageable wound, states it was unstageable since 3/4/16 when he last saw it, stated it was dark red then blister like, reported to him that it is now black/brown eschar with moderate odor, stated he wants to see it again when he makes round. All documented by LVN D. Nurses Notes documented the following: 3/20/16 - received personal call from Resident #1's son who stated that a family member was visiting from out of town and came by to visit his Dad and she reported to him that there was a bad odor from Resident #1's left heel. Advised son that physician was aware and notified of worsening condition to heel; that he was to come and check in on Friday but was unable to make it in. Son requesting that his father be sent at this time to the emergency room . Physician was advised of above; order given to send to emergency room for evaluation/treatment of [REDACTED]. 3/21/16 - personal call placed to hospital to check on resident's status and they advised me that he was admitted with left heel ulcer, infection. During an interview on 3/23/16 at 2:08 p.m., ADON I stated staff are to do a skin assessment on admission and weekly. ADON I stated on admit, pressure ulcers are identified and then it would be reported to the DON but now that are reported to me or the Weekend Supervisor. ADON I on the Pressure Ulcer sheet, there was a space to check when the dietary department was notified to order Med Plus and a space to check for notification of physician and family. ADON I stated on 2/14/16, the wound on Resident #1's left heel was reported to LVN C but she did not report the wound to the DON, physician or the family but she should have. ADON I stated Resident #1's wound was located on his heel and was not going to get better. ADON I stated when Resident #1's physician ordered dressing changes on 2/17/16 and 2/19/16, LVN C wrote the orders but ADON I never saw the February order so it was not transcribed to the MAR. ADON I stated LVN C got the doctor to sign the dressing change order for Resident #1's heel right after she wrote the order and LVN C put the order directly into the chart but LVN C did not transcribe the dressing change order to the Treatment Record; that was why there was no treatment record of dressing changes for Resident #1 for February. ADON I stated she would not document on a dressing change in nurses notes but would document a change of condition in the nurses notes. ADON I stated she was positive the CNAs would not let the nurse forget to change the dressings on Resident #1's heel after his shower. ADON I stated staff are to fill out an SBAR or an incident report on a change of condition but neither one was done. ADON I stated even on a Physician Telephone Order, there was a place to notify the doctor and family and that was not done. ADON I stated all systems to catch this were missed for Resident #1. Review of Resident #1's physician notes documented the following: 2/26/16 - patient is an elderly male who suffered a shearing trauma to left heel which caused wound and patient's dead skin is sloughing off now. Patient is currently on Bactrim for his left heel wound which is slowly getting better, does not have any drainage. Plan: Continue present wound care with alginate and change the dressing every other day. 3/4/16 - Evaluation of left heel wound [MEDICAL CONDITION]. Patient is an elderly male who had sheared the top skin on the left heel which has developed DTI (Deep Tissue Injury) now with the dark discoloration and some smell and some serosanguinous fluid. Skin: left heel had to have DTI with dark purplish discoloration, also with the superficial skin being sloughed off. There is a small area of an open wound at the very bottom of the heel with serosanguinous fluid and bad smell. Plan: Continue wound care and keep wound clean with wound cleanser and change dressing Monday, Wednesday and Friday. During an interview on 3/23/16 at 3:05 p.m., Resident #1's physician stated the resident does have a lot going on medically and has had a steady decline for the past 8 months. The physician stated he was not notified on 2/14/16 when the wound to Resident #1's heel was initially found. The physician stated a couple of weeks ago, he looked at Resident #1's heel and he thought the wound was getting better because not one notified him that is wasn't. The physician stated he expected the nurses to let him know when a wound was not responding to treatments so it can be changed but he was not notified until Resident #1 was sent to the hospital and now he needs an amputation. The physician stated he was very accessible by phone and did expect nursing staff to call him to let him know any changes so he could change the treatment. The physician stated, The nurses are supposed to be an extension of me but if I don't know, I can't help. They are my eyes and ears. During a follow-up interview on 3/24/16 at 9:15 a.m., LVN D stated on 3/18/16 (Friday), after she called Resident #1's physician about his heel wound, she stated she got real busy and forgot to call the physician again. LVN D stated on 3/19/16 (Saturday), she had a resident who passed away and again, she was real busy and just forgot to call Resident #1's physician again. LVN D stated she was going to call Resident #1's physician on 3/20/16 (Sunday) when she had time but the family called and wanted Resident #1 sent to the hospital so she never got a chance. Resident #7 Review of Resident #7's clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -An MDS resident assessment, dated 2/2/16, documented the resident scored 11 of 15 on a mini mental exam, required extensive assistance with bed mobility, dressing, personal hygiene, toileting and bathing, had limited range of motion for both lower extremities, used a wheelchair for locomotion, was frequently incontinent of bladder, continent of bowel, was 68 inches tall and 134 pounds. -A Physician Telephone Order, dated 3/8/16, documented to cleanse left lower leg with normal saline, pat dry gently with 4x4 gauze, apply triple antibiotic ointment and cover with non-adherent pad and wrap with [MEDICATION NAME] until healed - every day. -Review of Resident #7's Treatment Record for the daily dressing changes documented the dressing was changed in March on the 17th, 18th, 19th, 21st, and 22nd. On March 20th and 23rd, the date was circled which indicated the treatment was not provided. During an observation on 3/24/16 at 9:30 a.m., of LVN J providing wound care to Resident #7 revealed the resident's dressing on her left lower leg was dated 3/16/16 (8 days ago). During an interview on 3/24/16 at 9:45 a.m., LVN J stated she had not changed the dressing recently but had checked on Resident #7's dressing every day and the dressing was clean. LVN J stated, I don't want the facility to be in anymore trouble. Review of the Policy and Procedure for Medication - Treatment Administration and Documentation, revised 2/2/14, documented the following: Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Process: 5. Documented initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. 12. Review each MAR and TAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided according to physician orders. 15. Provide a summary of medication or treatment administration issues to on-coming nurse or CMA during shift to shift report. Review of the policy and procedure for Skin Management, revised 2/1/14, documented the following: Implement/Ongoing Strategy: 2. A weekly skin evaluation is completed by the licensed nurse for those patients identified with moderate to very high skin risk on the Braden Scale and do not have pressure ulcers. Documentation indicating the completion of the skin evaluation is entered on the Treatment Administration Record. 3. A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. 4. The wound nurse or licensed nurse re-assesses/re-evaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the Pressure Ulcer Form. Evaluate: 2. Pressure Ulcer healing is documented using descriptive characteristics of the sound (i.e., depth, width, presence of granulation tissue, exudate) and by using the PUSH Tool a validated pressure ulcer healing tool. 6. If a change in patient condition occurs, such as deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team, family or responsible party and documents follow up in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs. Communications with the physician, patient and family are documented in the clinical record. On 3/23/16 at 4:41 p.m., an IJ was identified and the Administrator and both ADONs were informed of the IJ due to the above failures. On 3/24/16 at 12:15 p.m., the Administrator and both ADONs were informed Plan of Removal was accepted and the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as a pattern as the facility was still monitoring the Plan of Removal. On 3/24/16 at 12:15 p.m., the facility's final Plan of Removal was accepted and contained the following: Plan to Remove Immediate Jeopardy: The plan of removal represents the centers allegation of compliance. This plan of removal serves as the nursing home's response to Immediate Jeopardy notification the center received on 3/23/16 at 4:41 p.m. from the Texas Department of Aging and Disability Services regarding neglect related to Physician notification related to a wound. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 2/14/16, LVN C identified a wound to the left heel of Resident #1. LVN C notified physician on 2/17/16 and obtained an order to treat the left heel. On 2/19/16, LVN C notified physici

Based on observation, interview and record review, the facility failed to implement their written policy and procedures that prohibit neglect for 2 of 7 residents (Resident #1 and Resident #7) reviewed for neglect. 1. The facility failed to provide the treatment, assessment and physician notification for a pressure sore that worsened to the point of requiring amputation. -Resident #1 was found to have a pin prick hole in the bottom of his left heel but LVN C failed to inform the physician or the family. -The next day, LVN D redressed a 7.5 cm x 6 cm open area to Resident #1's left heel without an order and failed to notify the physician or the family. -The facility did not have a record of Resident #1 receiving dressing changes from 2/17/16 to 3/2/16 - 13 days. -Nursing Staff failed to notice a change in Resident #1's wound to his left heel after two separate antibiotic treatments and failed to notify the doctor. -Nursing staff failed to conduct and document proper assessments for Resident #1's left heel. -Nursing staff failed to notice a foul smell which was worsening and radiating from Resident #1's foot. -Nursing staff failed to ensure Resident #1's physician and family were aware of the worsening of his left heel. As a result, Resident #1 had a necrotic unstageable large decubitus ulcer to his left heel and was sent, per family request, to the hospital with a foul-smelling odor coming out of his left heel, placing Resident #1 at risk for worsening infection, amputation and death. 2. Resident #7's dressing on her left lower leg had not been changed in 8 days. This failure resulted in identification of an Immediate jeopardy (IJ) on 3/23/16. While the IJ was removed on 3/24/16, the facility remained out of compliance at Harm at a scope of a pattern due to all active staff were still being in-serviced on notification of physician and family on a change of condition, skin management to identify skin observations, alterations, assessments, documentation guidelines related to skin alterations and the facility was still monitoring the Plan of Removal. Failure to put effective interventions into place and ensure staff knew how to assess and intervene to protect 5 other residents with wounds could place them at risk for developing an infection and worsening of a wound and lack of services. The evidence is as follows: Resident #1 Review of Resident #1's closed clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -An annual MDS resident assessment, dated 1/20/16, documented the resident rarely/never was understood, usually understands others, had short and long term memory problems, severely impaired cognitive skills for daily decision making, required extensive assistance with bed mobility, locomotion in the facility, eating, was totally dependent on two staff for transfers, dressing, toileting and bathing, was totally dependent on one staff for personal hygiene, had limited range of motion of one upper extremity and both lower extremities, used a wheelchair, was incontinent of bladder and bowel, 70 inches tall and 169 pounds, had weight loss but was not on a physician-prescribed weight-loss regimen, was at risk of developing pressure ulcers but did not have any pressure ulcers. -Review of a Care Plan, initiated on 1/20/16 and revised on 3/22/16, documented the following: Resident has [MEDICAL CONDITION]: Intervention - monitor/document/report to MD as needed any signs or symptoms of skin problems related to [MEDICAL CONDITION]: redness, [MEDICAL CONDITION], blistering, itching, burning, bruises, cuts, other [MEDICAL CONDITION]. Resident is currently taking Aspirin 81 mg daily as an anticoagulant related to [MEDICAL CONDITION] and [MEDICAL CONDITION]: Intervention - daily skin inspection. Report abnormalities to the nurse. Resident has potential for pressure ulcer development related to diabetes, incontinence and immobility. Patient developed Stage II on 2/17/16: Intervention - monitor and report to MD as needed changes in skin status: appearance, color, impaired skin. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas and other changes in skin integrity. Report new conditions to the physician. -Physician Telephone Orders documented the following: 2/17/16 - cleanse wound to left heel with wound cleanser, apply hydrogel and cover with non-adherent pad and wrap with [MEDICATION NAME] every day. 2/19/16 - Bactrim by mouth twice a day for 10 days for left heel wound, change dressing on Monday, Wednesday and Friday. 3/4/16 - Keflex 500 mg by mouth three times a day for 10 days for left heel wound. 3/20/16 - send to emergency room for evaluation/treatment for [REDACTED]. During a telephone interview on 3/22/16 at 8:52 a.m., family member #1 stated the facility did not do their job and now their choice is either an above the knee amputation or Hospice. Family member #1 stated, This has all been caused from neglect. Family member #1 stated he was never called about Resident #1's heel; the first time he saw a boot on Resident #1's foot, he asked the nurse about it and she informed him that his father had rubbed his foot on his bed sheet but he was ok. Family member #1 stated his sister was visiting on 3/20/16 and thought her father had pooped on himself because he smelled so bad so she asked the CNAs to clean him up. Family member #1 stated the CNAs told his sister that Resident #1 did not poop in his bed, his foot was what smelled. Family member #1 stated his father's heel was black and smelled something awful and his heel just got worse and worse. During an interview on 3/22/16 at 11:25 a.m., the facility Administrator stated Resident #1's son has some complaints, with one being he was not notified of his father's wound on his foot, but he was aware his father was wearing a boot. The Administrator stated Resident #1's son travels a lot and maybe he missed a message on his phone. Hospital Observations, Interviews and Record Review During an observation in ICU room [ROOM NUMBER] on 3/22/16 at 1:20 p.m., with RN E and RN F, Resident #1 had a small pressure ulcer to the side of his right foot which looked to be a deep tissue injury. Resident #1 left foot was covered with a clean dressing dated 3/22/16 which had a very foul odor. During an interview on 3/22/16 at 1:35 p.m., RN E stated she had taken care of Resident #1 since early on 3/21/16, when he was transferred to ICU. RN E stated Resident #1's left heel pressure ulcer had a very foul smell and was draining when he arrived on the unit. During an interview on 3/22/16 at 1:50 p.m., HNM stated she was aware his wound was really bad and the unstageable ulcer to his left heel smelled bad. During an observation in ICU room [ROOM NUMBER] at 2:15 p.m., with RN E assisting revealed the following: A strong foul smell was radiating out of Resident #1's room as the room was approached. The dressing was off and the unstageable pressure ulcer covered his entire left heel. The outer edges of the ulcer were a bright red, looked slimy and was bleeding. The bottom of his foot was light pink and [MEDICAL CONDITION] (puffy) all the way to the base of his toes. Resident #1 was grimacing in pain as the leg was raised. The attending physician was not interviewed at this time because he was at the end of the hallway talking with Resident #1's family. During a follow-up interview on 3/22/16 at 2:15 p.m., RN E stated the attending physician wanted to get an x-ray of Resident #1's foot to see if the wound has tunneling because the foot looks like it has tunneled all the way to his toes by the way the bottom of his foot looks. Review of hospital records, dated 3/21/16 at 2:39 p.m., which included hospital photos documented Resident #1's left heel pressure ulcer along with measurements, documented the pressure ulcer was 8.63 cm by 6.77 cm. Review of Emergency Department Report, dated 3/20/16 at 8:14 p.m., documented the following: patient presents with foul smelling infected left heel that apparently has been having dressing changes at the nursing home intermittently. Left heel with necrotic unstageable large decubitus ulcer with surrounding [DIAGNOSES REDACTED], purulence and foul smell. NOTE: Pressure Ulcer - also called bedsore, decubitus ulcer, pressure necrosis or pressure sore - an inflammation, sore, or ulcer in the skin over a bony prominence. It results from ischemic [MEDICAL CONDITION] of the tissues caused by prolonged pressure on them. Prevention of pressure ulcers is a cardinal aspect of nurse care. Prompt and continued care of early [MEDICAL CONDITION] can prevent invasion of underlying tissue and promote healing. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page1318 - 1319) Hospital physician progress notes [REDACTED]. The family is discussing the problem with the patient about his diabetic foot with multiple decubitus ulcers infected and poor circulation with significant [MEDICAL CONDITION]. This discussion is about the need to proceed with amputation versus transfer of the patient to hospice services. Nursing Home Nurses Notes documented the following: 2/14/16 - CNAs called nurse to room and noted that resident's left heel was dripping blood. Assessed the heel, it noted a small hole, cleaned wound and applied pressure to stop bleeding. Applied pressure dressing. 2/17/16 - Doctor here and assessed wound. Received order to cleanse wound with wound cleaner, apply hydrogel and cover with non-adherent pad and wrap with [MEDICATION NAME] every day. 2/19/16 - received order for Bactrim DS by mouth twice a day for 10 days and change dressing changes to Monday, Wednesday and Friday. Initial dose given. All documented by LVN C. During an interview on 3/22/16 at 2:50 p.m., LVN C stated she noticed a problem with Resident #1's foot when the aides called her down to his room on 2/14/16 because his foot was bleeding. LVN C stated there was a hole in the bottom of his heel so she cleaned the heel up and held pressure to get the wound to stop bleeding. When asked if she reported the wound on Resident #1's heel to the physician or the family, she stated she did not because she was so busy. She stated Resident #1 received his dressing changes on Monday, Wednesday and Fridays after he got showered. She stated Resident #1 was on antibiotics and to her, his wound did not look like it ever changed much. She stated she did not think Resident #1's foot stunk and no one had reported to her that his foot stunk but she had been having trouble with her allergies. She stated she was surprised how fast Resident #1's wound opened up. During an interview on 3/22/16 at 3:09 p.m., CNA G stated she was the aide who reported Resident #1's foot bleeding to LVN C. CNA G stated she took care of Resident #1 a lot and noticed his foot was starting to smell really bad. When asked when Resident #1's foot started to smell bad, she said around the beginning of March. CNA G stated she did not report the smell to the nurse because she figured the nurse could smell it herself without being told. CNA G stated when she had Resident #1 in the shower; she would clean his foot fast because it smelled so bad. CNA G stated when the nurse would change Resident #1's dressing; she would hold his leg up so the nurse could wrap his foot. During a follow-up interview on 3/22/16 at 3:45 p.m., LVN C stated when she first assessed Resident #1's heel on 2/14/16; the wound was the size of a pin prick. LVN C again stated she did not call the physician or family about the wound to Resident #1's heel. LVN C stated she took good care of Resident #1 but she just did not document like she should have. LVN C stated, I messed up. During an interview on 3/22/16 at 3:50 p.m., CNA H stated when she came back from vacation on 2/27/16; Resident #1 foot was already bandaged and had an inflated boot thing on his foot. CNA H stated she would prop up Resident #1's leg to assist with dressing changes and said, It stunk pretty bad. CNA H stated Resident #1's foot started stinking about two weeks ago. CNA H stated the nurse was doing the dressing changes every other day so she figured she knew Resident #1's foot stunk. During an interview on 3/22/16 at 4:00 p.m., with ADON I, when asked for Resident #1's Treatment Administration Record for February 2016, she stated it could not be found in his chart. Review of the Non-Pressure Skin Condition Report, documented the following: 2/9/16 - skin intact 2/16/16 (first documentation of left heel ulcer) - dressing intact to left heel prior to shower on 2/15/16, open area noted once dressing was removed: 7.5 cm x 6 cm with small amount of serosanguinous exudate, no odor, wound bed with [MEDICATION NAME] tissue and the surrounding skin color was normal. This was documented by LVN D. NOTE: serosanguinous: thin and red; composed of serum and blood. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 1480) Exudate: fluid, cells or other substances that have been slowly exuded, or discharged , from cells or blood vessels through small pores or breaks in cell membranes. Perspiration, pus and serum are sometimes identified as exudates. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 607) During an interview on 3/23/16 at 9:35 a.m., LVN D stated a CNA came to her on 2/15/16 and asked her if she wanted to change the dressing on Resident #1's foot. LVN D stated she was unaware Resident #1 had a dressing on his foot and said to the CNA, What dressing? LVN D stated when she last worked on 2/11/16 (Thursday) Resident #1 did not have any skin issues but when she came back to work on 2/15/16, Resident #1 had skin issues but she was not informed about the dressing change or skin issues from the evening nurse she received report from. LVN D stated she redressed Resident #1's heel on 2/15/16 but failed to document on the Non-Pressure Skin Condition Report until 2/16/16. LVN D stated Resident #1 heel was open with healthy pink tissue. LVN D stated the wound was big and covered the whole bottom of Resident #1's heel. When asked if there was an order for [REDACTED].#1's heel, LVN D stated there were not any orders for dressing changes for Resident #1. LVN D stated she redressed Resident #1's heel because there was dressing on it. When asked when there were no orders for dressing changes to Resident #1's did it raise her suspicion the doctor had not been notified, LVN D stated she thought the doctor had already been notified. LVN D stated she did not write an incident report or an SBAR (Situation, Background, Appearance, Review and notify) for Resident #1's heel because she was too busy as she had several people sick at the same time. LVN D stated she documented on the Non-Pressure Skin Condition Report on 2/16/16 for Resident #1's heel and wrote the measurements on it but she stated she did not contact the physician or the family because she thought the other nurse had already done that. When asked when she did not see any documentation for the previous day on the Non-Pressure Skin Condition Report for Resident #1's heel wound, did that raise a suspicion the physician and family had not been notified; LVN D stated she thought the other nurse had notified the physician and family. LVN D stated there was a day she took the physician to Resident #1's room to see his foot because the wound had an odor and that was when Resident #1's physician ordered antibiotics. LVN D stated she could not remember the day, but Resident #1's son had noticed a dressing on his father's foot and the son asked her a lot of questions about Resident #1's foot. Further review of the Non-Pressure Skin Condition Report documented the following: 2/23/16 - 7 x 6 with serosanguinous exudate with no odor, wound bed with [MEDICATION NAME] tissue which was a normal color. 3/1/16 - Left heel 7 cm x 6 cm - with no other documentation for exudate, odor condition of wound bed or surrounding skin color. Review of the Weekly Pressure Ulcer Healing Record for the left heel, with date of onset as 2/15/16, documented the following: 3/14/16 - 7 x 7 with a moderate amount of serosanguinous exudate, a moderate odor was dark red with the surrounding skin dark red/purple, with peripheral tissue [MEDICAL CONDITION]. 3/18/16 - 7 x 7 with a moderate amount of serosanguinous exudate, a moderate odor, wound bed was black/brown (eschar) with surrounding skin dark red/purple and peripheral tissue [MEDICAL CONDITION]. Both notations were documented by LVN D. NOTE: eschar - a scab or dry crust that results from trauma, such as a thermal or chemical burn, infection or excoriating skin disease. (Mosby's Medical, Nursing & Allied Health Dictionary, fifth edition, page 587) Interview on 3/23/16 at 9:35 a.m., with LVN D, continued: LVN D stated she thought she wrote the wrong date on 3/14/16 because it should be 3/4/16. LVN D stated she had allergies and to her, Resident #1's heel smelled moderately. She stated on 3/18/16 she gave the doctor a call because Resident #1's heel was worse but she did not notify Resident #1's son. LVN D stated she was working on Sunday, 3/20/16, when Resident #1's daughter came to visit. LVN D stated she was in Resident #1's room, checking his blood sugar, when Resident #1's daughter was asking about his foot because his foot smelled so bad. LVN D stated she thought Resident #1's daughter called Resident #1's son and the son called the nursing home and wanted his father sent to the hospital. LVN D stated she wished she would have been more aggressive with the doctor about Resident #1's heel but she was just so busy because she had several people sick at the same time and she had a lot of work to do. LVN D stated there should have been documentation of Resident #1's heel between 3/4/16 and 3/18/16 but confirmed there was no documentation for 3/11/16. During a follow-up interview on 3/23/16 at 10:00 a.m., the Administrator stated Resident #1's son knew his father had a wound and was aware of a boot that Resident #1 was wearing. The Administrator again stated she hoped staff did not leave a message on his phone and he never saw it. The Administrator stated the son's biggest issues was that he was not notified of his father's wound on his heel. The Administrator stated Resident #1's son was in the facility two weeks ago when the son noticed the boot and was asking questions. When informed that interviews with two of her nurses revealed that neither one had notified Resident #1's son of the wound on his heel or of the wound getting worse, the Administrator stated they should have notified the doctor and the family on 2/14/16 but they did not. At this time, she was informed on 2/15/16, when a nurse redressed a wound with no orders for dressing changes and that was significantly worse from the day before, the physician nor the family was notified. The Administrator stated skin assessments were to be conducted weekly. Nurses Notes documented the following: 3/4/16 - physician here making rounds, received new orders: Keflex 500 mg by mouth three times a day for 10 days, Diagnoses: [REDACTED]. PO fluids encouraged and accepted well, dressing to left heel changed, procedure tolerated well. Reflect: Son notified of new order. 3/18/16 - changed dressing to left heel wound, left heel with back/brown eschar, moderate odor noted, moderate amount of exudate, resident completed antibiotics on 3/13/16, physician notified of unstageable wound, states it was unstageable since 3/4/16 when he last saw it, stated it was dark red then blister like, reported to him that it is now black/brown eschar with moderate odor, stated he wants to see it again when he makes round. All documented by LVN D. Nurses Notes documented the following: 3/20/16 - received personal call from Resident #1's son who stated that a family member was visiting from out of town and came by to visit his Dad and she reported to him that there was a bad odor from Resident #1's left heel. Advised son that physician was aware and notified of worsening condition to heel; that he was to come and check in on Friday but was unable to make it in. Son requesting that his father be sent at this time to the emergency room . Physician was advised of above; order given to send to emergency room for evaluation/treatment of [REDACTED]. 3/21/16 - personal call placed to hospital to check on resident's status and they advised me that he was admitted with left heel ulcer, infection. During an interview on 3/23/16 at 2:08 p.m., ADON I stated staff are to do a skin assessment on admission and weekly. ADON I stated on admit, pressure ulcers are identified and then it would be reported to the DON but now that are reported to me or the Weekend Supervisor. ADON I on the Pressure Ulcer sheet, there was a space to check when the dietary department was notified to order Med Plus and a space to check for notification of physician and family. ADON I stated on 2/14/16, the wound on Resident #1's left heel was reported to LVN C but she did not report the wound to the DON, physician or the family but she should have. ADON I stated Resident #1's wound was located on his heel and was not going to get better. ADON I stated when Resident #1's physician ordered dressing changes on 2/17/16 and 2/19/16, LVN C wrote the orders but ADON I never saw the February order so it was not transcribed to the MAR. ADON I stated LVN C got the doctor to sign the dressing change order for Resident #1's heel right after she wrote the order and LVN C put the order directly into the chart but LVN C did not transcribe the dressing change order to the Treatment Record; that was why there was no treatment record of dressing changes for Resident #1 for February. ADON I stated she would not document on a dressing change in nurses notes but would document a change of condition in the nurses notes. ADON I stated she was positive the CNAs would not let the nurse forget to change the dressings on Resident #1's heel after his shower. ADON I stated staff are to fill out an SBAR or an incident report on a change of condition but neither one was done. ADON I stated even on a Physician Telephone Order, there was a place to notify the doctor and family and that was not done. ADON I stated all systems to catch this were missed for Resident #1. Review of Resident #1's physician notes documented the following: 2/26/16 - patient is an elderly male who suffered a shearing trauma to left heel which caused wound and patient's dead skin is sloughing off now. Patient is currently on Bactrim for his left heel wound which is slowly getting better, does not have any drainage. Plan: Continue present wound care with alginate and change the dressing every other day. 3/4/16 - Evaluation of left heel wound [MEDICAL CONDITION]. Patient is an elderly male who had sheared the top skin on the left heel which has developed DTI (Deep Tissue Injury) now with the dark discoloration and some smell and some serosanguinous fluid. Skin: left heel had to have DTI with dark purplish discoloration, also with the superficial skin being sloughed off. There is a small area of an open wound at the very bottom of the heel with serosanguinous fluid and bad smell. Plan: Continue wound care and keep wound clean with wound cleanser and change dressing Monday, Wednesday and Friday. During an interview on 3/23/16 at 3:05 p.m., Resident #1's physician stated the resident does have a lot going on medically and has had a steady decline for the past 8 months. The physician stated he was not notified on 2/14/16 when the wound to Resident #1's heel was initially found. The physician stated a couple of weeks ago, he looked at Resident #1's heel and he thought the wound was getting better because not one notified him that is wasn't. The physician stated he expected the nurses to let him know when a wound was not responding to treatments so it can be changed but he was not notified until Resident #1 was sent to the hospital and now he needs an amputation. The physician stated he was very accessible by phone and did expect nursing staff to call him to let him know any changes so he could change the treatment. The physician stated, The nurses are supposed to be an extension of me but if I don't know, I can't help. They are my eyes and ears. During a follow-up interview on 3/24/16 at 9:15 a.m., LVN D stated on 3/18/16 (Friday), after she called Resident #1's physician about his heel wound, she stated she got real busy and forgot to call the physician again. LVN D stated on 3/19/16 (Saturday), she had a resident who passed away and again, she was real busy and just forgot to call Resident #1's physician again. LVN D stated she was going to call Resident #1's physician on 3/20/16 (Sunday) when she had time but the family called and wanted Resident #1 sent to the hospital so she never got a chance. Resident #7 Review of Resident #7's clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -An MDS resident assessment, dated 2/2/16, documented the resident scored 11 of 15 on a mini mental exam, required extensive assistance with bed mobility, dressing, personal hygiene, toileting and bathing, had limited range of motion for both lower extremities, used a wheelchair for locomotion, was frequently incontinent of bladder, continent of bowel, was 68 inches tall and 134 pounds. -A Physician Telephone Order, dated 3/8/16, documented to cleanse left lower leg with normal saline, pat dry gently with 4x4 gauze, apply triple antibiotic ointment and cover with non-adherent pad and wrap with [MEDICATION NAME] until healed - every day. -Review of Resident #7's Treatment Record for the daily dressing changes documented the dressing was changed in March on the 17th, 18th, 19th, 21st, and 22nd. On March 20th and 23rd, the date was circled which indicated the treatment was not provided. During an observation on 3/24/16 at 9:30 a.m., of LVN J providing wound care to Resident #7 revealed the resident's dressing on her left lower leg was dated 3/16/16 (8 days ago). During an interview on 3/24/16 at 9:45 a.m., LVN J stated she had not changed the dressing recently but had checked on Resident #7's dressing every day and the dressing was clean. LVN J stated, I don't want the facility to be in anymore trouble. Review of the facility's Abuse/Neglect/Misappropriation Nursing Policy, revised 1/29/15, documented the following: Policy - Residents have the right to be free from abuse, neglect, corporal punishment, misappropriation of property and involuntary seclusion. Definition - Neglect - A deprivation of life ' s necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. Review of the facility's undated Freedom of Abuse Notice to Employees documented the following: Among the rights specified in the federal and state laws, each resident and patient has a right to a dignified existence and to be free from verbal, sexual, physical or mental abuse; corporal punishment; and involuntary seclusion. Abuse includes, but is not limited to: Neglect - the failure of a caregiver to provide the goods and services that are necessary to maintain the health or safety of a resident. Additionally neglect is the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs. Review of the Policy and Procedure for Medication - Treatment Administration and Documentation, revised 2/2/14, documented the following: Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Process: 5. Documented initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. 12. Review each MAR and TAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided according to physician orders. 15. Provide a summary of medication or treatment administration issues to on-coming nurse or CMA during shift to shift report. Review of the policy and procedure for Skin Management, revised 2/1/14, documented the following: Implement/Ongoing Strategy: 2. A weekly skin evaluation is completed by the licensed nurse for those patients identified with moderate to very high skin risk on the Braden Scale and do not have pressure ulcers. Documentation indicating the completion of the skin evaluation is entered on the Treatment Administration Record. 3. A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. 4. The wound nurse or licensed nurse re-assesses/re-evaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the Pressure Ulcer Form. Evaluate: 2. Pressure Ulcer healing is documented using descriptive characteristics of the sound (i.e., depth, width, presence of granulation tissue, exudate) and by using the PUSH Tool a validated pressure ulcer healing tool. 6. If a change in patient condition occurs, such as deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team, family or responsible party and documents follow up in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs. Communications with the physician, patient and family are documented in the clinical record. On 3/23/16 at 4:41 p.m., an IJ was identified and the Administrator and both ADONs were informed of the IJ due to the above failures. On 3/24/16 at 12:15 p.m., the Administrator and both ADONs were informed Plan of Removal was accepted and the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as a pattern as the facility was still monitoring the Plan of Removal. On 3/24/16 at 12:15 p.m., the facility's final Plan of Removal was accepted and contained the following: Plan to Remove Immediate Jeopardy: The plan of removal represents the centers allegation of compliance. This plan of removal serves as the nursing home's response to Immediate Jeopardy notification the center received on 3/23/16 at 4:41 p.m. from the Texas Department of Aging and Disability Services regarding neglect related to Physician notification related to a wound. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 2/14/16, LVN C identified a wound to the left heel of Resident #1. LVN C notified physician on 2/17/16 and obtained an order to treat the left heel. On 2/19/16, LVN C notified physician and he ordered Bactrim DS (antibiotic) twice a day for 10 days and dressing order changed to every Monday, Wednesday and Friday. Physician saw the resident's heel on 2/26/16 and 3/4/16. On 3/4/16, physician ordered Ke

Based on observation, interview, and record review, it was determined that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and pschosocial well-being for 1 (resident #8) of 7 sampled residents who sit in wheelchairs. The facility's administrator failed to develop and implement policies and procedures that would prevent resident injuries. The administrator failed to supervise nursing to ensure that staff were providing safe care for each resident. The DON failed to supervise nursing management to ensure that the residents were protected. The ADONs failed to monitor staff to ensure the residents were protected. Resident #8 was placed in the facility transportation van while in his wheelchair. CNA #1 did not secure the wheelchair to the van floor, and the resident later fell backwards hitting his back and head on the van floor. The Transportation Policy and Procedure for Center-Based Vehicle failed to address how to safely transport residents via the facility van, including residents who sat in a wheelchair while in the van. The DON was unaware of what procedures to follow when a resident refused to have his/her wheelchair secured to the van floor. No written instruction were provided for nursing management to follow. ADON #2 had previously instructed CNA #1 and CNA #3 to call the facility and notify nursing and the ADON about a resident refusing to have his/her wheelchair secured to the van floor. Resident #8 refused to have his wheelchair secured to the van floor. CNA #1 did not call the facility. She placed resident #8 in a position that allowed his wheelchair to tip over backwards. Resident #8 was sitting in the facility van while in his wheelchair. His wheelchair fell over backwards. CNA #1 called the facility and talked to LVN #2. LVN #2 sent CNA #2 to assist and assess resident #8. The practice of not having policies in place to prevent resident accidents could affect 1 (resident #8) of the 91 residents living in the facility that require the use of a wheelchair. The failure to formulate and implement policies that ensure resident safety could cause staff to provide care that is not safe, which could result in harm to the resident.The practice of not monitoring nursing staff could affect 1 (resident #8) of the 91 residents living in the facility that require the use of a wheelchair. The failure to monitor nursing staff could allow unsafe practices to occur, which could cause injury to the resident. The practice of not monitoring staff and ensuring they are following instructions could affect 1 (resident #8) of the 59 residents living in the facility who are at risk for falls. The failure to ensure staff call and notify the ADON of a resident refusing to have his/her wheelchair secured to the van floor could cause unsafe care to be provided, which could cause resident injury.The practice of not having a licensed nurse assess a resident directly after a fall could affect 1 (resident #8) of the 59 residents living in the facility who are at risk for falls. The failure to ensure that a licensed nurse assesses a resident directly after a fall could allow an injury to go unnoticed, which could cause further serious injury for the resident. An immediate jeopardy was identified on 2/13/13. While the IJ was removed on 2/14/13, the facility remained out of compliance at a pattern of no actual harm with a potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. The findings include: 1. During an interview with ADON #1 on 2/13/13 at 10:28 a.m., it was determined that resident #8 was in the facility van on 1/28/13. His chair was not secured to the van floor, and he fell backward and hit the van floor. ADON #1 said, "I expect that all wheelchairs should be secured to the van, and all residents should be buckled. CNA #1 should have secured resident #8's wheelchair to the van. If resident #8 was refusing to be secured, CNA #1 should have called the administrator." During an interview at 2:17 p.m., ADON #1 said that she didn't know the facility procedures to follow if the resident refused to be secured. "If a resident falls, the nurse does the initial assessment. The resident is not to be picked up off the floor unless the nurse is there." 2. During an interview with ADON #2 on 2/13/13 at 10:36 a.m., ADON #2 said, "Resident #8 would argue, but he would let them secure him. He was scared of falling, and said that staff didn't lock his brakes, and he would lean backward. So, he liked to be by the back seat so he could hold on to it." I told CNA #1 that if resident #8 refused, she needed to tell the nurse so she could document." "CNA #1 called and told me that she was taking off, and resident #8 fell backwards and hit his head. I sent CNA #2 to go help lift resident #8 up." "At about 1:30 p.m., resident #8 told me that he had back pain and a head ache. He said that CNA #1 didn't lock the brakes. I know CNA #1 should have secured resident #8 in the van. If he was being stubborn, she should have refused to take him." In an interview at 2:22 p.m., ADON #2 said, "Most of the time resident #8 refused to be secured to the van. I told the van drivers (CNA #1 and CNA #3) to notify the nurse or an ADON when any resident refused to have their wheelchair secured to the van. They were supposed to make the notification before leaving in the van." "If a resident falls, the nurse is supposed to do the initial assessment. The resident should not be picked up without the nurse being there." 3. During an interview with CNA #1 on 2/13/13 at 11:37 a.m., CNA #1 said, "Once I got resident #8 on the van, I tried to secure his chair to the van. He refused. He said he felt safer by the back seat so he could hold on to it. He has let us secure him before on 1/24/13. He was upset, but he let us. I placed him by the back seat. I locked his wheels. I went and sat in my seat, and put my seatbelt on. I reached for the hand brake. I looked in the mirror, and saw him raise his hands, as if he was dreaming. He had done this before. He was sleepy after [MEDICAL TREATMENT], and we had to talk to him to keep him awake. I then heard a noise. He had fallen backwards. I went to check on him. I asked him if he was okay. He said he didn't know. I called the facility and ADON #2 sent CNA #2 to help me. After we got him up, he said his head hurt from hitting it. He also complained of pain in his left shoulder." CNA #1 further said, "It's company policy to make sure the wheelchair is secure before we go to an appointment. I should not have went to the driver's seat unless he was secured. I should have called one of the ADONs and told them about the situation." "I've transported resident #8 several times without securing his wheelchair. I told ADON #2 and the social worker. The social worker said she would talk to him." 4. During an interview with CNA #2 on 2/13/13 at 12:21 p.m., CNA #2 said that he was asked to go help CNA #1 with resident #8. "Resident #8 was in his chair and was on his back. I asked him if he was okay. We picked him up, and he said his back and head hurt. I barely touched the back of his head, and he said that it hurt. When I got there, the chair was not secured to the van. It is facility policy that all residents should be secured to the van before going to an appointment. No matter what, you have to make sure all residents' wheelchairs are secured to the van. In my opinion, he should have been secured to the van, because their safety is what matters. He was very weak." CNA #2 said that the wheelchair was secured to the floor before transporting resident #8 to the facility. 5. During an interview with the administrator on 2/13/13 at 12:40 p.m., he said, "The transportation aide did not secure the resident's whhelchair to the van. It is company policy to follow state regulations befiore the van moves. All residents should be secured. The resident refused to be secured. He said he wanted to ride in the back holding on to the seat. He complained of soreness. There were no visual injuries. Staff have been instructed to notify the DON or myself if a resdient refuses to be secured. CNA #1 should have called the administrator so we could have gone and helped her." When asked if the wheelchair could have tipped over backward if it had been secured, the administrator said, "If the van would have been moving, and the chair would have been secured, the chair would not have tipped." 6. During an interview with the DON on 2/13/13 at 2:05 p.m., the DON said, "ADON #2 told me that resident #8 had fallen. I found out about it the next day in the stand up meeting." The DON said that he was not notified of the fall the day of the fall. "I don't know what procedures were in place when a resident refused to be safely secured in the van. Now, staff is to notify myself or the administrator, and we will go on site. The van will not move." "If a resident falls, the licensed nurse should do the initial assessment." 6. During an interview with CNA #3 on 2/13/13 at 2:48 p.m., CNA #3 said, "Probably 80-90% of the time resident #8 refused to be secured to the van. The last time I transported him was on 1/26/13 (Saturday) to UMC. I had no issues with him. He let me secure his wheelchair to the van. He has refused before, but then later let me secure him." "If he refused, I would call the ADON and report it to her; I was told by the ADON to notify an ADON or nurse of any refusal." "I have transported him before without his chair being secured to the van. He would sit in the back of the van. We would lock the brakes and he would hold on to the back of the seat. Holding on to the seat was his only security." CNA #3 said that she had not received any prior in-servicing pertaining to transporting residents in wheelchairs. "The policy is to secure all residents' wheelchairs to the van. If a wheelchair is properly secured to the van, there is no way possible for it to tip over backwards." 9. During an interview with CNA #4 on 2/13/13 at 2:42 p.m., CNA #4 said that she had transported resident #8 before via the facility van. "He refused to let me secure his wheelchair to the van. I always transported resident #8 without his wheelchair being secured to the van. He would sit between the back seats and hold on to the handle. Sometimes he would sit behind the seat and hold on to it. The brakes were locked." "Upon return to the facility, I would tell a nurse that he refused. She would say that that was his right." "The policy was to lock the brakes and secure the wheelchair to the van. The policy is now to secure the resident, and if he refuses, we're to notify the DON or administrator. We ' re not supposed to move the bus." "I don't recall ever being instructed on what to do when a resident refused to be secured to the van." "Several other residents have refused to let me secure them, because they saw resident #8, and we didn't secure him." 10. During an observation on 2/13/13 at 5:37 p.m., CNA #1 was outside with the surveyor at the facility van. She was asked to demonstrate and explain what occurred with resident #8 on 1/28/13. The following was the observation: CNA #1 started the van. She walked to the back of the van and opened the doors from the inside, and then lowered the lift to the ground. "I did this before I went inside to get him. I got resident #8, placed him on the lift, and put the belt behind his chair. I stood behind resident #8. When we got up to the van, I released the belt and wheeled him into the van. I took him to the spot where I could secure him. He wanted to sit behind the back seat. I placed him behind the back seat. He grabbed the handle on the back of the seat. I removed one of the security belt brackets from the floor so I could put his chair in. I went and sat in the driver's seat, closed the front door, and released the brake. I saw his arms in the air. I then heard him fall. I put the brake on, released my belt, and went back to him. He said his shoulder hurt. I called the facility, and they sent CNA #2. Resident #8 was lying on his back, with his wheelchair tipped over. He told me and CNA #2 that he hit his head. We checked his head. CNA #2 placed his wheelchair behind the back seat. " When asked by the surveyor multiple times, CNA #1 repeatedly said, "We did not secure resident #8's wheelchair to the van. CNA #2 stood behind the wheelchair holding on to it with one hand and holding on to the seat with the other hand. CNA #2 was not buckled. He was standing behind resident #8." CNA #1 said that she and CNA #2 transported resident #8 in his wheelchair via the van to the nursing home without his wheelchair being secured to the van. Upon observation of the inside of the facility van, it was noted that there were large metal brackets sticking up out of the floor of the van. These brackets were toward the back of the van, which would have been behind where resident #8 fell . 11. Upon review of CNA #1's undated written witness statement, the following was noted: "When resident #8 came out of the door from [MEDICAL TREATMENT] he was dozing off. I got him on our bus, as always, he refused to be tied or buckled up. He would say they always had let him ride that way before, and that's how he wanted to be. When he was in his spot I went to the driver seat and buckled up. When I was taking off the hand brake, I looked in the rear mirror and saw him like if he had gotten scared. I saw him raise his arms up over his head, and that's something he would always do, and would have to ask him constantly to wake up and hold on to chair. The next thing I heard was a thump. I looked back and saw him on the floor. Put handbrake on again, unbuckled myself and went to him. Asked him if he was hurting and he said not really, but he had his eyes closed at all times. Called the nursing home and ADON #2 answered phone. Told what happened and asked if she could send someone or if she wanted to check him before we got him up. She sent CNA #2. When he got there, he and I lifted resident #8 up with the wheelchair. CNA #2 rode back to the nursing home with us so he could hold him (resident #8). CNA asked him if he was hurting. He did say his head. There was a green chair cushion and half his head was on it. Also mentioned his left shoulder was hurting. His left side landed on his cloth bag with his blanket he would take to [MEDICAL TREATMENT]." 12. Upon review of CNA #2's undated written witness statement, the following was noted: "When I was told by ADON #2 that CNA #1 needed help with resident #8, that he fell down, I drove over where he fell and saw resident #8 on the floor on his back. I asked what happened. He said he fell back from his chair. I also asked what part hurt, and he said his shoulder and his head. So me and CNA #1 helped pick him up off the floor using the gait belt and the wheelchair to raise him up. After we did we made sure that he was secured and drove off back to the nursing home." 13. Upon review of a 2/11/13 facility statement concerning resident #8's 1/28/13 fall signed by the administrator and the DON, it was noted that the 3rd and 4th paragraphs were documented as the following: "As to why resident #8 was not secured safely: Resident #8 refused all seatbelt and wheel belts which would have locked him into place. Instead, he preferred to ride in a wheelchair pushed up close against the last seat so he could hold on and keep himself from falling forward. 'He did not trust the safety belts,' according to CNA #1. CNA #1 called ADON #2 and asked for a nurse to come assess. ADON #2 sent CNA #2 to assist CNA #1. CNA states there was no blood or sign of injury." 14. Upon review of the undated facility Transportation Policy and Procedure for Center-Based Vehicle, it was noted that there were no directions or instructions pertaining to how to transport residents in the facility van, including those who sit in a wheelchair. 15. Upon review of a typed list given to the surveyor on 2/13/13 by the DON, the following was noted: 1. Policy of transferring residents in van with wheelchair: The policy and procedure that was previously provided is all we have regarding van use and associated van policies. 16. It was noted upon record review of the resident roster Daily Census given to the surveyor by the administrator on 2/12/13 that there were 91 residents in the facility that utilized wheelchairs. 17. During an interview with ADON #1 on 2/19/13 at 3:45 p.m., ADON #1 said that there were 59 residents living in the facility who were at risk for falls. The IJ was called and facility administration was notified on 2/13/13 at 6:00 p.m. Facility's Plan to Remove Immediate Jeopardy: a) The Administrator and DON were in-serviced by the Regional Nurse Consultant on 2/13/13 on what constitutes neglect and reporting neglect in a timely manner. b) All current van drivers were educated on the Van Driver Policy Addendum, which explains how to transport residents in wheelchairs. The van drivers were also instructed on what to do if a resident refuses to have his/her wheelchair secured to the van. c) All staff has or will be re-educated on the Abuse Prohibition Policy and Procedures. They will be instructed on how to report abuse/neglect. d.) Nurses were and will be re-educated on how to complete an incident form with emphasis on how to review events of accidents, how to initiate an investigation, and hoe to initiate action to prevent future incidents. e.) All residents are in the process of being re-assessed for fall risk. Those at high risk will have identifiers put in place. The CNA assignment sheet will reflect those residents at risk for falls. residents deemed high risk for falls will have care plans that are individualized for that specific resident. f) The DON will review all incidents in daily stand-up meeting with other facility andministrative staff and therapy to ascertain completeness and whether preventative measures were implemented. g) Residents that sustain a fall will be screened by a therapist to assist with formulating preventative measures. h) The ADON or Case Mix Manager will update care plans and nurse aide assignment sheets to reflect protective measures put in place to prevent future injuries. i) The ADON will ensure that nurse aides receive communication of preventative measures. j) Licensed nurses have been in-serviced by the DON starting 2/11/13 that they are to assess all residents who experience falls regardless of the location at the time of the incident before a resident is transferred or lifted. All staff have been instructed that after an incident no resident is to be moved until a licensed nurse deems appropriate k) The administrator will spot check transports randomly for such safety compliance weekly x4 and report to QA committee monthly x3 until deemed resolved and randomly thereafter. All staff has or will be in-serviced before their next shift on assessing residents after an incident whether on site or off the premises or in the transport van by the Administrator or DON. The DON will investigate all incidents for such compliance and address staff out of compliance and report to QA monthly x3 until deemed resolved and randomly thereafter On 2/14/13, the surveyor confirmed through interviews with the DON, ADON #1, CNA #4, LVN #1, and LVN #2 and record reviews of facility in-services: a) In-service had begun pertaining to reporting abuse. neglect, and exploitation b) In-service had begun pertaining to making sure a resident who has had a fall is not to be moved until an LNN or RN assesses the resident. This in-service pertained to incidents in the facility, off the premises, or in the van c) All nurse managers were in-serviced on care plans, Fall Management-Plan of Care forms, Fall Risk Assessments, weekly hall checks to ensure compliance with fall interventions, and the company fall policy and procedures. d) In-service had begun pertaining to reporting neglect to the administrator immediately, and facility investigation procedures. e) All van drivers were in-serviced about the addendum to the van driver policy. This addendum described the procedures that should take place when transporting a resident who utilizes a wheelchair in the facility transportation van, including the following: Pulling van close to exit door. Bring resident out to van. Lower the lift til it is flat to the ground. Place resident on lift with legs facing away from the van. Lock the wheels in place. Put the belt across the lap of the resident and secure it by clicking it on the other side. Raise the lift while standing behind the resident. Once the lift is up, gently roll the resident back into the van. Situate the resident between the four safety harness buckles on the floor. Lock the resident's wheelchair. Pull the strap from the harness buckle on the floor to the frame of the wheelchair. All four straps must hook into the frame. Move the chair back and forth to ensure the straps are tight and chair is not going to move. As an extra precaution pull the safety belt down which is attached to the back frame of the van and pull it across the resident and click it into place. If by some chance the resident refuses to be safely transported, such as refusing safety belts, then the van is not to move. Notify your administrator or DON immediately and they will coordinate an intervention with you. THE VAN DOES NOT MOVE UNLESS EVERYONE IS SAFELY SECURED. CNA #4, who is also a transportation aide, verbalized understanding of the above policy. The Immediate Jeopardy was lifted. The administrator and corporate consultant were notified of this on 2/14/13 at 2:35 p.m. The facility remained out of compliance at the level of pattern with actual harm that is not immediate jeopardy because they had not yet monitored or evaluated the action plan for effectiveness.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that each resident was free from accidents. 1. The facility failed to ensure that 5 (residents 8, 9, 10, 11 and 12) of the 59 residents at risk for falls were protected from accidents. Residents' care plans documented that the facility should follow the facility fall protocol. This was not followed, resulting in residents 8, 9, 10, 11, and 12 falling multiple times. 2. The facility failed to ensure that 1 of 7 residents (#8) who sit in a wheelchair was appropriately secured in a transportation van while being transported to and from the facility. Resident #8 was placed in his wheelchair behind the back seat of the van, and his wheelchair was not secured to the van floor. Resident #8 fell backward and hit the van floor. Resident #8 had a history of [REDACTED]. No interventions were put into place prior to his fall to ensure that resident #8 was safe during facility van transportation. Resident #8 was then transported back to the facility while his wheelchair was not secured to the van floor. 3. An immediate jeopardy was identified on 2/13/13. While the IJ was removed on 2/14/13, the facility remained out of compliance at a pattern of no actual harm with a potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. 4. The practice of keeping residents free from neglect could affect 59 of 115 residents living in the facility who are at risk for falling. The failure to prevent neglectful behavior could cause serious injury to a resident. The practice of not securing a resideny's wheelchair to the van floor could affect 1 (resident #8) of the 7 sampled residents (resident #1, 2, 3, 4, 6, 7, and 8) who were transported in wheelchairs via the facility van. The failure to secure a resident's wheelchair to the van floor could cause serious injury to a resident. The findings include: 1. Resident #8 a) Upon review of resident #8's clinical record, it was determined that he was a [AGE] year old male with a history of double below-the-knee amputations. He was diagnosed with [REDACTED]. He utilized a regular wheelchair and an electric wheelchair for means of locomotion. b) Upon review of resident #8's 1/28/13 facility Incident/Accident report, it was noted that resident #8 "fell back in wheelchair while being transported in bus." It was also noted that "resident fell asleep when in wheelchair-fell backward." Interventions were listed as: "Safety belts during transfers- resdent frequently refuses." c) Upon review of resident #8's facility Fall Risk Assessment, the last four scores between 2/26/12 and 12/6/12 were 11, 12, 14, and a 15. The facility assessment for fall risk indicates that a total score of 10 or higher may represent high risk. d) Upon review of resident #8's 12/13/12 care plan it was noted that "Resident #8 has the potential for falls related to bilateral BKA (Below the Knee amputation) and weakness." The goals listed for resident #8 were to be free from falls during the next 90 days, and for side effects of resident #8's medications to be reduced within the next 90 days. Interventions were listed as the following: 1. Anticipate and meet resident #8's needs. 2. Be sure resident #8's call light is within reach and encourage him to use it for assistance as needed. 3. Follow facility fall protocol. There were no other intervention put in place in the written care plan to prevent further falls. e) Upon review of resident #8's 12/23/12 14-day MDS, it was noted that resident #8 was not steady for surface-to surface transfers, and required staff assistance for stablization. Resident #8 was at risk for falls, and had experienced 1 fall with an injury and 1 fall without injury since the last review. It was also noted that resident #8 required staff assistance x1 for bed mobility, transfers, personal hygiene, and bathing. He required staff assistance x2 with dressing. The MDS described resident #8 as having ROM impairment to bilateral upper and lower extremities. f) Upon review of the 06/11 facility's revised Fall Management System policy, the following was noted: Procedure B.2. The identifying factors will be provided to staff, and the individualized care plan will be developed with appropriate goals and interventions utilizing the Fall Management-Plan of Care form. D.1. A licensed nurse will complete an Incident/Accident Report after each fall. 2. The licensed nurse will document the fall on the nurse's notes of the medical record. 3. Documentation in the nurse's notes will reflect any intervention imposed by the attending physician or their agent. 8. An Administrative nurse will ensure that the resident's plan of care is revised to reflect each fall and interventions that were implemented. 9. An Administrative nurse will ensure that the nursing assistant's assignment sheet reflects interventions to prevent further falls and/or decrease potential for injury from a fall. E.1. The licensed nurse will initiate the Incident/Accident investigation immediately after each fall utilizing the "Investigation Follow-up" guideline. 2. Interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable. g) Upon review of resident #8's record, it was noted that he had experienced 5 falls between 11/25/13 and 1/2/13. The falls on 11/25/13 and 12/16/13 occurred outside of the facility while resident #8 was transporting himself via an electric wheelchair. According to facility documentation, no interventions were put into place to prevent these falls from happening again. The facility's Fall Management-Plan of Care form was not completed. Resident #8 fell out of his wheelchair while transferring himself from wheelchair to bed on 12/30/12. No nursing interventions were put into place. No facility Falls Management-Plan of Care form was completed. Resident fell again out of his chair in his room on 12/31/12. Nursing interventions were put into place via the facility's Falls Management- Plan of Care form, such as changing the resident's bed. Resident #8 fell when his wheelchair tipped over in his room on 1/2/13. Per facility documentation, no interventions were put into place. There is a date written on the facility's 12/31/12 Falls Management- Plan of Care form, but there is no documentation as to what that date was for, or who wrote the date. ADON #1 said she wrote the date on the form. h) Upon review of CNA #1's undated written witness statement, the following was noted: "When resident #8 came out of the door from dialysis he was dozing off. I got him on our bus, as always, he refused to be tied or buckled up. He would say they always had let him ride that way before, and that's how he wanted to be. When he was in his spot I went to the driver seat and buckled up. When I was taking off the hand brake, I looked in the rear mirror and saw him like if he had gotten scared. I saw him raise his arms up over his head, and that's something he would always do, and would have to ask him constantly to wake up and hold on to chair. The next thing I heard was a thump. I looked back and saw him on the floor. Put handbrake on again, unbuckled myself and went to him. Asked him if he was hurting and he said not really, but he had his eyes closed at all times. Called the nursing home and ADON #2 answered phone. Told what happened and asked if she could send someone or if she wanted to check him before we got him up. She sent CNA #2. When he got there, he and I lifted him up with the wheelchair. CNA #2 rode back to the nursing home with us so he could hold him (resident #8). CNA asked him if he was hurting. He did say his head. There was a green chair cushion and half his head was on it. Also mentioned his left shoulder was hurting. His left side landed on his cloth bag with his blanket he would take to dialysis." i) Upon review of resident #8's clinical record, it was noted that he was assessed on 1/28/13 by a licensed nurse upon return to the nursing home. Resident #8 complained of back and head pain. The doctor was notified, and orders were received for a lumbar x-ray, and to send resident #8 to the hospital for a CT if there were noted changes in LOC. Neuro-checks were implemented, and were documented as normal. The lumbar x-ray was completed. j) During an interview with ADON #1 on 2/13/13 at 10:28 a.m., it was determined that resident #8 was in the facility van on 1/28/13. His chair was not secured to the van floor, and he fell backward and hit the van floor. "I expect that all wheelchairs should be secured to the van, and all residents should be buckled. CNA #1 should have secured resident #8's wheelchair to the van. If resident #8 was refusing to be secured, CNA #1 should have called the administrator." During an interview at 2:17 p.m., ADON #1 said that she didn't know the facility procedures to follow if the resident refused to be secured. "If a resident falls, the nurse does the initial assessment. The resident is not to be picked up off the floor unless the nurse is there." After looking at Resident #8's care plan, ADON #1 said that there were not enough goals and intervention needed to prevent falls for the resident. k) During an interview with ADON #2 on 2/13/13 at 10:36 a.m., ADON #2 said, "Resident #8 would argue, but he would let them secure him. He was scared of falling, and said that staff didn't lock his brakes, and he would lean backward. So, he liked to be by the back seat so he could hold on to it. I told CNA #1 that if resident #8 refused, she needed to tell the nurse so she could document." "CNA #1 called and told me that she was taking off, and resident #8 fell backwards and hit his head. I sent CNA #2 to go help lift resident #8 up." "At about 1:30 p.m., resident #8 told me that he had back pain and a head ache. He said that CNA #1 didn't lock the brakes. I know CNA #1 should have secured resident #8 in the van. If he was being stubborn, she should have refused to take him." In an interview at 2:22 p.m., ADON #2 said, "Most of the time resident #8 refused to be secured to the van. I told the van drivers (CNA #1 and CNA #3) to notify the nurse or an ADON when any resident refused to be secured. They were supposed to make the notification before leaving in the van." "If a resident falls, the nurse is supposed to do the initial assessment. The resident should not be picked up without the nurse being there. l) During an interview with CNA #1 on 2/13/13 at 11:37 a.m., CNA #1 said, " Once I got resident #8 on the van, I tried to secure his chair to the van. He refused. He said he felt safer by the back seat so he could hold on to it. He has let us secure him before on 1/24/13. He was upset, but he let us. I placed him by the back seat. I locked his wheels. I went and sat in my seat, and put my seatbelt on. I reached for the hand brake. I looked in the mirror, and saw him raise his hands, as if he was dreaming. He had done this before. He was sleepy after dialysis, and we had to talk to him to keep him awake. I then heard a noise. He had fallen backwards. I went to check on him. I asked him if he was okay. He said he didn't know. I called the facility and ADON #2 sent CNA #2 to help me. After we got him up, he said his head hurt from hitting it. He also complained of pain in his left shoulder." "It's company policy to make sure the wheelchair is secure before we go to an appointment. I should not have went to the driver's seat unless he was secured. I should have called one of the ADONs and told them about the situation." "I've transported resident #8 several times without securing his wheelchair. I told ADON #2 and the social worker. The social worker said she would talk to him." m) During an interview with CNA #3 on 2/13/13 at 2:48 p.m., CNA #3 said, "Probably 80-90% of the time resident #8 refused to have his wheelchair secured to the van. The last time I transported him was on 1/26/13 (Saturday) to UMC. I had no issues with him. He let me secure his wheelchair to the van. He has refused before, but then later let me secure hs wheelchair." "If he refused, I would call the ADON and report it to her; I was told by the ADON to notify an ADON or nurse of any refusal." "I have transported him before without his chair being secured to the van. He would sit in the back of the van. We would lock the brakes and he would hold on to the back of the seat. Holding on to the seat was his only security." CNA #3 said that she had not received any prior in-servicing pertaining to transporting residents in wheelchairs. "The policy is to secure all residents' wheelchairs to the van. If a wheelchair is properly secured to the van, there is no way possible for it to tip over backwards." n) During an interview with CNA #4 on 2/13/13 at 2:42 p.m., CNA #4 said that she had transported resident #8 before via the facility van. "He refused to let me secure his wheelchair to the van. I always transported resident #8 without his wheelchair being secured to the van. He would sit between the back seats and hold on to the handle. Sometimes he would sit behind the seat and hold on to it. The brakes to his wheelchair were locked." "Upon return to the facility, I would tell a nurse that he refused. She would say that that was his right." "The policy was to lock the brakes and secure the wheelchair to the van. The policy is now to secure the resident, and if he refuses, we're to notify the DON or administrator. We're not supposed to move the bus." "I don't recall ever being instructed on what to do when a resident refused to have his wheelchair secured to the van." "Several other residents have refused to let me secure them, because they saw resident #8, and we didn't secure him." o) During an observation on 2/13/13 at 5:37 p.m., CNA #1 was outside with the surveyor at the facility van. She was asked to demonstrate and explain what occurred with resident #8 on 1/28/13. The following was the observation: CNA #1 started the van. She walked to the back of the van and opened the doors from the inside, and then lowered the lift to the ground. "I did this before I went inside to get him. I got resident #8, placed him on the lift, and put the belt behind his chair. I stood behind resident #8. When we got up to the van, I released the belt and wheeled him into the van. I took him to the spot where I could secure him. He wanted to sit behind the back seat. I placed him behind the back seat. He grabbed the handle on the back of the seat. I removed one of the security belt brackets from the floor so I could put his chair in. I went and sat in the driver's seat, closed the front door, and released the brake. I saw his arms in the air. I then heard him fall. I put the brake on, released my belt, and went back to him. He said his shoulder hurt. I called the facility, and they sent CNA #2. Resident #8 was lying on his back, with his wheelchair tipped over. He told me and CNA #2 that he hit his head. We checked his head. CNA #2 placed his wheelchair behind the back seat. " When asked several times, CNA #1 repeatedly said, "CNA #2 did not secure resident #8's wheelchair to the van. CNA #2 stood behind the wheelchair holding on to it with one hand and holding on to the seat with the other hand. CNA #2 was not buckled. He was standing behind resident #8." CNA #1 said that she and CNA #2 transported resident #8 in his wheelchair via the van to the nursing home without his wheelchair being secured to the van. Upon observation of the inside of the facility van, it was noted that there were large metal brackets sticking up out of the floor of the van. These brackets were toward the back of the van, which would have been behind where resident #8 fell . p) Upon review of a 2/11/13 facility statement concerning resident #8's 1/28/13 fall signed by the administrator and the DON, it was noted that the 3rd and 4th paragraphs were documented as the following: " As to why resident #8 was not secured safely: Resident #8 refused all seatbelt and wheel belts which would have locked him into place. Instead, he preferred to ride in a wheelchair pushed up close against the last seat so he could hold on and keep himself from falling forward. 'He did not trust the safety belts,' according to CNA #1. CNA #1 called ADON #2 and asked for a nurse to come assess. 2. Resident #9 a) Upon review of resident #9's care plan, the following interventions were noted: anticipate and meet needs, and call light within reach and encourage use of. There were no other interventions in the written care plan to prevent falls. is chair fell backwards and hit the floor. Thye practiceTThThe 12/5/12 quarterly MDS documented that there had been no falls since the last review, although resident #9 fell on [DATE]. It was also noted on the MDS that resident #9 was not steady when moving from seated to standing position, when walking, when turning around, when moving on and off the toilet, or with surface-to-surface transfers, and required staff assistance with stablization. Resident #9 required staff assistance x1 with all ADL's except for eating and locomotion. According to the MDS, resident #9's [DIAGNOSES REDACTED]. Resident #9's last four Fall Risk Asessment scores were 12, 19, 13, and 19. A total score of 10 or higher may represent high risk. Upon record review of resident #9's clinical record, it was noted that she had fallen five times between 3/30/12 and 10/1/12. Resident #9 slid to the floor from a sitting position twice, and fell while standing three times. The facility's Fall Management- Plan of Care form was completed after the 3/30/12 fall. All interventions were checked off. On the facility's Investigation Follow-Up form, interventions were listed as "tell resident to call for help, and keep eyes on her." Per facility documentation, no nursing interventions were put into place after the 6/12/12 fall and after the 10/1/12 fall, such as PT/OT evaluations, assessment of current wheelchair, the need for assistive devices, or encouraging the resident to ask for assistance before standing. These interventions could assist in preventing further falls. 3. Resident #10 a) During an interview with resident #10 on 2/14/13 at 11:30 a.m., resident #10 said that she had fallen several times. "I fell in the dining room when getting up to get a cup of coffee. There was a wet spot on the floor. I slipped on the spot and fell to the floor. They took me to the ER." Resident #10 said that she felt that the fall in the dining room could have been prevented. "They could have served me coffee instead of me getting it. I didn't ask them to get it because they get mad and make funny faces when I ask. The floor should have been dry." b) There were no facility care plans pertaining to falls for resident #10. This was verified by ADON #1 on 2/14/13 at 7:45 a.m. The 12/20/12 quarterly MDS documented one fall with injury since the last assessment. It was noted in the MDS that resident #10 was unsteady during transitions and walking, but could stabalize without staff assistance. The last three facility Fall Risk Assessment scores for resident #10 were 9, 17, and 17. A total score of 10 or higher may represent high risk. According to the MDS, resident #10's [DIAGNOSES REDACTED]. Upon review of resident #10's record, it was noted that she had fallen 4 times between 8/4/12 and 9/1/12. According to facility documentation, no nursing interventions were put into place after any of the four falls, such as encouraging staff for assistance when picking objects off of the floor, the use of an assistive device to pick objects off of the floor, encouraging the resident to ask for assistance when making her bed and when transferring to the bed, and PT/OT evaluation for strengthening and need for staff assistance. These interventions could assist in preventing future falls. The fall on 8/4/12 resulted in a left clavicle fracture. She fell while bending over to pick an object off of the floor. Resident #10's other falls occurred during transfers and making her bed.There was no facility Fall Management- Plan of Care form completed for resident #10. This was verified by ADON #1 on 2/14/13 at 7:45 a.m. 4. Resident #11 a) Upon review of resident #11's care plan, the following interventions were noted: ensure proper footwear, follow facility fall protocol, continue interventions, and a PT consult. No other interventions such as bed and chair alarms, floor mats, encouarging staff assistance for transfers and locomotion were put in place in the written care plan to prevent further falls. The 1/2/13 quarterly MDS documented 2 falls with injury and 2 falls without injury since the last review. It was noted on the MDS that resident #11 required staff assistance x 2 for bed mobility, transfers, and toilet use. He required staff assistance x1 with all other ADLs except for eating. Per the MDA, resident #11 was unsteady, and required staff assistance for stabalization with moving from seated to standing position, walking, turning around, and surface to surface transfers. Review of resident #11's last 3 Fall Risk Assessment scores were 22, 24, and 22. A total score of 10 or higher may represent high risk. According to the MDS, resident #11's [DIAGNOSES REDACTED]. Upon review of resident #11's clinical record, it was noted that he had fallen 8 times between 2/19/12 and 8/11/12. According to facility documentation, no nursing interventions were put in place after 5 of these falls. Three of the falls included the resident falling from the bed, and one of the falls involved falling out of a chair. Interventions such as encouraging the use of a call light and obtaining assistance were not implemented after these falls. Resident #11 fell in the shower while the CNA had turned to get his pants. Interventions such as keeping eyes on the resident at all times, keeping supplies within reach, and encouraging the resident to stay seated until assisted were not implemented to prevent a further fall of this type from occuring again. Up through the 8/11/12 fall, there had been no facility Falls Management- Plan of Care form completed. Resident #11 fell four more times between 11/6/12 and 12/25/12. There were no interventions put in place following the 11/6/12 fall, in which resident #11 fell from the bed. A facility Falls Management-Plan of Care form was completed with interventions on 11/2/12, and was updated on 11/15/102. Interventions such as hi/low bed, floor mats, wheelchair, and PT/OT evaluation were implemented. 5. Resident #12 a) Upon review of resident #12 ' s care plan, the following interventions were documented: Anticipate needs, call light within reach, and encourage use of. There were no other interventions put in place in the written care plan to prevent further falls. The 1/1/13 quarterly MDS documented 2 falls without injury since the last review. Upon review of the MDS, it was noted that resident #12 required staff assistance x2 with bed mobility, transfers, and toilet use. She required staff assistance x 1 with all other ADLs. Resident #12 was unsteady, and required staff assistance for stabalization with moving from seated to standing position and surface to surface transfers. She also had ROM impairments to bilateral upper and lower extremities. According to the MDS, resident #12's disgnoses included Huntington's Disease, anxiety, depression, and schizophrenia. Upon review of resident #12's clinical record, it was noted that she had fallen 19 times between 1/28/12 and 12/20/12. There were no interventions put in place after the 3/20/12, 3/23/12, 5/15/12and 9/1/12 falls. Resident #12 fell out of bed 11 times. There were no interventions put in place after three of these falls. Resident #12 fell out of a chair three times. Interventions were not put in place after one of these falls. One of these falls occurred in the dining room, and interventions put in place included high/low bed and floor mats, which are both in the resident's bedroom. Resident #12 fell five times while walking. Interventions after these falls including medicinal evaluation, high/low bed, floor mats, 1/2 side rails, and bed/chair alarms. The interventions for the majority of the falls were the same, such as alarms, side rails, high/low bed, and floor mats. These interventions were not appropriate for the falls that occurred in the didning room or hallway. "Closer monitoring" was only implemented after the fall out of the chair in the dining room. Up through the 5/4/12 (10th fall) fall, there had been no Falls Management- Plan of Care form completed. This form was completed on 5/8/12, and updated once on 12/21/12. 6. Upon review of the undated facility Transportation Policy and Procedure for Center-Based Vehicle, it was noted that there was no directions or instruction pertaining to how to transport residents in the facility van, including those who sit in a wheelchair. 7. Upon review of a typed list given to the surveyor on 2/13/13 by the DON, the following was noted: 1. Policy of transferring residents in van with wheelchair: The policy and procedure that was previously provided is all we have regarding van use and associated van policies. 8. During an interview with ADON #1 on 2/19/13 at 3:45 p.m., ADON #1 said that there were 59 residents living in the facility who were at risk for falls. The IJ was called and facility administration was notified on 2/13/13 at 6:00 p.m. Facility's Plan to Remove Immediate Jeopardy: a) All current van drivers were educated on the Van Driver Policy Addendum, which explains how to transport residents in wheelchairs. The van drivers were also instructed on what to do if a resident refuses to have his/her wheelchair secured to the van. b.) Nurses were and will be re-educated on how to complete an incident form with emphasis on how to review events of accidents, how to initiate an investigation, and hoe to initiate action to prevent future incidents. c.) All residents are in the process of being re-assessed for fall risk. Those at high risk will have identifiers put in place. The CNA assignment sheet will reflect those residents at risk for falls. residents deemed high risk for falls will have care plans that are individualized for that specific resident. d) The DON will review all incidents in daily stand-up meeting with other facility administrative staff and therapy to ascertain completeness and whether preventative measures were implemented. e) Residents that sustain a fall will be screened by a therapist to assist with formulating preventative measures. f) The ADON or Case Mix Manager will update care plans and nurse aide assignment sheets to reflect protective measures put in place to prevent future injuries. g) The ADON will ensure that nurse aides receive communication of preventative measures. h) Licensed nurses have been in-serviced by the DON starting 2/11/13 that they are to assess all residents who experience falls regardless of the location at the time of the incident before a resident is transferred or lifted. All staff have been instructed that after an incident no resident is to be moved until a licensed nurse deems appropriate i) The administrator will spot check transports randomly for such safety compliance weekly x4 and report to QA committee monthly x3 until deemed resolved and randomly thereafter. All staff has or will be in-serviced before their next shift on assessing residents after an incident whether on site or off the premises or in the transport van by the Administrator or DON. The DON will investigate all incidents for such compliance and address staff out of compliance and report to QA monthly x3 until deemed resolved and randomly thereafter On 2/14/13,at 2:35 p.m., the surveyor confirmed through interviews with the DON, ADON #1, CNA #4, LVN #1, and LVN #2 and record reviews of facility in-services: a) All van drivers were in-serviced about the addendum to the van driver policy. This addendum described the procedures that should take place when transporting a resident who utilizes a wheelchair in the facility transportation van, including the following: Pulling van close to exit door. Bring resident out to van. Lower the lift til it is flat to the ground. Place resident on lift with legs facing away from the van. Lock the wheels in place. Put the belt across the lap of the resident and secure it by clicking it on the other side. Raise the lift while standing behind the resident. Once the lift is up, gently roll the resident back into the van. Situate the resident between the four safety harness buckles on the floor. Lock the resident's wheelchair. Pull the strap from the harness buckle on the floor to the frame of the wheelchair. All four straps must hook into the frame. Move the chair back and forth to ensure the straps are tight and chair is not going to move. As an extra precaution pull the safety belt down which is attached to the back frame of the van and pull it across the resident and click it into place. If by some chance the resident refuses to be safely transported, such as refusing safety belts, then the van is not to move. Notify your administrator or DON immediately and they will coordinate an intervention with you. THE VAN DOES NOT MOVE UNLESS EVERYONE IS SAFELY SECURED. CNA #4, who is also a transportation aide, verbalized understanding of the above policy. b) In-service had begun pertaining to making sure a resident who has had a fall is not to be moved until an LNN or RN assesses the resident. This in-service pertained to incidents in the facility, off the premises, or in the van. LVN #1 and LVN #2 verbalized understand of the in-services provided. c) All nurse managers were in-serviced on care plans, Fall Management-Plan of Care forms, Fall Risk Assessments, weekly hall checks to ensure compliance with fall interventions, and the company fall policy and procedures. ADON #1 and the DON verbalized understanding of this in-service. ON 1/14/13 at 2:35 p.m., the administrator and corporate consultant were notified the Immedidiate Jeopardy was lowered to a level of no actual harm with a potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions.

Based on observation, interview, and record review it was determined that the facility failed to develop and implement its written policies and procedures that prohibit neglect for 5 (residents # 8, 9, 10, 11, and 12) of the 5 sampled residents who were at risk for falls.. 1. Resident #8 experienced 6 falls between [DATE] and [DATE] with interventions put i n place only after the [DATE] and [DATE] falls.. The last fall occurred while the resident was in his wheelchair sitting in the facility transportation van and his was not secured to the van floor, nor was he buckled in. He fell backwards and hit the van floor. The resident expired two days later. Residents #9, 10, 11, and 12 experienced multiple falls in 2012. There were multiple times where interventions were not put in place, and the facility fall policy protocol was not followed. 2. The facility failed to ensure that 5 (residents 8, 9, 10, 11 and 12) of 5 sampled residents who had multiple falls were protected from accidents by not following the plan of care. Residents' care plans documented that the facility should follow the facility fall protocol. This was not followed, resulting in residents 8, 9, 10, 11, and 12 falling. The failure to prevent neglectful behavior could cause serious injury to a resident. 3. The facility failed to ensure that 1 (resident #8) of 7 sampled residents who required the use of a wheelchair was appropriately secured in a facility transportation van that can accommodate wheelchairs while being transported to and from the facility. Resident #8 was placed in his wheelchair on the van. His chair was placed behind the back seat of the van, and his wheelchair was not secured to the van floor. Resident #8 fell backward and hit the floor. Resident #8 was transported to the facility while his wheelchair was not secured to the van floor. 4. The facility failed to develop written procedures for transporting residents in a facility vehicle. The current facility Transportation Policy and Procedure for Center-Based vehicle policy did not address how to safely transport residents in the facility van who sit in wheelchairs. 5. The facility failed to provide a resident assessment by a licensed nurse for a resident (resident #8) who sustained a fall while sitting in his wheelchair in the facility van. Rather than sending a licensed nurse, CNA #2 was sent to assist CNA #1 and resident #8. Resident #8 was then transported to the facility, and was then assessed by a nurse. 6. An immediate jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a pattern of no actual harm with a potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. 7. The practice of not putting interventions in place after resident falls could affect 5 of the 59 residents in the facility who are at risk for falls. The failure to put intervention is place after a resident falls could allow the same situatiojn to occur again, which could end with an injury for the resident. The practice of keeping residents free from neglect could affect 59 of 115 residents living in the facility who are at risk for falling. The failure to prevent neglectful behavior could cause serious injury to a resident. The practice of not securing a resident's wheelchair to the floor could affect 1 (resident #8) of the 7 sampled residents (resident #1, 2, 3, 4, 6, 7, and 8) who were transported in wheelchairs via the facility van. The failure to secure a resident's wheelchair to the van floor could cause an accident to occur, which could cause serious injury to a resident. The practice of not having facility policies/instructions for transporting residents in wheelchairs could affect the 91 residents living in the facility who sit in wheelchairs. The failure to have policies/procedures in place could allow facility staff to follow unsafe procedures, which could cause a serious injury for a resident. The failure to have a nurse assess a resident after a fall/accident could cause an injury to go unnoticed, which could cause further complications for the resident. The findings include: 1. Upon review of the facility ,[DATE] revised Abuse Prohibition Policy and Procedures, the following was noted: Neglect- A deprivation of life ' s necessities of food, water, or shelter, or a failure of an individual to provide services, treatments, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs. VII. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies. B. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON. C. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge. D. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. J. The results of all investigations will be reported to the administrator or designated representative, and other officials in accordance with state laws (including the state survey and certification agency) within 5 working days of the incident. K. The administrator or designee will analyze occurrences to determine what changes, if any, are needed to policies and procedures to prevent further occurrences. 2. Upon review of the undated facility Transportation Policy and Procedure for Center-Based Vehicle, it was noted that there were no directions or instructions pertaining to how to transport residents in the facility van, including those who sit in a wheelchair. 3. Upon review of a typed list given to the surveyor on [DATE] by the DON, the following was noted: 1. Policy of transferring residents in van with wheelchair: The policy and procedure that was previously provided is all we have regarding van use and associated van policies. 4. Upon review of the ,[DATE] facility revised Fall Management System policy, the following was noted: Procedure B.2. The identifying factors will be provided to staff, and the individualized care plan will be developed with appropriate goals and interventions utilizing the Fall Management-Plan of Care form. D.1. A licensed nurse will complete an Incident/Accident Report after each fall. 2. The licensed nurse will document the fall on the nurse ' s notes of the medical record. 3. Documentation in the nurse ' s notes will reflect any intervention imposed by the attending physician or their agent. 8. An Administrative nurse will ensure that the resident ' s plan of care is revised to reflect each fall and interventions that were implemented. 9. An Administrative nurse will ensure that the nursing assistant ' s assignment sheet reflects interventions to prevent further falls and/or decrease potential for injury from a fall. E.1. The licensed nurse will initiate the Incident/Accident investigation immediately after each fall utilizing the "Investigation Follow-up" guideline. 2. Interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable. 5. Resident #8 a) During an interview with ADON #1 on [DATE] at 10:28 a.m., it was determined that resident #8 was in the facility van on [DATE]. His chair was not secured to the van floor, and he fell backward and hit the van floor. ADON #1 said, "I expect that all wheelchairs should be secured to the van, and all residents should be buckled. CNA #1 should have secured resident #8's wheelchair to the van. If resident #8 was refusing to be secured, CNA #1 should have called the administrator." During an interview at 2:17 p.m., ADON #1 said that she didn't know the facility procedures to follow if the resident refused to be secured. "If a resident falls, the nurse does the initial assessment. The resident is not to be picked up off the floor unless the nurse is there." After looking at Resident #8's care plan, ADON #1 said that there were not enough goals and intervention needed to care for the resident. b) During an interview with ADON #2 on [DATE] at 10:36 a.m., ADON #2 said, "Resident #8 would argue, but he would let them secure him. He was scared of falling, and said that staff didn't lock his brakes, and he would lean backward. So, he liked to be by the back seat so he could hold on to it. I told CNA #1 that if resident #8 refused, she needed to tell the nurse so she could document." "CNA #1 called and told me that she was taking off (leaving the facility) , and resident #8 fell backwards and hit his head. I sent CNA #2 to go help lift resident #8 up." "At about 1:30 p.m., resident #8 told me that he had back pain and a head ache. He said that CNA #1 didn't lock the brakes. I know CNA #1 should have secured resident #8 in the van. If he was being stubborn, she should have refused to take him." In an interview at 2:22 p.m., ADON #2 said, "Most of the time resident #8 refused to be secured to the van. I told the van drivers (CNA #1 and CNA #3) to notify the nurse or an ADON when any resident refused to be secured. They were supposed to make the notification before leaving in the van." "If a resident falls, the nurse is supposed to do the initial assessment. The resident should not be picked up without the nurse being there." c) During an interview with CNA #1 on [DATE] at 11:37 a.m., CNA #1 said, "Once I got resident #8 on the van, I tried to secure his chair to the van. He refused. He said he felt safer by the back seat so he could hold on to it. He has let us secure him before on [DATE]. He was upset, but he let us. I placed him by the back seat. I locked his wheels. I went and sat in my seat, and put my seatbelt on. I reached for the hand brake. I looked in the mirror, and saw him raise his hands, as if he was dreaming. He had done this before. He was sleepy after [MEDICAL TREATMENT], and we had to talk to him to keep him awake. I then heard a noise. I went to check on him. I asked him if he was okay. He said he didn't know. I called the facility and ADON #2 sent CNA #2 to help me. After we got him up, he said his head hurt from hitting it. He also complained of pain in his left shoulder." CNA #1 further said, "It's company policy to make sure the wheelchair is secure before we go to an appointment. I should not have went to the driver's seat unless he was secured. I should have called one of the ADONs and told them about the situation." "I've transported resident #8 several times without securing his wheelchair. I told ADON #2 and the social worker. The social worker said she would talk to him." d) During an interview with CNA #2 on [DATE] at 12:21 p.m., CNA #2 said that he was asked to go help CNA #1 with resident #8. "Resident #8 was in his chair and was on his back. I asked him if he was okay. We picked him up, and he said his back and head hurt. I barely touched the back of his head, and he said that it hurt. When I got there, the chair was not secured to the van. It is facility policy that all residents should be secured to the van before going to an appointment. No matter what, you have to make sure all residents' wheelchairs are secured to the van. In my opinion, he should have been secured to the van, because their safety is what matters. He was very weak." CNA #2 said that the wheelchair was secured to the floor before transporting resident #8 to the facility. e) During an interview with the administrator on [DATE] at 12:40 p.m., he said, "I wasn't called and told about resident #8 ' s accident. I was notified via an incident report. I don't remember when I was told about it. All I remember is that an ADON (I don't remember which one) gave me an incident report. The transportation aide did not secure the resident's wheelchair to the van. It is facility policy to follow state regulations before the van moves. All residents should be secured. The resident refused to be secured. He said he wanted to ride in the back holding on to the seat. He complained of soreness. There were no visual injuries. Staff have been instructed to notify the DON or myself if a resident refuses to be secured. CNA #1 should have called the administrator so we could have gone and helped her." When asked if the wheelchair could have tipped over backward if it had been secured, the administrator said, "If the van would have been moving, and the chair would have been secured, the chair would not have tipped." f) During an interview with the DON on [DATE] at 2:05 p.m., the DON said, "ADON #2 told me that resident #8 had fallen. I found out about it the next day in stand up meeting." The DON said that he was not notified of the fall the day of the fall. "I don't know what procedures were in place when a resident refused to be secured to the van. Now, staff is to notify myself or the administrator, and we will go on site. The van will not move." "If a resident falls, the licensed nurse should do the initial assessment." g) During an interview with CNA #3 on [DATE] at 2:48 p.m., CNA #3 said, "Probably ,[DATE]% of the time resident #8 refused to be secured to the van. The last time I transported him was on [DATE] (Saturday) to UMC. I had no issues with him. He let me secure his wheelchair to the van. He has refused before, but then later let me secure him." "If he refused, I would call the ADON and report it to her; I was told by the ADON to notify an ADON or nurse of any refusal." "I have transported him before without his chair being secured to the van. He would sit in the back of the van. We would lock the brakes and he would hold on to the back of the seat. Holding on to the seat was his only security." CNA #3 said that she had not received any prior in-servicing pertaining to transporting residents in wheelchairs. "The policy is to secure all residents' wheelchairs to the van. If a wheelchair is properly secured to the van, there is no way possible for it to tip over backwards." h) During an interview with CNA #4 on [DATE] at 2:42 p.m., CNA #4 said that she had transported resident #8 before via the facility van. "He refused to let me secure his wheelchair to the van. I always transported resident #8 without his wheelchair being secured to the van. He would sit between the back seats and hold on to the handle. Sometimes he would sit behind the seat and hold on to it. The brakes were locked." "Upon return to the facility, I would tell a nurse that he refused. She would say that that was his right." "The policy was to lock the brakes and secure the wheelchair to the van. The policy is now to secure the resident, and if he refuses, we're to notify the DON or administrator. We're not supposed to move the bus." "I don't recall ever being instructed on what to do when a resident refused to be secured to the van." "Several other residents have refused to let me secure them, because they saw resident #8, and we didn't secure him." i) Upon review of resident #8's clinical record, it was noted that he was assessed on [DATE] by a licensed nurse upon return to the nursing home. Resident #8 complained of back and head pain. The doctor was notified, and orders were received for a lumbar x-ray, and to send resident #8 to the hospital for a CT if there were noted changes in LOC. Neuro-checks were implemented, and were documented as normal. The lumbar x-ray was completed. j) During an interview with the facility social worker on [DATE] at 12:33 p.m., the social worker said, "I was not aware of resident #8 refusing to be secured to the van. I wasn't made aware of this issue until yesterday ([DATE]). I didn't know that staff was unsafely transporting him. No resident should be transported in the facility van unsecured and unsafe." The social worker said that because she was not aware of the issue, she never talked to the resident or the family about it. "I should have been involved by visiting with resident #8 and his family. As a member of the IDT, I would hold care plan meetings with the family, and communicate the concerns with all necessary facility departments." "Through morning stand-up meetings, I was made aware of resident #11 and resident #12's falls last year. I addressed the concerns with resident #11's family during care plan meetings. His family wanted restorative to walk him more. He got other equipment, but ancillary departments handled the assistive equipment" "I was not involved at all with resident #12's plan of care. As the facility social worker, I should have been involved with resident #12's plan of care. I would have visited with the resident, interacted with nursing, and discussed the concerns with the family in care plan meetings." K) During an observation on [DATE] at 5:37 p.m., CNA #1 was outside with the surveyor at the facility van. She was asked to demonstrate and explain what occurred with resident #8 on [DATE]. The following was the observation: CNA #1 started the van. She walked to the back of the van and opened the doors from the inside, and then lowered the lift to the ground. "I did this before I went inside to get him. I got resident #8, placed him on the lift, and put the belt behind his chair. I stood behind resident #8. When we got up to the van, I released the belt and wheeled him into the van. I took him to the spot where I could secure him. He wanted to sit behind the back seat. I placed him, while still in his wheelchair, behind the back seat. He grabbed the handle on the back of the seat. I removed one of the security belt brackets from the floor so I could put his chair in. I went and sat in the driver's seat, closed the front door, and released the brake. I saw his arms in the air. I then heard him fall. I put the brake on, released my belt, and went back to him. He said his shoulder hurt. I called the facility, and they sent CNA #2. Resident #8 was lying on his back, with his wheelchair tipped over. He told me and CNA that he hit his head. We checked his head. CNA #2 placed his wheelchair behind the back seat. " When asked by the surveyor multiple times, CNA #1 repeatedly said, "We did not secure resident #8's wheelchair to the van. CNA #2 stood behind the wheelchair holding on to it with one hand and holding on to the seat with the other hand. CNA #2 was not buckled. He was standing behind resident #8." CNA #1 said that she and CNA #2 transported resident #8 in his wheelchair via the van to the nursing home without his wheelchair being secured to the van. Upon observation of the inside of the facility van, it was noted that there were large metal brackets sticking up out of the floor of the van. These brackets were toward the back of the van, which would have been behind where resident #8 fell . l) Upon review of resident #8's care plan, the following interventions were noted: Anticipate and meet resident #8's needs. Be sure resident #8's call light is within reach and encourage him to use it for assistance as needed. Follow facility fall protocol. There were no other intervention put in place in the written care plan to prevent falls. Upon review of resident #8's [DATE] 14 day MDS, it was noted that resident #8 required staff assistance x1 with bed mobility, transfers, locomotion, hygiene, and bathing. He required staff assistance x2 with dressing. Resident #8 was unsteady with moving on and off the toilet, and surface-to-surface transfers. He required staff assistance with stablization. Resident #8 had ROm impairment to his bilateral upper and lower extremities. Resident #8's [DIAGNOSES REDACTED]. Upon review of resident #8's record, it was noted that he had experienced 5 falls between [DATE] and [DATE]. The falls on [DATE] and [DATE] occurred outside of the facility while resident #8 was transporting himself via an electric wheelchair. According to facility documentation, no interventions were put into place to prevent these falls from happening again. The facility's Fall Management-Plan of Care form was not completed. Resident #8 fell out of his wheelchair while transferring himself from wheelchair to bed on [DATE]. No nursing interventions were put into place. No facility Falls Management-Plan of Care form was completed. Resident fell again out of his chair in his room on [DATE]. Nursing interventions were put into place via the facility's Falls Management- Plan of Care form, such as changing the resident's bed. Resident #8 fell when his wheelchair tipped over in his room on [DATE]. Per facility documentation, no interventions were put into place. There is a date written on the facility's [DATE] Falls Management- Plan of Care form, but there is no documentation as to what that date was for, or who wrote the date. ADON #1 said she wrote the date on the form. m) Upon review of CNA #1's undated written witness statement, the following was noted: "When resident #8 came out of the door from [MEDICAL TREATMENT] he was dozing off. I got him on our bus, as always, he refused to be tied or buckled up. He would say they always had let him ride that way before, and that's how he wanted to be. When he was in his spot I went to the driver seat and buckled up. When I was taking off the hand brake, I looked in the rear mirror and saw him like if he had gotten scared. I saw him raise his arms up over his head, and that's something he would always do, and would have to ask him constantly to wake up and hold on to chair. The next thing I heard was a thump. I looked back and saw him on the floor. Put handbrake on again, unbuckled myself and went to him. Asked him if he was hurting and he said not really, but he had his eyes closed at all times. Called the nursing home and ADON #2 answered phone. Told what happened and asked if she could send someone or if she wanted to check him before we got him up. She sent CNA #2. When he got there, he and I lifted resident #8 up with the wheelchair. CNA #2 rode back to the nursing home with us so he could hold him (resident #8). CNA asked him if he was hurting. He did say his head. There was a green chair cushion and half his head was on it. Also mentioned his left shoulder was hurting. His left side landed on his cloth bag with his blanket he would take to [MEDICAL TREATMENT]." n) Upon review of CNA #2's undated written witness statement, the following was noted: "When I was told by ADON #2 that CNA #1 needed help with resident #8, that he fell down, I drove over where he fell and saw resident #8 on the floor on his back. I asked what happened. He said he fell back from his chair. I also asked what part hurt, and he said his shoulder and his head. So me and CNA #1 helped pick him up off the floor using the gait belt and the wheelchair to raise him up. After we did we made sure that he was secured and drove off back to the nursing home." o) Upon review of a [DATE] facility statement concerning resident #8's [DATE] fall signed by the administrator and the DON, it was noted that the 3rd and 4th paragraphs were documented as the following: "As to why resident #8 was not secured safely: Resident #8 refused all seatbelt and wheel belts which would have locked him into place. Instead, he preferred to ride in a wheelchair pushed up close against the last seat so he could hold on and keep himself from falling forward. 'He did not trust the safety belts,' according to CNA #1. CNA #1 called ADON #2 and asked for a nurse to come assess. ADON #2 sent CNA #2 to assist CNA #1. CNA states there was no blood or sign of injury." 6. Resident #9 a) a) Upon review of resident #9's care plan, the following interventions were noted: anticipate and meet needs, and call light within reach and encourage use of. There were no other interventions in the written care plan to prevent falls. is chair fell backwards and hit the floor. Thye practiceTThThe [DATE] quarterly MDS documented that there had been no falls since the last review, although resident #9 fell on [DATE]. It was also noted on the MDS that resident #9 was not steady when moving from seated to standing position, when walking, when turning around, when moving on and off the toilet, or with surface-to-surface transfers, and required staff assistance with stablization. Resident #9 required staff assistance x1 with all ADL's except for eating and locomotion. According to the MDS, resident #9's [DIAGNOSES REDACTED]. Resident #9's last four Fall Risk Asessment scores were 12, 19, 13, and 19. A total score of 10 or higher may represent high risk. Upon record review of resident #9's clinical record, it was noted that she had fallen five times between [DATE] and [DATE]. Resident #9 slid to the floor from a sitting position twice, and fell while standing three times. The facility's Fall Management- Plan of Care form was completed after the [DATE] fall. All interventions were checked off. On the facility's Investigation Follow-Up form, interventions were listed as "tell resident to call for help, and keep eyes on her." Per facility documentation, no nursing interventions were put into place after the [DATE] fall and after the [DATE] fall, such as PT/OT evaluations, assessment of current wheelchair, the need for assistive devices, or encouraging the resident to ask for assistance before standing. These interventions could assist in preventing further falls. 7. Resident #10 a) During an interview with resident #10 on [DATE] at 11:30 a.m., resident #10 said that she had fallen several times. "I fell in the dining room when getting up to get a cup of coffee. There was a wet spot on the floor. I slipped on the spot and fell to the floor. They took me to the ER." Resident #10 said that she felt that the fall in the dining room could have been prevented. "They could have served me coffee instead of me getting it. I didn't ask them to get it because they get mad and make funny faces when I ask. The floor should have been dry." b) There were no facility care plans pertaining to falls for resident #10. This was verified by ADON #1 on [DATE] at 7:45 a.m. The [DATE] quarterly MDS documented one fall with injury since the last assessment. It was noted in the MDS that resident #10 was unsteady during transitions and walking, but could stabalize without staff assistance. The last three facility Fall Risk Assessment scores for resident #10 were 9, 17, and 17. A total score of 10 or higher may represent high risk. According to the MDS, resident #10's [DIAGNOSES REDACTED]. Upon review of resident #10's record, it was noted that she had fallen 4 times between [DATE] and [DATE]. According to facility documentation, no nursing interventions were put into place after any of the four falls, such as encouraging staff for assistance when picking objects off of the floor, the use of an assistive device to pick objects off of the floor, encouraging the resident to ask for assistance when making her bed and when transferring to the bed, and PT/OT evaluation for strengthening and need for staff assistance. These interventions could assist in preventing future falls. The fall on [DATE] resulted in a left clavicle fracture. She fell while bending over to pick an object off of the floor. Resident #10's other falls occurred during transfers and making her bed.There was no facility Fall Management- Plan of Care form completed for resident #10. This was verified by ADON #1 on [DATE] at 7:45 a.m. 8. Resident #11 a) Upon review of resident #11's care plan, the following interventions were noted: ensure proper footwear, follow facility fall protocol, continue interventions, and a PT consult. No other interventions such as bed and chair alarms, floor mats, encouarging staff assistance for transfers and locomotion were put in place in the written care plan to prevent further falls. The [DATE] quarterly MDS documented 2 falls with injury and 2 falls without injury since the last review. It was noted on the MDS that resident #11 required staff assistance x 2 for bed mobility, transfers, and toilet use. He required staff assistance x1 with all other ADLs except for eating. Per the MDA, resident #11 was unsteady, and required staff assistance for stabalization with moving from seated to standing position, walking, turning around, and surface to surface transfers. Review of resident #11's last 3 Fall Risk Assessment scores were 22, 24, and 22. A total score of 10 or higher may represent high risk. According to the MDS, resident #11's [DIAGNOSES REDACTED]. Upon review of resident #11's clinical record, it was noted that he had fallen 8 times between [DATE] and [DATE]. According to facility documentation, no nursing interventions were put in place after 5 of these falls. Three of the falls included the resident falling from the bed, and one of the falls involved falling out of a chair. Interventions such as encouraging the use of a call light and obtaining assistance were not implemented after these falls. Resident #11 fell in the shower while the CNA had turned to get his pants. Interventions such as keeping eyes on the resident at all times, keeping supplies within reach, and encouraging the resident to stay seated until assisted were not implemented to prevent a further fall of this type from occuring again. Up through the [DATE] fall, there had been no facility Falls Management- Plan of Care form completed. Resident #11 fell four more times between [DATE] and [DATE]. There were no interventions put in place following the [DATE] fall, in which resident #11 fell from the bed. A facility Falls Management-Plan of Care form was completed with interventions on [DATE], and was updated on [DATE]. Interventions such as hi/low bed, floor mats, wheelchair, and PT/OT evaluation were implemented. 9. Resident #12 a) Upon review of resident #12 ' s care plan, the following interventions were documented: Anticipate needs, call light within reach, and encourage use of. There were no other interventions put in place in the written care plan to prevent further falls. The [DATE] quarterly MDS documented 2 falls without injury since the last review. Upon review of the MDS, it was noted that resident #12 required staff assistance x2 with bed mobility, transfers, and toilet use. She required staff assistance x 1 with all other ADLs. Resident #12 was unsteady, and required staff assistance for stabalization with moving from seated to standing position and surface to surface transfers. She also had ROM impairments to bilateral upper and lower extremities. According to the MDS, resident #12's disgnoses included [MEDICAL CONDITION]'s Disease, anxiety, depression, and [MEDICAL CONDITION]. Upon review of resident #12's clinical record, it was noted that she had fallen 19 times between [DATE] and [DATE]. There were no interventions put in place after the [DATE], [DATE], [DATE]and [DATE] falls. Resident #12 fell out of bed 11 times. There were no interventions put in place after three of these falls. Resident #12 fell out of a chair three times. Interventions were not put in place after one of these falls. One of these falls occurred in the dining room, and interventions put in place included high/low bed and floor mats, which are both in the resident's bedroom. Resident #12 fell five times while walking. Interventions after these falls including medicinal evaluation, high/low bed, floor mats, ,[DATE] side rails, and bed/chair alarms. The interventions for the majority of the falls were the same, such as alarms, side rails, high/low bed, and floor mats. These interventions were not appropriate for the falls that occurred in the didning room or hallway. "Closer monitoring" was only implemented after the f

Based on observation, interview, and record review it was determined that the facility failed to develop and implement its policies and procedures that prohibit neglect for 5 (residents # 8, 9, 10, 11, and 12) of the 5 sampled residents who were at risk for falls.. 1. Resident #8 experienced 6 falls between [DATE] and [DATE] with interventions put i n place only after the [DATE] and [DATE] falls.. The last fall occurred while the resident was in his wheelchair sitting in the facility transportation van and his was not secured to the van floor, nor was he buckled in. He fell backwards and hit the van floor. The resident expired two days later. Residents #9, 10, 11, and 12 experienced multiple falls in 2012. There were multiple times where interventions were not put in place, and the facility fall policy protocol was not followed. 2. The facility failed to ensure that 5 (residents 8, 9, 10, 11 and 12) of 5 sampled residents who had multiple falls were protected from accidents by not following the plan of care. Residents' care plans documented that the facility should follow the facility fall protocol. This was not followed, resulting in residents 8, 9, 10, 11, and 12 falling. The failure to prevent neglectful behavior could cause serious injury to a resident. 3. The facility failed to ensure that 1 (resident #8) of 7 sampled residents who required the use of a wheelchair was appropriately secured in a facility transportation van that can accommodate wheelchairs while being transported to and from the facility. Resident #8 was placed in his wheelchair on the van. His chair was placed behind the back seat of the van, and his wheelchair was not secured to the van floor. Resident #8 fell backward and hit the floor. Resident #8 was transported to the facility while his wheelchair was not secured to the van floor. 4. The facility failed to develop written procedures for transporting residents in a facility vehicle. The current facility Transportation Policy and Procedure for Center-Based vehicle policy did not address how to safely transport residents in the facility van who sit in wheelchairs. 5. The facility failed to provide a resident assessment by a licensed nurse for a resident (resident #8) who sustained a fall while sitting in his wheelchair in the facility van. Rather than sending a licensed nurse, CNA #2 was sent to assist CNA #1 and resident #8. Resident #8 was then transported to the facility, and was then assessed by a nurse. 6. An immediate jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a pattern of no actual harm with a potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. 7. The practice of not putting interventions in place after resident falls could affect 5 of the 59 residents in the facility who are at risk for falls. The failure to put intervention is place after a resident falls could allow the same situatiojn to occur again, which could end with an injury for the resident. The practice of keeping residents free from neglect could affect 59 of 115 residents living in the facility who are at risk for falling. The failure to prevent neglectful behavior could cause serious injury to a resident. The practice of not securing a resident's wheelchair to the floor could affect 1 (resident #8) of the 7 sampled residents (resident #1, 2, 3, 4, 6, 7, and 8) who were transported in wheelchairs via the facility van. The failure to secure a resident's wheelchair to the van floor could cause an accident to occur, which could cause serious injury to a resident. The practice of not having facility policies/instructions for transporting residents in wheelchairs could affect the 91 residents living in the facility who sit in wheelchairs. The failure to have policies/procedures in place could allow facility staff to follow unsafe procedures, which could cause a serious injury for a resident. The failure to have a nurse assess a resident after a fall/accident could cause an injury to go unnoticed, which could cause further complications for the resident. The findings include: 1. Resident #8 a) During an interview with ADON #1 on [DATE] at 10:28 a.m., it was determined that resident #8 was in the facility van on [DATE]. His chair was not secured to the van floor, and he fell backward and hit the van floor. ADON #1 said, "I expect that all wheelchairs should be secured to the van, and all residents should be buckled. CNA #1 should have secured resident #8's wheelchair to the van. If resident #8 was refusing to be secured, CNA #1 should have called the administrator." During an interview at 2:17 p.m., ADON #1 said that she didn't know the facility procedures to follow if the resident refused to be secured. "If a resident falls, the nurse does the initial assessment. The resident is not to be picked up off the floor unless the nurse is there." After looking at Resident #8's care plan, ADON #1 said that there were not enough goals and intervention needed to care for the resident. b) During an interview with ADON #2 on [DATE] at 10:36 a.m., ADON #2 said, "Resident #8 would argue, but he would let them secure him. He was scared of falling, and said that staff didn't lock his brakes, and he would lean backward. So, he liked to be by the back seat so he could hold on to it. I told CNA #1 that if resident #8 refused, she needed to tell the nurse so she could document." "CNA #1 called and told me that she was taking off (leaving the facility) , and resident #8 fell backwards and hit his head. I sent CNA #2 to go help lift resident #8 up." "At about 1:30 p.m., resident #8 told me that he had back pain and a head ache. He said that CNA #1 didn't lock the brakes. I know CNA #1 should have secured resident #8 in the van. If he was being stubborn, she should have refused to take him." In an interview at 2:22 p.m., ADON #2 said, "Most of the time resident #8 refused to be secured to the van. I told the van drivers (CNA #1 and CNA #3) to notify the nurse or an ADON when any resident refused to be secured. They were supposed to make the notification before leaving in the van." "If a resident falls, the nurse is supposed to do the initial assessment. The resident should not be picked up without the nurse being there." c) During an interview with CNA #1 on [DATE] at 11:37 a.m., CNA #1 said, "Once I got resident #8 on the van, I tried to secure his chair to the van. He refused. He said he felt safer by the back seat so he could hold on to it. He has let us secure him before on [DATE]. He was upset, but he let us. I placed him by the back seat. I locked his wheels. I went and sat in my seat, and put my seatbelt on. I reached for the hand brake. I looked in the mirror, and saw him raise his hands, as if he was dreaming. He had done this before. He was sleepy after [MEDICAL TREATMENT], and we had to talk to him to keep him awake. I then heard a noise. I went to check on him. I asked him if he was okay. He said he didn't know. I called the facility and ADON #2 sent CNA #2 to help me. After we got him up, he said his head hurt from hitting it. He also complained of pain in his left shoulder." CNA #1 further said, "It's company policy to make sure the wheelchair is secure before we go to an appointment. I should not have went to the driver's seat unless he was secured. I should have called one of the ADONs and told them about the situation." "I've transported resident #8 several times without securing his wheelchair. I told ADON #2 and the social worker. The social worker said she would talk to him." d) During an interview with CNA #2 on [DATE] at 12:21 p.m., CNA #2 said that he was asked to go help CNA #1 with resident #8. "Resident #8 was in his chair and was on his back. I asked him if he was okay. We picked him up, and he said his back and head hurt. I barely touched the back of his head, and he said that it hurt. When I got there, the chair was not secured to the van. It is facility policy that all residents should be secured to the van before going to an appointment. No matter what, you have to make sure all residents' wheelchairs are secured to the van. In my opinion, he should have been secured to the van, because their safety is what matters. He was very weak." CNA #2 said that the wheelchair was secured to the floor before transporting resident #8 to the facility. e) During an interview with the administrator on [DATE] at 12:40 p.m., he said, "I wasn't called and told about resident #8 ' s accident. I was notified via an incident report. I don't remember when I was told about it. All I remember is that an ADON (I don't remember which one) gave me an incident report. The transportation aide did not secure the resident's wheelchair to the van. It is facility policy to follow state regulations before the van moves. All residents should be secured. The resident refused to be secured. He said he wanted to ride in the back holding on to the seat. He complained of soreness. There were no visual injuries. Staff have been instructed to notify the DON or myself if a resident refuses to be secured. CNA #1 should have called the administrator so we could have gone and helped her." When asked if the wheelchair could have tipped over backward if it had been secured, the administrator said, "If the van would have been moving, and the chair would have been secured, the chair would not have tipped." f) During an interview with the DON on [DATE] at 2:05 p.m., the DON said, "ADON #2 told me that resident #8 had fallen. I found out about it the next day in stand up meeting." The DON said that he was not notified of the fall the day of the fall. "I don't know what procedures were in place when a resident refused to be secured to the van. Now, staff is to notify myself or the administrator, and we will go on site. The van will not move." "If a resident falls, the licensed nurse should do the initial assessment." g) During an interview with CNA #3 on [DATE] at 2:48 p.m., CNA #3 said, "Probably ,[DATE]% of the time resident #8 refused to be secured to the van. The last time I transported him was on [DATE] (Saturday) to UMC. I had no issues with him. He let me secure his wheelchair to the van. He has refused before, but then later let me secure him." "If he refused, I would call the ADON and report it to her; I was told by the ADON to notify an ADON or nurse of any refusal." "I have transported him before without his chair being secured to the van. He would sit in the back of the van. We would lock the brakes and he would hold on to the back of the seat. Holding on to the seat was his only security." CNA #3 said that she had not received any prior in-servicing pertaining to transporting residents in wheelchairs. "The policy is to secure all residents' wheelchairs to the van. If a wheelchair is properly secured to the van, there is no way possible for it to tip over backwards." h) During an interview with CNA #4 on [DATE] at 2:42 p.m., CNA #4 said that she had transported resident #8 before via the facility van. "He refused to let me secure his wheelchair to the van. I always transported resident #8 without his wheelchair being secured to the van. He would sit between the back seats and hold on to the handle. Sometimes he would sit behind the seat and hold on to it. The brakes were locked." "Upon return to the facility, I would tell a nurse that he refused. She would say that that was his right." "The policy was to lock the brakes and secure the wheelchair to the van. The policy is now to secure the resident, and if he refuses, we're to notify the DON or administrator. We're not supposed to move the bus." "I don't recall ever being instructed on what to do when a resident refused to be secured to the van." "Several other residents have refused to let me secure them, because they saw resident #8, and we didn't secure him." i) Upon review of resident #8's clinical record, it was noted that he was assessed on [DATE] by a licensed nurse upon return to the nursing home. Resident #8 complained of back and head pain. The doctor was notified, and orders were received for a lumbar x-ray, and to send resident #8 to the hospital for a CT if there were noted changes in LOC. Neuro-checks were implemented, and were documented as normal. The lumbar x-ray was completed. j) During an interview with the facility social worker on [DATE] at 12:33 p.m., the social worker said, "I was not aware of resident #8 refusing to be secured to the van. I wasn't made aware of this issue until yesterday ([DATE]). I didn't know that staff was unsafely transporting him. No resident should be transported in the facility van unsecured and unsafe." The social worker said that because she was not aware of the issue, she never talked to the resident or the family about it. "I should have been involved by visiting with resident #8 and his family. As a member of the IDT, I would hold care plan meetings with the family, and communicate the concerns with all necessary facility departments." "Through morning stand-up meetings, I was made aware of resident #11 and resident #12's falls last year. I addressed the concerns with resident #11's family during care plan meetings. His family wanted restorative to walk him more. He got other equipment, but ancillary departments handled the assistive equipment" "I was not involved at all with resident #12's plan of care. As the facility social worker, I should have been involved with resident #12's plan of care. I would have visited with the resident, interacted with nursing, and discussed the concerns with the family in care plan meetings." K) During an observation on [DATE] at 5:37 p.m., CNA #1 was outside with the surveyor at the facility van. She was asked to demonstrate and explain what occurred with resident #8 on [DATE]. The following was the observation: CNA #1 started the van. She walked to the back of the van and opened the doors from the inside, and then lowered the lift to the ground. "I did this before I went inside to get him. I got resident #8, placed him on the lift, and put the belt behind his chair. I stood behind resident #8. When we got up to the van, I released the belt and wheeled him into the van. I took him to the spot where I could secure him. He wanted to sit behind the back seat. I placed him, while still in his wheelchair, behind the back seat. He grabbed the handle on the back of the seat. I removed one of the security belt brackets from the floor so I could put his chair in. I went and sat in the driver's seat, closed the front door, and released the brake. I saw his arms in the air. I then heard him fall. I put the brake on, released my belt, and went back to him. He said his shoulder hurt. I called the facility, and they sent CNA #2. Resident #8 was lying on his back, with his wheelchair tipped over. He told me and CNA that he hit his head. We checked his head. CNA #2 placed his wheelchair behind the back seat. " When asked by the surveyor multiple times, CNA #1 repeatedly said, "We did not secure resident #8's wheelchair to the van. CNA #2 stood behind the wheelchair holding on to it with one hand and holding on to the seat with the other hand. CNA #2 was not buckled. He was standing behind resident #8." CNA #1 said that she and CNA #2 transported resident #8 in his wheelchair via the van to the nursing home without his wheelchair being secured to the van. Upon observation of the inside of the facility van, it was noted that there were large metal brackets sticking up out of the floor of the van. These brackets were toward the back of the van, which would have been behind where resident #8 fell . l) Upon review of resident #8's care plan, the following interventions were noted: Anticipate and meet resident #8's needs. Be sure resident #8's call light is within reach and encourage him to use it for assistance as needed. Follow facility fall protocol. There were no other intervention put in place in the written care plan to prevent falls. Upon review of resident #8's [DATE] 14 day MDS, it was noted that resident #8 required staff assistance x1 with bed mobility, transfers, locomotion, hygiene, and bathing. He required staff assistance x2 with dressing. Resident #8 was unsteady with moving on and off the toilet, and surface-to-surface transfers. He required staff assistance with stablization. Resident #8 had ROm impairment to his bilateral upper and lower extremities. Resident #8's [DIAGNOSES REDACTED]. Upon review of resident #8's record, it was noted that he had experienced 5 falls between [DATE] and [DATE]. The falls on [DATE] and [DATE] occurred outside of the facility while resident #8 was transporting himself via an electric wheelchair. According to facility documentation, no interventions were put into place to prevent these falls from happening again. The facility's Fall Management-Plan of Care form was not completed. Resident #8 fell out of his wheelchair while transferring himself from wheelchair to bed on [DATE]. No nursing interventions were put into place. No facility Falls Management-Plan of Care form was completed. Resident fell again out of his chair in his room on [DATE]. Nursing interventions were put into place via the facility's Falls Management- Plan of Care form, such as changing the resident's bed. Resident #8 fell when his wheelchair tipped over in his room on [DATE]. Per facility documentation, no interventions were put into place. There is a date written on the facility's [DATE] Falls Management- Plan of Care form, but there is no documentation as to what that date was for, or who wrote the date. ADON #1 said she wrote the date on the form. m) Upon review of CNA #1's undated written witness statement, the following was noted: "When resident #8 came out of the door from [MEDICAL TREATMENT] he was dozing off. I got him on our bus, as always, he refused to be tied or buckled up. He would say they always had let him ride that way before, and that's how he wanted to be. When he was in his spot I went to the driver seat and buckled up. When I was taking off the hand brake, I looked in the rear mirror and saw him like if he had gotten scared. I saw him raise his arms up over his head, and that's something he would always do, and would have to ask him constantly to wake up and hold on to chair. The next thing I heard was a thump. I looked back and saw him on the floor. Put handbrake on again, unbuckled myself and went to him. Asked him if he was hurting and he said not really, but he had his eyes closed at all times. Called the nursing home and ADON #2 answered phone. Told what happened and asked if she could send someone or if she wanted to check him before we got him up. She sent CNA #2. When he got there, he and I lifted resident #8 up with the wheelchair. CNA #2 rode back to the nursing home with us so he could hold him (resident #8). CNA asked him if he was hurting. He did say his head. There was a green chair cushion and half his head was on it. Also mentioned his left shoulder was hurting. His left side landed on his cloth bag with his blanket he would take to [MEDICAL TREATMENT]." n) Upon review of CNA #2's undated written witness statement, the following was noted: "When I was told by ADON #2 that CNA #1 needed help with resident #8, that he fell down, I drove over where he fell and saw resident #8 on the floor on his back. I asked what happened. He said he fell back from his chair. I also asked what part hurt, and he said his shoulder and his head. So me and CNA #1 helped pick him up off the floor using the gait belt and the wheelchair to raise him up. After we did we made sure that he was secured and drove off back to the nursing home." o) Upon review of a [DATE] facility statement concerning resident #8's [DATE] fall signed by the administrator and the DON, it was noted that the 3rd and 4th paragraphs were documented as the following: "As to why resident #8 was not secured safely: Resident #8 refused all seatbelt and wheel belts which would have locked him into place. Instead, he preferred to ride in a wheelchair pushed up close against the last seat so he could hold on and keep himself from falling forward. 'He did not trust the safety belts,' according to CNA #1. CNA #1 called ADON #2 and asked for a nurse to come assess. ADON #2 sent CNA #2 to assist CNA #1. CNA states there was no blood or sign of injury." 2. Resident #9 a) Upon review of resident #9's care plan, the following interventions were noted: anticipate and meet needs, and call light within reach and encourage use of. There were no other interventions in the written care plan to prevent falls. is chair fell backwards and hit the floor. Thye practiceTThThe [DATE] quarterly MDS documented that there had been no falls since the last review, although resident #9 fell on [DATE]. It was also noted on the MDS that resident #9 was not steady when moving from seated to standing position, when walking, when turning around, when moving on and off the toilet, or with surface-to-surface transfers, and required staff assistance with stablization. Resident #9 required staff assistance x1 with all ADL's except for eating and locomotion. According to the MDS, resident #9's [DIAGNOSES REDACTED]. Resident #9's last four Fall Risk Asessment scores were 12, 19, 13, and 19. A total score of 10 or higher may represent high risk. Upon record review of resident #9's clinical record, it was noted that she had fallen five times between [DATE] and [DATE]. Resident #9 slid to the floor from a sitting position twice, and fell while standing three times. The facility's Fall Management- Plan of Care form was completed after the [DATE] fall. All interventions were checked off. On the facility's Investigation Follow-Up form, interventions were listed as "tell resident to call for help, and keep eyes on her." Per facility documentation, no nursing interventions were put into place after the [DATE] fall and after the [DATE] fall, such as PT/OT evaluations, assessment of current wheelchair, the need for assistive devices, or encouraging the resident to ask for assistance before standing. These interventions could assist in preventing further falls. 3. Resident #10 a) During an interview with resident #10 on [DATE] at 11:30 a.m., resident #10 said that she had fallen several times. "I fell in the dining room when getting up to get a cup of coffee. There was a wet spot on the floor. I slipped on the spot and fell to the floor. They took me to the ER." Resident #10 said that she felt that the fall in the dining room could have been prevented. "They could have served me coffee instead of me getting it. I didn't ask them to get it because they get mad and make funny faces when I ask. The floor should have been dry." b) There were no facility care plans pertaining to falls for resident #10. This was verified by ADON #1 on [DATE] at 7:45 a.m. The [DATE] quarterly MDS documented one fall with injury since the last assessment. It was noted in the MDS that resident #10 was unsteady during transitions and walking, but could stabalize without staff assistance. The last three facility Fall Risk Assessment scores for resident #10 were 9, 17, and 17. A total score of 10 or higher may represent high risk. According to the MDS, resident #10's [DIAGNOSES REDACTED]. Upon review of resident #10's record, it was noted that she had fallen 4 times between [DATE] and [DATE]. According to facility documentation, no nursing interventions were put into place after any of the four falls, such as encouraging staff for assistance when picking objects off of the floor, the use of an assistive device to pick objects off of the floor, encouraging the resident to ask for assistance when making her bed and when transferring to the bed, and PT/OT evaluation for strengthening and need for staff assistance. These interventions could assist in preventing future falls. The fall on [DATE] resulted in a left clavicle fracture. She fell while bending over to pick an object off of the floor. Resident #10's other falls occurred during transfers and making her bed.There was no facility Fall Management- Plan of Care form completed for resident #10. This was verified by ADON #1 on [DATE] at 7:45 a.m. 4. Resident #11 a) Upon review of resident #11's care plan, the following interventions were noted: ensure proper footwear, follow facility fall protocol, continue interventions, and a PT consult. No other interventions such as bed and chair alarms, floor mats, encouarging staff assistance for transfers and locomotion were put in place in the written care plan to prevent further falls. The [DATE] quarterly MDS documented 2 falls with injury and 2 falls without injury since the last review. It was noted on the MDS that resident #11 required staff assistance x 2 for bed mobility, transfers, and toilet use. He required staff assistance x1 with all other ADLs except for eating. Per the MDA, resident #11 was unsteady, and required staff assistance for stabalization with moving from seated to standing position, walking, turning around, and surface to surface transfers. Review of resident #11's last 3 Fall Risk Assessment scores were 22, 24, and 22. A total score of 10 or higher may represent high risk. According to the MDS, resident #11's [DIAGNOSES REDACTED]. Upon review of resident #11's clinical record, it was noted that he had fallen 8 times between [DATE] and [DATE]. According to facility documentation, no nursing interventions were put in place after 5 of these falls. Three of the falls included the resident falling from the bed, and one of the falls involved falling out of a chair. Interventions such as encouraging the use of a call light and obtaining assistance were not implemented after these falls. Resident #11 fell in the shower while the CNA had turned to get his pants. Interventions such as keeping eyes on the resident at all times, keeping supplies within reach, and encouraging the resident to stay seated until assisted were not implemented to prevent a further fall of this type from occuring again. Up through the [DATE] fall, there had been no facility Falls Management- Plan of Care form completed. Resident #11 fell four more times between [DATE] and [DATE]. There were no interventions put in place following the [DATE] fall, in which resident #11 fell from the bed. A facility Falls Management-Plan of Care form was completed with interventions on [DATE], and was updated on [DATE]. Interventions such as hi/low bed, floor mats, wheelchair, and PT/OT evaluation were implemented. 5. Resident #12 a) Upon review of resident #12 ' s care plan, the following interventions were documented: Anticipate needs, call light within reach, and encourage use of. There were no other interventions put in place in the written care plan to prevent further falls. The [DATE] quarterly MDS documented 2 falls without injury since the last review. Upon review of the MDS, it was noted that resident #12 required staff assistance x2 with bed mobility, transfers, and toilet use. She required staff assistance x 1 with all other ADLs. Resident #12 was unsteady, and required staff assistance for stabalization with moving from seated to standing position and surface to surface transfers. She also had ROM impairments to bilateral upper and lower extremities. According to the MDS, resident #12's disgnoses included [MEDICAL CONDITION]'s Disease, anxiety, depression, and [MEDICAL CONDITION]. Upon review of resident #12's clinical record, it was noted that she had fallen 19 times between [DATE] and [DATE]. There were no interventions put in place after the [DATE], [DATE], [DATE]and [DATE] falls. Resident #12 fell out of bed 11 times. There were no interventions put in place after three of these falls. Resident #12 fell out of a chair three times. Interventions were not put in place after one of these falls. One of these falls occurred in the dining room, and interventions put in place included high/low bed and floor mats, which are both in the resident's bedroom. Resident #12 fell five times while walking. Interventions after these falls including medicinal evaluation, high/low bed, floor mats, ,[DATE] side rails, and bed/chair alarms. The interventions for the majority of the falls were the same, such as alarms, side rails, high/low bed, and floor mats. These interventions were not appropriate for the falls that occurred in the didning room or hallway. "Closer monitoring" was only implemented after the fall out of the chair in the dining room. Up through the [DATE] (10th fall) fall, there had been no Falls Management- Plan of Care form completed. This form was completed on [DATE], and updated once on [DATE]. 6. Upon review of the undated facility Transportation Policy and Procedure for Center-Based Vehicle, it was noted that there was no directions or instruction pertaining to how to transport residents in the facility van, including those who sit in a wheelchair. 7. Upon review of a typed list given to the surveyor on [DATE] by the DON, the following was noted: 1. Policy of transferring residents in van with wheelchair: The policy and procedure that was previously provided is all we have regarding van use and associated van policies. 8. Upon review of the ,[DATE] facility revised Fall Management System policy, the following was noted: Procedure B.2. The identifying factors will be provided to staff, and the individualized care plan will be developed with appropriate goals and interventions utilizing the Fall Management-Plan of Care form. D.1. A licensed nurse will complete an Incident/Accident Report after each fall. 2. The licensed nurse will document the fall on the nurse's notes of the medical record. 3. Documentation in the nurse ' s notes will reflect any intervention imposed by the attending physician or their agent. 8. An Administrative nurse will ensure that the resident ' s plan of care is revised to reflect each fall and interventions that were implemented. 9. An Administrative nurse will ensure that the nursing assistant ' s assignment sheet reflects interventions to prevent further falls and/or decrease potential for injury from a fall. E.1. The licensed nurse will initiate the Incident/Accident investigation immediately after each fall utilizing the "Investigation Follow-up" guideline. 2. Interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable. 9. Upon review of the facility ,[DATE] revised Abuse Prohibition Policy and Procedures, the following was noted: Neglect- A deprivation of life ' s necessities of food, water, or shelter, or a failure of an individual to provide services, treatments, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs. VII. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies. B. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON. C. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge. D. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. J. The results of all investigations will be reported to the administrator or designated representative, and other officials in accordance with state laws (including the state survey and certification agenc