Every finding on record at Princeton Health & Rehabilitation

Based on record review and interviews, the facility failed to notify a resident representative and Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) following the removal of a medical device and death for 1 (R #12) of 3 (R #11, R #12, and R #18) resident reviewed. This deficient practice is likely to result in the resident's representative being unable to advocate for the resident and can create distress for the resident's POA, when the facility did not promptly notify the POA of the resident's death. The findings are: A. Record review of the facility's change in resident condition and status policy, last revised in 08/2024, revealed the policy required a nurse to notify the resident's representative, unless the resident instructed otherwise, when the resident was involved in any accident or incident resulting in an injury, including injuries of unknown origin. Facility staff were required to notify the resident's representative when the resident experienced a significant change in physical, mental, or psychosocial status, and when it was necessary to transfer the resident to a hospital or treatment facility. B. Record review of R #12's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) revealed an admission date of 06/23/26 with the diagnoses of tracheostomy (trach; a surgical procedure to create an artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing), dependence on supplemental oxygen use, gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach and used to provide fluids, nourishment and medications), and ST-segment elevation myocardial infarction (STEMI; severe heart attack completely blocking blood flow). R #12 was discharged on 06/25/26. C. Record review of R #12's advanced directive (a legally binding document that states your medical treatment preferences and may appoint someone to make health care decisions if you become unable to do so), dated 06/23/26, revealed it was signed by R #12's daughter (who was also the POA), with the contact number listed. D. Record review of R #12's progress notes revealed the following:Dated 06/24/26 at 7:33 am, an Interdisciplinary Team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident) note revealed R #12 was observed in bed during rounds holding his tracheostomy cannula (a tube inserted into the trachea to maintain an airway, often consisting of an outer tube and a removable inner cannula for cleaning and safety) in his left hand. The Respiratory Therapist (RT) was notified, responded immediately, and successfully re cannulated (reinserted) the tracheostomy without complications. Vital signs (body temperature, pulse rate, respiration rate (rate of breathing), oxygen saturation (amount of oxygen in the blood), and blood pressure) were within normal limits and remained stable. Staff attempted to notify the patient's POA, but no telephone number was listed in his profile. The on call provider was notified of the incident, assessment findings, and interventions performed. Dated 06/24/26 at 12:01 pm, a respiratory note revealed the night-shift RT stated R #12 had decannulated (cannula was removed) himself and the trach was replaced without resistance. R #12 had moved around throughout the night. The RT placed a shoestring tie (trach tie) to help prevent possible future decannulation. The RT educated the resident on why he should not handle the trach tube. Dated 06/25/26 at 12:41 am, a respiratory note reported the RT found R #12 unresponsive and not breathing upon entering his room. He did not respond to any arousal or stimuli. The nurse was called, and the RT suctioned a small amount of white secretions from the trach. R #12 was a do not resuscitate (DNR; lifesaving measures are not desired).Dated 06/25/26 at 2:00 am, documentation revealed R #12 was pronounced dead around 12:45 a.m. Upon assessment, vital signs were unreadable, and breath sounds and a pulse were absent. The nurse supervisor and the on call provider were notified.Dated 06/25/26 at 2:06 am, documentation revealed R #12's POA was notified of R #12's death by voicemail. The nurse attempted to call the phone number listed in R #12's electronic health record (EHR), but the call would not go through. The nurse supervisor was notified. E. Record review of R #12's EHR, dated 08/25/26, revealed R #12's POA and emergency contact were listed by name with the phone number present. Documentation was not available indicating facility staff made additional attempts to contact R #12's POA after R #12's trach decannulation and death. F. On 08/25/26 at 10:55 am, during an interview, Social Service Assistant (SSA) #1 stated on 06/25/26 around 11:00 am, she was walking by the front desk when she saw R #12's daughter appear a little frantic. SSA #1 stated she stopped and asked R #12's daughter if she was alright, and R #12's daughter told her she was trying to find R #12. SSA #1 stated she knew R #12 had died, and she felt she needed to tell R #12's daughter that R #12 had died. SSA #1 stated R #12's daughter's reaction indicated she did not know that R #12 had recently died. G. On 08/25/26 at 11:08 am, during an interview, the Unit Manager (UM) #3 stated R #12's daughter had come to visit her father and was unaware R #12 had died. UM #3 stated no one from the facility had called R #12's daughter to inform her that R #12 had died and should have. H. On 08/25/26 at 1:34 pm, during an interview, Registered Nurse (RN) #2 stated he had tried to call R #12's daughter, but the phone number listed in R #12's EHR was not accurate, and he was unable to contact her. I. On 08/27/26 at 2:22 pm, during an interview, R #12's daughter stated she was not notified by the facility when R #12 removed his trach cannula on 06/24/26. She stated that on 06/25/26 at about 1:00 pm, she went to see R #12, but when she reached his room, another person was in his bed. She stated she thought she had gone to the wrong room, so she looked at the name placard outside the door, and it displayed R #12's name. R #12's daughter stated she went to the nurse's station, and the nurses did not know where R #12 was and began searching for him in the EHR. She stated facility staff informed her R #12 had died. R #12's daughter stated the facility did not contact her when R #12 died and should have.

Based on record review and interviews, the facility failed to provide quality care that meets professional standards for 1 (R #12) of 3 (R #11, R #12 and R #18) resident reviewed, when staff failed to:Obtain a new set of R #12's vital signs (body temperature, pulse rate, respiration rate (rate of breathing), oxygen saturation (amount of oxygen in the blood), and blood pressure) after R #12 experienced a change in condition (CIC; any significant change in a resident's physical, mental, emotional, or functional health status that may require assessment, intervention, or communication with healthcare providers).Attempted to cancel an emergency medical services (EMS) response after R #12 experienced a medical emergency and was a do not resuscitate (DNR; lifesaving measures are not desired) . This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:A. Record review of the facility's change in resident's condition and status policy, last revised in 08/2024, revealed a significant change in condition was a major decline or improvement in the resident's status that would not normally resolve without staff intervention or standard disease related clinical interventions. Before notifying the physician or healthcare provider, the nurse will make detailed observations and gathered relevant and pertinent information for the provider. B. Record review of R #12's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) revealed an admission date of 06/23/26 with the diagnoses of tracheostomy (trach; a surgical procedure to create an artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing), dependence on supplemental oxygen use, gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach and used to provide fluids, nourishment and medications), and ST-segment elevation myocardial infarction (STEMI; severe heart attack completely blocking blood flow). R #12 was discharged on 06/25/26. C. Record review of R #12's advanced directive (a legally binding document that states your medical treatment preferences and may appoint someone to make health care decisions if you become unable to do so), dated 06/23/26, revealed R #12 was a DNR, but requested medical interventions that included intubation (the insertion of a tube into a patient's body, especially that of an artificial ventilation tube into the trachea), advanced airway interventions, mechanical ventilation (a medical intervention in which a machine assists or fully takes over a patient's breathing to ensure oxygen delivery and carbon dioxide removal), and cardioversion (a medical procedure used to restore a normal heart rhythm in people with irregular or fast heartbeats), as indicated. D. Record review of R #12's progress notes revealed the following:1.Dated 06/24/26 at 7:33 am, an Interdisciplinary Team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident) note revealed R #12 was observed in bed during rounds holding his tracheostomy cannula (a tube inserted into the trachea to maintain an airway, often consisting of an outer tube and a removable inner cannula for cleaning and safety) in his left hand. The Respiratory Therapist (RT) was notified, responded immediately, and successfully re cannulated (reinserted) the tracheostomy without complications. Vital signs were within normal limits and remained stable.Dated 06/24/26 at 10:40 am, a nursing note indicated R #12 was agitated, attempted to get out of bed, and tried to remove his trach tube. R #12's trach tube remained in place, and staff repositioned him in bed. R #12 was seen by the physician, who ordered hydroxyzine (an antihistamine used to treat anxiety) three times a day for anxiety.Dated 06/24/26 at 12:01 pm, a respiratory note revealed the night-shift RT stated R #12 had decannulated (cannula was removed) himself and the trach was replaced without resistance. R #12 had moved around throughout the night. The RT placed a shoestring tie (trach tie) to help prevent possible future decannulation. The RT educated the resident on why he should not handle the trach tube. Dated 06/24/26 at 6:54 pm, a respiratory note indicated R #12 was sleeping in bed when the RT entered. R #12's head of bed was elevated, and his hands were cold and shaking. He appeared to be shivering. Staff covered him with a blanket and turned off the air conditioner. R #12's oxygen saturation (measures the percentage of hemoglobin in your blood that is carrying oxygen, indicating how well oxygen is being delivered to your tissues) was obtained and measured 88% (percent). The RT suctioned the trach, and a moderate amount of white secretions were present. R #12's oxygen was increased to 3 liters per minute (LPM), and the nurse was notified of his status. R #12's oxygen saturation improved.Dated 06/24/26 at 9:53 pm, a respiratory note indicated R #12 was asleep in bed without signs of respiratory discomfort. R #12's oxygen saturation measured 90% on 3 LPM of oxygen. R #12's heart rate measured 65 beats per minute, and his respirations measured 20 per minute.Dated 06/25/26 at 12:41 am, a respiratory note reported the RT found R #12 unresponsive and not breathing upon entering his room. He did not respond to any arousal or stimuli. The nurse was called, and the RT suctioned a small amount of white secretions from the trach. R #12 was a DNR. Dated 06/25/26 at 12:50 am, a CIC note indicated R #12 was unresponsive. R #12's most recent vital signs included a blood pressure (normal range, 90/60 mm/Hg to 120/80 mm/Hg) of 100/65 obtained on 06/24/26 at 5:08 pm, a heart rate of 65 beats per minute obtained on 06/24/26 at 8:54 pm, 20 respirations per minute obtained on 06/24/26 at 8:54 pm, and an oxygen saturation that measured 92% obtained on 06/24/26 at 8:54 pm. Dated 06/25/26 at 12:50 am, a note revealed the RT found R #12 unresponsive. The RT called for help, entered R #12's room, and noted R #12 had a fast, thready pulse (a weak, thin, and often rapid pulse that feels like a fine thread under the fingers, indicating reduced blood flow or low blood volume) on the carotid artery (two major blood vessels in your neck that supply oxygen rich blood to your brain, face, and neck). Staff called 911, and the nurse learned R #12 was a DNR. The 911 call was cancelled, but emergency medical services (EMS) still responded to confirm the situation.Dated 06/25/26 at 2:00 am, documentation revealed R #12 was pronounced dead around 12:45 a.m. Upon assessment, vital signs were unreadable, and breath sounds and a pulse were absent. The nurse supervisor and the on-call provider were notified. E. Record review of R #12's electronic health record (EHR), dated 08/25/26, revealed nursing staff did not obtain additional vital signs after 8:54 pm on 06/24/26, when R #12 was documented as having a CIC on 06/25/26 at 12:50 am. The Nurse Practitioner (NP) #1 documented they had reviewed R #12's vital signs on 06/24/26, prior to R #12's death. F. On 08/25/26 at 9:46 am, during an interview, the RT Director (RTD) stated R #12's trach was capped (not in use), and he was still having secretions. The RTD stated if a resident had a large amount of secretions, the resident could aspirate (sucking food into the airway), so staff suctioned often. She stated she felt more interventions could have been done for R #12. G. On 08/25/26 at 12:17 pm, during an interview, the Director of Nursing (DON) #2 stated she saw the nursing progress note dated 06/25/26 at 12:50 am, which indicated R #12 was unresponsive, 911 was called, and then 911 was called again to cancel the response because R #12 was a DNR. She stated she would expect 911 to be called and the resident sent out if he still had a pulse. She stated she did not know why R #12's vital signs were not updated when it was determined R #12 was experiencing a CIC. DON #2 stated her expectation was that vital signs documented during a CIC should be accurate within the past hour of the CIC, and if respiratory complications were present, nursing staff should obtain new vital signs. DON #2 stated she was not aware R #12's advanced directive indicated medical interventions were requested if possible. H. On 08/25/26 at 1:34 pm, during an interview, Registered Nurse (RN) #2 stated R #12 was not stable, and when the RT entered R #12's room, he was requested to come in as well. RN #2 stated R #12 had a faint and fast pulse, so staff called 911. He stated he called 911 again to inform them R #12 was a DNR. RN #2 stated EMS informed him they were still going to respond to investigate the situation. He stated staff followed the resident's Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form when a resident was unresponsive and unable to make decisions. RN #2 stated he was not aware of any other interventions noted on R #12's MOST form. RN #2 stated he completed a CIC form for R #12 but did not check R #12's vital signs again and should have. I. On 08/25/26 at 3:45 pm, during an interview, DON #1 stated her expectation was that if a resident was unresponsive, staff needed to review the resident's MOST form. She stated if a resident's advance directive indicated DNR but the resident still had a pulse and the MOST form indicated all other interventions, she would expect the resident to be treated.

Based on record review and interviews, the facility failed to submit a separate initial incident report and five day follow up investigation report within the required timeframe to the State Agency for 1 (R #16) of 1 (R #16) resident, after R #16 experienced two separate falls with injuries requiring hospitalization. If the facility does not submit the summary of its investigation to the State Agency, the State Agency cannot appropriately review the allegation for further investigation. The findings are: A. Record review of the facility's abuse, neglect, exploitation or misappropriation reporting and investigating policy, last revised August 2025, revealed the Administrator (or designee) was responsible for reporting reportable incidents to the appropriate state agencies. The policy stated the Administrator would submit a follow-up investigation report within five business days of the incident, and the report would describe the results of the investigation. B. Record review of R #16's face sheet revealed R #16 was originally admitted to the facility on [DATE] with the following diagnoses:Metabolic encephalopathy (a degenerative brain disease that alters brain function or structure).Traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain).Vascular dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).Vascular Parkinsonism (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination).Falls.Muscle Weakness. C. Record review of R #16's nursing progress notes revealed the following:Dated 05/02/26 at 6:24 am, R #16 experienced a witnessed fall in the facility's smoking area after bending down to retrieve a cigarette. R #16 sustained injuries to his mouth and nose and was transported to the hospital for evaluation.Dated 05/02/26 at 4:00 pm, R #16 returned from the hospital after experiencing a fall at the facility, which resulted in bruising below both eyes and a nasal fracture. Dated 05/05/26 at 4:52 am, R #16 experienced a second, separate unwitnessed fall in his room at 3:10 am, and was found near his bed with a bleeding forehead laceration (a wound produced by tearing) and a right-hand abrasion (scrape or scratch). The provider was notified, Emergency Medical Services (EMS) was contacted, and R #16 was transported to the hospital for evaluation.Dated 05/08/26 at 2:41 pm, R #16 returned to the facility from the hospital wearing a neck brace following a fall on 05/05/26. Hospital documentation identified injuries including a multicompartment intracranial hemorrhage (bleeding that occurs in more than one distinct anatomical space within the skull), T12 compression fracture (a collapse of the 12th thoracic vertebra in the mid-to-lower back), and right pelvic fractures. D. Record review of the facility's incident report and five-day follow up reporting documentation for R #16's falls revealed the following:Dated 05/04/26 at 10:40 am, the facility submitted an incident report to the State Agency for R #16's fall with injury that occurred on 05/02/26. Dated 05/11/26 at 11:42 am, the facility submitted a five day follow up investigation report to the State Agency that combined R #16's falls with injuries from 05/02/26 and 05/05/26.The five day follow up investigation report for R #16's fall on 05/02/26 was not submitted to the State Agency until 05/11/26, and the facility did not complete or submit an initial incident report to the State Agency for R #16's unwitnessed fall with injury on 05/05/26. E. On 06/29/26 at 2:20 pm, during an interview, the Director of Nursing (DON) stated R #16 experienced an unwitnessed fall on 05/05/26 and was transported to the hospital, where he was later identified as having sustained a T12 fracture. The DON stated the facility did not submit a separate initial incident report to the State Agency for R #16's fall on 05/05/26 and should have. F. On 06/29/26 at 2:45 pm, during an interview, the Corporate Administrator stated her expectation was for R #16's second fall on 05/05/26 to be reported to the State Agency as a separate reportable incident, and for facility incident reports and five day follow up reports to be submitted within required timeframes.

Based on observation, record review, and interviews, the facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for 1 (R #1) of 1 (R #1) resident, when the facility failed to prevent a Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) drainage bag (also called a catheter collection bag; a device connected to the catheter tubing and collects urine) from touching the floor. This deficient practice has the potential to expose staff and other residents to infectious diseases. The findings are: A. Record review of the facility's catheter care and urinary policy, revised September 2024, revealed the purpose of the procedure was to prevent urinary catheter-associated complications, including urinary tract infections. The policy directed staff to use aseptic technique (a set of procedures used in healthcare to prevent the introduction of pathogens into a patient's body, thereby minimizing the risk of infection during medical procedures) when handling or manipulating the drainage system, ensure the catheter tubing and catheter drainage bag remained off the floor, and position the drainage bag below the level of the bladder to prevent urine from flowing back into the urinary bladder. B. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:Hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (paralysis and weakness on the left side of the body following a stroke).Neuromuscular dysfunction of the bladder (the bladder does not empty properly due to a neurological condition).Obstructive and reflux uropathy (a condition in which urine flow is blocked or flows backward, affecting the urinary tract). C. Record review of R #1's active physician orders, dated 09/27/25, revealed orders for a Foley catheter, including routine catheter care, catheter output monitoring every shift, catheter irrigation as needed, and catheter drainage bag changes as needed. D. On 06/26/26 at 2:17 pm, during an observation, R #1 was lying in bed with the urinary catheter drainage bag resting on the floor. E. On 06/26/26 at 2:18 pm, during an interview, Registered Nurse (RN #1) stated R #1's urinary catheter drainage bag should not rest on the floor because this could increase the risk of contamination and infection or become dislodged if pulled when the resident moved. F. On 06/29/26 at 9:00 am, during an interview, the Unit Manager (UM #1) stated R #1's urinary catheter drainage bag should be secured to the hook on the side of the bed and should not rest on the floor. UM #1 stated placing the catheter drainage bag on the floor could increase the risk of contamination and infection. G. On 06/29/26 at 2:40 pm, during an interview, the Director of Nursing (DON) stated a urinary catheter drainage bag should not be left on the floor. The DON stated leaving the catheter drainage bag on the floor created an infection control concern and increased the risk of contamination.

Based on interview and record review, the facility failed to ensure residents were free from neglect for 2 (R #20 and R #24) of 3 (R #20, #22 and #24) residents reviewed, when:The facility's nursing staff did not assess or change R #20's wound dressing for several hours after R #20 requested assistance.The facility's nursing staff did not assist R #24 as required, which caused R #24 to become upset.If the facility fails to assist residents as required or requested, then residents are likely to experience physical injury and psychological harm, including fear or distress related to staff interactions. The findings are: R #20:A. Record review of R #20's face sheet revealed an admission date of 01/30/26 with the following diagnoses:Cerebral infarction due to embolism (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain),Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly). B. Record review of R #20's Kardex (documentation system that enables nurses to write, organize, and easily reference key patient information) located in the electronic health record (EHR), dated 01/30/26, revealed R #20 required the assistance of one staff member for toileting, showering/bathing, hygiene, bed mobility and dressing. R #20 requires the assistance of two staff members and a mechanical lift for transferring from the bed to a wheelchair. C. Record review of R #20's nursing progress notes, dated 03/02/26, revealed a change in condition (CIC; a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) was completed when R #20 stated Certified Nursing Assistant (CNA) #5 was rude to him and would not assist him as he requested. D. On 03/26/26 at 9:00 am, during an interview, R #20 stated CNA #5 was mocking (making fun of someone or something in a cruel way) him and the nurse did not change his wound dressing for several hours after his request. R #20 was unable to recall any other details about the incident. E. On 03/26/26 at 9:52 am, during an interview, the Social Services Assistant (SSA) stated R #20 stated CNA #5 was mean to him during care. The SSA stated she reported it to the Administrator immediately. F. On 03/26/26 at 10:01 am, during an interview, the Administrator (ADM) stated she was told R #20 did not receive care during the morning on 03/02/26. The Administrator stated CNA #5 was observed going into R #20's room at 2:30 am, but no other staff entered R #20's room until a nurse entered R #20's room at 5:00 am. During the Administrators investigation, CNA #5 stated she changed R #20's brief, and he requested his wound dressing to be changed. The Administer stated CNA #5 reported that she told the nurse R #20's request for the dressing change. The Administrator stated the nurse told her that she entered R #20's room right away, but after watching the unit video footage, the Administrator confirmed the nurse did not go into R #20's room until 5:00 am. The Administrator stated R #20's wound dressing should have been addressed sooner than several hours after the request was made by R #20. G. On 03/26/26 at 2:33 pm, during an interview, the Director of Nursing (DON) stated R #20 filed a grievance on 03/02/26 indicating CNA #5 was rude to him and he did not get proper care. The DON stated R #20 told her that he wanted his wound dressing changed and it did not get changed until hours after he requested the wound dressing be changed. The DON stated CNA #5 went into R #20's room at 2:30 am on 03/02/26, but the nurse did not go into R #20's room to change the wound dressing until 5:00 am. The DON stated the nurse should have assessed and/or changed R #20's wound dressing sooner than 5:00 am. R #24:H. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE] with the following diagnoses:Fracture of the right femur (long bone that connects the hip to the knee),Type II diabetes (a disease in which the body cannot make or properly use insulin),Repeated falls. I. Record review of R #24's Kardex located in the EHR, dated 02/24/26, revealed R #24 required the assistance of one staff member for dressing, hygiene, showering/bathing, and bed mobility. R #24 was able to toilet herself with assistance in transferring, and R #24 required the assistance of one staff member when transferring from the bed to a wheelchair. J. Record review of R #24's nursing progress notes, dated 03/02/26, revealed an alleged abuse incident occurred on 03/02/26 involving R #24 when R #24 stated CNA #5 was rude and refused to help her. R #24 stated CNA #5 told her she can do some care areas herself and without staff assistance. K. Record review of R #24's abuse questionnaire, dated 03/02/26, revealed an answer of Yes to the question of Have you had any interactions or experiences in which you felt uncomfortable or felt negative while at the facility? In the explanation of what occurred, R #24 stated CNA #5 made her feel like she was not trying with her own recovery. L. On 03/26/26 at 10:03 am, during an interview, the Administrator (ADM) stated facility nursing staff should help residents as required. The Administrator stated due to the allegations made by R #24 regarding CNA #5 and the nurse, she terminated the employment of both employees. M. On 03/26/26 at 2:36 pm, during an interview, the Director of Nursing (DON) stated encouragement from nursing staff to residents is ok, but it must be encouragement and not making a resident feel bad about needing assistance. She stated since there were two incidents with residents having a grievance about CNA #5, they decided to terminate the employment of both CNA #5 and the nurse, which led to the allegations of neglect being confirmed.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #5) of 1 (R #5) residents reviewed, when:Facility staff failed to update R #5's plan of care to include substance use (the intake of various substances, including alcohol, tobacco products, and drugs, which can be consumed, inhaled, injected, or otherwise absorbed into the body). This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #5's face sheet revealed R #5 was originally admitted into the facility on [DATE] with the diagnosis of opioid dependence (physical and behavioral dependence on opioids, prescription or illicit). B. Record review of R #5's nursing notes revealed the following:Dated 02/01/26: Staff observed R #5 discarding an empty packet of Suboxone (a medication used to treat opioid dependence) in the trash. R #5 denied taking any, and R #5 was not prescribed Suboxone. Staff notified the on-call provider, who ordered monitoring for adverse reactions. Nursing staff and security conducted a room search and found no additional contraband (goods that have been imported or exported illegally). C. Record review of R #5's Care Plan revealed the following:Dated 01/21/26: R #5 resides on a secure unit related to polysubstance abuse disorder (a mental health condition involving the use of two or more substances in a pattern that negatively affects health, functioning, and quality of life). Interventions: perform safety risk evaluation on admission, as needed, and upon changes in condition.Dated 01/21/26: R #5 at risk for substance use disorder related to polysubstance abuse disorder. Interventions: monitor for signs or symptoms of substance abuse.R #5's care plan was not updated after the Suboxone incident on 02/01/26. D. On 03/27/26 at 12:23 pm, during an interview, the Director of Nursing (DON) stated she was aware of the 02/01/26 incident in which R #5 was found with an empty Suboxone packet. She confirmed the facility did not update R #5 's care plan following the incident. E. On 03/27/26 at 1:50 pm, during an interview, the Administrator (ADM) stated her expectation was when a new risk or behavior was identified, the facility would discuss it, and nursing would be responsible for updating the care plan. The ADM stated she would expect R #5's care plan to be updated to address the identified risk.

Based on interview, the facility failed to submit the required five-day follow-up investigation results to the State Agency (SA) for 1 (R #1) of 1 (R #1) resident reviewed for incidents.If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Refer to F0610 for related findings. B. On 12/19/25 at 1:49 pm during an interview with the Administrator (ADM), he confirmed the allegation of abuse grievance filed by R #1 on 10/31/25 was not submitted to the State Agency but should have.

Based on record review and interview, the facility failed to complete a thorough investigation for allegations of abuse and report the investigation findings within five working days for 1 (R #1) of 1 (R #1) resident reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Record review of R #1's grievance dated 10/13/25 revealed R #1 was spoken to rudely by a facility nurse regarding pain medication. R #1 wanted additional pain medication, but the nurse told him she could only give him Tylenol. R #1 stated, She [nurse] has just been rude since I've been here. R #1 also witnessed the same nurse threaten another resident on the unit. B. Record review of the facility's incident report list dated 10/31/25 through 12/12/25 revealed R #1's allegation of abuse was not documented, indicating an incident investigation and report was not completed for the incident. C. On 12/18/25 at 3:12 pm during an interview with R #1, he stated he no longer has concerns regarding pain medication, but the nurse used to be rude to him and made him feel bad. D. On 12/18/25 at 3:18 pm during an interview with Registered Nurse (RN) #1, she stated she was unaware R #1 filed a grievance against her (on 10/31/25). RN #1 also stated this incident was never discussed with her by facility management. E. On 12/18/25 at 4:55 pm during an interview with the Director of Nursing (DON), she stated she was out of town on 10/31/25, but she would have expected this allegation of abuse to be investigated by facility management. F. On 12/18/25 at 5:09 pm during an interview with the Unit Manager (UM) #1, he stated he remembered R #1's grievance dated 10/31/25, but he did not complete an investigation regarding R #1's abuse allegations. UM #1 also stated that he was unaware of the outcome of R #1's abuse allegations. G. On 12/18/25 at 5:31 pm during an interview with the Social Services Director (SSD), she stated she gave R #1's allegation of abuse grievance to UM #1 to investigate. The SSD confirmed she did not follow-up with UM #1 and should have. H. On 12/19/25 at 1:49 pm during an interview with the Administrator (ADM), he stated R #1's allegation of abuse grievance was not thoroughly invested nor reported to the State Agency and should have been.

Based on a record review and interviews, the facility failed to ensure medical records were complete for 1 (R #2) of 1 (R #2) resident reviewed when the facility failed to: Accurately document R #1's oxygen (O2) saturations (oxygen saturation levels, refer to the percentage of hemoglobin in the blood that is carrying oxygen). This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnosis: Chronic respiratory failure with hypoxia (low O2 levels). B. Record review of R #2's physician orders July 2025 through December 2025 revealed the following: 07/07/25 through 11/03/25: Obtain SPO2 (O2 saturations; a non-invasive measurement that estimates how effectively oxygen is being transported from the lungs to the body's tissues by red blood cells, reflected as a percentage) every shift (day and night). 11/03/25 through 12/09/25: Obtain SPO2 every shift. 12/11/25: Obtain SPO2 every shift. C. Record review of R #2's O2 saturations dated 09/01/25 through 12/18/25 revealed the following: 09/01/25 through 09/30/25: R #2 was documented as receiving O2 at 2 to 5 liters per minute (LPM) while also on room air (indicating R #2 was not receiving O2) seven times during this timeframe. 10/01/25 through 10/31/25: R #2 was documented as receiving O2 at 2 to 5 LPM while also on room air (indicating R #2 was not receiving O2) once during this timeframe.12/01/25 through 12/18/25: R #2 was documented as receiving O2 at 2 to 5 LPM while also on room air (indicating R #2 was not receiving O2) twice during this timeframe. D. On 12/18/25 at 4:24 pm during an interview with the Respiratory Therapist Manager (RTM), she stated the nursing staff are expected to document R #2's O2 saturations accurately and should not document R #2 as receiving supplemental oxygen while R #2 is on room air. The RTM confirmed R #2's O2 saturation documentation has been inaccurate on multiple occasions and stated that this should not have occurred. E. On 12/19/25 at 1:35 pm during an interview with the Director of Nursing (DON), she confirmed R #2's O2 saturations documentation was not accurate and should be.

Based on interviews and record reviews, the facility failed to demonstrate its measures to minimize the risk of Legionella (bacteria naturally found in water that can cause a severe type of lung infection called legionnaires' disease when people inhale tiny water droplets containing the bacteria) in the building's water system, when the Legionella Water Management Program (LWMP) team failed to develop and implement an adequate LWMP. This failure had the potential to affect all residents in the facility. This deficient practice is likely to lead to outbreaks of legionellosis (legionnaires' disease and Pontiac fever, a milder flu-like illness).The findings are:A. Record review of the facility's LWMP, last revised in August 2024, showed the following: - The policy did not have a procedure on how to use the control measures to control the introduction and/or spread of Legionella in the building water system. - The policy did not include control limits (the maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for legionella growth and spread) and parameters.- The policy did not have monitoring procedures to include:a. Specified and documented testing protocols for legionella.b. Established control limits acceptable for the control measures the facility monitored to reduce the risk for Legionella growth and spread.- The policy did not have established ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis in the facility. B. On 09/10/25 at 10:00 am, during an interview with the facility's Administrator, Regional Corporate Nurse, Director of Nursing, Maintenance Director, and Environmental Services Manager, they stated they were not aware the LWMP was inadequate to prevent the growth and spread of legionella in the building water system. They stated they were not aware the plan was missing procedures to explain how to use the control measures, acceptable control limits and parameters, monitoring procedures, and established ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis in the facility.

Based on record review and interview, the facility failed to ensure a resident was free from physical restraints for 1(R #10) of 1(R #10) resident when staff held a resident down to give him an injection of Haldol (anti-psychotic medication) for his behaviors. This deficient practice could likely cause harm to the resident from being restrained, fear to the resident if he does not understand what is going on, and does not promote a safe, secure environment. The findings are: A. Record review of R #10's face sheet revealed he was admitted on [DATE] with severe dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with agitation and suicidal ideation. B. Record review of R #10's physician order, dated 08/14/25, indicated an order for Haldol (antipsychotic medication) injection 5 milligram (mg). Inject one vial intramuscularly (IM; administered in the muscle) every eight hours for extreme agitation until 08/27/25. C. Record review of R #10's Medication Administration Record (MAR) indicated staff administered a Haldol injection 5 milligram (mg) to the resident on 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25, 08/20/25, 08/24/25, and 09/09/25. D. Record review of R #10's care plan, dated 08/12/25, indicated the following:- Focus: R #10 had a behavior problem, was angry with placement, resisted care, wandered and wanted to leave, and was exit seeking.- Interventions: Administer medications as ordered. Monitor and document for side effects and effectiveness. Anticipate and meet R #10's needs. Psychiatric referral sent 08/12/25. E. Record review R #10's nursing progress notes revealed the following:- Dated 08/16/25 at 10:05 pm, a struck through the note to indicate incorrect documentation. Further review of the struck through note revealed staff documented the resident lay in his bed, refused to eat his breakfast, and refused to take his scheduled medications. R #10 kept talking about going back to Santa Fe over and over until he became agitated. R #10 then became verbally and physical abusive. Three staff members held the resident's arms and legs, because he refused to get an IM Haldol. R #10 spat on the staff's face twice while they administered the injection. - Dated 08/16/25 at 10:05 pm, staff documented the resident lay in his bed, refused to eat his breakfast, and refused to take his scheduled medications. He kept talking about going back to Santa Fe, over and over, until he became agitated. The resident became verbally and physically abusive. Staff administered the Haldol intramuscularly. The resident spat on the staff's face twice while they administered the injection. Resident spat on another staff during dinner time later the same day. F. On 09/11/25 at 9:05 am, during an interview, the Unit Manager (UM) of Floor 200 stated R #10 was fairly new to the facility, and he did not want to be there. The UM stated R #10 became physically aggressive at times. She stated R #10 did not always require medication to calm him down. She stated R #10 liked cokes, so she would bargain with him using a coke. The UM stated she talked to the nurse who wrote the progress note on 08/16/25 at 10:05 pm. The UM stated she told the nurse the facility staff did not have a right to hold someone down and restrain them to give them medication. She stated her expectation was for staff to try other interventions first. She stated if nothing was working, then staff should leave R #10 alone for five minutes and go back to try again. She stated the medication should not be the first choice. The UM stated she had Nurse #4 strike out the note, because the charting was not appropriate. The UM stated a training with all staff about physically restraining residents needs to be done. She stated sometimes agency staff worked at the facility, and they thought restraints were okay to use. G. On 09/11/25 at 9:24 am, during an interview, Nurse #4 stated she worked at the facility for one year. She stated R #10 could be unpredictable, and he spat on her before. She stated R #10 was very difficult when he first came to the facility. She stated they only gave the injection when he was physically aggressive. She stated the resident fought her and spat at her the day she gave the injection to him. She stated he really needed the medication. Nurse #4 stated the UM spoke with her about not holding a resident down to give medication. She stated the UM told her holding R #10 down to give an injection for his behavior was not appropriate. H. On 09/11/25 at 12:00 pm, during an interview, Certified Nursing Assistant (CNA) #3 stated the nurse gave R #10 the injection on 08/16/25, and she held R #10 down while they gave the medication. She stated R #10 fought and spat on them. She stated they were not aggressive when they held R #10 down. I. On 09/11/25 at 12:30 pm, during an interview, the Director of Nursing (DON) stated she was familiar with R #10. The DON stated R #10 had a hard adjustment to the facility, and they were continuing to adjust his medications. The DON stated physically holding a resident down to give medication was not okay. She stated she would expect staff to re-direct and talk the resident through it. She stated she would not expect staff to hold the resident down. She stated if the resident was unsafe and could not be left alone, then staff should call the police to get a certificate of evaluation. She stated staff should call the resident's guardian as well.

Based on record review and interview the facility failed to ensure a resident was free from chemical restraints for 1(R #10) of 1(R #10) resident when staff administered Haldol (antipsychotic medication) injection, 5 milligram (mg), multiple times without a qualifying diagnosis and without attempting other interventions first. This deficient practice could likely create an environment of fear for the resident and does not promote a safe, secure environment. The findings are:A. Record review of R #10's face sheet revealed he was admitted on [DATE] with severe dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with agitation and suicidal ideation. B. Record review of R #10's care plan, dated 08/12/25, indicated the following: - Focus: R #10 had a behavior problem, was angry with placement, resisted care, wandered and wanted to leave, and was exit seeking. - Interventions: Administer medications as ordered. Monitor document for side effects and effectiveness. Anticipate and meet R #10's needs. Psychiatric referral sent 08/12/25. C. Record review of R #10's psychological evaluation, completed 08/13/25, indicated the following:- R #10 stated he did not want to be at the facility. He did not like his roommate, because he believed the roommate stole his clothes. R #10 made a comment that if he had a gun, then all these people would be dead. R #10 stated they were a bunch of crazy idiots. R #10 wanted to go back to Santa Fe.- Diagnoses attached to the encounter: R #10 was diagnosed with suicidal ideation, unspecified dementia with unspecified severity with agitation, and moderate major depressive disorder.- Plan: Resident was deemed safe to stay in the facility. The resident did not have a plan or a means to harm himself or others. Risperidone (anti-psychotic) medication was discontinued, and sertraline (used for depression) was increased. D. Record review of R #10's physician order, dated 08/14/25, indicated an order for Haldol (antipsychotic medication) injection 5 milligram (mg). Inject one vial intramuscularly (IM; administered in the muscle) every 8 hours for extreme agitation until 08/27/25. E. Record review of R #10's Medication Administration Record (MAR) indicated staff administered a Haldol injection 5 milligram (mg) to the resident on 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25, 08/20/25, 08/24/25, and 09/09/25. F. Record review of R #10's nursing progress notes indicated the following notes:- Dated 8/13/25 at 11:14 am, R #10 was at the nurse's station asking to go back to the hospital in Santa Fe. The nurse told R #10 he had been discharged from the hospital to the facility. R #10 stated if he could not leave this facility to go back to Santa Fe, then he would kill everybody and himself. Provider and Unit Manager (UM) notified. Haldol 5 mg intramuscularly given to left upper arm.- Dated 8/13/25 at 12:05 pm, the Psychiatric Provider saw R #10, and the resident verbalized he would get a gun and shoot everyone. R #10 had a history of suicidal ideation. The Psychiatric Provider cleared the resident, and one on one care was not initiated.- Dated 8/14/25at 10:27 pm, R #10 was given a Haldol 5 mg intramuscularly this morning when resident became agitated, yelling, screaming, and calling names. Re-assessed after 30 minutes, and the medication was effective. R #10 became calm and quiet while in the day room.-Staff did not document a nursing progress note on 08/15/25 to indicate why staff administered a Haldol injection to R #10. - Dated 8/16/25 at 10:05 pm, R #10 lay in bed, refused to eat breakfast, refused to take scheduled medications. He kept talking about going back to Santa Fe over and over until he became agitated. Resident became verbally and physically abusive. Haldol IM given. Resident spat on the staff's face twice while they gave the injection. Resident also spat on another staff during dinner time.- Dated 8/17/25 at 10: 06 pm, R #10 was agitated earlier in the shift, shouting he wanted to go look for his dog. R #10 was given redirection and medication, but it did not change R #10's behavior. Staff administered a Haldol injection to the resident. The medication took time to kick in, but it eventually helped as the patient went to sleep.- Dated 8/20/25 at 11:09 pm, staff administered Haldol 5 mg intramuscularly to the resident during the morning when the resident started screaming and acting upset. R #10 stayed in his room all day, and he decided to go to the nurse's station in the evening to look for his dog.- Dated 8/24/25 at 8:15 am, staff heard R #10 yelling in hallway and trying to hit hall monitor. He held onto the Hall Monitor's right forearm tightly. The Hall Monitor reported R #10 grabbed a spray bottle with chemicals from housekeepers' cart and tried to spray another resident with it. The Hall Monitor immediately reacted and took the spray bottle away from R #10. R #10 became very angry and began yelling and cussing at th eHall Monitor. The resident grabbed the Hall Monitor and tried to hit him. Staff assisted the Hall Monitor and redirected R #10 away from the Hall Monitor.- Dated 8/24/25 at 8:20 am, R #10 was redirected to his room and stated that man hated him and wanted to hurt him. R #10 was given Haldol 5 mg injection, and he tolerated it well. - Dated 9/9/25 at 1:00 pm, R #10 was out of bed ambulating (walking) in hall. R #10 did not have a steady gait. R #10 was impulsive and did not allow staff to help him. He tried to hit the Certified Nursing Assistants (CNAs) and threw food and drink at them. Called Nurse Practitioner and Haldol 5 mg was ordered and given on right dorsogluteal (upper part of the buttock) area. G. On 09/11/25 at 8:52 am, during an interview, the Social Services Assistant (SSA) stated R #10 had moments were he quiet and content. The SSA stated R #10's anger and behaviors were due to being at the facility. She stated R #10 made statements about killing everyone, but the SSA stated she thought he just wanted to be let out of the facility. She stated she did not think the resident was suicidal. H. On 09/11/25 at 9:05 am, during an interview, Unit Manager (UM) of Floor 200 stated R #10 was fairly new to the facility, and he did not want to be there. The UM stated R #10 became physically aggressive at times. She stated R #10 did not always require medication to calm him down. The UM stated her expectation was for staff to try other interventions before giving the Haldol medication for his behaviors. She stated if the other interventions did not work, then staff should leave R #10 alone for five minutes and try again later. She stated the medication should not be the first choice. I. On 09/11/25 at 1:30 pm, during an interview, the Physician Assistant (PA) stated he saw R #10 the first time, because R #10 made homicidal threats (threats to harm others). The PA stated he was not concerned R #10 would kill anyone, because the resident did not have any means to hurt someone. He stated R #10 made suicidal threats (threats to harm self) during a different visit. He stated he ordered the Haldol to be administered for severe agitation. He stated suicidal threats alone would not warrant R #10 receiving the Haldol. He stated the facility staff could interpret extreme agitation as they needed and perhaps making threats of killing everyone rose to the level.

Based on observation, interviews, and record reviews, the facility failed to protect the residents from the potential for accidents and hazards when the facility:- Permitted residents, with independent smoking privileges, to keep smoking materials, to include lighters and cigarettes, in their possession and to take them to their rooms.- Failed to ensure residents who utilized supplemental oxygen did not take their oxygen tanks into the designated smoking area.These failures had the potential to affect all residents. If residents have smoking materials in their possession, then there is the potential to light cigarettes or start fires in the facility. If this occurred around supplemental oxygen, then the oxygen could ignite and feed the fire. This puts residents at risk of serious injury, serious harm, and possibly death. The findings are:A. Record review of the facility's Smoking Policy - Residents, dated August 2024, revealed residents, who had independent smoking privileges were permitted to keep cigarettes, electronic cigarette pipes, tobacco, and other smoking items in their possession. B. Record review of the facility's list of residents who smoke, dated July 2025, revealed the facility had 53 residents with independent smoking privileges. C. Record review of the facility's Oxygen Administration Policy, dated September 2024, revealed the policy did not address safety precautions for the use of supplemental oxygen. D. Review of National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, revealed the following:- Chapter 11 Gas Equipment- 11.5 Administration- 11.5.1.1 Elimination of Sources of Ignition. - 11.5.1.1.1 Smoking materials (e.g., matches, cigarettes, lighters, lighter fluid, tobacco in any form) shall be removed from patients receiving respiratory [breathing] therapy [to include supplemental oxygen]. - 11.5.1.1.2* No sources of open flame shall be permitted in the area of oxygen administration. E. On 07/23/25 during the recertification survey, observation revealed the following:- Multiple residents throughout the facility received supplemental oxygen. - At 10:15 am, R #269 sat in her wheelchair in the designated smoking area. The resident wore a nasal cannula connected to an ambulatory liquid oxygen cylinder which hung on the back of her wheel chair, and she held a pack of cigarettes and a lighter. The resident's ambulatory oxygen cylinder contained a sticker which stated No Smoking. Further observation revealed R #31 sat in a wheelchair next to the resident and held a lit cigarette. F. On 07/23/25 at 10:16 am, during an interview and observation, R #269 stated she forgot to remove her oxygen cylinder prior to entering the designated smoking area. She stated she was aware she should not wear it in the smoking area. The resident propelled herself past multiple residents who were actively smoking and into the facility. G. On 07/23/25 at 10:20 am, during an interview, the Maintenance Director stated staff should be stationed at the facility exit to the designated smoking area to remind residents to remove their oxygen before entering the smoking area. He stated the staff was not present today (07/23/25). The Maintenance Director stated oxygen cylinders should not be brought into the designated smoking area because it was a fire hazard. H. On 07/23/25 at 10:25 am, observation revealed the exit from the facility to the designated smoking area did not have a designated staff present to remind residents to remove their oxygen tanks before entering the smoking area. I. On 07/23/25 at 10:35 am, during an interview, the Corporate Nurse and the Respiratory therapist stated the facility's policy was to educate the independent smokers. They stated the independent smokers were alert and oriented, so they educated them not to take their oxygen outside. The Corporate Nurse and the Respiratory therapist stated education was the facility's only precaution to prevent oxygen use in the designated smoking area, and they did not have any other systems in place. They stated the independent smokers were aware they should not take their oxygen tanks into the designated smoking areas. J. On 07/23/25 at 1:00 pm, during and interview, the Administrator, the DON, and the ADON stated independent smokers, to include independent smokers who utilized supplemental oxygen, could keep their smoking materials on them, to include cigarettes and lighters. He said some independent smokers kept their smoking materials in their room and others kept their smoking materials with the Receptionist. The Administrator stated the independent smokers were allowed to carry their smoking materials through the facility to the outside designated smoking area. He stated residents who utilize supplemental oxygen were allowed to be in the same space as the independent smokers with their smoking materials. Based on observations, interviews, and record review, an Immediate Jeopardy (IJ) was identified on 07/23/25 at 1:30 pm, and the facility Administrator was notified in person. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 07/23/2025 at 5:40 pm. - Facility staff will always be present during smoking hours, 7:00 am to 9:30 pm, in the designated smoking areas to monitor residents to ensure oxygen equipment (portable oxygen equipment, e-tanks, or concentrators) are not present in the smoking area, which may harm a resident who was present in the smoking area. - On 07/23/25, all staff education on the facility's smoking policy was initiated. The facility's smoking policy was updated and sent to all staff via the employee messaging system on 07/23/25. All staff education on the updated smoking policy will be completed on 07/27/25. - The smoking attendant who was present in the hallway close to the designated smoking area will receive disciplinary action for not being present in the designated smoking area.- Any smoking material, to include cigarettes and lighters, will be maintained by the facility in a secured cart and will be dispersed by facility personnel in the designated smoking area. The smoking cart will be located in the proximity of the designated smoking areas. The smoking cart will be under the supervision of the smoking attendant. This will become effective on 07/23/25 and will be completed by 07/23/25. - The facility resident smoking policy will be revised. The facility smoking policy will be revised to include independent smoking procedures. It will also include updated policy of smoking material storage. - Independent residents who wish to smoke between the hours of 9:30 pm and 7:00 am will be allowed to smoke under the facility staff's supervision. - Facility smoking sweep/audit of current smokers in the facility was completed on 07/23/25. All smokers identified were educated on the new procedures regarding smoking policy and management of smoking materials. All smoking materials were confiscated and placed in a secured smoking cart on 07/23/25. K. On 07/24/25 at 10:59 am, during an observation and interview, R #2 had his cigarettes and lighter. The resident stated he was going to refuse to give his smoking materials up when staff asked for them, but the staff did not ask him for his smoking materials. L. On 07/24/25 at 10:08 am, observation revealed R #144 walked through the 600 unit with two unlit cigarettes in his hands. The resident approached the smoking attendant and said he was leaving the building. The smoking attendant gave R #144 his pack of cigarettes. The resident walked away from the smoking area to the elevator, he boarded the elevator and went to another floor of the building with his smoking materials. M. On 07/24/25 at 10:23 am, observation revealed R #288 entered the building from the smoking area. The resident held his cigarettes and lighter, propelled himself past the smoking attendant, and told the attendant, I will be back. The smoking attendant did not stop the resident and did not collect the resident's smoking materials. The resident propelled themself through the building. N. On 07/24/25 at 10:23 am, during an interview, the smoking attendant stated she completed the training on the new smoking policy the morning of 07/24/25. She stated she was supposed to collect all smoking supplies from the residents when they entered the building from the smoking area. The smoking attendant stated she did not collect R #288's smoking materials because she had a lot going on. She stated she trusted the resident and knew he would return. The smoking attendant stated she was not supposed to allow residents to take their smoking materials past her, per her training that morning on the new smoking policy. She stated she was not going to argue with R #288 because she considered that abuse. The smoking attendant stated she gave R #144 his smoking materials, because he said he was leaving the facility. She stated she did not know if the resident left or when he was leaving. Implementation of the POR was verified onsite on 07/25/25, and the IJ was removed on 07/25/25 at 3:00 pm. The scope and severity was reduced from a L to an F. Implementation of the POR was verified by the following: - Record review of the facility's In-Service Attendance Sheets, dated 07/23/25, revealed the following: - Topic: All smoking materials must be kept in the smoking cart. The smoking attendant must be present at the smoking cart in the smoking area at all times. - Facilitators: The Director of Nursing and the Assistant Director of Nursing. - Staff signed they received the training, to include dietary, maintenance, nursing, administrative, laundry, activities, social services, security, and housekeeping staff.- Record review of the facility's audit of residents who smoked, dated 07/25/25, revealed the following: - Staff met with all residents with supervised smoking privileges to ensure they did not have any smoking materials on themselves or in their room. - Staff met with all residents with independent smoking privileges provided education on the new smoking policy and took their smoking materials to the smoking cart near the designated smoking area.- On 07/24/25 at 2:00 pm, record review and observation revealed staff conducted an education for all resident smokers. Topics covered included: review of the facility smoking policy, safety guidelines related to smoking, proper process for oxygen usage, proper process for smoking in designated areas, proper storage and keepsake of personal smoking items. Residents signed an attendance record. - Record review of the facility's updated Smoking Policy, dated July 2025, revealed residents with or without independent smoking privileges may not have or keep any smoking items, including cigarettes and tobacco, on their person. All smoking items must be kept and stored in the designated smoking cart. The facility maintains the right to confiscate smoking items found in violation of the smoking policies. - On 07/25/25 at 1:53 pm, during an interview, Registered Nurse (RN) #1 stated she completed the new oxygen training online, and residents could not keep their smoking materials with them in the facility. She stated staff confiscated all the resident smoking materials. - On 07/25/25 at 1:54 pm, during an interview, LPN #1 stated she completed the online training on 07/24/25, and the residents had a meeting on 07/24/25 to be informed of the changes. She stated if staff saw or suspected smoking materials with a resident, then they are to confiscate the smoking materials right away. - On 07/25/25 at 2:00 pm, during an interview, Smoking Attendant (SA) #1 stated worked during the resident smoking hours, 7:00 am to 9:30 pm. She stated residents were not allowed to have their cigarettes with them inside the facility. She stated she gave the residents two cigarettes each. She stated residents with supplemental oxygen had to leave their oxygen at the atrium door or she would not give them their two cigarettes. She stated if residents refused to return smoking materials to the cart when they reentered the facility, then she would call security to come and speak with the resident. - On 07/25/25 at 2:25 pm, during an interview, Therapist #1 stated she completed an online training regarding smoking materials and oxygen. She stated residents were not allowed to take their oxygen containers outside any longer. She stated residents also could not carry smoking materials on their person through the facility any longer. - On 07/25/25 at 2:29 pm, during an interview, the Front Receptionist stated all smoking materials were kept in a cart by the atrium door, and staff brought the cart to the front area for observation by security during the night. She stated oxygen was not allowed outside near the residents who smoked. The receptionist stated security locked the atrium door after smoking hours. She stated if a resident wanted to smoke after hours, then the night supervisor supervised the resident outside. She stated if staff saw a resident with smoking materials in the building, then they would call a CNA or other health staff to confiscate the items. - On 07/25/25 at 2:30 pm, during an interview, R #50 stated she got the smoking policy update by word of mouth in the courtyard from other smokers. She stated smoking near the doors and going outside with oxygen was no longer permitted. - On 07/25/25 at 2:45 pm, during an interview, R #78 stated he got the updated rules about oxygen and smoking materials. He stated he could not have his smoking materials in his room or carry them anymore. He stated he had to leave his oxygen at the door now and always sign out his cigarettes with the attendant.

Based on observation, record review, and interview, the facility failed to ensure resident was assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 2 (R #123 and R #296) of 3 (R #101, R #123 and R #296) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail. The findings are: R #123 A. On 07/22/25 at 8:29 am during an observation of R #123's room, there was a quarter size rail (rails that take up a quarter part of the bed) on each upper side of R #123's bed. B. Record review of R #123's admission Record revealed he was originally admitted to the facility on [DATE] with the following diagnoses: 1. Fracture of Neck of Left Femur (a break in the bone of the upper thigh, specifically within the region just below the hip joint ball), 2. Repeated Falls, 2. Muscle Wasting and Atrophy (decrease in muscle mass and strength), 3. Lack of Coordination, 4. Dementia (a general term for a decline in mental ability severe enough to interfere with daily life, not a specific disease), 5. Schizophrenia (a chronic and severe mental health disorder that affects how a person thinks, feels, and behaves), 6. Disorder of bone density and structure (conditions where bones become weaker, more fragile, and susceptible to fractures due to changes in bone mass and/or structural integrity). C. Record review of R #123's the Electronic Health Record (EHR) revealed: 1. the record did not contain any physician orders for the use of bedrails. 2. the record did not contain a bed rail assessment for the safe usage of bedrails. D. On 07/22/25 at 8:30 am during an interview with R #123, he stated he uses the bed rails for bed mobility and repositioning. R #123 could not remember how long he has the bed rails but did not recall having them upon admission. E. On 07/24/25 at 10:58 am, during an interview with the 2nd floor unit manager (UM2), she stated she did not know if R #123 had bed rails upon admission as he was on a previous floor before arriving to her unit. She confirmed R #123 did not have orders for use of bed rails nor a completed assessment and should have. R #296 E. Record review of R #296's admission Record revealed he was originally admitted to the facility on [DATE] with the following diagnoses: 1. Chronic systolic congestive heart failure (CHF; impaired heart function), 2. Moderate Persistent Asthma (condition where the airway becomes inflamed, narrow, and swell, and produces extra mucus which makes it difficult to breathe), 3. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 4. Essential Primary Hypertension HTN; high blood pressure), 5. Hyperthyroidism (the thyroid is not making enough thyroid hormone). F. On 07/22/2025 at10:25 AM, during an observation of R #296 laid in bed in an upright position with bilateral (both sides) half side rails up on both sides of the bed. G. Record review of R #296's the Electronic Health Record (EHR) revealed the record did not contain any physician orders for the use of bedrails and did not indicate a bed rail assessment had not been completed for the safe usage of bedrails.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring adequate indication of use based off of the residents' conditions for 3 (R #2, R #123, and R #282) of 4 (R #2, R #44, R #123, and R #282) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The Findings are: R #2 A. Record review of R #2's physician's orders revealed the following: 1. Topiramate Oral Tablet (an anticonvulsant medication that is used to treat seizures and prevent migraine headaches.) 50 milligrams (MG). Give 1 tablet by mouth one time a day for Seizures (a sudden, abnormal surge of electrical activity in the brain that can cause a variety of symptoms, including changes in behavior, movement, sensation, and awareness). Start Date: 04/12/25 2. Trazodone HCl Oral Tablet (an antidepressant medication primarily used to treat depression, anxiety, and insomnia) 100 MG (Trazodone HCl) Give 2 tablet by mouth at bedtime for insomnia (difficulty falling asleep, staying asleep, or experiencing non-restorative sleep, leading to daytime impairment). Start Date: 04/11/25 B. Record review of R #2's face sheet revealed R #2 was admitted to the facility on [DATE] and does not have the following diagnosis: 1. Seizures 2. Insomnia R #123 A. Record review of R #123's physician's orders revealed the following: 1. Atorvastatin Calcium Oral Tablet (a medication belonging to the statin class, commonly prescribed to lower cholesterol and triglyceride levels and reduce the risk of cardiovascular disease) 40 milligrams (MG). Give 0.5 tablet by mouth one time a day for hyperlipidemia (a condition in which there are high levels of fats (lipids) in the blood). Start date: 05/22/25 2. Benztropine Mesylate Oral Tablet (anticholinergic: it works by blocking the action of a neurotransmitter in the central nervous system) 2 Milligrams (MG). Give 1 tablet by mouth two times a day for Parkinsons (a progressive brain disorder that results from the death of dopamine-producing cells, leading to problems with movement, coordination, and other symptoms like tremor, rigidity, and slow movement). Start Date: 06/13/25. 3. Aspirin Oral Tablet (blood thinner and non-steroidal anti-inflammatory drug) 81 milligrams (MG). Give 1 tablet by mouth at bedtime for coronary artery disease (occurs when arteries supplying blood to the heart become narrowed by plaque buildup (atherosclerosis), reducing blood flow and potentially causing chest pain, shortness of breath, or a heart attack). Start Date: 04/21/25. B. Record review of R #123's face sheet revealed R #123 was admitted to the facility on [DATE] and does not have the following diagnoses: 1. Hyperlipidemia (a condition where there are abnormally high levels of lipids (fats) in the blood). 2. Parkinson's (a progressive neurodegenerative disorder that primarily affects movement). 3. Coronary Artery disease (occurs when the coronary arteries, which supply blood to the heart, narrow or become blocked). R #282 A. Record review of R #282's physician's orders revealed the following: 1. Valproic Acid oral solution (anticonvulsant; medication used to treat seizure activity), 250 milligrams (MG)/5 milliliters (ML). Give 5ML by mouth three times a day for seizure disorder. Start date 04/18/25. B. Record review of R #282's face sheet revealed R #123 was admitted to the facility on [DATE] and does not have a diagnosis of seizure disorder. C. On 07/24/25 at 10:58 AM, during an interview with the 2nd floor unit manager (UM2), confirmed the indications of use for medications should match residents' diagnoses. UM2 confirmed the indications of use for medication did not match diagnosis for R #2, R#123 and R#282.

Based on interview and record review, the facility failed to ensure residents received routine dental services (an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures) were provided dental visits annually for 2 (R #1 and R #14) of 2 (R# 1 and R #14) residents reviewed for routine dental services. This deficient practice is likely to negatively impact residents through pain, mood, and state of well-being if dental conditions have not been addressed in a timely manner. R #1 A. Record review of R #1's Electronic Health Record (EHR), R #1 was admitted on [DATE] with the following diagnoses: 1. Muscle wasting and atrophy (the decrease in size or wasting away of a cell, tissue, organ, or muscle), 2. Muscle Weakness, 3. Adult Failure to Thrive (decline in physical and cognitive function, accompanied by weight loss, decreased appetite, and inactivity), 4. Acute Respiratory Failure with Hypoxia (inadequate supply of oxygen to the tissues), 5. Gastro-Esophageal Reflux Disease (GERD; stomach acid frequently flows back into the esophagus, causing irritation). B. On 07/22/2025 at 9:06 AM, during an interview with R #1, she stated she needed bottom dentures and has been asking the nurses and social services for an appointment to get them, but nothing has happened. R #1 stated it is difficult to eat without lower teeth. C. On 7/24/25 at 3:45 pm, during an interview with the director of social services (DOSS), she confirmed that R #1 should have had a dental appointment scheduled and has not. R #14 D. Record review of R #14's face sheet on 05/14/25, was admitted with the following diagnoses: Paranoid Schizophrenia (a serious mental disorder (affects the brain and mood) 1. Other cerebral infarction due to occlusion or stenosis of the small artery (an area of dead tissue in the brain, 2. Leukemoid Reaction (very large short-term increase in your white blood cell count that can be mistaken for leukemia), 3. Rhabdomyolysis (serious condition caused by muscle injury or breakdown), 5. Primary insomnia (difficulty falling asleep, staying asleep, or experiencing non-restorative (not resting or restoring the body) sleep), 4. Dysphagia, oral phase (difficulty in swallowing or as a symptom of disease). E. On 07/21/25 at 12:54 pm, during an interview with R #14, she stated she has not had a dentist come into the facility and look at her teeth. F. Record review of R #14's progress notes dated 04/14/25 through 07/23/25 revealed the progress notes did not contain any documentation of dental service (a diagnostic, preventive, or corrective procedure furnished by or under the supervision of a dentist) visits for R #14. G. Record review of R #14's medication orders revealed an order dated 06/04/25 for Depakote, an anticonvulsant that has a side effect of causing enlargement of the gums. H. Record review of R #14's care plan dated 05/21/25 revealed she is to be monitored for side effects of this medication, and she has not been seen by a dentist for routine dental/gum care of the teeth and gums. I. On 07/21/25 at 1:06 pm, during an interview with Unit Manager (UM) #3, she stated dental evaluations are not performed annually for residents. Dental appointments are made through social services when the facility is informed of dental problems for a resident. She was not aware of any issues that R #14 is experiencing. J. On 07/21/23 at 1:29 pm during an interview with Social Services Staff (SS) #1, she stated she does not arrange resident transportation for dental appointments and is unsure how often routine dental care needs to be arranged per facility policy; but does know that resident dental visits are made by referral only and not performed annually (every year) for residents. K. Record review of the facility's Dental Services Policy obtained from SS #1, and dated December 2022, revealed the following: 1. Routine and emergency dental services are available to meet the resident's oral health services (the health of the teeth, gums, and the entire oral-facial system that allows us to smile, speak, and chew) in accordance with the resident's assessment and plan of care. 2. Social Services representatives will assist residents with appointments, transportation arrangements and reimbursement (repayment) of dental services under the state plan, if eligible (meeting criteria). 3. All dental services are recorded (documented) in the residents' medical record.

Based on observation, record review, and interview, the facility failed to maintain proper infection prevention measures by: 1. Not disinfecting direct patient care equipment after use. 2. Not adhering to Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities), 3. Not adhering to contact precautions (used for individuals with infections that can spread through direct or indirect contact with the patient or their environment). These deficient practices have the potential to affect all 291 residents residing in the facility according to the census provided by the Administrator (ADM) on 07/21/25 by experiencing an increase of infections leading to further health concerns. The findings are: Equipment A On 07/24/25 at 9:58 AM during an observation of the medication pass for R #75, Registered Nurse (RN) #32 took R #75 blood pressure with portable blood pressure cuff. Upon completion of blood pressure measurement RN placed cuff on her medication cart workspace and continued to work with another resident. She then put the cuff back into her pocket without cleansing. B. On 07/24/25 at 10:00 am during an interview with RN #32, she stated she should have cleaned the blood pressure cuff with disinfectants after use. C. On 7/25/25 at 11:39 am, during an interview with the IP (Infection Preventionist), she confirmed that all equipment used for residents should be clean before and after use. Contact Precautions D. On 07/21/25 at 09:25 am, during an observation, housekeeping (HK) #13 entered a resident's room without proper personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection), as directed by the Contact precaution sign posted on the outside of R #75's door. E. On 07/21/25 at 9:30 am, during an interview with HK #1, she stated she should have been wearing the proper PPE. F. On 07/21/25 at 9:42 am during an observation, Licensed Practical Nurse (LPN) #73 entered R #75's room without PPE. G. On 07/21/25 at 9:47 am, during an interview LPN #73 stated you only must use a gown if touching a resident even with contact isolation, she stated that the policy states should be gown and gloves when doing direct patient care. Enhanced Barrier Precautions H. On 07/25/25 at 10:30 am, during an observation of R #125 room had EPB signage outside the door to his room. I. On 07/25/25 at 10:35 am, during an observation of peri-care (cleaning from the front of the hips, between the legs and buttocks, and the back of the hips) and urinary catheter care. RN #32 and Certified Nurse's Aide (CNA) #77 entered room without putting on the appropriate PPE as directed by the sign on the door. J. On 07/25/25 at 10:42 am, during an interview with RN #32, she confirmed gown, and gloves should be worn during catheter care and infection control signs should be followed. K. On 07/25/25 at 10:47 am, during an interview with CNA # 77, she stated she should have worn gown and gloves according to the sign that was posted. L. On 7/25/25 at 11:39 am, during an interview with the Infection Control Nurse (ICN) with she stated the infection control signage is there for a reason and staff are expected to read the signs and follow directions accordingly. She stated her expectation is that staff should have worn PPE prior to entering the EBP during high contact interaction with resident and should have worn PPE prior to entering a room with contact precautions whether they were interacting with resident or not. She also stated that LPN #73 is incorrect about the current policy on contact isolation policies.

Based on observation and interview, the facility failed to maintain an effective pest control program for 3 (R #2, R #52, and R #172) of 3 (R #2, R #52, and R #172) residents reviewed by allowing insects and their waste in their living space. If the facility does not maintain an effective pest control program, then residents are at a greater risk of contracting certain diseases and may feel disgusted or embarrassed about their living space. The findings are: R #2 A. On 07/22/25 at 12:42 pm, an interview and observation with R #2 revealed the following: 1. R #2 stated the facility has a big bug problem and feels like they could do more to control it. R #2 stated his sister has to purchase bug traps (traps and kills insects) to keep in his room. 2. Two bug traps were located on the floor of the restroom in R #2's room. 3. Duct tape running along the border of the wall that R #2 stated he put there because bugs would come out of the wall there. 4. R #2 stated he has talked with the facility's staff several times regarding the pest infestation but nothing happens. R #52 and R #172 B. On 07/25/25 at 9:16 am, an observation of R #52's room revealed a corner of the wall where black spots appeared to form a larger black spot, approximately six inches by 10 inches. The black spots appear to be insects, larva (young insects), and insect eggs. C. On 07/25/25 at 9:37 am during an interview with the 5th floor unit manager, she stated she has not been told anything about a pest infestation in R #2's room or R #52 and R #172's room. The 5th floor unit manager confirmed the black spots in R #52 and R #172's room does appear to be an insect infestation.

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 3 (CNA #3, CNA #4, and CNA #5) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #3 A. Record review of CNA #3's personnel file revealed CNA #3 was hired on 05/06/24. B. Record review of CNA #3's in-service training Transcript Report revealed CNA #3 did not complete any of the required trainings. CNA #4 C. Record review of CNA #4's personnel file revealed CNA #4 was hired on 11/29/23. D. Record review of CNA #4's in-service training Transcript Report revealed CNA #4 did not complete the 12 hours of training as required per year. CNA #5 E. Record review of CNA #5's personnel file revealed CNA #5 was hired on 07/26/23. F. Record review of CNA #5's in-service training Transcript Report revealed CNA #5 d did not complete the 12 hours of training as required per year. G. On 07/24/25 at 3:09 pm, during an interview with the Human Resources Director (HRD), she confirmed the following: 1. CNA #3 has not completed any training during his employment at the facility. 2. CNA #3 continues to work shifts providing care for residents in the facility even though he has completed no trainings. 3. CNA #4 has not completed 12 hours of training annually. 4. CNA #4 continues to work shifts providing care for residents in the facility even though she has not completed all required trainings. 5. CNA #5 has not completed 12 hours of training annually. 6. CNA #5 continues to work shifts providing care for residents in the facility even though she has not completed all required trainings. The HRD further stated she expected all CNAs to complete at least 12 hours of training per year.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #282) of 3 (R #2, R #123, and R #282) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: A. Record review of R #282's physician's orders revealed the following: - An order for Gabapentin capsule (anticonvulsant; medication used to treat seizure activity), 100 milligrams (mg). Give one capsule by mouth three times a day for intrusive agitation (unwanted thoughts that enter one's mind despite efforts to avoid them, and agitation, a state of being unable to remain still or calm, characterized by motor hyperactivity, restlessness, emotional tension, and sometimes verbal aggression. Start date: 03/14/25. - An order for Trazadone oral tablet (antidepressant; medications used to treat depression and other mental health conditions), 100 milligrams (mg) Give one tablet by mouth at bedtime for sleep. Start date: 07/21/25. B. Record review of R #282's medical record revealed staff did not document the consent for Gabapentin and Trazadone. C. On 07/24/25 at 10:58 AM, during an interview with the 2nd floor unit manager (UM2) confirmed the indications of use for gabapentin and trazadone are considered psychotropic (psychotropic medication; any drug that affects brain activities associated with mental processes and behavior) use and require consent. She confirmed staff did not obtain the consent form for the Gabapentin and Trazadone for R #282. The UM2 confirmed staff are expected to complete the psychotropic medication consent form prior to the resident starting psychotropic medications.

Based on interview and record review, the facility failed to keep residents free from abuse and neglect for 1 (R #1) of (R #1) residents sampled for abuse when staff failed to: 1. Provide line of sight supervision for R #1 after she requested a one on one or to be sent to the hospital. This deficient practice could likely result in physical harm to residents, and/or psychosocial distress (unpleasant emotions associated with a highly stressful situation), or worsening of current mental health conditions for the residents who were subject to this behavior. The findings are: R #1 A. Record review of the face sheet for R #1 indicated the following: R #1 was admitted to the facility on [DATE]. She had the following diagnoses: - Anoxic brain damage (lack of oxygen to the brain), - Acute respiratory failure with hypoxia (lungs cannot deliver enough oxygen or remove enough carbon dioxide from your blood), - Cardiac arrest (heart suddenly and unexpectedly stops beating), - Tracheostomy (surgical opening in the neck allowing air to flow), - Dysarthia (difficulty in speech due to weakness of speech muscles), - Anarthria (severe motor speech disorder that prevents someone from articulating speech at all), - Depression. B. Record review of R #1's care plan initiated on 05/30/24. indicated the resident had a communication problem and was not able to verbalize words. The interventions were R #1 would maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, and using a sheet to spell out words. C. Record review of R #1's Subjective Objective Assessment and Plan (SOAP) note, dated 05/17/24, indicated R #1 had a communication barrier due to brain injury and tracheostomy. The resident could communicate with spelling out words and nodding yes or no. R #1 was frustrated with her inability to communicate and her over all condition, and she lashed out. D. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/30/24, indicated the resident had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 5, severely impaired. The MDS did not reveal any suicidal thoughts or behaviors. E. Record review of a social services progress note for R #1, dated 07/22/24 at 1:33 pm, indicated the following: Social Services Assistant (SSA) #2 went to see R #1. R #1 had tears in her eyes and stated that she needed to go to the hospital. The resident stated that she wanted to just die, and she was not worth anything now. SSA #2 asked R #1 if she had a plan, and the resident said she wanted one-on-one (one person in line of sight of the resident) or to go to the hospital. R #1 got more upset. SSA #2 spoke to the nurse and the Director of Nursing (DON), and she said to send the resident for a psychiatric evaluation (clinical interview that helps diagnose mental health conditions), and staff were to do frequent checks on R #1. SSA #2 let the nurse know for the staff to do the frequent checks, and SSA #2 would work on getting her sent out for a psychiatric evaluation. F. On 07/26/24 at 11:30 am, during an interview with Nurse #4, she stated R #1 could be difficult sometimes. She stated R #1 was lonely, sad, and angry. Nurse #4 stated she was aware the resident spoke with the SSA #2 on 07/22/24 and wanted to go to the hospital. Nurse #4 stated R #1 told SSA #2 that she wanted to die. Nurse #4 stated SSA #2 came and told her what R #1 said. Nurse #4 stated R #1 was up at the nurses station with her after she finished talking with SSA #2. Nurse #4 stated she went to assist another resident who needed her help, and when she went back to the nurses station, R #1 was not there. Nurse #4 stated she did not go to R #1's room to look for the resident. She stated shortly after got back to the nurses station, R #1 came out of her room and said she swallowed razor blades. Nurse #4 went into R #1's room and saw the broken razor on her bed. Nurse #4 stated she called 911. G. Record review of the nursing progress notes for R #1, dated 07/22/24 at 2:06 pm, indicated R #1 went to Nurse #3 and claimed she (R #1) swallowed a blade from the razor. Nurse #3 immediately went to her room and found the broken razor, Q-tips, and tissue paper. Staff called 911 and checked the resident's vitals, which were normal. Resident sent to the emergency room . H. Record review of the hospital gastroenterology (a branch of medicine concerned with the structure, functions, diseases, and pathology of the stomach and intestines) consultation note, dated 07/22/24, revealed the reason for the consultation was razor blades due to suicide attempt. Patient with suicide attempt with reportedly swallowing two razor blades, one of which was visualized on imaging. One razor blade surgically removed, and the other was not visualized on the x-ray. I. On 07/29/24 at 10:00 am, during an interview with SSA #2, she stated R #1 really did not want to be at the facility. She stated the resident was on the secured locked unit, because the resident did not make safe choices and wanted to leave the facility. She stated R #1 had anxiety and did not want to be at the facility. SSA #2 stated R #1 did not express she wanted to kill herself before 07/22/24. SSA #2 stated she saw R #1 on 07/22/24, and R #1 was crying and sad. She stated R #1 told her she did not want to live and asked for one-on-one and wanted to go to hospital. SSA #2 stated she told the nurse what R #1 said to her. She stated a one-on-one was not implemented for the resident. SSA #2 stated she went down stairs to chart the conversation, and the next thing she knew, she received a phone call that R #1 swallowed razor blades. R #1 was sent out to the hospital immediately. J. On 07/29/24 at 10:30 am, during an interview with the Director of Nursing (DON), she stated a staff member told her R #1 did not want to be at the facility and did not want to live. The DON stated that she was notified after R #1 told the SSA #2 that she wanted to go out to the hospital or have a one to one. The DON stated she asked the staff member if R #1 had a plan to hurt or kill herself, and the staff member stated no. She said since R #1 did not have a plan, she told the staff who worked on the 200 unit to do frequent checks on the resident. The DON stated that shortly afterwards, she received a call from Nurse #4 who reported R #1 swallowed razor blades. She stated they sent the resident out to the hospital. K. On 07/26/24 at 12:25 pm, during an interview with Power of Attorney (POA)/daughter, she stated her mother did not like it at the facility and was not used to having so many restrictions. The POA stated R #1 was confused a lot and made up things in the past to get out of situations. POA stated she put a camera in R #1's room, but R #1 would take it down. POA asked for it to be put back up when R #1 went to the memory care unit. She stated her mother would make allegations that people hurt her or abused her. The daughter stated that she never believed her mother. She stated this was not the first time her mother tried to hurt herself. The POA stated she watched on the video recording (after she found out about the suicide attempt) her mother take apart the razor. She said R #1 took the razor apart at 1:48 pm and at 1:53 pm she swallowed it. She stated immediately after swallowing the razor blade, R #1 left her room and told the nurse what she did. She stated she did not think her mother tried to kill herself. The daughter stated her mother was just trying to get out of the facility. L. Record review of the facility's Suicide Threats Policy, revised date 2007, indicated a staff member shall remain with the resident until the nurse supervisor/charge nurse arrived to evaluate the resident. Based on interview and record review, Immediate Jeopardy (IJ) was identified on 07/29/24 at 2:45 pm to the Administrator and the Director of Nursing, in person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 07/30/24 at 10:05 am. Implementation of the POR was verified onsite on 07/30/24 with ongoing trainings for staff around resident suicide threat policy, and a full sweep of all residents was completed to identify any other resident who maybe suicidal. After verification of POR on 07/30/24 at 2:45 pm, the scope and severity was reduced to D. Plan of removal: 1. The facility will identify any residents who have expressed a suicidal comment within the past sixty (60) days. 2. Social Services will interview any residents identified within the past sixty (60) days to evaluate the mental condition of the resident in reference to any suicidal thoughts. Social Services Director will begin resident interviews on 07/30/2024 and complete on 07/30/2024. The facility will immediately implement any measures per the facility's Suicide Threats Policy which are required to be initiated. 3. Education of staff, which includes Administration, Direct Care Staff on the facility. Policy and procedures for suicide threats voiced by a resident will begin on July 29, 2024. 4. Staff will report any resident threats of suicide immediately to the Nurse Supervisor, Charge Nurse, DON/designee, and Physician. 5. A staff member will remain with the resident until appropriate direction is provided by the physician. 6. Any resident who expresses a suicide threat will be transferred to the hospital for evaluation. 7. A psychiatric consultation will be initiated. 8. Facility will initiate a facility wide sweep of all residents to determine if any residents exhibit suicide ideation. The facility will follow the following procedures: a. A standard format of questions will be utilized. b. The format will include the resident's name, person who is conducting the interview, and date of interview. c. Resident interviews will be initiated on 07/30/2024 and completed by 07/30/2024 9. Any residents identified at Risk for Suicide Ideation during facility-wide screening, Suicide Threat Policy will be initiated. 48645 Surveyor: [NAME], [NAME]

R #1 was admitted to the facility on [DATE] with known history of decannulating (removing [CONDITION(S)] tube: curve tube inserted in the neck and windpipe) himself. On [DATE] and [DATE], R #1 is observed pulling on his [CONDITION(S)]. On [DATE], R #1 decannulated himself twice (in the morning and late afternoon) and was provided one on one (one resident to one staff) observation overnight which was then discontinued in the morning. On [DATE], R #1 decannulated himself and the [CONDITION(S)] was reinserted. No new interventions were implemented. On the morning of [DATE], R #1 decannulated himself and the [CONDITION(S)] was reinserted. The Provider was not notified and no interventions to prevent decannulation were implemented. Approximately 1.5 hours after the first decannulation on [DATE], R #1 was found unresponsive with his [CONDITION(S)] remove and life saving measures were unsuccessful. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being called on [DATE] at 5:15 pm with the Administrator being advised. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 11:59 am. Implementation of the POR was verified and approved onsite at 5:30 pm on [DATE] and the Scope and Severity was reduced from the level J to a level G. The Plan of Removal interventions included: IDENTIFICATION OF RESIDENTS AT RISK FOR SAME FAILED PRACTICE We immediately identified all active patients at risk for the alleged failed practice. Going forward, all [CONDITION(S)] referrals will be reviewed by the Respiratory Therapy (RT) Director with bedside review completed prior to admission. Any nursing concerns identified for potential high-risk patients will be reviewed by DON (Director of Nursing) and/or designee prior to admission. The DON and/or designee will assess new admissions in person within one business day of admission to identify any potential high risk needs and implement care plans. ASSESSMENTS REQUIRED TO DETERMINE WHAT IMMEDIATE ACTIONS ARE NECESSARY TO LIFT THE IMMEDIATE JEOPARDY Respiratory assessments were immediately performed by nursing leadership for all currently identified high risk patients in order to determine what immediate actions are necessary in order to ensure that there is no immediate jeopardy to their health and safety. TRAINING OF STAFF TO ENSURE THEY HAVE KNOWLEDGE OF ACTIONS REQUIRED UNTIL THE PLAN OF CORRECTION IS IMPLEMENTED Re-education began immediately on [DATE] for all licensed staff regarding facility policy related to change in condition, and orders and frequent monitoring of high-risk patients. Re-education for all staff regarding facility policy related to change in condition occurred on [DATE] and [DATE]. The respiratory therapy department and the admissions department received an in-service for identifying potential high risk patients on [DATE]. MONITORING BY SUPERVISORS TO ENSURE THAT STAFF ARE FOLLOWING THE PLAN OF REMOVAL Monitoring began immediately on [DATE]. DON's and/or ADON's (Assistant Director of Nursing) will run and review the Facility Activity Report daily to review abnormal progress notes and to review any abnormal vital signs. An IDT (Interdisciplinary Team which involves staff members from different departments discussing the care needs of residents) note will be completed within one business day of a change in condition to assure all updates and proper notifications were completed. The Regional Nurse Consultant (RNC) will perform daily audits of [CONDITION(S)] patients and will review daily the Change in Condition Report to assure proper follow up and care compliance. Nursing in-service on changes in condition requirements were completed on [DATE] and [DATE]. Within ,d+[DATE] hours of expected completion of this monitoring, the DON's and/or ADON's will assess the work to identify any missing items. The RNC will complete a weekly IDT audit to ensure that IDT items are completed in a timely manner. DOCUMENTATION OF FACILITY'S ACTIONS UNTIL THE PLAN OF CORRECTION IS IMPLEMENTED All actions herein will immediately be documented via in-service records and logs, where necessary. The IDT will audit the in-service records and logs daily in IDT. Based on record review and interview, the facility failed to ensure 1 (R #1) of 3 (R # 1, 2, and 3) residents reviewed received the appropriate care when R #1 was admitted with a known history of decannulating himself and decannulated himself 5 times in 4 days, and the facility failed to notify the Physician of frequent behaviors (decannulation), provide the appropriate supervision and implement interventions to prevent continued decannulation. This deficient practice likely resulted in R #1's death. The findings are: A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE]. B. Record review of R #1's face sheet revealed he was admitted to the facility with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review R #1 [hospital name] hospital records dated [DATE] revealed on [DATE] the resident had decannulated himself in the hospital. D. Record review of R #1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . E. Record review of R #1's progress notes dated [DATE] at 3:15 am revealed (R #1) was admitted with mitten restraints due to decannulizing (decannulating) himself in the hospital. Mittens were removed. F. Record review of R #1's progress notes posted by Respiratory Therapist [ RT] #1 dated [DATE] at 12:10 pm revealed Resident [CONDITION(S)] site cleaned, and new drain sponge and paper towel drape placed, he is pulling on the [CONDITION(S)] mask the drape and touching his face, I'm concerned that he may inadvertently (without intention, accidentally) pull his [CONDITION(S)] out. G. Record review of R #1's progress notes posted by Respiratory Director [RD] /RT #2 dated [DATE] at 8:30 am revealed Resident pulling at his [CONDITION(S)] collar. H. Record review of R #1's progress notes posted by RD/RT #2 dated [DATE] at 10:16 am revealed RT entered room and found the [CONDITION(S)] collar on the floor. Sterile technique performed and the #6 [MEDICATION(S)] (size and brand name) [CONDITION(S)] was put back in with the assistance of the nurse and CNA (Certified Nursing Assistant). I. Record review of R #1's progress notes posted by Registered Nurse [RN] #1 dated [DATE] at 16:11 (4:11 pm) revealed At 1530 (3:30 pm) the CNA notified this nurse and the eve (evening) shift nurse that the patient pulled his [CONDITION(S)] out, RT was called STAT (immediately), crash cart was brought to room, could not get an oxygen saturation. RT stabilized [CONDITION(S)] and oxygen. Saturation was at 98%. Patient begin to move hands up to [CONDITION(S)]. J. Record review of R #1's progress notes dated [DATE] at 22:23 (10:23 pm) and posted by RT #3 revealed Resident was awake at room entry and was restless (unable to rest or relax as a result of anxiety). K. Record review of R #1's Medication Administration History revealed [MEDICATION(S)] HCI was administered once (1 time) on [DATE] at 8:09 am. L. On [DATE] at 11:34 am, during an interview, RD/RT #2 confirmed R #1 had decannulated himself on [DATE]. RT #2 stated that R #1 was very agitated, so she needed help to put the [CONDITION(S)] back in. She stated she had to use the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations, which is the action taken when reviving someone from unconsciousness or apparent death) to bring him back to life. RD/RT #2 confirmed that night [[DATE]] he had been initiated with a one on one care nurse aide [supervision] and that this was initiated by nursing staff. M. Record review of R #1's progress notes dated [DATE] at 00:50 (12:50 am) and posted by RT #3 revealed Resident was awake and restless at room entry. N. Record review of R #1's progress notes posted by RT #3 dated [DATE] at 22:45 (10:45 pm) revealed Summoned (urgently called) to the resident's room. The resident had decannulated himself. Stoma (opening in the windpipe) and [CONDITION(S)] were sterilized and the [CONDITION(S)] was reinserted with small resistance (refusal to accept or comply with something). O. Record review of R #1's Medication Administration History revealed [MEDICATION(S)] HCI was not administered on [DATE]. P. Record review of R #1's progress notes posted by the Assistant Director of Nursing [ADON] dated [DATE] at 10:40 am revealed a late entry regarding the IDT (interdisciplinary team) meeting held on [DATE] at 9:30 am IDT discussed the intervention for the need to assess Mr. [last name of R #1] for air hunger (sensation of not being able to breathe sufficient air) and review of medications for agitation (state of being troubled or nervous). Q. Record review of R #1's progress notes posted by RN #2 dated [DATE] at 8:00 am revealed Resident noted with [CONDITION(S)] out of stoma. Resident labored breathing (difficulty breathing). RT notified. Repositioned resident with RT for [CONDITION(S)] reinsertion (to put back in place), [CONDITION(S)] reinserted. R. Record review of R #1's progress note dated [DATE] at 8:13 am stated the following: found him decannulated and he was struggling to breathe, the nurse said it just happened, soaked the [CONDITION(S)] in [MEDICATION(S)] solution and used a brush to clean it thoroughly, used sterile water-based lube to reinsert, some bleeding noted. Resident verbalized that, it wasn't so hard to breathe in response to me asking him, if it was (hard to breathe). S. Record review of R #1's progress notes posted by RN #2 dated [DATE] at 9:45 am revealed Called to resident room by CNA about resident not breathing. Upon entering room, resident not breathing. RT already in room re-inserting the [CONDITION(S)] that was out of the stoma. No heart sounds were heard to auscultation (act of listening to the internal sounds of the body). [CONDITION(S)] reinserted. CPR (Cardiopulmonary Resuscitation) now started at 0950 (9:50 am). 911 called at 0955 (9:55 am) will several rings and no answer. Called 911 again at 0957 (9:57 am). EMS (Emergency Medical Services) arrived at 1005 (10:05 am) to take over resident CPR. EMS continues CPR until 1030 (10:30 am). 1030 EMS stopped CPR and resident was deceased (no longer alive). 1035 (10:35 am) resident assessed for death. No lung sounds heard to auscultation. No heart sounds heard to auscultation. Eyes are dilated (to make wide or larger) non-reactive to light. Resident pronounced deceased at 1035 on [DATE]. T. On [DATE] at 9:23 am, during an interview, the Administrator (ADM) stated R #1 was admitted on [DATE] as a [CONDITION(S)] patient being followed by the respiratory department. The ADM confirmed that on [DATE] at 8:00 am R #1 was found decannulated in his room and they reinserted the cannula and resident was comfortable and received a nebulizer treatment with normal vital signs. The ADM reported that at 9:45 am, the Respiratory Therapist returned, and R #1 was decannulated and not breathing. He stated code blue was called and 911 was called. Compressions were done and EMS arrived at 10:05 am and called the code and R #1 expired at 10:30 am. U. On [DATE] at 11:09 am, during an interview, RT #1 stated he had worked with R #1 the day ([DATE]) he passed away. RT #1 confirmed that R #1 decannulated himself at 8:00 am and with the assistance of a nurse they put a new [CONDITION(S)] in and then he (RT #1) went to chart. RT #1 stated the R #1 told him It is ok while he was decannulated and that he was wearing mittens since he was admitted . RT #1 reported that mittens are used to prevent the resident from decannulating himself. V. On [DATE] at 11:56 am, during an interview, Director of Nursing [DON] #1 confirmed she never witnessed R #1 pull his [CONDITION(S)] out. DON #1 confirmed that at times R #1 was agitated but given [MEDICATION(S)] (a medication used to treat anxiety, a feeling of uneasiness, worry or fear) to assist with him not to pull it [[CONDITION(S)]] out. DON #1 stated on the day he passed away ([DATE]), [MEDICATION(S)] was not given. She confirmed the patient appeared stable and not agitated at that time as reason decision was made not to give R #1 [MEDICATION(S)]. DON #1 confirmed he [R #1] was not put back on one on one care due to not needing it after assessment of R #1 [on [DATE] when one to one staffing was discontinued] and that R #1 would sometimes take his mittens off. DON #1 reported that removing mittens would not be considered a behavior, but it could have been the result of irritation. DON #1 stated that she is not sure if she would have recommended one on one care the morning [[DATE]] he passed due to the resident being stable, but did confirm that nurses can initiate the one on one care when necessary. W. On [DATE] at 12:09 pm, during an interview, RN #1 stated she was not in the facility when R #1 was admitted . RN #1 confirmed that R #1 would take his mittens off at times. X. On [DATE] at 12:44 pm, during an interview, the ADM stated he had no reports by staff of behavior issues with R #1 and he is unsure of why he was pulling his [CONDITION(S)] out. The ADM reported that during staff rounding they would try to make sure he wore his mittens to not pull his [CONDITION(S)]. The ADM confirmed the judgement call made on [DATE] was R #1 was doing well and not in distress at the time to need one-on-one care the morning he expired. The ADM confirmed that at times he is a part of that conversation when one on one care is needed, but the clinical leaders and unit managers make the main call (decision). The ADM reported that he is not sure if he would have recommended one on one care at the time. The ADM confirmed they do not have a policy on one on one care and that R #1 just didn't want the [CONDITION(S)] in. Y. On [DATE] at 9:14 am, during an interview, RN #2 confirmed he had worked from the afternoon 11:00 pm on [DATE] through [DATE] the morning the R #1 expired. RN #2 stated R #1 was wearing his mittens. RN #2 confirmed he was told about the resident decannulating himself when he came on his shift on [DATE] and that R #1 was not on one on one care at the time he expired. RN #2 reported that on his shift R #1 was fine, no behaviors noted and no issues throughout the night, and one on one care was not needed due to resident being stable. RN #2 confirmed that after R #1 decannulated himself [on [DATE] at approximately 8:00 am (first time)] he did not call the provider for further direction. Z. On [DATE] at 8:59 am, during an interview, CNA #1 reported that he had only worked with R #1 on the morning ([DATE]) he passed away and he confirmed he did not observe any behaviors for R #1. CNA #1 confirmed that R #1 had mittens on his hand and would try to pull his [CONDITION(S)] out. CNA #1 stated R #1 does not talk very clearly, but he asked if he was doing ok throughout the shift. AA. On [DATE] at 11:01 am, during an interview, the Assistant Director of Nursing stated she reviewed the resident chart and confirmed she was aware of R #1 decannulating himself a few days after he was admitted to the facility. The ADON confirmed that they initiated the one on one care overnight [[DATE]] and the next day the staff were considering whether air hunger (strong urge to breathe or a feeling of severe breathlessness) was the reason R #1 was pulling out his [CONDITION(S)]. ADON confirmed that the one to one staff initiated on [DATE] was discontinued by the Unit Manager on [DATE] because the resident was stable. The ADON reported that the morning [[DATE]] R #1 passed, the Nurse on at the time did not call the physician. BB. On [DATE] at 11:27 am, during an interview, Unit Manager (UM) #2 stated she does not recall making the decision to take R #1 off the one on one care. UM #2 stated that R #1 should had not been admitted to the facility in the first place. UM #2 stated she spoke with all of the ADON's and let them know about him pulling his [CONDITION(S)] out. She confirmed she personally felt R #1 needed to be on one on one care for a longer period of time and that she told upper management that they can't provide the care he needs. She stated she did not know why they would accept him with the condition he was in. UM #2 stated she spoke with staffing, and they assigned one CNA for the evening [[DATE]] into the morning. UM #2 stated she never observed any behaviors that would indicate the resident had behaviors at the facility to pull out his [CONDITION(S)]. UM #2 reported that after R #1 pulled his [CONDITION(S)] out again, the Nurse should have initiate one on one care and contacted the provider to get him out of the facility due to him not being safe. UM #2 stated the agitation R #1 had, was not wanting it [[CONDITION(S)]] in. UM #2 stated he should have not been there in the first place and should have been sent to the hospital for further evaluation and a better placement elsewhere. UM #2 confirmed that she stepped down [from her position] because of the DON and ADM admitting [other] residents in this condition. CC. On [DATE] at 10:17 am, during an interview, DON #2 confirmed she requested a policy on one on one care that the facility had in place and was told they didn't have one. She stated she wanted to know why one to one would be initiated and then discontinued. DON #2 confirmed that she was unaware until she reviewed the notes that R #1 had a one on one initiated the first time, he decannulated himself and that she was unaware of his behaviors that he pulled his [CONDITION(S)] out. DON #2 stated she was told after his first time pulling his [CONDITION(S)] out that he was stable and doing good and she thought the physician was notified and it was not until after she did more investigating about the situation did she realize the provider was not notified. DON #2 confirmed RN #1 was supposed to call the physician for further guidance [on the morning of [DATE]]. DON #2 stated nobody asked her about the situation or told her about the decisions being made with the resident care. DON #2 stated had she been notified about the second decannulation she would have said to call the physician for further guidance and to recommend one on one care immediately. DON #2 confirmed she asked the nurse the morning of the death [[DATE]] how he did not see that the resident pulling his [CONDITION(S)] out was not a change of condition and to notify the provider. She confirmed that she educated the nurse that he should have contacted the physician and initiated one on one care until he got a hold of the physician for further guidance. DD. On [DATE] at 1:44 pm, during an interview, DON #1 confirmed they stopped the one on one care for R #1 on [DATE] in the morning due to stopped behaviors and stabilized after receiving medications. She stated they have not had this issue in the facility other than with R #1. DON #1 stated they continued to monitor him and he received treatments from the respiratory department. DON #1 stated that there was no reason R #1 should have continued to decannulated himself. EE. On [DATE] at 10:12 am, during an interview, DON #1 stated the nursing judgment is used for one on one care. She confirmed they do not have a policy on one on one care. DON #1 confirmed there could have been an order to put in for R #1 to be put on one on one care to indicate that patient safety is of concern. DON #1 confirmed that the facility could have notified the provider to get additional guidance to put R #1 on one on one care for a longer period of time. DON #1 confirmed that if a resident pulls out their [CONDITION(S)] death is the consequence if nobody intervenes right away within 10 minutes. FF. On [DATE] at 4:18 pm during an interview, the ADON reported that they did not use mittens for R #1 to prevent decannulation as they are considered a restraint. She reported that due to R #1 pulling out his [CONDITION(S)] and to prevent serious harm, the facility should have sent him back to the hospital for a higher level of care to include using a telesitter (someone that can continuously monitor for risky behavior). She reported staffing wise, we don't have that ability. The ADON reported that they did not think to assess R #1 for self-harm or suicidal behaviors. She reported that hospital records from [name of the transferring hospital] only listed one decannulation and they (the staff) do not consider that a history as it could have been an accidental decannulation. The ADON reported that they discussed R #1's medication for the agitation behaviors during the IDT (interdisciplinary meeting, which involves staff members from different departments discussing the care needs of residents) held on [DATE] and a staff member was to follow up with the physician to see what (medication) they could give him (R #1), but she was not sure if that happened or not. GG. On [DATE] at 2:37 pm, during an interview, DON #1 reported that they did not follow up with the physician regarding medication to address R #1's agitation, because making outreach to the physician was not discussed in the IDT meeting that occurred on [DATE] at 9:30 am. HH. On [DATE] at 11:10 am, during an interview, RN #4 reported that she remembers that R #1 was admitted to the facility with mitten restraints due to decannulizing himself in the hospital, but she does not remember why the staff decided to remove R #1's mittens. She reported given the risk of residents pulling out trachs, the appropriate level of care that should be given to prevent serious harm would be rounding at least every two hours by the respiratory department and nursing, because there is a lot of care needed in terms of checking on the residents and anticipating their needs. II. On [DATE] at 4:51 pm, during an interview, RT #3 reported that he advised R #1 of the consequences of pulling at his [CONDITION(S)]. RT #3 reported that he told R #1 this [CONDITION(S)] is there for a reason, it's there to help you breathe and without it you will not be able to breathe and you need to not pull at it. RT #3 reported that R #1 was definitely restless with his hands, but he is unsure if R #1 was pulling on his [CONDITION(S)] intentionally as they (the staff) were not sure if he (R #1) even understood what they (the staff) were telling him (R #1). RT #3 reported that when residents with trachs are restless, he notifies the nurse to see if there is anything they can do to address the issue such as administer medication. RT #3 confirmed that he told the nurses after every encounter with R #1 that he [R #1] was restless. JJ. On [DATE] at 1:41 pm, during an interview, the RD/RT #2 reported that she told R #1 to stop pulling out his [CONDITION(S)], because it's dangerous and that the hole (in his windpipe) could close up and he could pass away, but it was not charted (documented in R #1's electronic medical record). She reported that she felt R #1 did not understand what she was telling him due to his [CONDITION(S)]. RD/RT #2 reported that R #1 would become very agitated (appearing troubled or nervous) and she told the nurses so they could give him medication. She reported that the staff should have ensured that R #1 was checked on more frequently by the nurses. RD/RT #2 reported that a good staff to resident ratio is important and she feels they were short-staffed nursing wise at the time R #1 was at the facility. She reported that educating the residents and ongoing communication between the nurses and respiratory therapy should be occurring to ensure that issues are being addressed when a resident is decannulating themselves such as getting medications ordered for agitation. KK. On [DATE] at 2:37 pm, during an interview, DON #1 reported that R #1 was in the appropriate level of care and the team never thought they needed to send him (R #1) out (to another facility or hospital) or call the physician, because he was stabilized each time he decannulated himself. She reported we did not look at it on a global scale (entire health care situation), we looked at it on a per incident (per decannulation) basis. DON #1 reported R #1 did have a history of decannulation while at [name of transferring hospital] and he came with mittens (to prevent decannulation) from there, but we (the staff) did not continue that [the mittens] as there was no physicians order for them in the paperwork from [name of the transferring hospital] and our physician did not feel there was a need for them (the mittens). LL. On [DATE] at 4:45 pm, during an interview, RT #3 reported if he notices residents having behaviors (restlessness or agitation) or anything else out of the norm, he gets his care completed and then notifies the nurses so that they can address the issues. He reported these residents (with trachs) can't talk, so it's important that we pay attention to what's going on with them. MM. On [DATE] at 10:45 am, during an interview, DON #1 reported that sometimes a residents acuity level (the level of care the resident needs due to their diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . NN. On [DATE] at 11:04 am, during an interview, the DON #1 reported that a bedside assessment for R #1 should have been conducted by the RD/RT #2, who has since stepped down from her position as Respiratory Director. This assessment is not a written assessment and is also not charted in progress notes. OO. On [DATE] 1:32 pm, during an interview, the DON #1 reported that they do not have a written protocol regarding the pre-admission coordination that happens between the Community Liaison (CL) the nurses and/or other specialized teams such as respiratory. PP. On [DATE] at 5:04 pm, during an interview, the CL reported that part of their process in determining whether or not a resident should be admitted to the facility involves a bedside assessment. She reported that since R #1 was a [CONDITION(S)] patient, his bedside assessment would have been completed by Respiratory Director (RD)/RT #2. The CL reported that R #1 had no restraints in place (while at the transferring hospital) and there was no specific notation regarding decannulation. The CL reported I knew he was pulling at lines (his [CONDITION(S)]), but no decannulation and I did not know about the mittens or that he even came over that way (with mittens); maybe they put them on in ambulance. QQ. On [DATE] at 12:34 pm, during an interview, R #1's mother/responsible party (M/RP) reported via translator that she spoke to RN #2 the morning ([DATE]) that R #1 passed away and he told her that R #1 had decannulated himself three times while at the facility and that he decannulated himself again that morning resulting in his death. She reported that she and the rest of R #1's family do not believe that R #1 was fully aware due to his [CONDITION(S)] of what could happen to him as a result of pulling out his [CONDITION(S)]. R #1's M/RP reported that the family is very upset, because they were never notified that R #1 had been pulling out his [CONDITION(S)] and they had never witnessed that type of behavior before.

Based on record review and interview, the following was identified: 1. Per resident daily progress notes, a resident was observed by staff to be slow to respond. This was considered by the nurse to be a change in condition. The resident had a history of [REDACTED]. 2. Following the administration of [MEDICATION NAME], the nurse did not contact the attending physician. The nurse noted the resident's immediate response to the [MEDICATION NAME] but did not continue to monitor the resident's condition. 3. Approximately 70 minutes later, the resident was found to be unresponsive and was eventually declared to be deceased . These deficient practices resulted in Immediate Jeopardy being called on [DATE] at 6:13 PM. The facility Administrator was notified in person at this time. A first plan of removal was received and accepted on [DATE] at 9:04 pm. The scope and severity was reduced from Level 4, J to Level 3, G. The plan of removal included: 1. Nursing staff will be in-serviced on resident change of condition and the expected response following administration of [MEDICATION NAME]-to include contacting the attending physician, Director of Nursing and nurse managers and the expected follow-up post [MEDICATION NAME] administration. 2. Training for licensed nurses and newly hired nurses to immediately contact the attending physician/provider immediately when there is a noted change in condition including the administration of [MEDICATION NAME] and the expected follow-up. 3. The facility initiated in-servicing of licensed nurses on the protocols for notification and follow-up immediately, this included notifying the physician/provider of the change in condition and the administration of [MEDICATION NAME]. If the provider does not believe the resident's status does not warrant transfer to a local hospital then the nurse will contact and so notify the nurse manager 4. The facility nurse manager reviewed all [MEDICATION NAME] and Opiate orders and updated orders to include Implement 1 on 1 monitoring until 911 arrives 5. The Director of Nursing or designee will review all documented changes of condition with the interdisciplinary team to ensure proper assessments were completed. 6. Quality Assurance Performance Improvement committee will review this monthly for three months. Based on record reviews and interview, the facility failed to ensure that the nursing staff possessed the appropriate competencies and skills necessary to provide competent and professional nursing services to meet the needs of 1 (R#1, 2 and 3) of 3 (R#1, 2 and 3) reviewed for history of drug use and abuse. This deficient practice is likely to result in staff not recognizing, properly assessing and then reacting to a resident's change in condition which resulted in death. The findings are: A. Record review of R #1 face sheet dated [DATE] reveals he was admitted to the facility on [DATE] with the multiple [DIAGNOSES REDACTED]. B. Record review of R#1 Medication Administration Record [REDACTED] 1. [MEDICATION NAME] 10 mg (milligram) per note-given but charted late (a medication which treats muscle spasms) 2. [MEDICATION NAME] 40 mg (an antidepressant medication used to treat [MEDICAL CONDITION]) 3. [MEDICATION NAME] 300 mg (An antibiotic medication used to treat bacterial infections) 4. [MEDICATION NAME] 100 mg (A stool softener used to treat constipation) 5. Famotadine 10 mg (A medication used to treat excess stomach acid) 6. [MEDICATION NAME] Liquid 10mg/ml (mililiter) give 35mg (a narcotic used to treat symptoms of drug use and withdrawal) 7. Muscle Rub ([MEDICATION NAME]-Menthol) Cream ,[DATE]% (an over-the-counter cream applied to the skin to reduce pain in a specific area of the body) 8. Nicotine Patch 14 mg apply to skin per note-not given due to condition (An addictive substance found in tobacco-Patch is used to alleviate the symptoms of tobacco withdrawal) 9. Polyethelyne [MEDICATION NAME] 17 grams mixed with drink (a stool softener used to treat constipation) 10. Quetiapine 400 mg (an antipsychotic medication used to treat [MEDICAL CONDITION]) C. Record review of resident daily progress notes reveals the following: 1. [DATE] at 09:32 (9:32 am) Patient (R#1) Exhibits no Covid related symptoms. No fever, no cough, no sore throat, no loose stools. No complaints of general malaise (a feeling of discomfort, uneasiness or illness) . Vitals stable at this time. At baseline, no concerns (Name of Registered Nurse (RN) #1). 2. [DATE] at 14:20 (2:20 pm) Non-responsive to verbal commands however responded to sternal rub. [MEDICATION NAME] (an opioid drug often used to treat heroine addiction) held and PRN (physician order [REDACTED]. Resident now alert but agitated. Took other daily meds without difficulty. VS ,[DATE] P-89 R-18 -No drugs or paraphernalia (items used for the intake and administration of illegal drugs) found during patient care. Continue current plan of care. Notified wife of [MEDICATION NAME] administration. (name of RN #2), RN 3. [DATE] at 14:50 (2:50 pm) Addendum to progress note from [DATE] 0900 (9:00 AM ) resident asleep in bed. Respirations even and unlabored. Offered medications but he refused. At approximately 1015 (10:15 AM) this writer spoke with wife (R #1's wife) and gave her information of prior chest x-ray results and lab results and informed her he (R #1) had been started on antibiotic for UTI (Urinary Tract Infection). 1200 (12:00 PM)- Resident (R #1) continues to sleep. Respirations even and unlabored. Arousable (will awaken) but lethargic (slow to arouse). Offered medications but continued to refuse. At approximately 1400 (2:00 PM), this writer (RN #2) noted that resident had increased lethargy, respirations even and unlabored, unable to arouse but did respond to sternal (chest) rub. Due to resident history of recently having drugs and paraphernalia found on his person, and his prior history of drug abuse, this writer administered PRN order of [MEDICATION NAME]. At approximately 1415 (2:15 PM), resident was now noted to be alert and awake, alert and agitated. Resident did take PO (Oral) meds (medications) but refused his lunch tray. [MEDICATION NAME] held VS (Vital Signs) BP-,[DATE] P-89 R-18 Asked resident if he needed anything and he stated 'no just get the hell out' At 1420 (2:20 PM) this writer notified wife of resident condition and the administering of [MEDICATION NAME]. She stated she appreciated the notification. At 1430 (2:30 PM), this writer checked on resident and he was awake and alert in his room and in no apparent distress. At 1445 (2:45 PM), this writer gave report to ,[DATE] (Next Shift) nurse. I informed her of the resident's condition and administration of [MEDICATION NAME] and response of resident. Also notified her that family had been notified.(Name of RN #2), 4. [DATE] at 15:40 (3:40 pm) While CNA (Certified Nurses Aide) was rounding and gathering vital signs for afternoon shift, resident (R #1) was found to be pale, lips blue, fingertips blue and cold, unresponsive to painful stimuli, and no pulse palpated (to find or examine by touch). She (CNA) immediately called for this RN (RN #3). This RN (RN #3) ran to room when called, resident found in same state as above. Code blue (a call for emergency assistance) called and CPR (Cardio [MEDICAL CONDITION] Resuscitation)(the emergency administration of chest compressions and breathing assistance) started immediately. CNA arrived with code cart (Cart containing emergency equipment) soon after, board placed under resident, resident placed on partial re-breather mask (a respiratory device to deliver a high concentration of oxygen) to high flow 02 (Oxygen) while Ambu-bag (a bag with a large bulb used to force oxygen into the lungs) was assembled. RT (Respiratory Therapy) (a health care worker who specializes in the management of respiratory issues) at bedside. Resident did not respond to chest compressions or bagging, no spontaneous pulses or resps (respirations) during resuscitative efforts. s/(Name of RN #3), RN 5. [DATE] at 15:42 (3:42 pm) [MEDICATION NAME] in (sic) delivered to right nares (nose) by this RN (RN #3). no change in resident response. no change in LOC (Level of Consciousness), no pulses detected, no spontaneous resps (respirations). CPR continues. s/(Name of RN #3), RN 6. [DATE] at 15:45 (3:45 pm) House Supervisor notified pt (patient) was found down, no pulse or respirations found with palpation, auscultation (to find or examine by sound), or monitoring s/(Name of RN #3), RN 7. [DATE] at 15:48 (3:48 pm) EMS (Emergency Medical Services) crew arrives and takes over CPR. Pt (Patient) does not respond to efforts. (First names of other staff) notified by house supervisor. s/(Name of RN #3), RN 8. [DATE] at 16:28 (4:28 pm) EMS defers to on-site-MD (Medical Doctor) who calls resident code finished. Resident left in room by EMS staff, no transport done. Staff cleaned body and prepared resident for transport to OMI (Office of Medical Investigator) or mortuary. (Name of RN #3), RN 9. [DATE] at 16:43 (4:43 pm) This RN calls on-call physician and OMI. s/(Name of RN #3), RN 10. [DATE] at 16:52 (4:52 pm) RT responded to code at approximately 1540 (3:40 PM), found CPR to be in progress, effective compressions were being delivered, began bagging with O2 (oxygen). EMS arrived at approximately 1550 (3:50 PM) and took over code. s/(Name of Respiratory Therapist, (RT) D. On [DATE] at 9:34 am during interview with RN #2 reported that R#1 was usually awake and ready for his morning medications at 9:00. RN #2 further reported that he noted R #1 was sleepy and slow to respond during the morning. He stated that he had drawn R#1's medication but after assessing him he decided to hold R #1's morning medications. RN#2 stated that he didn't know how to strike the medications from the electronic medical record (EMR) and therefore he could not correct the Medication Administration Record. He checked on R #1 during the morning hours and eventually-he thinks about noon-he administered the morning medications but held his [MEDICATION NAME] because he was still lethargic. RN #2 stated that about 2:20 pm he found R #1 was still slow to respond and considered this to be a change in condition. He stated he was aware that resident had a past history of drug use and thought R #1 may have taken an unknown opioid substance. RN #2 stated that he decided to administer [MEDICATION NAME] at about 2:20 pm. RN #2 stated that after giving the [MEDICATION NAME], he returned to the administration of medication to other residents and returned to check on resident at about 2:30 pm. RN #2 stated that by 2:30 pm R #1 was up and responsive and that R #1 was upset and angry and told him (RN #2) to get out and leave him alone. RN #2 stated that he did not have direct contact with R #1 after being told to leave. At 3:00pm RN #2 stated he was off duty and passed care on to the next shift nurse (unknown nurse) telling her of the incident. RN #2 never indicated that he called the physician/provider regarding any change in condition or the administration of [MEDICATION NAME]. E. On [DATE] at 1:10 pm during interview with RN #3 she stated that she came on shift late and took over from another nurse who was being reassigned to another unit. RN#3 stated that during the hand off from the prior nurse she was informed of R#1's condition and his having been given [MEDICATION NAME] earlier in the day. RN#3 stated that after preparing for her shift, a CNA notified her that R#1 was non- responsive. RN #3 stated she went to R#1's room about 3:40 pm and noted that he was gray in color, non-responsive, not breathing and no pulse. She called a code blue and began CPR. She stated that she broke off from CPR and administered a dose of [MEDICATION NAME] per the PRN orders. She stated there was no response from this and continued CPR. She stated that EMS arrived and took over CPR. She stated that CPR was continued by EMS but he never responded. CPR was eventually halted and R #1 determined to be deceased . RN #2 stated that she then called the on-call medical provider to give notice of the situation. F. On [DATE] at 1:46 pm during an interview with with the Director of Nursing (DON), she stated, If it were my patient, I would have probably sent the patient out (to the hospital) or I would have been with him (R #1) more. (Name of RN #2) utilized his own nursing judgement. She stated that there was no particular protocol or policy for the use of [MEDICATION NAME] and that nurses were expected to use their own professional judgement of when to administer and how to follow up in the use of [MEDICATION NAME]. DON confirmed the physician should have been called sooner and R #1 should have been sent to the hospital and/or monitored more frequently. G. On [DATE] at 11:15 am during interview with MD #1,she stated that her service was not contacted on [DATE] by any facility staff member until R #1 had passed away. MD #1 stated that the use of [MEDICATION NAME] is for the reversal of Opioid overdose. She stated that any condition that required the administration of [MEDICATION NAME] would be considered a significant change of condition and that this should result in the facility staff calling her service as soon as possible and reporting this change. MD #1 stated that after giving [MEDICATION NAME] nursing staff should closely monitor the resident by maintaining close observation and frequent vital signs done every 15 minutes. H. Record review of Mosby's 2020 Nursing Drug Reference Manual 33rd Edition, Copyright 2020 by Elsevier Inc. reveals: [MEDICATION NAME] (generic name of [MEDICATION NAME]) is a opioid antagonist antidote. Nasal Route administration of the drug: Place patient in supine (back) position-allow head to tilt back Press plunger Turn patient on side and seek immediate medical assistance after the first dose Using a new nasal spray device, readminister every ,[DATE] minutes if the patient does not respond or responds then relapses into respiratory depression. Nursing Considerations: Administer only with resuscitative (CPR) equipment, Oxygen nearby Patients may become very agitated and violent after use Evaluate for therapeutic response: reversal of respiratory depression, Level of Consciousness.

Based on observation, record review and interview, the following was discovered: Two residents (R#1 and R#3) were observed: 1. R#1 and R#3 were residing in an admission quarantine unit (AQU) (a separate unit in which residents are monitored for possible infectious disease) 2. R#1 and R#3 were observed leaving their AQU and entering into a facility hallway that was not quarantined. 3. R#1 and R#3 were observed passing a nurses station where other non quarantined residents and staff were present. 4. R#1 and R#3 then exited the building into an open patio area where other non-quarantined residents were smoking 5. R#1 and R#3 joined these residents in the open patio area where they continued to smoke and congregate within 3 feet of each other. This resulted in Immediate Jeopardy being called on 07/31/20 at 2:47 pm. The Assistant Director of Nursing notified in person at this time. A first plan of removal was received on 08/01/20 at 10:06 pm and accepted on 08/02/20 at 1:26 pm. The facility Administrator was notified. The scope and severity was reduced from Level 4, K to Level 2, E. The plan of removal included: R's #1 and 3 are not staying in designated smoking areas or their quarantine unit and they don't adhere to social distancing. These residents were offered alternatives to smoking and their care plans updated 58 other smoking residents were identified as smokers. All were offered alternatives to smoking. 18 accepted alternate options and 40 refused. Those that chose to continue smoking were informed they could not smoke until they were released from quarantine period has been lifted. Staff was in-serviced regarding the smoking policy changes. An alternate smoking area that will be separate from and not require quarantined residents to pass through the open resident unit will be completed on or before 08/02/20 and staff will be in-serviced as to this unit. Compliance will be monitored daily and results presented to the Quality Assurance Performance Improvement Committee (a committee that monitors facility issues and activities and implements plans to review and improve identified issues.) Based on observation, record review and interview, the facility failed to ensure that 3 (R #s1, 2 and 3) of 3 (R #s1, 2, and 3) residents reviewed for isolation and quarantine practices complied with quarantine requirements. This deficient practice is likely to result in the spread of potentially deadly infectious diseases to other residents and staff. The findings are: Findings for R#1 A. Record review of R#1 face sheet reveals that R #1 was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. [MEDICAL CONDITION] (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall), [MEDICAL CONDITION] (a condition marked by a deficiency of red blood cells or hemoglobin in the blood), Major [MEDICAL CONDITION], Opoid dependence, Chronic pain, [MEDICAL CONDITION] (habitual sleeplessness), and Pressure ulcer of sacral region, stage 1 (Injury to skin and underlying tissues resulting from prolonged pressure on the skin). B. Record review of physician's orders [REDACTED].#1 an order for [REDACTED]. C. Record review of daily care notes reveals that R#1 left the facility for outside appointments on 07/17/20, 07/21/20, 07/23/20 and 07/24/20. D. On 7/30/20 at 2:53 pm R #1 was observed in the non-quarantine designated smoking area sitting within 3 feet of other unidentified residents as they all smoked Findings for R #2 E. Record review of face sheet for R #2 revealed a re-admission date of [DATE] and an original admission date of [DATE] with the following Diagnoses: [REDACTED]. F. Record review of physician's orders [REDACTED].#2 revealed the following:Start date: 07/22/20. End date: 08/05/20. Special instructions: For COVID precautions. G. On 07/31/20 at 11:00 am during an interview with Hospitality Aide (HA), he stated that R #2 is housed on one of the isolation floors and that R #2 smokes in the common area with other residents who are not on isolation precautions. He verified that there is only one entrance and one exit for all residents who smoke to access both the area designated for those residents on isolation precautions as well as the area for those residents who are not on isolation precautions. H. On 08/03/20 at 1:22 pm during an interview with Certified Nursing Assistant (CNA) #2, she stated that R #2 does not follow the quarantine orders and does not listen when staff redirect him. Findings for R#3 I. Record review of R#3 face sheet reveals that he was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. [MEDICAL CONDITION]. J. Record review of R#3 daily care notes reveals that R#3 left the faciity on [DATE], 07/21/20, 07/23/20 and 07/30/20. K. Record review of physician's orders [REDACTED].#3 is on isolation droplet precautions due to possible COVID-19 exposure due to appointments outside of the facility L. On 07/31/20 at 10:50 am R #3 was observed passing through an open area past a nurse's station, down a hallway, into the common smoking area. He sat within three feet of other unidentified residents as he smoked unsupervised by staff. M. On 07/31/20 at 11:05 am during an interview with Hospitality Aide (HA) he stated that he was responsible for monitoring and observing residents as they smoked. He stated that he usually stood at the doorway and handed cigarettes to residents as the left the building and entered the smoking courtyard. He stated he was unaware of R #3's isolation precautions. N. On 07/31/20 at 11:05 am during an interview with Certified Medication Aide (CMA) #1 she confirmed that R #3 is on isolation precautions and that residents on isolation precautions were to be smoking in a designated area away from the common smoking area. O. On 07/30/20 at 3:58 pm during interview with Director of Nursing (DON) she stated that R #1 and 3 are consistently noncompliant and are resistant to comply with quarantine orders. She stated that R#1 and #3 continue to exit their assigned quarantine areas and walk around the hallways and out to the smoking area.

This is a repeat deficiency from a recertification survey on 12/14/2018 and a revisit survey dated 02/02/2019. The facility failed to provide, maintain and practice infection control practices that would prevent the development and transmission of communicable diseases and infections as evidence by: 1. Not disinfecting blood glucose monitors (a medical device used for determining the approximate concentration of glucose in the blood) per manufacture guidelines between resident uses, which resulted in an immediate jeopardy (a situation in which the health and safety of individuals are at risk). 2. Not maintaining a cleaning and disinfection schedule for Hoyer lifts (an assistive device that allows patients in hospitals and nursing homes to be transferred between a bed and a chair) throughout the facility. 3. Not maintaining a cleaning schedule for a large fish tank located in a resident common area, which creates unnecessary exposure to mold spores and bacteria from dirty stagnant water sources. These deficient practices will likely effect the health and well being of residents by: 1. Increasing the risk of exposure to blood-borne pathogens. This deficient practice has the potential to impact 7 (R #'s: 78, 105, 52, 138, 247, 72, & 253) of 32 (R #'s: 105, 118, 78, 281, 52, 7, 64, 130, 295, 184, 211, 234, 253, 291, 274, 144, 162, 48, 92, 226, 190, 135, 216, 138, 74, 128, 276, 76, 88, 24, 247, 72) residents who receive CBG (Capillary Blood Glucose) checks (a process used to measure an individual's blood sugar level). 2. Providing exposure (being in contact with) to bacteria and/or spores and other fomites (objects which are likely to carry infection) on shared resident equipment that can last up to six months on surfaces. This deficient practice has the potential to impact all residents within the facility who require a hoyer lift for transferring. 3. Allowing stagnant water to grow mold and bacterial organisms to fester (becoming worse). This deficient practice has the potential to impact all residents who visit the common area of unit four. On 02/03/20, it was confirmed that the facility failed to disinfect the blood glucometer according to manufacturer's instructions after multi-patient use. Manufacturer's instructions for disinfection while using the device for multiple patients demonstrates an approved EPA (Environmental Protection Agency) product that is found to be effective in killing blood borne pathogens (infectious microorganisms in human blood that can cause disease in humans, including, but not limited to, [MEDICAL CONDITION] which is a [MEDICAL CONDITION] infection that attacks the liver and can cause both acute and chronic disease, [MEDICAL CONDITION], a [MEDICAL CONDITION] infection that causes liver inflammation, sometimes leading to serious liver damage, and human immunodeficiency virus, [MEDICAL CONDITION] that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases). It was identified that staff members used an alcohol wipe to disinfect a multi-patient use glucometer. This method of disinfecting is not sufficient when using multi-patient glucometers since alcohol has not been found to be effective in killing blood borne pathogens. This resulted in an IJ at a scope of a K (a pattern of an immediate jeopardy to resident health and safety) as identified on 02/03/20. The facility took corrective action by providing an acceptable Plan of Removal on 02/04/20 at 10:59 am. Implementation of the Plan of Removal was verified while onsite. Based on the Plan of Removal, the interventions included: 1. Licensed nurses will be in-serviced on the criteria of glucometer management, including using approved EPA registered disinfectant for cleaning of sampling devices. 2. Any nurse, on vacation or that works PRN (as needed) will receive this re-education prior to working their next scheduled shift. 3. The nurse will demonstrate competency by passing the designated quiz. If the staff nurse does not properly demonstrate understanding, they will receive continued education prior to working their shift. 4. This will be reviewed monthly in QAPI (Quality Assurance and Performance Improvement) meetings until compliance is met. 5. An updated Glucometer Procedure was tapped to all medication carts along with an extra glucometer. The procedure instructs licensed nurses to clean the device prior to use on resident. It states that the nurse should remove wipe containing solution and continually cleanse unit for 2 minutes then place glucometer in cup and allow to air dry for 2 minutes. 6. Observation of the medication cart confirmed that the disinfectant solution to be used by staff is Sani-Cloth Bleach, which contains a wet time (number of minutes a surface should remain wet to fully disinfect) of 4 minutes. The product information of the disinfectant solution states that it effectively kills [MEDICAL CONDITIONS] and human immunodeficiency virus within 4 minutes. Based on the Plan of Removal, the Scope and Severity for the deficiency related to the disinfection of the blood glucometer was reduced from a level K to a level E. The findings are: [NAME] Record review of an article by the Center for Disease Control and Prevention (CDC) titled Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration, dated (MONTH) 2, 2011, Infectious agents can be transmitted through indirect contact transmission, even in the absence of visible blood . The device may come into direct or close contact with the patient 's fingerstick wound. If blood is transferred from the patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them. Indirect contact transmission can also occur even if the patient never directly contacts the meter. Healthcare personnel hands can become contaminated with blood at various points while performing assisted blood glucose monitoring including pricking the patient 's finger or handling the test strip. Blood can then be transferred to the meter when healthcare personnel handle the meter to obtain the reading. If the meter is not cleaned and disinfected after use, the blood remaining on the meter can be transferred to subsequent patients via healthcare personnel hands when they handle the meter and then assist with fingerstick procedures. B. On 01/26/20 at 3:57 am, during an interview with LPN #5, when asked how the glucometer is cleaned, LP #5 stated We clean the machine with an alcohol pad, she then proceeded to cleaned the glucometer with the alcohol pad. C. On 01/29/20 at 4:36 pm, during an observation, LPN #4 was observed performing a CBG check on R #78, R #105, and R #52. During the CBG checks, it was noted that LPN #6 used alcohol wipes to disinfect the glucometer after each use. D. On 01/29/20 at 4:58 pm during an interview with LPN #4, when asked if she normally uses an alcohol wipe to disinfect the glucometer, LPN #6 stated yea, I use the alcohol wipe to clean the machine. E. Record review of resident face sheets indicate the following pertinent Diagnoses: [REDACTED].#105 is diagnosed with [REDACTED].#52 is diagnosed with [REDACTED]. F. On 01/30/20 at 11:34 am, during an observation, RN #7 was observed performing a CBG check on R #138 , R #247, and R #72 During the CBG checks, it was noted that RN #7 did not disinfect the glucometer in-between the use of residents. [NAME] On 01/30/20 at approximately 11:54 am, during an interview with RN #7, when asked when she disinfects the glucometer, RN #7 stated, I didn't wipe it down in-between patients. When I get here, I wipe everything in my cart. At the beginning of my shift and also at the end. I usually wipe the glucometer with an alcohol wipe. When advised that best practice is to disinfect the glucometer with bleach or primarily what is recommended by the manufacturer, RN #7 stated that is not a technique that is used by everyone. I know that is not happening. H. Record review of resident face sheets indicate the following pertinent Diagnoses: [REDACTED].#247 does not have a related diagnosis, and R #72 whose [DIAGNOSES REDACTED]. I. On 01/30/20 at 12:21 pm, during an observation, LPN #7 was observed performing a CBG check on R #253. During the CBG check, it was noted that LPN #7 used alcohol wipes to disinfect the glucometer before and after. [NAME] On 01/30/20 at approximately 12:30 pm, during an interview, when asked to explain her process of performing a CBG check, LPN #7 stated, I sanitize my hands. Clean the glucometer and the resident's finger. Check his blood sugar then clean the glucometer. When asked how she cleans the glucometer, LPN #7 stated I use the alcohol wipe. After 2 or 3 uses, I use Clorox. When asked what prompts her to use Clorox after a few uses, LPN #7 stated I use the Clorox if there is blood on the glucometer. K. Record review of face sheet forR #253 indicates the following pertinent [DIAGNOSES REDACTED]. L. Record review of the facility policy for Blood Sampling- Capillary (Finger Sticks), dated 9/2014, states that the equipment and supplies required include an approved EPA registered disinfectant for cleaning of sampling device. As explained under steps in the procedure, step number 8 states following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. M. On 02/03/20, product information of the alcohol wipes used by staff was given to the survey team. Record review of the product information states the product name is XHC-1A, and the EPA registered number is 1677-249. N. Record review of the product information for XHC-1A, when used as a virucide (having the capacity to or tending to destroy or [MEDICAL CONDITION]) states, in 5 minutes (amount of time that the surface must remain visibly wet to be effective), (this product can be used) against the following viruses: [MEDICAL CONDITION] Simplex Type [MEDICAL CONDITIONS] Simplex Type [MEDICAL CONDITION], Influenza A Hong Kong H3N2 Virus, and Rhinovirus Type 37. It does not include pathogens such as; [MEDICAL CONDITION]. O. Record review of the EPA's List F: EPA's Registered Antimicrobial Products Effective Against [MEDICAL CONDITION] Virus, dated 01/05/18, does not include product XHC-1A with registration number 1677-249. P. On 01/26/20 at 3:22 am, during initial tour of assigned unit observed two Hoyer lifts at either end of the unit that appeared visibly dirty with dust and dirt build up on the upper and lower frames. Also observed was a fish tank (approximately 30 gallons in size) located in the day room of this same unit that was about 1/2 full with dirty stagnant water with no fish in it. There was visible mold on all sides of the inside glass with a notable amount on the front glass of the tank. There was also a visible layer of slime on the top of the water that was inside the tank which appeared to have evaporated to 1/2 of the tank. The top cover top the tank was covered with crusted hard water and appeared dirty as well. There was no filtration pump on and running at this time. During the survey it was noted that there were three to five Hoyer lifts on each unit depending on resident needs. Some of the observations besides build up was dust, dirt, unidentifiable dried liquids and one was noted to have smeared feces on the bottom brace/legs. Q. On 01/26/20 at 3:32 am, during interview with Licensed Practical Nurse (LPN) #12 the tank had been down for quite some time and said she thought it has had no fish in it for over a month or so. R. On 02/03/20 at 9:45 am, during interview with the Infection Prevention and Control Nurse (IP) stated that she had been in her position since the end of October. When asked who responsibility it was to ensure resident equipment was being cleaned and disinfected? The IP stated, The unit managers use to follow up on equipment cleaning. Then she added that now she was not sure who does. During this interview, the IP was also asked about blood glucose monitoring and if she watched the nurses perform them for infection control practices. The IP stated that she has watched them. When asked how the nurses were clearing and disinfecting the CBG (Blood glucose) monitor, she stated, We are aware of the issue recently identified and we are now using (name of disinfectant wipe). S. On 02/03/20 at 1:25 pm, during Infection Control Environmental rounds accompanied by the facilities Administrator and the IP began on one of the units described above. When questioned if there was a cleaning log kept for cleaning and disinfecting resident shared equipment, specifically the Hoyer Lifts, the Administrator stated that he was unaware if a cleaning log for this equipment was being kept. During observation of the Hoyer lifts the Administrator and IP both agreed they were visibly dirty and the Administrator stated, I see what you mean. The 1/2 empty fish tank was then brought to the attention of both the Administrator and the IP. When questioned, the Administrator stated that the fish tank was Being taken out. When asked how long it had been in its current state, the Administrator and IP were unsure, but then the Administrator stated, maybe two or three weeks or so. Both the Administrator and IP confirmed the visible mold and dirty condition of the tank. T. On 02/03/20 at 2:36 pm, during interview with Certified Nursing Assistant (CNA) #4 stated that she wipes the Hoyer lift with bleach wipes between residents but could not speak to others doing it. CNA #4 then added that she usually works evenings and they (meaning the Hoyer lifts) are usually dirty. U. On 02/03/20 at 2:47 pm, during interview with CNA #1 stated, she uses bleach wipes with each lift when transferring residents. When asked to demonstrate how she would disinfect the Hoyer lift CNA #1 demonstrated that the control handle and the top bars are wiped only. CNA #1 then stated that she thinks the night shift cleans the equipment but was not sure. V. On 02/03/20 at 2:59 pm, during interview with LPN #8 stated, she thought the CNA's clean the wheelchairs at night but that was it. W. On 02/03/20 at 3:11 pm, during interview with CNA #5 stated, I work evenings and nights .we clean the wheelchairs and sometimes the residents rooms .sometimes they need it. When asked about the Hoyer lifts, CNA #5 stated that sometimes they do and added that the wheelchairs are on a schedule but the Hoyer lifts are not. X. Review of the Centers for Disease Control and Prevention (CDC) Disinfection of Healthcare Equipment -Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008) page 16 'Surface Disinfection' states, The effective use of disinfectants is part of a multibarrier strategy to prevent healthcare associated infections .Medical equipment surfaces can become contaminated with infectious agents and contribute to the spread of health-care associated infections. For this reason, non critical medical equipment surfaces should be disinfected with an EPA-registered low or intermediate level disinfectant. Y. Review of the Occupational Safety Health Administration (OSHA) Healthcare Advisor article dated (MONTH) 25, 2010, indicates, Controlling the Spread of Waterborne Microorganisms- Fish tanks can get right nasty very quickly if they are not well- cared for .Avoid placing decorative fountains and fish tanks in patient-care areas. Z. Review of the CDC Infection Control - Animals in Health-care Facilities Guidelines for Environmental Infection Control in Health-Care Facilities 2003 States, Animals in health-care facilities traditionally have been limited to laboratories and research areas. However, their presence in patient-care areas is now more frequent, both in acute-care and long-term care settings, prompting consideration for the potential transmission of zoonotic pathogens from animals to humans in these settings. Although dogs and cats may be commonly encountered in health-care settings, other animals (e.g., fish, birds, non-human primates, rabbits, rodents, and reptiles) also can be present as research, resident, or service animals. These animals can serve as sources of zoonotic pathogens that could potentially infect patients and health-care workers (Table 26).1327-1340 Animals potentially can serve as reservoirs for antibiotic-resistant microorganisms, which can be introduced to the health-care setting while the animal is present. VRE have been isolated from both farm animals and pets,1341 and a cat in a geriatric care center was found to be colonized [MEDICAL CONDITION].

On [DATE] at 7:00 am, R #500 was noted by facility staff to be physically weak, pale, not speaking and did not eat breakfast (a decline in function for this resident). He was placed back in his bed. The nurse (Licensed Practical Nurse (LPN) #2) did not notify the medical provider or the Director of Nursing or Assistant Director of Nursing (DON or ADON). No nursing assessment was documented. On [DATE] at 9:17 pm, the residents' nurse (LPN #3) noted resident to be unresponsive to his name, with abnormal respirations pattern and rate, the provider was called and ordered that the resident be sent to a local hospitals' Emergency Department. The Emergency Medical Technicians (EMT's) record for the arrival to transport resident from the facility at 9:57 pm, the note indicated the following: pt. found laying supine (symbol for with) legs curled to abdomen laying to the L (left) and both arms flexed toward chest . moans and withdraws from noxious (painful) stimulus. Pt. is tachypneic (rapid rate of breathing), dried emesis (secretions from vomiting) noted around airway (mouth/nose) . Circulation is weak at the radial (wrist, pulse point). Pt's skin is hot to the touch. The resident was diagnosed at the acute care facility [MEDICAL CONDITION] (an infection in the blood) as well as dehydration (body doesn't have enough water and other fluids to carry out its normal functions), a Non S-T Segment [MEDICAL CONDITION] Infarction (a [MEDICAL CONDITION]) ( NSTEMI) and Acute Kidney Injury (AKI) (new/severe injury to kidney). The resident was pronounced deceased on [DATE] at 1:28 pm. This resulted in an immediate jeopardy (IJ) at a scope and severity of J (isolated jeopardy to resident health and safety) being identified on [DATE] at 4:45 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 10:15 am. Implementation of the POR was verified onsite. Based on the Plan of Removal, the interventions included: 1. Licensed Nurses, Certified Medication Aides (CMA) (Certified Nursing Assistants with additional education that allows them to administer some medications in Nursing Homes), Certified Nursing Aides (CNA), and Direct Care Staff will be in-serviced on the criteria of response to residents who exhibit a change of condition. The training will include the instruction to the licensed nurse, Certified Medication Aides (CMA), Certified Nursing Aides (CNA), and Direct Care Staff to notify the DON/ADON ( or other additional RN/LPN (Registered Nurse/Licensed Practical Nurse) managers immediately of a resident exhibiting change. 2. The Certified Medication Aides (CMA), Certified Nursing Aides (CNA), and Direct Care Staff began in servicing, 2nd shift on [DATE], on the necessity of notifying the charge nurse or a nurse manager when a resident is noted to be demonstrating a change of condition. This in service was started by the DON. Training will continue until CMA's, CNAs and Direct Care Staff have received this training by DON/ADON or other additional designees. The CMA and/or CNA will verify their understanding of this expectation by signing an acknowledgement of the training. 3. Training for Licensed Nurse and newly hired nurses will include the instruction that the licensed nurse is to notify the DON/ADON or on call nurse manager immediately of resident is exhibiting change of condition. A post-test will be given to each nurse to ascertain their level of understanding. This re-education will be provided to the license nurses starting [DATE], 2nd shift, and will continue until all licensed nurses have received the training. Any nurse on vacation or that works PRN will receive this re-education prior to working their next schedule shift. The nurse will demonstrate competency for change of condition responses annually and when needed thereafter. This re-education will be provided either by DON/ADON and other additional designees. 4. Starting with the 2nd shift, licensed nurses were in-serviced on [DATE], on the protocols of assessing a resident with a change of condition specifically for unresponsiveness to include obtaining vital signs, oxygen saturation level, blood sugar value and level of consciousness by the licensed nurse and notification of the provider as needed. 5. If the provider indicates that the acuity of the resident's condition does not appear to require hospitalization , the nurse will notify the DON/ADON/or nurse manager on call of the resident's medical status. The nurse will re-contact the provider and notify them of any further changes of condition. 6. The DON/ ADON/designee will review all documentation on residents with change of conditions with the Interdisciplinary Team to ensure proper assessments were completed. Any deviations or omissions will be addressed immediately with applicable staff nurse. If the staff nurse does not properly assess the resident, they will have to reassess the resident under the directions of the DON/designee. 7. This will be reviewed monthly in QAPI (Quality Assurance Performance Improvement) until compliance is met. Based on the Plan of Removal, the Scope and Severity was reduced from the level J to a level [NAME] Based on record review and interview, the facility failed to: 1. Ensure that nursing staff responded timely to a decline in a residents physical and/or mental status by: [NAME] Not completing a thorough resident assessment. B. Not notifying the medical provider and DON/ADON. This deficient practice likely resulted in a delay in needed treatment interventions for 1 (R #'s 500) of 1 (R # 500) resident reviewed. The findings are: Findings for R #500: [NAME] Record review of face sheet revealed R #500 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. B. Record review of Occupational Therapy (OT) (a professional therapist who through use of assessment and intervention helps people to develop, recover, or maintain the meaningful activities of daily life that a person wants to do, for example, walking, dressing and eating). OT notes for R #500, dated [DATE], revealed: Maintains standing balance 1 -2 minutes w/o (without) UE (upper extremity ) support w/o LOB (loss of balance) . Functional Outcomes Self feeding = Set up (if the food is placed before him and lids opened, cream placed in coffee and similar preparations he will feed himself) .Dressing =Min (A) (resident will dress self with very little assistance from staff) .Patient has made consistent progress . C. Record review of care plan for R #500 revealed: 1. [DATE], Report signs of UTI (urinary tract infection) (acute confusion, urgency, frequency, bladder spasms, nocturia (urinating at night), burning, pain/difficulty urinating, nausea, emesis (vomit), chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine. 2. [DATE], He is non-compliant with being in a wheelchair and will stand and walk up and down the hallway. R #500 (Name of Resident) will exercise at times with encouragement. 3. [DATE], Report signs of UTI (acute confusion, urgency,frequency, bladder spasms, nocturia, burning,pain, difficulty urinating, low back/flank pain,malaise, nausea/vomiting, chills, fever, foul odor,concentrated urine (urine that appears dark instead of light yellow .often a sign of dehydration), blood in urine). 4. [DATE], Staff to assist with decision making. Encourage group and social activities. Monitor behaviors and notify Md.(Medical Doctor) and Family of change. D. Record review of nursing progress notes revealed: 1. On [DATE] at 2:46 pm, Late entry: Day [DATE] (by LPN #2)- Resident was taken to restorative dining (program in nursing home to ensure extra assistance for residents with disorders that affect their eating, such as difficulty swallowing) in a wheelchair 0700 (7:00 am) and returned by restorative staff because he was very sleepy 0730 (7:30 am). He was put to bed and he went to sleep. V/s (vital signs, usually include temperature, heart rate or pulse, blood pressure respirations and oxygen saturation (percent of red blood cells available carrying oxygen)) were taken BP (blood pressure) was low retaken and it was ,[DATE]. Did Call provider at approx (approximately). 900 am. No return call. Changed out his foley (brand name of catheter that is placed into bladder to drain urine) catheter and sent a UA (urine sample for lab analysis) (at) 1230 (pm). He was given a mighty shake (protein shake) and pudding, he was alert to eat but he had to be fed. 2. On [DATE] at 9:17 pm, Pt (patient/resident) lying in bed. Pt has periods where he is breathing normally, and then will have kussmauls (a deep and labored breathing pattern) VS: T: 99.7 P: 101 R: fluctuates between ,[DATE] BP: ,[DATE] O2: 93%. Pt unresponsive to his name. Head of bed raised. Respiratory paged, auscultated lungs, stated they were normal. Notified on call provider, . ordered to send resident out (to emergency department). E. Record review of emergency Medical personal documentation for date of service [DATE], and at destination (facility) at 21:57 (9:57 pm) revealed: 1. Chief Complaint: None voiced - Pt. is unconscious. 2. Foley (brand name of commonly utilized urinary catheter placed into bladder to drain urine) catheter in place with less than 50 cc dark yellow urine noted. 3. Narrative .Staff report, He's only been responsive to pain all day and his, breathing is fast then slow. Pt's baseline is normally alert and communicative with staff. Staff deny recent falls or trauma and explains that pt has been eating and drinking normally prior to today. Staff deny fever. Upon arrival pt. found laying supine (symbol for with) legs curled to abdomen laying to the L (left) and both arms flexed toward chest. Strong odor of urine noted emanating from pt. Pt. is fully clothed (symbol for with) no signs of trauma noted. Pt. moans and withdraws from noxious (painful) stimulus. Pt. is tachypneic (breathing rate above normal) (symbol for with) deep respirations (symbol for with) occasional snoring respirations and dried emesis noted around airway. Circulation is weak at the radial (wrist, pulse point). Pt's skin is hot to the touch. (signed [DATE] at 10:10 pm.) F. Record review of acute care facility Emergency Medicine documentation, dated [DATE], at 10:33 pm, revealed: 1. Fever Max temp prior to arrival 103.6 (degrees Fahrenheit). 2. Patient is febrile (has a fever) and hypotensive (low blood pressure) with repeat blood pressure ,[DATE]. Patient is [MEDICAL CONDITION] (elevated heart rate above normal range) and tachypneic Unresponsive (marked failure to respond to stimuli normally). 3. Dry MM (mucous membranes (a symptom of dehydration). 4. Respiratory distress present .breath sounds: Rhonchi (rattling, continuous and low-pitched breath sounds that are often said to be like to be like snoring. They are often caused by secretions in larger airways or obstructions) present 5. Cardiac failure, shock,Sepsis, [MEDICAL CONDITION] and dehydration. [NAME] Record review of medical provider documentation dated [DATE] at 1:28 pm revealed, Called to patient's room soon after IV (intravenous-administering fluid/medication into he blood stream) vasopressors (medications administered to constrict blood vessels and raise blood pressure) were discontinued and found patient pulseless (no pulse), asystole (heart not beating) on monitor Time of Death 13:28 (1:28 pm) on [DATE]. H. Record review of medication administration history, on [DATE] revealed [MEDICATION NAME] (generic for Tylenol) administered at 7:41 am, PRN (as needed) Reason: Fever Comment: At 0630 (6:30 am) temp (temperature) was 100. I. On [DATE] at 8:40 am, during interview, LPN #2 revealed, regarding R #500 during her day shift as his nurse on [DATE], They (Restorative Aides) got him up in the morning for restorative dining and then after a few minutes they brought him back and said he was too tired to eat, I didn't think too much about it at the time, Restorative Aide (RA) #1 put him back to bed and got his vitals. His blood pressure .it was low so when the CNA came out after breakfast I asked her to get them again .so they checked his VS (vital signs- blood pressure, heart rate ,respirations and temperature) again and his pressure was okay. He didn't really eat anything but he was talking to us. He didn't have that much out (urine) but in the night they said he had about 900 (cubic centimeters, cc's, there are ~ 30 cc's per ounce of fluid) I think, I didn't get much out (after new urinary catheter placed) it was concentrated (dark colored). I went home 3:30 or 4 o'clock I told them (in shift report) he wasn't himself and to keep an eye on him(Did you call the doctor?) I didn't think of it because he has had UTI's and he would pull on his catheter, we had tried to have his catheter out it would clog and we would flush it. [NAME] On [DATE] at 10:41 am, during interview, LPN #3 revealed, (regarding R #500 on [DATE], who was her resident on the evening shift). I don't remember the date I had him last but he had been up and walking that day, in report (between day shift and evening shift on [DATE]) it was just that he was going down, that he was not doing well, but we were waiting for his UA (urine analysis, a lab test to diagnose medical problems, often to diagnose infection in the urinary tract). (The report was you were waiting for a UA?) Yes, later that night he looked bad, I think his pulse was high, he wasn't responding to pain any more, I called the doctor and we sent him out right away. (Is that usually practice to wait awhile when someone is not doing well?) It just depends on the doctor, I had another patient like him and we sent him out right away. (Why did you wait to call the doctor on (name of R #500) then?) In report it sounded like the doctor wanted to wait for the UA results. K. On [DATE] at 8:15 am during interview with CMA #1 regarding R#500 on [DATE], she revealed, (Do you know why he did not go out to the hospital until after 9 pm?) I think he went before that .Sometimes when you call them, EMS (Emergency Medical Services), but don't call through 911(as an emergency) they take their time to come. (what training do you get on responding to a change in condition in a resident with dementia?) we get training sometimes, we were thinking he had a urinary tract infection because he had them before .we were waiting to get results back. L. On [DATE] at 8:25 am during interview with RA #1 (Who took R # 500 to/from restorative dining on [DATE] at 7:00 am/7:30 am respectively), she revealed, When I pick him up (on [DATE], for breakfast) I notify (the nurse) he is white, pale, I tell nurse he is, she said take him to see if he wants to eat. We went to restorative (dining hall) and he started to slide down in chair as soon as we got there. I brought him right back and told the nurse he had no strength to sit up. He did not eat. No, I did not take vital signs. No, I didn't see him again. I did ask about him later in the day, I asked the nurse, and the nurse said he was laying in bed . M. On [DATE] at 8:50 am, RA #2 revealed (do you remember the day in (MONTH) that you brought (name of R #500) back up to the room with (first name of RA #1) because he didn't feel well?) Vividly, he was just kind of out of it he wasn't able to speak he could barely sit up he was kind of slouching (first name of RA #1) spoke to the nurse. I believe they had a CNA do the vitals. N. On [DATE] at 11:04 am, during interview with Respiratory Therapist (RT), RT #1, re: documentation of evaluation of R #500 on [DATE], he revealed, no RT notes were made except what you would see in the in his progress notes .it looks like the RT spoke to the nurse . and told her what he or she found. O. Record review of nursing progress note on [DATE] at 9:17 pm, the nurse documented, Respiratory paged, auscultated (listened to) lungs, stated they were normal. No other RT documentation for this event was found. P. On [DATE] at 12:00 noon, during interview, the Nurse Practitioner, caring for R #500 when asked, if a resident such as (name of R #500) who was previously walking and was now slumping in his wheelchair would you expect to be notified? responded, Absolutely, I would expect to be notified .Common sense would tell you we need to escalate that as necessary. Q. On [DATE] at 12:35 pm, during interview, the ADON revealed, that she was not notified of R #500's change in condition until he was ordered to be sent out to the acute care hospital (per nursing notes, on [DATE] ~ 9:17 pm) and that, I would expect them (staff) to let me know (prior to that time) .we do education (regarding notification to ADON of resident change of condition) all the time, at meetings. (Why do you think they didn't call you this time {for R #500 on [DATE]}?, she responded He always acted like that when he had a UTI. R. Record review of Medication Administration Record [REDACTED]. S. Record review of nursing progress notes for previous UTI's and R #500's symptoms revealed: 1. On [DATE] at 9:05 am,Returned from Restorative dining reported residents behavior is different. States he has to pee. foley has very little output. Removed cath (a flexable tube inserted into the bladder). urine came out and he felt relief .Seems settled now is up in his wheelchair. (Most recent previous progress note was on [DATE] and did not mention any symptoms). On [DATE] No c/o pain or discomfort noted. 2. On [DATE] at 10:14 pm, .No c/o (complaints of) pain or discomfort noted. 3. On [DATE] at 10:49 pm, Urine cloudy and the resident states he has to pee. Cath. (Urinary catheter) changed and urine specimen obtained. Called provider (medical provider) will wait for results. (Most recent nurse progress note prior to this note was on [DATE] and does not mention any physical or mental issues for resident). 4. On [DATE] at 9:30 am (the very next time a nursing progress note is documented after the [DATE] note) revealed, Reviewed labs with (Name of MD #1); he states he does not want to start resident on ABT (antibiotic therapy) as he is asymptomatic (without symptoms) and has a foley. Notified Dr. (Doctor) of his upcoming urology (is the branch of medicine that focuses on diseases of the male and female urinary-tract system) appt. (appointment) VS are WNL (within normal limits). 5. On [DATE] at 8:16 am, Interdisciplinary ( Team IDT) meeting (bringing key players together (physicians, nurses, social workers, spiritual counselors, etc.) to discuss each patient, changes in their care and to make sure the patient ' s family and needs are being met) dated [DATE] noted, UTI [DATE] confirmed with ABT (antibiotic therapy) completed. 4. No other progress notes, until event on [DATE] indicated the resident had another UTI, a decrease in level of responsiveness or new onset of weakness. T. On [DATE] at 11:20 am, during interview, ADON confirms she, scoured that (R #500's) chart last night and even though I know he acted like that no one charted it. U. On [DATE] at 12:30 pm the ADON was asked for all policy's and any education for nurses and CNA's on Change of Condition monitoring/response as well as any protocols for vital sign monitoring. V. On [DATE] at 12:35 pm the ADON related that the facility does not have a written policy or protocol in place for change of condition monitoring/response nor any for vital sign monitoring, the education is done at staff meetings. She has the agendas for two staff meetings that include there was to be discussion/education on : 1. On [DATE], Changes in resident condition. 2. On [DATE], Notification to nurse and Documentation of changes. W. On [DATE] at 12:35 pm, ADON was requested to show documentation of LPN's #2 and #3 had attended the meetings on [DATE] and/or [DATE]. X. On [DATE] at 5:20 pm, ADON was requested to show documentation of all staff who attended the meetings on [DATE] and/or [DATE]. Y. On [DATE] at 11:20 am, the ADON produced sign in sheets for the [DATE] meeting with a total of 29 staff documented as having attended. Included in these is signature of LPN #3. There was no signature for LPN #2. Regarding the documentation of attendees at the [DATE] staff meeting she revealed, They are scouring my piles of paper for those sign in sheets now. Z. On [DATE] at 3:45 pm, the administrator dropped off paperwork that included 3 staff signature sheets, with a total of 54 staff signatures (not titled or dated.) When asked for clarification later that afternoon he revealed these were signatures of staff that attended the staff meetings on [DATE].

Based on record review and interview, the facility failed to ensure quality care for 4 (R #229, #401, #92, and #178) out of 6 (R #229, #401, #92, #178, #204 and #94) residents looked at for neglect; by not taking action on R #401's lab work when it indicated that he had a major infection, not following physician orders [REDACTED].#92 and R #178 made it to their scheduled appointments and not following physician's orders [REDACTED].#229, resulting in drug toxicity (a high accumulation of a drug in an individual's bloodstream, leading to adverse effects on the body). This deficient practice caused R #178 and R #92 to miss several pertinent appointments and for R #401 to have a serious wound infection that went without treatment for [REDACTED]. The findings are: Findings for R #401 [NAME] Record review of R #401's face sheet indicated that he was admitted to the facility on [DATE] with [MEDICAL CONDITION] (are caused by a complete lack of oxygen being provided to the brain), Persistent vegetative state (disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness), [MEDICAL CONDITION] (a disease in which the functioning of the brain is affected by some agent or condition), [MEDICAL CONDITION] (speech and language disorder that results from neurological damage to areas involved in language processing), Dysphagia oropharyngeal phase (it takes more time and effort to move food or liquid from your mouth to your stomach), Chronic [MEDICAL CONDITION] ([MEDICAL CONDITION] can happen when your respiratory system is unable to remove enough carbon [MEDICATION NAME] from the blood, causing it to build up in your body), Neuromuscular dysfunction of bladder (due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination), abdominal hernia (occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall) , ventral hernia (bulge of tissues through an opening of weakness within your abdominal wall muscles), Non-pressure chronic ulcer (wound to the foot) and other pertinent diagnoses. B. Record review of the physician orders [REDACTED]. C. Record review of the physician orders [REDACTED]. Start date 08/13/19. D. Record review of the MAR (medication administration record) for (MONTH) 2019 indicated that R #401 received one dose on the 13th and two doses from 08/14/19 -08/20/19. The documentation ends due to a switch in the electronic medical record to a different system. E. Record review of the MAR (medication administration record) for (MONTH) 2019 in the new electronic medical record system, indicated that R #401 did not receive another dose of the [MEDICATION NAME] Tablet 100 mg. The medication did not get transferred over to the new system. R #401 did not receive five doses of the antibiotic medication. F. Record review of the nursing progress notes indicated the following: On 09/03/19 resident (R #401) in bed no distress continues on ABT (antibiotic) via [DEVICE] for pleural effusion (pneumonia) and UTI (Urinary Tract Infection) no adverse reactions noted, spoke to PA (Physician's Assistant) regarding wife/POA (power of attorney) requesting resident to be seen. Verbal order for wound culture to right lateral foot order noted and collected. [NAME] Record review of lab work that was collected on 09/03/19 for a wound culture. The result of the culture on 09/07/19 was a critical lab for ESBL (Extended spectrum beta-lactamase's are a type of enzyme or chemical produced by some bacteria. ESBL enzymes cause some antibiotics not to work for treating bacterial infections. Common antibiotics used to treat bacterial infections can become useless ESBL) [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph (Staphylococcus aureus is a germ found on people's skin. Staph can cause serious infections if it gets into the blood and can lead [MEDICAL CONDITION] or death. Staph is either [MEDICAL CONDITION]-resistant staph (MRSA) or [MEDICAL CONDITION]-susceptible staph (MSSA). Staph can spread in and between hospitals and other healthcare facilities, and in communities) infections. [MEDICAL CONDITION] infections occur in people who've been in hospitals or other health care settings, such as nursing homes and [MEDICAL TREATMENT] centers). There was a unsuccessful attempt to call the facility to notify of the critical lab on 09/07/19 at 11:14 am. A second attempt was made at 11:50 am. On 09/08/19 at 5:57 pm a third unsuccessful attempt was made to call the facility about the critical lab. The culture and sensitivity or C & S (is the identification of microorganisms in a clinical specimen (as in a sample of blood, cerebrospinal fluid, sputum, or urine) and a determination of the antibiotic, antifungal, or [MEDICAL CONDITION] drugs that effectively kill them) had already been completed on 09/07/19 and was on the lab work. H . Record review of the nursing progress notes dated 09/09/19 at 13:41 (1:41 pm), received phone call from (name of lab), resident positive for ESBL . Culture was taken 9/3 (09/03/19). Informed wound care (unidentified nurse), and PA (physician's assistant). PA would like to wait for culture sensitivity to tx (treat). I. Record review of the written physician's orders [REDACTED]. Instead, it helps your healthcare provider determine whether you're experiencing inflammation) and STAT right foot xray rule out osteo[DIAGNOSES REDACTED] (bone infection). Please have a A PICC line placed (peripherally inserted central catheter is a form of intravenous access that can be used for a prolonged period of time or for administration of substances). Another order placed on 09/13/19 indicated that Ertapenem (is an antibiotic that fights bacteria. Ertapenem is used to treat severe infections of the skin, lungs, stomach, pelvis, and urinary tract)1 gm (gram) IV q (every) day x 7 days. Continue wound care per wound nurse. [NAME] Record review of the nursing progress notes dated 09/13/19, resident seen by facility MD (Medical Director) verbal order to transfer resident to (name of hospital) ER for right lateral foot treatment positive for ESBL [MEDICAL CONDITION]. Wife and POA (power of attorney) stating I feel better if he gets treated at the hospital. K. On 01/28/19 at 11:57 am, during an interview with the DON (Director of Nursing), she stated that she looks through the labs for new orders or for anything that could be critical. In our new electronic medical record system the labs are not automatically loaded to the residents chart like they were before. If it is a critical lab then it will notify the provider. If the lab calls and tries to notify the facility of a critical lab and they can't get through to one of the nurses on the floor they can always call the ADON (Assistant Director of Nursing) or the Unit Manager. They (ADON and Unit Manager) always have their phones. She stated that the nurses have access to labs in the system and they also have access to the labs that did the lab work. The DON looked up the lab work for R #401 and stated that the MD signed off that she saw the lab but did not date it. She also stated that yes she would expect to see this resident on a antibiotic. L. On 01/28/19 at 12:13 pm, during an interview with the ADON (Assistant Director of Nursing), she stated that the culture states it was for the chest but it wasn't, it was for his right foot. She stated that he did have an abdominal wound but that wasn't what was cultured on 09/03/19. She stated that the reason R #401 went out to the hospital had to do with a particular antibiotic that the facility didn't feel comfortable using on him. M. On 02/05/20 at 9:02 am, during an interview with R #401's wife and POA, stated that while he was at the facility he had chronic UTI's (urinary tract infection), and pneumonia. By the time he got to the hospital for his foot, it was too late, he lost two toes and then lost his leg. The infection was already in his bone. She stated that her husband stayed in the hospital until she took him home on hospice, and then he only lasted a day or so. N. On 02/05/20 at 10:45 am, during an interview with the Medical Director, she stated that she was not aware of the wound culture and sensitivity lab work that had come back, until 09/13/19. Findings for R #92 O. Record review of R #92's facesheet indicated that he had the following Diagnoses: [REDACTED].{has the same origins as that of an ischemic stroke, the most common type of stroke. In an ischemic stroke, a clot blocks the blood supply to part of your brain. In a [MEDICAL CONDITION], unlike a stroke, the blockage is brief, and there is usually no permanent damage), Cerebral Infarction (an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain. The restricted oxygen due to the restricted blood supply causes an ischemic stroke), Depression, Diabetic [MEDICAL CONDITION] (is a type of kidney disease caused by diabetes. Diabetes is the leading cause of kidney disease. The main job of the kidneys is to filter wastes and extra water out of your blood to make urine), Celluitisis (is a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat) of right lower limb, [MEDICAL CONDITION] (also called [MEDICAL CONDITION], refers to any disease or disorder of the circulatory system outside of the brain and heart), and other pertinent diagnoses. P. Record review of the physician's orders [REDACTED]. Q. On 01/28/20 at 9:53 am, during an interview with the Scheduling Director, he stated that he did not know if he was notified of this appointment. He is not sure a referral was made and there was no way to confirm this. He stated that he does see the order in PCC (point click care) but was not sure what happened from there. He stated that it failed to make it to his department or his department failed to set it up. R. Record review of the physician orders [REDACTED]. S. Record review of the physician orders [REDACTED].@ 0845 (name of hospital) Derm Clinic (name of physician). There is no documentation that the resident went to this appointment. T. On 01/28/20 at 10:15 am, during an interview with the Scheduling Director, he gave me the appointment sheet for 04/02/19. It did not have R #92 scheduled that day. U. Record review of 04/02/19 of the appointment sheet for 04/02/19 indicated that R #92 was not transported to this appointment. V. Record review of the physician orders [REDACTED].#92 had an appointment scheduled for 06/12/19@1000 (name of hospital) 1st Floor Amb Spec (Ambulatory Specialist) (name of physician). W. On 01/28/20 at 9:53 am, during an interview with the Scheduling Director, he stated that he looked up the appointment on 06/12/19 and R #92 did not make it to this appointment. X. Record review of the appointment sheet and the Exit/Entry log sheet dated 06/12/19 indicated that R #92 did not go this appointment. Y. Record review of the nursing progress notes did not indicate that resident refused to go to any of the above noted appointments. Findings for R #178: Z. On 01/26/20 at 11:37 am, during an interview with the sibling of R #178, when asked if an unresolved dental issue has occurred, the sibling stated, They said they would try to get him dentures. I requested them in (MONTH) last year (2019). A[NAME] On 01/26/20 at approximately 8:00 am, an observation of R #178 confirms a lack of dentures. BB. Record review of R #178's progress notes dated 10/16/2019 includes an entry from Social Services stating resident brother requested dentures and dental consult. Notified transportation via E-Mail. CC. On 01/28/20 at 02:18 pm, during an interview with the Transportation Coordinator, when asked to explain the process of scheduling an appointment, the Transportation Coordinator stated a lot of the residents request appointments and so do family members. If it comes from any source, we run it through the nursing staff and the PCP (Primary Care Physician) team. It has to be approved by them. It has to be something that is not done in house and not frivolous. Once its approved, we start the process. If it is unclear on who to go to (which physician to choose), we look at the insurance company and ask for a list of providers. When asked if R #178 received dental services, the Transportation Coordinator stated If its (Name of Dental Provider), we communicate with them via email. I will have to call (Name of Dental Provider) for any records, I don't have access to any of them since we are now web based. DD. On 01/29/20 11:06 am, during an interview with Social Services Coordinator #2, when asked about the request that was provided to the transportation team regarding dental services on 10/16/2019, SSC #2 stated During a meeting he (the sibling of R #178) did voice that he wanted voice therapy, and dental services. Usually, we will email (transportation). If it's a medical appointment, I let (the Transportation Coordinator) know. If its therapies, I email therapies. It is an email request. (The Transportation Coordinator) was emailed. I can't get into my old email system, but I know I emailed him. Findings for R #229 EE. R #229 was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. between [MEDICAL CONDITION]), Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions) without behavioral disturbance, Unspecified dementia with behavioral disturbance, [MEDICAL CONDITION] disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), current episode mixed, unspecified, [MEDICAL CONDITION] disorder, unspecified, Unspecified fall, subsequent encounter, and Disorientation, unspecified. FF. Record review of care plan indicates that a [MEDICAL CONDITION] disorder (a tendency to experience sudden uncontrollable, electrical disturbances in the brain) has been identified for R #229 and an approach to address the disorder includes administering medications as ordered and to monitor/document/report presence of side effects. G[NAME] Record review of physician orders [REDACTED]. 1. Levetiracetam tablet (a generic form of [MEDICATION NAME], a medication used to treat [MEDICAL CONDITION]), 500mg, 2 tablets by mouth, twice a day. Start date: 8/29/19, end date: 10/2/19. 2. [MEDICATION NAME] tablet (a medication used to treat [MEDICAL CONDITION]), 64.8mg, 1.5 tablet by mouth, twice a day. Start date: 08/19/19, end date: open ended. 3. [MEDICATION NAME] sodium extended capsule (a generic form of [MEDICATION NAME], a medication used to treat [MEDICAL CONDITION]), 100g, 2 capsules, twice a day. Start date: 08/29/19, end date: 09/09/19. 4. [MEDICATION NAME] sodium extended capsule, 100g, 3 capsules, at bedtime. Start date: 08/29/19, end date: 09/24/19. 5. [MEDICATION NAME] sodium extended capsule, 100g, 2 capsules, once a day. Start date: 09/09/19, end date: 09/24/19. 6. [MEDICATION NAME] sodium extended capsule, 100g, 3 capsules, once a day. Start date: 09/24/19, end date: 09/24/19. HH. Record review of physician orders [REDACTED]. All lab results were requested from medical records, this lab was not presented. II. Record review of progress notes does not include any documentation of labs performed on 09/06/19. J[NAME] Record review of physician's notes dated 09/17/19 states Previously ordered [MEDICATION NAME] and [MEDICATION NAME] level- do not appear to be in the chart, get these. KK. Record review of facility policy for Specimen Collection, Test Results, dated (MONTH) 2007, states The resident's attending physician will be notified of the results of diagnostic tests. Under Policy Interpretation and Implementation, the policy states; 1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's Attending Physician or to the facility. 2. Should the test results be provided to the facility, the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results. 4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record. LL. Record review of progress notes dated 09/22/19 states resident was not feeling well so I didn't ambulated (walk or move from place to place) resident, notify the nurse. MM. Record review of progress notes dated 09/22/19 indicates that the resident had a fall as she was found on the floor, resident was in sitting position, against her back on the closet . resident slipped when she pulled the TV cord from the hall. NN. Record review of progress notes dated 09/23/19 states Resident is stumbling around some. OO. Record review of progress notes dated 09/23/19 states Confused states her hands are shaking unable to eat in the dining room. PP. Record review of progress notes dated 09/23/19 states Resident slipped OOB (Out of Bed) and landed on her bottom. She has been very confused and lethargic (lack of enery) throughout the day POA (Power of Attorney) and daughter stated that she does not want her to go to the hospital unattended. MD (Doctor of Medicine) on call notified and Stat Labs ordered. QQ. Record review of progress notes dated 09/24/19 states Resident has been up in her wheelchair today. She is very unsafe, and we have to watch her closely. Blood was drawn earlier it was difficult because resident is dehydrated (lack of water). Did collect urine and it was sent. RR. Record review of progress notes dated 09/24/19 states [MEDICATION NAME] ([MEDICATION NAME]) lab telephoned to report critical and toxic lab level of [MEDICATION NAME]; 33.6 (a therapeutic range is 10-20 micrograms/ml). MD notified. Drug on hold. Lab request made for Thurs draw. SS. Record review of physician's notes dated 10/03/19 states Approximately 2 weeks ago the patient was exhibiting signs increasing confusion. Blood level for [MEDICATION NAME] and [MEDICATION NAME] were checked in the [MEDICATION NAME] level was toxic as listed later in this note. [MEDICATION NAME] level was normal. [MEDICATION NAME] was put on a temporary hold and when rechecked 2 days later the level had dropped to 8.4. Unfortunately there was a breakdown in communication and [MEDICATION NAME] was not restarted as planned. Nurse reports there have been no [MEDICAL CONDITION] activity during that time and the patient is acting more like herself. No other concerns right now.

Based on record review and interview, the facility failed to ensure, interventions were put in place to prevent facility acquired pressure wounds, wounds were identified and assessed on admission and treatments were being administered per physicians orders for 5 (R #207, 257, 261, 401 and 650) of 5 (R #207, 257, 261, 401 and 650) residents reviewed for pressure wounds. Failing to identify, assess, initiate and/or delay interventions, treatments and preventable measures in a residents with known or developing mobility deficits will likely result in developing pressure wounds/ulcers (injuries of the skin and underlying tissue due to prolonged pressure on the skin) directly effecting the health and well being of the resident creating potential and avoidable negative outcomes. The findings are: Findings for Resident #257 [NAME] Review of the medical record revealed R #257 was admitted to the facility on [DATE], with a medical [DIAGNOSES REDACTED]. lungs) and is in a persistent vegetative state. B. Review of the Nursing admission assessment record dated 11/19/2019, indicated R #257 had some tattoos, old scars, surgical incision to her head and a surgical wound to her abdomen (stomach). There was also noted, Bilateral Buttocks/coccyx- excoriation/open areas. There was no documentation or mention of a unstageable pressure wound as noted in her medical history when admitted , no wound measurements or further wound description noted. C. Review of the Nursing assessment/ skin assessment dated [DATE], indicated R #257 has a coccyx (aka sacral area) wound which is covered by a Duoderm dressing (a thick waterproof dressing that forms a gel for wound healing). There was no further description of the wound, the condition of the dressing, the date it was last changed or if there was any odor that would indicate an possible infectious process. D. Review of the Nursing Wound care assessment/skin assessment dated [DATE], again indicated R #257 has a Sacrum wound. Again, there was no further documentation regarding this wound and the assessment form clearly requires the nurse to Describe site, color and drainage if any. E. Review of the physician's orders [REDACTED]. 11/20/19, Wound care: Buttock wound: cleanse with normal saline or wound cleanser, apply skin protectant to peri wound, apply medical honey to wound bed and cover with [MEDICATION NAME] (oil [MEDICATION NAME] guaze) secure with large border foam dressing. Change daily and PRN (as needed) if soiled or missing. F. Review of the Nursing progress notes dated 11/19/19 through 02/03/20, revealed the following; 1. On 11/20/19, indicated: (Name of R #257) has unstageable bilateral pressure ulcer . Wound team will continue to follow-up. 2. On 11/25/19: Nursing Wound progress notes indicates: Wound care: Old dressings to buttock pressure ulcer and abdomen replaced. There was no further description of the wounds noted. 3. On 12/27/19, nursing progress notes revealed the only documentation which included a description and the characteristics of the wound. Progress notes through 02/03/2020, revealed no further wound descriptions. [NAME] Review of the wound 'Observation Details' reports dated 11/20/19 through 01/26/20, revealed the following; 1. On 11/20/19 - documented measurements of a mid abdomen surgical wound and only made mention of an ulcer wound described as Necrotic tissue with no further documentation that would indicate this wound was being measured or staged (meaning measuring the length, width and depth to identify if it was stageable). Pressure wounds are staged I, II, III and IV to determine the extent of tissue damage or loss. 2. On 01/08/20, documentation states, Sacral stage III meaning full thickness skin loss without exposing tendon or bone. There was no indication a complete wound assessment was completed that would have included a description of the wound and it's measurements. 3. On 01/22/20, documentation revealed the sacral pressure wound was fully assessed including measurements that described the wound as being 8.5 cm (centimeters) X (by) 7.3 cm X 3.6 cm (length times width times depth). This was the first documented measurements of R #257's sacral wound. H. Review of the 'Wound Management' reports from 11/19/19 through 02/09/20, revealed no Wound management reports available until 12/10/19 which described R #257's sacral wound as being unstageable and measuring 4.5 cm x 12 cm (meaning length and width). This information indicated that R # 257's wound, though present on admission 11/19/19, was never measured or fully assessed till 12/10/19. I. On 02/03/20 at 09:04 am, during interview with the interim Director of Nursing (DON), she was asked what her expectation was regarding proper wound assessments. The DON stated she would expect to see documentation including, when the wound had begun, the condition of the wound, what stage the wound was classified as and the recommended treatment. The DON also stated that if a resident was admitted with a wound the first assessment be completed- when the nurses do their initial admission assessment. The DON then explained that the unit nurses can assess the wounds and describe the wounds but they (meaning the facility) would rather have wound care nurse stage and measure the wounds. Then added that she would hope the wound care team would look at the wound the day of admission or that next morning. The DON also stated that the wound care team will do the measuring and the staging and will continue to monitor the wound and assess it on a weekly basis or more if there is a significant change. When asked what is your definition of measuring a wound? The DON stated, We have a tool that is used so we have consistency when measuring each wound, include length, width and depth and in centimeters .also if there is any undermining (meaning tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin), tunneling (meaning, wounds that reach through layers of tissue), odor (meaning, a smell that may indicate infection) or necrosis (meaning dead skin tissue). [NAME] Review of the facilities 'Wound Care' policy dated (MONTH) 2010 states, under documentation, The following must be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given . 6. All assessment data (i.e., wound bed color, size, drainage etc.) obtained when inspecting the wound . K. Review of the Nursing 2019 journal dated (MONTH) (YEAR)- Volume 47- Issue 3 p 68-69 states; A pressure injury is defined as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue . Pressure injuries are staged to indicate the extent of tissue damage .Unstageable pressure injury: obscured full-thickness skin and tissue loss .Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer can't be confirmed because it's obscured by slough(shedding off deade skin tissue) or eschar (dead skin tissue). If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. L. Review of the American Journal of Nursing (AJN) article 'Measuring Wounds to Improve Outcomes' (MONTH) 2013 Vol. 113, No. 8 states; Wounds must be assessed and monitored to detect important changes, quantify progress, and guide treatment decisions. Assessment covers a variety of variables, such as the amounts of exudate, necrotic tissue, [MEDICATION NAME] slough, and granulation tissue; the presence of undermining, tunneling, and epithelium; and the size of the wound .The Centers for Medicare and Medicaid Services State Operations Manual on long-term care states that pressure ulcer improvement must be documented during the first two to four weeks of care for healing to be considered to be taking place. And content-validated pressure ulcer and wound care guidelines now include the recommendation that all patient and wound care protocols be reevaluated if a wound doesn't exhibit a reduction in size (usually 20% to 50%) within that time frame . M. On 01/28/20 at 3:22 PM, during an interview with the ADON (Assistant Director of Nursing), she stated that the past several wound care nurses had documentation problems. They weren't doing what is expected, like wound measurements. Measurements should be getting done once per week for every wound. She stated that it is slowly getting better but it has been six months of these issues. N. On 01/29/20 at 11:46 AM, during an interview with the DON (Director of Nursing), she stated that the wound care nurse back in (MONTH) of 2019 left, they had a nurse step up to take on the wound care, he was doing the wound care and did it for several months, and then he didn't show up to work one day. Then we had another nurse step in, and he was good with wounds but didn't document, so that was a problem. Now they have a full time wound care nurse. DON stated that their future plan is to have a paid trainer, to come in and train nurses and CNA's (Certified Nursing Assistant). She stated that they aren't bringing in any complicated wounds at this time because there have been issues. She stated that documentation is expected to get done. Measurements should be done weekly. New admissions to the facility should have a skin assessment done in 24 hours. She stated that their wound care needs within the facility require wounds to be addressed everyday. R #401 O. Record review of R #401's face sheet indicated that he was admitted to the facility on [DATE] with [MEDICAL CONDITION] (are caused by a complete lack of oxygen being provided to the brain), Persistent vegetative state (disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness), [MEDICAL CONDITION] (a disease in which the functioning of the brain is affected by some agent or condition), [MEDICAL CONDITION] (speech and language disorder that results from neurological damage to areas involved in language processing), Dysphagia oropharyngeal phase (it takes more time and effort to move food or liquid from your mouth to your stomach), Chronic [MEDICAL CONDITION] ([MEDICAL CONDITION] can happen when your respiratory system is unable to remove enough carbon [MEDICATION NAME] from the blood, causing it to build up in your body), Neuromuscular dysfunction of bladder (due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination), abdominal hernia (occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall) , ventral hernia (bulge of tissues through an opening of weakness within your abdominal wall muscles), Non-pressure chronic ulcer (wound to the foot) and other pertinent diagnoses. P. Record review of the H and P (History and Physical) dated 02/26/19, indicated in the Physical Exam Section, under Skin that R #401's skin was dry and intact. Q. Record review of the H and P (History and Physical) dated 03/06/19, indicated in the Physical Exam Section, under Skin that R #401 was starting to develop pressure ulcers. They are starting to appear on right lower extremity as pointed out by nursing staff. R. Record review of the physician's orders [REDACTED]. Apply border foam to R (right) lateral foot, lateral heel and medial heel. Change every week and PRN (as needed) missing or soiled, every day shift every Thu (Tuesday). S. Record review of the H and P (History and Physical) dated 04/24/19, indicated in the Physical Exam Section, under Skin that R #401 was starting to develop pressure ulcers. They are starting to appear on right lower extremity as pointed out by nursing staff. Current wound measurements: Middle of the right lateral foot one by one with no discharge or odor. Lateral right heel 4 x 4 with intact skin . No discharge of odor. Medial right heel 3 x 3 intact no odor or discharge. T. Record review of the TAR (medication administration record) for (MONTH) 2019: indicated wound care for the right lateral foot and medial heel. Cleanse with wound care or normal saline bullet. Pat dry. Apply border foam to R. lateral foot and medial heel. Change every other day on day shift and PRN missing or soiled. Every day shift every other day. Start Date: 04/03/19. This order was D/C (discontinued) on 05/17/19. R #401 was receiving the wound care until 05/17/19 as it was ordered. U. Record review of the H and P (History and Physical) dated 06/18/19, indicated in the Physical Exam Section, under Skin that R #401 was starting to develop pressure ulcers. They are starting to appear on right lower extremity as pointed out by nursing staff. Current wound measurements: Middle of the right lateral foot one by one with no discharge or odor. Lateral right heel 4 x 4 with intact skin . No discharge of odor. Medial right heel 3 x 3 intact no odor or discharge. V. Record review of the TAR for (MONTH) 2019 indicated there were no orders for R #401's foot wound. No wound care was completed for the right lateral foot and medial heel. W. Record review of the TAR for (MONTH) 2019 indicated that an order for [REDACTED]. X. Record review of the physician's orders [REDACTED]. Cleanse with wound cleanser or normal saline, pat dry, apply foam padded dressing daily and PRN for missing or soiled. Start date 08/06/19. Y. Record review of the Wound Management Detail Report in the new electronic medical record system, indicated the following: Pressure wound identified on 08/16/19 on the right heel. Length 2 cm Width 2 cm Unstageable deep tissue Z. Record review of the Wound Management Detail Report in the new electronic medical record system, indicated the following: Pressure wound observed on 09/04/19 on the right heel. Length 4 cm Width 4 cm Unstageable DTI (Deep Tissue Injury) A[NAME] Record review of the physician orders [REDACTED]. BB. Record review of the labs/culture that was collected on 09/03/19, indicated that R #401 had a critical [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) and ESBL (extended spectrum beta-lactamase can cause illness and infection when they get into an area of the body where they are not usually found or in an individual that is elderly or immunocompromised. These infections are often very difficult to treat due to their resistance to antibiotics). CC. Record review of the nursing progress notes dated 09/13/19, indicated the following: R #401 seen by facility MD, (Medical Director), verbal order to transfer resident to (Name of Hospital) ER (emergency room ) for right lateral foot treatment positive [MEDICAL CONDITION] and ESBL. DD. On 01/30/20 at 10:55 am, during an interview with LPN #7 does remember R #401, LPN #7 stated that he had a [MEDICAL CONDITION], PEG tube, Foley cath, he was in a vegetative state, he was contracted, and had wounds on his right 4th and 5th toe and lateral side right foot. R #401 also had a hernia and the skin over the area was fragile. The wound on his right foot before he was sent out had a hole and slough at the wound base. It was draining with serosanguinous pus. A wound culture was completed and he [MEDICAL CONDITION] and ESBL. He was sent out to the hospital. EE. On 02/04/20 at 9:29 am, during an interview with RN #8 stated that there are currently two new wounds within the facility as of today. Staffing is a huge issue with getting residents turned and re-positioned. She stated that incontinence care isn't a huge issue, but there had been skin breakdown because of this. RN #8 stated that more frequent turning is a big thing and feels like staff could use more training on this. RN #8 stated that some residents like to go to bed early and they need to be turned more frequently. RN #8 stated that wounds need to be measured every week. Wound care team needs to assess and monitor for things like infection or if a different treatment is needed. RN #8 stated that organization and structure are two big things contributing to the wounds and that the facility is lacking. FF. On 02/05/20 at 9:02 am,during an interview with R #401's wife, she stated that while her husband was at the facility he had chronic UTI's (urinary tract infections). She stated that she had been asking for a physician to see her husband since (MONTH) 2019. By the time he got to the hospital he [MEDICAL CONDITION] in his foot. It had gone into the bone. He first lost a couple of toes and then he lost his leg. She finally took him home on hospice and he passed away within a couple of days. R #650 G[NAME] Record review of the History and Physical dated 10/4/19; review of systems section under skin/breast: indicated no rashes or skin breakdown for R #650. HH. Record review of the wound detail and measurements of the right buttock, left buttock, and left thigh dated 11/16/19 revealed the following: Right Buttock pressure ulcer (PU) Identified 11/16/19 states is declining 0.5 centimeters (cm) Length 0.5cm Width Depth 0.1cm Stage 3 pressure ulcer the wound extends through the dermis (second layer of skin) into the fatty subcutaneous (below the skin) tissue. Bone, tendon and muscle are not visible. Stage three ulcers open the body to infection and lead to serious complications, including osteo[DIAGNOSES REDACTED] (a bone infection) [MEDICAL CONDITION] (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). Right buttock PU identified 11/16/19 states is declining 2.1cm Length 2.3cm Width Depth 0.3cm Stage three pressure ulcer In the comments section, stated the pressure ulcer increased in size and slough (layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation.) present. Right Buttock PU identified 11/16/19 states is declining 2.7cm Length 0.9cm Width Depth 30cm (sic) wrong measurement Stage 3 pressure ulcer In the comment section, stated increased size and necrotic tissue (a medical condition in which there are dead cells in your body organ). Left Buttock PU identified 11/16/19 states is declining 0.7cm Length 0.5cm Width Depth yes No measurements were taken for the depth of the wound. Stage three pressure ulcer Left Buttock PU identified 11/16/19 states is declining 0.9cm Length 0.9cm Width 0 cm Depth Stage two pressure ulcer Stage two ulcers are diagnosed when intact skin suddenly breaks open, exposing the epidermis (the outermost layer of skin) and sometimes the dermis (the second layer of skin). Important to alter the body's position frequently. Left Buttock PU identified 11/16/19 states is declining 1.1cm Length 0.3cm Width D 0.1cm Stage three pressure ulcer Left Thigh PU identified on 11/16/19 states is declining 0.9cm Length 0.8cm Width Depth 0cm Unstageable pressure ulcer Unstageable pressure ulcer is a wound with substantial skin or tissue loss. The actual depth of the ulcer cannot be determined because slough (layer of dead tissue) and eschar (piece of dead tissue that is cast off from the surface of the skin). In the comments section, stated new wounding. II. Record review revealed on 11/18/19 R #650 filed a grievance stating she was not changed all day on 11/16/19 and CNA #16 called R #650 fat and would not put her to bed. The follow up was completed by the Unit Manager stating the Director of Nursing gave CNA #16 education, counseling, and training from the Director of Nursing (DON). J[NAME] Record review of R #650 point of care history under ADLs (Activities of daily living) indicated that resident was changed once on 11/16/2019 at 14:22 (2:22pm) that day. KK. Record review revealed on 11/21/19 Certified Occupational Therapist (COTA) #2 filed a grievance stating when the clinician arrived at 7:00 am on 11/20/19 R #650 reported that she had been soiled since the evening prior. Resident was found soaked with urine down to the mattress. COTA #2 cleaned the resident and changed the bed along with scrubbing the mattress. Resident also had increasingly worse wounds. Follow up was completed by the Unit Manager stating staff was talked to about making sure residents are changed and checked on every 2 hours. Unit Manager will make frequent visits to the floor to make sure resident being changed and to follow up with the resident. LL. Record review of the wound detail and measurements of the right buttock, left buttock, and left thigh dated 11/23/19 revealed the following: Right Buttock PU identified 11/23/19 and observed states is declining Length 2.1cm Width 4.2cm Depth 0.4cm Stage three pressure ulcer Right Buttock PU identified 11/23/19 and observed states is improving 1.5cm Length 0.9cm Width Depth 0.3cm Stage three pressure ulcer with slough Right buttock PU identified 11/23/19 and observed states is declining 1.9cm Length 1.9cm Width 0.3cm Depth Stage three pressure ulcer with Slough In the comments section, stated it was a new pressure ulcer. Right Buttock PU identified and observed 11/23/19 is declining 0.9cm Length 0.8cm Width Depth 0.1cm Stage three pressure ulcer Left Buttock PU Identified and Observed 11/23/19 improving 0.5cm Length 0.4cm Width Depth yes No measurements were taken for the wound for the depth section. Stage three pressure ulcer Left Buttock PU identified and observed on 11/23/19 1.4cm Length 0.3cm Width Depth No Unstageable pressure ulcer with slough and eschar Left thigh PU identified 11/23/19 States is improving 0.8cm Length 0.8 cm Width Depth yes No measurements were taken for the wound for the depth section. Stage three pressure ulcer MM. Record review of R #650 treatment administration record (TAR) for (MONTH) 2019 indicated a new order to treat the left buttock pressure ulcer identified on 11/16/19. On the reasons/comments section indicated that on 11/26/19 at 16:03 pm (4:03pm) wound care was not administered due to Registered Nurse (RN) #13 being the only Nurse on the unit available for wound care. Stated she tried but the resident was unavailable, no follow up with resident documented. NN. Record review of R #650 treatment administration record (TAR) for (MONTH) 2019 indicated a new order to treat the left buttock pressure ulcer identified on 11/16/19. On the reasons/comments section indicated that on 11/28/19 at 12:35 pm (2:35pm) wound care was not administered due to Registered Nurse (RN) #14 being the only Nurse on the unit available for wound care. Stated the resident was unavailable off the unit with activities, no follow up with resident documented. OO. On 2/3/20 1:19Pm, during an interview, the DON stated CNA #16 stated she did not call R #650 fat and the CNA stated she did change her brief but no documentation. Stated R #650 does complain a lot, but still gave the CNA a written warning signed by the CN[NAME] PP. Record review of the written warning dated 11/21/19 revealed CNA #16 received a written warning from the DON. CNA #16 stated she will be more considerate of her words, reviewed peri-care protocol, and will be more mindful of time between rounds. QQ. On 2/5/20 9:04am, during an interview, the Unit Manager stated that there should be documentation of the wound measurements weekly in the electronic file for (MONTH) through the end of December. Stated they do try and turn the resident every 2 hours. Stated the documentation should be in the resident file if she refused to be turned or was not available. Stated they are working on getting everyone to document better.

Based on record review, interview and observation the facility failed to prevent staff to resident abuse for 1 (R #1) of 6 (R #s 1, 2, 3, 4, 5 and 7) residents looked at for smoking; by allowing R #1 to go smoke outside of smoking hours, and staff leaving resident alone and not checking on him periodically. This deficient practice caused harm to the resident due to the resident becoming Hypothermic (a body temperature core, or internal body temperature, of less than about 95 degrees Fahrenheit (F)). The findings are: A. Record review of R #1's medical diagnose's indicated the following: [MEDICAL CONDITIONS], type 2 diabetes, sleep apnea, hypertension, history of falling, [MEDICAL CONDITION], major [MEDICAL CONDITION], hallucinations . B. Record review of the facility reported incident (FRI) dated 03/12/19 indicated that (Name of Resident (R #1)) was found outside at around 5:20 am, in the smoking area, on the ground. Staff reported that they had last seen (Name of Resident) at 3:00 am and found him outside on the ground at 5:20 am. R #1 told staff that he had fallen and was unable to get himself up. The FRI also indicated that after reviewing the security tapes, (Name of Resident) had gone outside late on 03/11/19. He fell , was unable to get himself up, spent a total of six hours on the ground where he was wet, before he was found by staff at 5:20 am. C. Record review of R #1's nursing progress note dated 03/12/19 indicated, . was lethargic unstable and refuse to be fully assess, denied pain, PT (patient) was soak and wet when found on the floor, refuse transfer to ER (emergency room ), neuro-checks (assessment made by a medical professional on someone with a head injury, cervical injury, nerve function in injury/surgery, or stroke) started and PT was hypothermia with temperature of 93.0 (Normal 98.6 degrees F) . D. Record review of R #1's Incident note dated 03/12/19, pt. noted on the floor at the smoking area next to a table and chair which was tick (sic) upside down while resident was lying straight on the floor with both shoes on his foot (sic) head to toe assessment down (sic) with no open area nor abrasion noted, pt. stat (sic) he just went to sleep and not complaint (sic) with assessment, denied pain, transfer via four employees to w/c (wheelchair), pt was wet and soak while on the floor, able to move all extremities, but very lethargic, neuro - checks (a brief neurological assessment ordered by the physician to be performed every 4 hours on patients) started, pt. was hypothermia with temperature of 93.0, pt. denied pain, redness to left knee and left ankle and bleachable (sic). E. Record review of R #1's Neurological Assessment Flowsheet indicated that on 03/12/19 at 5:15 am, R #1 had a temperature of 93.2 degrees F. F. On 03/27/19 at 2:47 pm, during an interview with the Assistant Director of Nursing (ADON) #1, she stated that after their investigation they fired five staff members who were either involved in the incident or should have known that R #1 was outside. ADON #1 stated that during her investigation into the incident it was revealed that they (staff) all knew that he was outside. They heard the alarm go off when he went out there and some of them smoked a cigarette with him. No one was checking on him. The Medication Administration Record [REDACTED]. When ADON #1 asked the nurse about this, the nurse admitted that she had not tried to give it him. ADON #1 also stated that the staff had become very complacent with an attitude of oh that's (name of resident), that is just who he is. G. On 03/29/19 at 11:44 am, during an interview with ADON #2, she stated that during their investigation into the incident the staff members involved told her that they allowed him out to smoke because they were tired of R #1 being aggressive with them and declining to follow the rules. H. Record review of R #1's Interdisciplinary Note dated 03/18/19 for Interventions indicated that At the time of incident resident was brought into the facility immediately and assessed for injuries and stability. Residents clothes was changed, and a warm shower provided. Vitals were stable and Medical Director assessed resident and treatment for [REDACTED]. Resident care plan was updated to reflect residents smoking and noncompliance to smoking times and hours and cape (sic) plan and orders have been updated to alert staff to frequently check on resident in-house status. Staff were all in-serviced and educated on frequent rounding and monitoring on 03/13/17 (sic) and its importance. I. Record review of the Treatment Administration Record (TAR) for the month of (MONTH) 2019, indicated that staff are checking on resident more frequently because he likes to smoke outside of designated times. The TAR did indicate that they were monitoring him more closely. I. On 3/28/19 at 11:06 am, during an interview, R #7 (who also smokes) stated They (name of facility) have very chatty staff. The residents know everything. (Name of R#1), he doesn't like to listen. Everyone (nursing staff) knew he was out there (during the night of his incident). They (the nursing staff) left him out there to 'teach him a lesson'. Security would usually bring him in but that night it was a young idiot working, he got fired. They later managed to bring him (R #1) in. J. On 3/28/19 at 2:45 pm, an attempt was made to conduct an interview with R #1 three different times on 03/28/19. Resident was either asleep or not available. K. On 03/28/19 at 2:55 pm, during an observation, R#1's, room is located directly across from nurse's station; which is also directly next to the unit Day Room. R #1 went through the day room door on the night of 03/11/19 to go smoke (the Day Room has a door with an alarm that exits onto the patio where the smoking area is). The alarm did work and sounded when the door was opened.

Based on observation, interview and record review the facility failed to ensure that residents were free from alleged staff to resident sexual abuse for 1 (R #5) of 7 (R #s 5, 6, 7, 12, 13, 14 and 16) residents reviewed for abuse. This deficient practice resulted in R #5 experiencing feelings of anxiety and fear. The findings are: A. Record review of the Administrator's incident report dated 03/05/17 indicated the following: On 03/05/17, at approximately 10:00 pm, I received a call from the House Supervisor. She stated that (Name of Alleged Perpetrator-AP) had been in the facility the previous afternoon and he took (Name of R #5) out for several hours .She (House Supervisor) then stated that she was told by a CNA (Certified Nursing Aide) that (Name of another resident) was telling her that while (Name of R #5) was out on Saturday (03/04/17) a large black man, he raped her .On 03/06/17 at approximately 10:30 am, I approached (Name of R #5) and identified myself (she is blind and a paraplegic) .I said, 'well, rumor on the floor is that when you were out with (Name of Alleged Perpetrator), he raped you. Did that happen?' (Name of R #5) firmly denied stating he did not rape me (Name of R #5) stated that (Name of Alleged Perpetrator) kissed her on the cheek. I asked how did that feel and she stated 'awkward' .I said, the only inappropriate thing he said to you was that he wanted to kiss you? (Name of R #5) stated yes and he also told me he wanted to have sex with me . B. On 04/13/17 at 10:45 am, during interview with R #5, she was asked about the incident on 03/04/17 with former employee (Name of AP). R #5 stated that AP came to the facility and took her to the bank and to lunch. R #5 stated that AP then gave her marijuana and alcohol and took her to his hotel room despite her protests. R #5 stated that he figured out some reason (to take her to the hotel room) and we went. He put it (his penis) in my butt because I was on my period that day. When asked if she informed the Administrator of this during her interview, R #5 stated that she did not because, I thought she (Administrator) would be mad at me because of the marijuana and alcohol so I told her that I wasn't raped. I was raped before (before admission to facility) and I just wanted to sweep it under the rug. But I can't. I can't stop thinking about it. At this time, the Social Services Designee, walked into the R #5's room to inform her of something unrelated. R #5 was asked if she would be comfortable going to the Administrator's office to inform her of the alleged rape and she agreed to do so. C. On 04/13/17 at 11:00 am, during interview with R #5 and the Administrator, R #5 repeated her account of the day of the alleged rape. R #5 informed the Administrator that she was afraid that she (Administrator) would be mad at her (R #5) because of the marijuana and alcohol consumption as she (R #5) was on a behavior plan and had agreed not to consume these substances. The Administrator informed the resident that, We (staff) are here for you to make sure you're safe. You don't ever have to worry about me being mad at you. After R #5 recounted the incident, she agreed to speak to law enforcement when they arrived at the facility to begin their investigation. The Administrator stated that she was made aware of the incident when the House Supervisor called her on the evening of 03/05/17 to notify her. D. On 04/13/17 at 1:30 pm, during interview with the House Supervisor (HS), she stated that on 03/05/17, she was called by the receptionist who informed her that AP had taken R #5 out of the facility for several hours the previous day (03/04/17). HS stated that another resident (D/C R #1) (resident was discharged at the time of the investigation) had informed the receptionist of this. HS stated that she spoke with the other resident and the resident informed her that R #5 had been raped when she was out with AP. HS stated that she informed the resident that she (HS) would need to hear this information directly from R #5. HS stated that she did not interview R #5 at this time. HS stated that she called the Administrator on 03/05/17 at about 10:00 pm to inform her of the rape allegations. HS stated that on 03/05/17, she observed R #5 earlier in the day out on the patio smoking and laughing with other residents and that she informed the Administrator of this and the Administrator informed her (HS) that the allegations would be taken care of the next day. HS stated that she did not speak with R #5 about the rape allegation report that she received from the other resident. E. On 04/13/17 at 1:57 pm, during interview with Alleged Perpetrator (AP), he stated that, during his 6 months as Administrator in Training at the facility, he had taken R #5 and another resident out of the building to run errands and that this was under the direction of the Administrator. He stated that he was afraid to lose his position if he refused to take the residents out of the building. AP stated that R #5 and another resident were known to be marijuana smokers and would do so in the smoking section at the facility. AP denied having any sexual contact with R #5 and stated that he did take her out of the facility on 03/04/17 but that they never got out of the vehicle and that R #5 ate her lunch in the car at a park near the fast food restaurant where they bought the food. F. On 04/13/17 at 2:37 pm, during interview with the Administrator, she stated that she never instructed AP to take any residents out of the building. She stated that she was aware that AP had taken a male resident out several times to run errands and go to the Social Security Office. He (AP) asked me once to take R #5 out but I told him no since she's a paraplegic and would need special assistance. She stated that she did report the incident in which AP took R #5 out of the building on 03/04/17 to the state agency but that she submitted the report two weeks late (03/20/17) as she was trying to gather information for her investigation. The Administrator stated that she did not initiate an investigation into the allegations that R #5 had been raped immediately because, on the night the HS informed her of the allegations, It was 10 o'clock (pm) already and (Name of R #5) was already in bed. G. Record review of the facility Abuse Prevention Policy and Procedure dated 08/14 indicated the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman and others as may be required by state or local laws, within five (5) working days of the reported incident.

Based on record review and interview, the facility 1) failed to report an allegation of staff to resident sexual abuse to the State Agency within 2 hours of the incident, and 2) failed to submit a five day follow-up to the State Agency (SA) within 5 days of the incident for 1 (R# 5) of 7 (R #'s 5, 6, 7, 12, 13, 14 and 16) residents reviewed for abuse. If a facility does not report and investigate allegations/incidents they are likely unable to protect residents from further harm. The findings are: A. Record review of the incident report dated 03/05/17 indicated the following: On 03/05/17, at approximately 10:00 pm, I received a call from the House Supervisor. She stated that (Name of Alleged Perpetrator-AP) had been in the facility the previous afternoon and he took (Name of R #5) out for several hours .She (House Supervisor) then stated that she was told by a CNA (Certified Nursing Aide) that (Name of another resident) was telling her that while (Name of R #5) was out on Saturday (03/04/17) with a large black man, he raped her .On 03/06/17 at approximately 10:30 am, I approached (Name of R #5) and identified myself (she is blind and a paraplegic) .I said, 'well, rumor on the floor is that when you were out with (Name of Alleged Perpetrator), he raped you. Did that happen?' (Name of R #5) firmly denied stating he did not rape me (Name of R #5) stated that (Name of Alleged Perpetrator) kissed her on the cheek. I asked how did that feel and she stated 'awkward' .I said, the only inappropriate thing he said to you was that he wanted to kiss you? (Name of R #5) stated yes and he also told me he wanted to have sex with me . B. On 04/13/17 at 10:45 am, during interview with R #5, she was asked about the incident on 03/04/17 with former employee (Name of Alleged Perpetrator-AP). R #5 stated that AP came to the facility and took her to the bank and to lunch. R #5 stated that AP then gave her marijuana and alcohol and took her to his hotel room despite her protests. R #5 stated that he figured out some reason (to take her to the hotel room) and we went. He put it (his penis) in my butt because I was on my period that day. When asked if she informed the administrator of this during her interview, R #5 stated that she did not because, I thought she (Administrator) would be mad at me because of the marijuana and alcohol so I told her that I wasn't raped. I was raped before (prior to admission) and I just wanted to sweep it under the rug. But I can't. I can't stop thinking about it. At this time, the Social Services Designee, walked into the R #5's room to inform her of something unrelated. R #5 was asked if she would be comfortable going to the administrator's office to inform her of the alleged rape and she agreed to do so. C. On 04/13/17 at 11:00 am, during interview with R #5 and the Administrator, R #5 repeated her account of the day of the alleged rape. R #5 informed the Administrator that she was afraid that she (Administrator) would be mad at her (R #5) because of the marijuana and alcohol consumption as she (R #5) was on a behavior plan and had agreed not to consume these substances. The Administrator informed the resident that, We (staff) are here for you to make sure you're safe. You don't ever have to worry about me being mad at you. After R #5 recounted the incident, she agreed to speak to law enforcement when they arrived at the facility to begin their investigation. The Administrator stated that she was made aware of the incident when the House Supervisor called her on the evening of 03/05/17 to notify her. D. On 04/13/17 at 1:30 pm, during interview with the House Supervisor (HS), she stated that on 03/05/17, she was called by the receptionist (time unknown) who informed her that AP had taken R #5 out of the facility for several hours the previous day (03/04/17). HS stated that another resident had informed the receptionist of this. HS stated that she spoke with the other resident D/C R #1 (resident was discharged at the time of the investigation) and the resident informed her that R #5 had been raped when she was out with AP. HS stated that she informed the resident that she (HS) would need to hear this information directly from R #5. HS stated that she did not interview R #5 at this time. HS stated that she called the administrator on 03/05/17 at about 10:00 pm to inform her of the rape allegations. HS stated that on 03/05/17, she observed R #5 earlier in the day out on the patio smoking and laughing with other residents and that she informed the administrator of this and the administrator informed her (HS) that the allegations would be taken care of the next day. HS stated that she did not speak with R #5 about the rape allegation report that she received from the other resident. E. On 04/13/17 at 1:57 pm, during interview with Alleged Perpetrator (AP), he stated that, during his 6 months as Administrator in Training at the facility, he had taken R #5 and another resident out of the building to run errands and that this was under the direction of the Administrator. He stated that he was afraid to lose his position if he refused to take the residents out of the building. AP stated that R #5 and another resident were known to be marijuana smokers and would do so in the smoking section at the facility. AP denied having any sexual contact with R #5 and stated that he did take her out of the facility on 03/04/17 but that they never got out of the vehicle and that R #5 ate her lunch in the car at a park near the fast food restaurant where they bought the food. F. Record review of the State Agency Incident Report dated 03/20/16 revealed that the allegation of resident abuse dated 03/04/17 was submitted two weeks after the incident. G. On 04/13/17 at 2:37 pm, during interview with the administrator, she stated that she did not initiate an investigation into the allegations that R #5 had been raped immediately because, on the night the HS informed her of the allegations, It was 10 o'clock (pm) already and (Name of R #5) was already in bed. H. Record review of the facility Abuse Prevention Policy and Procedure dated 08/14 indicated the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman and others as may be required by state or local laws, within five (5) working days of the reported incident.

Based on observation, interview and record review the facility failed to implement their policies and procedures 1) to ensure residents were free from alleged staff to resident sexual abuse and 2) failed to report an allegation of staff to resident sexual abuse to the State Agency within 2 hours of the incident, and to submit a five day follow-up to the State Agency (SA) within 5 days of the incident for 1 (R #5) of 7 (R #s 5, 6, 7, 12, 13, 14 and 16) residents reviewed for abuse. This deficient practice resulted in a two day delay of the identification of alleged staff to resident sexual abuse, resulting in R #5 to experience feelings of anxiety and fear. The findings are: A. Record review of the incident report dated 03/05/17 indicated the following: On 03/05/17, at approximately 10:00 pm, I received a call from the House Supervisor. She stated that (Name of Alleged Perpetrator-AP) had been in the facility the previous afternoon and he took (Name of R #5) out for several hours .She (House Supervisor) then stated that she was told by a CNA (Certified Nursing Aide) that (Name of another resident) was telling her that while (Name of R #5) was out on Saturday with a large black man, he raped her .On 03/06/17 at approximately 10:30 am, I approached (Name of R #5) and identified myself (she is blind and a paraplegic) .I said, 'well, rumor on the floor is that when you were out with (Name of Alleged Perpetrator), he raped you. Did that happen?' (Name of R #5) firmly denied stating he did not rape me (Name of R #5) stated that (Name of Alleged Perpetrator) kissed her on the cheek. I asked how did that feel and she stated 'awkward' .I said, the only inappropriate thing he said to you was that he wanted to kiss you? (Name of R #5) stated yes and he also told me he wanted to have sex with me . B. On 04/13/17 at 10:45 am, during interview with R #5, she was asked about the incident on 03/04/17 with former employee (Name of Alleged Perpetrator-AP). R #5 stated that AP came to the facility and took her to the bank and to lunch. R #5 stated that AP then gave her marijuana and alcohol and took her to his hotel room despite her protests. R #5 stated that he figured out some reason (to take her to the hotel room) and we went. He put it (his penis) in my butt because I was on my period that day. When asked if she informed the administrator of this during her interview, R #5 stated that she did not because, I thought she (Administrator) would be mad at me because of the marijuana and alcohol so I told her that I wasn't raped. I was raped before (prior to admission) and I just wanted to sweep it under the rug. But I can't. I can't stop thinking about it. At this time, the Social Services Designee, walked into the R #5's room to inform her of something unrelated. R #5 was asked if she would be comfortable going to the administrator's office to inform her of the alleged rape and she agreed to do so. C. On 04/13/17 at 11:00 am, during interview with R #5 and the administrator, R #5 repeated her account of the day of the alleged rape. R #5 informed the administrator that she was afraid that she (administrator) would be mad at her (R #5) because of the marijuana and alcohol consumption as she (R #5) was on a behavior plan and had agreed not to consume these substances. The administrator informed the resident that, We (staff) are here for you to make sure you're safe. You don't ever have to worry about me being mad at you. After R #5 recounted the incident, she agreed to speak to law enforcement when they arrived at the facility to begin their investigation. The administrator stated that she was made aware of the incident when the House Supervisor called her on the evening of 03/05/17 to notify her. D. On 04/13/17 at 1:30 pm, during interview with the House Supervisor (HS), she stated that on 03/05/17, she was called by the receptionist who informed her that AP had taken R #5 out of the facility for several hours the previous day (03/04/17). HS stated that another resident had informed the receptionist of this. HS stated that she spoke with the other resident (resident was discharged at the time of the investigation) and the resident informed her that R #5 had been raped when she was out with AP. HS stated that she informed the resident that she (HS) would need to hear this information directly from R #5. HS stated that she did not interview R #5 at this time. HS stated that she called the administrator on 03/05/17 at about 10:00 pm to inform her of the rape allegations. HS stated that on 03/05/17, she observed R #5 earlier in the day out on the patio smoking and laughing with other residents and that she informed the administrator of this and the administrator informed her (HS) that the allegations would be taken care of the next day. HS stated that she did not speak with R #5 about the rape allegation report that she received from the other resident. E. On 04/13/17 at 1:57 pm, during interview with Alleged Perpetrator (AP), he stated that, during his 6 months as Administrator in Training at the facility, he had taken R #5 and another resident out of the building to run errands and that this was under the direction of the administrator. He stated that he was afraid to lose his position if he refused to take the residents out of the building. AP stated that R #5 and another resident were known to be marijuana smokers and would do so in the smoking section at the facility. AP denied having any sexual contact with R #5 and stated that he did take her out of the facility on 03/04/17 but that they never got out of the vehicle and that R #5 ate her lunch in the car at a park near the fast food restaurant where they bought the food. F. Record review of the State Agency Incident Report dated 03/20/16 revealed that the allegation of resident abuse dated 03/04/17 was submitted two weeks after the incident. G. On 04/13/17 at 2:37 pm, during interview with the administrator, she stated that she never instructed AP to take any residents out of the building. She stated that she was aware that AP had taken a male resident out several times to run errands and go to the Social Security Office. He (AP) asked me once to take R #5 out but I told him no since she's a paraplegic and would need special assistance. She stated that she did report the incident in which AP took R #5 out of the building on 03/04/17 to the state agency but that she submitted the report two weeks late as she was trying to gather information for her investigation. The administrator stated that she did not initiate an investigation into the allegations that R #5 had been raped immediately because, on the night the HS informed her of the allegations, It was 10 o'clock (pm) already and (Name of R #5) was already in bed. H. Record review of the facility Abuse Prevention Policy and Procedure dated 08/14 indicated the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman and others as may be required by state or local laws, within five (5) working days of the reported incident.

Based on record review and interview, the facility failed to implement policies and procedures to ensure residents were free of neglect for 1 (R #1) of 4 (R #s 1, 2, 3 and 4) residents reviewed for accidents and neglect by not adequately supervising a resident identified as an elopement risk. This deficient practice likely resulted in the resident's elopement from the facility and subsequently being struck and killed by a vehicle on a main street in front of the facility. The findings are: A. Record review of the Incident Report dated [DATE] indicated the following: Before the incident: .She (R #1) was seen by two night shift CNAs (Certified Nursing Assistants) from her unit around 23:00 (11:00 pm) .Resident was equipped with a Wanderguard (an alert system designed to set off an alarm when residents leave the unit and/or facility) placed on her left ankle on [DATE] due to pacing in her wheelchair, going up and down elevator and back and forth throughout the facility. During the incident: Approximately 23:15 (11:15 pm), three CNAs and RN (registered nurse) had just gotten off shift and were standing in the front parking lot socializing. They heard a loud crash and ran towards the sound and observed the resident laying in the street with her wheelchair in pieces. RN ran to the resident and began CPR (cardiopulmonary resuscitation) which continued until EMS (emergency medical services) arrived. Police list the official incident time at 23:21 (11:21 pm) which is when they received the 911 call. After the incident: Staff immediately notified the house supervisor who notified the DON (Director of Nursing) and Administrator. Driver of the pick up truck that struck the resident made a right hand turn onto (Name of Street) .got out of vehicle, checked it for damages then got back in the truck and left. Staff obtained his license plate number and provided to police .Two police officers were in the building upon her (the Administrator's) arrival. They stated that the resident was dead on the scene .Administrator and house supervisor inquired if the wander guard was in place on her (resident's) left ankle at the time of the incident. Police called EMS/Coroner and asked about wander guard, they viewed body, no wander guard in place on either ankle. Administrator informed police resident must have taken her wander guard off which is why the door did not alarm when she left (the building). Staff were notified to search resident room for wander guard which was located in the drawer of the bedside table with the band cut. B. Record review of Progress Note dated [DATE] at 11:30 pm indicated the following: Notified via phone by House Supervisor that resident had left the building in her wheelchair. Stated she was self-propelling herself backwards, heading southbound in the northbound lane on a main street in front of the facility when she was struck by a pickup truck. Several staff were in the parking lot and witnessed/heard the incident. Driver of vehicle stopped on (Name of Street), got out of vehicle, checked his bumper, then got in vehicle and left the scene. Staff did obtain license plate number and gave to police. RN in parking lot rushed to the resident and began CPR until EMS/Police arrived and took charge of scene. Spoke with 2 (Name of Police Department) Officers about 1:15 am. They state resident was dead on the scene. Furnished police with face sheet with all pertinent information. Asked officers about wander guard band on ankle. Police called EMS/Corner, who checked the body and stated no wander guard in place. 1:30 am went to Unit #7 and spoke with night nurse, asked her to have CNAs search Resident room for wander guard. Nurse called me at about 2:30 am stating they found wander guard in Resident's bedside table with band cut in half. Notified all appropriate Corporate Staff. C. Record review of History and Physical [DATE]: [AGE] year-old female w/(with) past medical history significant for [MEDICAL CONDITION] (a psychiatric illness characterized by both manic and depressive episodes), borderline personality disorder, severe [MEDICAL CONDITIONS] [MEDICAL CONDITION] (a liver disease) and IBS (irritable bowel syndrome) who was hospitalized at (Name of Behavioral Hospital) for behavioral disturbances and polysubstance (multiple substances/drugs) abuse. D. Record review of Physician order [REDACTED]. 1. [DATE]: Wanderguard placed on left ankle. Klonopin 1 mg (milligrams) for [DIAGNOSES REDACTED]. 2. [DATE]: [MEDICATION NAME] (an anti-psychotic medication) 200 mg for [DIAGNOSES REDACTED]. 3. [DATE]: [MEDICATION NAME] (an anti-psychotic medication) 40 mg for [DIAGNOSES REDACTED]. E. Record review of Care Plan dated [DATE] indicated the following: Focus: (Name of R#1) at risk for elopement. Goals: Resident will remain safe in current environment. Interventions: Digital picture to resident's chart and front desk elopement book, quarterly elopement assessment, wander guard alarm. F. Record review of Progress Note dated [DATE] indicated the following: Resident came to writer at noon and stated that she was going to (Name of Store) on the bus. At approximately 1215 (12:15 pm), writer was going to lunch and noticed (Name of Resident) walking from the sidewalk up the hill to the parking lot .writer noticed traffic stopped in front of bus stop and did not see (Name of Resident). Writer then started toward bus stop and witnessed someone attempting to assist (Name of Resident) back into her wheelchair. When writer approached (Name of Resident), she stated that she was going to catch the north bound bus but decided to go south and was trying to cross the street. Writer asked her to return to facility so that she could be assessed for injuries. She stated that she was not coming in and that she was going to the store along with another resident. A male witness informed writer that he was driving south and saw (Name of Resident) fall and stopped to assist her, however, before he could get to her, she got herself up and started walking when she fell again. He (witness) stated that she got herself up again and was attempting to step up from the street to the sidewalk when she fell for the 3rd time. This time, she got herself up but allowed him to assist her back in her wheelchair. Resident got on the bus and left. G. Record review of PASRR (Pre-admission Screening and Resident Review dated [DATE] indicated the following: (Name of R #1) is a [AGE] year-old white woman who is somewhat recently status [REDACTED]. She has a long history of mental illness, drug abuse and social instability .she was discharged to (Name of Nursing Facility) for 30 days or less of convalescent care for skilled nursing care .Medical: [MEDICAL CONDITION] Disorder, [MEDICATION NAME] Induced Mood Disorder, [MEDICATION NAME] Dependence .Chronic [MEDICAL CONDITION] (post-traumatic stress disorder) .Borderline Personality Disorder . H. Record review of MDS (minimum data set) assessments indicated the following: 1. Admission MDS dated [DATE] revealed an admission date of [DATE] and indicated that R #1 had no wandering behaviors and did not present a risk of getting to a potentially dangerous place (e.g. stairs, outside of facility). 2. Discharge MDS dated [DATE] indicated that R #1 had no wandering behaviors and did not present a risk of getting to a potentially dangerous place (e.g. stairs, outside of facility). I. Record review of Elopement Risk Assessments indicated the following: 1. Elopement assessment dated [DATE] indicated that R #1 was cognitively impaired with poor decision making skills, had [DIAGNOSES REDACTED]. Does the resident have a history of leaving the facility without need of supervision? No. Does the resident have a history of leaving facility without informing staff? No. Does the resident wander aimlessly or non-goal oriented (i.e. confused, moves without purpose, may enter other's rooms and explore other's belongings)? Yes. Resident at risk of elopement at this time? Yes. 2. Elopement assessment dated [DATE] indicated that R #1 was not cognitively impaired with poor decision making skills, did not have a [DIAGNOSES REDACTED]. Does the resident have a history of leaving facility without informing staff? No. Does the resident wander aimlessly or non-goal oriented (i.e. confused, moves without purpose, may enter other's rooms and explore other's belongings)? No. Resident at risk of elopement at this time? No. J. Review of Leave of Absence Form for [DATE] indicated that R #1 signed herself out to leave the facility unattended on [DATE] and [DATE]. K. On [DATE] at 11:20 am, during interview with Administrator, she stated the following: 1. That on [DATE], after R #1's accident, she asked the police if R #1 had her wander guard on either ankle and was told that there was no wander guard in place after the body was checked by the coroner. The Administrator stated that after searching the room, staff found the wander guard in a drawer of a bed side dresser. 2. The Administrator stated that wander guards are checked for placement each shift and that, according to the documentation, R #1's wander guard was checked at about 6:30 pm on [DATE] and was in place. 3. The Administrator stated that staff informed R #1 that she wasn't safe to go outside the facility on her own and that they were placing the wander guard on her ankle as a reminder to R #1 that she shouldn't go outside alone. The administrator stated that R #1 was alert and oriented but made poor decisions and demonstrated very impulsive behavior. The administrator stated that the resident was not safe when she first got to the facility and wandered all over the building. 4. The Administrator stated that R #1 had been allowed to leave the facility unsupervised to go shopping or to run errands. When asked if R #1 was safe to be outside of the facility, the Administrator stated that she was. When asked why R #1 would need a wander guard if she was safe to be outside of the facility unsupervised, the Administrator again stated that R #1 made poor decisions and had impulsive behavior but did not have dementia or memory problems. When asked if poor decision making and impulsive behavior would mean that the resident was not safe to be unsupervised outside of the facility, the Administrator acknowledged that it did. 5. The Administrator acknowledged the conflicting information regarding whether R #1 was safe to be outside of the facility unsupervised versus needing to have a wander guard placed to prevent her from leaving the facility without the staff's knowledge as she (R #1) was a danger to herself. The Administrator agreed and stated that in hindsight, she should not have allowed R #1 to be out of the facility unsupervised. She acknowledged the conflicting information on R #1's Elopement Assessments and stated that she did not know why this was the case. L. On [DATE] at 1:31 pm, during interview with Administrator, she stated the following: 1. That she was planning on having the door alarms changed so that each door that opened to the outside would be alarmed any time it is opened. She stated that she was doing this because, Obviously, there was a failure somewhere (on the day of R #1's death), so I want to prevent this from occurring in the future. 2. The Administrator stated that on [DATE], R #1 was put on [MEDICATION NAME] (An antipsychotic drug used to treat symptoms of [MEDICAL CONDITION] and acute manic or mixed episodes associated with [MEDICAL CONDITION] disorder) to treat her escalating behaviors and that since she was put on this medication, her trips out of the facility had stopped and she was only allowed to go out the back patio which has gates that are locked. The Administrator stated that after the medication was added, staff began to watch the resident more closely and were checking on her every hour or so but stated that she did not have documentation to support this. 3. The Administrator stated that the resident did have one other episode of elopement but that she did not document this as she didn't think the resident got past the parking lot. 4. The Administrator stated that she may have made a bad decision by letting the resident go out of the facility on her own but that she was trying to assist the resident in transitioning back into the community. 5. The Administrator stated that when the resident first came to the facility, she was wandering all over the facility and the decision was made to place the wander guard. The Administrator stated that the resident stopped wandering after a couple of weeks and that the care plan should have been updated to reflect the fact that the resident was no longer wandering and was oriented to the building but verified that this had not been done. M. On [DATE] at 1:45 pm, during interview with Unit Manager (UM) #1, she stated that the Wanderguard was in place on R #1 for her impulsive behaviors and poor judgement. UM #1 stated that the resident had permission to go out of the facility and get things from the store and that this was ok as long as the resident signed out and notified staff that she was leaving the facility. UM #1 verified that the care plan indicated that the wander guard was placed due to the resident being at risk for elopement. UM #1 stated that at the time of R #1's elopement incident on [DATE], a lady had gotten out of her car and helped R #1 get out of the street since traffic was backed up due to R #1 being in the street. UM #1 stated that R #1 had gotten out of her wheelchair and was walking to cross the street. UM #1 stated that the witness who was assisting R #1 informed her (UM #1) that R #1 had fallen down but UM #1 stated that she didn't see this occur. UM #1 stated that when the city bus came, the resident refused to go back to the facility, left her wheelchair on the curb and boarded the bus. N. On [DATE] at 3:10 pm, during interview with UM #2, she stated that on [DATE] at about 12:15 pm, she was leaving for lunch and noticed R #1 on the sidewalk across from the facility. She stated that the resident had a 2 hour pass to go to the store at this time. UM #2 stated that for the wandering, R #1 had a Wanderguard in place and a picture in the elopement book which is a book that has the pictures and facesheets of all residents who are elopement risks so that the staff can visualize the resident and have notification of residents who are at risk for eloping. UM #2 stated that she didn't feel that the resident was safe due to her poor choices and impulsive behaviors. UM #2 stated that after the incident where the resident was found near the bus stop and almost hit by a car, she did not feel that the resident was safe to be outside unsupervised. UM #2 verified that after this incident, the resident did receive an additional pass to leave the facility unsupervised. O. On [DATE] at 3:45 pm: during interview with the Administrator, she verified that R #1 did have another episode of elopement on [DATE]. The Administrator stated that she initially thought that R #1 did not get past the parking lot but after reading the incident report, realized that she did, in fact, get out into the street and board a bus. The Administrator verified that R #1 was allowed to leave the facility again on [DATE] after having the incident on [DATE]. She stated that the reason that the resident was allowed to go out again was because on this outing, a cab came and picked the resident up, waited at the store and dropped her off. The Administrator stated that in retrospect, she should have sent an escort with the resident on outings, especially after the incident on [DATE]. The Administrator stated that she did not report R #1's elopement episode on [DATE] to the State Agency as she originally did not see this as an elopement. When she was asked about whether, after the resident fell down three times in the middle of the street and the nurses asked her to come back to the facility and R #1 refusing to return, if this would be considered an elopement, the Administrator stated that it would and that in hindsight, this should have been reported to the state but was not. P. Record review of the facility's Abuse/Neglect Policy dated 2012 indicated the following: Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse neglect to their supervisor, the Director of Nursing and Administrator immediately .Any staff member or person affiliated with the facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect or any other criminal offense shall immediately report, or cause a report to be made of the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information.

Based on record review and interview, the facility failed to ensure that incidents of resident elopement resulted in a follow-up investigation being conducted and a report to the state licensing agency being submitted for 1 (R #1) of 4 (R #s 1, 2, 3 and 4) residents reviewed for incidents/accidents. This deficient practice has the potential to prevent staff from determining the cause of the incident, identifying the need for staff training and implementing needed changes and likely resulted in the resident's elopement from the facility and subsequently, being struck and killed by a vehicle on a main road in front of the facility. The findings are: A. Record review of the Incident Report dated [DATE] indicated the following: Before the incident: .She (R #1) was seen by two night shift CNAs (Certified Nursing Assistants) from her unit around 2300 (11:00 pm) .Resident was equipped with a Wanderguard (an alert system designed to set off an alarm when residents leave the unit and/or facility) placed on her left ankle on [DATE] due to pacing in her wheelchair, going up and down elevator and back and forth throughout the facility. During the incident: Approximately 23:15 (11:15 pm), three CNAs and RN (registered nurse) had just gotten off shift and were standing in the front parking lot socializing. They heard a loud crash and ran towards the sound and observed the resident laying in the street with her wheelchair in pieces. RN ran to the resident and began CPR (cardiopulmonary resuscitation) which continued until EMS (emergency medical services) arrived. Police list the official incident time at 23:21 (11:21 pm) which is when they received the 911 call. After the incident: Staff immediately notified the house supervisor who notified the DON (Director of Nursing) and Administrator. Driver of the pick up truck that struck the resident made a right hand turn onto (Name of Street) .got out of vehicle, checked it for damages then got back in the truck and left. Staff obtained his license plate number and provided to police .Two police officers were in the building upon her (the Administrator's) arrival. They stated that the resident was dead on the scene .Administrator and house supervisor inquired if the wander guard was in place on her (resident's) left ankle at the time of the incident. Policy called EMS/Coroner and asked about wander guard, they viewed body, no wander guard in place on either ankle. Administrator informed police resident must have taken her wander guard off which is why the door did not alarm when she left (the building). Staff were notified to search resident room for wander guard which was located in the drawer of the bedside table with the band cut. B. Record review of Care Plan dated [DATE] indicated the following: Focus: (Name of R#1) at risk for elopement. Goals: Resident will remain safe in current environment. Interventions: Digital picture to resident's chart and front desk elopement book, quarterly elopement assessment, wander guard alarm. C. Record review of Physician order [REDACTED]. 1. [DATE]: Wanderguard placed on left ankle. Klonopin 1 mg(milligrams) for [DIAGNOSES REDACTED]. 2. [DATE]: [MEDICATION NAME] (an anti-psychotic medication) 200 mg for [DIAGNOSES REDACTED]. 3. [DATE]: [MEDICATION NAME] (an anti-psychotic medication) 40 mg for [DIAGNOSES REDACTED]. D. Record review of Progress Note dated [DATE] indicated the following: Resident came to writer at noon and stated that she was going to (Name of Store) on the bus. At approximately 1215 (12:15 pm), writer was going to lunch and noticed (Name of Resident) walking from the sidewalk up the hill to the parking lot .writer noticed traffic stopped in front of bus stop and did not see (Name of Resident). Writer then started toward bus stop and witnessed someone attempting to assist (Name of Resident) back into her wheelchair. When writer approached (Name of Resident), she stated that she was going to catch the north bound bus but decided to go south and was trying to cross the street. Writer asked her to return to facility so that she could be assessed for injuries. She stated that she was not coming in and that she was going to the store along with another resident. A male witness informed writer that he was driving south and saw (Name of Resident) fall and stopped to assist her, however, before he could get to her, she got herself up and started walking when she fell again. He (witness) stated that she got herself up again and was attempting to step up from the street to the sidewalk when she fell for the 3rd time. This time, she got herself up but allowed him to assist her back in her wheelchair. Resident got on the bus and left. E. Record review of R #1's medical record, incident log and incident reports revealed no documentation that a follow-up investigation had been conducted regarding R #1's elopement incident on [DATE]. No documentation was found to indicate that the incident was reported to the state licensing agency. F. On [DATE] at 1:31 pm, during interview with the Administrator, she verified that R #1 did have another episode of elopement on [DATE]. The Administrator stated that she initially thought that R #1 did not get past the parking lot but after reading the incident report, realized that she did, in fact, get out into the street and board a bus. The Administrator verified that R #1 was allowed to leave the facility again on [DATE] after having the incident on [DATE]. She stated that the reason that the resident was allowed to go out again was because on this outing, a cab came and picked the resident up, waited at the store and dropped her off. The Administrator stated that in retrospect, she should have sent an escort with the resident on outings, especially after the incident on [DATE]. The Administrator stated that she did not report R #1's elopement episode on [DATE] to the State Agency as she originally did not see this as an elopement. When she was asked about whether, after the resident fell down three times in the middle of the street and the nurses asked her to come back to the facility and R #1 refusing to return, this would be considered an elopement, the Administrator stated that it would and that in hindsight, this incident should have been reported to the state but was not. G. Record review of the facility's Abuse/Neglect Policy dated 2012 indicated the following: Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse neglect to their supervisor, the Director of Nursing and Administrator immediately .Any staff member or person affiliated with the facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect or any other criminal offense shall immediately report, or cause a report to be made of the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information.

Based on record review and interview, the facility failed to ensure that assessments accurately reflected the medical status for 1 (R #1) of 4 (R#s 1, 2, 3 and 4) reviewed for accidents by not accurately reflecting a resident's wandering and elopement risk. This deficient practice likely resulted in the resident's elopement from the facility and subsequently being struck and killed by a vehicle on a main street in front of the facility. The findings are: A. Record review of MDS (minimum data set) assessments indicated the following: 1. Admission MDS dated [DATE] revealed an admission date of [DATE] and indicated that R #1 had no wandering behaviors and did not present a risk of getting to a potentially dangerous place (e.g. stairs, outside of facility). 2. Discharge MDS dated [DATE] indicated that R #1 had no wandering behaviors and did not present a risk of getting to a potentially dangerous place (e.g. stairs, outside of facility). B. Record review of Elopement Risk Assessments indicated the following: 1. Elopement assessment dated [DATE] indicated that R #1 was cognitively impaired with poor decision making skills, had [DIAGNOSES REDACTED]. Does the resident have a history of leaving the facility without need of supervision? No. Does the resident have a history of leaving facility without informing staff? No. Does the resident wander aimlessly or non-goal oriented (i.e. confused, moves without purpose, may enter other ' s rooms and explore other ' s belongings)? Yes. Resident at risk of elopement at this time? Yes. 2. Elopement assessment dated [DATE] indicated that R #1 was not cognitively impaired with poor decision making skills, did not have a [DIAGNOSES REDACTED]. Does the resident have a history of leaving facility without informing staff? No. Does the resident wander aimlessly or non-goal oriented (i.e. confused, moves without purpose, may enter other ' s rooms and explore other ' s belongings)? No. Resident at risk of elopement at this time? No. C. Record review of History and Physical 08/24/16: [AGE] year-old female w/(with) past medical history significant for [MEDICAL CONDITION] (a psychiatric illness characterized by both manic and depressive episodes), borderline personality disorder, severe [MEDICAL CONDITIONS] [MEDICAL CONDITION] (a liver disease) and IBS (irritable bowel syndrome) who was hospitalized at (Name of Behavioral Hospital) for behavioral disturbances and polysubstance (multiple substances/drugs) abuse. D. Record review of Physician order [REDACTED]. 1. 08/20/16: Wanderguard placed on left ankle. Klonopin 1 mg (milligrams) for [DIAGNOSES REDACTED]. 2. 08/19/16: [MEDICATION NAME] (an anti-psychotic medication) 200 mg for [DIAGNOSES REDACTED]. 3. 09/21/16: [MEDICATION NAME] (an anti-psychotic medication) 40 mg for [DIAGNOSES REDACTED]. E. On 10/05/16 at 11:20 am, during interview with Administrator, she stated the following: 1. That on 09/29/16, after R #1's accident, she asked the police if R #1 had her wander guard on either ankle and was told that there was no wander guard in place after the body was checked by the coroner. The Administrator stated that after searching the room, staff found the wander guard in a drawer of a bed side dresser. 2. The Administrator stated that wander guards are checked for placement each shift and that, according to the documentation, R #1's wander guard was checked at about 6:30 pm on 09/29/16 and was in place. 3. The Administrator stated that staff informed R #1 that she wasn't safe to go outside the facility on her own and that they were placing the wander guard on her ankle as a reminder to R #1 that she shouldn't go outside alone. The administrator stated that R #1 was alert and oriented but made poor decisions and demonstrated very impulsive behavior. The administrator stated that the resident was not safe when she first got to the facility and wandered all over the building. 4. The Administrator stated that R #1 had been allowed to leave the facility unsupervised to go shopping or to run errands. When asked if R #1 was safe to be outside of the facility, the Administrator stated that she was. When asked why R #1 would need a wander guard if she was safe to be outside of the facility unsupervised, the Administrator again stated that R #1 made poor decisions and had impulsive behavior but did not have dementia or memory problems. When asked if poor decision making and impulsive behavior would mean that the resident was not safe to be unsupervised outside of the facility, the Administrator acknowledged that it did. 5. The Administrator acknowledged the conflicting information regarding whether R #1 was safe to be outside of the facility unsupervised versus needing to have a wander guard placed to prevent her from leaving the facility without the staff's knowledge as she (R #1) was a danger to herself. The Administrator agreed and stated that in hindsight, she should not have allowed R #1 to be out of the facility unsupervised. She acknowledged the conflicting information on R #1's Elopement Assessments and stated that she did not know why this was the case. F. On 10/05/16 at 1:45 pm, during interview with Unit Manager (UM) #1, she stated that the Wanderguard was in place on R #1 for her impulsive behaviors and poor judgement. UM #1 stated that the resident had permission to go out of the facility and get things from the store and that this was ok as long as the resident signed out and notified staff that she was leaving the facility. UM #1 verified that the care plan indicated that the wander guard was placed due to the resident being at risk for elopement. UM #1 stated that at the time of R #1's elopement incident on 09/02/16, a lady had gotten out of her car help R #1 get out of the street since traffic was backed up due to R #1 being in the street. UM #1 stated that R #1 had gotten out of her wheelchair and was walking to cross the street. UM #1 stated that the witness who was assisting R #1 informed her that R #1 had fallen down but UM #1 stated that she didn't see this occur. UM #1 stated that when the city bus came, the resident refused to go back to the facility, left her wheelchair on the curb and boarded the bus. G. On 10/05/16 at 3:10 pm, during interview with UM #2, she stated that on 09/02/16 at about 12:15 pm, she was leaving for lunch and noticed R #1 on the sidewalk across from the facility. She stated that the resident had a 2 hour pass to go to the store at this time. UM #2 stated that for the wandering, R #1 had a Wanderguard in place and a picture in the elopement book which is a book that has the pictures and facesheets of all residents who are elopement risks so that the staff can visualize the resident and have notification of residents who are at risk for eloping. UM #2 stated that she didn't feel that the resident was safe due to her poor choices and impulsive behaviors. UM #2 stated that after the incident where the resident was found near the bus stop and almost hit by a car, she did not feel that the resident was safe to be outside unsupervised. UM #2 verified that after this incident, the resident did receive an additional pass to leave the facility. H. On 10/05/16 at 3:45 pm: during interview with the Administrator, she verified that R #1 did have another episode of elopement on 09/02/16. The Administrator stated that she initially thought that R #1 did not get past the parking lot but after reading the incident report, realized that she did, in fact, get out into the street and board a bus. The Administrator verified that R #1 was allowed to leave the facility again on 09/08/16 after having the incident on 09/02/16. She stated that the reason that the resident was allowed to go out again was because on this outing, a cab came and picked the resident up, waited at the store and dropped her off. The Administrator stated that in retrospect, she should have sent an escort with the resident on outings, especially after the incident on 09/02/16. The Administrator stated that she did not report R #1 ' s elopement episode on 09/02/16 to the State Agency as she originally did not see this as an elopement. When she was asked about whether, after the resident fell down three times in the middle of the street and the nurses asked her to come back to the facility and R #1 refusing to return, if this would be considered an elopement, the Administrator stated that it would and that in hindsight, this should have been reported to the state but was not.

Based on record review and interview, the facility failed to ensure that care plans were revised with new interventions for 1 (R #1) of 4 (R #s 1, 2, 3 and 4) residents reviewed for accidents by not developing and/or revising interventions for a resident identified as an elopement risk. This deficient practice likely resulted in the resident's elopement from the facility and subsequently being struck and killed by a vehicle on a main street in front of the facility. The findings are: A. Record review of the Incident Report dated [DATE] indicated the following: Before the incident: .She (R #1) was seen by two night shift CNAs (Certified Nursing Assistants) from her unit around 2300 (11:00 pm) .Resident was equipped with a Wanderguard (an alert system designed to set off an alarm when residents leave the unit and/or facility) placed on her left ankle on [DATE] due to pacing in her wheelchair, going up and down elevator and back and forth throughout the facility. During the incident: Approximately 23:15 (11:15 pm), three CNAs and RN (registered nurse) had just gotten off shift and were standing in the front parking lot socializing. They heard a loud crash and ran towards the sound and observed the resident laying in the street with her wheelchair in pieces. RN ran to the resident and began CPR (cardiopulmonary resuscitation) which continued until EMS (emergency medical services) arrived. Police list the official incident time at 23:21 (11:21 pm) which is when they received the 911 call. After the incident: Staff immediately notified the house supervisor who notified the DON (Director of Nursing) and Administrator. Driver of the pick up truck that struck the resident made a right hand turn onto (Name of Street) .got out of vehicle, checked it for damages then got back in the truck and left. Staff obtained his license plate number and provided to police .Two police officers were in the building upon her (the Administrator's) arrival. They stated that the resident was dead on the scene .Administrator and house supervisor inquired if the wander guard was in place on her (resident's) left ankle at the time of the incident. Policy called EMS/Coroner and asked about wander guard, they viewed body, no wander guard in place on either ankle. Administrator informed police resident must have taken her wander guard off which is why the door did not alarm when she left (the building). Staff were notified to search resident room for wander guard which was located in the drawer of the bedside table with the band cut. B. Record review of Progress Note dated [DATE] at 11:30 pm indicated the following: Notified via phone by House Supervisor that resident had left the building in her wheelchair. Stated she was self-propelling herself backwards, heading southbound in the northbound lane on Louisiana when she was struck by a pickup truck. Several staff were in the parking lot and witnessed/heard the incident. Driver of vehicle stopped on (Name of Street), got out of vehicle, checked his bumper, then got in vehicle and left the scene. Staff did obtain license plate number and gave to police. RN in parking lot rushed to the resident and began CPR until EMS/Police arrived and took charge of scene. Spoke with 2 (Name of Police Department) Officers about 1:15 am. They state resident was dead on the scene. Furnished police with face sheet with all pertinent information. Asked officers about wander guard band on ankle. Police called EMS/Corner, who checked the body and stated no wander guard in place. 1:30 am went to Unit #7 and spoke with night nurse, asked her to have CNAs search Resident room for wander guard. Nurse called me at about 2:30 am stating they found wander guard in Resident's bedside table with band cut in half. Notified all appropriate Corporate Staff. C. Record review of Care Plan dated [DATE] indicated the following: Focus: (Name of R#1) at risk for elopement. Goals: Resident will remain safe in current environment. Interventions: Digital picture to resident's chart and front desk elopement book, quarterly elopement assessment, wander guard alarm. D. Record review of Progress Note dated [DATE] indicated the following: Resident came to writer at noon and stated that she was going to (Name of Store) on the bus. At approximately 1215 (12:15 pm), writer was going to lunch and noticed (Name of Resident) walking from the sidewalk up the hill to the parking lot .writer noticed traffic stopped in front of bus stop and did not see (Name of Resident). Writer then started toward bus stop and witnessed someone attempting to assist (Name of Resident) back into her wheelchair. When writer approached (Name of Resident), she stated that she was going to catch the north bound bus but decided to go south and was trying to cross the street. Writer asked her to return to facility so that she could be assessed for injuries. She stated that she was not coming in and that she was going to the store along with another resident. A male witness informed writer that he was driving south and saw (Name of Resident) fall and stopped to assist her, however, before he could get to her, she got herself up and started walking when she fell again. He (witness) stated that she got herself up again and was attempting to step up from the street to the sidewalk when she fell for the 3rd time. This time, she got herself up but allowed him to assist her back in her wheelchair. Resident got on the bus and left. E. Record review of R #1's medical record revealed that the Care Plan had not been updated after the elopement incident on [DATE] with new/revised interventions to address the wandering and exit seeking behavior. F. Review of Leave of Absence Form for [DATE] indicated that R #1 signed herself out to leave the facility unattended on [DATE] and [DATE]. G. On [DATE] at 11:20 am, during interview with Administrator, she stated the following: 1. That on [DATE], after R #1's accident, she asked the police if R #1 had her wander guard on either ankle and was told that there was no wander guard in place after the body was checked by the coroner. The Administrator stated that after searching the room, staff found the wander guard in a drawer of a bed side dresser. 2. The Administrator stated that staff informed R #1 that she wasn't safe to go outside the facility on her own and that they were placing the wander guard on her ankle as a reminder to R #1 that she shouldn't go outside alone. The administrator stated that R #1 was alert and oriented but made poor decisions and demonstrated very impulsive behavior. The administrator stated that the resident was not safe when she first got to the facility and wandered all over the building. 3. The Administrator stated that R #1 had been allowed to leave the facility unsupervised to go shopping or to run errands. When asked if R #1 was safe to be outside of the facility, the Administrator stated that she was. When asked why R #1 would need a wander guard if she was safe to be outside of the facility unsupervised, the Administrator again stated that R #1 made poor decisions and had impulsive behavior but did not have dementia or memory problems. When asked if poor decision making and impulsive behavior would mean that the resident was not safe to be unsupervised outside of the facility, the Administrator acknowledged that it did. 4. The Administrator acknowledged the conflicting information regarding whether R #1 was safe to be outside of the facility unsupervised versus needing to have a wander guard placed to prevent her from leaving the facility without the staff's knowledge as she (R #1) was a danger to herself. The Administrator agreed and stated that in hindsight, she should not have allowed R #1 to be out of the facility unsupervised. She acknowledged the conflicting information on R #1's Elopement Assessments and stated that she did not know why this was the case. H. On [DATE] at 1:31 pm, during interview with Administrator, she stated the following: 1. That she was planning on having the door alarms changed so that each door that opened to the outside would be alarmed any time it is opened. She stated that she was doing this because, Obviously, there was a failure somewhere (on the day of R #1's death), so I want to prevent this from occurring in the future. 2. The Administrator stated that on [DATE], R #1 was put on [MEDICATION NAME] to treat her escalating behaviors and that since she was put on this medication, her trips out of the facility had stopped and she was only allowed to go out the back patio which has gates that are locked. The Administrator stated that after the medication was added, staff began to watch the resident more closely and were checking on her every hour or so but stated that she did not have documentation to support this and verified that the care plan was not updated to reflect this. 3. The Administrator stated that the resident did have one other episode of elopement but that she did not document this as she didn't think the resident got past the parking lot. 4. The Administrator stated that she may have made a bad decision by letting the resident go out of the facility on her own but that she was trying to assist the resident in transitioning back into the community. 5. The Administrator stated that when the resident first came to the facility, she was wandering all over the facility and the decision was made to place the wander guard. The Administrator stated that the resident stopped wandering after a couple of weeks and that the care plan should have been updated to reflect the fact that the resident was no longer wandering and was oriented to the building but verified that this had not been done. I. On [DATE] at 1:45 pm, during interview with Unit Manager (UM) #1, she stated that the Wanderguard was in place on R #1 for her impulsive behaviors and poor judgement. UM #1 stated that the resident had permission to go out of the facility and get things from the store and that this was ok as long as the resident signed out and notified staff that she was leaving the facility. UM #1 verified that the care plan indicated that the wander guard was placed due to the resident being at risk for elopement. UM #1 stated that at the time of R #1's elopement incident on [DATE], a lady had gotten out of her car and helped R #1 get out of the street since traffic was backed up due to R #1 being in the street. UM #1 stated that R #1 had gotten out of her wheelchair and was walking to cross the street. UM #1 stated that the witness who was assisting R #1 informed her (UM #1) that R #1 had fallen down but UM #1 stated that she didn't see this occur. UM #1 stated that when the city bus came, the resident refused to go back to the facility, left her wheelchair on the curb and boarded the bus. J. On [DATE] at 3:10 pm, during interview with UM #2, she stated that on [DATE] at about 12:15 pm, she was leaving for lunch and noticed R #1 on the sidewalk across from the facility. She stated that the resident had a 2 hour pass to go to the store at this time. UM #2 stated that for the wandering, R #1 had a Wanderguard in place and a picture in the elopement book which is a book that has the pictures and facesheets of all residents who are elopement risks so that the staff can visualize the resident and have notification of residents who are at risk for eloping. UM #2 stated that she didn't feel that the resident was safe due to her poor choices and impulsive behaviors. UM #2 stated that after the incident where the resident was found near the bus stop and almost hit by a car, she did not feel that the resident was safe to be outside unsupervised. UM #2 verified that after this incident, the resident did receive an additional pass to leave the facility unsupervised. K. On [DATE] at 3:45 pm: during interview with the Administrator, she verified that R #1 did have another episode of elopement on [DATE]. The Administrator stated that she initially thought that R #1 did not get past the parking lot but after reading the incident report, realized that she did, in fact, get out into the street and board a bus. The Administrator verified that R #1 was allowed to leave the facility again on [DATE] after having the incident on [DATE]. She stated that the reason that the resident was allowed to go out again was because on this outing, a cab came and picked the resident up, waited at the store and dropped her off. The Administrator stated that in retrospect, she should have sent an escort with the resident on outings, especially after the incident on [DATE]. The Administrator stated that she did not report R #1's elopement episode on [DATE] to the State Agency as she originally did not see this as an elopement. When she was asked about whether, after the resident fell down three times in the middle of the street and the nurses asked her to come back to the facility and R #1 refusing to return, if this would be considered an elopement, the Administrator stated that it would and that in hindsight, this should have been reported to the state but was not.

The facility failed to ensure that the resident environment was free from accident hazards. A resident who was an elopement risk was found to have wandered out of the facility and on to a main road where she was struck by a vehicle and killed. This deficient practice resulted in an Immediate Jeopardy at a Scope and Severity of K being identified on [DATE] at 4:15 pm. The Administrator was notified at this time and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 9:04 am. Interventions included: 1. Current residents have been assessed for risk of elopement and those identified to be at risk have a plan of Care Developed to address this. New residents will be assessed for elopement risk on admit, quarterly and with change of condition. Licensed Nurses were in-services on how to complete the Elopement Risk Assessments on [DATE] per facility policy. 2. Residents that exit the building without escorts will be screened by OT(Occupational Therapy)/PT (Physical Therapy) for safety awareness. If they are deemed to have the capacity for safety, those residents will be educated on the sign out policy and the MD (Medical Doctor) will review and an order will be placed in the chart for those residents deemed capable of leaving the facility. 3. Residents identified to require use of Wanderguard (an alert system designed to set off an alarm when residents leave the unit and or facility) bracelet for elopement risk have an MD order for use, placement of device checked every shift, unit functioning checked daily and care plan developed. 4. Ground level exit doors have been alarmed and will sound loudly when door is opened and current staff have been educated on the current system. Permanent delayed emergency egress alarms will be installed [DATE] on ground floor exit doors. A sign will be posted at the main entrance requesting visitors to check with the front desk or nurse's station before letting a resident out of the facility. As the new system is installed, staff will be educated to the functioning of the new delayed egress doors. 5. The door alarms and Wanderguard system are checked and logged daily for proper functioning and logged weekly into the maintenance system. First floor windows will be checked to verify they pose no risk to residents determined to be at risk for elopement. 6. Current staff was in-serviced on the Elopement Policy and Procedure including changes to exit doors and location of Elopement Books at front lobby, therapy gym and Administrator's office. Staff will be educated on where extra Wanderguards are kept in the event one is not functioning when checked or a new order is placed on [DATE]. Based on the Plan of Removal, the IJ was lifted on [DATE] at 9:04 am. This resulted in the scope and severity being reduced from level K to level H. Based on record review and interview, the facility failed to ensure residents were free of accident hazards for 1 (R #1) of 4 (R #s 1, 2, 3 and 4) residents reviewed for accidents by not adequately supervising a resident identified as an elopement risk. This deficient practice likely resulted in the resident's elopement from the facility and subsequently being struck and killed by a vehicle on a main street in front of the facility. The findings are: A. Record review of the Incident Report dated [DATE] indicated the following: Before the incident: .She (R #1) was seen by two night shift CNAs (Certified Nursing Assistants) from her unit around 2300 (11:00 pm) .Resident was equipped with a Wanderguard (an alert system designed to set off an alarm when residents leave the unit and/or facility) placed on her left ankle on [DATE] due to pacing in her wheelchair, going up and down elevator and back and forth throughout the facility. During the incident: Approximately 23:15 (11:15 pm), three CNAs and RN (registered nurse) had just gotten off shift and were standing in the front parking lot socializing. They heard a loud crash and ran towards the sound and observed the resident laying in the street with her wheelchair in pieces. RN ran to the resident and began CPR (cardiopulmonary resuscitation) which continued until EMS (emergency medical services) arrived. Police list the official incident time at 23:21 (11:21 pm) which is when they received the 911 call. After the incident: Staff immediately notified the house supervisor who notified the DON (Director of Nursing) and Administrator. Driver of the pick up truck that struck the resident made a right hand turn onto (Name of Street) .got out of vehicle, checked it for damages then got back in the truck and left. Staff obtained his license plate number and provided to police .Two police officers were in the building upon her (the Administrator's) arrival. They stated that the resident was dead on the scene .Administrator and house supervisor inquired if the wander guard was in place on her (resident's) left ankle at the time of the incident. Policy called EMS/Coroner and asked about wander guard, they viewed body, no wander guard in place on either ankle. Administrator informed police resident must have taken her wander guard off which is why the door did not alarm when she left (the building). Staff were notified to search resident room for wander guard which was located in the drawer of the bedside table with the band cut. B. Record review of Progress Note dated [DATE] at 11:30 pm indicated the following: Notified via phone by House Supervisor that resident had left the building in her wheelchair. Stated she was self-propelling herself backwards, heading southbound in the northbound lane on Louisiana when she was struck by a pickup truck. Several staff were in the parking lot and witnessed/heard the incident. Driver of vehicle stopped on (Name of Street), got out of vehicle, checked his bumper, then got in vehicle and left the scene. Staff did obtain license plate number and gave to police. RN in parking lot rushed to the resident and began CPR until EMS/Police arrived and took charge of scene. Spoke with 2 (Name of Police Department) Officers about 1:15 am. They state resident was dead on the scene. Furnished police with face sheet with all pertinent information. Asked officers about wander guard band on ankle. Police called EMS/Corner, who checked the body and stated no wander guard in place. 1:30 am went to Unit #7 and spoke with night nurse, asked her to have CNAs search Resident room for wander guard. Nurse called me at about 2:30 am stating they found wander guard in Resident's bedside table with band cut in half. Notified all appropriate Corporate Staff. C. Record review of History and Physical [DATE]: [AGE] year-old female w/(with) past medical history significant for bipolar (a psychiatric illness characterized by both manic and depressive episodes), borderline personality disorder, severe osteoarthritis, COPD (chronic obstructive pulmonary disease), Hepatitis C (a liver disease) and IBS (irritable bowel syndrome) who was hospitalized at (Name of Behavioral Hospital) for behavioral disturbances and polysubstance (multiple substances/drugs) abuse. D. Record review of Physician order [REDACTED]. 1. [DATE]: Wanderguard placed on left ankle. Klonopin 1 mg (milligrams) for [DIAGNOSES REDACTED]. 2. [DATE]: Seroquel (an anti-psychotic medication) 200 mg for [DIAGNOSES REDACTED]. 3. [DATE]: Geodon (an anti-psychotic medication) 40 mg for [DIAGNOSES REDACTED]. E. Record review of Care Plan dated [DATE] indicated the following: Focus: (Name of R#1) at risk for elopement. Goals: Resident will remain safe in current environment. Interventions: Digital picture to resident's chart and front desk elopement book, quarterly elopement assessment, wander guard alarm. F. Record review of Progress Note dated [DATE] indicated the following: Resident came to writer at noon and stated that she was going to (Name of Store) on the bus. At approximately 1215 (12:15 pm), writer was going to lunch and noticed (Name of Resident) walking from the sidewalk up the hill to the parking lot .writer noticed traffic stopped in front of bus stop and did not see (Name of Resident). Writer then started toward bus stop and witnessed someone attempting to assist (Name of Resident) back into her wheelchair. When writer approached (Name of Resident), she stated that she was going to catch the north bound bus but decided to go south and was trying to cross the street. Writer asked her to return to facility so that she could be assessed for injuries. She stated that she was not coming in and that she was going to the store along with another resident. A male witness informed writer that he was driving south and saw (Name of Resident) fall and stopped to assist her, however, before he could get to her, she got herself up and started walking when she fell again. He (witness) stated that she got herself up again and was attempting to step up from the street to the sidewalk when she fell for the 3rd time. This time, she got herself up but allowed him to assist her back in her wheelchair. Resident got on the bus and left. G. Record review of PASRR (Pre-admission Screening and Resident Review dated [DATE] indicated the following: (Name of R #1) is a [AGE] year-old white woman who is somewhat recently status [REDACTED]. She has a long history of mental illness, drug abuse and social instability .she was discharged to (Name of Nursing Facility) for 30 days or less of convalescent care for skilled nursing care .Medical: Bipolar Disorder, Amphetamine Induced Mood Disorder, Amphetamine Dependence .Chronic PTSD (post-traumatic stress disorder) .Borderline Personality Disorder . H. Record review of MDS (minimum data set) assessments indicated the following: 1. Admission MDS dated [DATE] revealed an admission date of [DATE] and indicated that R #1 had no wandering behaviors and did not present a risk of getting to a potentially dangerous place (e.g. stairs, outside of facility). 2. Discharge MDS dated [DATE] indicated that R #1 had no wandering behaviors and did not present a risk of getting to a potentially dangerous place (e.g. stairs, outside of facility). I. Record review of Elopement Risk Assessments indicated the following: 1. Elopement assessment dated [DATE] indicated that R #1 was cognitively impaired with poor decision making skills, had [DIAGNOSES REDACTED]. Does the resident have a history of leaving the facility without need of supervision? No. Does the resident have a history of leaving facility without informing staff? No. Does the resident wander aimlessly or non-goal oriented (i.e. confused, moves without purpose, may enter other's rooms and explore other's belongings)? Yes. Resident at risk of elopement at this time? Yes. 2. Elopement assessment dated [DATE] indicated that R #1 was not cognitively impaired with poor decision making skills, did not have a [DIAGNOSES REDACTED]. Does the resident have a history of leaving facility without informing staff? No. Does the resident wander aimlessly or non-goal oriented (i.e. confused, moves without purpose, may enter other's rooms and explore other's belongings)? No. Resident at risk of elopement at this time? No. J. Review of Leave of Absence Form for [DATE] indicated that R #1 signed herself out to leave the facility unattended on [DATE] and [DATE]. K. On [DATE] at 11:20 am, during interview with Administrator, she stated the following: 1. That on [DATE], after R #1's accident, she asked the police if R #1 had her wander guard on either ankle and was told that there was no wander guard in place after the body was checked by the coroner. The Administrator stated that after searching the room, staff found the wander guard in a drawer of a bed side dresser. 2. The Administrator stated that wander guards are checked for placement each shift and that, according to the documentation, R #1's wander guard was checked at about 6:30 pm on [DATE] and was in place. 3. The Administrator stated that staff informed R #1 that she wasn't safe to go outside the facility on her own and that they were placing the wander guard on her ankle as a reminder to R #1 that she shouldn't go outside alone. The administrator stated that R #1 was alert and oriented but made poor decisions and demonstrated very impulsive behavior. The administrator stated that the resident was not safe when she first got to the facility and wandered all over the building. 4. The Administrator stated that R #1 had been allowed to leave the facility unsupervised to go shopping or to run errands. When asked if R #1 was safe to be outside of the facility, the Administrator stated that she was. When asked why R #1 would need a wander guard if she was safe to be outside of the facility unsupervised, the Administrator again stated that R #1 made poor decisions and had impulsive behavior but did not have dementia or memory problems. When asked if poor decision making and impulsive behavior would mean that the resident was not safe to be unsupervised outside of the facility, the Administrator acknowledged that it did. 5. The Administrator acknowledged the conflicting information regarding whether R #1 was safe to be outside of the facility unsupervised versus needing to have a wander guard placed to prevent her from leaving the facility without the staff's knowledge as she (R #1) was a danger to herself. The Administrator agreed and stated that in hindsight, she should not have allowed R #1 to be out of the facility unsupervised. She acknowledged the conflicting information on R #1's Elopement Assessments and stated that she did not know why this was the case. L. On [DATE] at 1:31 pm, during interview with Administrator, she stated the following: 1. That she was planning on having the door alarms changed so that each door that opened to the outside would be alarmed any time it is opened. She stated that she was doing this because, Obviously, there was a failure somewhere (on the day of R #1's death), so I want to prevent this from occurring in the future. 2. The Administrator stated that on [DATE], R #1 was put on Geodon to treat her escalating behaviors and that since she was put on this medication, her trips out of the facility had stopped and she was only allowed to go out the back patio which has gates that are locked. The Administrator stated that after the medication was added, staff began to watch the resident more closely and were checking on her every hour or so but stated that she did not have documentation to support this. 3. The Administrator stated that the resident did have one other episode of elopement but that she did not document this as she didn't think the resident got past the parking lot. 4. The Administrator stated that she may have made a bad decision by letting the resident go out of the facility on her own but that she was trying to assist the resident in transitioning back into the community. 5. The Administrator stated that when the resident first came to the facility, she was wandering all over the facility and the decision was made to place the wander guard. The Administrator stated that the resident stopped wandering after a couple of weeks and that the care plan should have been updated to reflect the fact that the resident was no longer wandering and was oriented to the building but verified that this had not been done. M. On [DATE] at 1:45 pm, during interview with Unit Manager (UM) #1, she stated that the Wanderguard was in place on R #1 for her impulsive behaviors and poor judgement. UM #1 stated that the resident had permission to go out of the facility and get things from the store and that this was ok as long as the resident signed out and notified staff that she was leaving the facility. UM #1 verified that the care plan indicated that the wander guard was placed due to the resident being at risk for elopement. UM #1 stated that at the time of R #1's elopement incident on [DATE], a lady had gotten out of her car and helped R #1 get out of the street since traffic was backed up due to R #1 being in the street. UM #1 stated that R #1 had gotten out of her wheelchair and was walking to cross the street. UM #1 stated that the witness who was assisting R #1 informed her (UM #1) that R #1 had fallen down but UM #1 stated that she didn't see this occur. UM #1 stated that when the city bus came, the resident refused to go back to the facility, left her wheelchair on the curb and boarded the bus. N. On [DATE] at 3:10 pm, during interview with UM #2, she stated that on [DATE] at about 12:15 pm, she was leaving for lunch and noticed R #1 on the sidewalk across from the facility. She stated that the resident had a 2 hour pass to go to the store at this time. UM #2 stated that for the wandering, R #1 had a Wanderguard in place and a picture in the elopement book which is a book that has the pictures and facesheets of all residents who are elopement risks so that the staff can visualize the resident and have notification of residents who are at risk for eloping. UM #2 stated that she didn't feel that the resident was safe due to her poor choices and impulsive behaviors. UM #2 stated that after the incident where the resident was found near the bus stop and almost hit by a car, she did not feel that the resident was safe to be outside unsupervised. UM #2 verified that after this incident, the resident did receive an additional pass to leave the facility unsupervised. O. On [DATE] at 3:45 pm: during interview with the Administrator, she verified that R #1 did have another episode of elopement on [DATE]. The Administrator stated that she initially thought that R #1 did not get past the parking lot but after reading the incident report, realized that she did, in fact, get out into the street and board a bus. The Administrator verified that R #1 was allowed to leave the facility again on [DATE] after having the incident on [DATE]. She stated that the reason that the resident was allowed to go out again was because on this outing, a cab came and picked the resident up, waited at the store and dropped her off. The Administrator stated that in retrospect, she should have sent an escort with the resident on outings, especially after the incident on [DATE]. The Administrator stated that she did not report R #1's elopement episode on [DATE] to the State Agency as she originally did not see this as an elopement. When she was asked about whether, after the resident fell down three times in the middle of the street and the nurses asked her to come back to the facility and R #1 refusing to return, if this would be considered an elopement, the Administrator stated that it would and that in hindsight, this should have been reported to the state but was not.

This is a repeat deficiency from a recertification survey conducted on 11/10/14. Based on record review and interview, the facility failed to follow the physician's orders [REDACTED].#1) of 5 (R#s 1, 2, 3, 4 and 5) residents reviewed for skin conditions by: 1. Not performing wound care for an infected surgical wound and; 2. Not implementing a care plan intervention to check vital signs every shift to monitor for infection. This deficient practice resulted in a failure of the surgical wound to heal without infection [MEDICAL CONDITION] (a potentially life-threatening complication of an infection). The findings are: Findings related to Wound Care A. Record review of a Physician order [REDACTED]. Apply Santyl (medicated cream) to wound base. Then NPWT (Negative Pressure Wound Therapy) at 100 mmHg (millimeters of mercury) per protocol. Secure with drape. Change every 48-72 hours. B. Record review of the Treatment Administration Record for June 2015 indicated that no wound care was completed from 06/13/15 to 06/25/15. C. On 10/06/15 at 8:42 am, during interview with the Wound Nurse (WN), she stated that if a wound dressing is not changed, this should be documented in the progress notes or wound assessment notes. Regarding the dates 06/13/15 to 06/25/15, WN was unable to say whether the wound therapy had occurred, was unable to provide documentation to indicate that wound therapy had occurred and was unable to provide documentation to indicate the reason that wound care was not performed with the exception of 06/17/15, in which a Progress Note indicated that wound care had been completed. WN stated that the resident's amputation wound was not progressing well at all and that she felt that the treatment was too aggressive given the resident's infection and overall declining health status. D. Record review of Hospital Progress Note dated 06/26/15 indicated the following: Wound care did evaluate today and found some necrotic (dead tissue) in the stump area with significant concerns. Impression:[MEDICAL CONDITION] with septic shock. Condition is unstable .We will continue supportive care at this time. E. Record review of the Hospital Discharge Summary dated 07/22/15 indicated the following: Admitting Diagnoses: [REDACTED]. lactic acidosis (when lactic acid builds up in the bloodstream faster than it can be removed)with septic shock, urosepsis a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream .Hospital course was complicated because the patient was DNR/DNI (Do Not Resuscitate/Do Not Intubate). The patient was not responding well to just fluid and antibiotics and was continuing to go into shock. Findings Related to Vital Signs F. Record review of the Care Plan dated 04/16/15 indicated the following: Focus: Infection left aka (above the knee amputation) stump. Goals: Resident will have no s/sx (signs/symptoms) of infection Interventions: Administer medication per order, observe universal precaution, obtain labs per order, vital signs Q (every) shift. G. Record review of the vital signs from 04/17/15 to 06/25/15 indicated that vital signs were not obtained 117 times out of 140 opportunities. H. On 10/06/15 at 11:00 am, during interview with the DON (Director of Nursing), he stated that if the care plan indicated that vital signs were to be taken on each shift, he would expect to see this either in the vital signs tab of the electronic chart or in the daily nurse's note. The DON verified that vital signs were not taken and not documented twice a day for this resident.

This is a repeat deficiency from a recertification survey conducted on [DATE]. Based on record review and interview, the facility failed to follow the physician's orders [REDACTED].#1) of 5 (R#s 1, 2, 3, 4 and 5) residents reviewed for skin conditions by: 1. Not performing wound care for an infected surgical wound and; 2. Not implementing a care plan intervention to check vital signs every shift to monitor for infection. This deficient practice resulted in a failure of the surgical wound to heal without infection [MEDICAL CONDITION] (a potentially life-threatening complication of an infection). The findings are: Findings related to Wound Care A. Record review of a Physician order [REDACTED]. Apply Santyl (medicated cream) to wound base. Then NPWT (Negative Pressure Wound Therapy) at 100 mmHg (millimeters of mercury) per protocol. Secure with drape. Change every ,[DATE] hours. B. Record review of the Treatment Administration Record for [DATE] indicated that no wound care was completed from [DATE] to [DATE]. C. On [DATE] at 8:42 am, during interview with the Wound Nurse (WN), she stated that the resident's amputation wound was not progressing well at all and that she felt that the treatment was too aggressive given the resident's infection and overall declining health status. WN stated that if wound care is not performed, this should be documented in the progress notes or wound assessment notes. Regarding the dates [DATE] to [DATE], WN was unable to say whether wound care had occurred, was unable to provide documentation to indicate that wound care had occurred and was unable to provide documentation to indicate the reason that wound care was not performed. D. Record review of Hospital Progress Note dated [DATE] indicated the following: Wound care did evaluate today and found some necrotic (dead tissue) in the stump area with significant concerns. Impression:[MEDICAL CONDITION] with septic shock. Condition is unstable .We will continue supportive care at this time. E. Record review of the Hospital Discharge Summary dated [DATE] indicated the following: Admitting Diagnoses: [REDACTED]. lactic acidosis (when lactic acid builds up in the bloodstream faster than it can be removed) with septic shock, urosepsis a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream .Hospital course was complicated because the patient was DNR/DNI (Do Not Resuscitate/Do Not Intubate). The patient was not responding well to just fluid and antibiotics and was continuing to go into shock. Resident expired during hospital stay related to above complications. Findings Related to Vital Signs F. Record review of the Care Plan dated [DATE] indicated the following: Focus: Infection left aka (above the knee amputation) stump. Goals: Resident will have no s/sx (signs/symptoms) of infection Interventions: Administer medication per order, observe universal precaution, obtain labs per order, vital signs Q (every) shift. G. On [DATE] at 11:00 am, during interview with the DON (Director of Nursing), he stated that if the care plan indicated that vital signs were to be taken on each shift, he would expect to see this either in the vital signs tab of the electronic chart or in the daily nurse's note. The DON verified that vital signs were not taken and not documented twice a day for this resident.Record review of the vital signs from [DATE] to [DATE] indicated that vital signs were not obtained 117 times out of 140 opportunities. H. On [DATE] at 11:00 am, during interview with the DON (Director of Nursing), he stated that if the care plan indicated that vital signs were to be taken on each shift, he would expect to see this either in the vital signs tab of the electronic chart or in the daily nurse's note. The DON verified that vital signs were not taken and not documented twice a day for this resident.

Based on observation, record review, and interviews, the facility failed to ensure 1 (R #281) of 1 (R #281) sampled resident was free from physical abuse. Resident #281 was found to have an acute non-displaced fracture (a break in a bone) of the fifth proximal phalanx (pinky bone) shaft and lucency in the second metacarpal (hand bone) head consistent with a non-displaced fracture, and bruising to the left eye. This deficient practice likely resulted in Resident #281 experiencing fear and anxiety. The findings are: A. Facility Incident Report dated 10/08/14 indicated, "Resident (R #281) observed with skin discoloration under left eye, skin is intact area is reddish-purple in color. Resident #281 stated, "I was viewing from the top." It (the Incident Report) further indicated, "Right eye is sluggish for reaction."...It further indicated, "Resident (R #281) frequently wanders in and out of rooms...History of [MEDICAL CONDITION], Aggression at home and [MEDICAL CONDITION] (Posttraumatic Stress Disorder)." B. Facility Incident Report dated 10/09/14 indicated, "Writer observed resident (R #281) was coming out of the dining room holding left hand with right hand. When asked resident (R #281) what happened, resident stated, "It's broken." Resident (R #281) was assessed, noted that residents' left hand/fingers had swelling, warm to touch...Level of pain: "Hurts a little more." C. Review of the facility Incident Report dated 10/10/14 indicated, that on 10/09/14, "Resident (referring to R #281) up and out of bed wandering on unit. Has advanced Dementia and wanders in and out of other residents rooms. Resident (R #281) observed on unit with left hand swelling...Resident (#281) remains on Dementia unit, continue education of staff to re-direct resident from wandering into other resident's rooms." D. Review of the facility Investigative Summary dated 10/10/14 indicated, (name of R #281) has advancing Dementia with behaviors, [MEDICAL CONDITIONS], agitation and sun-downing (which refers to a state of confusion at the end of the day and into the night). The investigation summary further indicated, "Resident (R #281) self ambulates and spends much time...wandering in and out of other residents rooms. Must be redirected often by staff." E. Review of the Medical Record for Resident #281 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. Special Unit Criteria assessment dated [DATE] indicated, that Resident #281 does have an Alzheimer's or Dementia diagnosis, habitually wanders, and has a significant behavioral problem that disrupts the rights of other residents. 3. Care Plan revised 09/11/14 indicated, "Behavioral symptoms present as evidenced by he (R #281) constantly goes in and out of rooms often times he is confrontational with residents. He appears to be more agitated in the evenings." The Care Plan further indicated that staff are to "Redirect as needed-especially to his own room and staff to redirect when he is seen wandering in and out of rooms." 4. Progress Notes dated 10/08/14 indicated, "(Name of Resident #281) observed with skin discoloration under left eye, area is reddish-purple in color...Resident stated, 'I was viewing from the top.' He (referring to R #281) frequently goes in and out of rooms without purpose." Progress Notes further indicated, "Large bruise noted on resident's face, under left eye, resident unable to explain what happened." 5. Progress Notes dated 10/09/14 indicated, "Observed resident coming out of dining room, holding left hand with right hand...Resident stated, 'It's broke. Last night I was helping someone with the vacuum...Swelling noted to left hand and fingers." 6. Nurse's Notes dated 10/09/14 indicated XR (X-ray) result showed an acute ono (sic) displaced [MEDICAL CONDITION] (sic) proximal phalanx finger and there is also lucency in the second metacarpal head with a non-displaced fracture." 7. Final X-ray Report dated 10/09/14 indicated, "Exam reason: Pain and swelling in Lt (left) hand and 5th digit. Findings: There is an acute non-displaced [MEDICAL CONDITION] proximal phalanx shaft. There is also lucency in the second metacarpal head consistent with a non-displaced fracture." 8. Social Services Note dated 10/09/14 indicated, "He (referring to R #281) wanders all over the unit and into others personal items...lives on a secured unit...He can be verbally aggressive." 9. Nurses Notes dated 10/10/14 indicated, "Color to L (left) eye remains purple/ecchymotic (bruising)...Wanders frequently and need to be directed to place." 10. Social Services Note dated 10/10/14 indicated, "Was walking up and down the hallway and he was opening and clossing (sic) the doors and looking and/or wandering in and out of rooms." Social Services Notes further stated, "(name of family member of R #281) said I was concerned for my dad...but concerned that my father just keeps getting himself into trouble. Explained that his father (R #281) wanders all over the unit." F. On 11/07/14 at 10:35 am, during interview the Director of Nursing (DON) stated, "I recall staff saying he (R #281) has a tendency to wander up and down the halls into resident rooms. He (R #281) couldn't say what happened to his hand. We thought maybe he had gone into another persons room and got into a tussle, but we don't know. I do know that he (R #281) will go into every room on the unit and the staff have been informed to redirect him. To be honest, we can only think that he wandered into someone's room and got into a tussle. The discoloration to his eye was already a few days old. We do have a few residents on the unit who are territorial and will get upset if someone else is in their space. We do have a mixed population on the 300 unit. We do have a CNA (Certified Nursing Assistant) who monitors the hall until every one is in bed. That CNA is supposed to be redirecting residents. But, with such a small unit with 60 residents, it becomes a challenge." G. On 11/07/14 at 10:40 am, during interview regarding Resident #281's fractured hand, Licensed Practical Nurse (LPN) #2 stated, "He was coming out of the dining room holding his left hand. When I looked, I saw his fingers were swollen and it turned out his finger was broken. All he (R #281) said was 'It's broken.'" LPN #2 then stated, "He wanders a lot. As for the hall monitors, sometimes we have different CNAs every day that has to monitor him." H. On 11/07/14 at 10:55 am, during interview, LPN #3 stated, "He (R #281) paces back and forth and he goes in and out of resident rooms. With the discoloration to the eye, nobody knows what happened and he was not able to tell us. Perhaps somebody hit him. Then the following day he had a swollen hand and the x-ray showed a fracture. On 10/08/14, we just saw him with a black eye. At times he does have issues with other residents in which he goes in and out of their rooms a lot. He also likes to touch, meaning he (R #281) likes to go in people's faces and we do have a few of the male residents that don't like that." LPN #3 then stated, "In my opinion, he could have been hit by one of them (residents). You can tell him to leave a room, but of course after a few minutes, he will go back." I. On 11/07/14 at 11:05 am, during interview Certified Nursing Assistant (CNA) #1/Hall Monitor stated, "As the hall monitor, I'm supposed to go up and down the halls to make sure no residents have fallen. Today though, since I'm a CNA as well, I had to do a couple of showers when the other CNAs are out. Sometimes we get understaffed to where we don't have enough staff, so we don't get a hall monitor. Sometimes if we do have a hall monitor, then that person generally will get pulled to be the CNA on the floor if that scheduled CNA called in. With (name of R #281), he does wander a lot and he checks each and every room." J. On 11/07/14 at 11:45 am, observation of R #281 on the locked 300 unit revealed the resident wandering on the unit. R #281 was observed walking from room to room and opening the bedroom doors to each resident's room on the unit and looking inside the rooms, then closing the door and walking to the next room. R #281 was observed doing this repeatedly on the unit. At this time, there were no staff observed to be re-directing R #281 from walking to residents bedrooms and opening the doors. K. Review of the facilities Abuse Investigations Policy and Procedure revised November 2010 indicated, "Our residents have the right to be free from abuse...Our facility is committee to protecting our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents...or any other individual." Based on record review and interviews, the facility failed to ensure residents were free from verbal abuse, intimidation, and verbal threats from 1 (R #326) of 1 (R #326) sampled residents with a known history of verbal aggression towards others. This deficient practice likely resulted in resident's experiencing additional anxiety, by not ensuring the safety of other residents. The findings are: A. Review of a Facility Incident Report dated 07/08/14 indicated, "When his (R #326) roommate came into the room, resident (referring to R #326) started verbally abusing his roommate, stating 'I am gonna kill him.'" Further review of the incident report indicated: Predisposing Situation Factors are: Dislikes roommate. B. Review of a Facility Incident Report dated 07/19/14 indicated, "Resident (who was not identified on the incident report) watching TV and got into argument with another resident. Resident (referring to R #326) picked up back of wheelchair and attempted to unseat other resident...Resident (referring to R #326) dislikes everyone. Resident has constant anger." C. Review of a Facility Incident Report dated 07/22/14 indicated, "Rsd (resident) was verbally abusive to his roommate...States, 'He will cut his roommates throat.' Rsd (resident) cont (continues) to be abusive to CNA (Certified Nursing Assistant) and everybody...Resident has persistent anger due to placement." D. Review of the Medical Record for Resident #326 indicated the following: 1. Face Sheet (not dated) indicated [DIAGNOSES REDACTED]. 2. Care Plan revised 05/19/14 indicated, (name of R #326) has behavioral symptoms present is now on a secured unit...Staff are to monitor behaviors, and redirect as needed." 3. Nurses Note dated 06/04/14 indicated, "At frequent intervals in his wheelchair resident (referring to R #326) very quickly self propelling himself back and forth from dayroom to his room. This behavior continued until 0200 (2:00 am)...Resident at this time continued yelling...at caregivers...Resident continued loudly cursing how he hated this place and the caregivers." 4. Nurses Note dated 07/10/14 indicated, "Resident (R #326) is threatening his roommate (who was not identified in the nurses note)again...Resident (referring to R #326) got out of bed and shook his fist at his roommate who was laying in bed. Resident (R #326) has been expressing anger on a daily basis this last week towards his roommates and staff. Resident (R #326) does state that he does not belong here because he is not crazy like everyone else in here. Resident is verbally abusive and show (sic) threatening signs towards other people." The nurses notes further indicated "Resident (R #326) shows verball (sic) and physical aggression to his roommate, yelling get out of my room, because am (sic) gonna take care for you. Rds (resident) (R #326) driving so fast thru hallway, it is very danger (sic) for other rsds (residents)." 5. Quarterly Nursing assessment dated [DATE] indicated, "Resident (referring to R #326) is verbally abusive with staff and other residents. At times will get combative. Resident (referring to R #326) is angry due to placement." 6. Nurses Note dated 07/11/14 indicated, "Rds (resident) continue to be agitated (sic) to others driving thru hallway very fast, not consider (sic) of other rsds." 7. Nurses Note dated 07/15/14 indicated, "Rds (resident) (referring to R #326) continue agitated at AM, (self propelling in wheelchair) last not (sic) consider (sic) of others an (sic) hallway." 8. Nurses Note dated 07/19/14 at 12:02 pm, indicated "Resident (referring to R #326) yelling at female resident (who was not identified in the nurses notes) due to her asking 'what time is it' repeatedly...Resident (R #326)states, 'I won't say anything to her anymore.' Few minutes later resident (R #326) went down the hall and told CNA (not indicated in nurses notes) that he was going to burn down the place because he is tired of these 'mother f***ers.'" 9. Nurses Note dated 07/19/14 at 9:32 pm, indicated "Resident (R #326) lifted up back of another residents (who was not identified in the nurses notes) wheelchair, attempting to unseat him." 10. Nurses Note dated 07/20/14 indicated, "Resident (R #326) did go (to) his room several times to toilet. Residents roommate (who was not identified in the nurses notes) was resistant to letting resident (R #326) use the toilet and even enter the room." 11. Nurses Note dated 07/21/14 at 7:04 pm, indicated "Rsd (R #326) sent out to ER (emergency room ) 2/0 (secondary) been verbally abusive and treating (sic) to slash the throat of his roommate (who was not identified in the nurses notes)." 12. Nurses Note dated 07/21/14 at 9:46 pm, indicated "Rsd (R #326) returned from ER...with no change of behavior, cont (continue) to be verbally abusive...continue to monitor." 13. Nurses Note dated 07/21/14 at 10:30 pm, indicated "Rsd (R #326) treating (sic) to cut his room-mate (sic) throat cut his stomach and make hime (sic) eat his bowls (sic)...Sent to ER...Returned from ER...cont (continues) to ambulate on hallway with verbal abuse to everybody, roommate (who was not identified in the nurses notes) moved temporarily...will cont (continue) to monitor for aggressive behavior. Rsd (R #326) roommate (who was not identified in the nurses notes) state he (R #326) is dengerours (sic)." E. On 11/10/14 at 4:23 pm, during interview regarding R #326, the Administrator stated that originally he (R #326) came in on unit 700, then he went to unit 600, then was placed on the locked unit." When the Administrator was asked about the other residents that R #326 may have come into contact with, and how R #326 was being monitored, the Administrator stated, "That is a good question regarding the other residents on the unit." The Administrator then stated, "I'm sure we put him on 1:1 (one-on-one), but I don't see that documented. We sent him out four times on 07/21/14 to the ER for being verbally abusive and he returned with no new orders and continued to be verbally abusive. From April 2014 through July 2014 he was on a secured unit (unit 200)." The Administrator then stated, "The one thing I'm getting from this is, if you look at the progression of his behaviors, he (R #326) started out as our typical non-compliant alcoholic person, but he kept escalating and escalating and it looked like his real threatening behaviors occurred right before he left to the ER. He was sent out to the ER with no interventions and during that time, we were watching him very closely. But I see what you're saying where it is not documented. It doesn't say 1:1." F. On 11/10/14 at 4:25 pm, during interview the DON stated, "We would send him (R #326) out to the ER with the hope they would diffuse his behaviors." When the DON was asked how was the staff monitoring R #326 behaviors or keeping the other residents safe, the DON stated, "They (staff) gave him [MEDICATION NAME] (an Anti-anxiety medication) but they (staff) were not charting the 1:1 monitoring. That is what I'm not seeing." G. Review of the facilities Abuse Investigations Policy and Procedure revised November 2010 indicated, "Our residents have the right to be free from abuse...Our facility is committee to protecting our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents...or any other individual."

Based on record review and interviews, the facility failed to implement the written policies and procedures for physical abuse for 1 (R #281) of 1 (R #281) residents who was found to have an acute non-displaced fracture (a break in a bone) of the fifth proximal phalanx (pinky bone) shaft and lucency in the second metacarpal (hand bone) head consistent with a non-displaced fracture, and bruising to the left eye. This deficient practice likely resulted in Resident #281 experiencing fear and anxiety. If incidents of physical abuse are not thoroughly investigated as per the facility policy, incidents of abuse may go unnoticed. The findings are: A. Review of the facilities Abuse Investigations Policy and Procedure revised November 2010 indicated, "Our residents have the right to be free from abuse...Our facility is committee to protecting our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents...or any other individual." B. Facility Incident Report dated 10/08/14 indicated, "Resident (R #281) observed with skin discoloration under left eye, skin is intact area is reddish-purple in color. Resident #281 stated, "I was viewing from the top." It (the Incident Report) further indicated, "Right eye is sluggish for reaction."...It further indicated, "Resident (R #281) frequently wanders in and out of rooms...History of [MEDICAL CONDITION], Aggression at home and [MEDICAL CONDITION] (Posttraumatic Stress Disorder)." C. Facility Incident Report dated 10/09/14 indicated, "Writer observed resident (R #281) was coming out of the dining room holding left hand with right hand. When asked resident (R #281) what happened, resident stated, "It's broken." Resident (R #281) was assessed, noted that residents' left hand/fingers had swelling, warm to touch...Level of pain: "Hurts a little more." D. Review of the Medical Record for Resident #281 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. Special Unit Criteria assessment dated [DATE] indicated, that Resident #281 does have an Alzheimer's or Dementia diagnosis, habitually wanders, and has a significant behavioral problem that disrupts the rights of other residents. 3. Progress Notes dated 10/08/14 indicated, "(Name of Resident #281) observed with skin discoloration under left eye, area is reddish-purple in color...Resident stated, 'I was viewing from the top.' He (referring to R #281) frequently goes in and out of rooms without purpose." Progress Notes further indicated, "Large bruise noted on resident's face, under left eye, resident unable to explain what happened." 4. Progress Notes dated 10/09/14 indicated, "Observed resident coming out of dining room, holding left hand with right hand...Resident stated, 'It's broke. Last night I was helping someone with the vacuum...Swelling noted to left hand and fingers." 5. Nurse's Notes dated 10/09/14 indicated XR (X-ray) result showed an acute ono (sic) displaced [MEDICAL CONDITION] (sic) proximal phalanx finger and there is also lucency in the second metacarpal head with a non-displaced fracture." 6. Final X-ray Report dated 10/09/14 indicated, "Exam reason: Pain and swelling in Lt (left) hand and 5th digit. Findings: There is an acute non-displaced [MEDICAL CONDITION] proximal phalanx shaft. There is also lucency in the second metacarpal head consistent with a non-displaced fracture." 7. Social Services Note dated 10/10/14 indicated, "Was walking up and down the hallway and he was opening and clossing (sic) the doors and looking and/or wandering in and out of rooms." Social Services Notes further stated, "(name of family member of R #281) said I was concerned for my dad...but concerned that my father just keeps getting himself into trouble. Explained that his father (R #281) wanders all over the unit." E. On 11/07/14 at 10:35 am, during interview the Director of Nursing (DON) stated, "I recall staff saying he (R #281) has a tendency to wander up and down the halls into resident rooms. He (R #281) couldn't say what happened to his hand. We thought maybe he had gone into another persons room and got into a tussle, but we don't know. I do know that he (R #281) will go into every room on the unit and the staff have been informed to redirect him. To be honest, we can only think that he wandered into someone's room and got into a tussle. The discoloration to his eye was already a few days old. We do have a few residents on the unit who are territorial and will get upset if someone else is in their space. We do have a mixed population on the 300 unit." F. On 11/07/14 at 10:40 am, during interview regarding Resident #281's fractured hand, Licensed Practical Nurse (LPN) #2 stated, "He was coming out of the dining room holding his left hand. When I looked, I saw his fingers were swollen and it turned out his finger was broken. All he (R #281) said was 'It's broken.'" LPN #2 then stated, "He wanders a lot." G. On 11/07/14 at 10:55 am, during interview, LPN #3 stated, "He (R #281) paces back and forth and he goes in and out of resident rooms. With the discoloration to the eye, nobody knows what happened and he was not able to tell us. Perhaps somebody hit him. Then the following day he had a swollen hand and the x-ray showed a fracture. On 10/08/14, we just saw him with a black eye. At times he does have issues with other residents in which he goes in and out of their rooms a lot. He also likes to touch, meaning he (R #281) likes to go in people's faces and we do have a few of the male residents that don't like that." LPN #3 then stated, "In my opinion, he could have been hit by one of them (residents). You can tell him to leave a room, but of course after a few minutes, he will go back." H. On 11/07/14 at 11:45 am, observation of R #281 on the locked 300 unit revealed the resident wandering on the unit. R #281 was observed walking from room to room and opening the bedroom doors to each resident's room on the unit and looking inside the rooms, then closing the door and walking to the next room. R #281 was observed doing this repeatedly on the unit. At this time, there were no staff observed to be re-directing R #281 from walking to residents bedrooms and opening the doors.

Based on record review and interviews, the facility failed to ensure 1 (R #139) of 1 (R #139) resident who was identified as being at risk for falls, had side rails on the bed to prevent an accident in which the resident (who was identified as being Quadriplegic-Paralysis of both the arms and legs, having contractures, was in a persistent vegetative state, and who had a [MEDICAL CONDITION]) was found face down on the floor by staff. This deficient practice likely caused the resident to sustain a closed head injury, and bruising to the face. The findings are: A. Review of a Incident Report dated 10/14/14 revealed, "Patient (referring to R #139) is unable to move secondary to her [MEDICAL CONDITION] found on the floor R (right) side when nurse and CNA (Certified Nursing Assistant) entered the room...Transported from (name of nursing facility) with a left black eye and laceration above her eyebrow...They (staff) reported she was found face down next to her bed." B. Review of the Medical Record for Resident #139 revealed the following: 1. Face Sheet (not dated) indicated [DIAGNOSES REDACTED]. 2. Physician order [REDACTED]. 3. Physician order [REDACTED].#139's [MEDICAL CONDITION] and Persistent Vegetative State, resident unable to reposition enough to alleviate pressure. 4. Care Plan revised on 10/22/2013 indicated "Resident is at risk for falls r/t (related to) unstable health condition. Interventions are Side rails up x2 at HOB (head of bed), for safety, to define bed parameters, to aid in bed mobility." The care plan further indicated that R #139 requires total assistance from staff for all Activities of Daily Living (ADLs) 5. Minimum Data Set ((MDS) dated [DATE] indicated Resident #139 is totally dependent on staff for bed mobility, transfers, and all ADL's to include dressing, toilet use, and personal hygiene. The MDS further indicated R #139 has a functional limitation in Range of Motion (ROM) to both the upper extremities (shoulder, elbow, wrist and hand) and lower extremities (hip, knees, ankle and foot). 6. Physician order [REDACTED]. Q (every) shift." 7. Side Rail assessment dated [DATE] indicated R #139 is not able to voice her choice about side rails. It further indicated R #139 has a Dx (diagnosis) of persistent vegetative state, unable to move in bed. 8. Nurses Notes dated 10/14/14 at 7:55 pm, indicated "Rsd (resident) was on the floor facing down on L (left) side out of the bed...Rsd had laceration to L (left) eyebrow and redness and swelling on left cheek bone." 9. Nurses Notes dated 10/14/14 at 7:56 pm, indicated "When arrived to residents room noted that patient was on floor at the left side of bed...Resident was bleeding from left eyebrow and was also having a nose bleed." 10. The resident was found to have a closed head injury, a black eye, and bruises to the face. The facility also failed to properly assess the resident for the use of side rails by taking the side rails off the residents bed without notifying the power of attorney. C. Review of the Emergency (ER) Dept. (department) notes dated 10/14/14 indicated, "The patient presents with head [MEDICAL CONDITION], non-communicative, who presented after being found on the floor, next to her bed...She had a left black eye and a 3 cm (centimeter) laceration in her eyebrow. There were no railings on her bed. Patient has very minimal movement of right hand. Left hand/arm and LE (lower extremities) have contractures, no movement noted." The ER notes further indicated, "As patient is unable to give any history...as history and observed ability of the patient to move (is not able to roll at all) is not consistent." D. Review of the Admitting hospital History and Physical dated 10/15/14 indicated, "She (referring to R #139) was found in her room with the rails down facing face down by a nurse." E. On 11/06/14 at 9:45 am, during interview Registered Nurse (RN #1) stated, "I was working on the front section of the 600 hall and they (staff) called for me to assist the other nurse (referring to LPN #4) help (R #139) off the floor. Once I walked in the room, I saw her (R #139) on the floor face down. She (R #139) was laying on the left side of the bed. All I was told by (name of LPN #4) was that she (R #139) was on the floor. There was blood on the floor and blood coming from her face. She (R #139) had a laceration on the left eyebrow and left cheek bone. Her nurse at the time (referring to LPN #4) told me that she (the nurse) just heard a beeping noise coming from the room and the beeping was due to the ([DEVICE]) and, as she (LPN #4) went to the room, she saw her (R #139) on the floor. RN #1 stated, "She (referring to R #139) can't tell you what she needs. She cannot get out of bed on her own and is totally dependent on staff for everything. She is total care...I've never known her (R #139) to roll by herself...She does have contractures in the upper extremities and both her legs are contracted straight." RN #1 then stated, "When I walked in her (R #139's) room, I saw the [DEVICE] pole turned over on her bed. The pole was on the right side of the bed and she (R #139) was found on the left side of the bed face down." RN #1 stated "I never saw her (R #139) moving and she definitely was not able to turn herself. There were no side rails on the bed." F. On 11/06/14 at 10:25 am, during interview, Licensed Practical Nurse (LPN) #4 stated, "When I was walking by, I heard her (R #139's) tube feeding machine beeping and I went to the room. There was nobody in the bed and I thought, well who got her up and I realized she (R #139) was then on the floor. She (R #139) was found face down on the floor. There were no other staff in the room at the time. She was bleeding quite a bit from her eyebrow...When I have worked with her, she (R #139) is not able to make her needs known. She can't talk...She has contractures on her elbows, and her hands are bent up to where she cannot move them and her neck is bent to one side. With her lower extremities, her feet are pointed and her legs are very stiff." LPN #4 then stated, the feeding tube was on the right side of the bed, and when she walked in R #139's room, the tubing to the feeding tube, was pulled very tight and she was found on the other side of the bed." LPN #4 stated, "The head of the bed was elevated due to her tube feeding and I do not recall seeing any side rails...She (R #139) cannot move herself or even turn herself at all and I've never seen her get out of bed." G. On 11/06/14 at 11:00 am, during interview Family Member #1 of R #139 stated, "I was notified 1/2 hour later by an EMT (Emergency Medical Technician) who had concerns of how she (R #139) was found face down and was being told she (R #139) fell out of bed on her own, but it didn't look to him how she (R #139) could have fallen out of bed because she can't even move or make her needs known." Family Member #1 of R #139 then stated, I asked the nurse if her side rails were up and I was told no." Family Member #1 of R #139 stated, after this happened, I was told that back in September 2014 the facility did away with her (R #139) side rails, but I was never notified of this. I was told 'If you would have signed a consent for the rails, we would have had them."' Family Member #1 of R #139 stated, "First of all, I was never informed they were taken off her side rails and then happened to her. She is not able to turn herself in bed and she has to be 100% cared for and have the staff turn her. She has no use of her lower body. She had side rails on her bed which were at the head of the bed on both sides and up until this point, she had them (side rails) for seven years. When she fell , she took the brunt of the fall to her face because she was not able to brace herself with her arms." H. On 11/06/14 at 11:45 am, during interview with the Director of Nursing (DON) she stated, "I can't recall if she (R #139) did or did not have side rails. She had no history of falls. With our side rails, they would have only been taken off for a paraplegic resident if there was no movement and if they were not at risk for falls. But for each resident, there has to be a consent and if the family wants side rails, then we would have to have a consent from the family. It would be up to the nurse manager who should have contacted the family to see if they wanted side rails or not. That would have to be done prior to taking the side rails off the bed and I don't know if that was done or not." The DON then stated, up until this point, we never had any issues with her (R #139) and she was definitely total assistance on staff for everything." I. On 11/06/14 at 12:11 pm, during interview with RN #2 (Unit Manager) she stated, "I don't remember talking to the family member about the use of side rails for (name of R #139). With the side rail consents, that would go through me to go and do a re-assessment of the side rails to see if they were needed or not. With the side rail assessment we need to know why they (residents) need them, and we also need a consent and a Doctors order. From what I recall, she (R #139) was total care and total assistance on staff for everything. She had a feeding tube in place, had a trach, and also had a catheter. She had a low air loss mattress in place and that could have been a possibility of it malfunctioning if it were to start to deflate." J. On 11/06/14 at 2:40 pm, during interview Certified Nursing Assistant (CNA) #2 stated, "I repositioned her (R #139) by myself at 7:00 pm. I pulled her up in her draw sheet by myself then turned her away from me to see if she was dirty. Then I rolled her onto her back. Then I moved her a little bit meaning I pulled her up with the draw sheet. The last time I checked on her (R #139) was around 7:45 pm and she was in bed. Then all I knew was another CNA (identified as CNA #4) told me the nurse wanted to see me because she (R #139) fell from her bed. When I went to her (R #139's) room, she was on the floor on her face. For me, I felt that her bed was too soft and it just wasn't fluffy enough when I originally went to check on her at 7:00 pm. It just felt deflated meaning the bed moves air through. It goes hard then soft." CNA #2 then stated, "She (R #139) did not have any side rails. I do recall seeing them at one point but about 2-3 months ago they were taken away. With her (R #139) she is very contracted she cannot not move." K. On 11/06/14 at 3:30 pm, during interview CNA #4 stated, "When I went in her (R #139's) room, she was face down on the floor. I didn't hear anything. She (R #139) was bleeding from a wound on her forehead." CNA #4 stated, when I have worked with her (R #139) before, I always got another CNA to help me turn her and clean her up and reposition her. We are supposed to be using two people to clean her and reposition her. When I helped the other CNA early before dinner around 5:00 pm, we used two people to turn her side to side with the draw sheet and to clean her. Because of the wound on her bottom I recall putting pillows behind her back and under her bottom and behind her back. I also recall there was another CNA from a different floor working that night." L. Review of the facility Proper Use of Side Rails Policy and Procedure revised October 2010 indicated, "An assessment will be made to determine the resident's symptoms or reason for using side rails, When used for mobility or transfer an assessment will include a review of the resident's bed mobility and ability to change positions, transfer to and from bed or chair, and to stand and toilet...Consent for using restrictive devices will be obtained from the resident or legal representative." M. Review of the facility Bed Safety Policy revised December 2007 indicated, "If side rails are used, there shall be an interdisciplinary assessment of the resident...and input from the resident and/or legal representative."

I. Based on record review and interviews, the facility failed to ensure 1 (R #139) of 1 (R #139) residents who was identified as being at risk for falls had side rails on the bed to prevent an accident in which the resident (who was identified as being Quadriplegic-Paralysis of both the arms and legs, having contractures, was in a persistent vegetative state, and who had a tracheotomy) was found face down on the floor by staff. The resident was found to have a closed head injury, a black eye and bruises to the face. The facility also failed to properly assess the resident for the use of side rails by taking the side rails off the residents bed without notifying the power of attorney. This deficient practice likely caused the resident to sustain a closed head injury, and bruising to the face. The findings are: A. Review of a Incident Report dated 10/14/14 revealed, "Patient (referring to R #139) is unable to move secondary to her quadriplegia...Before the Incident: Resident found on the floor R (right) side when nurse and CNA (Certified Nursing Assistant) entered the room...Transported from (name of nursing facility) with a left black eye and laceration above her eyebrow...They (staff) reported she was found face down next to her bed." B. Review of the Medical Record for Resident #139 revealed the following: 1. Face Sheet (not dated) indicated [DIAGNOSES REDACTED]. 2. Physician order [REDACTED]. 3. Care Plan revised on 10/22/2013 indicated Resident is at risk for falls r/t (related to) unstable health condition. Interventions are Side rails up x2 at HOB (head of bed), for safety, to define bed parameters, to aid in bed mobility." The care plan further indicated that R #139 requires total assistance from staff for all Activities of Daily Living (ADLs) 4. Minimum Data Set ((MDS) dated [DATE] indicated Resident #139 is totally dependent on staff for bed mobility, transfers, and all Activities of Daily Living (ADL's) to include dressing, toilet use, and personal hygiene. The MDS further indicated R #139 has a functional limitation in Range of Motion (ROM) to both the upper extremities (shoulder, elbow, wrist and hand) and lower extremities (hip, knees, ankle and foot). The MDS further indicated that R #139 has a [DEVICE] (Gastrostomy) tube (a tube inserted through into the stomach used for nutrition). 5. Physician order [REDACTED]. Q (every) shift." 6. Side Rail assessment dated [DATE] indicated R #139 is not able to voice her choice about side rails. It further indicated R #139 has a Dx (diagnosis) of persistent vegetative state, unable to move in bed. 7. Nurses Notes dated 10/14/14 at 7:55 pm, indicated, "Rsd (resident) was on the floor facing down on L (left) side out of the bed...Rsd had laceration to L (left) eyebrow and redness and swelling on left cheek bone." 8. Nurses Notes dated 10/14/14 at 7:56 pm, indicated, "When arrived to residents room noted that patient was on floor at the left side of bed...Resident was bleeding from left eyebrow and was also having a nose bleed." C. Review of the Emergency (ER) Dept. (department) notes dated 10/14/14 indicated, "The patient presents with head injury...quadriplegia, non-communicative, who presented after being found on the floor, next to her bed...She had a left black eye and a 3 cm (centimeter) laceration in her eyebrow. There were no railings on her bed. Patient has very minimal movement of right hand. Left hand/arm and LE (lower extremities) have contractures, no movement noted." The ER notes further indicated, "As patient is unable to give any history...as history and observed ability of the patient to move (is not able to roll at all) is not consistent." D. Review of the Admitting hospital History and Physical dated 10/15/14 indicated, "She (referring to R #139) was found in her room with the rails down facing face down by a nurse." E. On 11/06/14 at 9:45 am, during interview Registered Nurse (RN #1) stated, "I was working on the front section of the 600 hall and they (staff) called for me to assist the other nurse (referring to LPN #4) called to assist her (R #139) off the floor. Once I walked in the room, I saw her (R #139) on the floor face down. She (R #139) was laying on the left side of the bed. All I was told by (name of LPN #4) was that she (R #139) was on the floor. There was blood on the floor and blood coming from her face. She (R #139) had a laceration on the left eyebrow and left cheek bone. Her nurse at the time (referring to LPN #4) told me that she (the nurse) just heard a beeping noise coming from the room and the beeping was due to the ([DEVICE]) and, as she (LPN #4) went to the room, she saw her (R #139) on the floor. RN #1 stated, "She (referring to R #139) can't tell you what she needs. She cannot get out of bed on her own and is totally dependent on staff for everything. She is total care...I've never known her (R #139) to roll by herself...She does have contractures in the upper extremities and both her legs are contracted straight." RN #1 then stated, "When I walked in her (R #139's) room, I saw the [DEVICE] pole turned over on her bed. The pole was on the right side of the bed and she (R #139) was found on the left side of the bed face down." When RN #1 was asked, What do you think happened, RN #1 stated "I never saw her (R #139) moving and she definitely was not able to turn herself. There were no side rails on the bed." F. On 11/06/14 at 10:25 am, during interview, Licensed Practical Nurse (LPN) #4 stated, "When I was walking by, I heard her (R #139's) tube feeding machine beeping and I went to the room. There was nobody in the bed and I thought, well who got her up and I realized she (R #139) was then on the floor. She (R #139) was found face down on the floor. There were no other staff in the room at the time. She was bleeding quite a bit from her eyebrow...When I have worked with her, she (R #139) is not able to make her needs known. She can't talk...She has contractures on her elbows, and her hands are bent up to where she cannot move them and her neck is bent to one side. With her lower extremities, her feet are pointed and her legs are very stiff." LPN #4 then stated, the feeding tube was on the right side of the bed, and when she walked in R #139's room, the tubing to the feeding tube, was pulled very tight and she was found on the other side of the bed." LPN #4 stated, "The head of the bed was elevated due to her tube feeding and I do not recall seeing any side rails...She (R #139) cannot move herself or even turn herself at all and I've never seen her get out of bed." G. On 11/06/14 at 11:00 am, during interview Family Member #1 of R #139 stated, "I was notified 1/2 hour later by an EMT (Emergency Medical Technician) who had concerns of how she (R #139) was found face down and was being told she (R #139) fell out of bed on her own, but it didn't look to him how she (R #139) could have fallen out of bed because she can't even move or make her needs known." Family Member #1 of R #139 then stated, "All I was told was that my mom fell out of the bed and they (staff) found her on the floor. I asked the nurse if her side rails were up and I was told no." Family Member #1 of R #139 stated, after this happened, I was told that back in September 2014 the facility did away with her (R #139) side rails, but I was never notified of this. Then on October 16, I got a call from (name of RN #2) who told me that they had done away with my mohter's side rails and 'If you would have signed a consent for the rails, we would have had them'. I was never notified they took the side rails off and this was not my fault for my mother not having side rails on her bed. If anyone needed side rails, it was my mom. She is at the mercy of others and maybe by propping her up a little too high one way or the other caused her to fall. Family Member #1 of R #139 stated, "First of all, I was never informed they (the side rails) were taken off and then this happened to her. She is not able to turn herself in bed and she has to be 100% cared for and have the staff turn her. She has no use of her lower body. She had side rails on her bed which were at the head of the bed on both sides and up until this point, she had them (side rails) for seven years. When she fell , she took the brunt of the fall to her face because she was not able to brace herself with her arms." Family Member #1 of R #139 then stated, "Then I was being told from (name of RN #2) that maybe my mom had a seizure which caused her to fall out of bed, but even the Doctor said she didn't have one nor has she ever had a history of [REDACTED].#2) was if she did have a seizure, if she had the side rails there, they probably would have kept her in the bed and not face down on the floor." H. On 11/06/14 at 11:45 am, during interview the Director of Nursing (DON) stated, "I can't recall if she (R #139) did or did not have side rails. She had no history of falls. With our side rails, they would have only been taken off for a paraplegic resident if there was no movement and if they were not at risk for falls. But for each resident, there has to be a consent and if the family wants side rails, then we would have to have a consent from the family. It would be up to the nurse manager who should have contacted the family to see if they wanted side rails or not. That would have to be done prior to taking the side rails off the bed and I don't know if that was done or not." The DON then stated, up until this point, we never had any issues with her (R #139) and she was definitely total assistance on staff for everything." I. On 11/06/14 at 12:11 pm, during interview RN #2 (Unit Manager) stated, "I don't remember talking to the family member about the use of side rails for (name of R #139). With the side rail consents, that would go through me to go and do a re-assessment of the side rails to see if they were needed or not. With the side rail assessment we need to know why they (residents) need them, and we also need a consent and a Doctors order. From what I recall, she (R #139) was total care and total assistance on staff for everything. She had a feeding tube in place, had a trach, and also had a catheter. She had a low air loss mattress in place and that could have been a possibility of it malfunctioning if it were to start to deflate." J. On 11/06/14 at 2:40 pm, during interview Certified Nursing Assistant (CNA) #2 stated, "I repositioned her (R #139) by myself at 7:00 pm. I pulled her up in her draw sheet by myself then turned her away from me to see if she was dirty. Then I rolled her onto her back. Then I moved her a little bit meaning I pulled her up with the draw sheet. The last time I checked on her (R #139) was around 7:45 pm and she was in bed. Then all I knew was another CNA (identified as CNA #4) told me the nurse wanted to see me because she (R #139) fell from her bed. When I went to her (R #139's) room, she was on the floor on her face. For me, I felt that her bed was too soft and it just wasn't fluffy enough when I originally went to check on her at 7:00 pm. It just felt deflated meaning the bed moves air through. It goes hard then soft." CNA #2 then stated, "She (R #139) did not have any side rails. I do recall seeing them at one point but about 2-3 months ago they were taken away. With her (R #139) she is very contracted she cannot not move." K. On 11/06/14 at 3:30 pm, during interview CNA #4 stated, "When I went in her (R #139's) room, she was face down on the floor. I didn't hear anything. She (R #139) was bleeding from a wound on her forehead." CNA #4 stated, when I have worked with her (R #139) before, I always got another CNA to help me turn her and clean her up and reposition her. We are supposed to be using two people to clean her and reposition her. When I helped the other CNA early before dinner around 5:00 pm, we used two people to turn her side to side with the draw sheet and to clean her. Because of the wound on her bottom I recall putting pillows behind her back and under her bottom and behind her back. I also recall there was another CNA from a different floor working that night." L. Review of the facility Proper Use of Side Rails Policy and Procedure revised October 2010 indicated, "An assessment will be made to determine the resident's symptoms or reason for using side rails, When used for mobility or transfer an assessment will include a review of the resident's bed mobility and ability to change positions, transfer to and from bed or chair, and to stand and toilet...Consent for using restrictive devices will be obtained from the resident or legal representative." M. Review of the facility Bed Safety Policy revised December 2007 indicated, "If side rails are used, there shall be an interdisciplinary assessment of the resident...and input from the resident and/or legal representative." II. Based on observation, record review, and interview, the facility failed to ensure 1 (R #123) of 1 (R #123) residents received adequate supervision and assistance to prevent an accident in which the resident was being transferred to a wheelchair by use of a Hoyer lift (an assistive device that allows patients to be transferred between a bed and a chair) with only one person instead of the required two. This deficient practice presents a risk that the resident will fall, which could result in an injury such as hitting their head on the floor or on room furnishings or sustaining a fracture. The findings are: A. On 11/10/14 at 4:26 pm, observation on the 700 Unit revealed, CNA #10 was transfering Resident #123 using a Hoyer lift by himself, and not with the required two persons. Resident #123 was observed in a sling and approximately three feet off the ground in the center of the room. CNA #10 was standing away from Resident #123 using the controls to move Resident #123 to her wheelchair. B. Review of the Medical Record for Resident #123 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. Care Plan dated 05/27/14, indicated "Resident requires assist with Activities of Daily Living (ADL's) r/t (related to): CVA (cerebrovascular accident) with [DIAGNOSES REDACTED] (paralysis of one side of the body). Interventions include: Dx (diagnosis): muscle weakness, contractures; Hoyer for transfers. 3. Minimum Data Set (MDS) Section G dated 08/19/14, indicated Resident #123 requires extensive assistance from staff with bed mobility, transfers, toilet use and has an impairment of the upper and lower extremity (arms and legs) on one side. C. On 11/10/14 at 4:30 pm, the 700 Unit Manager was asked how many people are required to transfer a resident using a hoyer lift, she stated, "It's supposed to be two. Yeah, is supposed to be two people." At this time, the 700 Unit Manager walked from the nurses station down to Resident #123's room, where CNA #10 was transfering Resident #123 by himself. The 700 Unit Manager asked CNA #10 if anyone helped him transfer the resident (Resident #123), CNA #10 stated "No, nobody helped me." The 700 Unit Manager asked CNA #10 if he knows that he is required to use two people when transfering, CNA #10 stated "Yes." CNA #10 confirmed that nobody helped him transfer Resident #123 to her wheelchair and that he was required to use two people for transfers using a Hoyer lift.

Based on observation, record review and interviews, the facility failed to ensure 1 (R #1) of 1 (R #1) residents received adequate supervision and assistance from staff to prevent an accident in which the resident was being transferred from the bed to a wheelchair. The facility also failed to ensure a nursing assessment was immediately conducted when the resident was on the floor and prior to being moved. The resident was then transferred from the floor back to the wheelchair without an assessment being completed. The resident complained to the staff about being in pain and no pain assessment was documented. No prescribed pain medication was administered when the initial fall occurred earlier in the day. The resident was sent to the hospital in extreme pain. This deficient practice likely caused the resident significant pain as well as a left comminuted intertrochanteric femur fracture (a fracture in which the bone has broken into several pieces) that required surgical intervention. The findings are: A. Observations for Resident #1 revealed the following: 1. On 04/30/14 at 9:55 am, Resident #1 was observed to be seated in a wheelchair on the 700 unit. He was also observed to be hunched over, his head tilted to the side, and he was noted to have a contracture (a permanent shortening of a muscle or joint) to his left hand. When attempting to interview the resident, he was only able to communicate by raising his head up or down. 2. On 04/30/14 at 4:30 pm, the resident was seen sitting in his wheelchair on the 700 unit, leaning over to the left side with his head tilted to the side. 3. On 05/01/14 at 7:45 am, the resident was sitting in his wheelchair in the 700 day room unable to verbally communicate and leaning to the side. B. Review of the medical record for Resident #1 revealed the following: 1. [DIAGNOSES REDACTED]. 2. Physicians Orders dated 11/21/12, indicated Acetaminophen 325 mg (milligrams) orally one or two tablets q (every) 4-6 hours prn (as needed) for mild pain. 3. Care Plan initiated 02/26/13, indicated "Resident is at risk for falls r/t (related to) impaired balance...and unsteady gait." 4. Physicians Orders dated 02/19/14, indicated Vicodin (a narcotic) 5-300 mg one tablet by mouth every six hours prn for...pain. 5. Quarterly Minimum Data Set ((MDS) dated [DATE], indicated Resident #1 has a short term and long term memory problem and his cognitive skills for daily decision making are moderately impaired. The MDS further indicated Resident #1 is 71 inches tall, weighs 190 pounds, and requires extensive assistance for Activities of Daily Living (ADLs) to include bed mobility, transferring, dressing, eating, toilet use and personal hygiene...and is not steady for balance. He is only able to stabilize with staff assistance for moving from a seated to standing position and for surface to surface transfers. It further indicated that the resident has a functional limitation in range of motion in both the upper and lower extremities. 6. Nursing Progress Notes dated 04/03/14, indicated "At 1330 (1:30 pm) this writer (referring to Licensed Practical Nurse-LPN #1) returned from lunch and was told by Certified Nursing Assistant (CNA) #1 assigned to this patient when putting (name of Resident #1) to bed, his leg gave out so I lowered him to the floor and the new CNA (referring to CNA # 2) helped me put him back to bed." The nursing progress notes indicated no documentation that a nursing assessment was completed by LPN #1 when she was being made aware by CNA #1 that the resident was on the floor. 7. Nursing Progress Notes dated 04/03/14, indicated "At 1530 (3:30 pm) CNA (referring to CNA # 3 who was coming on evening shift) said patient was c/o (complaining of) pain to left leg...Left leg was externally rotated and swollen...Pt. (patient) c/o pain...Pt. medicated for pain." 8. Nursing Progress Notes dated 04/03/14, indicated that Acetaminophen 2 tablets was given to the resident at 4:30 pm (this was three hours later from when CNA #1 indicated she told LPN #1 he was having pain). The Nursing Progress notes indicated that no pain medication including Vicodin or Tylenol (which was available for administration) was documented as ever being administered to the resident when LPN #1 was initially told by CNA #1 that the resident was complaining of pain at 11:00 am. 9. Final X-ray Report dated 04/03/14, indicated, "Views of the left hip show a comminuted intertrochanteric fracture." 10. Intervention/Task Document dated 04/03/14, indicated that Resident #1 was transferred by one CNA (CNA #1) on the day shift. It further indicated that no pain assessment was documented by LPN #1 as being completed on 04/03/14 for the day or evening shift. 11. Q Shift CNA chart reporting document dated 03/04/14, indicated that during the day shift, Resident #1 was transferred with only "One person physical assist." 12. Medication Administration Record (MAR) dated April 2014, indicated that Vicodin was not administered to the resident until 7:23 pm (almost eight and a half hours later). C. Hospital Record dated 04/03/14, indicated, "The patient presents following fall...character of symptoms is pain and swelling...the degree at present is severe...The patient was being transferred by his caregivers when they accidentally dropped him onto his left side. The patient noticed immediate pain and swelling to his left hip...The patient has been in significant pain since the accident." D. Admitting Hospital Radiology Report dated 04/03/14, indicated "Comminuted displaced left intertrochanteric fracture." E. On 04/30/14 at 10:45 am, during interview LPN #2 stated, "For transfers, we use maximum two person assist and I don't think he (referring to Resident #1) can bear any weight. We always used two people with him because he is a heavy transfer (meaning he is a tall and heavy man)." F. On 04/30/14 at 10:50 am, during interview, CNA #3 stated that she came on the evening shift at 3:00 pm on 04/03/14, and wasn't told anything in change of shift report from the off going CNA (referring to CNA #1). So, "When I went to get him (referring to Resident #1) up before dinner, as I was putting his shoes on and I was raising his left leg, and he was screaming in pain. This was around 4:00 pm. Prior to this, I wasn't told anything. If you knew how to work with him and knew how to transfer him, usually I could get him up by myself. But, if you were someone who hardly worked on this unit or were new, it would be a lot harder. Now we have to transfer him in the Hoyer lift ( A mechanical device used to transfer)." G. On 04/30/14 at 1:35 pm, during interview CNA #1 stated that she has worked with Resident #1 before and, "We have always used a two person transfer with him because he is heavy." The CNA then stated, "At about 11:00 am, I started getting him up. The other CNA (referring to CNA #4) was busy getting people up and I couldn't find the orientee (referring to CNA #2) and I needed to get him (the resident) up. I went and looked down the hall and I couldn't find anybody else. So, I sat him (the resident ) up at the edge of the bed and I got his weaker side which was his right leg. I grabbed his left side and I picked him up and tried to transfer him by myself and I guess his leg buckled and it gave out. He couldn't bear any weight. I sat him down on the floor on the right side. I walked out of the room and left him on the floor. I couldn't find anyone on the floor to help me. They were on break or attending other residents. I let the nurse (referring to LPN #1) know that his knee buckled and that I sat him on the floor. The nurse said 'ok thanks for telling me.' I had to go look for CNA #2 and CNA #4 to help me. So me, (name of CNA #2 and CNA #4) then got him up off of the floor. We used three people to get him up to his wheelchair. I never saw the nurse (referring to LPN #1) go in the room when he (Resident #1) was on the floor. I then took him to the dining room. At lunch, I went to start to feed him and he was saying 'owe, owe'. I asked him where at. He said 'my leg'. I told the nurse again (referring to LPN #1) that he (Resident #1) is now saying his leg hurts. She said she would give him some Tylenol. Then, I went and had CNA #2 help me lay the resident back down in bed. This was after lunch. This was about 1:45 pm. Both me and CNA #2 did a arm to arm transfer and I grabbed his legs and we laid him (Resident #1) on the bed and swinged (sic) him over and laid him down. He was saying his leg hurts. I then told him (Resident #1) that I was going to change him and I asked him if he could pick up his butt to help me. He was curled up more on his left side. At this time, he was saying 'Owe, it hurts' I asked him what hurts? He didn't say anything. So, I then log rolled him on the left side and he was saying 'Owe'. I then rolled him to the other side and pulled down his pants and he was saying 'Owe". This time, he wasn't able to help me lift his butt and usually he is. Then, I told the nurse that he is still saying his leg hurt and she said she would give him some more Tylenol. Again, I never saw the nurse (referring to LPN #1) go in his room. At about 2:30 pm, was when CNA #3 came in. I did not let her know that I had to sit the resident on the floor or him having pain (referring to Resident #1)." When she was asked why? she stated, "I was in a rush and we (both CNA #1 and #3) didn't click. I didn't let her know about him having pain at all. Then I left at 3:00 pm." H. On 04/30/14 at 2:25 pm, during interview RN #2 stated, "With (name of Resident #1) regarding his pain, it looks like he was only given Vicodin one tablet at 7:23 pm and then was given Tylenol at 8:30 pm on 04/30/14. That was the only medications that were given to him before he went out to the hospital that evening. I'm not seeing anything documented on the MAR being given before then. If a resident falls, the nurse is then supposed to go into the room with the CNA to do an assessment and the CNA will do vital signs. The resident should not be moved until we, as the nurses, have the opportunity to assess the resident. The day nurse (referring to LPN #1) did not chart on the pain assessment anything about the residents pain. That would have been also on the progress notes or incident report and I'm not seeing that documented either. There was no pain assessment documented. That would be an expectation of the nurses to do so. I'm not seeing anything documented for his pain." I. On 04/30/14 at 3:20 pm, during interview LPN #1 stated, "The CNA (referring to CNA #1) told me when I was coming back from lunch (don't remember the time) that she had to ease the resident (referring to Resident #1) down to the ground. He is a very tall man and sometimes the transfer is difficult. She had another CNA help her put him back to bed. I did my assessment later on. It was at the change of shift about 2-2:30 pm when I did my first assessment. The evening CNA (referring to CNA #3) went to get him up and he was saying he was having a lot of pain. I went in his room and he was having a lot of pain on his leg and it looked swollen. He couldn't say what happened. He shook his head when I asked him if he was in pain and I could tell he was hurting really bad. When the CNA (referring to CNA #1) told me his leg buckled earlier on in the day, I took it as that's when she was putting him back to bed. Prior to 2-2:30 pm, I didn't do an assessment on him because I thought he was ok and I saw he was eating in the dining room and I thought he was fine. All I know is, it was so busy that afternoon. Later on, is when I went to do my assessment. He is a difficult transfer. He used to be a one person but sometimes depending on the staff, they will have to get help because he is a tall and heavy man. When someone falls, a nurse is supposed to be there to assess the patient. The CNAs can't move the person until we do our assessment, then if they are ok, they can be put back to bed." J. On 04/30/14 at 3:45 pm, during interview CNA #2 stated, "I recall (name of CNA #1) asked me for help to lift the resident off the floor and at that time all three of us (CNA #1, #2, and #4) helped pick him up off the floor. He was sitting on his butt. We did a three person transfer and transferred him to his wheelchair. Then we took him to lunch. After lunch, (name of CNA #1) and I laid him down and I left." K. On 04/30/14 at 3:50 pm, during interview RN #2 stated, "On 04/03/14, (the date of the incident) there was no assessment done by the nurse for pain. The nurse did not chart any pain for 04/03/14. From looking at the nursing pain assessment, there was nothing documented during the day shift of 04/03/14 or on the evening shift of 04/03/14." L. On 05/01/14 at 8:15 am, during interview RN #2 stated, "On the CNA transfer sheet, the CNA (referring to CNA #1) charted that she did a one person transfer on the morning of 04/03/14. It indicated that she transferred him with only one person even though the record indicated for him to be a two person transfer." M. On 05/01/14 at 9:00 am, during a second interview, LPN #1 stated that she did look at Resident #1 when she got back from lunch, but that he was already in the dining room. She indicated, "I didn't think it was anything urgent until the oncoming CNA (referring to CNA #3) came on and said he was in pain. Earlier on in the day, I just assumed that someone else (referring to another nurse) was told that he was on the floor and that there was a problem. The first time I would have given him any Tylenol was about 4:30 pm. I do recall she (referring to CNA #1) told me he (Resident #1) was having pain at 2:30 pm, and the first time I gave him any pain medication was at 4:30 pm. It was at the change of shift and it was hectic. At 4:30 pm, he shook his head that he was in pain and had his head covered up. I just couldn't get down there to his room to give the medication to him any sooner. If I did go to lunch at 1:00 pm, that was the first thing I was told by (name of CNA #1) that she had lowered him to the ground and she couldn't transfer him. She did tell me that she had to get help to get him up. But when I saw him, he was already in the dining room. Prior to this, most of the CNAs that work the unit use a two person transfer to transfer him. On this day, (name of CNA #1) didn't work on that unit very much." N. On 05/01/14 at 9:12 am, during interview, the Physical Therapist stated, "From what I was getting from the staff was that he (Resident #1) was pretty dependent on staff for transfers especially on the left side because he was contracted. Sometimes, I would hear from staff that he could stand on the right leg and then sometimes not. I don't think he could have put much weight on the left side though." O. On 05/01/14 at 10:04 am, during interview CNA #4 stated, "Right before lunch on the day of the incident (referring to 04/03/14) (name of CNA #1) came and got me and (name of CNA #2) and asked if we could help her. When we walked in his (Resident #1's) room, he was already on the floor. He was not saying anything. At that point, she (CNA #1) and (name of CNA #2) transferred him from the floor to the wheelchair. I pushed the wheelchair underneath him to sit on. After that, I left the room. I did not see the nurse ever go in the room before we moved him. I never saw her come in the room at all. When the three of us moved him from the floor to the wheelchair, he was just quiet and didn't say anything. He was then taken to the dining room and I don't know if he was complaining of pain. I was with other residents. When the evening CNA (referring to CNA #3) came in, he was complaining of pain and yelling before dinner time. He wasn't able to say what or where. Our process is, that if someone is on the floor, we are supposed to call the nurse and they are supposed to examine the resident before getting the resident up. Then, if they are fine, we can transfer them back to bed and get a full set of vitals. Again that day, I did not see the nurse physically go in the room or asking for the three of us to wait before moving him off the floor. Usually when I worked with (name of Resident #1), I got two people to transfer him because he was heavy even for me to transfer him, and usually his legs buckled. I would always get another person to help me transfer him." P. Review of the Fall Prevention and Management Policy and Procedure dated 10/08/13 indicated: "If a resident falls, the following steps shall be taken; assess the resident post fall including vitals signs, level of consciousness, presence of pain, presence of other injuries, obtain assistance to lift uninjured resident."

Based on observation, record review and interview the facility failed to ensure that an Emergency Exit doorway on the 700 unit was locked, secured or armed with an alarm system. The small key pad device that was permanently affixed to the wall also revealed it was not attached to any alarm mechanism on the doorway. The sign on the doorway read: "Emergency Exit only. Alarm sounds when opened. Stairs are for emergency use only." The unlocked emergency exit door led to a dark descending stairwell. At the bottom of the stairwell was a second exit door (which was identified as a fire exit door) was obstructed from freely opening by a clutter of defective medical equipment (over thirty wheelchairs, bed frames, mattresses, walkers, geriatric chairs, cabinets, and other durable medical equipment). Egress (an act of opening or going out) through these two doorways was identified by the facility as an emergency fire exit escape route from the building. This deficient practice of not maintaining an unimpeded (unobstructed) fire escape route had the potential to prevent 62 residents, 29 of which were congnitively impaired on the 700 Unit (per the Roster/Sample Matrix (CMS 802) provided by the Director of Nurses on 03/13/13) from escaping a fire and/or access to an unsafe environment with a high potential of falling down a stairwell while using a wheelchair, a walker, or ambulating independently. The findings are: This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 03/13/13 at 3:20 pm. The facility Administrator and Director of Nursing (DON) were notified on 03/13/13 at 3:20 pm. At 3:38 pm, The facility Director of Nursing (DON) acknowledged that the unit 700 back hall door was not latching properly. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included a sentry/monitor being placed at the Unit 700 back hall door to prevent any residents from going through that door and inadvertently falling down the stairwell. The door was repaired and secured at 3:45 pm. Facility staff checked that all other secured doors functioned properly. Interventions included that over the next thirty days the Maintenance Department would do daily checks for proper functioning on all secured doors. These checks will be documented daily on a log sheet. The facility assured the Local Fire Department Inspector that they would remove the clutter of medical equipment that obstructed the unimpeded escape from the 700 unit in the event of a fire or other internal disaster that necessitated exit from the building. Based on the Plan of Removal, and the information provided, the IJ was lifted on 03/13/13 at 3:45 pm. This resulted in the scope and severity being reduced from Level 4/Scope K to Level 2/Scope E. A. Observations revealed the following: 1. On 03/13/13 at 12:00 pm, the 700 Hall stairwell Emergency exit door was observed to be unlocked. The door was able to freely opened with no alarm sounding. The exit door led to a stairwell that descended down 16 steps (two flights of stairs) to a second exit door. This exit door was unlocked from the inside. Attempts to open this door were impeded by medical equipment directly out side of the door. The door could only be open about 16 to 18 inches. Once opened, there were multiple wheelchairs, meri walkers, mattresses, metal bed frames, four legged walkers, cabinets, chairs and other medical equipment identified in a cluttered courtyard. There was no way to re-enter the facility due to the fact that this door locked from the inside. In the courtyard, there were two gates identified. Gate number one facing to the west, was wired shut with a rusted wire and leading to a street with heavy traffic. Gate number two facing east, was tied shut with a plastic bag. 2. On 03/13/13 at 1:00 pm, a second observation of the 700 unit Emergency Exit doorway revealed it to still be unlocked. The door indicated, "Emergency Exit only...Alarm Sounds when opened...Stairs are for emergency use only." At this time, there were residents seen in the hallway as well as staff. The small alarm keypad on the wall was lit red, but there was no alarm mechanism device attached to this keypad or the doorway. The door was again able to be opened and walked through. The door was not locked, nor did it alarm when opened. The steep two story stairwell was able to be easily accessed through this doorway. At the bottom of the stairwell the fire exit door leading to the outside was again difficult to open and would only open 16 to 18 inches. This door was again observed to be blocked by medical equipment such as wheelchairs, walkers and large bed mattresses. Once the door was opened, numerous pieces of medical equipment were observed to be strewed throughout the courtyard. The two gates remained tied with a metal wire and a plastic garbage bag. When the door was shut, it locked and did not allow one to reenter the facility. 3. On 03/13/13 at 3:15 pm, during observation of the 700 unit doorway and interview, the Director of Nursing (DON) opened the unlocked Emergency exit doorway on the 700 unit without it being alarmed. The DON stated, "This door is supposed to be locked at all times. This should be locked right now...I honestly don't know why it is not locked and I was unaware it was not locked...Depending on the resident, it could be dangerous if they went beyond this door. I guess it's possible that an accident could occur. It would depend on the what type of residents went through the door." B. Interviews identified: 1. On 03/13/13 at 12:45 pm, LPN #1 stated, "There are 62 residents on this unit (identified as the 700 unit)...29 residents are identified with mild to severe cognitive impairment...They are either confused, disoriented, or cognitively impaired in some ways...There is one resident (who was identified as resident #10) who is a wanderer...He gets confused and wanders...Several of the residents are bed bound...We have residents with cognitive impairment who use a wheelchair or are ambulatory or both... 2. On 03/13/13 at 3:00 pm, Registered Nurse (RN) #2 stated, that there was one resident (who was identified as R #10) on the 700 unit who "Wanders on and off the unit...He has a wander guard (a wrist band device signaling when a person attempts to go through a monitored doorway) on...He comes and goes on and off the unit but the wander guard will only sound at the front entrance of the facility..." 3. On 03/13/13 at 3:30 pm, the Maintenance Assistant stated, "The problem with the door lock, was that the adjacent door to the laundry room gets used a lot and from that door continuously opening and closing, it vibrates the fire exit door...This continuous vibration caused the wire contact to break, which disarmed the magnetic lock." 4. On 03/13/13 at 4:10 pm, the Administrator stated, "The Maintenance Department checks those doors on a monthly basis. I was unaware of the door not locking or any issues in that regard...There is no wander guard system on the back door. The wander guard system is only on the main doors. If a resident with a wander guard went through that back door (referring to the 700 unit Emergency Exit door), it would not alarm." 5. On 03/13/13 at 4:15 pm, a local Fire Department Inspector stated, "The exit doors need to be locked. There should be no reason for this doorway to be blocked with all that medical equipment. This needs to be an easy exit the from the building in case of a fire." 6. On 03/14/13 at 10:15 am, the Administrator and the facilities Corporate Administrator, the Administrator stated that he was not aware of any issues that were ever brought to his attention by his maintenance staff or nursing staff regarding the 700 Emergency Exit doorway being unlocked. The facility's Corporate Administrator stated, "We have a log of when the doors were last checked by the maintenance supervisor. That was on 03/05/13...All the doors/locks and alarms were tested facility wide and were working and functioning properly at that time." 7. On 03/14/13 at 12:30 pm, the Maintenance Assistant stated, "There are a total of ten Emergency Exit doors leading to stairwells in the whole building...We did not document which six doors were checked. We really don't know what six doors were checked. I couldn't tell you the exact doors that were tested ...When the checks were done we should have listed which doors were checked and who did the security checks. This log does not indicate that." 8. On 03/18/13 at 11:50 am, the Maintenance Supervisor stated, "The doors that were being checked were just the wander guard doorways...We were only checking the wander guard doors...We were not checking all the magnetic locking exit doors. As a result of what happened (referring to the unit 700 exit doorway being unlocked) we are now...But when you see on the logs (referring to the Electronic Door Maintenance Log), there were six doors that were tested . This would have more than likely only been the wander guard doors." 9. On 03/19/13 at 1:35 pm, the 700 Unit Manager stated, "(name of R #10) is ambulatory...He walks around...When he first came here, he wanted to go home...He exit seeks and has a wander guard on...Sometimes, he will say that he is going home...He is an elopement risk." 10. On 03/20/13 at 10:20 am, the Medical Director Physician stated, "There are several residents on the 700 unit that range from mild cognitive impairment to being more confused...The majority of those cognitively impaired, are more disoriented or mildly confused." B. Record review revealed the following: 1. Safety and Supervision of Residents Policy and Procedure revised December 2007 indicated, "Safety risks and environmental hazards are identified on an ongoing basis...When accident hazards are identified...Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to remove the hazards..." 2. Review of the Electronic Preventative Maintenance System Log revealed that on 03/04/13, there were six doors (with no indication of what six doors in the facility) were tested and "Operation of door monitors and patient wandering system all system functions at this time." 3. Maintenance Assistant provided a written document of how many access doors with a stairwell in the facility which was identified as ten. Of those ten access doorways, it did indicate Unit 700 has a Fire exit doorway with access to rear parking lot. The Maintenance Assistant indicated that the Evacuation Route on the Second Floor and Unit 700 "Would have identified this exit as a secondary emergency emergency exit route that would have to be used in case of a fire."

Based on observation, record review and interview the facility failed to ensure a safe environment for residents. This failed practice resulted in an Emergency Exit Door identified as a fire exit escape egress (the act of coming or going out) route from the 700 unit was obstructed with a clutter of defective medical equipment (over 30 wheelchairs, bed frames, four legged walkers, shower chairs, bed mattresses, and other equipment) was piled up in an outside courtyard that impeded free escape from the facility in the event of a fire. A second door (located on the 700 unit) was found to have a defective lock and failed alarm system which permitted cognitively impaired residents unobserved access to a dimly lit descending stairwell and exit from the building. Once outside the building there was no way to re-enter as this door was locked from the outside. There were also two gates identified by the Fire Marshal's Office as posing a danger to residents on the 600 and 700 Units. The first gate located on the west end of the courtyard, led directly to a street with heavy traffic. It was being held together by a piece of rusted wire. The second gate located on the east side of the courtyard, was being held together with a white plastic garbage bag. This deficient practice of not maintaining an unimpeded (unobstructed) fire escape route had the potential to prevent 62 residents, 29 of which were congnitively impaired on the 700 Unit (per the Roster/Sample Matrix (CMS 802) provided by the Director of Nurses on 03/13/13) from escaping a fire and/or access to an unsafe environment with a high potential of falling down a stairwell while using a wheelchair, a walker, or ambulating independently. The findings are: This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 03/13/13 at 3:20 pm. The facility Administrator and Director of Nursing (DON) were notified on 03/13/13 at 3:20 pm. At 3:38 pm, The facility Director of Nursing (DON) acknowledged that the unit 700 back hall door was not latching properly. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included a sentry/monitor was placed at the Unit 700 back hall door to secure the area from any residents going through that door. The door was repaired and secured at 3:45 pm. A loose wire was discovered that demagnetized the door. Facility staff checked all secured doors for proper functioning. Other interventions were that the Maintenance Department staff would check all secured doors on a daily basis for proper functioning over the next 30 days. This would be documented daily for the next 30 days on a log sheet. The Fire Marshall's office was called by the Survey team, and the Administrator indicated to the Fire Marshall it would be corrected by 03/15/13. Based on the Plan of Removal and the information provided, the IJ was lifted on 03/13/13 at 3:45 pm. This resulted in the scope and severity being reduced from a scope and severity of Level 4/Scope K to Level 2/Scope E. A. Observations revealed the following: 1. On 03/13/13 at 12:00 pm, during an initial tour of the facility, the door leading to the 700 Hall stairwell was observed to be unlocked. The door did not alarm when it was opened. Immediately beyond this doorway was a poorly lit stairwell that descended 16 steps to an exit door. Attempts to open the exit door were obstructed by a clutter of medical equipment directly outside of the door. The door would open only partially 16 to 18 inches. There were more than thirty wheelchairs, multiple walkers, mattresses, bed frames, cabinets, shower chairs and other medical equipment piled in a small courtyard which blocked egress through the doorway. At either side of the courtyard, were two gates. Access to either gate was impeded by the clutter of medical equipment scattered throughout the courtyard. Gate number one located on the west end side of the building was wired shut. Gate number two located on the east side of the building was tied with a plastic garbage bag. This route exiting the building was identified as an emergency fire exit. 2. On 03/13/13 at 1:00 pm a second observation revealed that the Emergency Fire exit doorway leading to the outside courtyard was remained blocked. The two gates remained unsafely secured; one with a wire, the other tied with a trash bag. Once outside of the Emergency Fire exit doorway, there was no way to re-enter the building because the door locked preventing opening it. 3. On 03/13/13 at 4:20 pm, the Fire Department Inspector attempted to open the fire exit door leading from Unit 700 to an outside courtyard. The exit door was obstructed from opening fully by a wheelchair. He pushed forcibly on the door until the wheelchair that was blocking the door gave way which permitted the door to fully open. When the door was opened, it dislodged a four legged walker which fell into the doorway of the fire exit. B. Interviews indicated: 1. On 03/13/13 at 12:45 pm, LPN #1 stated, "There are 62 residents on this unit (identified as the 700 unit)...29 of those residents have mild to severe cognitive impairment...They are either confused, disoriented, or cognitively impaired in some ways...There is also one resident (who was identified as resident #10) who is a wanderer...He gets confused and wanders...Several of the residents are bed bound...We have residents with cognitive impairment who use a wheelchair or are ambulatory or both..." 2. On 03/13/13 at 3:15 pm, the Director of Nursing (DON) stated, "I honestly don't know why that door (door on Unit 7 that leads to a descending stairwell) is unlocked. It is supposed to be locked at all times. Depending on the resident, it could be dangerous if they went beyond this door.'' 3. On 03/13/13 at 3:30 pm, the Maintenance Department Assistant stated, "That door (referring to the door on Unit 7 that leads to a descending stairwell) is to remain locked by a magnetic locking mechanism. The problem was that the adjacent door to the dirty laundry gets used a lot. The laundry door continuously opening and closing vibrated the fire exit door. This continuous vibration caused the wire contact to break, which disarmed the magnetic lock." 4. On 03/13/13 4:10 pm, the Administrator stated, "There is no wander guard sensor system on this door (referring to the door on Unit 700 leading to a descending stairwell). It is only on the main entrance doors. If a resident with a wander guard went through that door, it would not alarm." 5. On 03/13/13 at 4:45 pm, the Fire Department Inspector stated, "That courtyard is to remain free of any obstructions at all times. Those gates should not be wired or tied shut. There should never be any medical equipment stored in that courtyard at any time. Ever!" 6. On 03/19/13 at 1:35 pm, the 700 Unit Manager stated, "(Name of Resident #10) is ambulatory. He exit seeks, but has a wander guard on. Sometimes he will say that he is going home. He is an elopement risk. He is oriented to person and knows he is in a nursing home but at times wants to go home." (This resident was identified as being at risk of going out the the stairwell door because it was unlocked and had no wander-guard sensor on it). 7. On 03/20/13 at 10:20 am, during interview, the facilities Medical Director Physician stated, "There are several residents on the 700 unit that range from mild cognitive impairment to being more confused. The majority of those cognitively impaired are disoriented or mildly confused." C. Record review revealed: 1. Evacuation Route Second Floor and Unit 700 document, indicated a map of the building that identified the outside exit door from Unit 700 as a designated escape route from the building in the event of a fire. 2. Fire Inspection Report Form dated 03/13/13, indicated: "... Called in regards to area outside of Fire Exit Stairway from 600 and 700 wing that was blocked...Found wheelchairs, walkers, beds, desks, and other assorted material that had been stored there recently and blocked the exit door...Also found gate was secured by wire tie...Gate shall either be removed or replaced with a gate with panic hardware to keep continuity of exit access to public way...There shall be no storage of materials in the area of that fire exit at any time, so as fire exit is free from any and all possible obstructions..."

Based on interview and record review the facility failed to provide the care and services necessary to protect one (#1) of 7 (#s 1, 2, 3, 4, 5, 6 and 7) sampled residents from significant harm by not recognizing the significance of the changes of condition and communicating to the physician those signs and symptoms. Resident #1 presented with symptoms including episodes of high temperatures, high blood sugars, hematuria (blood in the urine), large amounts of yellow green mucous from his [MEDICAL CONDITIONS] (low blood pressure) and high heart rates along with a pressure wound on his coccyx (identified to have full thickness tissue loss); all signs of an infectious process. The most recent significant change of condition for Resident #1 was swelling of his scrotum described to be the size of a grapefruit. The first indication/notification of Resident #1 having a significant change of condition (change in size of scrotum) was around 7:30 pm on [DATE]. The resident remained in the facility until he was sent to the emergency roiagnom on [DATE] around 9:00 pm (25 ? hours later). This failure to link the significance of the changes of condition and the urgency to transfer Resident #1 to the emergency room likely caused the resident's immediate need for intensive care and extensive surgical debridement of the scrotum and perineum (area between the anus and the scrotum). The resident was then put on hospice and died a short time later. This failure led to an Immediate Jeopardy (IJ) being identified on [DATE] at 9:15 am. The facility was notified of the IJ at 9:30 am. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 11:05 am and the IJ was lifted. The scope and severity was lowered to a G. The following is the Plan of Removal: 1. A new policy and procedure was written for non-emergent changes in resident condition that inform nurses of the lines of communication to be followed. For 911 emergencies nurses should follow the policy set for dealing with those types of problems. 2. A new assessment form was created for use by nurses when informing the doctor/designee of the need to transport residents to the hospital. The findings are: A. Review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] in the closed medical record revealed the resident was admitted to the nursing facility with [DIAGNOSES REDACTED]. Resident #1 received nutrition through the use of a feeding tube and presented with a stage III sacra-coccygeal (tailbone area) pressure ulcer. Resident #1 was admitted to the facility with a code status of a full code and had presented to the facility a power of attorney (POA) naming his sister as POA. B. Review of the Care Plan for Impaired Skin Integrity dated [DATE], revealed that Resident #1 had a history of [REDACTED]. Any and all signs of redness, injury, rashes or soiled dressing were to be reported immediately to the nurse by the CNA (Certified Nurse Aide). C. Review of the Care Plan for the Code Status of a Full Code dated [DATE] indicated that the facility was to respect the wishes of Resident #1 and notify the family and physician of any significant change of condition and to initiate CPR if needed and/or 911 procedures to transfer the resident to the emergency room . D. Review of Resident #1's assessments and nursing/respiratory notes beginning on [DATE] and ending on [DATE], indicated that, while in the nursing facility, the resident presented with definite indicators/symptoms (significant changes in condition) that infectious disease processes had taken hold of the urinary tract, respiratory tract and pressure ulcer areas along with an infection and significant change in size of the resident's scrotum. 1. A Pressure Ulcer assessment dated [DATE], indicated that Resident #1's pressure ulcer of the coccyx was staged as a III (full tissue thickness loss, the depth of tissue loss can be measured) and measured 9 cm (length) by 6 cm (width) by .2 cm (depth) and the current treatment order was for zinc incontinence barrier. 2. A Pressure Ulcer assessment dated [DATE], indicated that Resident #1's stage III pressure ulcer of the coccyx had increased in size now measuring 9 cm (length) by 10 cm (width) by .2 cm (depth) related to exposure to watery diarrhea that the resident was experiencing. 3. A Pressure Ulcer assessment dated [DATE], indicated that Resident #1's pressure ulcer of the coccyx had now become un-stageable (full thickness tissue loss in which the base of the ulcer is covered in slough (Dead Tissue That Has Been Shed) and/or Eschar (scab) not allowing the observer to see what damage has occurred and to what degree of tissue and skin layers have been damaged) and had changed in size now measuring 9 cm (length) by 10 cm (width) and was unable to assess (UTA) the depth because of the eschar . A new order for [MEDICATION NAME] (a [MEDICATION NAME] agent) was prescribed along with a recommendation for sharp debridement (removal of the slough and/or eschar in order to see had deep the pressure ulcer was and to see how many layers of skin and tissue were destroyed). 4. A Pressure Ulcer assessment dated [DATE], indicated that Resident #1 had developed a pressure ulcer of the left heel measuring 4 cm (length) by 4 cm (width) by UTA depth and assessed to be un-stageable. 5. A respiratory therapy note dated [DATE] at 4:05 pm, indicated that Resident #1's heart rate was abnormal as manifested by a heart rate of 144 beats per minute (normal heart rate is ,[DATE] beats per minute). 6. A respiratory therapy note dated [DATE] at 8:10 pm, indicated that Resident #1's tracheotomy had been suctioned for a moderate amount of thick yellowish secretions (a sign of a possible respiratory infection). The nurse also alerted of high heart rate of 118 beats per minute. 7. A Nursing Note dated [DATE] at 1:23 am, indicated that Resident #1 had definite signs and symptoms of a possible urinary tract infection as indicated by a temperature of 101.7 F (normal temperature rate 98.6), hematuria (blood) in his urine and a low blood pressure (B/P) of ,[DATE] (normal B/P ,[DATE]). 8. A Nurses Note dated [DATE] at 2:08 am, indicated a LOW PULSE WARNING (an automatic system indicator that alerts staff when an abnormal vital sign is entered in the system) of 38 beats per minute (normal is ,[DATE]) for the resident. 9. A Respiratory Therapy Note dated [DATE] at 6:15 pm, indicated that Resident #1's [MEDICAL CONDITION] was suctioned twice with "return of moderate amount of reddish tinge/brown/yellow thick secretions (normal secretions are clear)". Also noted was a high heart rate of ,[DATE] beats per minute during respiratory treatment (normal is ,[DATE]) and a high respiratory rate of 24 (normal is ,[DATE]). 10. A Nurses Note dated [DATE] at 10:10 pm, indicated that Resident #1's capillary blood glucose (CBG) (level of sugar in the blood used to determine DM) was "high" (no numerical value. Normal CBG value is ,[DATE] mg/dl (mg of sugar per dl of blood), and "scrotum [MEDICAL CONDITION]" (no specific indication of size and amount of swelling to the scrotum). It was also noted that the POA (Power of Attorney) had been in to visit the resident earlier and discovered the swollen scrotum and requested that the resident be sent to the hospital. Orders from the Physician Assistant (PA) were to recheck the CBG in two hours and to notify the PA if still "high". 11. A Nurses Note dated [DATE] at 3:33 am, (over 3 hours later than ordered by the PA) indicated that Resident #1's CBG "decreased to 392". No additional documentation could be found regarding care or treatment related to the "high" CBG's and the "[MEDICAL CONDITION]" scrotum. 12. A Nurses Notes dated [DATE] at 2:23 pm, indicated that Resident #1's POA called the unit numerous times during the night shift concerned with the swollen scrotum, requesting that the resident be sent to the emergency room . 13. A Nurses Note dated [DATE] at 8:43 pm, indicated a HIGH TEMPERATURE WARNING of 102.3 degrees F for Resident #1. 14. A Nurses Note dated [DATE] at 9:10 pm, indicated that Resident #1's POA had been in to visit and expressed concern regarding the size of his scrotum, requesting that the resident be transferred to the hospital immediately. Another nurses note dated [DATE] indicated that a decision had been made to transfer the resident to the hospital, contacted the ambulance and the resident was transferred to the hospital around 9:30 pm. The nurse then notified the PA on call and contacted the resident's POA confirming that the resident had been sent to the hospital. E. Interviews regarding Resident #1 revealed the following: 1. During an interview on [DATE] at 9:30 am, the PA indicated that she had not been made aware of the significance of the size of the scrotum. She had never been told that Resident #1's scrotum was equivalent to the size of a grapefruit. She was never made aware that the resident had ever had a temperature as high as 102 degrees F. The PA indicated that if she would have been given this information, her orders would have been to send the resident out. The PA indicated that the responsibility of the shift nurse is to evaluate and assess the resident when a change of condition occurs. If the nurse determines a need to send the resident to the hospital, he/she can do so immediately and then notify the physician that the resident has been sent to the hospital. When the PA received the call on [DATE] from the nurse that the paramedics had been called and that the resident was sent to the emergency room , she confirmed the decision. The PA also stated that if a family member believes that there is an emergent situation happening with their loved one, then by all means the resident should immediately be sent out. 2. During an interview on [DATE] at 11:45 am with RN (Registered Nurse) #5, who was the wound nurse, she indicated that she was familiar with and had assessed the pressure ulcer on the coccyx of Resident #1. RN #5 stated that she had conducted her weekly pressure ulcer assessment on [DATE] at 2:11 pm, and had assessed the resident's pressure ulcer to be 11.0 cm (length) by 10.2 cm (width) and the depth to be UTA. RN #5 staged the pressure ulcer as un-stageable. RN #5 also stated that she had assessed the resident to have a pressure ulcer on his left heel measuring 4.0 cm (length) by 4.0 cm (width), the depth to be UTA and un-stageable. RN #5 stated that while conducting the weekly assessment, she assessed the scrotum of the resident to be [MEDICAL CONDITION] (swollen, engorged) and indurated (hard). RN #5 indicated that when she reported the scrotum findings to nursing, she was told that the PA had already been notified. RN #5 also stated that anyone with diabetes who develops a swollen scrotum should be evaluated as quickly as possible to rule out Fournier's Gangrene (Infective Gangrene of the Scrotum). 3. During an interview on [DATE] at 3:30 pm with RN #4, who worked the 7 am to 3 pm shift on [DATE], she stated that on [DATE], she was made aware of the size of Resident #1's scrotum at the beginning of her shift. She stated that Resident #1 was total care and that the pressure ulcer on his backside looked terrible. 4. During an interview on [DATE] at 3:30 pm with RN #6, who worked the 3 pm to 11 pm shift on [DATE], she indicated that on [DATE] around 3 pm, she was made aware in report of the significant size of Resident #1's scrotum. The resident's POA had come in around 6:00 pm to visit and had continually expressed concern over the scrotum size, asking repeatedly to have Resident #1 sent to the hospital. RN #6 stated "We (RN #6 and the POA) talked about having him sent out. I then called the ambulance around 6:30 pm. The ambulance had an emergency and did not arrive until about 9 pm. I left a message with the PA to let her know that the resident had been sent out to (Name of Hospital)." 5. During an interview on [DATE] at 4:00 pm, LPN (Licensed Practical Nurse) #2, who worked the 3 pm to 11 pm shift on [DATE], indicated that she assessed Resident #1 to have swelling to his scrotum on [DATE] around 7:30 pm, after being notified by CNA #1 and the POA. The POA for the resident expressed her concern and asked LPN #2 to send the resident to the emergency room . LPN #2 notified the PA to report that the resident's "scrotum was swollen." The PA indicated that she would see the patient on Monday. 6. During an interview on [DATE] at 10:10 am, CNA #1, who worked the 3 pm to 11 pm shift on [DATE], indicated that on [DATE] around 3:30 pm she had given a bed bath to Resident #1 and saw no signs of his scrotum being swollen. CNA #1 went to lunch around 7 pm and returned at approximately 7:30 pm to find that the resident's POA was visiting. The POA asked CNA #1 if she could help her change and turn the resident. At this time, both the POA and CNA #1 noticed that the resident's scrotum was swollen to the size of a grapefruit. CNA #1 went to report the resident's change of condition to the nurse. The POA stated that she wanted the resident sent to the emergency room to evaluate why his scrotum was so large. 7. During an interview on [DATE] at 11:45 am, RN #3 who worked the 11 pm to 7 am shift on [DATE], indicated that on [DATE], she was told in report about Resident #1's swollen scrotum. RN #3 assessed the scrotum of the resident to be the size of a grapefruit. RN #3 also stated that the POA for the resident had called around midnight and several other times during the night expressing concern about the resident's scrotum and asking that he be sent out. RN #3 called the PA to get orders for the resident regarding his high CBG reading of 439 and the fever of over 102. No mention was made to the PA regarding the significant change to the size of the resident's scrotum or the pleading requests from the POA to send the resident to the emergency room . F. A review of Resident #1's medical records from the hospital indicated the following: 1. An emergency room physician consultation dated [DATE] revealed that upon admission, Resident #1 was admitted to the intensive care unit (ICU) diagnosed with [REDACTED]. 2. A urologist consultation dated [DATE] at 3:45 pm, revealed Resident #1 underwent an evacuation (To Remove a Substance From a Cavity, Space, Organ or Tract of the Body) of the Fournier's Gangrene by general surgery. "Extensive debridement needed including, but not limited to, scrotum, testicles and perineum (area between the anus and the scrotum). Death from procedure very likely . Patient has no quality of life. Recommend Ethic Committee evaluation." G. Review of a Hospice physician's hospital report dated [DATE] revealed that while in a nursing home Resident #1 developed an infection in his scrotum, underwent excision and debridement, however, the wound and the infection had spread to surrounding tissues. After weighing the options, the family felt that the resident would best be treated through hospice and kept comfortable. The report revealed the resident's date and cause of death to be [DATE] [MEDICAL CONDITION]/Fournier's Gangrene.