Every finding on record at Rockport Nursing and Rehabilitation Center

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure plastic cups were clean. 2. The facility failed to ensure all items in the freezer were tightly sealed. 3. The facility failed to ensure a worn spatula was discarded. 4. The facility failed to ensure there were no personal items in the refrigerator. 5. The facility failed to ensure the ice machine was clean and not leaking. These failures could place residents who received meals and/or snacks from the kitchen at risk for food contamination and food-borne illness. Findings were: Observation and initial tour of the kitchen on 04/22/26 beginning at 10:20 am revealed 41 of 58 plastic coffee cups on the clean rack were stained, had sediment in them, and scratches on the bottoms and sides. One of them had lipstick on the rim. A 1-gallon bag of frozen fish was not sealed in the freezer. There was a chipped and worn spatula hanging on the clean rack next to new spatulas. There were personal items in a bin in the refrigerator, with the facility's food for residents; 2 packages of meat items were unlabeled and unsealed, and a variety of unlabeled vegetables in a plastic bag, a 32-oz. jar of spaghetti sauce, and a 32 oz. jar of mayonnaise were in the bin. One can of soda and a package of store-bought pie crusts were on the shelf near the bin. There were three, 1 oz. containers with what appeared to be olives and jalapenos that were not sealed tightly, dated, or labeled in the bin. The ice machine was dripping rapidly onto the floor from the outside and inside of the machine. Water dripping from the ice chute (which had a black substance where the drips were falling from onto the ice), around the door, and onto the floor. In an interview with the DM on 04/22/25 beginning at 10:25 am, she said the dishwasher was responsible for making sure the dishes were clean before putting them on the clean rack. She said the cook, and the dietary aides were responsible for properly storing food in the refrigerators, freezers, and storeroom. She said the personal items in the refrigerator were in a bin that belonged to the cook. She said the items should not have been in the refrigerator because the transfer of germs from handling them could cause cross-contamination of the food and make residents sick. She said the cook was the only kitchen employee who had personal food items in the refrigerator. She said staff had in-services on labeling and dating everything in the refrigerator, freezer, and storeroom, as well as personal items. She said the kitchen staff did not have a refrigerator where they could store their items. She said she had verbally informed the MS about the ice machine leaking, but did not put the request in the electronic maintenance request system. (The MS was looking at the ice machine during this surveyor's interview with the DM). She said she thought the ice machine was not level, causing the heavy condensation. She said maintenance was supposed to return and inspect the ice machine again. She said she was not sure how long the ice machine had been leaking. She said the ice machine was dumped and cleaned monthly and wiped down inside and out daily. In an interview with the DW on 04/22/26 at 10:30 am, she said she was responsible for checking the dishes for cleanliness before they were placed on the clean racks. She said she did not know why the cups were dirty now and did not know from whom the lipstick came from that was on one of the cups. She said whatever the stuff was in the cups could make the residents sick, and it was called cross-contamination. She said she had been in-serviced and was making sure the dishes were clean for the residents. In an interview with the MS on 04/22/26 at 10:45 am, he said he was not informed about the leaking ice machine. He said he checked it that morning, and it was level. He said he needed to take the machine apart and look closer as to what was causing the heavy condensation. He said he did not know how long the ice machine had been leaking. In an interview with the CK on 04/22/26 at 11:50 am, she said she knew better than to keep her personal food and drink in the resident's refrigerator because she knew about cross-contamination and how it could make residents sick. She said she knew food had to be used or disposed of after 3 days, and that was why all food should be labeled and dated. She said her things were not labeled and dated. She said one of the residents had asked for a pie, so she bought some pie crust from the local store and made a pie. She could not recall how long ago it was or who the resident was. She said she had asked a past administrator for a refrigerator for the kitchen staff (2-3 years ago), but she had not brought it up again. In an interview with the DM on 04/24/25 at 10:25 am, kitchen in-services/training, food storage, and personal items policies were requested, but only food storage was received.Record review of the kitchen daily cleaning lists dated January 1, 2026, to April 23, 2026, revealed all dates were checked, indicating they were done. The cleaning lists included ice machine.Record review of the facility's kitchen policy, revised 06/01/2021, titled Food Storage, stated, To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines. Under 2. Refrigerators: 1d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: (E) .foods are protected from contamination . 2-4 Hygienic Practices 2-401 Food Contamination Prevention 2-401.11 Eating or Drinking: an employee shall eat or drink . only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. (B) A food employee may drink from a closed beverage container if the container is handled to prevent contamination of: (1) the employee's hands; (2) the container; and (3) Exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Ch. 3-305 Preventing contamination from the premises 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment, food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred.

Based on interviews and record review the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 7 residents (Resident #53) reviewed for resident rights in that: Resident #53 was prescribed and administered aripiprazole (an antipsychotic) without prior consent based on information of the benefits, risks, and options available. This failure could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts. The findings included: Record review of Resident #53's admission record dated 04/24/2026, revealed an [AGE] year-old female with an initial admission date of 12/20/2022 and a readmission date of 04/14/2026. Resident #53's diagnoses included dementia (an umbrella term for a range of progressive neurological conditions that cause a decline in memory, thinking, reasoning, and behavior, severely enough to interfere with daily life), moderate, with mood disturbance, Alzheimer's Disease (a progressive, irreversible neurodegenerative disease and the most common form of dementia that affects your thinking, behavior and ability to do everyday tasks), generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about every day, routine situations lasting at least six months), and major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest, and low energy lasting at least two weeks). Record review of Resident #53's Annual MDS assessment, dated 02/26/2026, revealed a BIMS score of 02, indicating severe cognitive impairment. Record review of Resident #53's care plan, dated 02/17/2026, revealed, FOCUS: [Resident #53] uses antipsychotic medication. Target behavior: aggressive behavior Date Initiated: 04/14/2025 Revision on: 06/03/2025. INTERVENTIONS/TASKS: Discuss side effects/Black Box warning of medications with resident/RP Date Initiated: 11/09/2025 Revision on: 11/09/2025 LN RN. Record review of Resident #53's Physician's orders dated 04/14/2025 revealed, ARIPiprazole Oral Tablet 2 MG. Give 1 tablet by mouth one time a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. Record review of Resident #53's medical record did not reveal the consent for the antipsychotic (aripiprazole) order dated 04/14/2025 being signed until 04/21/2025. Record review of Resident #53's April 2025 MAR revealed Resident #53 was administered aripiprazole 2 mg tablet by mouth daily from 04/15/2025 through 04/21/2026. During an interview on 04/24/2026 at 03:06 PM, LVN A stated she would definitely get a signed consent before administering an antipsychotic. She said antipsychotics required a special form that needed an RP's signature. LVN A stated they were regularly in-serviced on antipsychotics. She said they reviewed the steps and processes on antipsychotics and consents. LVN A stated they should never administer an antipsychotic without consent. She said the RP may not want the resident to have the antipsychotic because they may know of past side effects, or they did not want the resident to be given it. During an interview on 04/24/2026 at 03:29 PM, LVN B stated for antipsychotics, there was a special consent form. She said the RP and the doctor had to sign the consent. LVN B stated that the antipsychotic was not given before the consent was signed by the RP and doctor. LVN B stated the negative outcome of giving an antipsychotic without an appropriate indication could be abnormal behaviors, mood, labs, etc. LVN B stated the facility would have in-services on antipsychotics all the time. She said the last time they had that in-service in person (not on the computer) on antipsychotics was about a month ago. She said the in-services on antipsychotics also included getting signatures on the consent form. LVN B stated before she would administer an antipsychotic the first time, she would check that the consent was signed by the doctor and RP. During an interview on 04/24/2026 at 03:48 PM, RN RCS stated that a consent needed to be signed by the family and doctor/provider, and nurse. RN RCS stated the antipsychotic should not be given before the consent was signed unless the resident with Alzheimer's/dementia was admitted with the antipsychotic, and the RP would sign the consent as soon as possible. A record review of the facility's policy Use of Psychotropic Medication(s), dated 03/05/25, revealed, Policy Explanation and Compliance Guidelines: 9.Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 11.The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchens observed. The facility failed to provide each resident with properly prepared food that had the most nutritional value and follow their therapeutic diets.2. The facility failed to provide tasty food served to Residents #1, #12, and #79, and other anonymous complaints made during the resident council meeting who complained the food served did not taste good.This deficient practice could place residents at risk for poor food intake, weight loss, not having their nutritional needs met, and diminished quality of life.Findings were:In an interview with Resident #1 on 04/22/26 at 3:55 pm, she said, I can't eat most of the food because it is too salty. They said I have high blood pressure, but I don't. She said she was on a low salt diet.In an interview with Resident #12 on 04/22/26 at 4:15 pm, she said, The food is too salty. Last night's pinto beans, for example, there is no way I would eat that. She said she was not on any special diet. She said the food had been too salty since she had been at the facility since February 2026.In an interview with Resident #79 on 04/23/26 at 12:30 pm, during lunch, she said, The food is too salty, and I'm not supposed to have salt. She said the food had been salty since her admission to the facility in January, 2026. She said she did not eat everything on her plate because of the salt. She said she had mentioned it to the workers in the dining room, but could not remember any names.During a confidential interview of 6 anonymous residents on 04/23/2026 at 3:00 PM revealed grievance and complaints about the food being too salty. Record review of minutes from last week's resident council meeting held on 04/15/26 revealed a grievance and complaints of salty food.Record review of minutes from the resident council meeting held on 6/8/25 noted salty food and the RD saying it was the third-party contractor.Observation and interviews with the DM, survey team, and the ADM, revealed a test tray was ordered on 04/22/24 at 4:40 pm. A regular, pureed, and no added salt tray was delivered and sampled. The tray consisted of chicken [NAME], cauliflower, macaroni and cheese. The temperatures were pleasant, but all the food was salty to the point of not taking another bite. The DM said she did not think the food was overly salted. The ADM said the food was very salty. The survey team said the food was inedible.In an interview with the RD on 04/23/26 at 12:18 pm, she said she visited the facility once a month and she and/or her co-worker came in once a week. She said she had never tasted the food at this facility. She said she walked through the kitchen for full inspection at the beginning of the month. She said she tasted the food later in the month, and the last time she did was February 3, 2026. Then she said she did not taste the food at that time, but her co-worker did and there was some kind of issue, but she did not know what it was. She said she and her co-workers communicated constantly with each other via email and audits. She said she could not find the email or audit from her co-worker, and she only knew the audit in February scored 91% and it should have been 100%. She said she interviewed the residents for preferences, but her interviews were limited to new admissions, tube feeds, pressure injuries, and weight loss or gain. A second test tray with regular, pureed, and no added salt was obtained and tasted by the RD and the survey team. The food was beef tips with gravy over white rice. All agreed, all components of the food were too salty. She said there were 10 residents with no added salt diets. She said with food that salty, residents with heart problems, high blood pressure, or dehydration could become worse because of water retention, that could lead to high blood pressure, increased strain on the heart and blood vessels, and potential kidney damage. Observation and interviews with the DM, CK, RD, survey team, and the ADM, on 04/23/24 at 12:25 pm, the second test tray was sampled. The ADM said the food was salty and the DM had brought her a small sample to her office that was not salty at all. The CK and DM tasted the food, and the DM said the food was salty. The CK said the food was not too salty for her. The DM and CK said they used a powdered beef base to season most meals. The container of the beef base was obtained and showed on the nutritional facts there was 890 mg Sodium per teaspoon. The CK said she just eyeballed it, did not use a teaspoon, but dumped some out. They both said,When you've been doing this as long as we have, you know how much to use. Observation of the consistency of the powdered beef base was like wet sand and came out of the container in clumps.In an interview with the RD on 04/23/26 at 3:29 pm, she said she spoke with the residents, and would monitor modifications. She said she and the DM would check food preferences and modifications. She said she would make sure the DM would follow the menu and recipes. She said there were no weight gains or losses and all high blood pressure, heart, and residents with edema had no variations in vital signs.In an interview with the ADM on 04/23/26 at 4:00 pm, she said she would get a grievance when resident council had a concern, but did not always get the minutes to the meetings. She stated she was not sure why she did not get the minutes.In an interview with the DM on 04/24/2026 at 8:10 am, she said there had been no product change in the beef base powder. Policies for food storage, menus, and preferences were requested at that time. She said she had never had any complaints about food.A test tray was ordered on 04/24/24 at 12:10 pm. A regular, pureed, and no-added salt tray was delivered and sampled. The tray consisted of mashed potatoes (baked French fries for the regular plate), breaded baked fish, and spinach. The temperatures were pleasant and the food was edible, without overbearing salt.In an interview with Resident #35 on 04/24/26 at 1:45 pm regarding salty food from a grievance she filed on 02/11/26, she said the food had been salty for a while but that day was normal, and she ate all of it.Record review of therapeutic diets and preference cards revealed 14 residents had no added salt diets ordered.Record review of an undated facility diet and liquid conversion guide revealed diets ordered as no added salt (NAS), no salt on table, low sodium, cardiac, heart healthy diet, or low-fat diet would convert to a NAS (no added salt) diet.Record review of an undated facility document titled, Sodium-Controlled Diets revealed: Sodium-controlled diets may be used to manage hypertension in sodium-sensitive individuals, cardiovascular disease, impaired liver, and kidney function and to help promote the loss of excess fluids in patients/residents with edema or ascites. A physician's order is required to serve a salt-substitute to a patient/resident on a sodium-restricted diet.No Added Salt-The No Added Salt Diet is based on the House Diet with the elimination of salt at the table. The goal total sodium content is 3000 to 4000 mg daily. This level of restriction is appropriate in senior dining and long-term care to maintain palatability and encourage consumption to maintain weight or prevent weight loss.2 Gram Sodium-The 2 Gram Sodium Diet is planned with a goal of 2300 mg or less sodium per day. Generally, regular versions of recipes and food items are incorporated into sodium-controlled diets when possible. At times, the menu item does use a salt-free recipe to stay within the stated range of sodium.Most foods should have less than 300mg of sodium per serving.Review of the container of Beef-Based Powder revealed there was 890mg of Sodium in 1 teaspoon.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 1 (Resident #53) of 7 residents reviewed for unnecessary medications. The facility failed to have an adequate indication for the use of the medication aripiprazole (an antipsychotic) for Resident #53 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: Record review of Resident #53's admission record dated 04/24/2026, revealed a [AGE] year-old female with an initial admission date of 12/20/2022 and a readmission date of 04/14/2026. Resident #53's diagnoses included dementia (an umbrella term for a range of progressive neurological conditions that cause a decline in memory, thinking, reasoning, and behavior, severely enough to interfere with daily life), moderate, with mood disturbance, Alzheimer's Disease (a progressive, irreversible neurodegenerative disease and the most common form of dementia that affects your thinking, behavior and ability to do everyday tasks), generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about every day, routine situations lasting at least six months), and major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest, and low energy lasting at least two weeks). Record review of Resident #53's Annual MDS assessment, dated 02/26/2026, revealed a BIMS score of 02, indicating severe cognitive impairment. Record review of Resident #53's care plan, dated 02/17/26, revealed, FOCUS: [Resident #53] has a behavior problem. She will request food after eating, stating I didn't get any food. She will watch staff assist other residents at meals then request the same assistance, despite being able to eat independently. She will sit on the floor and call for help. Date Initiated: 04/14/2025 Revision on: 04/14/2026. Record review of Resident #53's care plan, dated 02/17/2026, revealed, FOCUS: [Resident #53] uses antipsychotic medication. Target behavior: aggressive behavior Date Initiated: 04/14/2025 Revision on: 06/03/2025. INTERVENTIONS/TASKS: Discuss side effects/Black Box warning of medications with resident/RP Date Initiated: 11/09/2025 Revision on: 11/09/2025 LN RN Keep environment free of clutter and safety hazards Date Initiated: 04/21/2025 Revision on: 11/09/2025 LN RN Monitor behaviors. Notify MD of new or worsening behaviors Date Initiated: 04/21/2025 Revision on: 11/09/2025 LN SS RN. Keep environment free of clutter and safety hazards Date Initiated: 04/21/2025 Revision on: 11/09/2025 LN RN Monitor behaviors. Notify MD of new or worsening behaviors Date Initiated: 04/21/2025 Revision on: 11/09/2025 LN SS RN Monitor vital signs as ordered by MD and PRN Date Initiated: 11/09/2025 LN Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 04/21/2025 LN Observe for adverse side effects of medication. Document and report to physician Date Initiated: 04/21/2025 LN Obtain consent for medication use. Date Initiated: 11/09/2025 LN RN Obtain lab work as ordered and notify MD of results Date Initiated: 11/09/2025 LN Pharmacy consultant to review medications at least monthly Date Initiated: 11/09/2025 LN. Record review of Resident #53's Physician's orders dated 04/14/2025 revealed, ARIPiprazole Oral Tablet 2 MG. Give 1 tablet by mouth one time a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. Black Box Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis. Record review of Resident #53's April 2025 MAR through April 2026 MAR revealed Resident #53 was administered aripiprazole 2 mg tablet by mouth daily from 04/15/2025 through 04/24/2026 with the indication of UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. During an interview on 04/24/2026 at 03:06 PM LVN A stated whoever took the verbal order would put the order in PCC. She said the indication for the medication was given by the doctor, and that was what they would write on the order they filled out on PCC. LVN A stated they were to clarify with the physician any order they needed clarification on. LVN A stated if a doctor gave an order for an antipsychotic with an indication of psychosis, she would not question that even if the resident had a diagnosis of dementia/Alzheimer's. LVN A stated during the in-services they went over appropriate indications for antipsychotics for residents with Alzheimer's/dementia. LVN A stated the negative effect of giving a resident an antipsychotic with an inappropriate indication such as psychosis could be the antipsychotic could cause harm. During an interview on 04/24/2026 at 03:29 PM, LVN B stated that the nurse who took the order was the one who put it in PCC. LVN B stated that when she put the order in PCC, she put it in exactly as the physician gave it. She said they did not change the indication from what the doctor gave. LVN B stated if she saw something that was not right or had questions about the order given, she would call the doctor back and clarify the order. LVN B stated if a doctor gave an order for an antipsychotic for an Alzheimer's/dementia resident with an indication of psychosis, she would ask for clarification. She said she would want to know what the medication was being given because psychosis was a broad term, and it would need to be narrowed. LVN B stated that the negative outcome of giving an antipsychotic without an appropriate indication could be abnormal behaviors, mood, labs, etc. During an interview on 04/24/2026 at 03:48 PM, RN RCS stated that the nurse who received the order from a doctor was the one who put it in PCC. RN RCS stated the nurse would call and clarify an order if in doubt. She said the nurse could also ask the ADON or DON for assistance. RN RCS stated, We don't give antipsychotics to a resident with the diagnosis of Alzheimer's or dementia. She said if she did see that, she would talk to the doctor. RN RCS stated the negative outcome of giving an antipsychotic with an inappropriate indication to a resident with a diagnosis of Alzheimer's/dementia could increase the risk of death per the black box warning and they wanted to ensure the resident with Alzheimer's/dementia was getting the antipsychotic for the right reason. Record review of the facility's Psychotropic Drug Use policy dated 03/05/2025 reflected, Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience which would deem it a chemical restraint. Definitions Chemical restraint refers to any drug used for discipline or makes it more convenient (i.e., less effort) for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated because they are less dangerous to a resident's health and safety. Policy Explanation and Compliance Guidelines: 1.A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 2.Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

Based on interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) out of 5 residents reviewed for care plans. The facility failed to update or revise Resident #1's care plan to reflect Resident #1's verbal and combative behavior of resistant to care or refusal of care. This failure could place resident at risk for receiving inadequate care and services. Findings included:Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Diagnoses included Alzheimer's with Late Onset (a chronic condition which primarily affects memory, thinking, and behavior), Dementia (decline in cognitive function which affects daily life, memory, reasoning, and language skills), Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive functions, such as attention, memory, reasoning, and problem-solving), and Need for Assistance with Personal Care.Record review of Resident #1's quarterly MDS assessment, dated [DATE], revealed BIMS was not conducted as Resident #1 was rarely or never understood. The language section of the MDS revealed the preferred language was Vietnamese, and MDS was unable to determine if an interpreter was needed to communicate with a doctor or health care staff.Record review of Resident #1's current care plan initiated [DATE] and revised [DATE] revealed a care plan for resident resistive to care related to dementia, Resident #1 yelled at staff during incontinent care and refused to allow staff to shower her, obtain vitals, or weigh her. Care plan goal initiated [DATE] revealed Resident #1 would cooperate with care through next review. Care Plan interventions initiated [DATE] revealed: allow resident to make decisions about treatment, encourage participation, and if resident resists ADLs, reassure her, leave and return 5-10 minutes later to try again. Goals and Interventions were added[DATE]. Care plan also revealed Resident #1 had a communication problem related to a language barrier, initiated [DATE], and revised [DATE]. Interventions for communication problem care plan, initiated [DATE], included anticipate and meet Resident #1's needs, Resident #1 preferred to communicate in Vietnamese, and Resident #1 required communication cue cards located in nightstand.Record review of Resident #1's progress note dated [DATE] revealed RN-A was called to Resident #1's room by the CNA, who had reported Resident #1 had slid off bed after incontinent care. Resident #1 was noted to be on the floor on the left side of her bed, lying on her left side with her sheet wrapped around her. Resident #1 was alert and yelling in Vietnamese, as well as moving her arms and legs. CNA attempted to use an electronic translator to attempt to interview resident, but translator was unable to produce a response. No visible injuries were noted, skin assessment performed, and Resident #1 was assisted by 2 staff back into bed, and incontinent care was provided. Resident refused to allow blood pressure or oxygen to be taken, but pulse was 74 and respirations were 18. Record review of Resident #1's Kardex (a quick reference or an extension of the care plan, derived from the care plan, used by CNAs and other staff to stay updated on residents key needs and care) dated [DATE] revealed a communication section with interventions to include: ask yes or no questions to determine resident's needs, Resident #1 prefers to communicate in Vietnamese, Resident #1 required communication cue cards which were located in the bedside table and ensure availability and functioning of adaptive communication equipment. In an interview on [DATE] at 10:05 AM, CNA-B stated Resident #1 spoke Vietnamese, so she could not understand her, but she would smile in response when spoken to like she understood some things which were said to her in English, but other than this, the staff had no way to formally communicate with this resident or understand what Resident #1 was saying to them or needing from them. CNA-B stated Resident #1 would get worked up frequently and yell, but she had never seen her get combative. CNA-B stated she walked into Resident #1's room on [DATE] after Resident had fallen out of bed. She stated she had offered assistance with the resident since she had showered her earlier in the day and had a good rapport with her. She stated Resident #1 was talking and yelling in Vietnamese but was not crying or grimacing like she was in pain. She stated she had no other way to communicate with her or understand her, as CNA-C had already tried the translator device, and it had not worked. It was not typically used for this resident as it would not pick up what she was saying or yelling. She did say she could answer some simple yes or no questions if they point to things and asked, such as pointing to or rubbing stomach and asking if it hurt. In an interview on [DATE] at 10:39 AM, CNA-C stated after Resident #1 fell out of bed on [DATE], she was being combative and yelling and speaking in Vietnamese, but she could not understand what Resident #1 was saying. CNA-C stated she and RN-A tried to use the translator to understand Resident #1, but it was not picking up or understanding what the resident was saying. She also stated Resident #1 yells frequently, which was typical for her. She stated she had no other way to formally communicate with Resident #1 to find out what she was saying or what she needed, but she would shake her head yes or no to simple questions such as pain.In an interview on [DATE] at 11:09 AM the ADON stated it was either her or the MDS nurse which typically updated the clinical care plans. She stated at some point in time between the previous care plan which was initiated [DATE] and the current care plan, which was initiated [DATE], there was a behavior problem listed, but it must have dropped off, been deleted, or gotten closed out, and this was why there was a new problem for resistive to care added on [DATE]. She stated she was not sure why the goals and interventions were not added to the care plan until [DATE], the day Resident #1 expired, and she also stated she did not remember if it was herself or the MDS nurse who had added them. The ADON stated Resident #1 had always been combative and verbally aggressive with incontinent care and ADLs, and it was something which should have always been care planned, so it dropping off or being removed was by mistake. She stated Resident #1 was able to nod in response or say simple phrases like thank you, but she did have the cue cards at bedside to assist with communication. She stated the CNAs utilized the Kardex, which was derived from the care plan, to learn and know more about the residents they were caring for, and Resident #1's language preferences were on the care plan and the Kardex. She stated if a CNA did not typically work the hall of a resident, then they may not have known the cue cards were in the bedside table. She stated the CNAs should have been looking at the Kardex, but many times they may have only skimmed it for the highlights such as transfer and mobility status. She stated she felt like maybe the CNAs needed more training on what the Kardex was and how it was used. In an interview on [DATE] at 1:17 PM, the MDS Nurse stated she hadn't really started working on care plans because she was new and just started this job and was still training. She also stated Resident #1's MDS assessment and care plan probably were not the best due to the language barrier with Resident #1, and she was not able to ask Resident #1 any questions, so she mostly asked staff which took care of her on a daily basis regarding the MDS questions. She also stated she was not able to consult with family as Resident #1 did not have any family, and the only contact was a friend who never returned phone calls or came to care plan meetings or to visit Resident #1. The MDS nurse stated the care plan problem resistive to care or refuses care was care planned previously, and she wasn't sure why it was ever removed or dropped off; she also was not sure why the current care plan was initiated [DATE], but the goals and interventions were not initiated until [DATE]. In an interview on [DATE] at 2:31 PM, CNA-B stated she knew what a Kardex was because she learned about it in her CNA program, and she knew she was supposed to be reviewing it and using it, but she admitted the Kardex rarely got used, and she had not reviewed it for Resident #1. She stated she had not known there were cue cards in Resident #1's bedside table. CNA-B also stated she had never had an in-service or training in this facility regarding the use of the Kardex. She stated if she and the other staff had reviewed the Kardex, they would have known there were cue cards in the bedside table, and they may have been able to better communicate with Resident #1 and understand what she was yelling about. Record review of the facility's Comprehensive Care Plan Policy, dated [DATE], revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs which were identified in the resident's comprehensive assessment. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed and 1 of 1 resident refrigerator/freezer reviewed for storage, preparation and sanitation. -The facility failed to ensure plastic dishes were clean on the clean rack in the kitchen. -The facility failed to ensure staff personal food items were kept out of the resident's refrigerator and freezer in the activities area. -The facility failed to ensure food items in the resident's refrigerator and freezer were labeled and dated. -The facility failed to ensure food items in the resident's refrigerator and freezer were not expired. -These failures could place residents at risk for complications from food contamination. Findings included: Observations during the initial tour of the kitchen on [DATE] at 10:30 am revealed 50 of 50 plastic cups had thick white or yellowish substances stuck to the insides and bottoms on the clean rack. The dirty bowls also had scratches on the insides and bottoms. One of them had what appeared to be melted plastic in the bottom of it. There was an open box of breakfast cereal mix on a prep table. Observation of the locked resident refrigerator and freezer on [DATE] 9:22 am in the activities area had 7 unlabeled ice cream sandwiches, 16 popsicles, a 3-pound tub of frozen cookie dough labeled with a staff member's name, a 2.7-pound box of another cookie dough labeled with a staff member's name, a half-melted popsicle that was unlabeled and undated, an unlabeled 22-count bag of frozen flour tortillas expired on [DATE], and an undated zip-type plastic bag of 4 eggrolls covered with frost inside the bag and covering the food. There was a large, partially full pitcher of a light red liquid dated [DATE], an unlabeled 10-ounce container of small tomatoes, an unlabeled, partially full 15.38-ounce container of hot sauce expired [DATE], a 12-ounce container of electrolyte drink labeled with a staff member ' s name, an unlabeled 13-ounce can of whipped cream expired [DATE], 1 unlabeled stick of butter, an unlabeled 10-ounce bag of shredded carrots expired on [DATE], an unlabeled 1-ounce bag of potato chips, an unlabeled 14-ounce container of chocolate drink expired on [DATE], an unlabeled and expired 24-ounce half-full jar of pasta sauce, and an unlabeled half-full jar of grape jelly. In an interview with DA on [DATE] at 10:32 am, she said the dirty bowls were on the clean rack and it was the dishwasher's responsibility to check the dishes for cleanliness. She said she was the dishwasher today but did not look at the bowls that were already on the clean rack. In an interview with the DM on [DATE] at 10:33 am, she said the dirty bowls were on the clean rack and it was the dishwasher's responsibility to check the dishes for cleanliness. She said she was responsible for monitoring the dishwashing staff but had not done so recently. She said the dirty bowls on the clean rack were old and had been there forever. She said those particular bowls should have been thrown away. She said the dirty bowls could harbor bacteria and could make residents sick if they were served from the dirty dishes. She said she had new bowls in the supply room. She did not have an answer to why the dirty bowls had not been thrown away. Kitchen policies and in-services requested at this time. In-services regarding the kitchen were not provided. In an interview with the [NAME] on [DATE] at 10:35 am, she said she opened the box of breakfast cereal mix yesterday and did not put it away properly. She said the open box of breakfast cereal mix could cause cross contamination and make residents sick. She said cross contamination could occur because the breakfast cereal mix could attract bugs. In an interview with the AD on [DATE] at 9:22 am, she identified the items in the locked refrigerator and freezer in the activities area as belonging to the staff. She identified the locked refrigerator and freezer in the activities area as being strictly for the residents. She said she told staff they could not use this refrigerator or freezer for personal items, but she found items in there frequently. She said she was the only one with the key for the refrigerator and the code for the freezer. The AD did not answer when asked how the staff items got inside the refrigerator and/or freezer. She said she did not have any training regarding the activities area refrigerator/freezer. In an interview with the ADM on [DATE] at 9:59 am, she said the AD was responsible for the activities room refrigerator/freezer and with other staff putting their belongings in there without her knowing was not acceptable. She said cross contamination of resident and staff items could cause illness to both parties, especially the residents. In an interview with MR on [DATE] at 10:12 am, she said she owned the tub of cookie dough in the resident's freezer. She said she had donated it to the activities department and was not sure how long ago-she thought less than a year. She said resident and staff food was not allowed together because of cross contamination and could make the resident's sick. In an interview with the SW on [DATE] at 10:16 am, she said she owned the box of cookie dough in the resident's freezer and she had forgotten about it. She said she bought it as a school fund-raiser from another staff member ' s child last year. She said she knew the activities area refrigerator/freezer was used for resident's but did not know she could not place her things in there because of infection control-like allergies or cross contamination. She said cross contamination could make the residents sick. She said monthly all-staff meetings were informative of not storing personal belongings with resident belongings but was not sure the last time they talked about it, but was sure they talked about it. She said she was going to take the dough home the day she got it but forgot. She said she asked the AD for the code to the freezer and the AD gave it to her. In an interview with the ADIR on [DATE] at 10:31 am, she said she sold the cookie dough to staff last November, and it was delivered in [DATE]. She said one person donated her dough (MR) to the activities department for the residents. She said the activities area refrigerator/freezer was for residents only. She said staff had training on personal belongings not too long ago, so it was common knowledge. She said we (staff) could not put anything in that refrigerator/freezer because it was specifically for the residents only. She said everything had to be labeled and dated with their names to keep cross- contamination from happening and the residents could get sick. We just don't do it. Record review of the facility ' s policy dated [DATE], titled, General Kitchen Sanitation revealed All nutrition and food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and United States Food Codes in order to minimize the risk of infection and food borne illness. Record review of the facility policy dated [DATE], titled, Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment revealed 3. Rinse or scrape equipment and utensils and, when necessary, soak to remove gross food particles and soil prior to being washed. FDA Food Code 2022 Ch. ,d+[DATE] Preventing contamination from the premises ,d+[DATE].11 Food Storage (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (2) Where it is not exposed to splash, dust, or other contamination. Ch. ,d+[DATE] Cleanability ,d+[DATE].11 Food-Contact Surfaces. Frequency ,d+[DATE].11 Equipment Food-Contact Surfaces and Utensils. (A) food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred.

Based on interview and record review, the facility failed to ensure the right to be free from abuse for one (Resident #1) of two residents reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. On 01/25/25, Resident #2 hit Resident #1 in the stomach with a closed fist as she was walking past her. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #1's face sheet dated 10/19/24 revealed a [AGE] year-old female with diagnoses including dementia (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, high blood pressure, congenital (present at birth) malformation of brain, and abnormalities of gait and balance. Record review of Resident #1's Admission MDS Assessment, dated 10/24/24, reflected a [AGE] year-old female who admitted on [DATE]. Her BIMS score of 03 indicated the resident had severe cognitive impairment with inattention and disorganized thinking. She required supervision for all ADL ' s. She could walk without the use of a wheelchair, walker, or cane. She was occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #1's Care Plan dated 11/07/24, reflected Resident #1 was an elopement risk related to degenerative cognitive disease and was appropriate for placement in the secure unit. Resident #1 had a behavior problem r/t degenerative cognitive disease and declined showers and assistance with care. She carried her clothes and items from her room with her keys around unit asking to open door as she had been dismissed. Record review of Resident #2's face sheet dated 07/16/21 revealed an [AGE] year-old female with an original admitted [DATE]. Diagnoses included Alzheimer ' s Disease, dementia, lack of coordination, major depression, Diabetes with glaucoma and neuropathy, anxiety, and spinal stenosis (could not walk). Record Review of Resident #2's Quarterly MDS Assessment, dated 12/26/24, reflected her BIMS score of 02 indicated the resident had severe cognitive impairment with inattention and disorganized thinking. She required partial assistance with eating and oral hygiene and substantial assistance with all other ADL ' s. She utilized a manual wheelchair and required assistance to propel. She was always incontinent of bladder and bowel. She did not display any behaviors at the time (look back period) of the MDS assessment. She took antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. Resident #2's quarterly care plan dated 01/27/25 reflected Resident #2 was the aggressor of physical aggression towards another resident. Resident yelling and throwing drinks at one resident, then punched another resident in the abdomen. Date Initiated: 01/27/25. The goal was the resident would have no long-term issues related to incident through the target date of 12/26/24. Interventions included labs drawn per physician order, referral sent to local psychiatric hospital for in-patient psych evaluation, placed on 1:1 post incident per physician order, and social services to perform a psychosocial assessment. Date Initiated: 01/27/25. Resident #2 was physically aggressive related to anger; resident will occasionally grab other residents by the arms without provocation. Date Initiated: 10/09/20 Revision on: 11/25/24. The goal was the resident would demonstrate effective coping skills through the review date. Date Initiated: 10/09/20 Revision on: 10/24/24 Target Date: 12/26/24. Interventions included place resident on 1:1 due to aggressive episode until discontinued by physician, administer medications as ordered Date initiated 11/25/24, monitor/document for side effects and effectiveness Date Initiated: 10/09/20, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 10/09/20, assess and address for contributing sensory deficits. Date Initiated: 10/09/20, assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 10/09/20, monitor/document/report PRN any signs or symptoms of resident posing danger to self and others. Date Initiated: 10/09/20, place resident on 1:1 for aggressive episodes as ordered if indicated. Date Initiated: 11/25/24. Resident #2 required a structured environment in the secure unit related to cognitive deficit Date Initiated: 09/16/24, Revision on: 12/27/24. The goal was the resident safety would be maintained through review date. Date Initiated: 10/03/24. Revision on: 12/27/24. Target Date: 12/26/24. Interventions included encourage activity participation, explain what you are going to do before touching the person with cognitive loss, speak calmly. Date Initiated: 10/03/24. Revision on: 12/27/24. The resident had impaired cognitive function and impaired thought processes related to dementia with behavior issues and delusions. Date Initiated: 09/11/20. Revision on: 09/25/24. Interventions included cue, reorient and supervise as needed, Date Initiated: 09/11/20. Engage the resident in simple, structured activities that avoid overly demanding tasks, keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Date Initiated: 01/20/21. Monitor/document frustration level. Wait 30 seconds before providing resident with word. Date Initiated: 09/16/20. Observation of Residents #1 and #2 in the secure unit on 01/29/25 from 1:40 pm to 2:30 pm revealed Resident #2 was sitting at a table with no one next to her, but across the table from her. She was pulling the hem out of her dress. Three different residents walked near or toward Resident #2 and LVN G was quick to intervene by approaching each of them calmly and redirecting them away from Resident #2. Resident #2 would intermittently burst out laughing for no apparent reason. Resident #2 would stare at everyone and occasionally, she would look at the television. Resident #1 was independently ambulating around the secure unit with a steady gait. She had shoes on, she was braless but well kempt otherwise, and had a large purse over her left shoulder. The purse appeared to be stuffed full. She was smiling, cheerful, and talkative. Attempted interview with Resident #2 on 01/29/25 at 2:00 pm was unsuccessful. She stared at this surveyor and did not answer any questions. She maintained a flat affect. In an interview with Resident #1 on 01/29/25 at 2:15 pm, she said she did not remember ever being hit by anyone. She said she was carrying her purse (packed with her clothes) because she was leaving for home today. In an interview with the ADM on 01/29/2025 at 10:55 am, she said Resident #2 was referred to a behavioral hospital either locally or in another town. She said the facility had exhausted interventions (no roommate, seating during meals at her own table and not allowing others within arm ' s reach of her in the common areas). She said Resident #2 ' s family refused to allow her out of the secured unit even as a trial because the secure unit was all females there and the family was adamant about keeping her there. In an interview with LVN G on 01/29/2025 at 1:42 pm she said staff in the secure unit were monitoring Resident #2 by making sure she was always in eyesight unless she was in bed. LVN G said she took Resident #2 with her when she needed to give meds or go down the hall. She said Resident #2 was not left unattended. LVN G said she had bruising on her right forearm from 01/26/25 during Resident #2 ' s incident, but she knew she could step away, whereas the residents did not know to get out of harm ' s way. She said the residents in the secure unit did not understand their behavior, why, or how to behave in certain circumstances. She said the main thing was to keep others away from Resident #2. She said she only worked in the secure unit. In an interview with RN F on 01/29/2025 at 2:12 pm, she said staff in the secure unit were monitoring Resident #2 by making sure she was always in sight of a CNA or nurse and making sure others (residents) were not within Resident #2 ' s arm ' s reach. She said Resident #2 ' s demeanor would change frequently. She said it was difficult to pinpoint triggers with Resident #2. She said some days she would not see those behaviors and she never knew when Resident #2 would act out. She said nurses documented behaviors daily in their progress notes. She said the 1:1 ordered over the weekend was discontinued the next day because Resident #2 ' s behaviors dissipated. She said the behavior monitoring came from the physician orders but did not trigger to go into the care plan. She said she was informed about Resident #2 ' s 1:1 and continuing monitoring from the charge nurse (LVN G). She said Resident #2 had her nails done yesterday with no problems. She said the resident was seated at the end of the table, the others were on the sides of the table, out of arm ' s reach. She said she had not experienced Resident #2 throwing objects but had been cussed out by her before. She said she was surprised to hear Resident #2 had hit Resident #1 in the stomach on 01/25/25. In a phone interview with LVN H on 01/29/2025 at 3:15 pm, she said she was the nurse on duty on 01/25/25 and Resident #1 did not start the altercation on 01/25/25. She said 2 other residents had begun dickering at the table in the common area of the secure unit. She said she was in the process of removing Resident #2 from the situation as a de-escalation tactic. She said as she was locking the brakes on Resident #2 ' s wheelchair (LVN ' s back was toward the hallway), Resident #1 came walking around the corner from the hallway and Resident #2 stuck out her fisted hand, striking Resident #1 in the center of her upper abdomen. She said she saw a red mark on Resident#1 ' s upper abdomen when she assessed her. She said Resident #1 denied any pain but said she got the wind knocked out of her-she was not in any distress. She said not very aggressive for me. Neither of them remembered what had occurred. LVN H said she tried to keep an eye on all of them equally. She said Resident #2 was not typically aggressive for her. She said she heard about Resident #2 ' s aggression from others. In an interview with the DON on 01/29/25 at 4:13 pm, she said for the most part because it was a secure and behavioral unit, the nurses were aware of the ones that tended to have more behaviors than others. Staff monitored them a little more closely- they do not need to necessarily keep them in their line of sight. She said all residents there had constant behavior that would require that kind of monitoring. Staff kept a close eye on Resident #2 and there were a lot of residents around the area when the incident occurred. She said there was a heightened awareness with Resident #2. The residents with a history of aggressive behaviors were monitored more closely than residents without aggressive behaviors. She said they have tried medication adjustments but were not seeing the improvements that we needed to see for her to remain at the facility. She said before the incident on 01/25/25, she thought there was still a chance Resident #2 could have stayed, but afterwards she did not feel Resident #2 could stay there to keep everyone safe. She said she did not know if LVN H could have prevented the punch. She said Resident #1 happened to be walking by. She said Resident #2 had a specialty wheelchair with a high back. She said LVN H assessed a slight red mark on Resident #1 that dissipated quickly. She said Resident #2 went on 1 to 1 after the incident and was discontinued by the physician on Monday, 01/27/25 because Resident #2 was no longer displaying aggressive behaviors. She said staff had not identified any type of trigger for her outbursts. She said staff in the secure unit tried to keep her more distant from other residents without isolating her. She said there has been some heightened awareness since this incident. She said the family had been very difficult throughout this ordeal with a lot of denial. They don't see the aggressive behaviors. We had a lot of talks with them (the family) while adjusting medications. She said the facility did not have a behavioral agreement with the family. She said the aides in the secured unit were very consistent-they were very familiar with the residents back there and their propensity for different behaviors. She said increased monitoring was not added to the care plan after the incident on the 25th. She said the nurses in the secure unit should say that they were monitoring Resident #2 more closely now after the incident. She said if Resident #2 was out of her room, then she would want to have a line of sight on her. When asked why that was not in the care plan the DON did not respond. She said it was important to keep the care plan updated to keep everyone on the team on the same page. She said if everyone was not on the same page, then someone could miss a specific intervention that was recently added. She said every resident at the facility had a right to be free from abuse. Record review of the facility policy dated 08/15/22, titled Abuse, Neglect, and Exploitation revealed under policy, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury with resulting physical harm, pain or mental anguish, which can include certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Policy Explanation and Compliance Guidelines: The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse . The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment. Existing staff will receive annual education through planned in-services and as needed. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations in which abuse . is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 1 resident (Resident #2) of 5 residents whose care plans were reviewed for timing and revision. The facility failed to include heightened monitoring strategies to Resident #2 ' s care plan after she hit another resident on 01/25/25. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings included: Record review of Resident #2's face sheet dated 07/16/21 revealed an [AGE] year-old female with an original admitted [DATE]. Diagnoses included Alzheimer ' s Disease, dementia, lack of coordination, major depression, Diabetes with glaucoma and neuropathy, anxiety, and spinal stenosis (could not walk). Record Review of Resident #2's Quarterly MDS Assessment, dated 12/26/24, reflected her BIMS score of 02 indicated the resident had severe cognitive impairment with inattention and disorganized thinking. She required partial assistance with eating and oral hygiene and substantial assistance with all other ADL ' s. She utilized a manual wheelchair and required assistance to propel. She was always incontinent of bladder and bowel. She did not display any behaviors at the time (look back period) of the MDS assessment. She took antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. Resident #2's quarterly care plan dated 01/27/25 reflected Resident #2 was the aggressor of physical aggression towards another resident. Resident yelling and throwing drinks at one resident, then punched another resident in the abdomen. Date Initiated: 01/27/25. The goal was the resident would have no long-term issues related to incident through the target date of 12/26/24. Interventions included labs drawn per physician order, referral sent to local psychiatric hospital for in-patient psych evaluation, placed on 1:1 post incident per physician order, and social services to perform a psychosocial assessment. Date Initiated: 01/27/25. Resident #2 was physically aggressive related to anger; resident will occasionally grab other residents by the arms without provocation. Date Initiated: 10/09/20 Revision on: 11/25/24. The goal was the resident would demonstrate effective coping skills through the review date. Date Initiated: 10/09/20 Revision on: 10/24/24 Target Date: 12/26/24. Interventions included place resident on 1:1 due to aggressive episode until discontinued by physician, administer medications as ordered Date initiated 11/25/24, monitor/document for side effects and effectiveness Date Initiated: 10/09/20, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 10/09/20, assess and address for contributing sensory deficits. Date Initiated: 10/09/20, assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 10/09/20, monitor/document/report PRN any signs or symptoms of resident posing danger to self and others. Date Initiated: 10/09/20, place resident on 1:1 for aggressive episodes as ordered if indicated. Date Initiated: 11/25/24. Resident #2 required a structured environment in the secure unit related to cognitive deficit Date Initiated: 09/16/24, Revision on: 12/27/24. The goal was the resident safety would be maintained through review date. Date Initiated: 10/03/24. Revision on: 12/27/24. Target Date: 12/26/24. Interventions included encourage activity participation, explain what you are going to do before touching the person with cognitive loss, speak calmly. Date Initiated: 10/03/24. Revision on: 12/27/24. The resident had impaired cognitive function and impaired thought processes related to dementia with behavior issues and delusions. Date Initiated: 09/11/20. Revision on: 09/25/24. Interventions included cue, reorient and supervise as needed, Date Initiated: 09/11/20. Engage the resident in simple, structured activities that avoid overly demanding tasks, keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Date Initiated: 01/20/21. Monitor/document frustration level. Wait 30 seconds before providing resident with word. Date Initiated: 09/16/20. In an interview with the ADM on 01/29/2025 at 10:55 am, she said Resident #2 was referred to a behavioral hospital either locally or in another town. She said the facility had exhausted interventions (no roommate, seating during meals at her own table and not allowing others within arm ' s reach of her in the common areas). She said Resident #2 ' s family refused to allow her out of the secured unit even as a trial because the secure unit was all females there and the family was adamant about keeping her there. In a phone interview with RMDS on 01/29/25 at 1:00 pm, she said Resident #2 did not display any behaviors at the time (look back period) of the MDS assessment on 12/26/24. In an interview with LVN G on 01/29/2025 at 1:42 pm she said staff in the secure unit were monitoring Resident #2 by making sure she was always in eyesight unless she was in bed. LVN G said she took Resident #2 with her when she needed to give meds or go down the hall. She said Resident #2 was not left unattended. LVN G said she had bruising on her right forearm from 01/26/25 during Resident #2 ' s incident, but she knew she could step away, whereas the residents did not know to get out of harm ' s way. She said the residents in the secure unit did not understand their behavior, why, or how to behave in certain circumstances. She said the main thing was to keep others away from Resident #2. She said she worked only in the secure unit. She said she did not update care plans. She said care plans should be updated whenever something changed with a resident. In an interview with RN F on 01/29/2025 at 2:12 pm, she said staff in the secure unit were monitoring Resident #2 by making sure she was always in sight of a CNA or nurse and making sure others (residents) were not within Resident #2 ' s arm ' s reach. She said Resident #2 ' s demeanor would change frequently-it could be daily or several times a day or not for days. She said it was difficult to pinpoint triggers with Resident #2. She said some days she would not see those behaviors and she never knew when Resident #2 would act out. She said nurses documented behaviors daily in their progress notes. She said the behavior monitoring came from the physician orders but did not trigger to go into the care plan. She said she was informed about Resident #2 ' s 1:1 and continuing monitoring from the charge nurse (LVN G). She said she did not update care plan and nothing had changed with Resident #2. In a phone interview with LVN H on 01/29/2025 at 3:15 pm, she said she was the nurse on duty on 01/25/25 and Resident #1 did not start the altercation on 01/25/25. She said 2 other residents had begun dickering at the table in the common area of the secure unit. She said she was in the process of removing Resident #2 from the situation as a de-escalation tactic. She said as she was locking the brakes on Resident #2 ' s wheelchair (LVN ' s back was toward the hallway), Resident #1 came walking around the corner from the hallway and Resident #2 stuck out her fisted hand, striking Resident #1 in the center of her upper abdomen. She said she saw a red mark on Resident#1 ' s upper abdomen when she assessed her. She said Resident #1 denied any pain but said she got the wind knocked out of her-she was not in any distress. She said not very aggressive for me. Neither of them remembered what had occurred. LVN H said she tried to keep an eye on all of them equally. She said Resident #2 was not typically aggressive for her. She said she heard about Resident #2 ' s aggression from others. She said she did not update care plans. In an interview with the DON on 01/29/25 at 4:13 pm, she said, For the most part, because it was a secure and behavioral unit, the nurses were aware of the residents that tended to have more behaviors than others. Staff monitored them a little more closely- they did not necessarily need to keep them in their line of sight. She said all residents there (in the secure unit) had constant behavior that would require monitoring. Staff kept a close eye on Resident #2. She said there was a heightened awareness with Resident #2. The residents with a history of aggressive behaviors were monitored more closely than residents without aggressive behaviors. She said she did not know if anyone could have prevented the punch. She said Resident #2 had a specialty wheelchair with a high back. She said Resident #2 went on 1 to 1 after the incident. She said staff had not identified any type of trigger for her outbursts. She said staff in the secure unit tried to keep her more distant from other residents without isolating her. She said the facility did not have a behavioral agreement with the family. She said increased monitoring was not added to the care plan after the incident on the 25th. She said the nurses in the secure unit should say that they were monitoring Resident #2 more closely now after the incident. She said if Resident #2 was out of her room, then she would want to have a line of sight on her. When asked why that was not in the care plan the DON did not respond. She said it was important to keep the care plan updated to keep everyone on the team on the same page. She said if everyone was not on the same page, then someone could miss a specific intervention that was recently added. She said every resident at the facility had a right to be free from abuse. Record review of the facility policy dated 10/24/22, titled, Care Plan revisions Upon Status Change. 1. The comprehensive care plans will be reviewed and revised as necessary when a resident experiences a status change.

Based on observation and interviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 medication rooms (Medication room [ROOM NUMBER]). The facility failed to keep Medication room [ROOM NUMBER] free from the employee personal food items on 01/28/25 as there were sunflower seeds, coke, and a tumbler cup in the room. This deficient practice could place residents at risk of receiving medications contaminated by food and drinks. The findings included: During an observation of Medication room [ROOM NUMBER] on 01/28/25 at 4:30 PM, this state surveyor found an opened box designed to hold 12 bags of sunflower seeds containing 5 sealed individual bags of sunflower seeds, a 12-pack of coke cans with 8 unopened cans remaining in the 12-pack, and a [NAME] cup. The box of sunflower seeds had MA D's name written on the top. The items were all in lower cabinets inside Medication room [ROOM NUMBER]. In an interview with the ADON on 01/29/25 at 9:53 AM, the ADON stated employee personal food items should not be stored in the medication rooms. The ADON stated employee personal food items should be stored in the employee break room. The ADON stated personal food items should not be stored in the medication rooms because it could cause cross contamination and become an infection control problem. The ADON stated MA D's name was written on the box of sunflower seeds. The ADON stated the [NAME] cup belonged to CNA E. The ADON stated she did not know who the cans of coke belonged to. The ADON stated CNA E did not have access to the medication rooms. In an interview with MA D on 01/29/25 at 10:01 AM, MA D stated she did not put the box of sunflower seeds in Medication room [ROOM NUMBER]. MA D stated she did not know the coke was in Medication room [ROOM NUMBER] either. MA D stated she went in Medication room [ROOM NUMBER] about once per shift, but only opened the top cabinets that contained the medications. MA D stated the sunflower seeds were a gag gift given to her about 2 weeks ago by an anonymous person at the facility. MA D stated she did eat sunflower seeds at the facility on her break in the employee break room. MA D stated she kept her sunflower seeds in her backpack in the employee break room. MA D stated the last time she remembered seeing the box of sunflower seeds was about a week ago at the 200-hall nurse's station. MA D stated she was going to take the box home, but someone removed it from the 200-hall nurse's station, and she was not worried about it so she did not search for it. MA D stated personal food items did not belong in the medication rooms. MA D stated employee personal food items could go in the break room. MA D stated personal food items were not allowed in the medication room because of a risk for cross contamination. In an interview with CNA E on 01/29/25 at 10:12 AM, CNA E stated it was her [NAME] cup that was found in Medication room [ROOM NUMBER]. CNA E stated she did not have access to either medication room. CNA E stated the last time she had the cup was at the facility on Sunday, 01/26/25 when she worked from 6:00 AM to 6:00 PM. CNA E stated she always stored her [NAME] cup in the break room. CNA E stated she thought she left her [NAME] cup at the 200-hall nurse's station before she left work on 01/26/25. CNA E stated another employee must have seen it at the nurse's station and put it in the lower cabinet in Medication room [ROOM NUMBER]. CNA E stated personal food items should not be kept in the medication room because it was a contamination risk. In an interview with the DON on 01/29/25 at 10:22 AM, the DON stated personal food items should not be stored in the medication rooms. The DON stated employee personal food items should be stored in the break room. The DON stated they go in the medication rooms and clean them out every few weeks. The DON stated she did not know who put the sunflower seeds, coke, or [NAME] cup in Medication room [ROOM NUMBER]. The DON stated personal employee food items should not be stored in the medication rooms because of the potential for cross contamination. This state surveyor requested a facility policy regarding the proper storage of medications in the medication room or proper storage of employee personal food items. The DON reported on 01/29/25 at 1:50 PM that she was unable to find any facility policy covering the requested parameters. In an interview with the ADM on 01/29/25 at 1:55 PM, a facility policy was requested regarding the proper storage of medications in the medication room or proper storage of employee personal food items. The ADM reported on 01/29/25 at 2:40 PM that she was unable to find any facility policy covering the requested parameters.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #178) of 4 residents reviewed for infection control in that: 1. The facility failed to ensure that Resident #178 had EBP (Enhanced Barrier Precautions) signage and PPE (Personal Protective Equipment) available for staff providing care to Resident #178 on 1/27/25 and 1/28/25 due to Resident #178 having an indwelling urinary catheter. Findings included: Observation on 1/27/25 at 11:00am reflected EBP signage and a PPE cart on the door of Resident 178's original room which was shared with a roommate who also required EBP. Observation on 1/28/25 at 9:00am and 3:30pm reflected that Resident #178 had been moved to another room. That room did not have any EBP signage or PPE available for staff. Record review of Resident #178's admission record reflected a [AGE] year-old female that was admitted to the facility on [DATE]. Diagnoses included acute transverse myelitis (acute inflammation of the spinal cord that causes pain, weakness, sensory problems and bladder/ bowel dysfunction) in demyelinating disease (condition that causes damage to the protective layer of the spinal cord) of the central nervous system, paraplegia (inability to move the legs), and urinary retention (difficulty urinating and completely emptying the bladder). Record review of Resident #178's admission MDS dated [DATE] reflected Resident #178 had a BIMS score of 15 which indicated no cognitive impairment. Record review of Resident #178's Initial Nursing Evaluation dated 1/23/25 at 9:52pm reflected the presence of an indwelling catheter upon admission to the facility. Record review of Resident #178's Initial Baseline/Advanced Care Plan form dated 1/24/25 at 12:28am reflected in part: Problem: The resident has an Indwelling Catheter. Goal: The resident will be/remain free from catheter-related trauma through review date. Goal: The resident will show no s/sx of Urinary infection through review date. Record review of Resident #178's order skilled nurse's note dated 1/24/25 at 9:20am reflected in part: E. BLADDER/GU 1. Bladder Function: a. Bladder function unchanged 2. Catheter b. Foley Catheter with care provided c. Catheter patent, draining and insitu. Record review of Resident #178's care plan on 1/27/25 at 2:23pm reflected in part: Problem: Resident #178 has an indwelling catheter r/t urinary retention. Initiated: 1/24/25. Interventions: Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks each shift. Monitor and document output as ordered. Initiated 1/24/25. Problem: Resident #178 has a urinary tract infection. Initiated: 1/24/25. Interventions: Administer antibiotic medications as ordered. Maintain universal precautions when providing resident care. Initiated: 1/24/25. Record review of Resident #178's Order Summary Report on 1/28/25 at 1:51pm reflected the following orders: Check foley catheter every shift. Foley cath care q shift and PRN as needed. Foley cath care q shift and PRN every shift. Foley catheter: Change 16F with 10ml bulb as needed for PRN plugged or out. Foley: Document output for foley catheter Q shift every shift. Foley: Foley catheter: Irrigate foley catheter with 60ml of NS as needed. Monitor for privacy bag placement everyy shift. Monitor that collection bag is off the floor and hung below bladder level every shift. There were no orders for any type of precautions or PPE use listed. In an interview on 1/28/25 at 3:34pm, CNA A stated that she was not aware that Resident #178 should have been on enhanced barrier precautions and that she had not been wearing any PPE while performing resident care activities such as brief changes, hygiene, and transfers. CNA A was not able to tell me specifically what EBP was for but was able to recall with prompting. CNA stated that infection control in-services were done monthly and were also part of their required online quarterly training and the last in-service was approximately one month ago. CNA A stated if PPE was not used with residents who had indwelling devices, it could lead to infections and possibly hospitalization s. In an interview on 1/28/25 at 3:40pm, CNA B stated that Resident #178 should have had EBP (after prompting). CNA B stated she had not been wearing PPE when helping with Resident #178's transfers or peri-care. CNA B stated the last in-service for infection control was about a month ago and that it was also part of the monthly in-services. CNA B stated if EBP was not observed with residents who had urinary catheters it could lead to the resident getting a urinary tract infection. In an interview on 1/28/25 at 3:45pm, RN C stated that EBP was used to protect the resident from infections. RN C stated that EBP was used with residents that had surgical wounds or open wounds. RN C recalled that EBP was also used for residents that had urinary catheters, feeding tubes, and/or external dialysis catheters after prompting. RN C stated she had been working at this facility for approximately six months and that staff was in-serviced on infection control upon hire and quarterly and that her last in-service was 3 months ago. RN C stated maybe Resident #178 was not on EBP because she had just gotten here three days ago and it had been overlooked. In an interview on 1/28/25 at 3:50pm, the DON stated when R#178 was in the original room, the EBP covered both residents. She was moved to another room due to her roommate's wound culture requiring her to be placed on contact precautions, the EBP signage did not get re-posted. The DON stated that EBP should have been ordered and care planned and she was not sure why the EBP order did not get put in or care planned for Resident #178. The DON stated in-services on infection control were done pretty frequently and it was part of staff's ongoing HealthStream (online) training. The DON stated if EBP was not utilized for residents that required it, those residents could potentially contract an infection that could lead to sepsis, hospitalization , and/or death. In an interview on 1/29/25 at 10:51am, the IP stated Resident #178 was moved to another room due to her roommate's wound culture results indicating that she needed to be placed on contact precautions. Resident #178 was on EBP along with her roommate prior to the move, however staff just overlooked the need to place her back on EBP. The IP stated it was important to place residents with indwelling devices on EBP so that they did not acquire any infections. The IP further stated if staff did not use appropriate PPE and the resident developed an infection it could lead to sepsis, hospitalization , or even death. The IP stated staff was in-serviced on infection control upon hire, at least monthly, and as needed. The IP stated that the EBP should have been ordered and care planned when the resident arrived and that it had been ordered and care planned prior to this interview. The IP stated that she thought that Resident #178 had come in over the weekend and that they started reviewing all the orders for the weekend admissions on Monday morning. The IP stated that she was going to in-service staff on EBP during this week. In an interview on 1/29/25 at 11:17am, the ADM stated it was important to place residents with indwelling devices on EBP to prevent them from developing an infection that may be inadvertently passed along by staff. The ADM stated if staff failed to utilize EBP, it could lead to residents developing infections which could cause sepsis. The ADM stated the IP oversaw all of the precautions and/or isolations for the facility and the charge nurses for each hall were responsible for making sure that the precautions or isolations are implemented. The ADM stated it is up to all staff to ensure that appropriate precautions are being implemented for residents and if a staff member came across a resident who should have some type of precautions but did not, they were responsible for making the charge nurse aware so that the orders and care plan could be updated and the signs and PPE put into place. The ADM stated education and in-services are done upon hire and then monthly and as needed as well as in staff's online training quarterly. Record review of the facility's Enhanced Barrier Precautions policy dated 4/5/24 reflected in part: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident ' s room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident ' s room. e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes 9. Enhanced barrier precautions should be used for the duration of the affected resident ' s stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs, for 1 resident (Resident #3) of 4 residents reviewed for care plans. The facility did not care plan Resident #3's refusal of care nor his aggressive behaviors. These failures could place residents at risk for not receiving necessary care and services. The findings included: Record review of Resident #3's Face Sheet dated [DATE] documented an [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with the diagnoses of: Alzheimer's disease (cognitive deficits), dementia (cognitive deficits), mood disorder due to physiological condition with depressive features, dementia in other diseases classified elsewhere, moderate, with psychotic disturbance, and generalized anxiety disorder. Resident #3 was discharged [DATE]. Record review of Resident #3's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 had a brief interview of mental status score of 3 (severe impaired cognition). Resident #3 was coded for rejection of care occurring 1 to 3 days, but not coded for verbal/physical behaviors directed to others (including: hitting, kicking, pushing, scratching, grabbing, abusing other sexually, threatening other, screaming at others, or cursing at others). Resident #3 was additionally coded for needing substantial assistance for toileting, showering, dressing, and personal hygiene. Resident #3 was coded for needing partial/moderate assistance for transferring from chair/bed-to-chair transfer. Record review of Resident #3's Care Plan date initiated [DATE] refelcted care plans [resident] uses antipsychotic medication (Seroquel) related to behaviors. However, there are no specific behaviors (including verbal or physical aggressiveness) noted throughout the care plan. Nor is there any plan of care for Resident #3's refusal of care. Record review of Resident #3's Progress note dated [DATE] at 15:58 (3:58PM) the Administrator documented Admin and DON spoke with [family member] that nursing staff will be instructed to notify her of any updates regarding resident, including when resident refuses ADL care. Record review of Resident #3's Progress note dated [DATE] at 8:18AM revealed LVN C documented CNA reported that resident refused to go to dining room for breakfast, yelling and telling staff to get out of his room. Reapproached by nurse and assisted to dining room, pleasant mood, good appetite, no further refusal of care. X1 extensive assist with shower. Record review of Resident #3's Progress note dated [DATE] at 11:57 AM revealed LVN B documented Spoke with [family member], to inform that [Resident #3] has refused his shower x2, she informed me he was probably tired from being gone all day yesterday and it was alright if he does not have a shower today, but if he refuses on his next shower day on Monday to call her so she can help. Record review of Resident #3's Progress note dated [DATE] at 1:32AM LVN D documented, Phlebotomist in facility to obtain ordered labs for procedure. Resident refusing to have labs drawn. Attempted to call [family member] x2 to speak with resident. No answer left voicemail. Attempted to encourage resident to allow labs to be drawn after explaining the purpose and resident became combative and attempted throwing remote at this nurse. Repeatedly screaming to get the f*** out and don't come back. Left the room with the phlebotomist and attempted calling RP again. No answer. Will update when call is returned. Record review of Resident #3's Progress note dated [DATE] at 11:50AM, the SW documented [Resident #3 was on the schedule to see optometry today ([DATE]). He declined. I called his [family member] to inform her. Record review of Resident #3's Progress note dated [DATE] at 22:38 (10:38PM) RN A documented Refused to be assessed by this nurse. Yelling at aides and roommate. Record review of Resident #3's Progress note dated [DATE] at 7:30AM LVN D documented, CNA attempted to assist resident to change brief and resident grabbed CNAs wrist and began yelling at her to get out of his room. This nurse went into room to intervene and attempted to find out why he is upset, and he immediately became verbally aggressive again yelling to get out of his room and to leave him alone. Attempted to encourage help due to being fall risk, resident continued with agitation. Record review of Resident #3's Progress note dated [DATE] at 14:40 (2:40PM) revealed LVN C documented Resident continues with increased agitation at times. Much reorientation, redirection, and reapproach when needed. Resident arguing with residents at lunch table where he normally sits, moved to another table. Record review of Resident #3's Progress note dated [DATE] at 10:00AM revealed LVN C documented Resident sitting in recliner refusing assistance with toileting and incontinent care. Different staff members attempted to assist, and resident continues to refuse care. Resident stated I know I am wet. This is my body and I do not want you to touch me. Record review of Resident #3's Progress note dated [DATE] at 10:30AM revealed LVN C documented Call to [family member] and notified that resident continues to refuse care after several attempts . Record review of Resident #3's Progress note dated [DATE] at 12:00PM revealed LVN C documented Resident allowed OT to transfer to wheelchair and to dining room, continued to refuse incontinent care. Record review of Resident #3's Progress note dated [DATE] at 15:32 (3:32PM) revealed LVN C documented Call to [physician] reported that resident continues to refuse care with episodes of anxiety and agitation/ aggression. Record review of Resident #3's Progress note dated [DATE] at 13:01 (1:01PM) revealed LVN C documented Reported to [primary care provider] continuation of behaviors including refusing care, easily agitated, argumentative, episodes of anxiety. During an interview on [DATE] at 1:25PM LVN C stated Resident #3 would refuse care often. LVN C stated Resident #3 was diagnosed with dementia. LVN C stated when Resident #3 would refuse care, she would instruct the CNAs to revisit and offer showers, with different people. LVN C stated CNAs would document refusal for shower in Resident #3's electronic health record. LVN C stated the CNA, would notify her each time Resident #3 refused care. LVN C stated Resident #3 was combative with several CNAs but does not recall specific names. LVN C stated if she were to encounter any care refusals, she would document in nurses' notes. LVN C also stated she would also notify the administration during daily care meetings, and Administrator was made aware of all concerns, and addressed them in care plan meetings. LVN C stated she does not edit resident care plans, and stated the care plans are updated by the MDS Coordinator and possibly the managerial administration. LVN C stated care plans afford the nursing clinical staff to know what the plan of care is for each of their residents. LVN C stated if a resident was exhibiting certain behaviors, the nurse could review the care plan and see which interventions were viable for taking care of those specific resident behaviors. LVN C stated if care plans are not updated accordingly, there could be a potential negative effect on the resident's well-being. LVN C stated she could not recall when she was last in-serviced about care plans. During an interview on [DATE] at 3:12PM ADON A stated Resident #3 was physically aggressive towards staff. ADON A stated Resident #3's family member would be notified each time Resident #3 was refusing showers, and when he was exhibiting aggressive behaviors. ADON A stated Resident #3 would chronically refuse brief changes, transfers from bed to chair, showers, became very confused, and would become angry and combative with staff and family. ADON A stated care plans were utilized to notify the clinical staff that there is a problem, and interventions needed to fix the issues. ADON A stated care plans were in place to communicate what goal is warranted for each resident. ADON A stated Resident #3's chronic refusals of care would be something to care plan. ADON A stated, while reviewing the care plan for Resident #3, Resident #3's chronic refusals of care should have been care planned. ADON A stated she did not see the chronic refusal behavior on Resident #3's care plan, nor did she see any interventions for Resident #3's aggressive behavior. ADON A stated the care plan would be updated by the MDS Coordinator. ADON A stated care plans would aid in interventions, like if family wanted to be called, or if something works, care plans should be updated to reflect current concerns and effective interventions. ADON A stated the well-being of Resident #3 could have been affected negatively since his care plan was not updated accordingly. ADON A stated nurses have access to edit care plans. ADON A stated, while reviewing Resident #3's care plan, that it should have been updated to include specific aggressive behaviors, and his refusal of care. ADON A stated she does not know why Resident #3's care plan was not updated to reflect the two noted concerns. ADON A stated she was certain the care plan was updated to include Resident #3's aggressive behaviors and refusal of care, but does not understand why those two concerns are not in Resident #3's care plan. ADON A stated last month nurses were educated via in-service on the expectation of documenting in care plans. During an interview on [DATE] at 2:35PM the MDS Coordinator/Case Management Specialist (CM), stated ,d+[DATE] months before Resident #3 expired, the resident would refuse to shower, eat, and became physically and verbally combative. CM stated Resident #3 was combative with staff, stopped eating, and refused to take showers. CM stated nurses would try hard to advocate for the resident's well-being, but he would refuse. CM stated the family would be notified when Resident #3 would refuse showers. CM stated Resident #3's violent and refusal behaviors were care planned. CM stated, while reviewing Resident #3's care plan, she did not see the behaviors care planned. CM stated Resident #3's refusal for care including incontinent care, and bathing are not care planned. CM stated these behaviors and refusals should be care planned. CM stated nurses, social workers, activities director, ADONs, and DON all have access to edit. CM stated ADONs and DON, and nurses update acute incident/accidents. CM stated this particular care plan for Resident #3 was not updated to reflect Resident #3's refusal of care, and aggressive behaviors. CM stated care plans are utilized to know what is happening with resident, and what is needed to provide an in-depth perspective of what is going on with Resident #3 and is also used to know the facility is doing what they are supposed to do for the resident. CM stated interventions used when Resident #3 was exhibiting aggressive behaviors (including verbal and physical aggression) included offering sandwiches or coffee. CM stated care planning could have helped de-escalate Resident #3's aggression, but continued to state, nothing was helping during Resident #3's progressive decline. CM stated by not editing Resident #3's care plan, Resident #3's well-being could have been negatively impacted. CM stated department heads from the facility were in-serviced by their corporation consultant about care planning last March/April of 2023. During an interview on [DATE] at 3:29PM the DON stated she began her employment with the facility the end of [DATE]. The DON stated aggressive behaviors and refusals would be care planned. The DON stated care plans are tools that communicate to staff interventions if they had questions regarding the care of the resident. The DON gave no definitive answer when asked how non-updated care plans could affect the resident. The DON gave no definitive answer when asked, why Resident#3's care plan was not updated. The DON stated she could not speak to the previous DON's actions or intent. The DON stated if a resident did exhibit aggressive behaviors, she would care plans the specific behaviors, additionally if a resident was exhibiting/verbalizing refusal of care, she would include that concern into the care plan. The DON stated, her process is that if there is a concern, it is addressed during next IDT meeting which happens daily Monday-Friday. The DON stated during the IDT meetings, care plans are updated accordingly. The DON could not recall when the last care plan in-service was conducted. The DON stated the MDS Coordinator, ADONs, and department heads have access to edit care plans, but gave no definitive answer as to why Resident #3's care plan was not updated for his refusal of care nor his aggressive behaviors. Record review of the facility's [DATE], [DATE] Care Plans in-service reviewed. Record review of the facility's Care Plan Revisions Upon Status Change date implemented [DATE] documented, Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change 2. Procedure for reviewing and revising the care plan when a resident experience a status change 2d. The care plan will be updated with the new or modified interventions. 2f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member.

Based on interviews and record review the facility failed to notify the resident, resident's representative, and ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood before transferring or discharging the resident for 1 of 4 residents (Resident #2) reviewed for transfer and discharge. Resident #2's responsible party and the ombudsman were not notified in writing of the effective date of transfer or discharge for Resident #2, the reason for the transfer/discharge, the location to which the resident would be transferred, or the right of appeal. Resident #2 was discharged on [DATE] to an emergency room hospital for a psychological evaluation. This deficient practice could affect residents who are transferred or discharged from the facility at risk of having their discharge rights violated. The findings included: Record review of Resident #2's face sheet dated 12/15/2024 revealed a [AGE] year-old female who was admitted on [DATE]. Diagnoses included Alzheimer's disease (decline in cognitive abilities that impacts a person's ability to perform everyday activities), and frontotemporal neurocognitive disorder (types of dementia involving the progressive degeneration of the brain's frontal and temporal lobes). Date of discharge 05/21/2024, discharged to behavioral hospital. Record review of Resident #2's Optional State Assessment MDS assessment dated [DATE] reflected a BIMS score of 12 (moderate cognitive impairment) with supervision oversight for bed mobility, transfers, eating, and was not coded for any behavioral issues. Record review of Resident #2's care plan date initiated 5/15/2024 reflected no behaviors including physical or psychological (suicidal ideation, or homicidal ideations) noted. Resident #2 was admitted on [DATE] and discharged [DATE]. The resident has impaired cognitive function/dementia or impaired thought processes. Communicate with the resident/family/caregivers regarding residents' capabilities and needs. Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues stop and return if agitated. Cue, reorient and supervise as needed. Engage the resident in simple, structured activities that avoid overly demanding tasks. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Record review of Resident #2's progress notes dated 05/21/2024 at 15:37 (3:37PM) revealed, Charge Nurse notified this nurse that [Resident #2] is inconsolable and crying, stated she wanted slit her throat Upon entering the dining area in the tradition's unit, [Resident #2] was sitting at the table and crying. She stated, I want to take a knife and cut my throat When asked what happened she stated she wanted a cigarette, and no one will let me smoke when I want to smoke! this nurse assisted resident to smoking area and she calmed a bit. She continued to express the want to harm herself. Administrator, DON, MD and [family member] notified. Orders received to send to ER for evaluation. Record review of Resident #2's physician's order dated 05/21/2024 revealed, send to ED for further evaluation and treatment. Record review of Resident #2's Transfer/Discharge notice on Resident #2's electronic health record dated 05/21/2024 at 16:00 (4:00PM) revealed, 1. On this date 05/21/2024, the facility representative is notifying a. Resident and b. Resident Representative of a transfer/discharge. 3. The resident is being discharged /transferred for the reasons below: a. Emergency transfer to Acute Care setting. 4. Bed Hold Policy Provided. 5. CC: Facility Ombudsman. Requested on 12/15/2024 at 11:16AM for DON and ADON A to provide the written notification of Resident #2's discharge to Resident #2's responsible party and ombudsman. No documentation was provided by exit conference. Requested on 12/15/2024 at 12:34PM for the Administrator to provide the written notification of Resident #2's discharge to local ombudsman and responsible party. No documentation was provided by exit conference. Record review of the facility's Complaint/Grievance Follow-up Report date received 06/11/2024, date of initial contact: 06/11/2024, Name of Person Contacted: [Ombudsman B], Name of person Assigned to Resolve Compliant/grievance: Administrator, Nature of Complaint: Ombudsman stating she filed complaint with state for improper discharge of resident to behavioral hospital and now facility does not have a bed available for her on secure unit. Follow up: Comments: Please see attached document. The attached document is the Resident Admission Agreement revised: 10/14/2021, with a highlighted portion on page 10 entitled Bed Hold stating Consequently it is the responsibility of the Medicaid recipient or responsible party to reserve a bed at this healthcare facility and to [ay bed hold charges as stated in this agreement .The first notice is provided upon admission or readmission to the facility. The second notice is provided at the time of transfer for hospitalization or therapeutic leave that does not meet the criteria for Medicaid payment. There were no other documents attached to grievance complaint. During an interview on 12/15/2024 at 11:57AM and on 12/16/2024 at 11:41AM the SW stated she started her employment at the facility in late March 2024. The SW stated once a resident is admitted /readmitted to the facility she will conduct a series of assessments including demographic information, and transitional planning care form. The SW stated she is not involved in the discharge process if the resident is transferred to an emergency room but does play a part in facility-to-facility transfer, and when a resident is discharged to home. The SW stated she was notified during a morning meeting of Ombudsman B's concern of improper discharge of Resident #2. During a morning clinical meeting and stated she does not recall the date of the meeting. The SW stated on 5/21/2024 Resident #2 was discharged to the emergency room for a psych evaluation. The SW stated once the resident is outside of the facility, she does not follow up with outside facility entities. The SW stated if a resident verbalized suicidal ideations, the clinical staff would advocate for a psychological evaluation and treatment for the well-being of the resident. The SW stated during June 2024 she recalls speaking with the Ombudsman A about the concern of not receiving the discharge list from the facility. The SW stated she does not recall the specific details when she spoke to Ombudsman A. The SW stated, when the residents are discharged home, she will provide a discharge summary and when they need to follow up with the PCP. The SW stated maybe the hospital nurse case manager may provide discharge notification something, but it is more for home discharge, but she herself does not send any written notification to RPs if a resident is being transferred to another facility after the hospital. During an interview on 12/16/2024 at 11:26AM the BOM stated she does not send out any discharge/transfer written notifications to the RP or Ombudsman. The BOM stated her scope of practice, within the electronic health record was to ensure the electronic health record is complete to which she will then close out the record to reflect the resident is no longer within the facility. The BOM stated her normal practice is to close out the electronic health record, the day after the resident is transferred/discharged . The BOM stated that is the extent of her role regarding the discharge process. During an interview on 12/16/2024 at 12:20PM the Admissions Director/Coordinator stated she does not send out any discharge/transfer written notifications to the RP or Ombudsman. The Admissions Director stated she is not a part of the discharge process. During an interview on 12/16/2024 at 12:36PM the Administrator stated Resident #2 was transferred to a hospital for a psychological evaluation on 05/21/2024 as she was voicing suicidal ideations. The Administrator stated she was unaware that the facility needed to notify the RP and Ombudsman in written form about the discharge/transfer of Resident #2. The Administrator stated on 5/21/2024 the RP was notified verbally of Resident #2's transfer to the hospital for a psychological evaluation, but stated she was unaware that she needed to additionally notify the ombudsman. The Administrator stated she does not recall discharge written notifications being sent out for Resident #2. The Administrator did not provide a definitive answer when asked how could not providing the written discharges/transfer notifications affect the residents. The Administrator reiterated she was unaware that she needed to provide written notifications to RPs and Ombudsman. The Administrator stated once the resident is transferred/discharged out of the facility to another facility she, herself, does not have a follow up process. The Administrator stated she will attempt to locate written discharge documents for Resident #2 to RP and Ombudsman. Record review of the facility's Discharge Summary and Place of Care date implemented 10/24/2022 reflected it does not include the process for providing documentation upon discharge.

Based on interview and record review the facility failed to immediately consult with the resident's physician when there was a significant change or a need to alter treatment, for one resident (Resident #1) of three residents reviewed for notification of changes. The facility failed to consult with Resident #1's physician when Resident #1 held her groin, indicating pain, yelling ow ow ow on 07/06/2024. On 07/06/2024 there was indication of groin pain, which was different from 07/05/2024's left and right knee pain. These failures could affect residents who experience a change in condition that require immediate pain assessment and assistance. The findings included: Record review of Resident #1's face sheet dated 12/15/2024, revealed Resident #1 was initially admitted on [DATE], and readmitted on [DATE]. Resident #1 was a [AGE] year-old female who was admitted with diagnosis' fracture of unspecified part of neck of right femur (the bone of the thigh or upper hind limb, articulating at the hip and the knee), subsequent encounter for closed fracture with routine healing, cognitive communication deficit, age-related osteoporosis without current pathological fracture, dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance, and history of falling. Record review of Resident #1's discharge MDS assessment dated [DATE] revealed, a BIMS of empty value indicating unable to complete the interview, and needed substantial assistance with toileting, bathing, dressing, personal hygiene and dependent for bed-to-chair transfer. Additionally, Resident #1 was coded for history of falling. Record review of Resident #1's care plan date initiated 07/06/2024 revealed, Problem: [Resident #1] has had an actual fall r/t impaired cognition, impaired mobility, behaviors, psychotropic drug use, unrealistic sense of abilities. 7/5/24- ambulating without walker; no injuries. Interventions: 7/5/24- Placed sign with resident name on her door due to wandering into other residents' rooms. Will speak to family regarding moving resident closer to nurses' station. (7/8/24- Pelvic x-ray ordered due to increased pain, noted right femoral neck fracture. Resident sent to hospital.) Continue interventions on the at-risk plan. For no apparent acute injury, determine and address causative factors of the fall. Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks per policy if applicable. Pharmacy consults to evaluate medications if indicated. Report to nurse any s/sx 72hour post fall: Pain, bruises, change in mental status, sleepiness, inability to maintain posture, agitation. Therapy screening evaluation. Record review of Resident #1's progress note dated 07/05/2024 at 15:32 (3:32PM) revealed, ADON A documented CNA notified Charge nurse that [Resident #1] was ambulating in hallway towards the nurses' station without her walker and upon approaching the resident to redirect and assist her, [Resident #1] then leaned her back against the wall and slid herself to the floor in a soft manner and upright position. Resident was assessed from head to toe and vitals obtained. Assisted to a standing position per staff assist x 1 and ambulated with assist to her room. No complaints voiced at this time. call light in reach. [primary care provider] was notified and no further orders were received. skin intact. Record review of Resident #1's pain evaluation effective date 07/05/2024 at 16:13 (4:13PM) revealed, Resident #1's complaint of right knee (front): description: chronic pain with ambulation; left knee (rear) description: chronic pain with ambulation. 4b: Negative vocalization-occasional moan or groan low-level of speech with a negative or disapproving quality. 4c: Facial expression: Sad/frightened/frown- Sad. Frightened. Frown. Record review of Resident #1's progress notes administration note dated 07/06/2024 at 9:50AM LVN A documented, Tramadol HCL Tablet 50mg. Give 50mg by mouth every 6 hours as needed for pain. Note: Resident crying and yelling out it hurts while rubbing her thighs and knees. Record review of Resident #1's progress notes effective date 07/06/2024 at 13:54 (1:54PM) LVN A documented follow up pain scale was effective and numerical value 0. Record review of Resident #1's progress notes effective date 07/06/2024 at 21:24 (9:24PM) LVN A documented Administration note: Tramadol HCl tablet 50MG: Give 50MG by mouth every 6 hours as needed for pain Resident holding groin and yelling OW OW OW nurse assessed area for any redness or any other irregularity, none noted. Bowel sounds active in all 4 quadrants, no bowel movement at the time no hardened area near anus. Record review of Resident #1's progress note dated 07/07/2024 at 12:37PM LVN A documented Resident refusing to sit up into a complete sitting position yells out in pain when staff assist her to turn. Resident grabbing and holding onto her groin thighs and knees. All medication orders followed with no relief. Nurse attempted nonpharmacological interventions. no changes noted in pain. [Primary Care Provider] notified of increased pain. DON notified of change. Received N.O for Tramadol 50 MG PO Q6H X5 DAYS and Acetaminophen 500 MG PO Q6H X5 DAYS. Resident has accepted all medications. Record review of Resident #1's radiology results report examination dated 07/08/2024 at 14:24 (2:24PM) Impression: The bones are osteoporotic. There is an acute right femoral neck fracture. On 12/16/2024 at 1:13PM, 1:28PM, 1:49PM attempted interview with LVN A. Additionally, ADON A, DON, and Administrator attempted to contact LVN A, but staff member was not responding. ADON A stated LVN A was on maternity leave. LVN A did not return call prior to exit conference. During an interview on 12/15/2024 at 3:56PM ADON A stated Resident #1 had a witnessed fall on 07/05/2024 and 2 days later, Resident #1began to complain about a lot of pain. ADON A stated after Resident #1's verbalized pain the facility advocated for an x-ray, but that Resident #1 was still walking around up to that point. ADON A stated Resident #1 always complained about her chronic knee pain. ADON A stated Resident #1 would often refuse medications and care, and to persuade Resident #1 to receive an x-ray, for her, was identical to pulling teeth. ADON A stated Resident #1 on 07/05/2024 did not show any indication of unusual pain other than her chronic knee and thigh pain. ADON A stated Resident #1 was seen on 07/06/2024, was seen wandering in the hallway. ADON A stated on 07/07/2024 Resident #1 exhibited signs of severe pain and the primary care physician was notified. ADON A stated on 07/08/2024 Resident #1 again exhibited unmanaged pain to which an x-ray was ordered, and results concluded Resident #1 had an acute fracture. ADON A stated Resident #1 was very hard to treat as Resident #1 would refuse care. ADON A stated while reviewing 07/06/2024's progress note, as LVN A described a different area of pain, the expectation would be for the nurse to notify the practitioner of the pain irregularity. ADON A stated Resident #1's complaints of knee and thigh pain were not out of character. ADON A stated, while reading LVN A's 07/06/2024 progress notes, LVN A should have notified the primary care physician as an effort to advocate for the well-being of Resident #1. ADON A stated LVN A had previously been re-educated on a separate nursing matter concerning documentation, and stated once LVN A returns she will be removed from independently caring for residents and will be retrained with another staff member. ADON A reiterated that LVN A should have notified the primary care physician of Resident #1's groin pain, and potentially compromised the resident's well-being. ADON A stated while reviewing the progress notes, the resident's pain was being managed on 07/06/2024, and it wasn't until the following day on 07/07/2024 that Resident #1 exhibited pain that was then deemed unmanageable, to which the nurses advocated for additional interventions including medications and x-rays. ADON A stated LVN A is out on maternity leave. ADON A stated while, reviewing Resident #1's progress notes if Resident #1 had a change in pain location or an increase in pain, LVN A should have notified the primary care physician to inquire about any additional interventions, and stated LVN A had been educated on notifying physicians. ADON A stated she would want to see that staff was doing something about the pain. ADON A stated she would provide those above mentioned LVN A re-trainings. During an interview on 12/16/2024 at 3:29PM the DON stated she has worked for this facility since the end of June 2024. The DON stated Resident #1 had horrible knee pain and it was difficult to see Resident #1 endure the pain while Resident #1 walked the hallway. The DON stated she does not know what LVN A was thinking or her intent on 07/06/2024, but that Resident #1 would not be able to verbalize pain. The DON stated the expectation of the facility would be to follow the professional standard of nursing and conduct a thorough head to toe exam and notify the primary care provider if any irregularities are noted. The DON stated she could not provide a definitive answer regarding if pain would be an irregular finding. The DON stated she could not give a definitive answer or what was an abnormal and normal finding regarding a pain assessment. The DON stated Resident #1 was still ambulating on 07/05/2024 and 07/06/2024, but if LVN A found something irregular during her assessment, she should have notified the primary care physician, as an effort to advocate for the well-being of Resident #1. The DON stated the groin is anatomically different from the knees and thighs, and that if she were the nurse taking care of the resident, she would have notified the physician of Resident #1's groin pain. The DON stated any unusual findings on assessment the provider would be notified. The DON stated if LVN A did not notify the physician of Resident #1's complaint of groin pain on 07/06/2024, she could have potentially compromised the well-being of Resident #1, by prolonging pain endurance. The DON stated while reviewing Resident #1's progress notes, on 07/06/2024 Resident #1's pain was being managed, but that there appeared to be no documentation of notifying the physician of Resident #1's groin pain. The DON stated the plan once LVN A returns from maternity leave, is to retrain her with another knowledgeable clinical staff member. During a brief interview on 12/16/2024 at 2:13PM the Administrator stated that she would have to locate LVN A's individual documentation re-training in-service within her in-service binder but alluded to not being able to locate the requested documentation. Additionally, that retraining document for LVN A was not provided by time of exit conference. Record review of the facility's Notification of Changes policy and procedure date implemented 10/24/2022 documents, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. Record review of the facility's Pain Management policy and procedure date implemented 08/15/2022 documented, the facility must ensure that pain management is provided to resident who require such services, consistent with professional standards of practice, the comprehensive person-entered care plan and the residents' goals and preferences. Recognition: 2. The facility will observe for nonverbal indicators which may indicate the presence of pain. Theses indicators include but are no limited to b. Loss of function or inability to perform activities of daily living (e.g., rubbing a specific location of the body, or guarding a limb or other body parts). Pain Management and Treatment: 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual's resident pain beginning at admission.

[NAME], [NAME] Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #7 and #48) of 5 residents reviewed for infection control. CNA A failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #7. CNA D and NA G failed to wash their hands and change their gloves after they became contaminated during incontinent care while assisting Resident #48. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: RESIDENT #7 Record review of Resident #7's admission record dated 11/02/2023 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy. She was [AGE] years of age. Record review of Resident #7's care plan dated 08/06/23 indicated in part: Problem: Skin integrity: The resident is at risk for impaired skin integrity related to: bladder incontinence, bowel incontinence, contractures. Goal: The resident will remain free from alterations in skin integrity. Interventions: Provide timely incontinent care; provide and/or encourage good skin care (keeping skin clean, conditioned, and reducing excess moisture). Avoid massage over boney prominences during provision of care. Record review of Resident #7's MDS dated [DATE] indicated in part: BIMS = 09 indicating resident was moderately impaired. Urinary continence = Always incontinent. Bowel continence = Always incontinent. During an observation on 10/31/23 at 10:02 AM, CNA A performed incontinent care for Resident #7. CNA A washed her hands and then put on some clean gloves. CNA A then undid the resident's brief and took some wet wipes and wiped the resident vaginal and rectal area. CNA A then applied a clean brief, changed the bed sheets, adjusted the resident's pillow and then covered her, while still wearing the same gloves she used to wipe the residents vaginal and rectal area. During an interview on 11/01/23 at 10:54 AM, CNA A said she should have changed her gloves after she wiped Resident #7's vaginal and rectal area. CNA A said not changing her gloves could lead to cross contamination as she had also touched the bed sheets and other items with the same gloves that possibly came in contact with the resident's urine and other areas. CNA A said she had received training on when to change her gloves once they were contaminated. CNA A said the failure occurred because she got nervous and forgot to change her gloves once they became contaminated. RESIDENT #48 Review of Resident #48's Admission Record dated 11/2/23 revealed he was an [AGE] year-old male admitted to the facility 3/31/22 with diagnoses which included Alzheimer's Disease, hypertension (high blood pressure), chronic kidney disease stage 2, and muscle wasting and atrophy. Review of Resident #48's Annual MDS assessment dated [DATE] revealed: He scored a 3 on his mental status exam indicating severe cognitive impairment. He required extensive assistance with ADLs except for eating which only required supervision. He was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #48's Care Plan, revision date 7/26/23, revealed: Problem - Skin Integrity : Resident #48 is at risk for impaired skin integrity related to anemia, bladder incontinence, impaired circulation o sensation, impaired cognition, peripheral vascular disease. Goal - The resident will remain free from alterations in skin integrity (i.e., pressure ulcers) by/through next review date. Interventions - Provide timely incontinent care; provide and/or encourage good skin care (keeping skin clean, conditioned, and reducing excess moisture); avoid massage over boney prominences during provision of care. During observation on 10/31/23 on 12:21 PM, CNA D and NA G entered Resident #48's room and informed him they were there to do incontinent care and get him dressed for lunch. NA G and CNA D both washed their hands and donned gloves. CNA D stated that Resident #48's sheets and clothing were saturated with urine and that all the bedding would need to be removed. CNA D unfastened the soiled brief and then CNA D used wipes to clean resident front to back using each wipe only once then discarding into trash bag placed at bedside. NA G assisted resident to turn to his left side and held him in place while CNA D cleaned the resident's left buttock and tucked soiled brief and bedding under resident. CNA D placed clean brief under the resident and NA G and CNA D then rolled resident to his right side and NA G pulled the soiled bedding and soiled brief the rest of the way out from under him, placing them in a trash bag, pulled the clean brief further under him and used wipes to clean his right buttock. Resident #48 was rolled onto his back and the clean brief was repositioned and fastened. CNA D and NA G then assisted the resident in dressing. Neither CNA D nor NA G changed their gloves or performed hand hygiene after coming into contact with the soiled linens and soiled brief, or after performing incontinent care. In an interview on 11/2/23 at 2:48 PM, CNA D stated that the proper procedure for incontinent care was to knock, introduce herself, explain what she was going to do, make sure she had supplies (wipes, clothes, brief, trash bag for dirty stuff), close curtain before she undressed the resident and make sure door is closed for privacy. She stated that she would wash her hands for 20 seconds to a minute, washing under nails, palms of hands, between fingers and thumb, then rinse, and get paper towels to dry hands and turn off faucet - never used clean hands to turn off faucet. After her washing hands then she would put on gloves and tell the resident again, what she was about to do. She stated then she would remove the resident's pants or dirty clothing and place them in dirty laundry bag. CNA D stated after removing the resident's clothes, she unfastened the soiled brief. She stated that to clean the resident, she would use a wipe and clean the groin from front to back once, then throw the wipe away and repeat that process until the area was clean. Then she would tell the resident that she was going to turn them and turn them to the side and repeat cleaning with wipes using only once then throwing away until resident is clean. Then she would tuck the soiled brief under resident. CNA D stated that after removing the soiled brief she would remove her dirty gloves, use hand sanitizer, or wash her hands and put on clean gloves. She stated she would tuck a clean brief under resident and make sure it was positioned correctly and then tell the resident to roll back over towards her and then roll them back onto the other side and remove the soiled brief then roll them back to flat on their back and pull the clean brief out and adjust it to fasten. She stated she would throw soiled brief away after she had gotten the clean brief on the resident. She stated that after the incontinent care was done, she would continue assisting the resident with whatever else they needed at that time. CNA D stated that the care with Resident #48 did not go great because they did not have hand sanitizer and they did not wash their hands after they finished. CNA D acknowledged that she and NA G did not change their gloves during the incontinent care. She stated she just forgot to change her gloves because it was a very busy time of day and that she was frustrated with herself because she knew better. CNA D stated that the importance of changing gloves during resident care was to prevent cross contamination from dirty areas to clean areas, and to help stop the spread of infections in the facility whether it was from resident to staff or staff to resident. During an interview on 11/02/23 at 03:20 PM, the DON said it was her expectation that staff used good infection control practices during resident personal care such as if they touched a dirty surface then they had to use hand sanitize or wash their hands. The DON said staff were expected to remove their gloves after the gloves were soiled or became contaminated and wash their hands. The DON was made aware of the observations of incontinent care. The DON said the infection control nurse who is ADON E did audits such and check-offed staff for infection control on a monthly basis. During an interview on 11/02/23 at 03:25 PM, ADON E said she monitored staff when they performed incontinent care as part of her weekly audit and would sample at least 4 staff per week and all staff annually. ADON E said it was expected for staff to wash their hands prior to performing personal care and after they removed their gloves. ADON E was made aware of the observations of incontinent care. ADON E said staff were expected to change their gloves once they became contaminated to prevent contamination of the clean items. ADON E said the failure probably occurred because the staff got nervous and forgot to change their gloves once they became contaminated. During an interview on 11/02/23 at 03:47 PM, the Administrator said it was his expectation for residents to be free from cross contamination or infection. The Administrator said it was his expectation for the staff to follow the policy regarding hand hygiene in order to prevent health issues. The Administrator said the DON, ADON, infection control preventionist and himself were responsible to monitor the infection prevention procedures. The Administrator was made aware of the observations of incontinent care. The Administrator said if the staff used contaminated gloves to perform resident care that could lead to the spread of infections. The Administrator said the failure occurred due to missed steps and staff could have forgotten some of the steps. Record review of the facility's policy titled Infection control - purpose and policy dated 04/15 indicated in part: The infection control program is the umbrella program that encompasses both policy and procedures that fall under the purview of infection control. Periodic changes should be published under the direction of the infection control committee. The purpose of the infection control program is to investigate, control and prevent infections in our facilities; decide which procedures such as isolation should be applied to an individual resident; maintain a record of incidents and corrective actions related to infections. The following general policy to prevent the spread of infection applies - Employees should wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Record review of the facility's policy titled Gloves dated 04/15 indicated in part: Gloves should be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. All employees should wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. When gloves are indicated they should be used only once and discarded into the appropriate receptacle. Handwashing and/or hand disinfectant is necessary when gloves are removed. Record review of the facility's policy titled Incontinence Care (Male/Female, Catheters) dated 04/15 indicated in part: The purpose of this procedure is to provide guidelines that should aid in preventing the resident's exposure and spread of infections. Soiled disposable items should be handled so as to prevent contamination of the environment. Wash your hands thoroughly at the following intervals - before the procedures; anytime they become soiled with blood or body fluids; whenever in doubt; and upon completion of your task or procedure. Wash your hands thoroughly or use hand sanitizer at the following intervals: before resuming the procedure after an interruption; and when changing/removing gloves or any personal protective equipment. Use a washcloth with warm water and soap or incontinent product to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke, wipe from front to back, cleanse around the urethral area, move outward towards thighs and avoid rectum, finish with a clean moist cloth to remove soap and other incontinent product that may require rinsing. Remove gloves sanitize hands and apply clean gloves. Remove soiled items, replace with clean dry briefs or under pad as indicated, place disposable brief or under pad into waste container, discard disposable equipment and supplies in designated containers. Remove gloves and discard into designated container, wash and dry your hands, reposition the bed covers, make resident comfortable. Wash and dry your hands thoroughly.

Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 16 residents (Resident #38, Resident # 41, Resident #63) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #38 prior to administering Ativan, a sedative used to treat anxiety (excessive worry and tension that disrupts daily life and lasts 6 months or longer). The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #41 prior to administering Mirtazapine, an antidepressant used to treat depression (a mood disorder that causes a persistent feeling of sadness or loss of interest). The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #63 prior to administering Mirtazapine, an antidepressant used to treat depression (a mood disorder that causes a persistent feeling of sadness or loss of interest). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings include: Record review of Resident #38's face sheet revealed admitted [DATE] with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), and dementia a condition characterized by progressive or persistent loss of intellectual functioning), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and anxiety (excessive worry and tension that disrupts daily life and lasts 6 months or longer) . She was [AGE] years of age. Record review of Resident #38's quarterly MDS, dated [DATE], indicated he had a BIMS score of 02, which indicated she was severely cognitively impaired. The MDS also indicated Resident #38 was diagnosed with Alzheimer's, dementia, anxiety and depression. Record review of Resident #38's care plan dated 08/31/23 indicated, in part: Focus: resident is verbally aggressive related to dementia, Poor impulse control. Goal: The resident will demonstrate effective coping skills through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #38's medication profile dated 05/29/23 indicated in part: Ativan 1 milligram, give 1 tablet by mouth 2 times a day related to anxiety. Record review of Resident #38's Medication Administration record shows that Ativan tablet 1mg was administered by mouth two times a day at 1200 and 2000 starting 05/29/2023. Record review of Resident #38's clinical records revealed no evidence that the resident or the residents representative signed a consent form for the use of Ativan with start date of 05/29/23. Record review of Record review of Resident #41's face sheet revealed admitted [DATE] with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). She was [AGE] years of age. Record review of Resident #41's admission MDS, dated [DATE], indicated he had a BIMS score of 04, which indicated she was severely cognitively impaired. The MDS also indicated Resident #41 had diagnosis of non-Alzheimer's dementia and depression. Record review of Resident #41's care plan indicated, in part: Focus: resident has an ADL self-care performance deficit related to Alzheimer's, Dementia. Goal: The resident will continue to participate in at least 3 out of room activities a week through next review date. Intervention: Monitor, document, and report any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of Resident #41's medication profile dated 05/22/23 indicated in part: Mirtazapine 15 milligram, give 1 tablet by mouth at bedtime. Record review of Resident #41's Medication Administration record shows that Mirtazapine oral tablet 15mg was administered once a day at 2100 starting 05/22/2023. Record review of Resident #41's clinical records revealed no evidence that the resident or the residents representative signed a consent form for the use of Mirtazapine with start date of 05/22/23. Record review of Record review of Resident #63's face sheet revealed admitted [DATE] with diagnoses of dementia (progressive loss of intellectual functioning, memory, and abstract thinking), anxiety disorder (ongoing anxiety that interferes with daily activities), Alzheimer's (a progressive disease that destroys memory and other important mental functions). She was [AGE] years of age. Record review of Resident #63's quarterly MDS, dated [DATE], indicated he had a BIMS score of 01, which indicated he was severely cognitively impaired. The MDS also indicated Resident #63 was diagnosed with mood disorder, Alzheimer's, dementia, and anxiety. Record review of Resident #63's care plan indicated, in part: Focus: has potential to be physically aggressive related to Dementia. Goal: The resident will demonstrate effective coping skills through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #63's medication profile dated 08/15/23 indicated in part: Mirtazapine 15 milligram, give 1 tablet by mouth at bedtime. Record review of Resident #63's Medication Administration record shows that Mirtazapine oral tablet 15mg was administered by mouth once a day at 2100 starting 08/15/2023. Record review of Resident #63's clinical records revealed no evidence that the resident or the residents representative signed a consent form for the use of Mirtazapine with start date of 08/15/23. Interview on 11/01/2023 at 1:00pm, RN C stated that when a new order is received, the nurse who takes the order is responsible for calling the residents representative to obtain consent, prior to administering the medication. The consent is then scanned in by medical records. RN C stated that if the consent is not in chart, then it could be in medical records. Interview on 11/01/2023 at 1:30 pm, Medical records staff stated that she scanned in all consents that nurses have turned in to her. She stated that she kept hard copies of all consents that she received. She stated that the missing consents were not in her possession. Interview on 11/01/2023 at 1:45 pm, the DON stated that all residents receiving psychiatric medications should have a written consent signed and scanned into their chart. When the nurse gets the order, they should immediately contact the family representative and get consent. I could not find those consents, which means we failed to get those consents prior to administration of medications. We need to tighten ship on that, we currently have no one checking behind the nurses to ensure they obtained consent. Record review of the facility's policy revised 08/15/22, titled Psychotropic Medications indicated, in part: Upon noting an order for psychoactive medication on admission or initiation of therapy: Complete the Consent for Use of Psychoactive Medication therapy with the resident and/ or the resident representative at the initiation of psychoactive medication and educate on the benefits, potential negative outcomes, alternatives, and outcomes of psychoactive medication use. Consent prior to the use of initiating medication. Consent prior to the use of initiating medication.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 3 residents (Residents #1, #2, and #3) reviewed for abuse. Resident #1 was placed in a chair and tied to it with a lab coat by LVN A. Resident #2 was held down with the full force of LVN A's body. Resident #3 had her hands held above her head and her mouth covered when she protested by LVN A. LVN B and CNA C had knowledge and/or witnessed LVN A abuse Residents #1, #2, and #3 and failed to notify the Abuse Prevention Coordinator/Administrator immediately. The Abuse Prevention Coordinator did not notify the licensing agent (Board of Nursing - BON) of abuse committed by LVN A after an investigation was completed and until the surveyor's inquiry. This failure could place residents at risk of abuse and injury. The staff failing to immediately report the incidents to the administrator/other officials could have led to the further abuse from LVN A. If the administrator/other officials were immediately notified, actions could have been taken to remove LVN A from the facility therefor preventing further abuse. On 7/11/2023 at 2:10 PM, the facility Administrator, DON, and the Corporate HR were notified that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with an Immediate Jeopardy Template at that time, with a revised Template on 7/13/2023 at 2:47 PM. These failures resulted in the identification of Immediate Jeopardy (IJ) on 07/11/23 at 2:10 PM. While the immediacy was removed on 7/14/2023 at 12:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm after the IJ immediacy was removed due to the facility's need to monitor the implementation of the plan of removal. The findings were: A review of Resident #1's face sheet accessed on 7/7/2023 indicated a [AGE] year-old female with a diagnosis included dementia, senile degeneration (of older individuals who suffered from cognitive decline, memory loss), epilepsy, anxiety, and age-related osteoporosis. A review of Resident #1's Annual Minimum Data Set assessment for Cognitive Patterns dated 5/26/2023 and accessed on 7/7/2023 revealed a BIMS score of 00, which indicated severe cognitive impairment. A review of Resident #1's care plan initiated on 5/25/2023 indicated she was unable to sit still for any length of time and will sit herself down on the floor from chair, wheelchair and bed and crawl around on the floor. Interventions included, among other things, to approach/speak in a calm manner. Divert attention. Monitor for restlessness and assist resident to sit on the floor in a safe space. A review of Resident #2's face sheet accessed on 7/7/2023 revealed an [AGE] year-old female with a diagnosis of dementia with other behavioral disturbance and major depressive disorder. A review of Resident #2's Quarterly Minimum Data Set assessment for Cognitive Pattern dated 4/13/2023 and accessed 7/7/2023 revealed a BIMS score of 6, which indicated severe cognitive impairment. A review of Resident #2's care plan initiated on 3/1/2023 revealed she was an elopement risk/wanderer and had behavioral problems with episodes of aggression. Interventions included diverting attention and speaking to resident in a calm manner. A review of Resident #3's face sheet accessed on 7/7/2023 indicated an [AGE] year-old female with a diagnosis of Alzheimer's disease, dementia, osteoporosis and anxiety disorder. A review of Resident #3's Annual Minimum Data Set assessment for Cognitive Pattern dated 4/3/2023 and accessed 7/7/2023 indicated a BIMS score of 1, which indicates severe cognitive impairment. A review of Resident #3's care plan initiated on 11/4/2022 indicates resident becomes physically aggressive with staff during resident care with interventions that include redirection, provide physical and verbal cues to alleviate anxiety, and 1:1 supervision until calm. Record review of a witness statement dated 6/15/2023 at 5:10 PM authored by CNA C documented that LVN A was aggressive with residents and that CNA C saw Resident #1 tied up. Record review of a witness statement dated 6/15/2023 authored by LVN B documented she untied Resident #1 with the help of CNA C. LVN B said she asked LVN A why she tied the resident up and LVN A said she was exhausted by resident #1 wandering up and down the halls. Interview with the DON on 6/23/2023 at 4:40 PM she said she knew the nurse that tied up Resident #1. The DON said she did not report it to the BON. The DON said she called the agency the next day, as soon as she found out. The DON said LVN A worked for the rest of her shift the night of the incidents after it was discovered she had tied up Resident #1 because no one immediately reported the incidents. The DON said LVN B was not allowed to work again for the facility because she did not report the abuse in a timely manner. The DON did not notify the BON about LVN B not reporting witnessed abuse. The DON said LVN B called her the next day to report the incident. The DON said she did call the police, but the police decided to not come out. The DON said the facility social worker assessed Resident #1 to make sure there were no effects they would have noticed. The DON said they have a lot of agency nurses, and she said she understood the nurses she got from agencies were the responsibility of the facility. During an observation and interview of Resident #1 on 7/6/2023 at 10:50 AM Resident #1 was found in her room, resting. Fall mat was in place. She was in no obvious distress. She was easily aroused and smiling upon hearing her name. Resident #1 was deemed un-interviewable. During an interview with CNA C on 7/7/2023 at 2:00 PM she indicated there were several things not in the witness statement she gave dated 6/15/2023 at 5:10 PM. CNA C said she asked LVN A to help her change resident #2 during the early morning of July 15, 2023, and LVN A put her whole-body weight on resident #2 to hold her down. CNA C said resident #2 seemed upset by being restrained. CNA C also indicated she asked LVN A for assistance changing resident #3 on the night of June 14 and 15, 2023. CNA C said LVN A took resident #3's hands and held them above her head and LVN A held her hand over Resident #3's mouth when Resident #3 screamed. CNA C said after she completed her rounds, she exited the secured unit and told LVN B about LVN A's actions towards Resident's #2 and #3. Further interview with CNA C revealed at approximately 3:30 AM, she and LVN B found Resident #1 sitting in a chair with a lab jacket tied around her and the chair with a tight knot at Resident #1's stomach area. CNA C said at first Resident #1 was calm but then she began to scream for help and was attempting to get up and out of the restraint. CNA C said she observed LVN A cover Resident #1's mouth with LVN A's hand when she started to scream. CNA C said she and LVN B attempted to remove the knot, but both were unsuccessful since the knot was too tight. CNA C said LVN B was going to cut the lab coat to get Resident #1 free, but LVN A protested saying it was an expensive jacket. CNA C said LVN A just stood there and watched while CNA C and LVN B attempted to free Resident #1. CNA C said LVN B had to tilt the chair back on its two back legs as CNA C slid Resident #1 out of the chair from under the jacket. CNA C said she was not aware how to report the things that happened but was aware that abuse should be reported to the administrator or DON immediately after the incident. She stated We weren't taught those things in my class. CNA C said she was made aware of the protocol after it happened. She said she was trained to call the cops if she saw someone hitting a resident. CNA C said she was going to come in the next day and leave a note under the DONs door. Interview with LVN B on 07/09/23 at 5:35 PM revealed she was working the 6:00 PM- 6:00 AM shift on 07/14/23-07/15/23 on the 200 Hall. LVN B stated she was a pool nurse for the facility's parent company as was LVN A. LVN B said she worked with LVN A on a couple of other occasions and had not had any issues with her. LVN B said at approximately between 2:00 AM - 3:00 AM, CNA C walked out of the 100 Hall (secured unit) into the 200 Hall and approached LVN B as CNA C was crying and appeared upset. LVN B said CNA C told LVN B that she was upset and frustrated because LVN A was being rough with the residents, further saying LVN A was rough handling the residents, pinning them down. LVN B said CNA C took a few minutes to calm down and then went back to the 100 hall to finish her rounds. LVN B said she heard yelling coming from the 100 hall and when she went to check, she saw both LVN A and CNA C changing Resident #2 and was told by LVN A We got this, we got it. LVN B said she did not see anything wrong, so she went back to her hall. LVN B said later on (unsure of time lapse) CNA C again came out of the 100 hall looking upset with a flushed red face saying she could not take this. LVN B said she was dealing with two residents arguing on the 200 hall but she told CNA C she would go to the 100 Hall as soon as she could. LVN B said approximately 30-45 minutes later she opened the 100 hall locked doors, entered the 100 hall, and walked toward the dining area, hearing someone crying. LVN B said she saw Resident #1 sitting in a dining room chair with her arms down to her sides. A lab jacket was tied around the chair and tied into a tight knot in front of Resident #1's stomach. LVN B said Resident #1 was crying, screaming, and attempting to get loose from the tied lab jacket. LVN B said LVN A was standing by her medication cart approximately 3-4 feet away from Resident #1 and CNA C stood behind Resident #1 trying to remove the lab jacket. LVN B said she asked LVN A what was going on and LVN A said she was frustrated and tired that Resident #1 was agitated and was waking everyone else up. LVN B said she told LVN A This cannot happen, you're trippin, untie her now. LVN B said LVN A refused so LVN B attempted to remove the knot but was unable. LVN B said CNA C tried to undo the knot but was also unsuccessful. LVN B said she told LVN A that she was going to cut her jacket and that LVN A began to argue that her jacket was expensive, and it was not going to be cut. LVN B said Resident #1 was getting more agitated and her screaming was getting louder, Resident #1 was attempting to stand up with the chair on her back and LVN A began laughing at her. LVN B said she and CNA C leaned the chair back on the back to legs and slid Resident #1 out from under the jacket. LVN A said she did not do a head-to-toe assessment on Resident #1, but that Resident #1 did not seem to have any injuries or to be hurt. LVN B said she asked LVN A since she was frustrated, for her to take the 200 hall and she would cover the 100 hall but LVN A refused. LVN B said she went back to the 200 hall to continue her duties and check on the residents. LVN B said she did not go back to check any resident in the 100 hall after that. LVN B said she did not call any management at any time during her shift to report the incidents because she was overwhelmed and was also dealing with two residents fighting and trying to remove televisions from the walls. LVN B said she dealt with the two agitated residents for approximately two hours which led to her being behind with her other duties such as passing medications, collecting lab draws, and making the schedule for the next shift. LVN B said she got so behind that she did not finish her shift until 9 AM that morning. LVN B stated she did not know how long Resident #1 was restrained but estimated it was at least 30 minutes. LVN B said she left the facility without reporting any incident that happened. LVN B said she was tired and said she had worked her fifth 16-hour shift and had to return to the facility at 2:00 PM for another double shift. LVN B said she realized she had not reported the incident until she returned to the facility at 2:00 PM. LVN B said she immediately told the DON and then called the ADON with the DON present and LVN B's supervisor on the phone listening to her statement of the incident. LVN B said she was asked why she did not report the incident immediately or before the end of her shift, and she said she knew she should have reported the situation immediately but was so busy and tired and distraught that she simply forgot to report it before she left the building. LVN B said she did not remember to report the incident until she arrived back at the facility later that day at 2:00 PM and saw she was assigned to the secured unit and that was when she remembered the incident and to report it. During an interview with the ADON on 7/10/2023 at 10:25 AM she said no one had complained about LVN A before this event. The ADON said LVN A worked at the facility quite a bit, for the company. She said that none of the other nurses had reported any previous complaints about LVN A. The ADON said she wrote CNA C's statement of witnessed incident during her interview and CNA C did not mention there were other things that happened besides Resident #1 being tied up. During an interview with the Administrator on 7/10/2023 at 12:45 PM he said no one had complained to him about LVN A before this incident. On 07/11/23 at 2:10 PM, an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. Specific to this citation, the severity was changed after administrative review, on 08/10/23 at 2:30 PM, the Administrator was provided with the IJ template, and a Plan of Removal (POR) was explained and requested at that time. Due to no change in deficiency after re-entering the facility on 08/10/23, the facility's original plan of removal was accepted. On 7/12/2023 at 5:37 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: PLAN OF REMOVAL 7/12/2023 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On July 11, 2023, at approximately 2:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 604 Right to be free from physical restraints Done for those affected: Head to toe assessment was completed on 6/15/23 for Resident #1 with no negative outcome. The Medical Director and the attending physician were notified on 6/15/23. Social Services completed a psychosocial assessment on Resident #1 on 6/16/23 with no ill effects. Head to toe assessment was completed by Licensed Nurse on Resident #2 on 7/11/23 with no negative outcome. Social Service completed a psychosocial assessment on Resident #2 on 7/11/23 with no ill effects. Head to toe assessment was completed on 07/12/2023 for Resident #3 with no negative outcome. The Medical Director and the attending physician were notified on 07/12/2023. Regional Clinical Nurse completed a psychosocial assessment on Resident #3 on 07/12/2023 with no ill effects. Identify residents who could be affected: Director of Nursing and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Action Taken: Effective immediately on 7/11/2023, the Administrator/ DON and/ or designee began education to all staff on the new process. This process includes defining of restraints, demonstration of said restraints, and what the observer/employee should do if they observe behavior issues or catastrophic behaviors from residents. This should include providing safety of the resident and contacting abuse coordinator. The education will also include the different types of Abuse including restraints, timely reporting, and reporting to the Abuse Prevention Coordinator. The facility Administrator and/or Director of Nursing will be responsible for monitoring the implementation of the new process. This will be conducted by utilization of designated check list to be completed three times a week for four weeks. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any inappropriate use of restraints. Re-education of all staff will be completed by 07/12/2023. Those that are PRN and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 7/11/2023. Involvement of QA: On 7/11/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Medical Director, Regional [NAME] President of Operations, to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 7/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/11/2023. Sincerely, Administrator The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record reviews of In-services included: In-Service training report for nursing, therapy, dietary, housekeeping, maintenance, managers (7/11/2023) abuse/neglect and restraint management. The in-service included definitions of abuse and restraints, and instructions on procedures to follow if abuse is witnessed, i.e. stopping the abuse, calling the abuse Coordinator immediately and not going home. Other tools used for training included the [company] Restraints Policy (8/15/2022) and Abuse/Neglect Policy (8/15/2022). A staff roster was used to ensure training was received by all staff. 92 staff were identified, and 9 PRN staff were pending in-service as of 7/14/2023 at 12:00 PM. Provisions were made to in-service untrained staff upon entrance to facility. A staff education tracking list was created to review in-service retention for staff with 100% success for ten out of ten staff on 7/13/2023. During in-person and telephone interviews with day, evening, and night facility staff on 7/13/2023 and 7/14/2023 it was determined 14 out of 14 staff interviewed were able to define types of restraints, identify restraints as a form of abuse, and describe steps to be taken in the event of witnessing such an occurrence. The following 14 staff were interviewed: CNA G LVN H Nursing assistant in training I CNA J LVN K CNA L LVN M CNA N LVN O CNA P CNA Q LVN R Med Aid S LVN T Record review of the facility's Abuse Policy dated 8/15/2022 indicated the facility will implement policies and procedures to prevent and prohibit all types of abuse that achieves: Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . Reporting/Response: the facility will have written procedures that include reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. During an interview with the DON on 7/13/2023 at 2:50 PM revealed she knew why notification to the BON was important and stated it was important To remove their license and to protect the patients. Record review of facility's policy on abuse (Revised December 2017) indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of facility's policy on restraints (Implemented 8/15/2022) indicated that it is the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. On 7/14/2023 at 12:00 PM, the Administrator and DON were informed the IJ was lifted. However, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm after the IJ immediacy was removed due to the facility's need to monitor and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience for 3 of 3 residents (Residents #1, #2, and #3) reviewed for abuse and failed to provide ongoing oversight and supervision of staff to assure that its policies are implemented as written for three (Residents #1, #2, and #3) of three residents reviewed for abuse, oversight, and supervision. 1. Resident #1 was placed in a chair and tied to it with a lab coat by LVN A. 2. Resident #2 was held down with the full force of LVN A's body. 3. Resident #3 had her hands held above her head and her mouth covered when she protested by LVN A. On 7/11/2023 at 2:10 PM, the facility Administrator, DON, and the Corporate HR were notified that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with an Immediate Jeopardy Template at that time, with a revised Template on 7/13/2023 at 2:47 PM. These failures resulted in the identification of Immediate Jeopardy (IJ) on 07/11/23 at 2:10 PM. While the immediacy was removed on 7/14/2023 at 12:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm after the IJ immediacy was removed due to the facility's need to monitor the implementation of the plan of removal. The findings included: A review of Resident #1's face sheet accessed on 7/7/2023 indicated a [AGE] year-old female with a diagnosis included dementia, senile degeneration (of older individuals who suffered from cognitive decline, memory loss), epilepsy, anxiety, and age-related osteoporosis. A review of Resident #1's Annual Minimum Data Set assessment for Cognitive Patterns dated 5/26/2023 and accessed on 7/7/2023 revealed a BIMS score of 00, which indicated severe cognitive impairment. A review of Resident #1's care plan initiated on 5/25/2023 indicated she was unable to sit still for any length of time and will sit herself down on the floor from chair, wheelchair and bed and crawl around on the floor. Interventions included, among other things, to approach/speak in a calm manner. Divert attention. Monitor for restlessness and assist Resident to sit on the floor in a safe space. A review of Resident #2's face sheet accessed on 7/7/2023 revealed an [AGE] year-old female with a diagnosis of dementia with other behavioral disturbance and major depressive disorder. A review of Resident #2's Quarterly Minimum Data Set assessment for Cognitive Pattern dated 4/13/2023 and accessed 7/7/2023 revealed a BIMS score of 6, which indicated severe cognitive impairment. A review of Resident #2's care plan initiated on 3/1/2023 revealed she was an elopement risk/wanderer and had behavioral problems with episodes of aggression. Interventions included diverting attention and speaking to Resident in a calm manner. A review of Resident #3's face sheet accessed on 7/7/2023 indicated an [AGE] year-old female with a diagnosis of Alzheimer's disease, dementia, osteoporosis, and anxiety disorder. A review of Resident #3's Annual Minimum Data Set assessment for Cognitive Pattern dated 4/3/2023 and accessed 7/7/2023 indicated a BIMS score of 1, which indicates severe cognitive impairment. A review of Resident #3's care plan initiated on 11/4/2022 indicates Resident becomes physically aggressive with staff during Resident care with interventions that include redirection, provide physical and verbal cues to alleviate anxiety, and 1:1 supervision until calm. Record review of a witness statement dated 6/15/2023 at 5:10 PM authored by CNA C documented that LVN A was aggressive with residents and that CNA C saw Resident #1 tied up. Record review of a witness statement dated 6/15/2023 authored by LVN B documented she untied Resident #1 with the help of CNA C. LVN B said she asked LVN A why she tied the Resident up and LVN A said she was exhausted by Resident #1 wandering up and down the halls. Record review of transcript of training for LVN A indicate training on abuse (6/2/2022), managing aggressive behaviors (6/21/2022), preventing abuse (6/22/2022) and (9/27/2022). Record review of Resident #1 incident report dated 6/15/2023 at 5:45 PM documented in the investigation summary the following: On 6-15-2023 at 4:00 PM CNA C was assigned to the 100 hall memory unit. She then noticed that Resident #1 had been tied to a chair at the nurse's station by means of a lab coat that belonged to LVN A. She tried to untie Resident #1 but was not able to. She then contacted LVN B, charge nurse assigned to 200 hall, about the situation. Both attempted to unite the resident but needed to have the resident slip underneath the knot in order to get her free. LVN B then contacted LVN A to ask if Resident #1 was OK. LVN A answered that she was exhausted due to the resident wandering all over. Upon learning of this incident, the person in charge of LVN A was contacted and advised of the incident involving her nurse. She was advised to never send the alleged perpetrator back to our facility. No further information at this time. Investigation findings: confirmed. During a telephone interview with the Administrator on 6/23/2023 at 3:45 PM he said I don't know where (LVN A) is now. She's not in my building. I did not report her to the BON. I thought you were going to do that. We are in the process of reporting her to the BON now. She doesn't work for me directly. She was contracted through the (company). During a telephone interview with the [company] regional staffing scheduler on 7/6/2023 at 10:30 AM revealed LVN A was suspended on June 15, 2023. She said LVN A was terminated after the investigation. She said they reported her to the BON for sure. She said their corporate RN, would have made the report to the BON. During a telephone interview with the [company] Corporate RN on 7/6/2023 at 1:30 PM she said she did not notify the BON. The Corporate RN said she assumed LVN A was already working at her previous job. She said she would report to the BON today. Record review of US Postal Service Certified First Class indicated notification to the Texas Board of Nursing was made on 7/6/2023. The Abuse Prevention Coordinator (APC) did not notify the licensing agent- Board of Nursing (BON) after an investigation was completed and until the surveyor's inquiry of LVN A's confirmed abuse of Residents #1, #2, and #3. The Abuse Prevention Coordinator did not notify the licensing agent (BON) after LVN B was issued a do-not-return to the facility for failure to immediately report witnessed abuse by LVN A to Resident #1 or being informed of abuse by LVN A to Residents #2 and #3. During an interview with the DON on 6/23/2023 at 4:40 PM she said she knew the nurse that tied up Resident #1. The DON said she did not report it to the BON. The DON said she called the agency the next day as soon as she found out. The DON said LVN A worked for the rest of her shift the night of the incidents after it was discovered she had tied up Resident #1 because no one immediately reported the incidents. The DON said LVN B was not allowed to work again for the facility because she did not report the abuse in a timely manner. The DON did not notify the BON about LVN B not reporting witnessed abuse. The DON said LVN B called her the next day to report the incident. The DON said she did call the police, but the police decided to not come out. The DON said the facility social worker assessed Resident #1 to make sure there were no ill effects they would have noticed. The DON said they have a lot of agency nurses, and she said she understood the nurses she got from agencies were the responsibility of the facility. The DON stated LVN B made her aware of the incident on 6/15/2023 when LVN B came in to work at 2 PM. During an observation and interview of Resident #1 on 7/6/2023 at 10:50 AM Resident #1 was found in her room, resting. Fall mat was in place. She was in no obvious distress. She was easily aroused and smiling upon hearing her name. Resident #1 was deemed un-interviewable. Resident #2 was observed in her room in bed. Resident #2 was deemed un-interviewable. Resident #2 was in no obvious distress. Resident #3 was observed in a common area in the locked unit. Resident #3 was deemed un-interviewable. Resident #3 was smiling and in no obvious distress. During an interview on 7/6/2023 at 11:00 AM with CNA D she said Resident #1 was usually nice, but around 4 PM her sundowners started kicking in and she would want to murder you. Resident #1 was usually sweet though. CNA D said there were enough staff on the floor. CNA D said her hall had two CNAs and a nurse for a census that was not that high. During an interview with CNA C on 7/7/2023 at 2:00 PM she indicated there were several things not in the witness statement she gave dated 6/15/2023 at 5:10 PM. CNA C said she told the DON, HR, and the ADON there were other things that happened, but they wanted to hear about Resident #1. CNA C said she asked LVN A to help her change Resident #2 during the early morning of June 15, 2023, and LVN A put her whole-body weight on Resident #2 to hold her down. CNA C said resident #2 seemed upset by being restrained. CNA C also indicated she asked LVN A for assistance changing Resident #3 on the night of June 14 and 15, 2023. CNA C said LVN A took Resident #3's hands and held them above her head and LVN A held her hand over Resident #3's mouth when Resident #3 screamed. CNA C said after she completed her rounds, she exited the secured unit and told LVN B about LVN A's actions towards Resident's #2 and #3. Further interview with CNA C revealed at approximately 3:30 AM, she and LVN B found Resident #1 sitting in a chair with a lab jacket tied around her and the chair with a tight knot at Resident #1's stomach area. CNA C said at first Resident #1 was calm but then she began to scream for help and was attempting to get up and out of the restraint. CNA C said she observed LVN A cover Resident #1's mouth with LVN A's hand when she started to scream. CNA C said she and LVN B attempted to remove the knot, but both were unsuccessful since the knot was too tight. CNA C said LVN B was going to cut the lab coat to get Resident #1 free, but LVN A protested saying it was an expensive jacket. CNA C said LVN A just stood there and watched while CNA C and LVN B attempted to free Resident #1. CNA C said LVN B had to tilt the chair back on its two back legs as CNA C slid Resident #1 out of the chair from under the jacket. CNA C said she was not aware how to report the things that happened but was aware that abuse should be reported to the administrator or DON immediately after the incident. She stated, We weren't taught those things in my class. CNA C said she was made aware of the protocol after it happened. She said she was trained to call the cops if she saw someone hitting a resident. CNA C said she was going to come in the next day and leave a note under the DONs door. An attempt was made to interview LVN A via telephone on 07/07/23 at 2:46 PM and 07/09/23 at 7:20 PM. No answer, voice message was left and return phone call received. Interview with LVN B on 07/09/23 at 5:35 PM revealed she was working the 6:00 PM- 6:00 AM shift on 06/14/23-06/15/23 on the 200 Hall. LVN B stated she was a pool nurse for the facility's parent company as was LVN A. LVN B said she worked with LVN A on a couple of other occasions and had not had any issues with her. LVN B said at approximately between 2:00 AM - 3:00 AM, CNA C walked out of the 100 Hall (secured unit) into the 200 Hall and approached LVN B as CNA C was crying and appeared upset. LVN B said CNA C told LVN B that she was upset and frustrated because LVN A was being rough with the residents, further saying LVN A was rough handling the residents, pinning them down. LVN B said CNA C took a few minutes to calm down and then went back to the 100 hall to finish her rounds. LVN B said she heard yelling coming from the 100 hall and when she went to check, she saw both LVN A and CNA C changing Resident #2 and was told by LVN A We got this, we got it. LVN B said she did not see anything wrong, so she went back to her hall. LVN B said later on (unsure of time lapse) CNA C again came out of the 100 hall looking upset with a flushed red face saying she could not take this. LVN B said she was dealing with two residents arguing on the 200 hall but she told CNA C she would go to the 100 Hall as soon as she could. LVN B said approximately 30-45 minutes later she opened the 100 hall locked doors, entered the 100 hall, and walked toward the dining area, hearing someone crying. LVN B said she saw Resident #1 sitting in a dining room chair with her arms down to her sides. A lab jacket was tied around the chair and tied into a tight knot in front of Resident #1's stomach. LVN B said Resident #1 was crying, screaming, and attempting to get loose from the tied lab jacket. LVN B said LVN A was standing by her medication cart approximately 3-4 feet away from Resident #1 and CNA C stood behind Resident #1 trying to remove the lab jacket. LVN B said she asked LVN A what was going on and LVN A said she was frustrated and tired that Resident #1 was agitated and was waking everyone else up. LVN B said she told LVN A This cannot happen, you're trippin, untie her now. LVN B said LVN A refused so LVN B attempted to remove the knot but was unable. LVN B said CNA C tried to undo the knot but was also unsuccessful. LVN B said she told LVN A that she was going to cut her jacket and that LVN A began to argue that her jacket was expensive, and it was not going to be cut. LVN B said Resident #1 was getting more agitated and her screaming was getting louder, Resident #1 was attempting to stand up with the chair on her back and LVN A began laughing at her. LVN B said she and CNA C leaned the chair back on the back to legs and slid Resident #1 out from under the jacket. LVN A said she did not do a head-to-toe assessment on Resident #1, but that Resident #1 did not seem to have any injuries or to be hurt. LVN B said she asked LVN A since she was frustrated, for her to take the 200 hall and she would cover the 100 hall but LVN A refused. LVN B said she went back to the 200 hall to continue her duties and check on the residents. LVN B said she did not go back to check any resident in the 100 hall after that. LVN B said she did not call any management at any time during her shift to report the incidents because she was overwhelmed and was also dealing with two residents fighting and trying to remove televisions from the walls. LVN B said she dealt with the two agitated residents for approximately two hours which led to her being behind with her other duties such as passing medications, collecting lab draws, and making the schedule for the next shift. LVN B said she got so behind that she did not finish her shift until 9 AM that morning. LVN B stated she did not know how long Resident #1 was restrained but estimated it was at least 30 minutes. LVN B said she left the facility without reporting any incident that happened. LVN B said she was tired and said she had worked her fifth 16-hour shift and had to return to the facility at 2:00 PM for another double shift. LVN B said she realized she had not reported the incident until she returned to the facility at 2:00 PM. LVN B said she immediately told the DON and then called the ADON with the DON present and LVN B's supervisor on the phone listening to her statement of the incident. LVN B said she was asked why she did not report the incident immediately or before the end of her shift, and she said she knew she should have reported the situation immediately but was so busy and tired and distraught that she simply forgot to report it before she left the building. LVN B said she did not remember to report the incident until she arrived back at the facility later that day at 2:00 PM and saw she was assigned to the secured unit and that was when she remembered the incident and to report it. During an interview with the ADON on 7/10/2023 at 10:25 AM she said no one had complained about LVN A before this event. The ADON said LVN A worked at the facility quite a bit, for the corporation. She said that none of the other nurses had reported any previous complaints about LVN A. The ADON said she wrote CNA C's statement of witnessed incident during her interview and CNA C did not mention there were other things that happened besides Resident #1 being tied up. During an interview with the Administrator on 7/10/2023 at 12:45 PM he said no one had complained to him about LVN A before this incident. During an interview with LVN E on 7/12/2023 at 12:40 PM she said she knew why the surveyor was present for physical restraints on Resident #1, and LVN A. LVN E said it tore her up when she heard it. LVN E came back on 6/19/2023 and heard it. LVN E said the CNAs told her what happened. LVN E said nurse B relieved her a few times. LVN E said she didn't know LVN B well, but she threatened her and that is why LVN E went back to PRN. LVN E said she was not aware that LVN A restrained anyone before Resident #1. LVN E said she never saw LVN A restrain anyone. LVN E said she never saw LVN A be abusive with any residents. LVN E said she would have stopped the abuse and reported it immediately. During an interview with the DON on 7/13/2023 at 2:50 PM revealed she knew why notification to the BON was important and stated it was important To remove their license and to protect the patients. Record review of facility's policy on abuse (Revised December 2017) indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of facility's policy on restraints (Implemented 8/15/2022) indicated that it is the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. On 07/11/23 at 2:10 PM, an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template, and a Plan of Removal (POR) was explained and requested at that time. On 7/12/2023 at 5:37 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: PLAN OF REMOVAL 7/12/2023 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On July 11, 2023, at approximately 2:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 604 Right to be free from physical restraints Done for those affected: Head to toe assessment was completed on 6/15/23 for Resident #1 with no negative outcome. The Medical Director and the attending physician were notified on 6/15/23. Social Services completed a psychosocial assessment on Resident #1 on 6/16/23 with no ill effects. Head to toe assessment was completed by Licensed Nurse on Resident #2 on 7/11/23 with no negative outcome. Social Service completed a psychosocial assessment on Resident #2 on 7/11/23 with no ill effects. Head to toe assessment was completed on 07/12/2023 for Resident #3 with no negative outcome. The Medical Director and the attending physician were notified on 07/12/2023. Regional Clinical Nurse completed a psychosocial assessment on Resident #3 on 07/12/2023 with no ill effects. Identify residents who could be affected: Director of Nursing and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Action Taken: Effective immediately on 7/11/2023, the Administrator/ DON and/ or designee began education to all staff on the new process. This process includes defining of restraints, demonstration of said restraints, and what the observer/employee should do if they observe behavior issues or catastrophic behaviors from residents. This should include providing safety of the resident and contacting abuse coordinator. The education will also include the different types of Abuse including restraints, timely reporting, and reporting to the Abuse Prevention Coordinator. The facility Administrator and/or Director of Nursing will be responsible for monitoring the implementation of the new process. This will be conducted by utilization of designated check list to be completed three times a week for four weeks. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any inappropriate use of restraints. Re-education of all staff will be completed by 07/12/2023. Those that are PRN and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 7/11/2023. Involvement of QA: On 7/11/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Medical Director, Regional [NAME] President of Operations, to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 7/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/11/2023. Sincerely, Administrator The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record reviews of In-services included: In-Service training report for nursing, therapy, dietary, housekeeping, maintenance, managers (7/11/2023) abuse/neglect and restraint management. The in-service included definitions of abuse and restraints, and instructions on procedures to follow if abuse is witnessed, i.e. stopping the abuse, calling the abuse Coordinator immediately and not going home. Other tools used for training included the [company] Restraints Policy (8/15/2022) and Abuse/Neglect Policy (8/15/2022). A staff roster was used to ensure training was received by all staff. 92 staff were identified, and 9 PRN staff were pending in-service as of 7/14/2023 at 12:00 PM. Provisions were made to in-service untrained staff upon entrance to facility. A staff education tracking list was created to review in-service retention for staff with 100% success for ten out of ten staff on 7/13/2023. During in-person and telephone interviews with day, evening, and night facility staff on 7/13/2023 and 7/14/2023 it was determined 14 out of 14 staff interviewed were able to define types of restraints, identify restraints as a form of abuse, and describe steps to be taken in the event of witnessing such an occurrence. The following 14 staff were interviewed: CNA G LVN H Nursing assistant in training I CNA J LVN K CNA L LVN M CNA N LVN O CNA P CNA Q LVN R Med Aid S LVN T Record review of the facility's Abuse Policy dated 8/15/2022 indicated the facility will implement policies and procedures to prevent and prohibit all types of abuse that achieves: Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . Reporting/Response: the facility will have written procedures that include reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Review of the Nursing Practice Act, Texas Occupations Code, Section 301.401 - 301.419, requires nurse, nursing peer view committees, employers of nurses, as well as other entities, to report to the Texas Board of Nursing any nurse who engages in conduct subject to reporting, pursuant of Section 301,401 in that: Constitutes abuse Indicates that a nurse lacks knowledge, skill, judgement, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient, regardless of whether the conduct consists of a single incident or a pattern of behavior. If an employer terminates, suspends for 7 or more days, makes an agency nurse a do-not-return, or takes other substantive disciplinary action against a nurse for practice related errors, a report to the BON is required. Review of the Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice revealed The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; . (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; .(ii) abuse . (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; . The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.12, Unprofessional Conduct revealed The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or public. Actual injury to a client need not be established. These behaviors include but are not limited to: Unsafe Practice--actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advance practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11 Record review of facility's policy on abuse (Revised December 2017) indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of facility's policy on restraints (Implemented 8/15/2022) indicated that it is the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Record review of training for LVN A indicates on 6/2/2022 and 9/27/2022 Preventing, Recognizing and Reporting Abuse training was completed. Record review of training for LVN B indicates on 5/30/2023 a last reminder was received and acknowledged by LVN B for Abuse Prevention Program ([NAME] 2) training due. No transcript was forthcoming from the facility. Record review of training for CNA C indicates Certification as a Texas Nurse Aid on 6/1/2023, with expiration on 6/1/2025. On 7/14/2023 at 12:00 PM, the Administrator and DON were informed the IJ was lifted. However, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm after the IJ immediacy was removed due to the facility's need to monitor and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 3 residents (Residents #1, #2, and #3) reviewed for abuse. Resident #1 was placed in a chair and tied to it with a lab coat by LVN A. Resident #2 was held down with the full force of LVN A's body. Resident #3 had her hands held above her head and her mouth covered when she protested by LVN A. LVN B and CNA C had knowledge and witnessed LVN A abuse Residents #1, #2, and #3 and failed intervene to remove LVN A away from the residents to further prevent abuse. LVN B and CNA C had knowledge and/or witnessed LVN A abuse Residents #1, #2, and #3 and failed to notify the Abuse Prevention Coordinator/Administrator immediately. This failure could place residents at risk of abuse and injury. The staff failing to immediately report the incidents to the administrator/other officials could have led to the further abuse from LVN A. If the administrator/other officials were immediately notified, actions could have been taken to remove LVN A from the facility therefor preventing further abuse. On 7/11/2023 at 2:10 PM, the facility Administrator, DON, and the Corporate HR were notified that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with an Immediate Jeopardy Template at that time, with a revised Template on 7/13/2023 at 2:47 PM. These failures resulted in the identification of Immediate Jeopardy (IJ) on 07/11/23 at 2:10 PM. While the immediacy was removed on 7/14/2023 at 12:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm after the IJ immediacy was removed due to the facility's need to monitor the implementation of the plan of removal. The findings were: A review of Resident #1's face sheet accessed on 7/7/2023 indicated a [AGE] year-old female with a diagnosis included dementia, senile degeneration (of older individuals who suffered from cognitive decline, memory loss), epilepsy, anxiety, and age-related osteoporosis. A review of Resident #1's Annual Minimum Data Set assessment for Cognitive Patterns dated 5/26/2023 and accessed on 7/7/2023 revealed a BIMS score of 00, which indicated severe cognitive impairment. A review of Resident #1's care plan initiated on 5/25/2023 indicated she was unable to sit still for any length of time and will sit herself down on the floor from chair, wheelchair and bed and crawl around on the floor. Interventions included, among other things, to approach/speak in a calm manner. Divert attention. Monitor for restlessness and assist resident to sit on the floor in a safe space. A review of Resident #2's face sheet accessed on 7/7/2023 revealed an [AGE] year-old female with a diagnosis of dementia with other behavioral disturbance and major depressive disorder. A review of Resident #2's Quarterly Minimum Data Set assessment for Cognitive Pattern dated 4/13/2023 and accessed 7/7/2023 revealed a BIMS score of 6, which indicated severe cognitive impairment. A review of Resident #2's care plan initiated on 3/1/2023 revealed she was an elopement risk/wanderer and had behavioral problems with episodes of aggression. Interventions included diverting attention and speaking to resident in a calm manner. A review of Resident #3's face sheet accessed on 7/7/2023 indicated an [AGE] year-old female with a diagnosis of Alzheimer's disease, dementia, osteoporosis and anxiety disorder. A review of Resident #3's Annual Minimum Data Set assessment for Cognitive Pattern dated 4/3/2023 and accessed 7/7/2023 indicated a BIMS score of 1, which indicates severe cognitive impairment. A review of Resident #3's care plan initiated on 11/4/2022 indicates resident becomes physically aggressive with staff during resident care with interventions that include redirection, provide physical and verbal cues to alleviate anxiety, and 1:1 supervision until calm. Record review of a witness statement dated 6/15/2023 at 5:10 PM authored by CNA C documented that LVN A was aggressive with residents and that CNA C saw Resident #1 tied up. Record review of a witness statement dated 6/15/2023 authored by LVN B documented she untied Resident #1 with the help of CNA C. LVN B said she asked LVN A why she tied the resident up and LVN A said she was exhausted by resident #1 wandering up and down the halls. Interview with the DON on 6/23/2023 at 4:40 PM she said she knew the nurse that tied up Resident #1. The DON said she did not report it to the BON. The DON said she called the agency the next day, as soon as she found out. The DON said LVN A worked for the rest of her shift the night of the incidents after it was discovered she had tied up Resident #1 because no one immediately reported the incidents. The DON said LVN B was not allowed to work again for the facility because she did not report the abuse in a timely manner. The DON did not notify the BON about LVN B not reporting witnessed abuse. The DON said LVN B called her the next day to report the incident. The DON said she did call the police, but the police decided to not come out. The DON said the facility social worker assessed Resident #1 to make sure there were no effects they would have noticed. The DON said they have a lot of agency nurses, and she said she understood the nurses she got from agencies were the responsibility of the facility. During an observation and interview of Resident #1 on 7/6/2023 at 10:50 AM Resident #1 was found in her room, resting. Fall mat was in place. She was in no obvious distress. She was easily aroused and smiling upon hearing her name. Resident #1 was deemed un-interviewable. During an interview with CNA C on 7/7/2023 at 2:00 PM she indicated there were several things not in the witness statement she gave dated 6/15/2023 at 5:10 PM. CNA C said she asked LVN A to help her change resident #2 during the early morning of July 15, 2023, and LVN A put her whole-body weight on resident #2 to hold her down. CNA C said resident #2 seemed upset by being restrained. CNA C also indicated she asked LVN A for assistance changing resident #3 on the night of June 14 and 15, 2023. CNA C said LVN A took resident #3's hands and held them above her head and LVN A held her hand over Resident #3's mouth when Resident #3 screamed. CNA C said after she completed her rounds, she exited the secured unit and told LVN B about LVN A's actions towards Resident's #2 and #3. Further interview with CNA C revealed at approximately 3:30 AM, she and LVN B found Resident #1 sitting in a chair with a lab jacket tied around her and the chair with a tight knot at Resident #1's stomach area. CNA C said at first Resident #1 was calm but then she began to scream for help and was attempting to get up and out of the restraint. CNA C said she observed LVN A cover Resident #1's mouth with LVN A's hand when she started to scream. CNA C said she and LVN B attempted to remove the knot, but both were unsuccessful since the knot was too tight. CNA C said LVN B was going to cut the lab coat to get Resident #1 free, but LVN A protested saying it was an expensive jacket. CNA C said LVN A just stood there and watched while CNA C and LVN B attempted to free Resident #1. CNA C said LVN B had to tilt the chair back on its two back legs as CNA C slid Resident #1 out of the chair from under the jacket. CNA C said she was not aware how to report the things that happened but was aware that abuse should be reported to the administrator or DON immediately after the incident. She stated We weren't taught those things in my class. CNA C said she was made aware of the protocol after it happened. She said she was trained to call the cops if she saw someone hitting a resident. CNA C said she was going to come in the next day and leave a note under the DONs door. Interview with LVN B on 07/09/23 at 5:35 PM revealed she was working the 6:00 PM- 6:00 AM shift on 07/14/23-07/15/23 on the 200 Hall. LVN B stated she was a pool nurse for the facility's parent company as was LVN A. LVN B said she worked with LVN A on a couple of other occasions and had not had any issues with her. LVN B said at approximately between 2:00 AM - 3:00 AM, CNA C walked out of the 100 Hall (secured unit) into the 200 Hall and approached LVN B as CNA C was crying and appeared upset. LVN B said CNA C told LVN B that she was upset and frustrated because LVN A was being rough with the residents, further saying LVN A was rough handling the residents, pinning them down. LVN B said CNA C took a few minutes to calm down and then went back to the 100 hall to finish her rounds. LVN B said she heard yelling coming from the 100 hall and when she went to check, she saw both LVN A and CNA C changing Resident #2 and was told by LVN A We got this, we got it. LVN B said she did not see anything wrong, so she went back to her hall. LVN B said later on (unsure of time lapse) CNA C again came out of the 100 hall looking upset with a flushed red face saying she could not take this. LVN B said she was dealing with two residents arguing on the 200 hall but she told CNA C she would go to the 100 Hall as soon as she could. LVN B said approximately 30-45 minutes later she opened the 100 hall locked doors, entered the 100 hall, and walked toward the dining area, hearing someone crying. LVN B said she saw Resident #1 sitting in a dining room chair with her arms down to her sides. A lab jacket was tied around the chair and tied into a tight knot in front of Resident #1's stomach. LVN B said Resident #1 was crying, screaming, and attempting to get loose from the tied lab jacket. LVN B said LVN A was standing by her medication cart approximately 3-4 feet away from Resident #1 and CNA C stood behind Resident #1 trying to remove the lab jacket. LVN B said she asked LVN A what was going on and LVN A said she was frustrated and tired that Resident #1 was agitated and was waking everyone else up. LVN B said she told LVN A This cannot happen, you're trippin, untie her now. LVN B said LVN A refused so LVN B attempted to remove the knot but was unable. LVN B said CNA C tried to undo the knot but was also unsuccessful. LVN B said she told LVN A that she was going to cut her jacket and that LVN A began to argue that her jacket was expensive, and it was not going to be cut. LVN B said Resident #1 was getting more agitated and her screaming was getting louder, Resident #1 was attempting to stand up with the chair on her back and LVN A began laughing at her. LVN B said she and CNA C leaned the chair back on the back to legs and slid Resident #1 out from under the jacket. LVN A said she did not do a head-to-toe assessment on Resident #1, but that Resident #1 did not seem to have any injuries or to be hurt. LVN B said she asked LVN A since she was frustrated, for her to take the 200 hall and she would cover the 100 hall but LVN A refused. LVN B said she went back to the 200 hall to continue her duties and check on the residents. LVN B said she did not go back to check any resident in the 100 hall after that. LVN B said she did not call any management at any time during her shift to report the incidents because she was overwhelmed and was also dealing with two residents fighting and trying to remove televisions from the walls. LVN B said she dealt with the two agitated residents for approximately two hours which led to her being behind with her other duties such as passing medications, collecting lab draws, and making the schedule for the next shift. LVN B said she got so behind that she did not finish her shift until 9 AM that morning. LVN B stated she did not know how long Resident #1 was restrained but estimated it was at least 30 minutes. LVN B said she left the facility without reporting any incident that happened. LVN B said she was tired and said she had worked her fifth 16-hour shift and had to return to the facility at 2:00 PM for another double shift. LVN B said she realized she had not reported the incident until she returned to the facility at 2:00 PM. LVN B said she immediately told the DON and then called the ADON with the DON present and LVN B's supervisor on the phone listening to her statement of the incident. LVN B said she was asked why she did not report the incident immediately or before the end of her shift, and she said she knew she should have reported the situation immediately but was so busy and tired and distraught that she simply forgot to report it before she left the building. LVN B said she did not remember to report the incident until she arrived back at the facility later that day at 2:00 PM and saw she was assigned to the secured unit and that was when she remembered the incident and to report it. During an interview with the ADON on 7/10/2023 at 10:25 AM she said no one had complained about LVN A before this event. The ADON said LVN A worked at the facility quite a bit, for the company. She said that none of the other nurses had reported any previous complaints about LVN A. The ADON said she wrote CNA C's statement of witnessed incident during her interview and CNA C did not mention there were other things that happened besides Resident #1 being tied up. During an interview with the Administrator on 7/10/2023 at 12:45 PM he said no one had complained to him about LVN A before this incident. On 07/11/23 at 2:10 PM, an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. Specific to this citation, the severity was changed after administrative review, on 08/10/23 at 2:30 PM, the Administrator was provided with the IJ template, and a Plan of Removal (POR) was explained and requested at that time. Due to no change in deficiency after re-entering the facility on 08/10/23, the facility's original plan of removal was accepted. On 7/12/2023 at 5:37 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: PLAN OF REMOVAL 7/12/2023 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On July 11, 2023, at approximately 2:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 604 Right to be free from physical restraints Done for those affected: Head to toe assessment was completed on 6/15/23 for Resident #1 with no negative outcome. The Medical Director and the attending physician were notified on 6/15/23. Social Services completed a psychosocial assessment on Resident #1 on 6/16/23 with no ill effects. Head to toe assessment was completed by Licensed Nurse on Resident #2 on 7/11/23 with no negative outcome. Social Service completed a psychosocial assessment on Resident #2 on 7/11/23 with no ill effects. Head to toe assessment was completed on 07/12/2023 for Resident #3 with no negative outcome. The Medical Director and the attending physician were notified on 07/12/2023. Regional Clinical Nurse completed a psychosocial assessment on Resident #3 on 07/12/2023 with no ill effects. Identify residents who could be affected: Director of Nursing and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Action Taken: Effective immediately on 7/11/2023, the Administrator/ DON and/ or designee began education to all staff on the new process. This process includes defining of restraints, demonstration of said restraints, and what the observer/employee should do if they observe behavior issues or catastrophic behaviors from residents. This should include providing safety of the resident and contacting abuse coordinator. The education will also include the different types of Abuse including restraints, timely reporting, and reporting to the Abuse Prevention Coordinator. The facility Administrator and/or Director of Nursing will be responsible for monitoring the implementation of the new process. This will be conducted by utilization of designated check list to be completed three times a week for four weeks. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any inappropriate use of restraints. Re-education of all staff will be completed by 07/12/2023. Those that are PRN and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 7/11/2023. Involvement of QA: On 7/11/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Medical Director, Regional [NAME] President of Operations, to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 7/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/11/2023. Sincerely, Administrator The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record reviews of In-services included: In-Service training report for nursing, therapy, dietary, housekeeping, maintenance, managers (7/11/2023) abuse/neglect and restraint management. The in-service included definitions of abuse and restraints, and instructions on procedures to follow if abuse is witnessed, i.e. stopping the abuse, calling the abuse Coordinator immediately and not going home. Other tools used for training included the [company] Restraints Policy (8/15/2022) and Abuse/Neglect Policy (8/15/2022). A staff roster was used to ensure training was received by all staff. 92 staff were identified, and 9 PRN staff were pending in-service as of 7/14/2023 at 12:00 PM. Provisions were made to in-service untrained staff upon entrance to facility. A staff education tracking list was created to review in-service retention for staff with 100% success for ten out of ten staff on 7/13/2023. During in-person and telephone interviews with day, evening, and night facility staff on 7/13/2023 and 7/14/2023 it was determined 14 out of 14 staff interviewed were able to define types of restraints, identify restraints as a form of abuse, and describe steps to be taken in the event of witnessing such an occurrence. The following 14 staff were interviewed: CNA G LVN H Nursing assistant in training I CNA J LVN K CNA L LVN M CNA N LVN O CNA P CNA Q LVN R Med Aid S LVN T Record review of the facility's Abuse Policy dated 8/15/2022 indicated the facility will implement policies and procedures to prevent and prohibit all types of abuse that achieves: Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . Reporting/Response: the facility will have written procedures that include reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. During an interview with the DON on 7/13/2023 at 2:50 PM revealed she knew why notification to the BON was important and stated it was important To remove their license and to protect the patients. Record review of facility's policy on abuse (Revised December 2017) indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of facility's policy on restraints (Implemented 8/15/2022) indicated that it is the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. On 7/14/2023 at 12:00 PM, the Administrator and DON were informed the IJ was lifted. However, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm after the IJ immediacy was removed due to the facility's need to monitor and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments on 2 of 5 medication carts reviewed for storage of drugs. Nurses' Medication Cart was left unattended and unlocked by nurse's station area on the 300 hall. Nurses' Medication Cart was left unlocked in the 200 hall by nurse's station. This deficient practice could affect residents who have medications on the Nurses' Medication Cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. Findings included: Findings included: Observation on 09/21/22 at 09:45 AM 300 hall nurse medication cart revealed it was unlocked and unattended. This surveyor opened the top drawer recognizing the cart being unlocked. Multiple medications in bulk bottles and blister packs were easily assessable for removable. LVN A walked out with the DON of the medication room located behind the nurses' station and identified herself as being responsible for the unlocked medication cart. Interview with LVN A at 09/21/22 09:46 AM Revealed she said the medication cart should be locked at all times and got distracted from locking it. LVN A stated it was important to keep medication cart locked at all times due to anyone being able to open it and get medications not prescribed to them. 09/21/22 at 11:30 AM This surveyor requested the Policy on Medication Storage from DON. Observation on 09/22/22 09:31 AM Revealed 200 hall nurse medication cart was unlocked and 200 hall nurse LVN D was behind nurses' station. This surveyor opened the top drawer recognizing the cart being unlocked. Multiple medications in bulk bottles and blister packs were easily assessable for removable. LVN D walked around nurses' station to and identified herself as being responsible for the unlocked cart. Interview with LVN D on 09/22/22 at 09:33 AM revealed she forgot to lock it after getting an inhaler for a resident just moments ago. This surveyor asked LVN D why is it important to keep medication locked at all times, LVN D did not answer this surveyors question and stated I understand the importance of keeping the medication cart locked at all times. 09/21/22 01:11 PM Record review of the Facility's Medication Carts and Supplies for Administering Medication policy and procedure dated 10/01/19, states; #2. The Medication cart is locked at all times when not in use. #3. Do not leave the medication cart unlocked or unattended in the resident care areas. 09/22/22 01:39 PM Interview with DON revealed, when asked about the facilities policy and procedure for medication carts, DON stated I have only been here for four days, I don't know what the policy states. This surveyor read facility's Policy and Procedure for Medication Carts and Supplies for Administering Medication to DON, line #2, which states, The medication cart is locked at all times when not in use. This surveyor asked DON what at all times meant to her and she stated, at all times when not using medication cart. This surveyor asked, if a nurse is in the medication room away from the medication cart, should it be locked? DON stated, well yeah, when not standing right in front of it and not using it, yeah. Record Review of Policy on Medication Storage dated 10/01/19 Record review of the Facility's Medication Carts and Supplies for Administering Medication Policy and Procedure dated 10/01/19 stated .#2. The Medication cart is locked at all times when not in use. #3. Do not leave the medication cart unlocked or unattended in the resident care areas.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for four Residents (#3, #15, 27, and #54) of 17 residents reviewed for infection control practices during personal care: 1. Certified Medication Aide (CMA) B did not perform hand hygiene after touching various objects in the immediate vicinity, prior to putting on clean gloves, and prior to administering Resident #15 her eyedrops. 2. Licensed Vocational Nurse (LVN) C did not perform hand hygiene between glove changes and did not wash her hands for at least 20 seconds when performing wound care for Resident #3, #27, and #54. These failures could place residents that require assistance with personal care and medication administration at risk for healthcare associated cross-contamination and infections. The findings included: 1. Record review of Resident #15's Face Sheet dated 09/22/22 documented a [AGE] year-old female admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #15 had severely impaired vision, had clear speech, and had a brief interview of mental status score of 9- moderately impaired cognition. Record review of Resident #15's September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Solution 0.005 % (used to treat increased eye pressure), Instill 1 drop in both eyes one time a day for pressure in eyes. [MEDICATION(S)] Solution 200 Units ([MEDICATION(S)]- used to treat osteporosis), 1 spray alternating nostrils one time a day for [CONDITION(S)]. Odd days use left nare and even days use right nare (nostril). Observation of medication pass on 09/21/22 at 09:29 AM revealed CMA B locked her medication cart using her right hand, knocked on Resident #15's door with her right hand and moved the privacy curtain to the right side with her right hand. CMA B spoon fed Resident #15 her crushed medications then administered Calcitonin-Salmon 200 units nasal spray in Resident #15's left nostril. CMA B retrieved gloves from a box in the wall mount beside the sink, put them on and administered Resident #15 her [MEDICATION(S)] 2% eye drops in both eyes, without performing hand hygiene. At 9:36 PM, CMA B knocked on Resident #15's door with her right hand, moved the privacy curtain to the side with her right hand, retrieved gloves from the wall mount, put the gloves on, and administered Resident #15's [MEDICATION(S)] 0.005% to both eyes, without performing any hand hygiene. Interview with CMA B on 09/21/22 at 09:39 AM revealed she said she should have washed her hands before putting on her gloves and administering Resident #15 her eye drops but forgot. CMA B said it was important to perform hand hygiene before administering eye drops to prevent cross contamination and possibly infection. 2.) Resident #3 Record review of Resident #3's Face Sheet dated 09/23/22 documented a [AGE] year-old female admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Quarterly Minimum Data Set, dated dated dated [DATE] revealed she had a brief interview of mental status score of 4- severe cognitive impairment, usually made self understood and usually understood others. Resident #3 required extensive assistance with one person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #3 was at risk for pressure ulcer development. No pressure ulcers documented at the time of this assessment. Record review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/22/22 at 09:17 AM revealed Resident #3 was lying in bed on her right side with her eyes closed. LVN C stood outside of Resident #3's room and gathered supplies for wound care. At 9:24 AM, LVN C removed Resident #3's left hip dressing that had moderate clear drainage. LVN C removed her gloves and immediately put on clean gloves, without performing any hand hygiene. LVN C cleaned Resident #3's wound, dried the wound, removed her gloves, applied clean gloves and placed a Calcium Alginate dressing over Resident #3's wound. LVN C did not perform hand hygiene between glove changes. LVN C washed her hands, scrubbed her hands with soap and water for a total of 10 seconds then rinsed her hands with water. Resident #27 Record review of Resident #27's Face Sheet dated 09/23/22 documented an [AGE] year-old female admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #27's Quarterly Minimum Data Set, dated dated dated [DATE] revealed she had a brief interview of mental status score of 9- moderately impaired cognition, usually made self understood and usually understood others. Resident #27 required extensive assistance with one person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #27 was at risk for pressure ulcer development. No pressure ulcers documented at the time of this assessment. Record review of Resident #27's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #27 on 09/22/22 at 09:43 AM revealed she was lying in bed on her left side with her eyes closed. LVN C entered the room and informed Resident #27 of wound care needed to be done. LVN C washed her hands, scrubbed her hands with soap and water for a total of 13 seconds before rinsing her hands with water. LVN C removed Resident #27's coccyx dressing and threw it away in the trash. LVN C removed her gloves and put on clean gloves, without performing hand hygiene between glove changes. LVN C cleaned Resident #27's coccyx wound then removed her gloves and put on clean gloves, without performing any hand hygiene between glove change. LVN C washed her hands, scrubbed her hands with soap and water for a total of 11 seconds then rinsed her hands with water. Resident #54 Record review of Resident #54's Face Sheet dated 09/23/22 documented a [AGE] year-old female admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #54's Quarterly Minimum Data Set, dated dated dated [DATE] revealed she had short and long term memory problem, had severe cognitive impairment, rarely/never made self understood and sometimes understood others. Resident #54 required extensive assistance with one person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #54 was at risk for pressure ulcer development but did not have any pressure ulcers at the time of the assessment. Record review of Resident #54's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse DTI to right bunion with normal saline, pat dry, apply skin prep, and leave open to air. Observation of Resident #54 on 09/22/22 at 10:02 AM revealed she was lying in bed on her right side with her right foot elevated on a pillow. LVN C washed her hands, scrubbed her hands with soap and water for a total of 14 seconds before rinsing her hands with water. LVN C applied clean gloves, cleaned Resident #54's right great toe wound with normal saline and gauze, pat dried with clean dry gauze, and rubbed skin prep over the wound. LVN C removed her gloves and washed her hands, scrubbed her hands with soap and water for a total of 15 seconds before rinsing her hands with water. Interview with LVN C on 09/22/22 at 01:06 PM revealed she said she forgot to perform hand hygiene between glove changes. LVN C said she Usually sing the Happy Birthday song in my head three times when washing my hands. When asked if she sang the song while performing hand washing she said I didn't. LVN C said she was trained to wash her hands with soap and water for 20 seconds before rinsing her hands with water. LVN C said she was last trained on hand hygiene approximately 3-4 months ago. LVN C said it was important to perform proper hand hygiene to prevent infection. Interview with Registered Nurse (RN) E on 09/22/22 at 11:20 AM revealed she said she was the facility's Infection Preventionist. RN E said the facility's hand hygiene policy was to wash hands with soap and water for a total of 20 seconds before rinsing. RN E said staff were expected to perform hand hygiene before and after resident contact, between glove changes, and glove removal. RN E said the importance of hand hygiene was to prevent infection and disease. RN E said she conducted random monthly observations of personal care and hand hygiene but said she had not been able to meet her observation quota in the last couple of months due to other duties. Interview with the Director of Nurses (DON) on 09/22/22 at 01:39 PM revealed she said the facility policy was to perform and hygiene before putting on gloves, between gloves changes, and after removing gloves. The DON said she was employed just four days ago and had not had a chance to do any care observations of staff. The DON said it was important to perform hand hygiene to prevent cross contamination and wound infection. Record review of LVN C's Hand Washing competency and proficiency test dated 04/04/22 revealed competency was met. Record review of CMA B's Hand Washing competency and proficiency test dated 04/24/22 revealed competency was met. Record review of the facility's Handwashing- Hand Hygiene policy and procedure dated 01/2018 documented Use a alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; . l. After contact with objects in the immediate vicinity of the resident . The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Applying gloves: 1. Perform hand hygiene before applying non-sterile gloves .

Based on observation, interview, and record review the facility failed to implement its written policies and procedures that prohibit and prevent abuse, neglect, and/or exploitation of residents, for four (R #176, R #6, R #126, and R #125) of six residents reviewed for neglect. The facility failed to develop and implement written policies, procedures, and practices to prevent the development of and deterioration of pressure ulcers, in that: -The facility did not have a policy and procedure to follow in regards to pressure ulcer care and/or prevention. -The facility failed to implement pressure ulcer prevention/care as per the Lippincott's guidance manual the facility identified as their reference. The facility lacked structures and processes to prevent the development and/or deterioration of pressure ulcers. in that: -The facility did not have a policy and procedure to follow in regards to pressure ulcer prevention/care and did not implement pressure ulcer care as per the guidance manual the facility identified as their reference. R #176: -R #176's Baseline Care Plan did not include specific preventative measures/interventions R #176 should have been provided with for off-loading purposes. -The facility failed to accurately identify and document R #176's left heel community acquired pressure ulcer. The facility continued to stage and document the ulcer as a DTI (Deep Tissue Injury) despite the description of the ulcer not meeting the definition of a DTI. The facility did not obtain a Doppler ultrasound (measures the amount of blood flow through the arteries and veins that supply blood to your arms and legs) order until surveyor's inquiry. -The facility failed to accurately identify and document R #176's right buttock community acquired pressure ulcer. The facility continued to stage and document the ulcer as a Moisture Lesion despite the description of the ulcer not meeting the definition of a Moisture Lesion. -The facility failed to provide or document a detailed description of R #176's pressure ulcers upon admission. -The facility failed to consult the physician upon R #176's admission regarding no treatment orders for pressure ulcers nor did the facility attempt to retrieve treatment orders for R #176 pressure ulcers. -Nursing staff failed to demonstrate competency in knowledge, identification, staging, and describing R #176's pressure ulcers. R #6: -The facility failed to include interventions for pressure ulcer care/prevention in R #6's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to perform a risk assessment (Braden Scale) to assess R #6's risk for pressure ulcer development on admission instead, the facility completed R #6's Braden scale 15 days after admission. -The facility failed to consult and retrieve wound care orders for R #6's pressure ulcers upon admission therefore, R #6 did not receive treatments on her facility acquired Unstageable Pressure Ulcers, described as having 100% eschar tissue, for two days after discovery of the wounds. -The facility failed to offload R #6's right heel to prevent pressure on her Unstageable Pressure Ulcer which had 100% eschar. -The facility failed to reposition R #6, leaving her in the same position for over three hours on two seperate days. -The facility failed to specify how often R #6 required repositioning in her Acute Care Plan. -The facility failed to ensure all nursing staff had access and were aware of R #6's interventions for pressure ulcer care/prevention specified in the Acute Care Plan. -The faility inconsistently staged R #6's right heel pressure ulcer, identifying it as an Unstageable or a Deep Tissue Injury (DTI) on seperate facility documents. R #126: -The facility failed to include interventions for pressure ulcer care/prevention in R #126's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to provide timely repositioning for R #126 who was identified as dependent on staff assistance for repositioning and a high risk for pressure ulcer development. -The facility failed to appropriately treat R #126's Moisture Associated Skin [MEDICAL CONDITION] (MASD) which worsened to the development of a Stage 2 pressure ulcer. -The facility failed to include positioning/repositioning and offloading interventions in R #126's comprehensive care plan and Kardex. R #125: -The facility failed to include interventions for pressure ulcer care/prevention in R #125's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to provide R #125, whom was assessed by the facility as a high risk for pressure ulcer development, with necessary timely repositioning and incontinent care on two seperate days. --The facility failed to include positioning/repositioning and offloading interventions in R #125's comprehensive care plan and Kardex. The above failures resulted in an IJ situation on 10/12/18. While the IJ was removed on 10/13/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures have the potential to result in development of new pressure ulcers or a decline in existing pressure ulcers. The findings included: 1.)R #176: Record review of Resident #176's face sheet revealed a [AGE] year old female who was admitted on [DATE] at 2:00 AM with one [DIAGNOSES REDACTED]. Record review of Resident #176's Nursing Admission/Readmission Nursing Evaluation dated 10/08/18 at 6:30 P.M. revealed, Skin color: Normal for ethnic group, Skin temperature: warm/dry, Skin turgor: normal. -There was no detailed description or locations of R #176's 5 wounds and 1 surgical incision. Record review of R #176's Nursing Braden Scale for Predicting Pressure Score Risk dated 10/09/18 revealed a score of 13 & is at moderate risk. Record review of R #176's physician's orders [REDACTED]. Record review of R #176's physician's orders [REDACTED]. Record review of R #176's Initial wound evaluation dated 10/09/18 and performed by LVN E revealed: -left heel - 10.5 lengthX10.0WidthX0.2Depth centimeters, type: Pressure, Unable to stage due to necrotic tissue, undetermined, shape irregular, exudate: serous and at 25%, edges attached, surrounding skin: [DIAGNOSES REDACTED], -Right Buttock- 1.5 lengthX 1.3WidthX0.2Depth centimeters and listed wound type as a Moisture-Associated Skin Damagepr (Inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) Moisture Lesion. Partial thickness, exudate: serous & 25%, wound bed: granular (red) 100%, no odor, edges attached, surrounding skin [DIAGNOSES REDACTED], Denuded, and [MEDICAL CONDITION]. -Right Posterior thigh - 3.9LX9.5WX0.8D centimeters Type: Pressure, wound bed: Granular 100%, wound edges: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left Great Toe - 1.3lengthX2.3WidthX0depth centimeters, Type: blank, stage: Unable to stage due to necrotic tissue, shape: irregular, exudate: 0, wound bed slough/Eschar: 100%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left 2nd Toe - 0.9lengthX1.0WidthX0depth centimeters, Type: Pressure, stage: unable to stage due to necrotic tissue, shape: blank, exudate: none, wound bed: slough/eschar 100%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. Observation on 10/10/18 at 10:46 A.M. of R #176 was awake, alert, lying flat on her back in bed, buttocks flat on mattress (not off-loaded), her right thigh with pillow under it, and her left foot laid flat on her heel (not off-loaded) on her mattress with a bed sheet. Record review of R #176's wound evaluation dated 10/11/18 and performed by LVN J and observed by surveyor and nurse practitioner revealed, measurements of wound on: -Left heel at 4.0 lengthX3.5 widthX 0.1 Depth centimeters, type: Yes, vascular studies have been ordered, Stage: blank, shape: round, exudate: 0, wound bed: granular (red) at 25%, slough: 75% and firmly adhering to bed, surrounding skin: macerated. -Right Buttock- 2.1 lengthX 2.1WidthX0.1Depth centimeters and listed wound type: Pressure, stage: unable to stage due to necrotic tissue, shape: round, exudate & color: none, wound edge: edges attached, surrounding skin: macerated. -Right Posterior thigh - 2.3LX6WX0.2D centimeters Type: yes, vascular studies have been ordered, shape: irregular, exudate: 0, wound bed: grandular (red) at 75%, slough at 5%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left Great Toe - 2.5lengthX2.9WidthX0depth centimeters, Type: blank, stage: Type: yes, vascular studies have been ordered, shape: oval, exudate: 0, Wound bed: Eschar: 100%, wound edge: edges attached, surrounding skin: intact, [DIAGNOSES REDACTED]. -Left 2nd Toe - 0.9lengthX1.0WidthX0depth centimeters, Type: yes, vascular studies have been ordered, shape: round, exudate: none, wound bed: Eschar 100%, wound edge: edges attached, surrounding skin: intact, [DIAGNOSES REDACTED]. Record review of R #176's wound evaluation dated 10/11/18 and performed by LVN J revealed, measurements of wound on right buttock at 2.1 lengthX2.1WidthX0.1Depth. -Wounds deteriorated compared to measurements with LVN E on 10/09/18. Record review of R #176's Nursing Initial Baseline Care Plan undated revealed, Skin interventions upon admission: wound care. Skin & wound treatments: Blank. Record review of R #176's physician's orders [REDACTED]. -Cleanse left heel DTI with NS (normal saline), pat dry with 4x4, apply wound gel with AG to granulated area, apply skin prep to surrounding skin, cover with a foam dressing and wrap with [MEDICATION NAME] dressing every day shift for wound care. -physician's orders [REDACTED]. -Cleanse moisture lesion to right buttocks with NS, pat dry with 4x4, apply wound gel with AG, cover with dry dressing every day shift for wound care. Review of R #176's Treatment Administration record for (MONTH) (YEAR) revealed, -Cleanse Left heel DTI with NS, pay dry with 4x4, apply wound gel with AG to granulated area, apply skin prep to surrounding skin, cover with a foam dressing, and wrap with [MEDICATION NAME] dressing. Start date: 10/10/18 every day shift for wound care. -Cleanse moisture lesion to right buttocks with NS, pat dry with 4x4, apply wound gel with AG, cover with dry dressing every day shift for wound care. Interview on 10/12/18 at 11:40 AM with DON (Director of Nursing) stated, We had called the previous facility several times to send the Doppler ultrasound report from (MONTH) 10, (YEAR). DON stated, I agree R #176's wounds should never have been staged. I would not use silver (AG) on R #176's wound on her right buttock. DON stated There's different wound care for each stage and the consequence of not accurately treating, staging, or identifying a wound correctly and not off-loading R #176 left heel is that the wound will not heal or it will get worse. -After surveyor's inquiry, Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of R #176's [MEDICAL CONDITION]. Observation on 10/11/18 at 11:26 AM of LVN J performing wound care on R #176 revealed, R #176 was lying in bed with her head of bed raised at 30 degrees, buttocks flat on mattress (not off-loaded), her right thigh with pillow under it, her left foot laid flat on her heel (not off-loaded) on her mattress with a bed sheet. R #176's skin of left leg was flaky, LVN J stated, Yes, she has [MEDICAL CONDITIONS], when asked if R #176 had [MEDICAL CONDITION]. Observed R #176's w/c (wheelchair) seat cushion with stains of exudate and brownish old blood in center of cushion and on the edge of seat cushion. LVN J stated R #176 had A Stage 3 Right posterior thigh, an unstageable left great toe, unstageable left 2nd toe, lesion on right buttock, a DTI on the left heel, and surgical incision right AKA (above the knee amputation). LVN J removed R #176's island dressing from her surgical incision on right thigh exposing the sutures and 3 dehiscence open wounds (one on left with eschar, center wound beefy red with blood, 3rd on right with eschar) and observed 3 circular red pressure unopened wounds. LVN J measured R #176's right posterior thigh at 2.3LenghtX6Width centimeters with no depth measured with wound appearing pink and wet with minimal yellow slough tissue. LVN J removed the [MEDICATION NAME] dressing off of R #176's left foot exposing an oval shaped wound covered with black tissue on left great toe and a circular wound covered with black tissue on left 2nd toe. LVN J then removed a foam dressing and gauzes from left heel exposing an open wound with 100% light yellow tissue, appeared wet and softened surrounding the wound with dark pink discoloration on the right side of R#176's wound. LVN J measured the open wound on the left heel at 4.0LengthX3.5Width centimeters with no depth measured and covered with slough yellow tissue with pink on right side of the wound. LVN J measured the wound on R #176's left great toe at 2.5LengthX2.9Width centimeters with no depth measured and covered with black tissue, left 2nd toe at 1.6LengthX1.7Width centimeters with no depth measured with pink tissue, appeared wet, and minimal slough yellow tissue. LVN J measured R #176's surgical incision on right thigh at 1.1 LengthX25Width centimeters. LVN J measured R #176's wound on right buttock at 2.1LengthX2.1Width centimeters with no depth measured and covered with slough yellow tissue with fungal rash surrounding the wound. LVN J performed wound care as ordered. LVN J cleaned R #176's open wound with 99% yellow slough on right buttock with normal saline. LVN J stated, It's an unstageable with 99% slough, wet, maceration from the fungal rash. LVN J patted dry with 4x4 gauze, applied [MEDICATION NAME] AG, applied a 4x5 Island dressing. - [MEDICATION NAME] AG (silver) promotes moisture to dry or minimally exudating wounds for an optimal moist environment Interview on 10/11/18 at 5:07 P.M. with LVN J The right buttock was covered with 100% slough and I could not measure the depth on the right buttock. LVN J stated, You saw what I saw and the nurse practitioner who was also there, after showing the difference in measurements on 10/09/18 by LVN E and measurements on 10/11/18 by LVN J. No explanation was provided. Interview on 10/11/18 at 6:24 PM with DON stated, The only thing I can think of is that it is a different measurement that includes a darker area around the wound bed. A measurement of 10.5LX10WX0.2D would be too big for R #176's heel. Interview on 10/12/18 at 11:24 AM with NPE (Nurse Practice Educator) stated, I assessed R #176's wound to her right buttock yesterday and felt it was a pressure ulcer and determined it was a stage 3. I've never seen lesion used as a terminology in wound care and I talked to LVN E who identified the stage 3 wound as a lesion. Interview on 10/13/18 at 6:06 PM with NPE stated, I did not know about R #176's [MEDICAL CONDITION], I tried calling R #176's previous facility. The person that does wound care called the wounds pressure ulcers to R #176's feet. I did not have direct care of R #176. I was with LVN E to help review the wounds. Wounds are not my specialty and I need more training. NPE signed off as the RN who performed R #176's initial wound evaluations with LVN E on 10/09/18. Interview on 10/14/18 at 11:20 AM with LVN E revealed, R#176 had scratches scabs and brown [MEDICAL CONDITION] skin discoloration. I would check and see if a resident had [MEDICAL CONDITION] and get my orders from my physician. R #176 had unstageable pressures ulcers on her left foot, a DTI on her left heel, and an open area on her right buttocks. I think she came in previous Monday or Tuesday and I saw her the next day. Before I saw R #176, LVN I told me R #176 had a lot of wounds such as the surgical site on right side and told me I needed to go see her. I did look over her packet from the previous facility, looked at her orders and there were none for wound care nor isolation precautions. The admission assessments were incomplete. There were hardly any admission orders [REDACTED]. I know she had cardiac things and diabetes. R #176 had multiple wounds that needed to be staged so I had NPE come with me because she is an RN and showed NPE all of R #176's sites and my completed assessment. NPE concurred with my assessment papers, I got the physician's orders [REDACTED]. I told the physician about all of R #176's wounds, the fungal rash on her buttocks. It depends on each area and each stage of wounds. Without a doppler study, I can't say it was [MEDICAL CONDITION] if we don't have an Doppler done. I did enter DTI on the left heel. DTI is just a deep tissue injury and discoloration of the skin. You don't know how far down the injury goes and you can't stage it. Sometimes a DTI opens up or sometimes they don't. When I saw R#176's heel, it looked very pink and the circumference of the wound became unblanchable and was not getting as much blood perfusion. I measure from where the non-blanching starts and stops at that point. I measure the extent of the non-blanching area. NPE was with me and held her leg up so I can see better. The wound to the right buttock was a circular opened ulceration with granulation tissue and had no [MEDICATION NAME] tissue. The wound to the right buttock was surrounded by a macerated fungal rash throughout her whole buttock area. A moisture lesion caused by moisture that has nothing to do with pressure and is from moisture and incontinence. Other than the moisture lesion having granulation tissue, was circular, and it's measurements were 1 something by 1 something. -A DTI is a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Interview on 10/14/18 at 2:15 PM CL RN stated, It's the wound care nurse's job to look at the wound and tell if it's wet, dry, infection, irritated and the RN stages the wounds. The wound care nurse notifies the RN and the RN puts in the order for a doppler ultrasound. We don't' always go by the doppler study from the previous facility, as you know with diagnostics they are not always accurate. With the wound care nurse is an RN who reviews the wound evaluation and stages the wounds. Wounds may be staged until confirmation from a doppler ultrasound is received. Record review of R #176's Face Sheet from previous facility dated 10/8/18 at 2:27 P.M. from R # 176's chart revealed, Admit Diagnosis: [REDACTED]. -After surveyor's inquiry, Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of [MEDICAL CONDITION]. Interview on 10/13/18 at 6:50PM with DON stated, If a new resident comes after hours, the nurse reviews the paperwork and if a new resident comes in before 6:00 PM or so then NPE and I (DON) review it. The nurse, myself (DON), NPE, and MDS enter the new resident's information into PCC (point click care program). The nurse is the first one that gets the paperwork and looks over the new resident's orders, paperwork, assesses the resident, inputs the orders in so that the orders can get to the pharmacy and we can get their medications. The nurse that is doing the orders reports and reads off all the orders to the doctor. We (nurses) would read the [DIAGNOSES REDACTED].#176's [MEDICAL CONDITION], I did not talk to staff to find out what happened and was not aware they didn't know. I found out about R #176's [MEDICAL CONDITION] [DIAGNOSES REDACTED]. -After surveyor's inquiry, the Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of [MEDICAL CONDITION] 2.) Resident #6: R #6's Admission Record dated 10/11/18 documented an [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Initial Nursing assessment dated [DATE] documented Integumentary: Rarely moist- usually dry, skin condition warm; Skin Impairments: not present . R #6's Skin Check dated 09/24/18 documented New Skin Injury/Wound Types: Rash, bilateral underarms. Observe skin condition with activities of daily living (ADL) care daily and report abnormality/skin check per policy. No other skin impairment was identified or documented on the Skin Check Report. R #6's Admission/Readmission Nursing Evaluation dated 10/01/18 documented Skin Integrity: -Right Posterior Forearm bruising X 2 -Left 2nd Toe DTI (Deep Tissue Injury) 0.5 X 0.7 X 0 -Right Heel DTI 1.0 X 0.4 X 0 -Left Heel boggy 4.0 X 5.0 X 0 -Right Great Toe 1.5 X 3.0 X 0 According to the DON on 10/10/18 at 5:10 PM, this Readmission Evaluation was performed on 10/01/18 because the facility had a change in management company. R #6's Initial Wound Evaluation dated 10/01/18 documented Pressure: Left 2nd Toe, Onset: 10/01/18, Unable to stage due to necrotic tissue, 0.5 X 0.7 X 0 centimeters, irregular shape, no exudate, 100% eschar (black) (eschar: is a slough or piece of dead tissue that is cast off from the surface of the skin) wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Skin - Acute Care Plan dated 10/01/18 documented Pressure ulcer: Right Great Toe Unstageable Pressure Injury/DTI related to decreased sensation/decreased mobility. Approach: Pressure relief device: Wheelchair Cushion; Reposition every (line left blank), Float Heels, apply skin prep daily, Assess wound weekly, Multivitamin with Minerals. -Left 2nd Toe Unstageable with Eschar related to decreased sensation and decreased mobility: wheelchair cushion, float heels when in bed, apply skin prep . R #6's Initial Wound Evaluation dated 10/01/18 documented Pressure: Right heel, Onset: 10/01/18, Unable to stage due to necrotic tissue, full thickness, 1.0 X 0.4 X 0 centimeters, round shape, no exudate, 100% eschar (black) wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. Review of all of R #6's written and electronic physician's orders [REDACTED]. R #6's physician's orders [REDACTED]. R #6's physician's orders [REDACTED]. R #6's Nurse's Note dated 10/03/18 documented Interdisciplinary Team met to discuss patient due to change in condition. Decreased appetite, nausea, and increased confusion .She has DTI (DTI: Persistent non-blanchable deep red, maroon or purple discoloration . If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTI to describe vascular, traumatic, neuropathic, or dermatologic conditions) to 2nd toe right foot and right heel. Wound care following patient. -This is the first time R #6's right 2nd toe was identified as a DTI. R #6's Weekly Wound Evaluation dated 10/08/18 documented Pressure: Left 2nd Toe, Onset: 10/01/18, Unable to stage due to necrotic tissue, 0.5 X 0.7 X 0 centimeters, irregular shape, no exudate, 100% eschar (black), firmly adhering to wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Weekly Wound Evaluation dated 10/08/18 documented Pressure: Right heel, Onset: 10/01/18, Unable to stage due to necrotic tissue, full thickness, 1.0 X 0.5 X 0 centimeters, round shape, no exudate, 100% eschar (black) firmly adhering to wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Admission Braden Scale for Predicting Pressure Sore Risk dated 10/09/18 documented a score of 15- At Risk. Review of all of R #6's electronic and written Braden Scales revealed only one assessment dated [DATE], 15 days after her initial admission. Interview with LVN E on 10/09/18 at 3:47 PM revealed she stated the facility's procedure for resident risk of pressure ulcer development was conducting a Braden Scale. LVN E said each resident Automatically has a Braden Scale done on admission, quarterly, and after every pressure ulcer discovery. We do it so we can assess to see if the resident is at risk for pressure ulcer development which guides us to place immediate interventions to prevent ulcer development. Observation and interview of R #6 on 10/09/18 at 10:10 AM she was alert and oriented to person, place, and time. R #6 stated she had pressure sores to her heels and toes and did not think she had any sores on her buttocks R #6 was lying in bed, on her back with her head of bed elevated more than 15 degrees. R #6 said she could move her arms and legs minimally but could not turn side to side or raise herself up in bed. Observation of R #6 on 10/09/18 at 11:49 AM revealed she was lying in bed on her back, asleep. R #6's feet rested on one flat pillow that was positioned horizontally. R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/09/18 at 12:30 AM revealed R #6 was lying in bed with her head of bed elevated, feeding herself lunch. R #6's feet rested on the same flat horzontally positioned pillow. R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/09/18 at 1:13 PM revealed R #6 continued to lay in bed, on her back with her head of the bed elevated in the same degrees as seen in previous observations. R #6's eyes were closed and did not awaken to verbal stimuli. R #6 was slouched in bed with the plantar of her feet against the foot board. The horzontal positioned pillow was remained beneath her ankles/feet however, R #6's heels rested on the bed/pillow. Observation of R #6 on 10/09/18 at 3:04 PM revealed R #6 continued to lay in her bed, on her back with her head of bed lower than previously observed. There was approximately a pillow's width of unoccupied bed above R #6's head and R #6's bottom of her feet were pushed against her foot board. R #6's feet rested on the same flat horzontally positioned pillow; R #6's feet/heel were not off-loaded off the bed/pillow. When asked if staff had offered or attempted to reposition her at any time in the morning and afternoon R #6 replied No, they come in her to bring me my meals and take them but no one moves me. I have a catheter so they don't have to change me unless I tell them I pooped myself. My feet are killing me, they are so sore. Yeah, my heels, the entire foot on both of them. I let my head down some using my control because I felt like I couldn't breath. No I haven't asked for anyone to help me, I just though someone would come by soon. R #6 activated her call button as instructed and Certified Nurse Aide (CNA) F entered the room. CNA F said Were you trying to get out of bed? R #6 replied No, I just slid down. CNA F asked R #6 if she wanted to get out of bed however, R #6 responded No, I don't feel well right now. CNA F informed R #6 she was going to get some help to lift R #6 up in bed. R #6's Comprehensive Care Plan dated 10/10/18 revealed the plan did not address skin integrity or pressure ulcers. Observation of R #6 on 10/10/18 at 09:08 AM revealed she was lying in bed on her back with her head of bed elevated more than 15 degrees. R #6 was talking on her personal telephone. There was one flat pillow under R #6's ankles/feet; R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/10/18 at 10:15 AM revealed she remained lying in bed, on her back, watching television. R #6's feet/heels remained in the same position and were not raised off the bed. Observation of R #6 on 10/10/18 at 10:51 AM revealed she continued to lay, on her back, asleep. R #6's feet/heels remained in the same position and were not off-loaded. Observation of R #6 on 10/10/18 at 11:21 AM revealed R #6 continued to lay in bed, on her back with her head of bed elevated more than 15 degrees. R #6 was slouched in bed with her feet pressed against the foot board. Licensed Vocational Nurse (LVN) E entered the room and informed R #6 of wound care to be performed. R #6's ankles rested on a pillow however, her heels were not off-loaded and continued to rest on the bed. LVN E began removing R #6's socks and R #6 immediately grimaced and raised her voice saying My feet hurt, they are sore, especially my heels. LVN E stated Her left second toe is an unstageable pressure ulcer. It measures 0.5 X 0.8 centimeters, with 100% brown/black hardened eschar covering the wound bed. The right heel has a dry brown blackish scab and the surrounding skin is light purple; it measures 1.0 X 2.5 centimeters. The pillow was supposed to be used for off-loading her heels off the bed but her heels are not offloaded and her feet are touching the foot board, we need to pull her up in bed, she obviously slid down in bed. Off-loading is important to allow the right heel to heal and prevent further injury due to pressure. They were identified as pressure ulcers because she has no evidence or [DIAGNOSES REDACTED]. Continued interview with LVN E on 10/10/18 at 11:30 AM revealed she confirmed R #6 was not able to reposition or offload herself. LVN E was informed of multiple observations of R #6 laying in the same position in bed and LVN E said She should be repositioned and offloaded every two hours. When asked what her role was, since she was the treatment nurse, in ensuring residents were repositioned or offloaded, LVN E said I was being used as a regular nurse because we could not have a treatment nurse. Until I was given the Treatment Nurse position back just these past several days, the nurses were doing some wound care and I would help to. I am certified in wound care. I used to have a timer on my cart and when it would go off, I would do rounds and check on positioning and offloading but I have not done that since we reopened. LVN E confirmed the nuses, nurse aides, and she was responsible for ensuring dependent residents with wounds or at high risk for developing wounds were repositioned at least every two hours. LVN E confirmed she had not checked on any resident's positioning aside from providing their wound care. LVN E verified that R #6's wounds may not be healing due to not offloading and repositioning But other factors contribute to it too like her obesity and diabetes. When asked how R #6 was discovered with two seperate wounds with eschar without any prior signs not noticed by nursing staff, LVN E said I don't know. It's not likely that she just woke up with black dead tissue, there are usually previous signs like redness or slough. I can't tell you what happened. Interview with R #6 on 10/10/18 at 11:38 PM revealed she stated none of the staff had offered to reposition her. R #6 said I guess I should tell them but they know I can't do it. R #6 confirmed she did not like to get out of bed often. R #6 complained that her feet/heels were very sore and rated her feet pain at a 6. In(TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure that licensed nurses and nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs including assessing, planning, and implementing resident care plans, for five (R #176, R #6, R #126, R #125, and R #177) of 12 residents reviewed for quality of care and nursing services, in that: 1.) R #176: -The facility failed to accurately identify and document R #176's left heel community acquired pressure ulcer. The facility continued to stage and document the ulcer as a stage DTI (Deep Tissue Injury) despite the description of the ulcer not meeting the definition of a DTI. The facility did not obtain a Doppler ultrasound (measures the amount of blood flow through the arteries and veins that supply blood to your arms and legs) order until surveyor's inquiry. -The facility failed to accurately identify and document R #176's right buttock community acquired pressure ulcer. The facility continued to stage and document the ulcer as a Moisture Lesion despite the description of the ulcer not meeting the definition of a Moisture Lesion. -R #176's Baseline Care Plan did not include specific preventative measures/interventions R #176 should have been provided with for off-loading purposes. -The facility failed to provide or document a detailed description of R #176's pressure ulcers upon admission. -The facility failed to consult the physician upon R #176's admission regarding no treatment orders for R #176's pressure ulcers or attempted to retrieve treatment orders for R #176. -Nursing staff failed to demonstrate competency in knowledge and identification staging, describing R #176's pressure ulcers. -The failed to implement contact precautions on R #176 for the prevention and control of infections of residents, staff, and visitors at the time of admission. -CNA L failed to don PPE (personal protective equipment) prior to entering R #176's room who had ESBL of the urine (Extended Spectrum Beta-Lactamase). -Nursing staff failed to ensure R #176's PICC (peripherally inserted central catheter) site dressing had been changed according to current physician's orders [REDACTED]. 2.) R #6: -Nursing staff failed to consult and retrieve wound care orders for R #6's pressure ulcers upon admission therefore, R #6 did not receive treatments on her facility acquired Unstageable Pressure Ulcers, described as having 100% eschar tissue, for two days after discovery of the wounds. -Nursing staff failed to offload R #6's right heel to prevent pressure on her Unstageable Pressure Ulcer which had 100% eschar. -Nursing staff failed to reposition R #6, leaving her in the same position for over three hours on two seperate days. -Licensed Vocational Nurse (LVN) E failed to specify how often R #6 required repositioning in her Acute Care Plan. -LVN E failed to ensure all nursing staff had access and were aware of R #6's interventions for pressure ulcer care/prevention specified in the Acute Care Plan. -Nursing staff failed to include interventions for pressure ulcer care/prevention in R #6's Comprehensive Care Plan and Kardex/CNA Care Plan. -Nursing staff inconsistently staged R #6's right heel pressure ulcer, identifying it as an Unstageable or a Deep Tissue Injury (DTI) on seperate facility documents. -Nursing staff failed to retrieve physician's orders [REDACTED].#6 needed. -Certified Nurse Aide (CNA) H failed to keep R #6's indwelling catheter drainage bag off the floor. -CNA H failed to keep R #6's indwelling urinary drainage bag below R #6's bladder level. -CNA H failed to accurately perform hand hygiene, while providing R #6 a shower, as per the facility's policy and procedure. -CNA H failed to keep R #6's indwelling catheter drainage bag off the floor. -CNA H failed to keep R #6's indwelling urinary drainage bag below R #6's bladder level. 3.) R #126: -Nursing staff failed to provide timely repositioning for R #126 who was identified as dependent on staff assistance for repositioning and a high risk for pressure ulcer development. -Nursing staff failed to appropriately treat R #126's Moisture Associated Skin [MEDICAL CONDITION] (MASD) which worsened to the development of a Stage 2 pressure ulcer. -Nursing staff failed to include positioning/repositioning and offloading interventions in R #126's comprehensive care plan and Kardex. -Nursing staff failed to retrieve physician's orders [REDACTED].#126 needed. -CNA F failed to keep R #6's indwelling urinary drainage bag below R #126's bladder level. -Nursing staff failed to ensure R #126's indwelling urinary catheter tubing was secure/anchored to prevent urethral trauma. R #126 had some bleeding from the catheter insertion site. -CNA F failed to keep R #6's indwelling urinary drainage bag below R #126's bladder level. 4.) R #125: -Nursing staff failed to provide R #125, whom was assessed by the facility as a high risk for pressure ulcer development, with necessary timely repositioning and incontinent care on two seperate days. --Nursing staff failed to include positioning/repositioning and offloading interventions in R #125's comprehensive care plan and Kardex. 5.) R#177: -CNA F did not doff her gloves nor washed/hand sanitized her hands after folding up R #177's dirty brief and throwing it into R #177's trashcan. -CNA F did not wash/hand sanitized her hands nor donned clean gloves prior to touching R #177's clean brief. These failures have the potential to result in development of new pressure ulcers or a decline in existing pressure ulcers and result in infection. The findings incuded: 1) R #176: Record review of Resident #176's face sheet revealed a [AGE] year old female who was admitted on [DATE] with one [DIAGNOSES REDACTED]. -Admission of R #176 on 10/8/18 at 2:00AM. Record review of R #176's 24 hour report undated & with no nurse's signature revealed, Hall Appt (appointment) at Dr.(NAME)ortho 10/11/18 1:45 P.M. Contact isolation -ESBL, PICC (peripherally inserted central catheter). Record review of Resident #176's Nursing Admission/Readmission Nursing Evaluation dated 10/08/18 at 6:30 P.M. revealed, Skin color: Normal for ethnic group, Skin temperature: warm/dry, Skin turgor: normal. -There was no detailed description or locations of R #176's 5 wounds and 1 surgical incision. Record review of Resident #176's physicians orders dated 10/08/18 revealed Dressing change to PICC site every 48 hours for IV therapy and [MEDICATION NAME] HCL ([MEDICATION NAME]) in [MEDICATION NAME] Solution 500-5 MG (milligrams)/100 ML(milliliters)-% Use 200 ML/HR intravenously one time a day for infection. Record review of R #176's Nursing Braden Scale for Predicting Pressure Score Risk dated 10/09/18 revealed a score of 13 & is at moderate risk. Record review of Resident #176's care plan undated revealed, Is the resident on isolation? Yes Type: Contact. Bladder and Bowel: Incontinent. Record review of R #176's Woodridge Nursing & Rehabilitation Departmental notes sent to Oak Crest Nursing & Rehabilitation dated 10/08/18 revealed, Resident continues on Vanco ([MEDICATION NAME]) IV (intravenously) and continues on contact precaution. Record review of Resident #176's care plan undated revealed, Active order for IV medication(s)? Yes. Type: PICC. Record review of R #176's physician's orders [REDACTED]. -physician's orders [REDACTED]. Record review of R #176's physician's orders [REDACTED]. Record review of R #176's Initial wound evaluation dated 10/09/18 and performed by LVN E revealed: -left heel - 10.5 lengthX10.0WidthX0.2Depth centimeters, type: Pressure, Unable to stage due to necrotic tissue, undetermined, shape irregular, exudate: serous and at 25%, edges attached, surrounding skin: [DIAGNOSES REDACTED], -Right Buttock- 1.5 lengthX 1.3WidthX0.2Depth centimeters and listed wound type as a Moisture-Associated Skin Damagepr (Inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) Moisture Lesion. Partial thickness, exudate: serous & 25%, wound bed: granular (red) 100%, no odor, edges attached, surrounding skin [DIAGNOSES REDACTED], Denuded, and [MEDICAL CONDITION]. -Right Posterior thigh - 3.9LX9.5WX0.8D centimeters Type: Pressure, wound bed: Granular 100%, wound edges: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left Great Toe - 1.3lengthX2.3WidthX0depth centimeters, Type: blank, stage: Unable to stage due to necrotic tissue, shape: irregular, exudate: 0, wound bed slough/Eschar: 100%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left 2nd Toe - 0.9lengthX1.0WidthX0depth centimeters, Type: Pressure, stage: unable to stage due to necrotic tissue, shape: blank, exudate: none, wound bed: slough/eschar 100%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. Observation on 10/09/18 09:17 AM outside of Resident # 176's door (room [ROOM NUMBER]) says, Stop please see nurse before entering the room. Contact precaution instructions on R #176's door beneath the PPE (personal protective equipment) equipment. Record review of Resident #176's physicians orders dated 10/09/18 revealed Contact Isolation: ESBL. Interview on 10/09/18 at 11:46 AM with LVN I stated, There were no contact isolation in R #176's orders and now the orders are there. The contact is for ESBL in the urine. But earlier none of that (isolation precautions for ESBL) was in the orders and I asked the DON and they did not know at that time. At the time you (surveyors) asked about the type of isolation precautions, there was no order for that because I checked the orders. I (LVN I) am the charge nurse and I would not know why the precaution sign was there because there were no orders. After you (surveyors) asked about the isolation precautions, I went and and asked the DON about the isolation and that is where I got the information from. I (LVN I) came on shift at 6:00am this morning and there was no sign and I don't know who put the sign (precaution sign) up at R #176's room. I don't' know who put the PPE on the door. Observation on 10/10/18 at 10:46 A.M. of R #176 was awake, alert, lying flat on her back in bed, buttocks flat on mattress (not off-loaded), her right thigh with pillow under it, and her left foot laid flat on her heel (not off-loaded) on her mattress with a bed sheet. Observation on 10/10/18 at 11:09 AM of R # 176's PICC line on right arm dressing dated 10/5/18 with initials JB. Observation on 10/11/18 at 10:01 AM of CNA L grabbed the gown and gloves and proceeded to walk into R #176's room without donning the PPE prior to entering R #176's room. Record review of R #176's wound evaluation dated 10/11/18 and performed by LVN J and observed by surveyor and nurse practitioner revealed, measurements of wound on: -Left heel at 4.0 lengthX3.5 widthX 0.1 Depth centimeters, type: Yes, vascular studies have been ordered, Stage: blank, shape: round, exudate: 0, wound bed: granular (red) at 25%, slough: 75% and firmly adhering to bed, surrounding skin: macerated. -Right Buttock- 2.1 lengthX 2.1WidthX0.1Depth centimeters and listed wound type: Pressure, stage: unable to stage due to necrotic tissue, shape: round, exudate & color: none, wound edge: edges attached, surrounding skin: macerated. -Right Posterior thigh - 2.3LX6WX0.2D centimeters Type: yes, vascular studies have been ordered, shape: irregular, exudate: 0, wound bed: grandular (red) at 75%, slough at 5%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left Great Toe - 2.5lengthX2.9WidthX0depth centimeters, Type: blank, stage: Type: yes, vascular studies have been ordered, shape: oval, exudate: 0, Wound bed: Eschar: 100%, wound edge: edges attached, surrounding skin: intact, [DIAGNOSES REDACTED]. -Left 2nd Toe - 0.9lengthX1.0WidthX0depth centimeters, Type: yes, vascular studies have been ordered, shape: round, exudate: none, wound bed: Eschar 100%, wound edge: edges attached, surrounding skin: intact, [DIAGNOSES REDACTED]. Record review of R #176's wound evaluation dated 10/11/18 and performed by LVN J revealed, measurements of wound on right buttock at 2.1 lengthX2.1WidthX0.1Depth. -Wounds deteriorated compared to measurements with LVN E on 10/09/18. Record review of R #176's Nursing Initial Baseline Care Plan undated revealed, Skin interventions upon admission: wound care. Skin & wound treatments: Blank. Record review of R #176's physician's orders [REDACTED]. -Cleanse left heel DTI with NS (normal saline), pat dry with 4x4, apply wound gel with AG to granulated area, apply skin prep to surrounding skin, cover with a foam dressing and wrap with [MEDICATION NAME] dressing every day shift for wound care. -physician's orders [REDACTED]. -Cleanse moisture lesion to right buttocks with NS, pat dry with 4x4, apply wound gel with AG, cover with dry dressing every day shift for wound care. Observation on 10/11/18 at 11:26 AM of LVN J performing wound care on R #176 revealed, R #176 was lying in bed with her head of bed raised at 30 degrees, buttocks flat on mattress (not off-loaded), her right thigh with pillow under it, her left foot laid flat on her heel (not off-loaded) on her mattress with a bed sheet. R #176's skin of left leg was flaky, LVN J stated, Yes, she has [MEDICAL CONDITIONS], when asked if R #176 had [MEDICAL CONDITION]. Observed R #176's w/c (wheelchair) seat cushion with stains of exudate and brownish old blood in center of cushion and on the edge of seat cushion. LVN J stated R #176 had A Stage 3 Right posterior thigh, an unstageable left great toe, unstageable left 2nd toe, lesion on right buttock, a DTI on the left heel, and surgical incision right AKA (above the knee amputation). LVN J removed R #176's island dressing from her surgical incision on right thigh exposing the sutures and 3 dehiscence open wounds (one on left with eschar, center wound beefy red with blood, 3rd on right with eschar) and observed 3 circular red pressure unopened wounds. LVN J measured R #176's right posterior thigh at 2.3LenghtX6Width centimeters with no depth measured with wound appearing pink and wet with minimal yellow slough tissue. LVN J removed the [MEDICATION NAME] dressing off of R #176's left foot exposing an oval shaped wound covered with black tissue on left great toe and a circular wound covered with black tissue on left 2nd toe. LVN J then removed a foam dressing and gauzes from left heel exposing an open wound with 100% light yellow tissue, appeared wet and softened surrounding the wound with dark pink discoloration on the right side of R#176's wound. LVN J measured the open wound on the left heel at 4.0LengthX3.5Width centimeters with no depth measured and covered with slough yellow tissue with pink on right side of the wound. LVN J measured the wound on R #176's left great toe at 2.5LengthX2.9Width centimeters with no depth measured and covered with black tissue, left 2nd toe at 1.6LengthX1.7Width centimeters with no depth measured with pink tissue, appeared wet, and minimal slough yellow tissue. LVN J measured R #176's surgical incision on right thigh at 1.1 LengthX25Width centimeters. LVN J measured R #176's wound on right buttock at 2.1LengthX2.1Width centimeters with no depth measured and covered with slough yellow tissue with fungal rash surrounding the wound. LVN J performed wound care as ordered. LVN J cleaned R #176's open wound with 99% yellow slough on right buttock with normal saline. LVN J stated, It's an unstageable with 99% slough, wet, maceration from the fungal rash. LVN J patted dry with 4x4 gauze, applied [MEDICATION NAME] AG, applied a 4x5 Island dressing. - [MEDICATION NAME] AG (silver) promotes moisture to dry or minimally exudating wounds for an optimal moist environment Interview on 10/11/18 at 5:07 P.M. with LVN J The right buttock was covered with 100% slough and I could not measure the depth on the right buttock. LVN J stated, You saw what I saw and the nurse practitioner who was also there, after showing the difference in measurements on 10/09/18 by LVN E and measurements on 10/11/18 by LVN J. No explanation was provided. Interview on 10/11/18 at 6:24 PM with DON stated, The only thing I can think of is that it is a different measurement that includes a darker area around the wound bed. A measurement of 10.5LX10WX0.2D would be too big for R #176's heel. Review of R #176's Treatment Administration record for (MONTH) (YEAR) revealed, -Cleanse Left heel DTI with NS, pay dry with 4x4, apply wound gel with AG to granulated area, apply skin prep to surrounding skin, cover with a foam dressing, and wrap with [MEDICATION NAME] dressing. Start date: 10/10/18 every day shift for wound care. -Cleanse moisture lesion to right buttocks with NS, pat dry with 4x4, apply wound gel with AG, cover with dry dressing every day shift for wound care. Interview on 10/11/18 at 4:06 P.M. with LVN K stated, R #176's [DIAGNOSES REDACTED]. The name of the infection starts with an S. I should have put her on isolation and I did not do that. I don't know, I guess I was really busy and did not have the time to do it. I messed up, sorry. I believe early the next morning when the next nurse came in which was LVN I. I probably did not tell her about R #176's infection. It was in the back of my head to put R #176 on isolation but I forgot to do that and I knew R #176 needed to be on isolation. No, I did not give the doctor their (R #176, R #177) [DIAGNOSES REDACTED].#176's and R #177's medications. Interview on 10/12/18 at 11:24 AM with NPE (Nurse Practice Educator) stated, I assessed R #176's wound to her right buttock yesterday and felt it was a pressure ulcer and determined it was a stage 3. I've never seen lesion used as a terminology in wound care and I talked to LVN E who identified it as that. Interview on 10/12/18 at 11:40 AM with DON (Director of Nursing) stated, We had called the previous facility several times to send the Doppler ultrasound report from (MONTH) 10, (YEAR). DON stated, I agree R #176's wounds should never have been staged. I would not use silver (AG) on R #176's wound on her right buttock. DON stated There's different wound care for each stage and the consequence of not accurately treating, staging, or identifying a wound correctly and not off-loading R #176 left heel is that the wound will not heal or it will get worse. -After surveyor's inquiry, Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of R #176's [MEDICAL CONDITION]. Interview on 10/12/18 at 4:11 PM with NPE (Nurse Practice Educator) stated no response as to observation of CNA L not donning PPE prior to entering R #176's room. Interview on 10/13/18 at 3:34 P.M. with LVN I stated, An infection could result from PICC line dressing not being changed or following physician's orders [REDACTED]. Interview on 10/13/18 at 4:50 P.M. with NPE confirmed PICC dressing date & stated, 10/5/18 and I don't know who JB (initials on dressing) is. Interview on 10/13/18 at 6:06 PM with NPE stated, I did not know about R #176's [MEDICAL CONDITION], I tried calling R #176's previous facility. The person that does wound care called the wounds as pressure ulcers to R #176's feet. I did not have direct care of R #176. I was with LVN E to help review the wounds. Wounds are not my specialty and I need more training. - NPE signed off as the RN who performed R #176's initial wound evaluations with LVN E on 10/09/18. Interview on 10/13/18 at 6:50PM with DON stated, If a new resident comes after hours, the nurse reviews the paperwork and if a new resident comes in before 6:00 PM or so, the NPE and I (DON) review it. The nurse, myself (DON), NPE, and MDS enter the new resident's information into PCC (point click care program). The nurse is the first one that gets the paperwork and looks over the new resident's orders, paperwork, assesses the resident, inputs the orders in so that the orders can get to the pharmacy and we can get their medications. Interview on 10/14/18 at 11:20 A.M. with LVN E stated, Yes, I did not know about the isolation precautions until they were hanging it (PPE) up on the door. Right as I was about to enter R #176's room, they were putting up the isolation precautions and I believe it was a (unidentified staff) and our administrator putting up isolation precautions. I asked (unidentified staff) and she did not have any information on the isolation precautions. I asked LVN I and she didn't know anything about the isolation precautions. So I asked NPE and the DON about it and they told me that it's probably so but not 100% sure that it was ESBL (Extended Spectrum Beta-Lactamase) bacteria in the urine. Interview on 10/14/18 at 11:20 AM with LVN E revealed, R#176 had scratches scabs and brown [MEDICAL CONDITION] skin discoloration. I would check and see if a resident had [MEDICAL CONDITION] and get my orders from my physician. R #176 had unstageable pressures ulcers on her left foot, a DTI on her left heel, and an open area on her right buttocks. I think she came in previous Monday or Tuesday and I saw her the next day. Before I saw R #176, LVN I told me R #176 had a lot of wounds such as the surgical site on right side and told me I needed to go see her. I did look over her packet from the previous facility, looked at her orders and there were none for wound care nor isolation precautions. The admission assessments were incomplete. There were hardly any admission orders [REDACTED]. I know she had cardiac things and diabetes. R #176 had multiple wounds that needed to be staged so I had NPE come with me because she is an RN and showed NPE all of R #176's sites and my completed assessment. NPE concurred with my assessment papers, I got the physician's orders [REDACTED]. I told the physician about all of R #176's wounds, the fungal rash on her buttocks. It depends on each area and each stage of wounds. Without a doppler study, I can't say it was [MEDICAL CONDITION] if we don't have an Doppler done. I did enter DTI on the left heel. DTI is just a deep tissue injury and discoloration of the skin. You don't know how far down the injury goes and you can't stage it. Sometimes a DTI opens up or sometimes they don't. When I saw R#176's heel, it looked very pink and the circumference of the wound became unblanchable and was not getting as much blood perfusion. I measure from where the non-blanching starts and stops at that point. I measure the extent of the non-blanching area. NPE was with me and held her leg up so I can see better. The wound to the right buttock was a circular opened ulceration with granulation tissue and had no [MEDICATION NAME] tissue. The wound to the right buttock was surrounded by a macerated fungal rash throughout her whole buttock area. A moisture lesion caused by moisture that has nothing to do with pressure and is from moisture and incontinence. Other than the moisture lesion having granulation tissue, was circular, and it's measurements were 1 something by 1 something. -A DTI is a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Interview on 10/14/18 at 2:15 PM CL RN stated, It's the wound care nurse's job to look at the wound and tell if it's wet, dry, infection, irritated and the RN stages the wounds. The wound care nurse notifies the RN and the RN puts in the order for a doppler ultrasound. We don't' always go by the doppler study from the previous facility, as you know with diagnostics they are not always accurate. With the wound care nurse is an RN who reviews the wound evaluation and stages the wounds. Wounds may be staged until confirmation from a doppler ultrasound is received. Record review of R #176's Face Sheet from previous facility dated 10/8/18 at 2:27 P.M. from R # 176's chart revealed, Admit Diagnosis: [REDACTED]. -After surveyor's inquiry, Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of [MEDICAL CONDITION]. 2.) Resident #6: R #6's Admission Record dated 10/11/18 documented an [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Initial Nursing assessment dated [DATE] documented Integumentary: Rarely moist- usually dry, skin condition warm; Skin Impairments: not present . R #6's Skin Check dated 09/24/18 documented New Skin Injury/Wound Types: Rash, bilateral underarms. Observe skin condition with activities of daily living (ADL) care daily and report abnormality/skin check per policy. No other skin impairment was identified or documented on the Skin Check Report. R #6's Admission/Readmission Nursing Evaluation dated 10/01/18 documented Skin Integrity: -Right Posterior Forearm bruising X 2 -Left 2nd Toe DTI (Deep Tissue Injury) 0.5 X 0.7 X 0 -Right Heel DTI 1.0 X 0.4 X 0 -Left Heel boggy 4.0 X 5.0 X 0 -Right Great Toe 1.5 X 3.0 X 0 This Readmission Evaluation was performed due to the facility being taken over by a new company. R #6's Initial Wound Evaluation dated 10/01/18 documented Pressure: Left 2nd Toe, Onset: 10/01/18, Unable to stage due to necrotic tissue, 0.5 X 0.7 X 0 centimeters, irregular shape, no exudate, 100% eschar (black) (eschar: is a slough or piece of dead tissue that is cast off from the surface of the skin) wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Skin - Acute Care Plan dated 10/01/18 documented Pressure ulcer: Right Great Toe Unstageable Pressure Injury/DTI related to decreased sensation/decreased mobility. Approach: Pressure relief device: Wheelchair Cushion; Reposition every (line left blank), Float Heels, apply skin prep daily, Assess wound weekly, Multivitamin with Minerals. -Left 2nd Toe Unstageable with Eschar related to decreased sensation and decreased mobility: wheelchair cushion, float heels when in bed, apply skin prep . R #6's Initial Wound Evaluation dated 10/01/18 documented Pressure: Right heel, Onset: 10/01/18, Unable to stage due to necrotic tissue, full thickness, 1.0 X 0.4 X 0 centimeters, round shape, no exudate, 100% eschar (black) wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. Review of all of R #6's written and electronic physician's orders [REDACTED]. R #6's physician's orders [REDACTED]. R #6's physician's orders [REDACTED]. R #6's Nurse's Note dated 10/03/18 documented Interdisciplinary Team met to discuss patient due to change in condition. Decreased appetite, nausea, and increased confusion .She has DTI (DTI: Persistent non-blanchable deep red, maroon or purple discoloration . If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions) to 2nd toe right foot and right heel. Wound care following patient. This is the first time R #6's wound was identified as a DTI. R #6's Weekly Wound Evaluation dated 10/08/18 documented Pressure: Left 2nd Toe, Onset: 10/01/18, Unable to stage due to necrotic tissue, 0.5 X 0.7 X 0 centimeters, irregular shape, no exudate, 100% eschar (black), firmly adhering to wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Weekly Wound Evaluation dated 10/08/18 documented Pressure: Right heel, Onset: 10/01/18, Unable to stage due to necrotic tissue, full thickness, 1.0 X 0.5 X 0 centimeters, round shape, no exudate, 100% eschar (black) firmly adhering to wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Admission Braden Scale for Predicting Pressure Sore Risk dated 10/09/18 documented a score of 15- At Risk. Review of all of R #6's electronic and written Braden Scales revealed only one assessment dated [DATE], 15 days after her initial admission. Observation and interview of R #6 on 10/09/18 at 10:10 AM she was alert and oriented to person, place, and time. R #6 stated she had pressure sores to her heels and toes and did not think she had any sores on her buttocks R #6 was lying in bed, on her back with her head of bed elevated more than 15 degrees. R #6 said she could move her arms and legs minimally but could not turn side to side or raise herself up in bed. R #6 stated she needed an indwelling urinary catheter because she retained urine. When asked if her catheter tubing was secured to her leg she pulled the cover off her right leg and presented a white catheter holder holding the catheter in place. R #6's catheter size was an 18 French (fr)/ 30 ml (milliliter) balloon. Observation of R #6 on 10/09/18 at 11:49 AM revealed she was lying in bed on her back, asleep. R #6's feet rested on one flat pillow that was positioned horizontally. R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/09/18 at 12:30 AM revealed R #6 was lying in bed with her head of bed elevated, feeding herself lunch. R #6's feet rested on the same flat horzontally positioned pillow. R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/09/18 at 1:13 PM revealed R #6 continued to lay in bed, on her back with her head of the bed elevated in the same degrees as seen in previous observations. R #6's eyes were closed and did not awaken to verbal stimuli. R #6 was slouched in bed with the plantar of her feet against the foot board. The horzontal positioned pillow was remained beneath her ankles/feet however, R #6's heels rested on the bed/pillow. Observation of R #6 on 10/09/18 at 3:04 PM revealed R #6 contined to lay in her bed, on her back with her head of bed lower than previously observed. There was approximately a pillow's width of unoccupied bed above R #6's head and R #6's bottom of her feet were pushed against her foot board. R #6's feet rested on the same flat horzontally positioned pillow; R #6's feet/heel were not off-loaded off the bed/pillow. When asked if staff had offered or attempted to reposition her at any time in the morning and afternoon R #6 replied No, they come in her to bring me my meals and take them but no one moves me. I have a catheter so they don't have to change me unless I tell them I pooped myself. My feet are killing me, they are so sore. Yeah, my heels, the entire foot on both of them. I let my head down some using my control because I felt like I couldn't breath. No I hav't asked for anyone to help me, I just though s (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure each resident had the right to be free from neglect for four residents (R #176, R#6, R #126, and R #125) of six residents reviewed for neglect. The facility lacked structures and processes to prevent the development and/or deterioration of pressure ulcers. in that: -The facility did not have a policy and procedure to follow in regards to pressure ulcer prevention/care. -The facility failed to implement pressure ulcer prevention/care as per the Lippincott's guidance manual the facility identified as their reference. R #176: -R #176's Baseline Care Plan did not include specific preventative measures/interventions R #176 should have been provided with for off-loading purposes. -The facility failed to accurately identify and document R #176's left heel community acquired pressure ulcer. The facility continued to stage and document the ulcer as a DTI (Deep Tissue Injury) despite the description of the ulcer not meeting the definition of a DTI. The facility did not obtain a Doppler ultrasound (measures the amount of blood flow through the arteries and veins that supply blood to your arms and legs) order until surveyor's inquiry. -The facility failed to accurately identify and document R #176's right buttock community acquired pressure ulcer. The facility continued to stage and document the ulcer as a Moisture Lesion despite the description of the ulcer not meeting the definition of a Moisture Lesion. -The facility failed to provide or document a detailed description of R #176's pressure ulcers upon admission. -The facility failed to consult the physician upon R #176's admission regarding no treatment orders for pressure ulcers nor did the facility attempt to retrieve treatment orders for R #176 pressure ulcers. -Nursing staff failed to demonstrate competency in knowledge, identification, staging, and describing R #176's pressure ulcers. R #6: -The facility failed to include interventions for pressure ulcer care/prevention in R #6's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to perform a risk assessment (Braden Scale) to assess R #6's risk for pressure ulcer development on admission instead, the facility completed R #6's Braden scale 15 days after admission. -The facility failed to consult and retrieve wound care orders for R #6's pressure ulcers upon admission therefore, R #6 did not receive treatments on her facility acquired Unstageable Pressure Ulcers, described as having 100% eschar tissue, for two days after discovery of the wounds. -The facility failed to offload R #6's right heel to prevent pressure on her Unstageable Pressure Ulcer which had 100% eschar. -The facility failed to reposition R #6, leaving her in the same position for over three hours on two seperate days. -The facility failed to specify how often R #6 required repositioning in her Acute Care Plan. -The facility failed to ensure all nursing staff had access and were aware of R #6's interventions for pressure ulcer care/prevention specified in the Acute Care Plan. -The faility inconsistently staged R #6's right heel pressure ulcer, identifying it as an Unstageable or a Deep Tissue Injury (DTI) on seperate facility documents. R #126: -The facility failed to include interventions for pressure ulcer care/prevention in R #126's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to provide timely repositioning for R #126 who was identified as dependent on staff assistance for repositioning and a high risk for pressure ulcer development. -The facility failed to appropriately treat R #126's Moisture Associated Skin [MEDICAL CONDITION] (MASD) which worsened to the development of a Stage 2 pressure ulcer. -The facility failed to include positioning/repositioning and offloading interventions in R #126's comprehensive care plan and Kardex. R #125: -The facility failed to include interventions for pressure ulcer care/prevention in R #125's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to provide R #125, whom was assessed by the facility as a high risk for pressure ulcer development, with necessary timely repositioning and incontinent care on two seperate days. --The facility failed to include positioning/repositioning and offloading interventions in R #125's comprehensive care plan and Kardex. The above failures resulted in an IJ situation on 10/12/18. While the IJ was removed on 10/13/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures have the potential to result in development of new pressure ulcers or a decline in existing pressure ulcers. The findings included: 1.)R #176: Record review of Resident #176's face sheet revealed a [AGE] year old female who was admitted on [DATE] at 2:00 AM with one [DIAGNOSES REDACTED]. Record review of Resident #176's Nursing Admission/Readmission Nursing Evaluation dated 10/08/18 at 6:30 P.M. revealed, Skin color: Normal for ethnic group, Skin temperature: warm/dry, Skin turgor: normal. -There was no detailed description or locations of R #176's 5 wounds and 1 surgical incision. Record review of R #176's Nursing Braden Scale for Predicting Pressure Score Risk dated 10/09/18 revealed a score of 13 & is at moderate risk. Record review of R #176's physician's orders [REDACTED]. Record review of R #176's physician's orders [REDACTED]. Record review of R #176's Initial wound evaluation dated 10/09/18 and performed by LVN E revealed: -left heel - 10.5 lengthX10.0WidthX0.2Depth centimeters, type: Pressure, Unable to stage due to necrotic tissue, undetermined, shape irregular, exudate: serous and at 25%, edges attached, surrounding skin: [DIAGNOSES REDACTED], -Right Buttock- 1.5 lengthX 1.3WidthX0.2Depth centimeters and listed wound type as a Moisture-Associated Skin Damagepr (Inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) Moisture Lesion. Partial thickness, exudate: serous & 25%, wound bed: granular (red) 100%, no odor, edges attached, surrounding skin [DIAGNOSES REDACTED], Denuded, and [MEDICAL CONDITION]. -Right Posterior thigh - 3.9LX9.5WX0.8D centimeters Type: Pressure, wound bed: Granular 100%, wound edges: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left Great Toe - 1.3lengthX2.3WidthX0depth centimeters, Type: blank, stage: Unable to stage due to necrotic tissue, shape: irregular, exudate: 0, wound bed slough/Eschar: 100%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left 2nd Toe - 0.9lengthX1.0WidthX0depth centimeters, Type: Pressure, stage: unable to stage due to necrotic tissue, shape: blank, exudate: none, wound bed: slough/eschar 100%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. Observation on 10/10/18 at 10:46 A.M. of R #176 was awake, alert, lying flat on her back in bed, buttocks flat on mattress (not off-loaded), her right thigh with pillow under it, and her left foot laid flat on her heel (not off-loaded) on her mattress with a bed sheet. Record review of R #176's wound evaluation dated 10/11/18 and performed by LVN J and observed by surveyor and nurse practitioner revealed, measurements of wound on: -Left heel at 4.0 lengthX3.5 widthX 0.1 Depth centimeters, type: Yes, vascular studies have been ordered, Stage: blank, shape: round, exudate: 0, wound bed: granular (red) at 25%, slough: 75% and firmly adhering to bed, surrounding skin: macerated. -Right Buttock- 2.1 lengthX 2.1WidthX0.1Depth centimeters and listed wound type: Pressure, stage: unable to stage due to necrotic tissue, shape: round, exudate & color: none, wound edge: edges attached, surrounding skin: macerated. -Right Posterior thigh - 2.3LX6WX0.2D centimeters Type: yes, vascular studies have been ordered, shape: irregular, exudate: 0, wound bed: grandular (red) at 75%, slough at 5%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left Great Toe - 2.5lengthX2.9WidthX0depth centimeters, Type: blank, stage: Type: yes, vascular studies have been ordered, shape: oval, exudate: 0, Wound bed: Eschar: 100%, wound edge: edges attached, surrounding skin: intact, [DIAGNOSES REDACTED]. -Left 2nd Toe - 0.9lengthX1.0WidthX0depth centimeters, Type: yes, vascular studies have been ordered, shape: round, exudate: none, wound bed: Eschar 100%, wound edge: edges attached, surrounding skin: intact, [DIAGNOSES REDACTED]. Record review of R #176's wound evaluation dated 10/11/18 and performed by LVN J revealed, measurements of wound on right buttock at 2.1 lengthX2.1WidthX0.1Depth. -Wounds deteriorated compared to measurements with LVN E on 10/09/18. Record review of R #176's Nursing Initial Baseline Care Plan undated revealed, Skin interventions upon admission: wound care. Skin & wound treatments: Blank. Record review of R #176's physician's orders [REDACTED]. -Cleanse left heel DTI with NS (normal saline), pat dry with 4x4, apply wound gel with AG to granulated area, apply skin prep to surrounding skin, cover with a foam dressing and wrap with [MEDICATION NAME] dressing every day shift for wound care. -physician's orders [REDACTED]. -Cleanse moisture lesion to right buttocks with NS, pat dry with 4x4, apply wound gel with AG, cover with dry dressing every day shift for wound care. Review of R #176's Treatment Administration record for (MONTH) (YEAR) revealed, -Cleanse Left heel DTI with NS, pay dry with 4x4, apply wound gel with AG to granulated area, apply skin prep to surrounding skin, cover with a foam dressing, and wrap with [MEDICATION NAME] dressing. Start date: 10/10/18 every day shift for wound care. -Cleanse moisture lesion to right buttocks with NS, pat dry with 4x4, apply wound gel with AG, cover with dry dressing every day shift for wound care. Interview on 10/12/18 at 11:40 AM with DON (Director of Nursing) stated, We had called the previous facility several times to send the Doppler ultrasound report from (MONTH) 10, (YEAR). DON stated, I agree R #176's wounds should never have been staged. I would not use silver (AG) on R #176's wound on her right buttock. DON stated There's different wound care for each stage and the consequence of not accurately treating, staging, or identifying a wound correctly and not off-loading R #176 left heel is that the wound will not heal or it will get worse. -After surveyor's inquiry, Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of R #176's [MEDICAL CONDITION]. Observation on 10/11/18 at 11:26 AM of LVN J performing wound care on R #176 revealed, R #176 was lying in bed with her head of bed raised at 30 degrees, buttocks flat on mattress (not off-loaded), her right thigh with pillow under it, her left foot laid flat on her heel (not off-loaded) on her mattress with a bed sheet. R #176's skin of left leg was flaky, LVN J stated, Yes, she has [MEDICAL CONDITIONS], when asked if R #176 had [MEDICAL CONDITION]. Observed R #176's w/c (wheelchair) seat cushion with stains of exudate and brownish old blood in center of cushion and on the edge of seat cushion. LVN J stated R #176 had A Stage 3 Right posterior thigh, an unstageable left great toe, unstageable left 2nd toe, lesion on right buttock, a DTI on the left heel, and surgical incision right AKA (above the knee amputation). LVN J removed R #176's island dressing from her surgical incision on right thigh exposing the sutures and 3 dehiscence open wounds (one on left with eschar, center wound beefy red with blood, 3rd on right with eschar) and observed 3 circular red pressure unopened wounds. LVN J measured R #176's right posterior thigh at 2.3LenghtX6Width centimeters with no depth measured with wound appearing pink and wet with minimal yellow slough tissue. LVN J removed the [MEDICATION NAME] dressing off of R #176's left foot exposing an oval shaped wound covered with black tissue on left great toe and a circular wound covered with black tissue on left 2nd toe. LVN J then removed a foam dressing and gauzes from left heel exposing an open wound with 100% light yellow tissue, appeared wet and softened surrounding the wound with dark pink discoloration on the right side of R#176's wound. LVN J measured the open wound on the left heel at 4.0LengthX3.5Width centimeters with no depth measured and covered with slough yellow tissue with pink on right side of the wound. LVN J measured the wound on R #176's left great toe at 2.5LengthX2.9Width centimeters with no depth measured and covered with black tissue, left 2nd toe at 1.6LengthX1.7Width centimeters with no depth measured with pink tissue, appeared wet, and minimal slough yellow tissue. LVN J measured R #176's surgical incision on right thigh at 1.1 LengthX25Width centimeters. LVN J measured R #176's wound on right buttock at 2.1LengthX2.1Width centimeters with no depth measured and covered with slough yellow tissue with fungal rash surrounding the wound. LVN J performed wound care as ordered. LVN J cleaned R #176's open wound with 99% yellow slough on right buttock with normal saline. LVN J stated, It's an unstageable with 99% slough, wet, maceration from the fungal rash. LVN J patted dry with 4x4 gauze, applied [MEDICATION NAME] AG, applied a 4x5 Island dressing. - [MEDICATION NAME] AG (silver) promotes moisture to dry or minimally exudating wounds for an optimal moist environment Interview on 10/11/18 at 5:07 P.M. with LVN J The right buttock was covered with 100% slough and I could not measure the depth on the right buttock. LVN J stated, You saw what I saw and the nurse practitioner who was also there, after showing the difference in measurements on 10/09/18 by LVN E and measurements on 10/11/18 by LVN J. No explanation was provided. Interview on 10/11/18 at 6:24 PM with DON stated, The only thing I can think of is that it is a different measurement that includes a darker area around the wound bed. A measurement of 10.5LX10WX0.2D would be too big for R #176's heel. Interview on 10/12/18 at 11:24 AM with NPE (Nurse Practice Educator) stated, I assessed R #176's wound to her right buttock yesterday and felt it was a pressure ulcer and determined it was a stage 3. I've never seen lesion used as a terminology in wound care and I talked to LVN E who identified the stage 3 wound as a lesion. Interview on 10/13/18 at 6:06 PM with NPE stated, I did not know about R #176's [MEDICAL CONDITION], I tried calling R #176's previous facility. The person that does wound care called the wounds pressure ulcers to R #176's feet. I did not have direct care of R #176. I was with LVN E to help review the wounds. Wounds are not my specialty and I need more training. NPE signed off as the RN who performed R #176's initial wound evaluations with LVN E on 10/09/18. Interview on 10/14/18 at 11:20 AM with LVN E revealed, R#176 had scratches scabs and brown [MEDICAL CONDITION] skin discoloration. I would check and see if a resident had [MEDICAL CONDITION] and get my orders from my physician. R #176 had unstageable pressures ulcers on her left foot, a DTI on her left heel, and an open area on her right buttocks. I think she came in previous Monday or Tuesday and I saw her the next day. Before I saw R #176, LVN I told me R #176 had a lot of wounds such as the surgical site on right side and told me I needed to go see her. I did look over her packet from the previous facility, looked at her orders and there were none for wound care nor isolation precautions. The admission assessments were incomplete. There were hardly any admission orders [REDACTED]. I know she had cardiac things and diabetes. R #176 had multiple wounds that needed to be staged so I had NPE come with me because she is an RN and showed NPE all of R #176's sites and my completed assessment. NPE concurred with my assessment papers, I got the physician's orders [REDACTED]. I told the physician about all of R #176's wounds, the fungal rash on her buttocks. It depends on each area and each stage of wounds. Without a doppler study, I can't say it was [MEDICAL CONDITION] if we don't have an Doppler done. I did enter DTI on the left heel. DTI is just a deep tissue injury and discoloration of the skin. You don't know how far down the injury goes and you can't stage it. Sometimes a DTI opens up or sometimes they don't. When I saw R#176's heel, it looked very pink and the circumference of the wound became unblanchable and was not getting as much blood perfusion. I measure from where the non-blanching starts and stops at that point. I measure the extent of the non-blanching area. NPE was with me and held her leg up so I can see better. The wound to the right buttock was a circular opened ulceration with granulation tissue and had no [MEDICATION NAME] tissue. The wound to the right buttock was surrounded by a macerated fungal rash throughout her whole buttock area. A moisture lesion caused by moisture that has nothing to do with pressure and is from moisture and incontinence. Other than the moisture lesion having granulation tissue, was circular, and it's measurements were 1 something by 1 something. -A DTI is a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Interview on 10/14/18 at 2:15 PM CL RN stated, It's the wound care nurse's job to look at the wound and tell if it's wet, dry, infection, irritated and the RN stages the wounds. The wound care nurse notifies the RN and the RN puts in the order for a doppler ultrasound. We don't' always go by the doppler study from the previous facility, as you know with diagnostics they are not always accurate. With the wound care nurse is an RN who reviews the wound evaluation and stages the wounds. Wounds may be staged until confirmation from a doppler ultrasound is received. Record review of R #176's Face Sheet from previous facility dated 10/8/18 at 2:27 P.M. from R # 176's chart revealed, Admit Diagnosis: [REDACTED]. -After surveyor's inquiry, Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of [MEDICAL CONDITION]. Interview on 10/13/18 at 6:50PM with DON stated, If a new resident comes after hours, the nurse reviews the paperwork and if a new resident comes in before 6:00 PM or so then NPE and I (DON) review it. The nurse, myself (DON), NPE, and MDS enter the new resident's information into PCC (point click care program). The nurse is the first one that gets the paperwork and looks over the new resident's orders, paperwork, assesses the resident, inputs the orders in so that the orders can get to the pharmacy and we can get their medications. The nurse that is doing the orders reports and reads off all the orders to the doctor. We (nurses) would read the [DIAGNOSES REDACTED].#176's [MEDICAL CONDITION], I did not talk to staff to find out what happened and was not aware they didn't know. I found out about R #176's [MEDICAL CONDITION] [DIAGNOSES REDACTED]. -After surveyor's inquiry, the Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of [MEDICAL CONDITION] 2.) Resident #6: R #6's Admission Record dated 10/11/18 documented an [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Initial Nursing assessment dated [DATE] documented Integumentary: Rarely moist- usually dry, skin condition warm; Skin Impairments: not present . R #6's Skin Check dated 09/24/18 documented New Skin Injury/Wound Types: Rash, bilateral underarms. Observe skin condition with activities of daily living (ADL) care daily and report abnormality/skin check per policy. No other skin impairment was identified or documented on the Skin Check Report. R #6's Admission/Readmission Nursing Evaluation dated 10/01/18 documented Skin Integrity: -Right Posterior Forearm bruising X 2 -Left 2nd Toe DTI (Deep Tissue Injury) 0.5 X 0.7 X 0 -Right Heel DTI 1.0 X 0.4 X 0 -Left Heel boggy 4.0 X 5.0 X 0 -Right Great Toe 1.5 X 3.0 X 0 According to the DON on 10/10/18 at 5:10 PM, this Readmission Evaluation was performed on 10/01/18 because the facility had a change in management company. R #6's Initial Wound Evaluation dated 10/01/18 documented Pressure: Left 2nd Toe, Onset: 10/01/18, Unable to stage due to necrotic tissue, 0.5 X 0.7 X 0 centimeters, irregular shape, no exudate, 100% eschar (black) (eschar: is a slough or piece of dead tissue that is cast off from the surface of the skin) wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Skin - Acute Care Plan dated 10/01/18 documented Pressure ulcer: Right Great Toe Unstageable Pressure Injury/DTI related to decreased sensation/decreased mobility. Approach: Pressure relief device: Wheelchair Cushion; Reposition every (line left blank), Float Heels, apply skin prep daily, Assess wound weekly, Multivitamin with Minerals. -Left 2nd Toe Unstageable with Eschar related to decreased sensation and decreased mobility: wheelchair cushion, float heels when in bed, apply skin prep . R #6's Initial Wound Evaluation dated 10/01/18 documented Pressure: Right heel, Onset: 10/01/18, Unable to stage due to necrotic tissue, full thickness, 1.0 X 0.4 X 0 centimeters, round shape, no exudate, 100% eschar (black) wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. Review of all of R #6's written and electronic physician's orders [REDACTED]. R #6's physician's orders [REDACTED]. R #6's physician's orders [REDACTED]. R #6's Nurse's Note dated 10/03/18 documented Interdisciplinary Team met to discuss patient due to change in condition. Decreased appetite, nausea, and increased confusion .She has DTI (DTI: Persistent non-blanchable deep red, maroon or purple discoloration . If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTI to describe vascular, traumatic, neuropathic, or dermatologic conditions) to 2nd toe right foot and right heel. Wound care following patient. -This is the first time R #6's right 2nd toe was identified as a DTI. R #6's Weekly Wound Evaluation dated 10/08/18 documented Pressure: Left 2nd Toe, Onset: 10/01/18, Unable to stage due to necrotic tissue, 0.5 X 0.7 X 0 centimeters, irregular shape, no exudate, 100% eschar (black), firmly adhering to wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Weekly Wound Evaluation dated 10/08/18 documented Pressure: Right heel, Onset: 10/01/18, Unable to stage due to necrotic tissue, full thickness, 1.0 X 0.5 X 0 centimeters, round shape, no exudate, 100% eschar (black) firmly adhering to wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Admission Braden Scale for Predicting Pressure Sore Risk dated 10/09/18 documented a score of 15- At Risk. Review of all of R #6's electronic and written Braden Scales revealed only one assessment dated [DATE], 15 days after her initial admission. Interview with LVN E on 10/09/18 at 3:47 PM revealed she stated the facility's procedure for resident risk of pressure ulcer development was conducting a Braden Scale. LVN E said each resident Automatically has a Braden Scale done on admission, quarterly, and after every pressure ulcer discovery. We do it so we can assess to see if the resident is at risk for pressure ulcer development which guides us to place immediate interventions to prevent ulcer development. Observation and interview of R #6 on 10/09/18 at 10:10 AM she was alert and oriented to person, place, and time. R #6 stated she had pressure sores to her heels and toes and did not think she had any sores on her buttocks R #6 was lying in bed, on her back with her head of bed elevated more than 15 degrees. R #6 said she could move her arms and legs minimally but could not turn side to side or raise herself up in bed. Observation of R #6 on 10/09/18 at 11:49 AM revealed she was lying in bed on her back, asleep. R #6's feet rested on one flat pillow that was positioned horizontally. R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/09/18 at 12:30 AM revealed R #6 was lying in bed with her head of bed elevated, feeding herself lunch. R #6's feet rested on the same flat horzontally positioned pillow. R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/09/18 at 1:13 PM revealed R #6 continued to lay in bed, on her back with her head of the bed elevated in the same degrees as seen in previous observations. R #6's eyes were closed and did not awaken to verbal stimuli. R #6 was slouched in bed with the plantar of her feet against the foot board. The horzontal positioned pillow was remained beneath her ankles/feet however, R #6's heels rested on the bed/pillow. Observation of R #6 on 10/09/18 at 3:04 PM revealed R #6 continued to lay in her bed, on her back with her head of bed lower than previously observed. There was approximately a pillow's width of unoccupied bed above R #6's head and R #6's bottom of her feet were pushed against her foot board. R #6's feet rested on the same flat horzontally positioned pillow; R #6's feet/heel were not off-loaded off the bed/pillow. When asked if staff had offered or attempted to reposition her at any time in the morning and afternoon R #6 replied No, they come in her to bring me my meals and take them but no one moves me. I have a catheter so they don't have to change me unless I tell them I pooped myself. My feet are killing me, they are so sore. Yeah, my heels, the entire foot on both of them. I let my head down some using my control because I felt like I couldn't breath. No I haven't asked for anyone to help me, I just though someone would come by soon. R #6 activated her call button as instructed and Certified Nurse Aide (CNA) F entered the room. CNA F said Were you trying to get out of bed? R #6 replied No, I just slid down. CNA F asked R #6 if she wanted to get out of bed however, R #6 responded No, I don't feel well right now. CNA F informed R #6 she was going to get some help to lift R #6 up in bed. R #6's Comprehensive Care Plan dated 10/10/18 revealed the plan did not address skin integrity or pressure ulcers. Observation of R #6 on 10/10/18 at 09:08 AM revealed she was lying in bed on her back with her head of bed elevated more than 15 degrees. R #6 was talking on her personal telephone. There was one flat pillow under R #6's ankles/feet; R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/10/18 at 10:15 AM revealed she remained lying in bed, on her back, watching television. R #6's feet/heels remained in the same position and were not raised off the bed. Observation of R #6 on 10/10/18 at 10:51 AM revealed she continued to lay, on her back, asleep. R #6's feet/heels remained in the same position and were not off-loaded. Observation of R #6 on 10/10/18 at 11:21 AM revealed R #6 continued to lay in bed, on her back with her head of bed elevated more than 15 degrees. R #6 was slouched in bed with her feet pressed against the foot board. Licensed Vocational Nurse (LVN) E entered the room and informed R #6 of wound care to be performed. R #6's ankles rested on a pillow however, her heels were not off-loaded and continued to rest on the bed. LVN E began removing R #6's socks and R #6 immediately grimaced and raised her voice saying My feet hurt, they are sore, especially my heels. LVN E stated Her left second toe is an unstageable pressure ulcer. It measures 0.5 X 0.8 centimeters, with 100% brown/black hardened eschar covering the wound bed. The right heel has a dry brown blackish scab and the surrounding skin is light purple; it measures 1.0 X 2.5 centimeters. The pillow was supposed to be used for off-loading her heels off the bed but her heels are not offloaded and her feet are touching the foot board, we need to pull her up in bed, she obviously slid down in bed. Off-loading is important to allow the right heel to heal and prevent further injury due to pressure. They were identified as pressure ulcers because she has no evidence or [DIAGNOSES REDACTED]. Continued interview with LVN E on 10/10/18 at 11:30 AM revealed she confirmed R #6 was not able to reposition or offload herself. LVN E was informed of multiple observations of R #6 laying in the same position in bed and LVN E said She should be repositioned and offloaded every two hours. When asked what her role was, since she was the treatment nurse, in ensuring residents were repositioned or offloaded, LVN E said I was being used as a regular nurse because we could not have a treatment nurse. Until I was given the Treatment Nurse position back just these past several days, the nurses were doing some wound care and I would help to. I am certified in wound care. I used to have a timer on my cart and when it would go off, I would do rounds and check on positioning and offloading but I have not done that since we reopened. LVN E confirmed the nuses, nurse aides, and she was responsible for ensuring dependent residents with wounds or at high risk for developing wounds were repositioned at least every two hours. LVN E confirmed she had not checked on any resident's positioning aside from providing their wound care. LVN E verified that R #6's wounds may not be healing due to not offloading and repositioning But other factors contribute to it too like her obesity and diabetes. When asked how R #6 was discovered with two seperate wounds with eschar without any prior signs not noticed by nursing staff, LVN E said I don't know. It's not likely that she just woke up with black dead tissue, there are usually previous signs like redness or slough. I can't tell you what happened. Interview with R #6 on 10/10/18 at 11:38 PM revealed she stated none of the staff had offered to reposition her. R #6 said I guess I should tell them but they know I can't do it. R #6 confirmed she did not like to get out of bed often. R #6 complained that her feet/heels were very sore and rated her feet pain at a 6. Interview with CNA F on 10/10/18 12:15 PM revealed she stated she and CNA I were caring for R #6 from 6:00 AM - 6:00 PM. CNA F said she did not recall when or how many times she repositioned or offloaded R #6 on 10/09/18 and verified she had not offered R #6 any position changes today because She does not like to get out of bed. CNA F confirmed R #6 was unable to reposition herself. CNA F said If residents are not repositioned, they can breakdown.(TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for four (R #176, R #6, R #126 and R #125) of six residents reviewed for pressure ulcers. 1.) R #176 -R #176's Baseline Care Plan did not include specific preventative measures/interventions R #176 should have been provided with for off-loading purposes. -The facility failed to accurately identify and document R #176's left heel community acquired pressure ulcer. The facility continued to stage and document the ulcer as a DTI (Deep Tissue Injury) despite the description of the ulcer not meeting the definition of a DTI. The facility did not obtain a Doppler ultrasound (measures the amount of blood flow through the arteries and veins that supply blood to your arms and legs) order until surveyor's inquiry. -The facility failed to accurately identify and document R #176's right buttock community acquired pressure ulcer. The facility continued to stage and document the ulcer as a Moisture Lesion despite the description of the ulcer not meeting the definition of a Moisture Lesion. -The facility failed to provide or document a detailed description of R #176's pressure ulcers upon admission. -The facility failed to consult the physician upon R #176's admission regarding no treatment orders for pressure ulcers nor did the facility attempt to retrieve treatment orders for R #176 pressure ulcers. -Nursing staff failed to demonstrate competency in knowledge, identification, staging, and describing R #176's pressure ulcers. 2.) R #6: -The facility failed to include interventions for pressure ulcer care/prevention in R #6's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to perform a risk assessment (Braden Scale) to assess R #6's risk for pressure ulcer development on admission instead, the facility completed R #6's Braden scale 15 days after admission. -The facility failed to consult and retrieve wound care orders for R #6's pressure ulcers upon admission therefore, R #6 did not receive treatments on her facility acquired Unstageable Pressure Ulcers, described as having 100% eschar tissue, for two days after discovery of the wounds. -The facility failed to offload R #6's right heel to prevent pressure on her Unstageable Pressure Ulcer which had 100% eschar. -The facility failed to reposition R #6, leaving her in the same position for over three hours on two seperate days. -The facility failed to specify how often R #6 required repositioning in her Acute Care Plan. -The facility failed to ensure all nursing staff had access and were aware of R #6's interventions for pressure ulcer care/prevention specified in the Acute Care Plan. -The faility inconsistently staged R #6's right heel pressure ulcer, identifying it as an Unstageable or a Deep Tissue Injury (DTI) on seperate facility documents. 3.) R #126: -The facility failed to include interventions for pressure ulcer care/prevention in R #126's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to provide timely repositioning for R #126 who was identified as dependent on staff assistance for repositioning and a high risk for pressure ulcer development. -The facility failed to appropriately treat R #126's Moisture Associated Skin [MEDICAL CONDITION] (MASD) which worsened to the development of a Stage 2 pressure ulcer. -The facility failed to include positioning/repositioning and offloading interventions in R #126's comprehensive care plan and Kardex. 4.) R #125: -The facility failed to include interventions for pressure ulcer care/prevention in R #125's Comprehensive Care Plan and Kardex/CNA Care Plan. -The facility failed to provide R #125, whom was assessed by the facility as a high risk for pressure ulcer development, with necessary timely repositioning and incontinent care on two seperate days. --The facility failed to include positioning/repositioning and offloading interventions in R #125's comprehensive care plan and Kardex. The above failures resulted in an IJ situation on 10/12/18. While the IJ was removed on 10/13/18, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures have the potential to result in development of new pressure ulcers or a decline in existing pressure ulcers. The findings included: 1.)R #176: Record review of Resident #176's face sheet revealed a [AGE] year old female who was admitted on [DATE] at 2:00 AM with one [DIAGNOSES REDACTED]. Record review of Resident #176's Nursing Admission/Readmission Nursing Evaluation dated 10/08/18 at 6:30 P.M. revealed, Skin color: Normal for ethnic group, Skin temperature: warm/dry, Skin turgor: normal. -There was no detailed description or locations of R #176's 5 wounds and 1 surgical incision. Record review of R #176's Nursing Braden Scale for Predicting Pressure Score Risk dated 10/09/18 revealed a score of 13 & is at moderate risk. Record review of R #176's physician's orders [REDACTED]. Record review of R #176's physician's orders [REDACTED]. Record review of R #176's Initial wound evaluation dated 10/09/18 and performed by LVN E revealed: -left heel - 10.5 lengthX10.0WidthX0.2Depth centimeters, type: Pressure, Unable to stage due to necrotic tissue, undetermined, shape irregular, exudate: serous and at 25%, edges attached, surrounding skin: [DIAGNOSES REDACTED], -Right Buttock- 1.5 lengthX 1.3WidthX0.2Depth centimeters and listed wound type as a Moisture-Associated Skin Damagepr (Inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) Moisture Lesion. Partial thickness, exudate: serous & 25%, wound bed: granular (red) 100%, no odor, edges attached, surrounding skin [DIAGNOSES REDACTED], Denuded, and [MEDICAL CONDITION]. -Right Posterior thigh - 3.9LX9.5WX0.8D centimeters Type: Pressure, wound bed: Granular 100%, wound edges: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left Great Toe - 1.3lengthX2.3WidthX0depth centimeters, Type: blank, stage: Unable to stage due to necrotic tissue, shape: irregular, exudate: 0, wound bed slough/Eschar: 100%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left 2nd Toe - 0.9lengthX1.0WidthX0depth centimeters, Type: Pressure, stage: unable to stage due to necrotic tissue, shape: blank, exudate: none, wound bed: slough/eschar 100%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. Observation on 10/10/18 at 10:46 A.M. of R #176 was awake, alert, lying flat on her back in bed, buttocks flat on mattress (not off-loaded), her right thigh with pillow under it, and her left foot laid flat on her heel (not off-loaded) on her mattress with a bed sheet. Record review of R #176's wound evaluation dated 10/11/18 and performed by LVN J and observed by surveyor and nurse practitioner revealed, measurements of wound on: -Left heel at 4.0 lengthX3.5 widthX 0.1 Depth centimeters, type: Yes, vascular studies have been ordered, Stage: blank, shape: round, exudate: 0, wound bed: granular (red) at 25%, slough: 75% and firmly adhering to bed, surrounding skin: macerated. -Right Buttock- 2.1 lengthX 2.1WidthX0.1Depth centimeters and listed wound type: Pressure, stage: unable to stage due to necrotic tissue, shape: round, exudate & color: none, wound edge: edges attached, surrounding skin: macerated. -Right Posterior thigh - 2.3LX6WX0.2D centimeters Type: yes, vascular studies have been ordered, shape: irregular, exudate: 0, wound bed: grandular (red) at 75%, slough at 5%, wound edge: edges attached, surrounding skin: [DIAGNOSES REDACTED]. -Left Great Toe - 2.5lengthX2.9WidthX0depth centimeters, Type: blank, stage: Type: yes, vascular studies have been ordered, shape: oval, exudate: 0, Wound bed: Eschar: 100%, wound edge: edges attached, surrounding skin: intact, [DIAGNOSES REDACTED]. -Left 2nd Toe - 0.9lengthX1.0WidthX0depth centimeters, Type: yes, vascular studies have been ordered, shape: round, exudate: none, wound bed: Eschar 100%, wound edge: edges attached, surrounding skin: intact, [DIAGNOSES REDACTED]. Record review of R #176's wound evaluation dated 10/11/18 and performed by LVN J revealed, measurements of wound on right buttock at 2.1 lengthX2.1WidthX0.1Depth. -Wounds deteriorated compared to measurements with LVN E on 10/09/18. Record review of R #176's Nursing Initial Baseline Care Plan undated revealed, Skin interventions upon admission: wound care. Skin & wound treatments: Blank. Record review of R #176's physician's orders [REDACTED]. -Cleanse left heel DTI with NS (normal saline), pat dry with 4x4, apply wound gel with AG to granulated area, apply skin prep to surrounding skin, cover with a foam dressing and wrap with [MEDICATION NAME] dressing every day shift for wound care. -physician's orders [REDACTED]. -Cleanse moisture lesion to right buttocks with NS, pat dry with 4x4, apply wound gel with AG, cover with dry dressing every day shift for wound care. Review of R #176's Treatment Administration record for (MONTH) (YEAR) revealed, -Cleanse Left heel DTI with NS, pay dry with 4x4, apply wound gel with AG to granulated area, apply skin prep to surrounding skin, cover with a foam dressing, and wrap with [MEDICATION NAME] dressing. Start date: 10/10/18 every day shift for wound care. -Cleanse moisture lesion to right buttocks with NS, pat dry with 4x4, apply wound gel with AG, cover with dry dressing every day shift for wound care. Interview on 10/12/18 at 11:40 AM with DON (Director of Nursing) stated, We had called the previous facility several times to send the Doppler ultrasound report from (MONTH) 10, (YEAR). DON stated, I agree R #176's wounds should never have been staged. I would not use silver (AG) on R #176's wound on her right buttock. DON stated There's different wound care for each stage and the consequence of not accurately treating, staging, or identifying a wound correctly and not off-loading R #176 left heel is that the wound will not heal or it will get worse. -After surveyor's inquiry, Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of R #176's [MEDICAL CONDITION]. Observation on 10/11/18 at 11:26 AM of LVN J performing wound care on R #176 revealed, R #176 was lying in bed with her head of bed raised at 30 degrees, buttocks flat on mattress (not off-loaded), her right thigh with pillow under it, her left foot laid flat on her heel (not off-loaded) on her mattress with a bed sheet. R #176's skin of left leg was flaky, LVN J stated, Yes, she has [MEDICAL CONDITIONS], when asked if R #176 had [MEDICAL CONDITION]. Observed R #176's w/c (wheelchair) seat cushion with stains of exudate and brownish old blood in center of cushion and on the edge of seat cushion. LVN J stated R #176 had A Stage 3 Right posterior thigh, an unstageable left great toe, unstageable left 2nd toe, lesion on right buttock, a DTI on the left heel, and surgical incision right AKA (above the knee amputation). LVN J removed R #176's island dressing from her surgical incision on right thigh exposing the sutures and 3 dehiscence open wounds (one on left with eschar, center wound beefy red with blood, 3rd on right with eschar) and observed 3 circular red pressure unopened wounds. LVN J measured R #176's right posterior thigh at 2.3LenghtX6Width centimeters with no depth measured with wound appearing pink and wet with minimal yellow slough tissue. LVN J removed the [MEDICATION NAME] dressing off of R #176's left foot exposing an oval shaped wound covered with black tissue on left great toe and a circular wound covered with black tissue on left 2nd toe. LVN J then removed a foam dressing and gauzes from left heel exposing an open wound with 100% light yellow tissue, appeared wet and softened surrounding the wound with dark pink discoloration on the right side of R#176's wound. LVN J measured the open wound on the left heel at 4.0LengthX3.5Width centimeters with no depth measured and covered with slough yellow tissue with pink on right side of the wound. LVN J measured the wound on R #176's left great toe at 2.5LengthX2.9Width centimeters with no depth measured and covered with black tissue, left 2nd toe at 1.6LengthX1.7Width centimeters with no depth measured with pink tissue, appeared wet, and minimal slough yellow tissue. LVN J measured R #176's surgical incision on right thigh at 1.1 LengthX25Width centimeters. LVN J measured R #176's wound on right buttock at 2.1LengthX2.1Width centimeters with no depth measured and covered with slough yellow tissue with fungal rash surrounding the wound. LVN J performed wound care as ordered. LVN J cleaned R #176's open wound with 99% yellow slough on right buttock with normal saline. LVN J stated, It's an unstageable with 99% slough, wet, maceration from the fungal rash. LVN J patted dry with 4x4 gauze, applied [MEDICATION NAME] AG, applied a 4x5 Island dressing. - [MEDICATION NAME] AG (silver) promotes moisture to dry or minimally exudating wounds for an optimal moist environment Interview on 10/11/18 at 5:07 P.M. with LVN J The right buttock was covered with 100% slough and I could not measure the depth on the right buttock. LVN J stated, You saw what I saw and the nurse practitioner who was also there, after showing the difference in measurements on 10/09/18 by LVN E and measurements on 10/11/18 by LVN J. No explanation was provided. Interview on 10/11/18 at 6:24 PM with DON stated, The only thing I can think of is that it is a different measurement that includes a darker area around the wound bed. A measurement of 10.5LX10WX0.2D would be too big for R #176's heel. Interview on 10/12/18 at 11:24 AM with NPE (Nurse Practice Educator) stated, I assessed R #176's wound to her right buttock yesterday and felt it was a pressure ulcer and determined it was a stage 3. I've never seen lesion used as a terminology in wound care and I talked to LVN E who identified the stage 3 wound as a lesion. Interview on 10/13/18 at 6:06 PM with NPE stated, I did not know about R #176's [MEDICAL CONDITION], I tried calling R #176's previous facility. The person that does wound care called the wounds pressure ulcers to R #176's feet. I did not have direct care of R #176. I was with LVN E to help review the wounds. Wounds are not my specialty and I need more training. NPE signed off as the RN who performed R #176's initial wound evaluations with LVN E on 10/09/18. Interview on 10/14/18 at 11:20 AM with LVN E revealed, R#176 had scratches scabs and brown [MEDICAL CONDITION] skin discoloration. I would check and see if a resident had [MEDICAL CONDITION] and get my orders from my physician. R #176 had unstageable pressures ulcers on her left foot, a DTI on her left heel, and an open area on her right buttocks. I think she came in previous Monday or Tuesday and I saw her the next day. Before I saw R #176, LVN I told me R #176 had a lot of wounds such as the surgical site on right side and told me I needed to go see her. I did look over her packet from the previous facility, looked at her orders and there were none for wound care nor isolation precautions. The admission assessments were incomplete. There were hardly any admission orders [REDACTED]. I know she had cardiac things and diabetes. R #176 had multiple wounds that needed to be staged so I had NPE come with me because she is an RN and showed NPE all of R #176's sites and my completed assessment. NPE concurred with my assessment papers, I got the physician's orders [REDACTED]. I told the physician about all of R #176's wounds, the fungal rash on her buttocks. It depends on each area and each stage of wounds. Without a doppler study, I can't say it was [MEDICAL CONDITION] if we don't have an Doppler done. I did enter DTI on the left heel. DTI is just a deep tissue injury and discoloration of the skin. You don't know how far down the injury goes and you can't stage it. Sometimes a DTI opens up or sometimes they don't. When I saw R#176's heel, it looked very pink and the circumference of the wound became unblanchable and was not getting as much blood perfusion. I measure from where the non-blanching starts and stops at that point. I measure the extent of the non-blanching area. NPE was with me and held her leg up so I can see better. The wound to the right buttock was a circular opened ulceration with granulation tissue and had no [MEDICATION NAME] tissue. The wound to the right buttock was surrounded by a macerated fungal rash throughout her whole buttock area. A moisture lesion caused by moisture that has nothing to do with pressure and is from moisture and incontinence. Other than the moisture lesion having granulation tissue, was circular, and it's measurements were 1 something by 1 something. -A DTI is a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Interview on 10/14/18 at 2:15 PM CL RN stated, It's the wound care nurse's job to look at the wound and tell if it's wet, dry, infection, irritated and the RN stages the wounds. The wound care nurse notifies the RN and the RN puts in the order for a doppler ultrasound. We don't' always go by the doppler study from the previous facility, as you know with diagnostics they are not always accurate. With the wound care nurse is an RN who reviews the wound evaluation and stages the wounds. Wounds may be staged until confirmation from a doppler ultrasound is received. Record review of R #176's Face Sheet from previous facility dated 10/8/18 at 2:27 P.M. from R # 176's chart revealed, Admit Diagnosis: [REDACTED]. -After surveyor's inquiry, Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of [MEDICAL CONDITION]. Interview on 10/13/18 at 6:50PM with DON stated, If a new resident comes after hours, the nurse reviews the paperwork and if a new resident comes in before 6:00 PM or so then NPE and I (DON) review it. The nurse, myself (DON), NPE, and MDS enter the new resident's information into PCC (point click care program). The nurse is the first one that gets the paperwork and looks over the new resident's orders, paperwork, assesses the resident, inputs the orders in so that the orders can get to the pharmacy and we can get their medications. The nurse that is doing the orders reports and reads off all the orders to the doctor. We (nurses) would read the [DIAGNOSES REDACTED].#176's [MEDICAL CONDITION], I did not talk to staff to find out what happened and was not aware they didn't know. I found out about R #176's [MEDICAL CONDITION] [DIAGNOSES REDACTED]. -After surveyor's inquiry, the Facility ordered a Doppler ultrasound on 10/12/18 for confirmation of [MEDICAL CONDITION] 2.) Resident #6: R #6's Admission Record dated 10/11/18 documented an [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #6's Initial Nursing assessment dated [DATE] documented Integumentary: Rarely moist- usually dry, skin condition warm; Skin Impairments: not present . R #6's Skin Check dated 09/24/18 documented New Skin Injury/Wound Types: Rash, bilateral underarms. Observe skin condition with activities of daily living (ADL) care daily and report abnormality/skin check per policy. No other skin impairment was identified or documented on the Skin Check Report. R #6's Admission/Readmission Nursing Evaluation dated 10/01/18 documented Skin Integrity: -Right Posterior Forearm bruising X 2 -Left 2nd Toe DTI (Deep Tissue Injury) 0.5 X 0.7 X 0 -Right Heel DTI 1.0 X 0.4 X 0 -Left Heel boggy 4.0 X 5.0 X 0 -Right Great Toe 1.5 X 3.0 X 0 According to the DON on 10/10/18 at 5:10 PM, this Readmission Evaluation was performed on 10/01/18 because the facility had a change in management company. R #6's Initial Wound Evaluation dated 10/01/18 documented Pressure: Left 2nd Toe, Onset: 10/01/18, Unable to stage due to necrotic tissue, 0.5 X 0.7 X 0 centimeters, irregular shape, no exudate, 100% eschar (black) (eschar: is a slough or piece of dead tissue that is cast off from the surface of the skin) wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Skin - Acute Care Plan dated 10/01/18 documented Pressure ulcer: Right Great Toe Unstageable Pressure Injury/DTI related to decreased sensation/decreased mobility. Approach: Pressure relief device: Wheelchair Cushion; Reposition every (line left blank), Float Heels, apply skin prep daily, Assess wound weekly, Multivitamin with Minerals. -Left 2nd Toe Unstageable with Eschar related to decreased sensation and decreased mobility: wheelchair cushion, float heels when in bed, apply skin prep . R #6's Initial Wound Evaluation dated 10/01/18 documented Pressure: Right heel, Onset: 10/01/18, Unable to stage due to necrotic tissue, full thickness, 1.0 X 0.4 X 0 centimeters, round shape, no exudate, 100% eschar (black) wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. Review of all of R #6's written and electronic physician's orders [REDACTED]. R #6's physician's orders [REDACTED]. R #6's physician's orders [REDACTED]. R #6's Nurse's Note dated 10/03/18 documented Interdisciplinary Team met to discuss patient due to change in condition. Decreased appetite, nausea, and increased confusion .She has DTI (DTI: Persistent non-blanchable deep red, maroon or purple discoloration . If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTI to describe vascular, traumatic, neuropathic, or dermatologic conditions) to 2nd toe right foot and right heel. Wound care following patient. -This is the first time R #6's right 2nd toe was identified as a DTI. R #6's Weekly Wound Evaluation dated 10/08/18 documented Pressure: Left 2nd Toe, Onset: 10/01/18, Unable to stage due to necrotic tissue, 0.5 X 0.7 X 0 centimeters, irregular shape, no exudate, 100% eschar (black), firmly adhering to wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Weekly Wound Evaluation dated 10/08/18 documented Pressure: Right heel, Onset: 10/01/18, Unable to stage due to necrotic tissue, full thickness, 1.0 X 0.5 X 0 centimeters, round shape, no exudate, 100% eschar (black) firmly adhering to wound bed, edges attached, surrounding skin attached, Interventions: Clean with normal saline, skin prep daily. R #6's Admission Braden Scale for Predicting Pressure Sore Risk dated 10/09/18 documented a score of 15- At Risk. Review of all of R #6's electronic and written Braden Scales revealed only one assessment dated [DATE], 15 days after her initial admission. Interview with LVN E on 10/09/18 at 3:47 PM revealed she stated the facility's procedure for resident risk of pressure ulcer development was conducting a Braden Scale. LVN E said each resident Automatically has a Braden Scale done on admission, quarterly, and after every pressure ulcer discovery. We do it so we can assess to see if the resident is at risk for pressure ulcer development which guides us to place immediate interventions to prevent ulcer development. Observation and interview of R #6 on 10/09/18 at 10:10 AM she was alert and oriented to person, place, and time. R #6 stated she had pressure sores to her heels and toes and did not think she had any sores on her buttocks R #6 was lying in bed, on her back with her head of bed elevated more than 15 degrees. R #6 said she could move her arms and legs minimally but could not turn side to side or raise herself up in bed. Observation of R #6 on 10/09/18 at 11:49 AM revealed she was lying in bed on her back, asleep. R #6's feet rested on one flat pillow that was positioned horizontally. R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/09/18 at 12:30 AM revealed R #6 was lying in bed with her head of bed elevated, feeding herself lunch. R #6's feet rested on the same flat horzontally positioned pillow. R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/09/18 at 1:13 PM revealed R #6 continued to lay in bed, on her back with her head of the bed elevated in the same degrees as seen in previous observations. R #6's eyes were closed and did not awaken to verbal stimuli. R #6 was slouched in bed with the plantar of her feet against the foot board. The horzontal positioned pillow was remained beneath her ankles/feet however, R #6's heels rested on the bed/pillow. Observation of R #6 on 10/09/18 at 3:04 PM revealed R #6 continued to lay in her bed, on her back with her head of bed lower than previously observed. There was approximately a pillow's width of unoccupied bed above R #6's head and R #6's bottom of her feet were pushed against her foot board. R #6's feet rested on the same flat horzontally positioned pillow; R #6's feet/heel were not off-loaded off the bed/pillow. When asked if staff had offered or attempted to reposition her at any time in the morning and afternoon R #6 replied No, they come in her to bring me my meals and take them but no one moves me. I have a catheter so they don't have to change me unless I tell them I pooped myself. My feet are killing me, they are so sore. Yeah, my heels, the entire foot on both of them. I let my head down some using my control because I felt like I couldn't breath. No I haven't asked for anyone to help me, I just though someone would come by soon. R #6 activated her call button as instructed and Certified Nurse Aide (CNA) F entered the room. CNA F said Were you trying to get out of bed? R #6 replied No, I just slid down. CNA F asked R #6 if she wanted to get out of bed however, R #6 responded No, I don't feel well right now. CNA F informed R #6 she was going to get some help to lift R #6 up in bed. R #6's Comprehensive Care Plan dated 10/10/18 revealed the plan did not address skin integrity or pressure ulcers. Observation of R #6 on 10/10/18 at 09:08 AM revealed she was lying in bed on her back with her head of bed elevated more than 15 degrees. R #6 was talking on her personal telephone. There was one flat pillow under R #6's ankles/feet; R #6's feet/heel were not off-loaded off the bed/pillow. Observation of R #6 on 10/10/18 at 10:15 AM revealed she remained lying in bed, on her back, watching television. R #6's feet/heels remained in the same position and were not raised off the bed. Observation of R #6 on 10/10/18 at 10:51 AM revealed she continued to lay, on her back, asleep. R #6's feet/heels remained in the same position and were not off-loaded. Observation of R #6 on 10/10/18 at 11:21 AM revealed R #6 continued to lay in bed, on her back with her head of bed elevated more than 15 degrees. R #6 was slouched in bed with her feet pressed against the foot board. Licensed Vocational Nurse (LVN) E entered the room and informed R #6 of wound care to be performed. R #6's ankles rested on a pillow however, her heels were not off-loaded and continued to rest on the bed. LVN E began removing R #6's socks and R #6 immediately grimaced and raised her voice saying My feet hurt, they are sore, especially my heels. LVN E stated Her left second toe is an unstageable pressure ulcer. It measures 0.5 X 0.8 centimeters, with 100% brown/black hardened eschar covering the wound bed. The right heel has a dry brown blackish scab and the surrounding skin is light purple; it measures 1.0 X 2.5 centimeters. The pillow was supposed to be used for off-loading her heels off the bed but her heels are not offloaded and her feet are touching the foot board, we need to pull her up in bed, she obviously slid down in bed. Off-loading is important to allow the right heel to heal and prevent further injury due to pressure. They were identified as pressure ulcers because she has no evidence or [DIAGNOSES REDACTED]. Continued interview with LVN E on 10/10/18 at 11:30 AM revealed she confirmed R #6 was not able to reposition or offload herself. LVN E was informed of multiple observations of R #6 laying in the same position in bed and LVN E said She should be repositioned and offloaded every two hours. When asked what her role was, since she was the treatment nurse, in ensuring residents were repositioned or offloaded, LVN E said I was being used as a regular nurse because we could not have a treatment nurse. Until I was given the Treatment Nurse position back just these past several days, the nurses were doing some wound care and I would help to. I am certified in wound care. I used to have a timer on my cart and when it would go off, I would do rounds and check on positioning and offloading but I have not done that since we reopened. LVN E confirmed the nuses, nurse aides, and she was responsible for ensuring dependent residents with wounds or at high risk for developing wounds were repositioned at least every two hours. LVN E confirmed she had not checked on any resident's positioning aside from providing their wound care. LVN E verified that R #6's wounds may not be healing due to not offloading and repositioning But other factors contribute to it too like her obesity and diabetes. When asked how R #6 was discovered with two seperate wounds with eschar without any prior signs not noticed by nursing staff, LVN E said I don't know. It's not likely that she just woke up with black dead tissue, there are usually previous signs like redness or slough. I can't tell you what happened. Interview with R #6 on 10/10/18 at 11:38 PM revealed she stated none of the staff had offered to reposition her. R #6 said I guess I should tell them but they know I can't do it. R #6 confirmed she did not like to get out of bed often. R #6 complained that her feet/heels were very sore and rated her feet pain at a 6. Interview with CNA F on 10/10/18 12:15 PM revealed she stated she and CNA I were caring for R #6 from 6:00 AM - 6:00 PM. CNA F said she did not recall when or how many times she repositioned or offloaded R #6 on 10/09/18 and verified she had not offered R #6 any position changes today because She does not like to get out of bed. CNA F confirmed R #6 was unable to reposition herself. CNA F said If residents are not repositioned, they can breakdown. She wears a brief but does not urinate, she has a catheter and she will tell us when she needs to have a bowel movement. When asked i(TRUNCATED)

Based on observation, interview and record review, the facility failed to implement their abuse, neglect and exploitation policy when they failed to protect one Resident, R#1, of four residents reviewed for abuse and neglect, from serious injury. The facility did not ensure that R#1 was supervised when she was being assisted with toileting, and she sustained a fractured humerus (shoulder) and clavicle. This failure could affect R#1 in that neglect or abuse could have caused her fractured humerus and clavicle. The findings were: Review of the Facility Abuse Prohibition Policy, revised 11/28/16, revealed the following: POLICY (Facility) will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Center will implement an abuse prohibition program through the following: -Screening of potential hires; -Training of employees (both new employees and ongoing training for all employees); -Prevention of occurrences; -Identification of possible incidents or allegations which need investigation; -Investigation of incidents and allegations; -Protection of patients during investigations; and -Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. State Definitions: Neglect is defined as the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property for all patients. PR(NAME)ESS 1. The Center Executive Director (CED), or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. 4. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, will include: 4.3. Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. 5. Staff will identify events--such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse--and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the CED or designee and other officials in accordance with state law. 5.1.1.1 If the patient/resident sustains serious bodily injury, report no later than two (2) hours after forming the suspicion. Refer to Reporting Suspected Crimes Under the Elder Justice Act (EJA) policy. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of property, the CED or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Immediately, not to exceed 24 hours, notify the Texas Department of Aging and Disability Services either: 6.2.1 Online at report incident online, or 6.2.2 By phone at [PHONE NUMBER], regardless of the day or time; select option 5 from the main menu 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 Interventions to prevent further injury. 7.3 The CED or designee will report findings of all completed investigations within five (5) working days utilizing: 7.3.1 DADS Form 3613-A, Provider Investigation Report 7.3.2 Submit the investigation as follows: 7.3.2.2.1 Texas Department of Aging and Disability Services Consumer Rights and Services-Complaint Intake Unit Review of R#1's Admission Record dated 05/08/17 revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. Review of Minimum Data Set ((MDS) dated [DATE] revealed R#1 could usually make herself understood and could understand others, and wore a hearing aid. R#1 scored three points on the Brief Interview for Mental Status (BIMS), indicating she had severe cognitive deficits. R#1 had no mood concerns and no behavior concerns. R#1 required extensive assistance with the help of one person with transfer, toileting, personal hygiene, and dressing. Extensive assistance was defined as Resident involved in the activity, staff provide weight-bearing support. R#1 did not walk and required extensive assistance with the help of one person to move about the facility in a wheelchair. R#1's balance when moving from a seated position to a standing position and moving on and off the toilet was not steady and she was only able to stabilize with staff assistance. R#1 was always incontinent of bladder and frequently incontinent of bowel. She was not on a toileting program. Review of R#1's care plan revealed: R#1 was at risk for falls due to impaired mobility, cognitive loss and lack of safety awareness. Interventions included monitoring for and assisting with toileting needs. R#1 was at risk for decreased ability to perform ADLs (activities of daily living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to changes in mental status. Her ability to assist with ADLs may fluctuate due to her impaired cognition. Interventions inclluded monitoring for decline in ADL function; monitoring for complications of immobility; and providing resident/patient with extensive assist of one or two for transfers. Restorative transfers: R#1 demonstrates deficit in transferring with functional deterioration (initiated 01/16/17). Goal was to maintain balance in standing/sitting for safe mobility as evidenced by no reported decline when transferring X 90 days. Interventions included sit to stand exercises. R#1 has impaired communication as evidenced by R#1 requiring hearing amplifiers and R#1 has inattention and disorganized thought. R#1 experiences sleep pattern disturbance as evidenced by periods of [MEDICAL CONDITION] (initiated 05/03/17). Interventions included administration of medications as ordered and monitoring for effectiveness. R#1 was at risk of adverse reactions to the use of Hypnotic [MEDICATION NAME](initiated 05/03/17) Interventions included monitoring for side effects and behaviors. R#1 was at risk for fractures related to [MEDICAL CONDITION] (initiated 05/03/17). Interventions included montoring for signs of discomfort during care. Review of Medication Review Report (Physician Orders) for May, 2017, revealed R#1 was prescribed the following: Fall mat @ (at) bedside (01/31/16) Pain management every shift-reference pain scale (ordered 12/21/15) [MEDICATION NAME]-[MEDICATION NAME] 300-30mg q4h (every four hours) prn (as needed) (ordered 05/15/17) Ambien 5 mg (milligram) QHS PRN (at night as needed) for [MEDICAL CONDITION] (ordered 09/14/16) [MEDICATION NAME] HCl 50 mg q6h (every six hours) for pain (ordered 05/12/17) Tylenol Extra Strength 500 mg q6h prn for pain/fever (ordered 09/14/16) Review of Medication Administration Record [REDACTED]. Review of the Pain Management record revealed no assessment of R#1's pain on the 6:00 a.m. to 2:00 p.m. shift on 04/02/17, 04/03/17, 04/06/17, 04/10/17, 04/11/17, 04/14/17; 04/15/17; 04/16/17, 04/23/17, 04/24/17; no assessment of R#1's pain on the 2:00 p.m. to 10:00 p.m. shift on 04/05/17, 04/10/17, 04/16/17, 04/19/17, 04/23/17, 04/24/17, 04/25/17, 04/28/17; and no assessment of R#1's pain on the 10:00 p.m. to 6:00 a.m. shift on 04/19/17, 04/21/17, 04/22/17, 04/23/17, 04/24/17, 04/26/17, 04/27/17, 04/28/17, 04/29/17, and 04/30/17. Review of the MAR for May, 2017 revealed no administration [MEDICATION NAME] mg; administration of Tylenol Extra Strength 500 mg on 05/09/17 at 0700; and administration of [MEDICATION NAME] HCl 50 mg once each day on 05/07/17, 05/08/17 and 05/09/17. Review of the Pain Management assessment revealed no assessment was done on the 6:00 a.m. to 2:00 p.m. shift on 05/01/17, 05/03/17, 05/04/17, 05/08/17, 05/09/17; no assessment of R#1's pain on the 2:00 p.m. to 10:00 p.m. shift on 05/03/17, 05/04/17, 05/08/17, 05/09/17; and no assessment of R#1's pain on the 10:00 p.m. shift on 05/01/17, 05/04/17, 05/05/17, and 05/09/17. There were no further pain assessment on any shift after 05/10/17. This form was given to surveyor on 05/17/17. Review of Hospital Emergency Admission Record dated 05/08/17 revealed R#1 was seen in the hospital emergency room and X-Rays revealed she had a fractured clavicle and fractured humerus on her right side. The emergency room report said R#1 was a poor historian and she fell from her bed changing positions. R#1 was discharged back to the facility on [DATE] with instructions to follow up with a physician, to take acetominophen for pain and to use precautions to prevent recurrent fall. Observation and interview of R#1 at 1:45 p.m. on 05/16/17 in the common area near the side exit door of the facility revealed R#1 sitting in her wheelchair with her right arm in a sling and a pillow on her lap that appeared to be sliding down. R#1 was crying and her right arm appeared to be swollen and discolored. When asked if she was in pain R#1 said, Yes. An interview with Licensed Vocational Nurse (LVN) A at 1:50 p.m. on 05/16/17 revealed R#1 took a scheduled pain medication, [MEDICATION NAME] q6h (every six hours) around noon. LVN A said R#1 had Tylenol #3 for breakthrough pain and she was going to give her a Tylenol 3 because she appeared to be hurting. An interview with LVN A at 2:10 p.m. on 05/16/17 revealed R#1 was found in bed on 05/08/17 around 6:15 or 6:30 a.m. by a CNA (Certified Nurse Aid) when the CNA was trying to get R#1 up for breakfast. R#1 did not want to get up and she complained of her arm hurting. The CNA reported to LVN A that R#1 was hurting and did not want to get out of bed. LVN A said she found R#1 in bed with a large purple bruise and her right arm and she appeared to be in a lot of pain. R#1 could not tell her what happened. LVN A said she called R#1's physician and family, and a portable xray was ordered. LVN A said she made the decision to send R#1 to the hospital due to the length of time it might take for the xray company to arrive at the facility, and R#1 was in a lot of pain. LVN A said nothing was passed on to her in report from the night staff about R#1 having a fall or sustaining any kind of injury or discomfort. LVN A said the CNA who found R#1 in bed said they also were not advised of any concerns at the beginning of their shift. LVN A said she completed the first incident report regarding R#1's injury on 05/08/17. In an interview at 3:05 p.m.with R#2 on 05/16/17 in her room, when asked if she heard or saw anything related to R#1's injury on 05/07/17 or 05/08/17, R#2, who was R#1's roommate, said R#1 fell in the bathroom. R#2 said she called for help as soon as R#1 fell . R#2 said R#1 was crying. R#2 said R#1 cannot walk but she did not wait for the nurse to come get her off the toilet. When asked other details about the incident, like who responded, R#2 said she did not know anything more. Review of R#2's Face Sheet dated 05/18/17 revealed she was admitted to the facility on [DATE]. R#2's [DIAGNOSES REDACTED]. R#2 was [AGE] years old. Review of R#2's Quarterly MDS dated [DATE] revealed she was always able to understand others and make herself understood. She did not have corrective lenses. R#2 scored nine points on the BIMS, indicating she had moderate cognitive impairment. R#2 had some disorganized thinking that fluctuated in severity and would come and go. R#2 had no behavior concerns. R#2 was independent in transferring, required minimal assistance with bed mobility and supervision in walking. Review of the Investigation Report submitted by the facility to DADS Consumer Rights and Services Section dated 05/12/17 revealed no Incident Report dated 05/08/17 completed by LVN A and no witness report or statement submitted by the charge nurse, LVN B, who worked the 6:00 p.m. to 6:00 a.m. shift on 05/07/17 to 05/08/17. The Incident Category was Injury of Unknown Origin and the incident date was 05/08/17 at 9:00 a.m. when the injury was observed by staff. The incident report indicated R#1 required extensive assistance but no special supervision. R#1 was not interviewable and was not independently ambulatory. The Description of the Allegation was Resident observed around 0830-0900 AM with bruising and swelling to right upper arm. Resident unable to state what occurred. The Investigation Report dated 05/12/17 revealed the following investigation summary: Investigation reveals resident has DX (diagnosis) [MEDICAL CONDITION] and [MEDICAL CONDITION], Dementia, [DIAGNOSES REDACTED], back pain, muscle wasting and atrophy, history of falling, Dysphagia, [MEDICAL CONDITION], Depression,[MEDICAL CONDITION](Hypertension), ASCD ([MEDICAL CONDITION]). Statements obtained from staff who had worked with resident from 5/7-5/8. On 5/7 statements revealed resident had no bruise areas to upper right arm. On the night of 5/7/2017; investigation reveals that around 2110-2130; resident requested to be placed on toilet; shortly after, resident roommate in hallway requesting assistance, resident on toilet yelling for help and crying. Resistant to care and yelling for help during care. Previously witnessed behaviors. Reported to charge nurse. At 2150 5/7/2017 resident was medicated with [MEDICATION NAME] for pain. 5/8/2017; statements indicate that resident presented with bruising and swelling to right upper extremity in the morning and resident had told CNA (Certified Nursing Assistant) at 0615 that she did not want to get up as she did not feel well. At 0650 CNA reported to nurse that resident was screaming in pain and was medicated with [MEDICATION NAME]. This was reported to physician and xrays were ordered. At 0830; bruise and swelling to arm reported to DON (Director of Nurses), Resident was transported to ED (Emergency Department) in (location), at 1350; report was received from hospital that resident (R#1) had a fracture to humerus head and clavicle. Resident returned from hosptial that same day with order for sling and ortho follow up. Investigation initiated. Statements obtained. Statements from staff and resident are inconclusive as to if resident had a fall. Resident in interview says she guesses she fell . Staff who worked with her report that resident did not fall on their shift, but that Sunday night she was transferred off of the toilet and was tearful. Re-education initiated regarding abuse, neglect, and exploitation, recognizing and prevention and reporting. Preventing and reporting falls. Schedule re-training with transferring. Resident's medication for pain has been scheduled to routine to assist with optimal pain managment. Review of Witness reports included in the facility Investigation report revealed the following: In a phone interview on 05/09/17 at 2:29 p.m., CNA D said about 9:10 p.m. she assisted R#1 to the toilet. R#1 requested to be left on the toilet for a while and said she would let CNA D know when she needed help. CNA D said she went to attend to another resident and was assisted with the other resident by CNA C. CNA D said about five to seven minutes elapsed between when she left R#1 and CNA C went in to assist R#1 off the toilet. CNA D said CNA C told her (R#1) is acting skiddish near the end of the shift. CNA D said she did not know what this meant. Witness Statement dated 05/09/17 by CNA E revealed she saw R#1 in bed on 05/08/17 and R#1 was crying and upset. R#1 said her arm hurt and CNA E said R#1's right arm appeared swollen and bruised. R#2 (R#1's roommate) said R#1 fell in the bathroom and the big guy helped her up the night before. Witness statement dated 05/09/17 by Certified Medication Aide (CMA) F revealed at about 7:15 a.m. (no date given) she saw R#1 in bed and she appeared upset when CMA F gave her medications that were ordered. R#1 took most of her medications and had already received a pain pill. LVN A told CMA F that R#1 had a fall and that she had already medicated her for pain. LVN A told CMA F that no fall was reported in the pass a long at the change of shift. CMA F said she heard the CNAs on the unit saying the same thing. R#2 reported to CMA F that R#1 had been calling for help and was in the bathroom. She said no one came right away so R#1 attempted to walk out of the bathroom and fell . R#2 then got out of the bed and attempted to get help. R#2 did not tell her when R#1 fell . Witness statement dated 05/08/17 at 2:30 p.m. by CNA H revealed at 6:50 a.m. on 05/08/17, staff went into get R#1 up for breakfast. She was complaining of pain her right shoulder/arm. CNA H and CNA I did a body check and R#1 was yelling out in pain and did not want to be touched or moved. Swelling was noted in her right shoulder. CNA H notified LVN A of R#1's pain and swelling. At 8:30 a.m. on 05/08/17 CNA H checked on R#1 and noted R#1 was not moving her right arm and R#1's right arm looked like there was increased swelling and a long oval shaped bruise was noted on R#1's upper arm. CNA H notifed LVN A that R#1's arm looked worse than before. LVN A checked R#1 and contacted the DON. CNA H said no report of a fall was given to staff. CNA H said when she asked R#1 what happened, R#1 said she had fallen. R#2 also said R#1 had fallen. Witness statement dated 05/08/17 at 2:38 p.m. by CNA J revealed at 6:15 a.m. on 05/08/17 she went into R#1's room to get her up for breakfast. CNA J pulled R#1's covers down to change her and tried to roll her but R#1 said I am in pain and I don't feel good. R#1 started crying. CNA J told LVN A that R#1 was in pain and needed a pain pill. Witness statement dated 05/08/17 at 2:40 p.m. by CNA I revealed at 6:50 a.m. on 05/08/17 CNA J came to get her and CNA H to tell them R#1 was screaming in pain. CNA I went into with CNA H to try to get R#1 up. R#1 was screaming and saying she was in pain. A full body check revealed R#1 had swelling to her right upper arm and the CNAs notified LVN A. When CNA I went back into R#1's room around 8:45 a.m. (on 05/08/17) R#1 and R#2 informed CNA I that R#1 had fallen off the toilet the night before and CNA C picked R#1 up. During report on 05/08/17, CNA C did not mention anything all he stated was she (R#1) had been crying in pain all night. Witness statement dated 07/08/17 (05/08/17 possibly) by CNA C revealed at approximately 8:45 p.m. on 05/07/17, CNA D assisted R#1 to the toilet. CNA D told CNA C that R#1 was on the toilet when they were assisting another resident across the hall, who had a large amount of bowel movement and needed a shower. CNA C said he and CNA D took that resident to the shower. When CNA C exited the shower room, R#2 was in the middle of the hall yelling for help. CNA C said he tried to calm R#2 down and R#2 told him that R#1 needed help. I ask her (R#2) to find a place to relax and I enter the room, then bathroom. (R#1) is still on the toilet, but is yelling for help and crying. I ask her if she is finished and she states she needs me to help her to bed. I then assist her to the wheelchair and then to the bed. She is resistant to care and crying and yelling for me to help her, but this is not outside of her normal behaviors I have witnessed. The behavior of both (R#1) and (R#2) are reported to my charge nurse, (LVN B). Review of Interview with R#1 dated 05/09/17 at 11:10 a.m. in R#1's room, submitted as part of the facility investigation report dated 05/12/17 revealed R#1's responses to some of the questions LVN G asked her: Q: Can you tell me what happened to your arm? A: I guess I fell . Q: Do you remember falling? A: No. Q: Where do you think you fell from? A: Maybe out of my bed. Q: Do you remember falling out of your bed? A: No. Q: What makes you think that you fell ? A: When your pain starts it's just . Q: What happened to cause the bruise on your arm? A: I think I fell , I hurt after I fall and I fall quite often (smiles) Q: Did you go to the hospital for your injury? A: No. Responses to other questions from LVN G to R#1 revealed R#1 had not been abused or hurt by anyone. Interview on 05/18/17 at approximately 10:40 a.m. with CNA C revealed he usually worked the 10:00 p.m. to 6:00 a.m. shift. CNA C said R#1 needed extensive assistance with most activities of daily living (ADLs), was incontinent, had episodes of crying, seemed scared sometimes and required one person assistance. CNA C said he did not usually transfer R#1 since he worked the overnight shift and he did not know much about R#1's daily routine. CNA C said he checked the Kardex (electronic tool used to review and input data regarding resident ADLs) every shift during walking rounds. CNA C said each shift did rounds at the beginning of the shift and at the end of shift. CNA C said he came in a little early, around 8:00 p.m. or 8:30 p.m. on 05/07/17 because the facility needed help. CNA D had put R#1 on the toilet and CNA D went across the hall to another room because a resident needed incontinent care. CNA C said he heard R#1's roommate calling for help and he went into R#1's room and found R#1 on the toilet. CNA C said R#1 was sitting normally on the toilet, was not slouched and had nothing askew. R#1 was visibly agitated and asked for help because she couldn't get to bed by herself. CNA C said he went into R#1's room alone and assisted R#1 off the toilet using a gait belt and assisted her back into bed. CNA C said he got a new brief on R#1 and laid her down and covered her up. CNA C said he told LVN B that R#1 was resisting care and upset, and was crying and scared, which was not out of character for R#1. CNA C said R#1 was only left on the toilet for about one-two-three minutes at around 8:45 p.m. on 05/07/17. CNA C said he checked on R#1 twice during the night, assisted her with incontinent care, and she was upset each time, and he reported this to LVN B. CNA C said he told R#2 to calm down. CNA C said R#1 could not have fallen to the floor and R#1 was incapable of lifting herself off the ground. Phone interview on 05/18/17 at 11:00 a.m. with LVN B revealed she was passing medications and she heard R#1's roommate in the hall yelling for help and she and CNA C went into R#1's room together and found R#1 on the toilet. LVN B said she held the wheelchair while CNA C transferred R#1 off the toilet and back to bed. LVN B said R#1 was not crying and did not appear upset or restless when she checked on her throughout the night. LVN B said R#1 could not get off the toilet by herself and R#1 did not appear to be doing anything out of the ordinary. LVN B said she went to get R#1 an [MEDICATION NAME] for pain LVN B said they got her into bed and R#1 did not scream during brief changes. LVN B said she talked with CNA C during the night and CNA C said R#1 was not upset or crying. Surveyor asked LVN B if she was aware that R#1 had had previous falls, and LVN B answered that R#1 had a pretty major fall at a previous facility and broke her pelvis and several vertebrae. LVN B said she had not yet completed her report of what happened the night of 05/07/17 with R#1 and said it was on her dining room table to complete. Surveyor requested that LVN B come into the facility to be interviewed but she said she could not come in. LVN B agreed to submit a written statement of the events of her shift on 05/07/17-05/08/17 regarding R#1 by sending a statement to surveyor's email address. LVN B said she would send the statement in about 20 minutes. Phone interview on 05/18/17 at 11:20 a.m. with CNA C to clarify his report due to conflicting statements by CNA C and LVN B as to whether CNA C was alone when he went in to assist R#1 off the toilet on 05/07/17 at approximately 8:45 p.m. CNA C again said he was alone when he went in and found R#1 on the toilet and he assisted R#1 off the toilet and into bed without assistance. Interview on 05/18/17 at 11:45 a.m. with R#3 revealed R#2 was upset on the evening of 05/07/17 about her roommate falling and R#3 tried to keep R#2 close to her and comforted her. Interview on 05/18/17 at 11:50 a.m. with CNA D revealed she started working on 05/07/17 at about 2:00 p.m. CNA D said she put R#1 on the toilet on 05/07/17 (no time given) and told R#1 to pull the string (call light) when she was ready to get off the toilet. CNA D said R#1 could stand on a bar in the bathroom and could pivot and sit down on the toilet. R#1 required assistance to pull her underwear down. CNA D said she did not use a gait belt when she put R#1 on the toilet because R#1 could pull herself up from the wheelchair using the grab bars. CNA D said R#1's legs could bear weight. CNA D said R#1 was acting skittish. CNA D said LVN B was passing medications. CNA D said she never heard R#2 call for help and never saw R#2 in the hallway. CNA D said she did not check on R#1 after that because she was assisting another resident and CNA C went to assist R#1 off the toilet and into bed. At 12:00 p.m. on 05/18/17, surveyor asked the Administrator and DON if there was a statement from the Charge Nurse, LVN B, as part of the incident investigation. The DON said she finally got in touch with LVN B at 01:22 a. m. on 05/12/17 and told LVN B she needed a written statement from her regarding the incident with R#1. The DON said LVN B said she wanted to rewrite the statement and bring it back. The DON said the last day LVN B worked was 05/07/17 and she was out sick after that. At 12:50 p.m. on 05/18/17, the DON and Administrator gave surveyor a copy of an email sent to the surveyor at the Texas Department of Aging and Disability email address from LVN B, which they said was forwarded to LVN G by LVN B. Surveyor never received the email from LVN B directly and only received the copy of the email from LVN B from the DON and Administrator on 05/18/17. Review of Statement from LVN B dated 05/18/17 and received at 12:50 p.m. on 05/18/17 revealed on 05/07/17 at approximately 9:00 p.m., LVN B was passing medications at the end of the hall and heard R#2 calling for help, saying R#1 had fallen. LVN B said CNA C came from another room and the two of them went into see what happened with R#1. R#1 was sitting upright on the toilet and yelled out, I can't walk! I can't walk! LVN B said they were there to help her lie down. R#1 continued to yell out and her right hand was patting LVN B's left arm and R#1 left hand was squeezing LVN B's right hand. LVN B moved R#1's wheelchair closer to transfer her off the toilet and then to bed. During transfers LVN B did not observe any abnormal movements or guarding, but LVN B decided to give R#1 a prn (as needed) [MEDICATION NAME] since she had been sitting in her wheelchair for a while beforehand. R#1 took the medication with no problem. R#1 never cried or yelled out after being assisted to bed or during incontinent care. She had no symptoms of pain or restlessness overnight. I asked her how she was feeling when I gave her [MEDICAL CONDITION] medication at approximately 545 a.m., to which she smiled and said, oh, I'm fine I asked her if she was in any pain and she replied no. On 05/18/17 at 2:40 p.m., surveyor advised the Administrator that there were two different reports from the CNA and LVN charge nurse (LVN B) who were working the night of 05/07/17; LVN B said she assisted CNA C with R#1's getting off the toilet and back to bed, while CNA C said he did this alone. At surveyor's request, the Administrator called LVN B and interviewed her using the speaker phone. LVN B reported that she went into R#1's room to assist CNA C with R#1 after R#2 called for help on 05/07/17. LVN B said she helped set up the transfer for CNA C but did not assist with putting R#1 into bed. LVN B said R#1 had no signs of restlessness or pain but kept saying I can't walk. On 05/18/17 at 2:45 p.m., using a speaker phone, at Surveyor's request, the Administrator called CNA C to ask about the incident. CNA C reported he was alone in the bathroom with R#1 when he assisted her off the toilet and back to bed when he responded to her roommates concerns that R#1 had fallen on 05/07/17. The Administrator said, (CNA C) said she (R#1) was leaning against the wall and said that R#1 did have [MEDICAL CONDITION]. The Administrator said she did not see a problem with these reports because they were basically saying the same thing. The Administrator said there was no fall. When asked if she had obtained a written statement from LVN B, she showed surveyor a handwritten page that she said was the DON's documentation that she tried to obtain a written statement. The Administrator said LVN B submitted a written statement and then pulled the statement right after she submitted it. The Administrator said LVN B had been sick the week after 05/08/17 but had returned to work on 05/15/17. LVN B had not submitted a written statement to them until they received the copy of the one that LVN B submitted to surveyor at surveyor's DADS email address with a copy to LVN G at the facility. Surveyor gave the Administrator the incident investigation packet which was given to surveyor on 05/17/17 and asked her to check for a written statement from LVN B and an incident report from LVN A. The Adminstrator looked through the investigation packet and said she did not find these reports. Surveyor requested a copy of the reports. Review of Event Summary Report dated 05/08/17 at 3:05 p.m. revealed R#1 was noted on the morning of 05/08/17 to have brusing and swelling to RUE (right upper extremity). R#1 was exhibiting signs and symptoms of pain, and was assessed and sent to the emergency room at 08:30 a.m. Upon return to the facility on [DATE] at 01:50 p.m., R#1 was reported to have a fracture to her right humerus head and clavicle. R#1 was able to state her name and that she was in bed. She believed herself to be in a hospital. When asked about her arm, R#1 stated she guessed she fell but did not remember fallling and that it may have been out of her bed. R#1 did not remember falling out of her bed. Review of the handwritten copy of the note w(TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure that one Resident, R#1, of four residents reviewed for freedom from abuse, neglect, misappropriation of property, was free from neglect. The facility did not ensure that R#1 had adequate care and supervision when she was left on the toilet unsupervised, and sustained a fractured humerus (shoulder) and clavicle. This failure could affect R#1 in that neglect or abuse could have caused her to sustain a fractured humerus and clavicle. The findings were: Review of R#1's Admission Record dated 05/08/17 revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. Review of Minimum Data Set ((MDS) dated [DATE] revealed R#1 could usually make herself understood and could understand others, and wore a hearing aid. R#1 scored three points on the Brief Interview for Mental Status (BIMS), indicating she had severe cognitive deficits. R#1 had no mood concerns and no behavior concerns. R#1 required extensive assistance with the help of one person with transfer, toileting, personal hygiene, and dressing. Extensive assistance was defined as Resident involved in the activity, staff provide weight-bearing support. R#1 did not walk and required extensive assistance with the help of one person to move about the facility in a wheelchair. R#1's balance when moving from a seated position to a standing position and moving on and off the toilet was not steady and she was only able to stabilize with staff assistance. R#1 was always incontinent of bladder and frequently incontinent of bowel. She was not on a toileting program. Review of R#1's care plan revealed: R#1 was at risk for falls due to impaired mobility, cognitive loss and lack of safety awareness. Interventions included monitoring for and assisting with toileting needs. R#1 was at risk for decreased ability to perform ADLs (activities of daily living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to changes in mental status. Her ability to assist with ADLs may fluctuate due to her impaired cognition. Interventions inclluded monitoring for decline in ADL function; monitoring for complications of immobility; and providing resident/patient with extensive assist of one or two for transfers. Restorative transfers: R#1 demonstrates deficit in transferring with functional deterioration (initiated 01/16/17). Goal was to maintain balance in standing/sitting for safe mobility as evidenced by no reported decline when transferring X 90 days. Interventions included sit to stand exercises. R#1 has impaired communication as evidenced by R#1 requiring hearing amplifiers and R#1 has inattention and disorganized thought. R#1 experiences sleep pattern disturbance as evidenced by periods of [MEDICAL CONDITION] (initiated 05/03/17). Interventions included administration of medications as ordered and monitoring for effectiveness. R#1 was at risk of adverse reactions to the use of Hypnotic [MEDICATION NAME](initiated 05/03/17) Interventions included monitoring for side effects and behaviors. R#1 was at risk for fractures related to [MEDICAL CONDITION] (initiated 05/03/17). Interventions included montoring for signs of discomfort during care. Review of Medication Review Report (Physician Orders) for May, 2017, revealed R#1 was prescribed the following: Fall mat @ (at) bedside (01/31/16) Pain management every shift-reference pain scale (ordered 12/21/15) [MEDICATION NAME]-[MEDICATION NAME] 300-30mg q4h (every four hours) prn (as needed) (ordered 05/15/17) Ambien 5 mg (milligram) QHS PRN (at night as needed) for [MEDICAL CONDITION] (ordered 09/14/16) [MEDICATION NAME] HCl 50 mg q6h (every six hours) for pain (ordered 05/12/17) Tylenol Extra Strength 500 mg q6h prn for pain/fever (ordered 09/14/16) Review of Medication Administration Record [REDACTED]. Review of the Pain Management record revealed no assessment of R#1's pain on the 6:00 a.m. to 2:00 p.m. shift on 04/02/17, 04/03/17, 04/06/17, 04/10/17, 04/11/17, 04/14/17; 04/15/17; 04/16/17, 04/23/17, 04/24/17; no assessment of R#1's pain on the 2:00 p.m. to 10:00 p.m. shift on 04/05/17, 04/10/17, 04/16/17, 04/19/17, 04/23/17, 04/24/17, 04/25/17, 04/28/17; and no assessment of R#1's pain on the 10:00 p.m. to 6:00 a.m. shift on 04/19/17, 04/21/17, 04/22/17, 04/23/17, 04/24/17, 04/26/17, 04/27/17, 04/28/17, 04/29/17, and 04/30/17. Review of the MAR for May, 2017 revealed no administration [MEDICATION NAME] mg; administration of Tylenol Extra Strength 500 mg on 05/09/17 at 0700; and administration of [MEDICATION NAME] HCl 50 mg once each day on 05/07/17, 05/08/17 and 05/09/17. Review of the Pain Management assessment revealed no assessment was done on the 6:00 a.m. to 2:00 p.m. shift on 05/01/17, 05/03/17, 05/04/17, 05/08/17, 05/09/17; no assessment of R#1's pain on the 2:00 p.m. to 10:00 p.m. shift on 05/03/17, 05/04/17, 05/08/17, 05/09/17; and no assessment of R#1's pain on the 10:00 p.m. shift on 05/01/17, 05/04/17, 05/05/17, and 05/09/17. There were no further pain assessment on any shift after 05/10/17. This form was given to surveyor on 05/17/17. Review of Hospital Emergency Admission Record dated 05/08/17 revealed R#1 was seen in the hospital emergency room and X-Rays revealed she had a fractured clavicle and fractured humerus on her right side. The emergency room report said R#1 was a poor historian and she fell from her bed changing positions. R#1 was discharged back to the facility on [DATE] with instructions to follow up with a physician, to take acetominophen for pain and to use precautions to prevent recurrent fall. Observation and interview of R#1 at 1:45 p.m. on 05/16/17 in the common area near the side exit door of the facility revealed R#1 sitting in her wheelchair with her right arm in a sling and a pillow on her lap that appeared to be sliding down. R#1 was crying and her right arm appeared to be swollen and discolored. When asked if she was in pain R#1 said, Yes. An interview with Licensed Vocational Nurse (LVN) A at 1:50 p.m. on 05/16/17 revealed R#1 took a scheduled pain medication, [MEDICATION NAME] q6h (every six hours) around noon. LVN A said R#1 had Tylenol #3 for breakthrough pain and she was going to give her a Tylenol 3 because she appeared to be hurting. An interview with LVN A at 2:10 p.m. on 05/16/17 revealed R#1 was found in bed on 05/08/17 around 6:15 or 6:30 a.m. by a CNA (Certified Nurse Aid) when the CNA was trying to get R#1 up for breakfast. R#1 did not want to get up and she complained of her arm hurting. The CNA reported to LVN A that R#1 was hurting and did not want to get out of bed. LVN A said she found R#1 in bed with a large purple bruise and her right arm and she appeared to be in a lot of pain. R#1 could not tell her what happened. LVN A said she called R#1's physician and family, and a portable xray was ordered. LVN A said she made the decision to send R#1 to the hospital due to the length of time it might take for the xray company to arrive at the facility, and R#1 was in a lot of pain. LVN A said nothing was passed on to her in report from the night staff about R#1 having a fall or sustaining any kind of injury or discomfort. LVN A said the CNA who found R#1 in bed said they also were not advised of any concerns at the beginning of their shift. LVN A said she completed the first incident report regarding R#1's injury on 05/08/17. In an interview at 3:05 p.m.with R#2 on 05/16/17 in her room, when asked if she heard or saw anything related to R#1's injury on 05/07/17 or 05/08/17, R#2, who was R#1's roommate, said R#1 fell in the bathroom. R#2 said she called for help as soon as R#1 fell . R#2 said R#1 was crying. R#2 said R#1 cannot walk but she did not wait for the nurse to come get her off the toilet. When asked other details about the incident, like who responded, R#2 said she did not know anything more. Review of R#2's Face Sheet dated 05/18/17 revealed she was admitted to the facility on [DATE]. R#2's [DIAGNOSES REDACTED]. R#2 was [AGE] years old. Review of R#2's Quarterly MDS dated [DATE] revealed she was always able to understand others and make herself understood. She did not have corrective lenses. R#2 scored nine points on the BIMS, indicating she had moderate cognitive impairment. R#2 had some disorganized thinking that fluctuated in severity and would come and go. R#2 had no behavior concerns. R#2 was independent in transferring, required minimal assistance with bed mobility and supervision in walking. Review of the Investigation Report submitted by the facility to DADS Consumer Rights and Services Section dated 05/12/17 revealed no Incident Report dated 05/08/17 completed by LVN A and no witness report or statement submitted by the charge nurse, LVN B, who worked the 6:00 p.m. to 6:00 a.m. shift on 05/07/17 to 05/08/17. The Incident Category was Injury of Unknown Origin and the incident date was 05/08/17 at 9:00 a.m. when the injury was observed by staff. The incident report indicated R#1 required extensive assistance but no special supervision. R#1 was not interviewable and was not independently ambulatory. The Description of the Allegation was Resident observed around 0830-0900 AM with bruising and swelling to right upper arm. Resident unable to state what occurred. The Investigation Report dated 05/12/17 revealed the following investigation summary: Investigation reveals resident has DX (diagnosis) [MEDICAL CONDITION] and [MEDICAL CONDITION], Dementia, [DIAGNOSES REDACTED], back pain, muscle wasting and atrophy, history of falling, Dysphagia, [MEDICAL CONDITION], Depression,[MEDICAL CONDITION](Hypertension), ASCD ([MEDICAL CONDITION]). Statements obtained from staff who had worked with resident from 5/7-5/8. On 5/7 statements revealed resident had no bruise areas to upper right arm. On the night of 5/7/2017; investigation reveals that around 2110-2130; resident requested to be placed on toilet; shortly after, resident roommate in hallway requesting assistance, resident on toilet yelling for help and crying. Resistant to care and yelling for help during care. Previously witnessed behaviors. Reported to charge nurse. At 2150 5/7/2017 resident was medicated with [MEDICATION NAME] for pain. 5/8/2017; statements indicate that resident presented with bruising and swelling to right upper extremity in the morning and resident had told CNA (Certified Nursing Assistant) at 0615 that she did not want to get up as she did not feel well. At 0650 CNA reported to nurse that resident was screaming in pain and was medicated with [MEDICATION NAME]. This was reported to physician and xrays were ordered. At 0830; bruise and swelling to arm reported to DON (Director of Nurses), Resident was transported to ED (Emergency Department) in (location), at 1350; report was received from hospital that resident (R#1) had a fracture to humerus head and clavicle. Resident returned from hosptial that same day with order for sling and ortho follow up. Investigation initiated. Statements obtained. Statements from staff and resident are inconclusive as to if resident had a fall. Resident in interview says she guesses she fell . Staff who worked with her report that resident did not fall on their shift, but that Sunday night she was transferred off of the toilet and was tearful. Re-education initiated regarding abuse, neglect, and exploitation, recognizing and prevention and reporting. Preventing and reporting falls. Schedule re-training with transferring. Resident's medication for pain has been scheduled to routine to assist with optimal pain managment. Review of Witness reports included in the facility Investigation report revealed the following: In a phone interview on 05/09/17 at 2:29 p.m., CNA D said about 9:10 p.m. she assisted R#1 to the toilet. R#1 requested to be left on the toilet for a while and said she would let CNA D know when she needed help. CNA D said she went to attend to another resident and was assisted with the other resident by CNA C. CNA D said about five to seven minutes elapsed between when she left R#1 and CNA C went in to assist R#1 off the toilet. CNA D said CNA C told her (R#1) is acting skiddish near the end of the shift. CNA D said she did not know what this meant. Witness Statement dated 05/09/17 by CNA E revealed she saw R#1 in bed on 05/08/17 and R#1 was crying and upset. R#1 said her arm hurt and CNA E said R#1's right arm appeared swollen and bruised. R#2 (R#1's roommate) said R#1 fell in the bathroom and the big guy helped her up the night before. Witness statement dated 05/09/17 by Certified Medication Aide (CMA) F revealed at about 7:15 a.m. (no date given) she saw R#1 in bed and she appeared upset when CMA F gave her medications that were ordered. R#1 took most of her medications and had already received a pain pill. LVN A told CMA F that R#1 had a fall and that she had already medicated her for pain. LVN A told CMA F that no fall was reported in the pass a long at the change of shift. CMA F said she heard the CNAs on the unit saying the same thing. R#2 reported to CMA F that R#1 had been calling for help and was in the bathroom. She said no one came right away so R#1 attempted to walk out of the bathroom and fell . R#2 then got out of the bed and attempted to get help. R#2 did not tell her when R#1 fell . Witness statement dated 05/08/17 at 2:30 p.m. by CNA H revealed at 6:50 a.m. on 05/08/17, staff went into get R#1 up for breakfast. She was complaining of pain her right shoulder/arm. CNA H and CNA I did a body check and R#1 was yelling out in pain and did not want to be touched or moved. Swelling was noted in her right shoulder. CNA H notified LVN A of R#1's pain and swelling. At 8:30 a.m. on 05/08/17 CNA H checked on R#1 and noted R#1 was not moving her right arm and R#1's right arm looked like there was increased swelling and a long oval shaped bruise was noted on R#1's upper arm. CNA H notifed LVN A that R#1's arm looked worse than before. LVN A checked R#1 and contacted the DON. CNA H said no report of a fall was given to staff. CNA H said when she asked R#1 what happened, R#1 said she had fallen. R#2 also said R#1 had fallen. Witness statement dated 05/08/17 at 2:38 p.m. by CNA J revealed at 6:15 a.m. on 05/08/17 she went into R#1's room to get her up for breakfast. CNA J pulled R#1's covers down to change her and tried to roll her but R#1 said I am in pain and I don't feel good. R#1 started crying. CNA J told LVN A that R#1 was in pain and needed a pain pill. Witness statement dated 05/08/17 at 2:40 p.m. by CNA I revealed at 6:50 a.m. on 05/08/17 CNA J came to get her and CNA H to tell them R#1 was screaming in pain. CNA I went into with CNA H to try to get R#1 up. R#1 was screaming and saying she was in pain. A full body check revealed R#1 had swelling to her right upper arm and the CNAs notified LVN A. When CNA I went back into R#1's room around 8:45 a.m. (on 05/08/17) R#1 and R#2 informed CNA I that R#1 had fallen off the toilet the night before and CNA C picked R#1 up. During report on 05/08/17, CNA C did not mention anything all he stated was she (R#1) had been crying in pain all night. Witness statement dated 07/08/17 (05/08/17 possibly) by CNA C revealed at approximately 8:45 p.m. on 05/07/17, CNA D assisted R#1 to the toilet. CNA D told CNA C that R#1 was on the toilet when they were assisting another resident across the hall, who had a large amount of bowel movement and needed a shower. CNA C said he and CNA D took that resident to the shower. When CNA C exited the shower room, R#2 was in the middle of the hall yelling for help. CNA C said he tried to calm R#2 down and R#2 told him that R#1 needed help. I ask her (R#2) to find a place to relax and I enter the room, then bathroom. (R#1) is still on the toilet, but is yelling for help and crying. I ask her if she is finished and she states she needs me to help her to bed. I then assist her to the wheelchair and then to the bed. She is resistant to care and crying and yelling for me to help her, but this is not outside of her normal behaviors I have witnessed. The behavior of both (R#1) and (R#2) are reported to my charge nurse, (LVN B). Review of Interview with R#1 dated 05/09/17 at 11:10 a.m. in R#1's room, submitted as part of the facility investigation report dated 05/12/17 revealed R#1's responses to some of the questions LVN G asked her: Q: Can you tell me what happened to your arm? A: I guess I fell . Q: Do you remember falling? A: No. Q: Where do you think you fell from? A: Maybe out of my bed. Q: Do you remember falling out of your bed? A: No. Q: What makes you think that you fell ? A: When your pain starts it's just . Q: What happened to cause the bruise on your arm? A: I think I fell , I hurt after I fall and I fall quite often (smiles) Q: Did you go to the hospital for your injury? A: No. Responses to other questions from LVN G to R#1 revealed R#1 had not been abused or hurt by anyone. Interview on 05/18/17 at approximately 10:40 a.m. with CNA C revealed he usually worked the 10:00 p.m. to 6:00 a.m. shift. CNA C said R#1 needed extensive assistance with most activities of daily living (ADLs), was incontinent, had episodes of crying, seemed scared sometimes and required one person assistance. CNA C said he did not usually transfer R#1 since he worked the overnight shift and he did not know much about R#1's daily routine. CNA C said he checked the Kardex (electronic tool used to review and input data regarding resident ADLs) every shift during walking rounds. CNA C said each shift did rounds at the beginning of the shift and at the end of shift. CNA C said he came in a little early, around 8:00 p.m. or 8:30 p.m. on 05/07/17 because the facility needed help. CNA D had put R#1 on the toilet and CNA D went across the hall to another room because a resident needed incontinent care. CNA C said he heard R#1's roommate calling for help and he went into R#1's room and found R#1 on the toilet. CNA C said R#1 was sitting normally on the toilet, was not slouched and had nothing askew. R#1 was visibly agitated and asked for help because she couldn't get to bed by herself. CNA C said he went into R#1's room alone and assisted R#1 off the toilet using a gait belt and assisted her back into bed. CNA C said he got a new brief on R#1 and laid her down and covered her up. CNA C said he told LVN B that R#1 was resisting care and upset, and was crying and scared, which was not out of character for R#1. CNA C said R#1 was only left on the toilet for about one-two-three minutes at around 8:45 p.m. on 05/07/17. CNA C said he checked on R#1 twice during the night, assisted her with incontinent care, and she was upset each time, and he reported this to LVN B. CNA C said he told R#2 to calm down. CNA C said R#1 could not have fallen to the floor and R#1 was incapable of lifting herself off the ground. Phone interview on 05/18/17 at 11:00 a.m. with LVN B revealed she was passing medications and she heard R#1's roommate in the hall yelling for help and she and CNA C went into R#1's room together and found R#1 on the toilet. LVN B said she held the wheelchair while CNA C transferred R#1 off the toilet and back to bed. LVN B said R#1 was not crying and did not appear upset or restless when she checked on her throughout the night. LVN B said R#1 could not get off the toilet by herself and R#1 did not appear to be doing anything out of the ordinary. LVN B said she went to get R#1 an [MEDICATION NAME] for pain LVN B said they got her into bed and R#1 did not scream during brief changes. LVN B said she talked with CNA C during the night and CNA C said R#1 was not upset or crying. Surveyor asked LVN B if she was aware that R#1 had had previous falls, and LVN B answered that R#1 had a pretty major fall at a previous facility and broke her pelvis and several vertebrae. LVN B said she had not yet completed her report of what happened the night of 05/07/17 with R#1 and said it was on her dining room table to complete. Surveyor requested that LVN B come into the facility to be interviewed but she said she could not come in. LVN B agreed to submit a written statement of the events of her shift on 05/07/17-05/08/17 regarding R#1 by sending a statement to surveyor's email address. LVN B said she would send the statement in about 20 minutes. Phone interview on 05/18/17 at 11:20 a.m. with CNA C to clarify his report due to conflicting statements by CNA C and LVN B as to whether CNA C was alone when he went in to assist R#1 off the toilet on 05/07/17 at approximately 8:45 p.m. CNA C again said he was alone when he went in and found R#1 on the toilet and he assisted R#1 off the toilet and into bed without assistance. Interview on 05/18/17 at 11:45 a.m. with R#3 revealed R#2 was upset on the evening of 05/07/17 about her roommate falling and R#3 tried to keep R#2 close to her and comforted her. Interview on 05/18/17 at 11:50 a.m. with CNA D revealed she started working on 05/07/17 at about 2:00 p.m. CNA D said she put R#1 on the toilet on 05/07/17 (no time given) and told R#1 to pull the string (call light) when she was ready to get off the toilet. CNA D said R#1 could stand on a bar in the bathroom and could pivot and sit down on the toilet. R#1 required assistance to pull her underwear down. CNA D said she did not use a gait belt when she put R#1 on the toilet because R#1 could pull herself up from the wheelchair using the grab bars. CNA D said R#1's legs could bear weight. CNA D said R#1 was acting skittish. CNA D said LVN B was passing medications. CNA D said she never heard R#2 call for help and never saw R#2 in the hallway. CNA D said she did not check on R#1 after that because she was assisting another resident and CNA C went to assist R#1 off the toilet and into bed. At 12:00 p.m. on 05/18/17, surveyor asked the Administrator and DON if there was a statement from the Charge Nurse, LVN B, as part of the incident investigation. The DON said she finally got in touch with LVN B at 01:22 a. m. on 05/12/17 and told LVN B she needed a written statement from her regarding the incident with R#1. The DON said LVN B said she wanted to rewrite the statement and bring it back. The DON said the last day LVN B worked was 05/07/17 and she was out sick after that. At 12:50 p.m. on 05/18/17, the DON and Administrator gave surveyor a copy of an email sent to the surveyor at the Texas Department of Aging and Disability email address from LVN B, which they said was forwarded to LVN G by LVN B. Surveyor never received the email from LVN B directly and only received the copy of the email from LVN B from the DON and Administrator on 05/18/17. Review of Statement from LVN B dated 05/18/17 and received at 12:50 p.m. on 05/18/17 revealed on 05/07/17 at approximately 9:00 p.m., LVN B was passing medications at the end of the hall and heard R#2 calling for help, saying R#1 had fallen. LVN B said CNA C came from another room and the two of them went into see what happened with R#1. R#1 was sitting upright on the toilet and yelled out, I can't walk! I can't walk! LVN B said they were there to help her lie down. R#1 continued to yell out and her right hand was patting LVN B's left arm and R#1 left hand was squeezing LVN B's right hand. LVN B moved R#1's wheelchair closer to transfer her off the toilet and then to bed. During transfers LVN B did not observe any abnormal movements or guarding, but LVN B decided to give R#1 a prn (as needed) [MEDICATION NAME] since she had been sitting in her wheelchair for a while beforehand. R#1 took the medication with no problem. R#1 never cried or yelled out after being assisted to bed or during incontinent care. She had no symptoms of pain or restlessness overnight. I asked her how she was feeling when I gave her [MEDICAL CONDITION] medication at approximately 545 a.m., to which she smiled and said, oh, I'm fine I asked her if she was in any pain and she replied no. On 05/18/17 at 2:40 p.m., surveyor advised the Administrator that there were two different reports from the CNA and LVN charge nurse (LVN B) who were working the night of 05/07/17; LVN B said she assisted CNA C with R#1's getting off the toilet and back to bed, while CNA C said he did this alone. At surveyor's request, the Administrator called LVN B and interviewed her using the speaker phone. LVN B reported that she went into R#1's room to assist CNA C with R#1 after R#2 called for help on 05/07/17. LVN B said she helped set up the transfer for CNA C but did not assist with putting R#1 into bed. LVN B said R#1 had no signs of restlessness or pain but kept saying I can't walk. On 05/18/17 at 2:45 p.m., using a speaker phone, at Surveyor's request, the Administrator called CNA C to ask about the incident. CNA C reported he was alone in the bathroom with R#1 when he assisted her off the toilet and back to bed when he responded to her roommates concerns that R#1 had fallen on 05/07/17. The Administrator said, (CNA C) said she (R#1) was leaning against the wall and said that R#1 did have [MEDICAL CONDITION]. The Administrator said she did not see a problem with these reports because they were basically saying the same thing. The Administrator said there was no fall. When asked if she had obtained a written statement from LVN B, she showed surveyor a handwritten page that she said was the DON's documentation that she tried to obtain a written statement. The Administrator said LVN B submitted a written statement and then pulled the statement right after she submitted it. The Administrator said LVN B had been sick the week after 05/08/17 but had returned to work on 05/15/17. LVN B had not submitted a written statement to them until they received the copy of the one that LVN B submitted to surveyor at surveyor's DADS email address with a copy to LVN G at the facility. Surveyor gave the Administrator the incident investigation packet which was given to surveyor on 05/17/17 and asked her to check for a written statement from LVN B and an incident report from LVN A. The Adminstrator looked through the investigation packet and said she did not find these reports. Surveyor requested a copy of the reports. Review of Event Summary Report dated 05/08/17 at 3:05 p.m. revealed R#1 was noted on the morning of 05/08/17 to have brusing and swelling to RUE (right upper extremity). R#1 was exhibiting signs and symptoms of pain, and was assessed and sent to the emergency room at 08:30 a.m. Upon return to the facility on [DATE] at 01:50 p.m., R#1 was reported to have a fracture to her right humerus head and clavicle. R#1 was able to state her name and that she was in bed. She believed herself to be in a hospital. When asked about her arm, R#1 stated she guessed she fell but did not remember fallling and that it may have been out of her bed. R#1 did not remember falling out of her bed. Review of the handwritten copy of the note written by the DON and received at 03:30 p.m. on 05/18/17 by surveyor from the Administrator revealed 5/12/17 (5/13/17) 1:22 AM-(LVN B) stated she was not aware of any fall with (R#1) She stated she assisted (CNA C) in transferring her from the commode. Review of the Facility Abuse Prohibition Policy, revised 11/28/16, revealed the following: POLICY (Facility) will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Center will implement an abuse prohibition program through the following: -Screening of potential hires; -Training of employees (both new employees and ongoing training for all employees); -Prevention of occurrences; -Identification of possible incidents or allegations which need investigation; -Investigation of incidents and allegations; -Protection of patients during investigations; and -Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. State Definitions: Neglect is defined as the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property for all patients. PR(NAME)ESS 1. The Center Executive Director (CED), or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. 4. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, will include: 4.3. Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. 5. Staff will identify events--such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse--and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the CED or designee and other officials in accordance with state law. 5.1.1.1 If the patient/resident sustains serious bodily injury, report no later than two (2) hours after forming the suspicion. Refer to Reporting Suspected Crimes Under the Elder Justice Act (EJA) policy. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of property, the CED or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Immediately, not to exceed 24 hours, notify the Texas Department of Aging and Disability Services either: 6.2.1 Online at report incident online, or 6.2.2 By phone at [PHONE NUMBER], regardless of the day or time; select option 5 from the main menu 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 Interventions to prevent further injury. 7.3 The CED or designee will report findings of all completed investigations within five (5) working days utilizing: 7.3.1 DADS Form 3613-A, Pro(TRUNCATED)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for Resident, R#1, of four residents reviewed for provision of adequate supervision. The facility did not provide adequate supervison when R#1 was left alone on the toilet and was later found with an injury of unknown origin, a fractured humerus and clavicle. This failure could affect 54 residents who required assistance with toileting. The findings were: Review of R#1's Admission Record dated 05/08/17 revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. Review of Minimum Data Set ((MDS) dated [DATE] revealed R#1 could usually make herself understood and could understand others, and wore a hearing aid. R#1 scored three points on the Brief Interview for Mental Status (BIMS), indicating she had severe cognitive deficits. R#1 had no mood concerns and no behavior concerns. R#1 required extensive assistance with the help of one person with transfer, toileting, personal hygiene, and dressing. Extensive assistance was defined as Resident involved in the activity, staff provide weight-bearing support. R#1 did not walk and required extensive assistance with the help of one person to move about the facility in a wheelchair. R#1's balance when moving from a seated position to a standing position and moving on and off the toilet was not steady and she was only able to stabilize with staff assistance. R#1 was always incontinent of bladder and frequently incontinent of bowel. She was not on a toileting program. Review of R#1's care plan revealed: R#1 was at risk for falls due to impaired mobility, cognitive loss and lack of safety awareness. Interventions included monitoring for and assisting with toileting needs. R#1 was at risk for decreased ability to perform ADLs (activities of daily living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to changes in mental status. Her ability to assist with ADLs may fluctuate due to her impaired cognition. Interventions inclluded monitoring for decline in ADL function; monitoring for complications of immobility; and providing resident/patient with extensive assist of one or two for transfers. Restorative transfers: R#1 demonstrates deficit in transferring with functional deterioration (initiated 01/16/17). Goal was to maintain balance in standing/sitting for safe mobility as evidenced by no reported decline when transferring X 90 days. Interventions included sit to stand exercises. R#1 has impaired communication as evidenced by R#1 requiring hearing amplifiers and R#1 has inattention and disorganized thought. R#1 experiences sleep pattern disturbance as evidenced by periods of insomnia (initiated 05/03/17). Interventions included administration of medications as ordered and monitoring for effectiveness. R#1 was at risk of adverse reactions to the use of Hypnotic medication Ambien (initiated 05/03/17) Interventions included monitoring for side effects and behaviors. R#1 was at risk for fractures related to Osteoporosis (initiated 05/03/17). Interventions included montoring for signs of discomfort during care. Review of Medication Review Report (Physician Orders) for May, 2017, revealed R#1 was prescribed the following: Fall mat @ (at) bedside (01/31/16) Pain management every shift-reference pain scale (ordered 12/21/15) Acetaminophen-Codeine 300-30mg q4h (every four hours) prn (as needed) (ordered 05/15/17) Ambien 5 mg (milligram) QHS PRN (at night as needed) for insomnia (ordered 09/14/16) Tramadol HCl 50 mg q6h (every six hours) for pain (ordered 05/12/17) Tylenol Extra Strength 500 mg q6h prn for pain/fever (ordered 09/14/16) Review of Medication Administration Record (MAR) for April, 2017 revealed no administration of Ambien 5 mg or Tylenol Extra Strenth 500 mg, , and only one dose of Tramadol HCl 50 mg on 05/25/17. Review of the Pain Management record revealed no assessment of R#1's pain on the 6:00 a.m. to 2:00 p.m. shift on 04/02/17, 04/03/17, 04/06/17, 04/10/17, 04/11/17, 04/14/17; 04/15/17; 04/16/17, 04/23/17, 04/24/17; no assessment of R#1's pain on the 2:00 p.m. to 10:00 p.m. shift on 04/05/17, 04/10/17, 04/16/17, 04/19/17, 04/23/17, 04/24/17, 04/25/17, 04/28/17; and no assessment of R#1's pain on the 10:00 p.m. to 6:00 a.m. shift on 04/19/17, 04/21/17, 04/22/17, 04/23/17, 04/24/17, 04/26/17, 04/27/17, 04/28/17, 04/29/17, and 04/30/17. Review of the MAR for May, 2017 revealed no administration of Ambien 5 mg; administration of Tylenol Extra Strength 500 mg on 05/09/17 at 0700; and administration of Tramadol HCl 50 mg once each day on 05/07/17, 05/08/17 and 05/09/17. Review of the Pain Management assessment revealed no assessment was done on the 6:00 a.m. to 2:00 p.m. shift on 05/01/17, 05/03/17, 05/04/17, 05/08/17, 05/09/17; no assessment of R#1's pain on the 2:00 p.m. to 10:00 p.m. shift on 05/03/17, 05/04/17, 05/08/17, 05/09/17; and no assessment of R#1's pain on the 10:00 p.m. shift on 05/01/17, 05/04/17, 05/05/17, and 05/09/17. There were no further pain assessment on any shift after 05/10/17. This form was given to surveyor on 05/17/17. Review of Hospital Emergency Admission Record dated 05/08/17 revealed R#1 was seen in the hospital emergency room and X-Rays revealed she had a fractured clavicle and fractured humerus on her right side. The emergency room report said R#1 was a poor historian and she fell from her bed changing positions. R#1 was discharged back to the facility on [DATE] with instructions to follow up with a physician, to take acetominophen for pain and to use precautions to prevent recurrent fall. Observation and interview of R#1 at 1:45 p.m. on 05/16/17 in the common area near the side exit door of the facility revealed R#1 sitting in her wheelchair with her right arm in a sling and a pillow on her lap that appeared to be sliding down. R#1 was crying and her right arm appeared to be swollen and discolored. When asked if she was in pain R#1 said, Yes. An interview with Licensed Vocational Nurse (LVN) A at 1:50 p.m. on 05/16/17 revealed R#1 took a scheduled pain medication, Tramadol q6h (every six hours) around noon. LVN A said R#1 had Tylenol #3 for breakthrough pain and she was going to give her a Tylenol 3 because she appeared to be hurting. An interview with LVN A at 2:10 p.m. on 05/16/17 revealed R#1 was found in bed on 05/08/17 around 6:15 or 6:30 a.m. by a CNA when the CNA was trying to get R#1 up for breakfast. R#1 did not want to get up and she complained of her arm hurting. The CNA reported to LVN A that R#1 was hurting and did not want to get out of bed. LVN A said she found R#1 in bed with a large purple bruise and her right arm and she appeared to be in a lot of pain. R#1 could not tell her what happened. LVN A said she called R#1's physician and family, and a portable xray was ordered. LVN A said she made the decision to send R#1 to the hospital due to the length of time it might take for the xray company to arrive at the facility, and R#1 was in a lot of pain. LVN A said nothing was passed on to her in report from the night staff about R#1 having a fall or sustaining any kind of injury or discomfort. LVN A said the CNA who found R#1 in bed said they also were not advised of any concerns at the beginning of their shift. LVN A said she completed the first incident report regarding R#1's injury on 05/08/17. In an interview with R#2 at 3:05 p.m. on 05/16/17 in her room, when asked if she heard or saw anything related to R#1's injury on 05/07/17 or 05/08/17, R#2, who was R#1's roommate, said R#1 fell in the bathroom. R#2 said she called for help as soon as R#1 fell . R#2 said R#1 was crying. R#2 said R#1 cannot walk but she did not wait for the nurse to come get her off the toilet. When asked other details about the incident, like who responded, R#2 said she did not know anything more. Review of R#2's Face Sheet dated 05/18/17 revealed she was admitted to the facility on [DATE]. R#2's [DIAGNOSES REDACTED]. R#2 was [AGE] years old. Review of R#2's Quarterly MDS dated [DATE] revealed she was always able to understand others and make herself understood. She did not have corrective lenses. R#2 scored nine points on the BIMS, indicating she had moderate cognitive impairment. R#2 had some disorganized thinking that fluctuated in severity and would come and go. R#2 had no behavior concerns. R#2 was independent in transferring, required minimal assistance with bed mobility and supervision in walking. Review of the Investigation Report submitted by the facility to DADS Consumer Rights and Services Section dated 05/12/17 revealed no Incident Report dated 05/08/17 completed by LVN A and no witness report or statement submitted by the charge nurse, LVN B, who worked the 6:00 p.m. to 6:00 a.m. shift on 05/07/17 to 05/08/17. The Incident Category was Injury of Unknown Origin and the incident date was 05/08/17 at 9:00 a.m. when the injury was observed by staff. The incident report indicated R#1 required extensive assistance but no special supervision. R#1 was not interviewable and was not independently ambulatory. The Description of the Allegation was Resident observed around 0830-0900 AM with bruising and swelling to right upper arm. Resident unable to state what occurred. The Investigation Report dated 05/12/17 revealed the following investigation summary: Investigation reveals resident has DX (diagnosis) Osteoporosis and Osteoarthritis, Dementia, [DIAGNOSES REDACTED], back pain, muscle wasting and atrophy, history of falling, Dysphagia, Polyneuropathy, Depression, HTN (Hypertension), ASCD (Heart disease). Statements obtained from staff who had worked with resident from 5/7-5/8. On 5/7 statements revealed resident had no bruise areas to upper right arm. On the night of 5/7/2017; investigation reveals that around 2110-2130; resident requested to be placed on toilet; shortly after, resident roommate in hallway requesting assistance, resident on toilet yelling for help and crying. Resistant to care and yelling for help during care. Previously witnessed behaviors. Reported to charge nurse. At 2150 5/7/2017 resident was medicated with Tramadol for pain. 5/8/2017; statements indicate that resident presented with bruising and swelling to right upper extremity in the morning and resident had told CNA (Certified Nursing Assistant) at 0615 that she did not want to get up as she did not feel well. At 0650 CNA reported to nurse that resident was screaming in pain and was medicated with Tramadol. This was reported to physician and xrays were ordered. At 0830; bruise and swelling to arm reported to DON (Director of Nurses), Resident was transported to ED (Emergency Department) in (location), at 1350; report was received from hospital that resident (R#1) had a fracture to humerus head and clavicle. Resident returned from hosptial that same day with order for sling and ortho follow up. Investigation initiated. Statements obtained. Statements from staff and resident are inconclusive as to if resident had a fall. Resident in interview says she guesses she fell . Staff who worked with her report that resident did not fall on their shift, but that Sunday night she was transferred off of the toilet and was tearful. Re-education initiated regarding abuse, neglect, and exploitation, recognizing and prevention and reporting. Preventing and reporting falls. Schedule re-training with transferring. Resident's medication for pain has been scheduled to routine to assist with optimal pain managment. Review of Witness reports included in the facility Investigation report revealed the following: In a phone interview on 05/09/17 at 2:29 p.m., CNA D said about 9:10 p.m. she assisted R#1 to the toilet. R#1 requested to be left on the toilet for a while and said she would let CNA D know when she needed help. CNA D said she went to attend to another resident and was assisted with the other resident by CNA C. CNA D said about five to seven minutes elapsed between when she left R#1 and CNA C went in to assist R#1 off the toilet. CNA D said CNA C told her (R#1) is acting skiddish near the end of the shift. CNA D said she did not know what this meant. Witness Statement dated 05/09/17 by CNA E revealed she saw R#1 in bed on 05/08/17 and R#1 was crying and upset. R#1 said her arm hurt and CNA E said R#1's right arm appeared swollen and bruised. R#2 (R#1's roommate) said R#1 fell in the bathroom and the big guy helped her up the night before. Witness statement dated 05/09/17 by Certified Medication Aide (CMA) F revealed at about 7:15 a.m. (no date given) she saw R#1 in bed and she appeared upset when CMA F gave R#1 her medications that were ordered. R#1 took most of her medications and had already received a pain pill. LVN A told CMA F that R#1 had a fall and that she had already medicated her for pain. LVN A told CMA F that no fall was reported in the pass a long at the change of shift. CMA F said she heard the CNAs on the unit saying the same thing. R#2 reported to CMA F that R#1 had been calling for help and was in the bathroom. She said no one came right away so R#1 attempted to walk out of the bathroom and fell . R#2 then got out of the bed and attempted to get help. R#2 did not tell her when R#1 fell . Witness statement dated 05/08/17 at 2:30 p.m. by CNA H revealed at 6:50 a.m. on 05/08/17, staff went into get R#1 up for breakfast. She was complaining of pain her right shoulder/arm. CNA H and CNA I did a body check and R#1 was yelling out in pain and did not want to be touched or moved. Swelling was noted in her right shoulder. CNA H notified LVN A of R#1's pain and swelling. At 8:30 a.m. on 05/08/17 CNA H checked on R#1 and noted R#1 was not moving her right arm and R#1's right arm looked like there was increased swelling and a long oval shaped bruise was noted on R#1's upper arm. CNA H notifed LVN A that R#1's arm looked worse than before. LVN A checked R#1 and contacted the DON. CNA H said no report of a fall was given to staff. CNA H said when she asked R#1 what happened, R#1 said she had fallen. R#2 also said R#1 had fallen. Witness statement dated 05/08/17 at 2:38 p.m. by CNA J revealed at 6:15 a.m. on 05/08/17 she went into R#1's room to get her up for breakfast. CNA J pulled R#1's covers down to change her and tried to roll her but R#1 said I am in pain and I don't feel good. R#1 started crying. CNA J told LVN A that R#1 was in pain and needed a pain pill. Witness statement dated 05/08/17 at 2:40 p.m. by CNA I revealed at 6:50 a.m. on 05/08/17 CNA J came to get her and CNA H to tell them R#1 was screaming in pain. CNA I went into with CNA H to try to get R#1 up. R#1 was screaming and saying she was in pain. A full body check revealed R#1 had swelling to her right upper arm and the CNAs notified LVN A. When CNA I went back into R#1's room around 8:45 a.m. (on 05/08/17) R#1 and R#2 informed CNA I that R#1 had fallen off the toilet the night before and CNA C picked R#1 up. During report on 05/08/17, CNA C did not mention anything all he stated was she (R#1) had been crying in pain all night. Witness statement dated 07/08/17 (05/08/17 possibly) by CNA C revealed at approximately 8:45 p.m. on 05/07/17, CNA D assisted R#1 to the toilet. CNA D told CNA C that R#1 was on the toilet when they were assisting another resident across the hall, who had a large amount of bowel movement and needed a shower. CNA C said he and CNA D took that resident to the shower. When CNA C exited the shower room, R#2 was in the middle of the hall yelling for help. CNA C said he tried to calm R#2 down and R#2 told him that R#1 needed help. I ask her (R#2) to find a place to relax and I enter the room, then bathroom. (R#1) is still on the toilet, but is yelling for help and crying. I ask her if she is finished and she states she needs me to help her to bed. I then assist her to the wheelchair and then to the bed. She is resistant to care and crying and yelling for me to help her, but this is not outside of her normal behaviors I have witnessed. The behavior of both (R#1) and (R#2) are reported to my charge nurse, (LVN B). Review of Interview with R#1 dated 05/09/17 at 11:10 a.m. in R#1's room, submitted as part of the facility investigation report dated 05/12/17 revealed R#1's responses to some of the questions LVN G asked her: Q: Can you tell me what happened to your arm? A: I guess I fell . Q: Do you remember falling? A: No. Q: Where do you think you fell from? A: Maybe out of my bed. Q: Do you remember falling out of your bed? A: No. Q: What makes you think that you fell ? A: When your pain starts it's just . Q: What happened to cause the bruise on your arm? A: I think I fell , I hurt after I fall and I fall quite often (smiles) Q: Did you go to the hospital for your injury? A: No. Responses to other questions from LVN G to R#1 revealed R#1 had not been abused or hurt by anyone. Interview on 05/18/17 at approximately 10:40 a.m. with CNA C revealed he usually worked the 10:00 p.m. to 6:00 a.m. shift. CNA C said R#1 needed extensive assistance with most activities of daily living (ADLs), was incontinent, had episodes of crying, seemed scared sometimes and required one person assistance. CNA C said he did not usually transfer R#1 since he worked the overnight shift and he did not know much about R#1's daily routine. CNA C said he checked the Kardex (electronic tool used to review and input data regarding resident ADLs) every shift during walking rounds. CNA C said each shift did rounds at the beginning of the shift and at the end of shift. CNA C said he came in a little early, around 8:00 p.m. or 8:30 p.m. on 05/07/17 because the facility needed help. CNA D had put R#1 on the toilet and CNA D went across the hall to another room because a resident needed incontinent care. CNA C said he heard R#1's roommate calling for help and he went into R#1's room and found R#1 on the toilet. CNA C said R#1 was sitting normally on the toilet, was not slouched and had nothing askew. R#1 was visibly agitated and asked for help because she couldn't get to bed by herself. CNA C said he went into R#1's room alone and assisted R#1 off the toilet using a gait belt and assisted her back into bed. CNA C said he got a new brief on R#1 and laid her down and covered her up. CNA C said he told LVN B that R#1 was resisting care and upset, and was crying and scared, which was not out of character for R#1. CNA C said R#1 was only left on the toilet for about one-two-three minutes at around 8:45 p.m. on 05/07/17. CNA C said he checked on R#1 twice during the night, assisted her with incontinent care, and she was upset each time, and he reported this to LVN B. CNA C said he told R#2 to calm down. CNA C said R#1 could not have fallen to the floor and R#1 was incapable of lifting herself off the ground. Phone interview on 05/18/17 at 11:00 a.m. with LVN B revealed she was passing medications and she heard R#1's roommate in the hall yelling for help and she and CNA C went into R#1's room together and found R#1 on the toilet. LVN B said she held the wheelchair while CNA C transferred R#1 off the toilet and back to bed. LVN B said R#1 was not crying and did not appear upset or restless when she checked on her throughout the night. LVN B said R#1 could not get off the toilet by herself and R#1 did not appear to be doing anything out of the ordinary. LVN B said she went to get R#1 an Ultram for pain LVN B said they got her into bed and R#1 did not scream during brief changes. LVN B said she talked with CNA C during the night and CNA C said R#1 was not upset or crying. Surveyor asked LVN B if she was aware that R#1 had had previous falls, and LVN B answered that R#1 had a pretty major fall at a previous facility and broke her pelvis and several vertebrae. LVN B said she had not yet completed her report of what happened the night of 05/07/17 with R#1 and said it was on her dining room table to complete. Surveyor requested that LVN B come into the facility to be interviewed but she said she could not come in. LVN B agreed to submit a written statement of the events of her shift on 05/07/17-05/08/17 regarding R#1 by sending a statement to surveyor's email address. LVN B said she would send the statement in about 20 minutes. Phone interview on 05/18/17 at 11:20 a.m. with CNA C to clarify his report due to conflicting statements by CNA C and LVN B as to whether CNA C was alone when he went in to assist R#1 off the toilet on 05/07/17 at approximately 8:45 p.m. CNA C again said he was alone when he went in and found R#1 on the toilet and he assisted R#1 off the toilet and into bed without assistance. Interview on 05/18/17 at 11:45 a.m. with R#3 revealed R#2 was upset on the evening of 05/07/17 about her roommate falling and R#3 tried to keep R#2 close to her and comforted her. Interview on 05/18/17 at 11:50 a.m. with CNA D revealed she started working on 05/07/17 at about 2:00 p.m. CNA D said she put R#1 on the toilet on 05/07/17 (no time given) and told R#1 to pull the string (call light) when she was ready to get off the toilet. CNA D said R#1 could stand on a bar in the bathroom and could pivot and sit down on the toilet. R#1 required assistance to pull her underwear down. CNA D said she did not use a gait belt when she put R#1 on the toilet because R#1 could pull herself up from the wheelchair using the grab bars. CNA D said R#1's legs could bear weight. CNA D said R#1 was acting skittish. CNA D said LVN B was passing medications. CNA D said she never heard R#2 call for help and never saw R#2 in the hallway. CNA D said she did not check on R#1 after that because she was assisting another resident and CNA C went to assist R#1 off the toilet and into bed. At 12:00 p.m. on 05/18/17, surveyor asked the Administrator and DON if there was a statement from the Charge Nurse, LVN B, as part of the incident investigation. The DON said she finally got in touch with LVN B at 01:22 a. m. on 05/12/17 and told LVN B she needed a written statement from her regarding the incident with R#1. The DON said LVN B said she wanted to rewrite the statement and bring it back. The DON said the last day LVN B worked was 05/07/17 and she was out sick after that. At 12:50 p.m. on 05/18/17, the DON and Administrator gave surveyor a copy of an email sent to the surveyor at the Texas Department of Aging and Disability email address from LVN B, which they said was forwarded to LVN G by LVN B. Surveyor never received the email from LVN B directly and only received the copy of the email from LVN B from the DON and Administrator on 05/18/17. Review of Statement from LVN B dated 05/18/17 and received at 12:50 p.m. on 05/18/17 revealed on 05/07/17 at approximately 9:00 p.m., LVN B was passing medications at the end of the hall and heard R#2 calling for help, saying R#1 had fallen. LVN B said CNA C came from another room and the two of them went into see what happened with R#1. R#1 was sitting upright on the toilet and yelled out, I can't walk! I can't walk! LVN B said they were there to help her lie down. R#1 continued to yell out and her right hand was patting LVN B's left arm and R#1 left hand was squeezing LVN B's right hand. LVN B moved R#1's wheelchair closer to transfer her off the toilet and then to bed. During transfers LVN B did not observe any abnormal movements or guarding, but LVN B decided to give R#1 a prn (as needed) Ultram since she had been sitting in her wheelchair for a while beforehand. R#1 took the medication with no problem. R#1 never cried or yelled out after being assisted to bed or during incontinent care. She had no symptoms of pain or restlessness overnight. I asked her how she was feeling when I gave her thyroid medication at approximately 545 a.m., to which she smiled and said, oh, I'm fine I asked her if she was in any pain and she replied no. On 05/18/17 at 2:40 p.m., surveyor advised the Administrator that there were two different reports from the CNA and LVN charge nurse (LVN B) who were working the night of 05/07/17; LVN B said she assisted CNA C with R#1's getting off the toilet and back to bed, while CNA C said he did this alone. At surveyor's request, the Administrator called LVN B and interviewed her using the speaker phone. LVN B reported that she went into R#1's room to assist CNA C with R#1 after R#2 called for help on 05/07/17. LVN B said she helped set up the transfer for CNA C but did not assist with putting R#1 into bed. LVN B said R#1 had no signs of restlessness or pain but kept saying I can't walk. On 05/18/17 at 2:45 p.m., using a speaker phone, at Surveyor's request, the Administrator called CNA C to ask about the incident. CNA C reported he was alone in the bathroom with R#1 when he assisted her off the toilet and back to bed when he responded to her roommates concerns that R#1 had fallen on 05/07/17. The Administrator said, (CNA C) said she (R#1) was leaning against the wall and said that R#1 did have Osteoporosis. The Administrator said she did not see a problem with these reports because they were basically saying the same thing. The Administrator said there was no fall. When asked if she had obtained a written statement from LVN B, the Administrator showed surveyor a handwritten page that she said was the DON's documentation that the DON tried to obtain a written statement. The Administrator said LVN B submitted a written statement and then pulled the statement right after she submitted it. The Administrator said LVN B had been sick the week after 05/08/17 but had returned to work on 05/15/17. LVN B had not submitted a written statement to them until they received the copy of the one that LVN B submitted to surveyor at surveyor's DADS email address with a copy to LVN G at the facility. Surveyor gave the Administrator the incident investigation packet which was given to surveyor on 05/17/17 and asked her to check for a written statement from LVN B and an incident report from LVN A. The Adminstrator looked through the investigation packet and said she did not find these reports. Surveyor requested a copy of the reports. Review of Event Summary Report dated 05/08/17 at 3:05 p.m. revealed R#1 was noted on the morning of 05/08/17 to have brusing and swelling to RUE (right upper extremity). R#1 was exhibiting signs and symptoms of pain, and was assessed and sent to the emergency room at 08:30 a.m. Upon return to the facility on [DATE] at 01:50 p.m., R#1 was reported to have a fracture to her right humerus head and clavicle. R#1 was able to state her name and that she was in bed. She believed herself to be in a hospital. When asked about her arm, R#1 stated she guessed she fell but did not remember fallling and that it may have been out of her bed. R#1 did not remember falling out of her bed. Review of the handwritten copy of the note written by the DON and received at 03:30 p.m. on 05/18/17 by surveyor from the Administrator revealed 5/12/17 (5/13/17) 1:22 AM-(LVN B) stated she was not aware of any fall with (R#1) She stated she assisted (CNA C) in transferring her from the commode. Review of Form 672 dated 05/17/17 revealed there were 54 residents dependent on the assistance of one or two staff with toileting.

Based on interview and record review, the facility failed to ensure that three Residents, (R #1, R#4 and R#14), of 26 Residents reviewed for abuse and neglect, was free from neglect, in that: -The facility staff did not follow R #4's Physician order [REDACTED]. R#4's oxygen concentrator setting was observed at 2 and 2.5 LPM on three occasions on [DATE]-[DATE], and during transfer to the shower room when R #4 was provided with no oxygen. The facility did not ensure that R #14 wore her oxygen during ambulation, she became short of breath and she fell , fracturing her right hip and hitting her head. The facility did not follow R #14's Physician order [REDACTED]. R #14 expired on [DATE], in the facility. The facility did not ensure R #4's most current oxygen therapy order of continuous Oxygen at 3 liters per nasal cannula was accurate on her Treatment Administartion Record and the oxygen therapy was consistently monitored. The facility did not ensure the oxygen tubings were changed weekly, as per the facility's policy and oxygen concentrator filters remained clean for R #4, R #17, and R #19. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This failure could place 22 residents who required oxygen therapy at risk for shortness of breath and respiratory distress. -R #1's Stage 2 coccyx pressure ulcer discovered on [DATE], acquired in the facility, steadily worsened to an unstageable pressure ulcer by [DATE]. The facility did not provide R #1 with pressure relief (offloading) off her buttocks at least every two hours on two separate days. The facility did not ensure R #1 wore her Prevelon Boots (pressure relieving devices for the feet) as ordered. R #1 developed three separate Deep Tissue Injuries (DTI) on her left heel that the facility was not aware of, until the surveyor's injury. The facility's Assistant Director of Nurses (ADON) inaccurately identified R #1's DTI's as calluses and incorrectly measured each wound. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect four residents with pressure ulcers and 53 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #4: R #4's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's [DATE] Treatment Administration Record (TAR) documented O2 (Oxygen) via NC (nasal cannula) @ (at) 2LPM as needed for SOB. Start date: [DATE]. R #4's physician's orders [REDACTED].@ 3 LPM via NC continuously. R #4's Care Plan dated [DATE] documented (R #4) exhibits a risk for complications of infection related to increased risk of reoccurence of aspiration pneumonia .Approaches: .O2 as ordered. R #4's Significant Change MDS dated [DATE] documented R #4: -Rarely made self understood and rarely understood others. -Had short and long-term memory problems and had severely impaired cognitive skills for daily decision making. -Had an active [DIAGNOSES REDACTED]. -Received oxygen therapy while not a resident and while a resident at the facility. Observation of R #4 on [DATE] at 8:50 a.m. revealed R #4 was sleeping and was receiving O2 @ 2 LPM via NC. Observation of R #4 on [DATE] at 10:51 a.m. revealed R #4 was receiving O2 @ 2.5 LPM per NC. At 10:54 a.m., Licensed Vocational Nurse (LVN) I and Certified Nurse Aides H and J assisted to transfer R #4 from the bed to the Geriatric chair. During this time, CNA H removed R #4's nasal cannula, leaving R #4 without any oxygen administration. Both CNAs escorted R #4 to the shower room, without any oxygen therapy. At 11:33 a.m., R #4 was escorted back to her bedroom in the Geriatric chair and transferred to bed with the assistance of LVN I and CNAs H and J. Once R #4 was in bed, LVN I replaced R #4's nasal cannula in R #4's nares at 11:45 a.m The oxygen concentrator was set at 2.5 LPM. -R #4 was not provided with oxygen therapy from 10:51 a.m.- 11:45 a.m. Observation of R #4 on [DATE] at 11:30 a.m. revealed R #4 was lying in bed receiving O2 @ 2.5 LMP via NC. LVN K entered the room and said R #4 had continuous O2 @ 3LPM ordered when asked how much oxygen R #4 should be receiving. Upon the surveyor's request, LVN K inspected R #4's oxygen concentrator and stated It is set at 2.5 liters, it should be at 3 liters. LVN K adjusted R #4's oxygen concentrator to 3 LPM and then checked R #4's oxygen saturation which was 92%. LVN K stated LVN I was currently R #4's nurse. Interview with LVN I on [DATE] at 11:35 a.m. revealed she stated R #4 was ordered to receive continuous O2 @3LPM via NC. LVN I was informed of R #4 only receiving O2 @ 2.5 LPM on [DATE] and [DATE]. At this time LVN K approached LVN I and the surveyor that R #4's concentrator was set at 2.5 LPM but was adjusted to 3LPM. LVN I verified she had not verified that R #4's oxygen concentrator was set at 3 liters. LVN I explained R #4 used to receive O2 at 2.5 LPM but her order was recently changed to 3 LPM. LVN I reviewed R #4's Treatment Administration Record and said It still say's 2 liters as needed, that's not right. After LVN I reviewed R #4's physician's orders [REDACTED]. The new order was not transcribed to the record, I will do it immediately. LVN I was informed of the surveyor's observation of R #4 not receiving any oxygen on [DATE] while being prepared and escorted to the shower room; LVN I verified she witnessed R #4 without any oxygen in the shower room then said R #4 should have had the oxygen since her order was to receive oxygen continuously. LVN I stated R #4 should have been provided with a portable oxygen tank. LVN I said she took responsibility for not ensuring R #4 had oxygen on and then said each nurse caring for R #4 was responsible to ensure R #4 received continuous oxygen. LVN I stated the procedure was that any nurse that received a new order, transcribed that order to the Medication Administration Record. LVN I said each nurse caring for R #4 should have referred to the Treatment Administration Record to document the prescribed treatment administered but that was not done. R #14: Review of the Admission Record (closed record) dated [DATE] revealed R#14 was initially admitted on [DATE] and readmitted on [DATE]. R#14's [DIAGNOSES REDACTED]. R#14 was [AGE] years old. R #14 expired on [DATE], in the facility. Review of R#14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was clearly able to understand others and had good ability to express her ideas and wants. R#14 had no cognitive deficits and scored 15 out of 15 points on the Brief Interview for Mental Status (BIMS). R#14 had no mood or behavior problems. R#14 was able to walk independently using a walker in her room or corridor with supervision, could dress herself, toilet herself, but required physical help in part of the bathing activity with the help of one person. R#14 was not steady in her balance during transitions and walking but was able to stabilize herself without staff assistance. R#14 was continent of bowel and bladder. R#14 had frequent pain and was on scheduled pain medication. R#14 had shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat. R#14 received oxygen therapy. Review of R#14's Care Plan included the following: R#14 requires assistance/is dependent for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: SOB (shortness of breath) with exertion secondary to [MEDICAL CONDITION]. Interventions included R#14 was independent with bed mobility and with transfers. There were no other interventions listed. Initiated [DATE] and revised [DATE]. R#14 is at nutritional risk and may gain or lose weight due to fluid retention as evidenced by [MEDICAL CONDITION] to lower extremities. Interventions included evaluating for proper consistency of diet, honoring food preferences within meal plan, weighing weekly and alerting dietitian and physician to any significant loss or gain, monitoring for changes in nutritional status, and monitoring intake at all meals. Initiated [DATE]. No interventions were noted regarding elevating BLE when [MEDICAL CONDITION] was present. R#14 has [MEDICAL CONDITION]. Interventions included administering oxygen as ordered/indicated, evaluating breath sounds and respiratory function for rate, rhythm, depth, rhonchi, wheezes q (every) shift and with a change of condition, notify physician of changes from baseline; observe patient at rest and exertion, notify physician of increased weakness and fatigue, and observe for worsening SOB, notify physician if unrelieved or new SOB at rest. Initiated [DATE] with no updates. Review of R#14's Order Summary Report printed on [DATE] for the date range [DATE] to [DATE] revealed the following physician orders [REDACTED]. [DATE]: [MEDICATION NAME] 2 puffs inhale two times a day related to [MEDICAL CONDITION] [DATE]: Oxygen at 2L(liters)/min (minute) via nasal cannula continuously, every shift related to [MEDICAL CONDITION] [DATE]: [MEDICATION NAME] ER Extended Release 30 mg two times daily for pain [DATE]: Duo Neb .5 mg (milligram)/3 mg one vial with Nebulizer every six hours as needed [DATE]: [MEDICATION NAME] Liquid 100 mg/5ML Give 10 ml by mouth every 6 hours as needed for cough [DATE]: Check O2 (oxygen) daily and prn (as needed) every day shift for dyspnea. [DATE]: [MEDICATION NAME] Solution XXX,[DATE].5 (3) mg/3ML (milliliters) 1 vial inhale orally every 6 hours related to [MEDICAL CONDITION] [DATE]: Daliresp Tablet 500 mcg (micrograms) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION] [DATE]: [MEDICATION NAME] Tablet 20 mg once daily for [MEDICAL CONDITION] Review of Interdisciplinary Team Notes dated [DATE] revealed After speaking with nurse verified that resident is on continuous O2 at 2 L/M per NC (two liters of oxygen per nasal canula). Review of R#14's Treatment Administration Record (TAR) for February, 2017 revealed the following oxygen levels when they were checked during the day shift 8:00 a.m. to 4:00 p.m.: [DATE]: 93 [DATE]: 95 [DATE]: 95 [DATE]: 93 [DATE]: 93 [DATE]: 96 [DATE]: 94 Review of Progress Notes from R#14's facility record revealed the following: [DATE]: R#14 was found on floor in front of her recliner. Cause of fall was slippery socks. Socks changed out. [DATE]: R#14 with increased occurrence of shortness of breath/cough. Administered nebulizer treatment with little results observed. Oxygen inspected and working properly. Oxygen sats = 84% and toes cyanotic. Oxygen increased to 3.5L via nasal canula. Oxygen sats were 90% after oxygen adjustment. [DATE]: R#14 slipped while ambulating to the restroom in her room. No injury sustained. Root cause was R#14 was wearing inappropriate footwear. [DATE]: Family member of R#14 expressed concern that R#14 had swelling in bilateral extremities (BLE). Nurse noted 2+ [MEDICAL CONDITION]. Nurse notified physician and physician gave no new orders but will see R#14 on [DATE]. [DATE]: physician progress notes [REDACTED]. Referral to Pulmonologist was pending since [DATE]. Cancel that referral and refer R#14 to a different physician. BLE Venous Doppler (blood flow test) ordered, as well as chest xray, an echocardiogram, and labs. For [MEDICAL CONDITION], change [MEDICATION NAME] 60 mg QD (daily) to [MEDICATION NAME] 60 mg BID (twice daily) and monitor fluid status. Review of Telephone Physician order [REDACTED]. Review of chest xray report dated [DATE] revealed R#14 had mild [MEDICAL CONDITIONS]. Review of Progress Notes from R#14's facility record revealed the following: [DATE]: Results from Ultrasound and Venous Doppler were negative at this time. [DATE] 02:25: R#14 resting quietly in bed with head of bed raised for comfort. Oxygen via nasal canula in place at this time. 3+ [MEDICAL CONDITION] to BLE noted. No cough observed or reported. Seems to tolerate increased [MEDICATION NAME] well. Denies pain. [DATE] 15:09: Nurse Practitioner (NP) Progress Note. NP seeing R#14 due to episode of [MEDICAL CONDITION] with sats dropping to 85%. Staff report she was walking to the bathroom without her oxygen and became very short of breath. ,[DATE]+ [MEDICAL CONDITION] to BLE. Chest xray showed mild [MEDICAL CONDITION]. [MEDICATION NAME] increased to 80 mg BID X 3days, then resume 60 mg BID. Prognosis: Guarded, worse today. Today with episode of [MEDICAL CONDITION]. [DATE]: Facility staff meeting, reviewed R#14's condition. Nursing, Social Services, Dietary Manager, ADON, and Administrator present. R#14 has gained 11 pounds in 30 days. R#14 has 2+ [MEDICAL CONDITION] to BLE, is sedentary and compliant with elevating her lower extremities. Started on weekly weights X 4 weeks to monitor fluid balance. [DATE] 10:37: Referral to Pulmonologist. Expected to be one to two weeks before appointment can be made but it would be made as soon as possible. [DATE] 12:25: physician progress notes [REDACTED]. Yesterday with episode of [MEDICAL CONDITION]. Follow up in a few days around ,[DATE]. [DATE] 12:16: R#14 had an unplanned transfer. [DATE] 17:55: Change in Condition. Per CNA F, R#14 was standing awaiting shower and fell against door, hitting head, arm and hip on floor upon landing. R#14 oxygen saturation 82 on room air at time of incident and 95% on 31 NC (nasal canula) upon return to room. Observations included labored breathing, shallow breathing crackles/rales present, right upper, right lower, left upper, left lower pitting right LE [MEDICAL CONDITION], pitting left LE [MEDICAL CONDITION], lower body right side weakness. Review of hospital History and Physical revealed R#14 was admitted to the hospital on [DATE] at 18:21. Review of R#14's present illness revealed she had [MEDICAL CONDITION] from diastolic dysfunction [MEDICAL CONDITION], hypertensive [MEDICAL CONDITION], type 2 diabetes, chronic [MEDICAL CONDITION] pacemaker defibrillator, dementia, history of [MEDICAL CONDITION] (rapid heart rate), [MEDICAL CONDITION], left carotid endarterectomy (surgery on neck artery), depression, history of back surgery, hysterectomy, and rotator cuff injury. Review of hospital Assessment and Plan dated [DATE] revealed R#14 had Pneumonia, right femoral neck fracture, [MEDICAL CONDITIONS] with exacerbation, and Chronic [MEDICAL CONDITION]. In an interview on [DATE] at 11:45 a.m., CNA E said on [DATE] she assisted R#14 out of her room to go to the shower room. CNA E said R#14 complained of being a little dizzy when she opened the shower room door and R#14 fell to the side. CNA E said R#14 fell right inside the shower room by the door. CNA E said R#14 said she was dizzy and could not breathe. CNA E said R#14 used her regular walker with a portable oxygen tank on it but she was not using oxygen when she was walking. CNA E said she had showered R#14 before and R#14 usually only needed help with washing her back and drying off. CNA E said R#14 usually had her portable oxygen on the other side of the wall from the shower and she wore the nasal canula in the shower. CNA E said R#14 told her she did not need her oxygen and sometimes did not wear her oxygen. CNA E said she was not given instructions about whether R#14 needed to wear her oxygen all of the time but she knew R#14 could not be left alone. CNA E said they just walked two doors down from R#14's room to the shower room when R#14 fell . In an interview at 11:55 a.m. on [DATE], Family Member (FM) BB, who also resided in the facility, said he was receiving therapy when R#14 fell on [DATE]. FM BB went to check on R#14 and found her sitting in a chair in bad pain. FM BB said R#14 told him she got out of her wheelchair and walked into the bathroom and fell . R#14 had a big knot on the right side of her head and broke the knob off of her hip. FM BB said R#14 returned to the facility after her hip was repaired, and passed away as he was talking to her on [DATE]. In an interview on [DATE] at 1:00 p.m., FM CC, a family member of R#14, said R#14 always had her oxygen on when he visited her, and when R#14 left the facility, she was always using her portable oxygen In an interview at 10:10 a.m. on [DATE] with CNA E, when asked if she had asked R#14 to put her oxygen on before they walked down the hall toward the shower room on [DATE], CNA E said she did not ask R#14 to put on her oxygen because she did not want to pressure her to wear her oxygen. CNA E said sometimes R#14 wore her oxygen and sometimes she did not wear it. In an interview at 10:20 a.m. on [DATE], the Assistant Director of Nurses (ADON), when asked how often R#14 wore her oxygen, said R#14 went without her oxygen sometimes and probably wore her oxygen about 50% of the time. The ADON said R#14 would go around the building without it sometimes. Surveyor asked the ADON if there was any change in R#14's breathing and need for oxygen the week before she fell , and the ADON replied that she did not know of any change. In an interview with the Administrator on [DATE] at 10:10 a.m., the Administrator said she did not report the incident with R#14's fall on [DATE] because it was a witnessed fall. The Administrator said they talked with staff and determined it was not a reportable incident. Review of Event Summary Report of incident with R#14 dated [DATE] at 11:30 a.m. revealed R#14 sustained an abrasion, bruise, fracture and skin tear. Emergency Medical was called and R#14 was transferred to the hospital at 12:15 p.m. Circumstances of the event and immediate actions taken: Resident (R#14) amb (ambulated) 30 ft (feet) to shower room. became dizzy and fell . CNA reported immediately to LVN who assessed. O2 Sat at 85%. Resident c/o (complained of) pain to head and right arm, skin tear noted. Neuro check complete and WNL (within normal limits). Full ROM (range of motion) to all extremities. Resident assisted back to room and requests to sit in recliner. O2 applied, SAT return to 95% (in less than) 1 min. (minute). Skin Tear cleansed and covered. The fall was related to ambulation status, resident was weak and stated she felt dizzy once arriving to shower area. R#14 had a change of condition in the last seven days with 3+ [MEDICAL CONDITION] to bilateral feet, with [MEDICATION NAME] increased to 80 mg. Current medication that may be causative to the fall included antihypertensives, diuretics, and narcotics. R#14 was administered [MEDICATION NAME] ER Tablet Extended Release 30 mg within eight hours prior to the fall. Review of Event Summary Report of incident with R#14 dated [DATE] revealed root cause to be Resident oxygen saturation decreased and caused resident become dizzy. O2 at 2L ordered continuous, but resident refuses to wear O2 while in bathroom in room and while showering. CNA was unable to effectively catch resident in time to prevent fall. Corrective actions included further education on use of oxygen continuous, standby assistance and s/s (signs/symptoms) of possible complications related to oxygen dependent residents. Resident needs to use her portable oxygen during bathing process to prevent desaturation. Resident c/o pain to right hip over one hour after being in chair and was sent out to hospital with a right [MEDICAL CONDITION]. Review of Witness Statements dated [DATE], attached to the facility Risk Management System report, revealed the following: I, (CNA E) did observe on [DATE] at 10:20 a.m. I went to (R#14's) room and told her it's her shower day. Let's go get your shower. She said okay. I have my clothes and stuff together lets go. I was walking her to the shower room. We opened the door. Right when she was entering the bathroom, (R#14) stood very still then she lost balance and fell over on the floor. I tried to catch her but she fell too quickly. She ended up falling on her shoulder and hit her head. I, (CNA G), did observe on (blank) at (blank). Have witnessed (R#14) to refuse to use her oxygen to the restroom or the shower room. On occasion. I, (CNA H), did observe on (blank) at (blank). In the past I have known (R#14) not to wear her o2 to bathroom or shower room. The facility's Oxygen: Transport of Patient on Continuous Oxygen Policy dated [DATE] documented The center will provide full (oxygen level at time of departure), portable oxygen equipment (concentrator, compressed oxygen, liquid portable oxygen) for patients requiring continuous oxygen .Portable oxygen will be set up by a licensed nurse, respiratory therapist, or rehabilitation therapist as appropriate. The duration begins . or allows for travel time to the destination where capability to continue to deliver oxygen exists. The facility's Oxygen Concentrator Procedure dated [DATE] documented 1. Verify order .11. Set liter flow per order. 12. Attach prescribed oxygen delivery device and apply oxygen delivery to the resident . Review of the Facility Abuse Prohibition Policy, revised [DATE], revealed the following: POLICY (Facility) will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Center will implement an abuse prohibition program through the following: -Screening of potential hires; -Training of employees (both new employees and ongoing training for all employees); -Prevention of occurrences; -Identification of possible incidents or allegations which need investigation; -Investigation of incidents and allegations; -Protection of patients during investigations; and -Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. State Definitions: Neglect is defined as the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property for all patients. PROCESS 1. The Center Executive Director (CED), or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. 4. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, will include: 4.3. Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. 5. Staff will identify events--such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse--and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the CED or designee and other officials in accordance with state law. 5.1.1.1 If the patient/resident sustains serious bodily injury, report no later than two (2) hours after forming the suspicion. Refer to Reporting Suspected Crimes Under the Elder Justice Act (EJA) policy. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of property, the CED or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Immediately, not to exceed 24 hours, notify the Texas Department of Aging and Disability Services either: 6.2.1 Online at report incident online, or 6.2.2 By phone at [PHONE NUMBER], regardless of the day or time; select option 5 from the main menu 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 Interventions to prevent further injury. 7.3 The CED or designee will report findings of all completed investigations within five (5) working days utilizing: 7.3.1 DADS Form 3613-A, Provider Investigation Report 7.3.2 Submit the investigation as follows: 7.3.2.2.1 Texas Department of Aging and Disability Services Consumer Rights and Services-Complaint Intake Unit R #17: R #17's [DATE] physician's orders [REDACTED].Oxygen at 3 LPNC continuously- start date: [DATE]. R #17's [DATE] TAR indicated the order for oxygen at 3 LPNC but did not indicate when her oxygen tubing should have been changed. Observation of R #17 on [DATE] at 9:48 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #17's oxygen tubing was dated [DATE]. On [DATE] at 9:50 a.m., the Administrator was informed an IJ situation was identified due to the above failures. Observation of R #16 on [DATE] at 9:51 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #16's oxygen concentrator filter had white dust covering the filter. R #16's oxygen tubing was dated [DATE]. R #19: R #19's Face Sheet dated [DATE] documented a [AGE] year-old female asmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #19's admission orders [REDACTED]. Observation of R #19 on [DATE] at 9:54 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #19's oxygen tubing was not dated. Interview with LVN U on [DATE] at 10:14 a.m. revealed she did not know how many liters of oxygen R #19 should be receiving. LVN U reviews R #19's [DATE] Medication Administration Record [REDACTED]. I have to check her orders. LVN U consulted with LVN K then LVN K reviewed R #19's physician's orders [REDACTED]. On [DATE] at 11:08 a.m., LVN K informed the surveyor that she received orders for R #19 and provided a copy of the orders. R #19's physician's orders [REDACTED].@ 2LPNC PRN (as needed) for saturation level less than 90% for [DIAGNOSES REDACTED].#19's oxygen should have retrieved anorder from her physician for the oxygen. R #18: R #18's [DATE] physician's orders [REDACTED]. Review of R #18's [DATE] TAR indicated her oxygen concentrator filter was only cleaned on [DATE]. The TAR contained a signature on [DATE], indicating that the oxygen tubing was changed on that day. -However, observation on [DATE] revealed R #18's tubing was dated [DATE]. Observation of R #18 on [DATE] at 9:57 a.m. revealed she received oxygen at 4 liters per nasal cannula. R #18's oxygen concentrator filter was covered with white dust. R #18's oxygen tubing was dated [DATE]. Interview with LVN U on [DATE] at 10:09 a.m. revealed she stated she had recently started working in the facility approximately one week ago. LVN U said oxygen tubing should be changed weekly but did not know what the facility's policy and procedure was or who was responsible for cleaning them. LVN U stated she did not know anything about the maintenance of the filters. Interview with LVN I on [DATE] at 10:12 a.m. revealed she stated oxygen tubing should be changed and dated weekly, at the same time the concentrator filters were cleaned. LVN I said this was scheduled on Sundays and the night shift was responsible for ensuring it was done. LVN I said each resident's Treatment Administration Record should have address the cleaning of filters and changing of oxygen tubing. On [DATE] at 5:59 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR). The final Plan of Removal documented: This Plan of Removal is in response to the alleged identification of Immediate Jeopardy communicated by the survey team on [DATE] during a return visit prompted by the annual survey with exit date of [DATE] at (the facility). The alleged Immediate Jeopardy findings were identified in the following areas: -Quality of Care -Neglect The facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of Immediate Jeopardy and/or any subsequent Statement of Deficiencies. Corrective Action and Identification: Review of orders identified 22 of 72, residents as having orders for Oxygen. This facility has put in place immediate corrective action as evidenced by: 1. On [DATE], nursing administration provided education on abuse and neglect to staff members. On [DATE], nursing administration reeducated staff members on abuse and neglect. 2. On [DATE] residents on oxygen therapy assessed and compliance with orders verified by nursing administration. 3. On [DATE], a complete audit of residents using oxygen was conducted by nursing administration and care plans were reviewed and revised accordingly. 4. On [DATE], nursing administration provided education to nursing staff regarding use of oxygen and maintenance of filter and tubing. 5. On [DATE], the MAR indicated [REDACTED]. MAR indicated [REDACTED]

Based on interview and record review, the facility failed to report to the State Survey Agency an incident of neglect of one Resident,( R#14), of 15 Residents reviewed for abuse and neglect. The facility did not report an incident in which R#14 walked to the shower without wearing her oxygen, which was ordered by the physician to be worn continuously, became short of breath and fell , fracturing her right hip and hitting her head. This failure to provide specialty care services for R#14 resulted in an Immediate Jeopardy (IJ) situation on 04/13/17 at 9:50 a.m. While the IJ was removed on 04/14/17 at 2:54 p.m., the facility remained out of compliance at a potential for more than actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. The failure to thoroughly investigate and report the incident in which R#14 fell and fractured her hip while not receiving oxygen could place 22 residents who required oxygen therapy at risk for neglect. The findings were: Review of the Admission Record dated 02/22/17 revealed R#14 was initially admitted on [DATE] and readmitted on [DATE]. R#14's [DIAGNOSES REDACTED]. R#14 was [AGE] years old. Review of R#14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was clearly able to understand others and had good ability to express her ideas and wants. R#14 had no cognitive deficits and scored 15 out of 15 points on the Brief Interview for Mental Status (BIMS). R#14 had no mood or behavior problems. R#14 was able to walk independently using a walker in her room or corridor with supervision, could dress herself, toilet herself, but required physical help in part of the bathing activity with the help of one person. R#14 was not steady in her balance during transitions and walking but was able to stabilize herself without staff assistance. R#14 was continent of bowel and bladder. R#14 had frequent pain and was on scheduled pain medication. R#14 had shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat. R#14 received oxygen therapy. Review of R#14's Care Plan included the following: R#14 requires assistance/is dependent for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: SOB (shortness of breath) with exertion secondary to [MEDICAL CONDITION]. Interventions included R#14 was independent with bed mobility and with transfers. There were no other interventions listed. Initiated 11/06/16 and revised 01/24/17. R#14 is at nutritional risk and may gain or lose weight due to fluid retention as evidenced by [MEDICAL CONDITION] to lower extremities. Interventions included evaluating for proper consistency of diet, honoring food preferences within meal plan, weighing weekly and alerting dietition and physician to any significant loss or gain, monitoring for changes in nutritional status, and monitoring intake at all meals. Initiated 02/07/17. No interventions were noted regarding elevating BLE when [MEDICAL CONDITION] was present. R#14 has [MEDICAL CONDITION]. Interventions included administering oxygen as ordered/indicated, evaluating breath sounds and respiratory function for rate, rhythm, depth, rhonchi, wheezes q (every) shift and with a change of condition, notify physician of changes from baseline; observe patient at rest and exertion, notify physician of increased weakness and fatigue, and observe for worsening SOB, notify physician if unrelieved or new SOB at rest. Initiated 11/03/16 with no updates. Review of R#14's Order Summary Report printed on 03/30/17 for the date range 01/01/16 to 02/28/17 revealed the following physician orders [REDACTED]. 10/28/16: [MEDICATION NAME] 2 puffs inhale two times a day related to [MEDICAL CONDITION] 10/31/16: Oxygen at 2L(liters)/min (minute) via nasal cannula continuously, every shift related to [MEDICAL CONDITION] 11/22/16: [MEDICATION NAME] ER Extended Release 30 mg two times daily for pain 11/28/16: Duo Neb .5 mg (milligram)/3 mg one vial with Nebulizer every six hours as needed 11/28/16: [MEDICATION NAME] Liquid 100 mg/5ML Give 10 ml by mouth every 6 hours as needed for cough 12/23/16: Check O2 (oxygen) daily and prn (as needed) every day shift for dyspnea. 12/26/16: [MEDICATION NAME] Solution .5-2.5 (3) mg/3ML (milliliters) 1 vial inhale orally every 6 hours related to [MEDICAL CONDITION] 12/27/16: [MEDICATION NAME] Tablet 20 mg once daily for [MEDICAL CONDITION] 12/27/16: Daliresp Tablet 500 mcg (micrograms) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION] Review of Interdisciplinary Team Notes dated 11/10/16 revealed After speaking with nurse verified that resident is on continuous O2 at 2 L/M per NC (two liters of oxygen per nasal canula). Review of R#14's Treatment Administration Record (TAR) for February, 2017 revealed the following oxygen levels when they were checked during the day shift 8:00 a.m. to 4:00 p.m.: 02/01/17: 93 02/02/17: 95 02/03/17: 95 02/04/17: 93 02/05/17: 93 02/06/17: 96 02/07/17: 94 Review of R#14's TAR for February, 2017 revealed nebulizer treatments were administered at noon only on 02/01/17, 02/06/17 and 02/08/17. Review of Progress Notes from R#14's facility record revealed the following: 01/14/17: R#14 was found on floor in front of her recliner. Cause of fall was slippery socks. Socks changed out. 01/19/17: R#14 with increased occurrence of shortness of breath/cough. Administered nebulizer treatment with little results observed. Oxygen inspected and working properly. Oxygen sats = 84% and toes cyanotic. Oxygen increased to 3.5L via nasal canula. Oxygen sats were 90% after oxygen adjustment. 01/27/17: R#14 slipped while ambulating to the restroom in her room. No injury sustained. Root cause was R#14 was wearing inappropriate footwear. 02/02/17: Family member of R#14 expressed concern that R#14 had swelling in bilateral extremeties (BLE). Nurse noted 2+ [MEDICAL CONDITION]. Nurse notified physician and physician gave no new orders but will see R#14 on 02/03/17. 02/03/17: physician progress notes [REDACTED]. Referral to Pulmonologist was pending since 12/27/16. Cancel that referral and refer R#14 to a different physician. BLE Venous Doppler (blood flow test) ordered, as well as chest xray, an echocardiogram, and labs. For [MEDICAL CONDITION], change [MEDICATION NAME] 60 mg QD (daily) to [MEDICATION NAME] 60 mg BID (twice daily) and monitor fluid status. Review of Telephone Physician order [REDACTED]. Review of chest xray report dated 02/03/17 revealed R#14 had mild [MEDICAL CONDITIONS] Review of Progress Notes from R#14's facility record revealed the following: 02/04/17: Results from Ultrasound and Venous Doppler were negative at this time. 02/06/17 02:25: R#14 resting quietly in bed with head of bed raised for comfort. Oxygen via nasal canula in place at this time. 3+ [MEDICAL CONDITION] to BLE noted. No cough observed or reported. Seems to tolerate increased [MEDICATION NAME] well. Denies pain. 02/06/17 15:09: Nurse Practitioner (NP) Progress Note. NP seeing R#14 due to episode of [MEDICAL CONDITION] with sats dropping to 85%. Staff report she was walking to the bathroom without her oxygen and became very short of breath. 2-3+ [MEDICAL CONDITION] to BLE. Chest xray showed mild [MEDICAL CONDITION]. [MEDICATION NAME] increased to 80 mg BID X 3days, then resume 60 mg BID. Prognosis: Guarded, worse today. Today with episode of [MEDICAL CONDITION]. 02/07/17: Facility staff meeting, reviewed R#14's condition. Nursing, Social Services, Dietary Manager, ADON, and Administrator present. R#14 has gained 11 pounds in 30 days. R#14 has 2+ [MEDICAL CONDITION] to BLE, is sedentary and compliant with elevating her lower extremities. Started on weekly weights X 4 weeks to monitor fluid balance. 02/07/17 10:37: Referral to pulmonologist. Expected to be one to two weeks before appointment can be made but it would be made as soon as possible. 02/07/17 12:25: physician progress notes [REDACTED]. Yesterday with episode of [MEDICAL CONDITION]. Follow up in a few days around 2/9. 02/08/17 12:16: R#14 had an unplanned transfer. 02/08/17 17:55: Change in Condition. Per CNA F, R#14 was standing awaiting shower and fell against door, hitting head, arm and hip on floor upon landing. R#14 oxygen saturation 82 on room air at time of incident and 95% on 31 NC (nasal canula) upon return to room. Observations included labored breathing, shallow breathing crackles/rales present, right upper, right lower, left upper, left lower pitting right LE [MEDICAL CONDITION], pitting left LE [MEDICAL CONDITION], lower body right side weakness. Review of hospital History and Physical revealed R#14 was admitted to the hospital on [DATE] at 18:21. Review of R#14's present illness revealed she had [MEDICAL CONDITION] from diastolic dysfunction [MEDICAL CONDITION], hypertensive [MEDICAL CONDITION], type 2 diabetes, chronic [MEDICAL CONDITION] pacemaker defibrillator, dementia, history of [MEDICAL CONDITION] (rapid heart rate), [MEDICAL CONDITION], left carotid endarterectomy (surgery on neck artery), depression, history of back surgery, hysterectomy, and rotator cuff injury. Review of hospital Assessment and Plan dated 02/08/17 revealed R#14 had Pneumonia, right femoral neck fracture, [MEDICAL CONDITIONS] with exacerbation, and Chronic [MEDICAL CONDITION]. In an interview on 03/30/17 at 11:45 a.m., CNA E said on 02/08/17 she assisted R#14 out of her room to go to the shower room. CNA E said R#14 complained of being a little dizzy when she opened the shower room door and R#14 fell to the side. CNA E said R#14 fell right inside the shower room by the door. CNA E said R#14 said she was dizzy and could not breathe. CNA E said R#14 used her regular walker with a portable oxygen tank on it but she was not using oxygen when she was walking. CNA E said she had showered R#14 before and R#14 usually only needed help with washing her back and drying off. CNA E said R#14 usually had her portable oxygen on the other side of the wall from the shower and she wore the nasal canula in the shower. CNA E said R#14 told her she did not need her oxygen and sometimes did not wear her oxygen. CNA E said she was not given instructions about whether R#14 needed to wear her oxygen all of the time but she knew R#14 could not be left alone. CNA E said they just walked two doors down from R#14's room to the shower room when R#14 fell . Review of ADL Report of ADLs provided by CNAs revealed no documentation of the bathing task in the month of January, 2017. In February, 2017, R#14 was showered on 02/03/17 and 02/06/17 and required extensive assistance with the help of one person. The Walk in Corridor task in February, 2017 was not applicable or resident refused for almost all entries, which were made three times daily, for 02/02/17 through 02/08/17. In an interview at 11:55 a.m. on 03/30/17, Family Member (FM) BB, who also resided in the facility, said he was receiving therapy when R#14 fell on [DATE]. FM BB went to check on R#14 and found her sitting in a chair in bad pain. FM BB said R#14 told him she got out of her wheelchair and walked into the bathroom and fell . R#14 had a big knot on the right side of her head and broke the knob off of her hip. FM BB said R#14 always wore her oxygen and only took it off once in a while if she was eating ice cream. FM BB said R#14 returned to the facility after her hip was repaired, and passed away as he was talking to her on 02/17/17. In an interview on 04/14/17 at 1:00 p.m., FM CC, a family member of R#14, said R#14 always had her oxygen on when he visited her, and when R#14 left the facility, she was always using her portable oxygen. In an interview at 10:10 a.m. on 03/31/17, when asked if she had asked R#14 to put her oxygen on before they walked down the hall toward the shower room on 02/08/17, CNA E said she did not ask R#14 to put on her oxygen because she did not want to pressure her to wear her oxygen. CNA E said sometimes R#14 wore her oxygen and sometimes she did not wear it. In an interview at 10:20 a.m. on 03/31/17, the Assistant Director of Nurses (ADON), when asked how often R#14 wore her oxygen, said R#14 went without her oxygen sometimes and probably wore her oxygen about 50% of the time. The ADON said R#14 would go around the building without it sometimes. Surveyor asked the ADON if there was any change in R#14's breathing and need for oxygen the week before she fell , and the ADON replied that she did not know of any change. In an interview with the Administrator on 03/31/17 at 10:10 a.m., the Administrator said she did not report the incident with R#14's fall on 02/08/17 because it was a witnessed fall. The Administrator said they talked with staff and determined it was not a reportable incident. Review of Event Summary Report of incident with R#14 dated 02/08/17 at 11:30 a.m. revealed R#14 sustained an abrasion, bruise, fracture and skin tear. Emergency Medical was called and R#14 was transferred to the hospital at 12:15 p.m. Circumstances of the event and immediate actions taken: Resident (R#14) amb (ambulated) 30 ft (feet) to shower room. became dizzy and fell . CNA reported immediately to LVN who assessed. O2 Sat at 85%. Resident c/o (complained of) pain to head and right arm, skin tear noted. Neuro check complete and WNL (within normal limits). Full ROM (range of motion) to all extremities. Resident assisted back to room and requests to sit in recliner. O2 applied, SAT return to 95% (in less than) 1 min. (minute). Skin Tear cleansed and covered. The fall was related to ambulation status, resident was weak and stated she felt dizzy once arriving to shower area. R#14 had a change of condition in the last seven days with 3+ [MEDICAL CONDITION] to bilateral feet, with [MEDICATION NAME] increased to 80 mg. Current medication that may be causative to the fall included antihypertensives, diuretics, and narcotics. R#14 was administered [MEDICATION NAME] ER Tablet Extended Release 30 mg within eight hours prior to the fall. Review of Event Summary Report of incident with R#14 dated 02/08/17 revealed root cause to be Resident oxygen saturation decreased and caused resident become dizzy. O2 at 2L ordered continuous, but resident refuses to wear O2 while in bathroom in room and while showering. CNA was unable to effectively catch resident in time to prevent fall. Corrective actions included further education on use of oxygen continuous, standby assistance and s/s (signs/symptoms) of possible complications related to oxygen dependent residents. Resident needs to use her portable oxygen during bathing process to prevent desaturation. Resident c/o pain to right hip over one hour after being in chair and was sent out to hospital with a right [MEDICAL CONDITION]. Review of Witness Statements dated 02/10/17, attached to the facility Risk Management System report, revealed the following: I, (CNA E) did observe on 02/08/17 at 10:20 a.m. I went to (R#14's) room and told her it's her shower day. Let's go get your shower. She said okay. I have my clothes and stuff together lets go. I was walking her to the shower room. We opened the door. Right when she was entering the bathroom, (R#14) stood very still then she lost balance and fell over on the floor. I tried to catch her but she fell too quickly. She ended up falling on her shoulder and hit her head. I, (CNA G), did observe on (blank) at (blank). Have witnessed (R#14) to refuse to use her oxygen to the restroom or the shower room. On occasion. I, (CNA H), did observe on (blank) at (blank). In the past I have known (R#14) not to wear her o2 to bathroom or shower room. The facility's Oxygen: Transport of Patient on Continuous Oxygen Policy dated 01/02/14 documented The center will provide full (oxygen level at time of departure), portable oxygen equipment (concentrator, compressed oxygen, liquid portable oxygen) for patients requiring continuous oxygen .Portable oxygen will be set up by a licensed nurse, respiratory therapist, or rehabilitation therapist as appropriate. The duration begins . or allows for travel time to the destination where capability to continue to deliver oxygen exists. The facility's Oxygen Concentrator Procedure dated 12/08/14 documented 1. Verify order .11. Set liter flow per order. 12. Attach prescribed oxygen delivery device and apply oxygen delivery to the resident . On 04/13/17 at 9:50 a.m., the Administrator was informed an IJ situation was identified due to the above failures. On 04/13/17 at 5:59 p.m., the facility was notified of the acceptance of the Plan of Removal (POR). The Plan of Removal documented: This Plan of Removal is in response to the alleged identification of Immediate Jeopardy communicated by the survey team on April 13, 2017 during a return visit prompted by the annual survey with exit date of March 31, 2017 at Oak Crest Nursing Center in Rockport, Texas. The alleged Immediate Jeopardy findings were identified in the following areas: Quality of Care Neglect The facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of Immediate Jeopardy and/or any subsequent Statement of Deficiencies. Corrective Action and Identification: Review of orders identified 22 of 72, residents as having orders for Oxygen. This facility has put in place immediate corrective action as evidenced by: 1. On March 30, 2017, nursing administration provided education on abuse and neglect to staff members. On April 13, 2017, nursing administration reeducated staff members on abuse and neglect. 2. On April 13, 2017 residents on oxygen therapy assessed and compliance with orders verified by nursing administration. 3. On March 30, 2017, a complete audit of residents using oxygen was conducted by nursing administration and care plans were reviewed and revised accordingly. 4. On April 13, 2017, nursing administration provided education to nursing staff regarding use of oxygen and maintenance of filter and tubing. 5. On April 13, 2017, the MAR indicated [REDACTED]. MAR indicated [REDACTED]. 6. On March 31, 2017 Kardexes were updated to reflect those residents receiving oxygen with the verbiage 'respiratory therapy'. A Kardex is a tool that is used by the CNAs and nursing to communicate what type of care the resident needs from the CNA perspective. The Kardex is located in the CNA electronic tablet that is used to document resident care and provides information regarding resident care and needs specific to the CNA level. It is the equivalent of a care plan. Examples of items on a Kardex are mobility, transfer, eating and oxygen status. 7. On April 13, 2017, Kardexes were updated to reflect those residents that are on oxygen with the verbiage 'Continuous Oxygen therapy' or 'PRN oxygen therapy'. 8. On April 13, 2017, nursing staff educated regarding the MAR updates that reflect the tubing and filter changing and the oxygen tubing/filter maintenance process. The tubing will be changed on Sunday by the charge nurse on the 10-6 shift. Charge nurse to remove and replace old tubing and date new tubing. Remove old filter and replace with new filter. Humidification bottles are to be removed and replaced as needed. Humidification bottles will be dated each time they are replaced. 9. CNAs on April 13, 2017 received education provided regarding the updated Kardex that reflects the verbiage, 'Continuous Oxygen therapy' or 'PRN oxygen therapy'. 10. CNAs on April 13, 2017 received education to alert charge nurses or nurse managers on all resident oxygen use refusals and changes of condition for appropriate intervention and documentation. Example: If the resident refuses oxygen the CNA will alert the charge nurse so that the charge nurse can come assess and speak to the resident to explain the importance of using the oxygen as ordered and check the residents oxygen saturation levels, level of consciousness, nail beds and fingers for cyanosis and encourage the resident to comply with the oxygen as ordered. The nurse will be sure to document the resident's status and concerns and communicate this to nurse management, the attending MD and family if needed. Charge nurse and CNA will ensure that resident is safe from falls or other injury related to refusal of oxygen. Changes of condition related to respiratory distress such as shortness of breath, dusky nail beds, increase in confusion, drowsiness CNA to alert charge nurse, charge nurse to perform respiratory assessment of resident including but not limited to oxygen saturation levels, vital signs, lung sounds and intervene and notify as appropriate, and document findings and outcomes. 11. Care Plans were reviewed and revised to ensure they reflect the current oxygen therapy orders. Care plans will be updated April 13, 2017. 12. Nursing staff to receive the above education before returning to the floor. The Administrator and other consultants re-assessed residents who were identified by the facility as having a need for oxygen thereapy Through this process, on 04/13/17, the facility provided an updated list of those residents on oxygen therapy. Four residents were identified as having physician orders [REDACTED]. The surveyors confirmed through observation, interview and record review that the facility re-assessed all the residents in the facility, including those receiving oxygen therapy. The residents receiving oxygen therapy were found to be receiving oxygen per physician's orders [REDACTED]. On 04/14/17 at 2:54 p.m., the Administrator and the Regional Vice President were informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments and interventions for oxygen therapy were accurate for all residents. Review of the Facility Abuse Prohibition Policy, revised 11/28/16, revealed the following: POLICY (Facility) will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Center will implement an abuse prohibition program through the following: -Screening of potential hires; -Training of employees (both new employees and ongoing training for all employees); -Prevention of occurrences; -Identification of possible incidents or allegations which need investigation; -Investigation of incidents and allegations; -Protection of patients during investigations; and -Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. State Definitions: Neglect is defined as the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property for all patients. PROCESS 1. The Center Executive Director (CED), or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. 4. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, will include: 4.3. Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. 5. Staff will identify events--such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse--and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the CED or designee and other officials in accordance with state law. 5.1.1.1 If the patient/resident sustains serious bodily injury, report no later than two (2) hours after forming the suspicion. Refer to Reporting Suspected Crimes Under the Elder Justice Act (EJA) policy. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of property, the CED or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Immediately, not to exceed 24 hours, notify the Texas Department of Aging and Disability Services either: 6.2.1 Online at report incident online, or 6.2.2 By phone at [PHONE NUMBER], regardless of the day or time; select option 5 from the main menu 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 Interventions to prevent further injury. 7.3 The CED or designee will report findings of all completed investigations within five (5) working days utilizing: 7.3.1 DADS Form 3613-A, Provider Investigation Report 7.3.2 Submit the investigation as follows: 7.3.2.2.1 Texas Department of Aging and Disability Services Consumer Rights and Services-Complaint Intake Unit Review of List of Patients on Oxygen dated 04/12/17 and received on 04/13/17 identified four residents as requiring continuous oxygen; one resident as requiring continuous oxygen at night, and 17 residents requiring oxygen as needed, for a total of 22 residents requiring oxygen therapy.

Based on interview and record review, the facility failed to ensure that three Residents, (R #1, R#4, and R#14), of 26 Residents reviewed for abuse and neglect, was free from neglect, in that: -The facility staff did not follow R #4's Physician order [REDACTED]. R#4's oxygen concentrator setting was observed at 2 and 2.5 LPM on three occasions on [DATE]-[DATE], and during transfer to the shower room when R #4 was provided with no oxygen. The facility did not ensure that R #14 wore her oxygen during ambulation, she became short of breath and she fell , fracturing her right hip and hitting her head. The facility did not follow R #14's Physician order [REDACTED]. R #14 expired on [DATE] in the facility. The facility did not ensure R #4's most current oxygen therapy order of continuous Oxygen at 3 liters per nasal cannula was accurate on her Treatment Administartion Record and the oxygen therapy was consistently monitored. The facility did not ensure the oxygen tubings were changed weekly, as per the facility's policy and oxygen concentrator filters remained clean for R #4, R #17, and R #19. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This failure could place 22 residents who required oxygen therapy at risk for shortness of breath and respiratory distress. -R #1's Stage 2 coccyx pressure ulcer discovered on [DATE], acquired in the facility, steadily worsened to an unstageable pressure ulcer by [DATE]. The facility did not provide R #1 with pressure relief (offloading) off her buttocks at least every two hours on two separate days. The facility did not ensure R #1 wore her Prevelon Boots (pressure relieving devices for the feet) as ordered. R #1 developed three separate Deep Tissue Injuries (DTI) on her left heel that the facility was not aware of, until the surveyor's injury. The facility's Assistant Director of Nurses (ADON) inaccurately identified R #1's DTI's as calluses and incorrectly measured each wound. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect four residents with pressure ulcers and 53 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: Review of the Facility Abuse Prohibition Policy, revised [DATE], revealed the following: POLICY (Facility) will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Center will implement an abuse prohibition program through the following: -Screening of potential hires; -Training of employees (both new employees and ongoing training for all employees); -Prevention of occurrences; -Identification of possible incidents or allegations which need investigation; -Investigation of incidents and allegations; -Protection of patients during investigations; and -Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. State Definitions: Neglect is defined as the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. PURPOSE To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property for all patients. PR[NAME]ESS 1. The Center Executive Director (CED), or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property. 4. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, will include: 4.3. Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. 5. Staff will identify events--such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse--and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the CED or designee and other officials in accordance with state law. 5.1.1.1 If the patient/resident sustains serious bodily injury, report no later than two (2) hours after forming the suspicion. Refer to Reporting Suspected Crimes Under the Elder Justice Act (EJA) policy. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of property, the CED or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Immediately, not to exceed 24 hours, notify the Texas Department of Aging and Disability Services either: 6.2.1 Online at report incident online, or 6.2.2 By phone at [PHONE NUMBER], regardless of the day or time; select option 5 from the main menu 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 Interventions to prevent further injury. 7.3 The CED or designee will report findings of all completed investigations within five (5) working days utilizing: 7.3.1 DADS Form 3613-A, Provider Investigation Report 7.3.2 Submit the investigation as follows: 7.3.2.2.1 Texas Department of Aging and Disability Services Consumer Rights and Services-Complaint Intake Unit The facility's Oxygen: Transport of Patient on Continuous Oxygen Policy dated [DATE] documented The center will provide full (oxygen level at time of departure), portable oxygen equipment (concentrator, compressed oxygen, liquid portable oxygen) for patients requiring continuous oxygen .Portable oxygen will be set up by a licensed nurse, respiratory therapist, or rehabilitation therapist as appropriate. The duration begins . or allows for travel time to the destination where capability to continue to deliver oxygen exists. The facility's Oxygen Concentrator Procedure dated [DATE] documented 1. Verify order .11. Set liter flow per order. 12. Attach prescribed oxygen delivery device and apply oxygen delivery to the resident . R #4: R #4's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's (MONTH) (YEAR) Treatment Administration Record (TAR) documented O2 (Oxygen) via NC (nasal cannula) @ (at) 2LPM as needed for SOB. Start date: [DATE]. R #4's physician's orders [REDACTED].@ 3 LPM via NC continuously. R #4's Care Plan dated [DATE] documented (R #4) exhibits a risk for complications of infection related to increased risk of reoccurence of aspiration pneumonia .Approaches: .O2 as ordered. R #4's Significant Change MDS dated [DATE] documented R #4: -Rarely made self understood and rarely understood others. -Had short and long-term memory problems and had severely impaired cognitive skills for daily decision making. -Had an active [DIAGNOSES REDACTED]. -Received oxygen therapy while not a resident and while a resident at the facility. Observation of R #4 on [DATE] at 8:50 a.m. revealed R #4 was sleeping and was receiving O2 @ 2 LPM via NC. Observation of R #4 on [DATE] at 10:51 a.m. revealed R #4 was receiving O2 @ 2.5 LPM per NC. At 10:54 a.m., Licensed Vocational Nurse (LVN) I and Certified Nurse Aides H and J assisted to transfer R #4 from the bed to the Geriatric chair. During this time, CNA H removed R #4's nasal cannula, leaving R #4 without any oxygen administration. Both CNAs escorted R #4 to the shower room, without any oxygen therapy. At 11:33 a.m., R #4 was escorted back to her bedroom in the Geriatric chair and transferred to bed with the assistance of LVN I and CNAs H and J. Once R #4 was in bed, LVN I replaced R #4's nasal cannula in R #4's nares at 11:45 a.m The oxygen concentrator was set at 2.5 LPM. -R #4 was not provided with oxygen therapy from 10:51 a.m.- 11:45 a.m. Observation of R #4 on [DATE] at 11:30 a.m. revealed R #4 was lying in bed receiving O2 @ 2.5 LMP via NC. LVN K entered the room and said R #4 had continuous O2 @ 3LPM ordered when asked how much oxygen R #4 should be receiving. Upon the surveyor's request, LVN K inspected R #4's oxygen concentrator and stated It is set at 2.5 liters, it should be at 3 liters. LVN K adjusted R #4's oxygen concentrator to 3 LPM and then checked R #4's oxygen saturation which was 92%. LVN K stated LVN I was currently R #4's nurse. Interview with LVN I on [DATE] at 11:35 a.m. revealed she stated R #4 was ordered to receive continuous O2 @3LPM via NC. LVN I was informed of R #4 only receiving O2 @ 2.5 LPM on [DATE] and [DATE]. At this time LVN K approached LVN I and the surveyor that R #4's concentrator was set at 2.5 LPM but was adjusted to 3LPM. LVN I verified she had not verified that R #4's oxygen concentrator was set at 3 liters. LVN I explained R #4 used to receive O2 at 2.5 LPM but her order was recently changed to 3 LPM. LVN I reviewed R #4's Treatment Administration Record and said It still say's 2 liters as needed, that's not right. After LVN I reviewed R #4's physician's orders [REDACTED]. The new order was not transcribed to the record, I will do it immediately. LVN I was informed of the surveyor's observation of R #4 not receiving any oxygen on [DATE] while being prepared and escorted to the shower room; LVN I verified she witnessed R #4 without any oxygen in the shower room then said R #4 should have had the oxygen since her order was to receive oxygen continuously. LVN I stated R #4 should have been provided with a portable oxygen tank. LVN I said she took responsibility for not ensuring R #4 had oxygen on and then said each nurse caring for R #4 was responsible to ensure R #4 received continuous oxygen. LVN I stated the procedure was that any nurse that received a new order, transcribed that order to the Medication Administration Record. LVN I said each nurse caring for R #4 should have referred to the Treatment Administration Record to document the prescribed treatment administered but that was not done. R #14: Review of the Admission Record (closed record) dated [DATE] revealed R#14 was initially admitted on [DATE] and readmitted on [DATE]. R#14's [DIAGNOSES REDACTED]. R#14 was [AGE] years old. R #14 expired on [DATE], in the facility. Review of R#14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was clearly able to understand others and had good ability to express her ideas and wants. R#14 had no cognitive deficits and scored 15 out of 15 points on the Brief Interview for Mental Status (BIMS). R#14 had no mood or behavior problems. R#14 was able to walk independently using a walker in her room or corridor with supervision, could dress herself, toilet herself, but required physical help in part of the bathing activity with the help of one person. R#14 was not steady in her balance during transitions and walking but was able to stabilize herself without staff assistance. R#14 was continent of bowel and bladder. R#14 had frequent pain and was on scheduled pain medication. R#14 had shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat. R#14 received oxygen therapy. Review of R#14's Care Plan included the following: R#14 requires assistance/is dependent for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: SOB (shortness of breath) with exertion secondary to [MEDICAL CONDITION]. Interventions included R#14 was independent with bed mobility and with transfers. There were no other interventions listed. Initiated [DATE] and revised [DATE]. R#14 is at nutritional risk and may gain or lose weight due to fluid retention as evidenced by [MEDICAL CONDITION] to lower extremities. Interventions included evaluating for proper consistency of diet, honoring food preferences within meal plan, weighing weekly and alerting dietitian and physician to any significant loss or gain, monitoring for changes in nutritional status, and monitoring intake at all meals. Initiated [DATE]. No interventions were noted regarding elevating BLE when [MEDICAL CONDITION] was present. R#14 has [MEDICAL CONDITION]. Interventions included administering oxygen as ordered/indicated, evaluating breath sounds and respiratory function for rate, rhythm, depth, rhonchi, wheezes q (every) shift and with a change of condition, notify physician of changes from baseline; observe patient at rest and exertion, notify physician of increased weakness and fatigue, and observe for worsening SOB, notify physician if unrelieved or new SOB at rest. Initiated [DATE] with no updates. Review of R#14's Order Summary Report printed on [DATE] for the date range [DATE] to [DATE] revealed the following physician orders [REDACTED]. [DATE]: [MEDICATION NAME] 2 puffs inhale two times a day related to [MEDICAL CONDITION] [DATE]: Oxygen at 2L(liters)/min (minute) via nasal cannula continuously, every shift related to [MEDICAL CONDITION] [DATE]: [MEDICATION NAME] ER Extended Release 30 mg two times daily for pain [DATE]: Duo Neb .5 mg (milligram)/3 mg one vial with Nebulizer every six hours as needed [DATE]: [MEDICATION NAME] Liquid 100 mg/5ML Give 10 ml by mouth every 6 hours as needed for cough [DATE]: Check O2 (oxygen) daily and prn (as needed) every day shift for dyspnea. [DATE]: [MEDICATION NAME] Solution XXX,[DATE].5 (3) mg/3ML (milliliters) 1 vial inhale orally every 6 hours related to [MEDICAL CONDITION] [DATE]: Daliresp Tablet 500 mcg (micrograms) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION] [DATE]: [MEDICATION NAME] Tablet 20 mg once daily for [MEDICAL CONDITION] Review of Interdisciplinary Team Notes dated [DATE] revealed After speaking with nurse verified that resident is on continuous O2 at 2 L/M per NC (two liters of oxygen per nasal canula). Review of R#14's Treatment Administration Record (TAR) for February, (YEAR) revealed the following oxygen levels when they were checked during the day shift 8:00 a.m. to 4:00 p.m.: [DATE]: 93 [DATE]: 95 [DATE]: 95 [DATE]: 93 [DATE]: 93 [DATE]: 96 [DATE]: 94 Review of Progress Notes from R#14's facility record revealed the following: [DATE]: R#14 was found on floor in front of her recliner. Cause of fall was slippery socks. Socks changed out. [DATE]: R#14 with increased occurrence of shortness of breath/cough. Administered nebulizer treatment with little results observed. Oxygen inspected and working properly. Oxygen sats = 84% and toes cyanotic. Oxygen increased to 3.5L via nasal canula. Oxygen sats were 90% after oxygen adjustment. [DATE]: R#14 slipped while ambulating to the restroom in her room. No injury sustained. Root cause was R#14 was wearing inappropriate footwear. [DATE]: Family member of R#14 expressed concern that R#14 had swelling in bilateral extremities (BLE). Nurse noted 2+ [MEDICAL CONDITION]. Nurse notified physician and physician gave no new orders but will see R#14 on [DATE]. [DATE]: physician progress notes [REDACTED]. Referral to Pulmonologist was pending since [DATE]. Cancel that referral and refer R#14 to a different physician. BLE Venous Doppler (blood flow test) ordered, as well as chest xray, an echocardiogram, and labs. For [MEDICAL CONDITION], change [MEDICATION NAME] 60 mg QD (daily) to [MEDICATION NAME] 60 mg BID (twice daily) and monitor fluid status. Review of Telephone Physician order [REDACTED]. Review of chest xray report dated [DATE] revealed R#14 had mild [MEDICAL CONDITIONS]. Review of Progress Notes from R#14's facility record revealed the following: [DATE]: Results from Ultrasound and Venous Doppler were negative at this time. [DATE] 02:25: R#14 resting quietly in bed with head of bed raised for comfort. Oxygen via nasal canula in place at this time. 3+ [MEDICAL CONDITION] to BLE noted. No cough observed or reported. Seems to tolerate increased [MEDICATION NAME] well. Denies pain. [DATE] 15:09: Nurse Practitioner (NP) Progress Note. NP seeing R#14 due to episode of [MEDICAL CONDITION] with sats dropping to 85%. Staff report she was walking to the bathroom without her oxygen and became very short of breath. ,[DATE]+ [MEDICAL CONDITION] to BLE. Chest xray showed mild [MEDICAL CONDITION]. [MEDICATION NAME] increased to 80 mg BID X 3days, then resume 60 mg BID. Prognosis: Guarded, worse today. Today with episode of [MEDICAL CONDITION]. [DATE]: Facility staff meeting, reviewed R#14's condition. Nursing, Social Services, Dietary Manager, ADON, and Administrator present. R#14 has gained 11 pounds in 30 days. R#14 has 2+ [MEDICAL CONDITION] to BLE, is sedentary and compliant with elevating her lower extremities. Started on weekly weights X 4 weeks to monitor fluid balance. [DATE] 10:37: Referral to Pulmonologist. Expected to be one to two weeks before appointment can be made but it would be made as soon as possible. [DATE] 12:25: physician progress notes [REDACTED]. Yesterday with episode of [MEDICAL CONDITION]. Follow up in a few days around ,[DATE]. [DATE] 12:16: R#14 had an unplanned transfer. [DATE] 17:55: Change in Condition. Per CNA F, R#14 was standing awaiting shower and fell against door, hitting head, arm and hip on floor upon landing. R#14 oxygen saturation 82 on room air at time of incident and 95% on 31 NC (nasal canula) upon return to room. Observations included labored breathing, shallow breathing crackles/rales present, right upper, right lower, left upper, left lower pitting right LE [MEDICAL CONDITION], pitting left LE [MEDICAL CONDITION], lower body right side weakness. Review of hospital History and Physical revealed R#14 was admitted to the hospital on [DATE] at 18:21. Review of R#14's present illness revealed she had [MEDICAL CONDITION] from diastolic dysfunction [MEDICAL CONDITION], hypertensive [MEDICAL CONDITION], type 2 diabetes, chronic [MEDICAL CONDITION] pacemaker defibrillator, dementia, history of [MEDICAL CONDITION] (rapid heart rate), [MEDICAL CONDITION], left carotid endarterectomy (surgery on neck artery), depression, history of back surgery, hysterectomy, and rotator cuff injury. Review of hospital Assessment and Plan dated [DATE] revealed R#14 had Pneumonia, right femoral neck fracture, [MEDICAL CONDITIONS] with exacerbation, and Chronic [MEDICAL CONDITION]. In an interview on [DATE] at 11:45 a.m., CNA E said on [DATE] she assisted R#14 out of her room to go to the shower room. CNA E said R#14 complained of being a little dizzy when she opened the shower room door and R#14 fell to the side. CNA E said R#14 fell right inside the shower room by the door. CNA E said R#14 said she was dizzy and could not breathe. CNA E said R#14 used her regular walker with a portable oxygen tank on it but she was not using oxygen when she was walking. CNA E said she had showered R#14 before and R#14 usually only needed help with washing her back and drying off. CNA E said R#14 usually had her portable oxygen on the other side of the wall from the shower and she wore the nasal canula in the shower. CNA E said R#14 told her she did not need her oxygen and sometimes did not wear her oxygen. CNA E said she was not given instructions about whether R#14 needed to wear her oxygen all of the time but she knew R#14 could not be left alone. CNA E said they just walked two doors down from R#14's room to the shower room when R#14 fell . In an interview at 11:55 a.m. on [DATE], Family Member (FM) BB, who also resided in the facility, said he was receiving therapy when R#14 fell on [DATE]. FM BB went to check on R#14 and found her sitting in a chair in bad pain. FM BB said R#14 told him she got out of her wheelchair and walked into the bathroom and fell . R#14 had a big knot on the right side of her head and broke the knob off of her hip. FM BB said R#14 returned to the facility after her hip was repaired, and passed away as he was talking to her on [DATE]. In an interview on [DATE] at 1:00 p.m., FM CC, a family member of R#14, said R#14 always had her oxygen on when he visited her, and when R#14 left the facility, she was always using her portable oxygen In an interview at 10:10 a.m. on [DATE] with CNA E, when asked if she had asked R#14 to put her oxygen on before they walked down the hall toward the shower room on [DATE], CNA E said she did not ask R#14 to put on her oxygen because she did not want to pressure her to wear her oxygen. CNA E said sometimes R#14 wore her oxygen and sometimes she did not wear it. In an interview at 10:20 a.m. on [DATE], the Assistant Director of Nurses (ADON), when asked how often R#14 wore her oxygen, said R#14 went without her oxygen sometimes and probably wore her oxygen about 50% of the time. The ADON said R#14 would go around the building without it sometimes. Surveyor asked the ADON if there was any change in R#14's breathing and need for oxygen the week before she fell , and the ADON replied that she did not know of any change. In an interview with the Administrator on [DATE] at 10:10 a.m., the Administrator said she did not report the incident with R#14's fall on [DATE] because it was a witnessed fall. The Administrator said they talked with staff and determined it was not a reportable incident. Review of Event Summary Report of incident with R#14 dated [DATE] at 11:30 a.m. revealed R#14 sustained an abrasion, bruise, fracture and skin tear. Emergency Medical was called and R#14 was transferred to the hospital at 12:15 p.m. Circumstances of the event and immediate actions taken: Resident (R#14) amb (ambulated) 30 ft (feet) to shower room. became dizzy and fell . CNA reported immediately to LVN who assessed. O2 Sat at 85%. Resident c/o (complained of) pain to head and right arm, skin tear noted. Neuro check complete and WNL (within normal limits). Full ROM (range of motion) to all extremities. Resident assisted back to room and requests to sit in recliner. O2 applied, SAT return to 95% (in less than) 1 min. (minute). Skin Tear cleansed and covered. The fall was related to ambulation status, resident was weak and stated she felt dizzy once arriving to shower area. R#14 had a change of condition in the last seven days with 3+ [MEDICAL CONDITION] to bilateral feet, with [MEDICATION NAME] increased to 80 mg. Current medication that may be causative to the fall included antihypertensives, diuretics, and narcotics. R#14 was administered [MEDICATION NAME] ER Tablet Extended Release 30 mg within eight hours prior to the fall. Review of Event Summary Report of incident with R#14 dated [DATE] revealed root cause to be Resident oxygen saturation decreased and caused resident become dizzy. O2 at 2L ordered continuous, but resident refuses to wear O2 while in bathroom in room and while showering. CNA was unable to effectively catch resident in time to prevent fall. Corrective actions included further education on use of oxygen continuous, standby assistance and s/s (signs/symptoms) of possible complications related to oxygen dependent residents. Resident needs to use her portable oxygen during bathing process to prevent desaturation. Resident c/o pain to right hip over one hour after being in chair and was sent out to hospital with a right [MEDICAL CONDITION]. Review of Witness Statements dated [DATE], attached to the facility Risk Management System report, revealed the following: I, (CNA E) did observe on [DATE] at 10:20 a.m. I went to (R#14's) room and told her it's her shower day. Let's go get your shower. She said okay. I have my clothes and stuff together lets go. I was walking her to the shower room. We opened the door. Right when she was entering the bathroom, (R#14) stood very still then she lost balance and fell over on the floor. I tried to catch her but she fell too quickly. She ended up falling on her shoulder and hit her head. I, (CNA G), did observe on (blank) at (blank). Have witnessed (R#14) to refuse to use her oxygen to the restroom or the shower room. On occasion. I, (CNA H), did observe on (blank) at (blank). In the past I have known (R#14) not to wear her o2 to bathroom or shower room. R #17: R #17's (MONTH) (YEAR) physician's orders [REDACTED].Oxygen at 3 LPNC continuously- start date: [DATE]. R #17's (MONTH) (YEAR) TAR indicated the order for oxygen at 3 LPNC but did not indicate when her oxygen tubing should have been changed. Observation of R #17 on [DATE] at 9:48 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #17's oxygen tubing was dated [DATE]. On [DATE] at 9:50 a.m., the Administrator was informed an IJ situation was identified due to the above failures. Observation of R #16 on [DATE] at 9:51 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #16's oxygen concentrator filter had white dust covering the filter. R #16's oxygen tubing was dated [DATE]. R #19: R #19's Face Sheet dated [DATE] documented a [AGE] year-old female asmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #19's admission orders [REDACTED]. Observation of R #19 on [DATE] at 9:54 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #19's oxygen tubing was not dated. Interview with LVN U on [DATE] at 10:14 a.m. revealed she did not know how many liters of oxygen R #19 should be receiving. LVN U reviews R #19's (MONTH) (YEAR) Medication Administration Record [REDACTED]. I have to check her orders. LVN U consulted with LVN K then LVN K reviewed R #19's physician's orders [REDACTED]. On [DATE] at 11:08 a.m., LVN K informed the surveyor that she received orders for R #19 and provided a copy of the orders. R #19's physician's orders [REDACTED].@ 2LPNC PRN (as needed) for saturation level less than 90% for [DIAGNOSES REDACTED].#19's oxygen should have retrieved anorder from her physician for the oxygen. R #18: R #18's (MONTH) (YEAR) physician's orders [REDACTED]. Review of R #18's (MONTH) (YEAR) TAR indicated her oxygen concentrator filter was only cleaned on [DATE]. The TAR contained a signature on [DATE], indicating that the oxygen tubing was changed on that day. -However, observation on [DATE] revealed R #18's tubing was dated [DATE]. Observation of R #18 on [DATE] at 9:57 a.m. revealed she received oxygen at 4 liters per nasal cannula. R #18's oxygen concentrator filter was covered with white dust. R #18's oxygen tubing was dated [DATE]. Interview with LVN U on [DATE] at 10:09 a.m. revealed she stated she had recently started working in the facility approximately one week ago. LVN U said oxygen tubing should be changed weekly but did not know what the facility's policy and procedure was or who was responsible for cleaning them. LVN U stated she did not know anything about the maintenance of the filters. Interview with LVN I on [DATE] at 10:12 a.m. revealed she stated oxygen tubing should be changed and dated weekly, at the same time the concentrator filters were cleaned. LVN I said this was scheduled on Sundays and the night shift was responsible for ensuring it was done. LVN I said each resident's Treatment Administration Record should have address the cleaning of filters and changing of oxygen tubing. On [DATE] at 5:59 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR). The final Plan of Removal documented: This Plan of Removal is in response to the alleged identification of Immediate Jeopardy communicated by the survey team on (MONTH) 13, (YEAR) during a return visit prompted by the annual survey with exit date of (MONTH) 31, (YEAR) at (the facility). The alleged Immediate Jeopardy findings were identified in the following areas: -Quality of Care -Neglect The facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of Immediate Jeopardy and/or any subsequent Statement of Deficiencies. Corrective Action and Identification: Review of orders identified 22 of 72, residents as having orders for Oxygen. This facility has put in place immediate corrective action as evidenced by: 1. On (MONTH) 30, (YEAR), nursing administration provided education on abuse and neglect to staff members. On (MONTH) 13, (YEAR), nursing administration reeducated staff members on abuse and neglect. 2. On (MONTH) 13, (YEAR) residents on oxygen therapy assessed and compliance with orders verified by nursing administration. 3. On (MONTH) 30, (YEAR), a complete audit of residents using oxygen was conducted by nursing administration and care plans were reviewed and revised accordingly. 4. On (MONTH) 13, (YEAR), nursing administration provided education to nursing staff regarding use of oxygen and maintenance of filter and tubing. 5. On (MONTH) 13, (YEAR), the MAR indicated [REDACTED]. MAR indicated [REDACTED]

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for one resident (R #1) of four residents reviewed for pressure ulcers. R #1's Stage 2 coccyx pressure ulcer discovered on 03/27/17, acquired in the facility, steadily worsened to an unstageable pressure ulcer by 03/28/17. The facility did not provide R #1 with pressure relief (offloading) off her buttocks at least every two hours on two separate days. The facility did not ensure R #1 wore her Prevelon Boots (pressure relieving devices for the feet) as ordered. R #1 developed three separate Deep Tissue Injuries (DTI) on her left heel that the facility was not aware of, until the surveyor's injury. The facility's Assistant Director of Nurses (ADON) inaccurately identified R #1's DTI's as calluses and incorrectly measured each wound. The abovce failures resulted in an Immediate Jeopardy (IJ) situation on 04/14/17. While the IJ was removed on 04/18/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect four residents with pressure ulcers and 53 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #1's Face Sheet dated 03/30/17 documented a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED].(presence of right artificial hip joint) on 03/09/17, and Anxiety Disorder. R #1's Quarterly Minimum (MDS) data set [DATE] documented R #1: -Sometimes made self understood and sometimes understood others. -Had a Brief Interview of Mental Status score of 0 (severely impaired). -Required extensive assistance with one person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. -Was frequently incontinent of urine and always incontinent of bowel. -Was 62 inches tall and weighed 95 pounds. -Was at risk for pressure ulcer development but did not have any unhealed pressure ulcers. -Skin and Ulcer Treatments: Pressure reducing device for bed. R #1's Braden Scale for Predicting Pressure Ulcer Risk dated 01/18/17 revealed a score of 14. The assessments score guide documented MODERATE RISK: Total Score 13-14. R #1's Care Plan revised 02/09/17 documented Resident is at risk for skin breakdown as evidenced by incontinence of bowel and bladder . The care plan did not include a turning schedule specific for R #1. R #1's most current Care Plan was dated 10/20/16, revised 02/09/17 and documented: -(R #1) is at risk for decreased ability to perform ADL (activities of daily living) in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to Dementia. Requires extensive assist of two . -(R #1) has impaired/decline in cognitive function/impairment thought processes related to a condition other than [MEDICAL CONDITION]: Dementia . R #1's Admission assessment dated [DATE] revealed R #1 did not have any pressure ulcers. R #1's Skin assessment dated [DATE] revealed no evidence of R #1 having any pressure injury/ulcer to her coccyx/buttocks. R #1's Five Day Assessment Minimum (MDS) data set [DATE] documented R #1: -Sometimes made self understood and sometimes understood others. -Had a Brief Interview of Mental Status score of 1 (severely impaired). -Required extensive assistance with one person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. -Was frequently incontinent of urine and always incontinent of bowel. -Was 62 inches tall and weighed 101 pounds. -Was at risk for pressure ulcer development but did not have any unhealed pressure ulcers. -Skin and Ulcer Treatments: Pressure reducing device for bed and wheelchair. R #1's Care Plan revised 03/27/17 documented (R #1) has actual alteration in skin integrity as evidenced by Stage 2 Pressure Ulcer (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) to coccyx. Goal: Wound will remain free from signs and symptoms of infection X 90 days. Interventions: Apply skin barrier cream, Pressure redistribution surfaces to chair as per protocol, Weekly wound assessment to include measurement and description of wound . The care plan did not include a turning schedule specific for R #1. R #1's physician's orders [REDACTED]. Softens and loosens necrotic tissue while maintaining a moist wound healing environment) every shift. R #1's Skin-Pressure Ulcer Report dated 03/27/17 at 12:30 p.m. documented: Initial Stage: Stage 2 Date first observed: 03/27/17, acquired in-house Body Location: Coccyx, light drainage amount- serous Wound appearance: Intact/pink: No; Intact/Deep purple: No; Granulation (red): 0%; Eschar (grey/black/brown) (eschar: a slough or piece of dead tissue that is cast off from the surface of the skin): 0% Slough (moist yellow/grey) (slough-yellow [MEDICATION NAME] tissue associated with bacterial activity): 0%; [MEDICATION NAME] (Stage 2): 100%; Surrounding tissue: mascerated (softening and breaking down of skin resulting from prolonged exposure to moisture), purple/maroon; Wound edges: distinct, even with base; Measurement: 3.3 X 3.5 X 0.1 centimeters Interventions: turning program and chair cushion. R #1's Braden Scale for Predicting Pressure Ulcer Risk dated 03/28/17 at 6:21 p.m. revealed a score of 13. The assessments score guide documented MODERATE RISK: Total Score 13-14. Observation of R #1 on 03/28/17 at 8:52 a.m. revealed she sat in her wheelchair (on pressure relieving cushion) in front of the television of the common area of the 300 Hall. Observation of R #1 on 03/28/17 at 9:35 a.m. revealed R #1 sat in her wheelchair in the therapy room engaged in therapy with the speech therapist. Observation of R #1 on 03/28/17 at 10:38 a.m. revealed R #1 she sat in her wheelchair in front of the television of the common area of the 300 Hall. Observation of R #1 on 03/28/17 at 11:05 a.m. revealed R #1 sat in her wheelchair and was being escorted to the dining room. Observation of R #1 on 03/28/17 at 1:20 p.m. revealed R #1 sat in her wheelchair in front of the television of the common area of the 300 Hall. Interview with Licensed Vocational Nurse (LVN) L on 03/28/17 at 2:38 p.m. revealed LVN L stated she was the facility's Treatment Nurse. LVN L explained the facility had a turning program that included repositioning of a any resident needing assistance to turn every two hours. As LVN L was gathering equipment from her Treatment Cart for R #1, LVN L explained R #1 had a Stage 2 pressure ulcer that was acquired in the facility on 03/27/17. LVN L described R #1's wound as An open area, a broken blister to her coccyx with the peri-wound red and it measured 3.3 X 3.5 X 0.1. The surveyor accompanied LVN L into R #1's room. R #1's coccyx/sacrum wound presented as a wound to the coccyx/sacrum extending to both upper buttocks. the wound bed was covered with yellow and black tissue and the peri-wound was red, blanchable at 12 o'clock - 3 o'clock, non-blanchable on the rest of the surrounding area. LVN L said, The wound has significantly deteriorated. I see slough and eschar with some granulation around the wound. The peri-wound is slightly blanchable on top area. There is approximately 75% eschar and slough and there is an [MEDICATION NAME] island. The wound measures 9.5 X 8.5 X 0.4 centimeters. The wound is now Unstageable. I am going to call the doctor before I do the treatment for [REDACTED]. Interview with CNA M on 03/28/17 at 3:33 p.m. revealed she stated all residents who needed assistance in turning or changing were to be repositioned and/or changed at least every two hours. CNA M said that included R #1 until LVN L told her to reposition R #1 every hour due to her wound worsening. CNA M stated she did not ususally reposition R #1 while she was in her wheelchair. CNA M said she did not know if she needed to reposition her while in the wheelchair because That isn't included in her Kardex. It just says to reposition every two hours when in bed. The Kardex is the CNA Care Plan/instructions we follow to care for the residents. Each resident has their own Kardex. CNA M said she assisted R #1 out of bed at approximately 7:30 a.m. CNA M said R #1 was out of bed from approximately 7:30 a.m. to 2:15 p.m. CNA M said R #1 had been busy with therapy all morning and then she went to the dining room for lunch therefore, she could not change or get her out of the wheelchair. CNA M confirmed she provided R #1 with incontinent care twice her shift at 7:15 a.m. and at 2:15 p.m. R #1's Skin-Pressure Ulcer Report dated 03/28/17 at 5:06 p.m. documented: Initial Stage: Stage 2 Date first observed: 03/27/17, acquired in-house Body Location: Coccyx, moderate drainage amount- serous. Deepest Stage: Unstageable (slough and/or eschar prevents evaluation) (unstageable pressure ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) Wound appearance: Intact/pink: No; Intact/Deep purple: No; Granulation (red): 0%; Eschar (grey/black/brown): 75-99%; Slough (moist yellow/grey): 25-49%; [MEDICATION NAME] (Stage 2): 1-24%; Surrounding tissue: purple/maroon; Wound edges: distinct, diffuse, not clearly visible; Measurement: 8.5 X 9.5 X 0.4 centimeters Interventions: mattress- low air loss, turning program, and chair cushion. R #1's Physician order [REDACTED]. treatment for [REDACTED]. Low Air Loss Mattress and Prevalon Boots when in bed. R #1's Care Plan updated 03/28/17 documented 03/28/17: Stage 2 wound area has deteriorated to an unstageable wound with 75% eschar, 25% slough, and [MEDICATION NAME] islands present. Interventions: 03/28/17: Provide wound treatment as tolerated, Prevelon Boots when in bed, Pressure redistribution surfaces to bed, Pressure redistribution surfaces to chair as per protocol, Weekly wound assessment to include measurement and description of wound. Observation of R #1 on 03/29/17 at 8:50 a.m. revealed she sat in her wheelchair (on wheelchair cushion) in front of the television of the common area of the 300 Hall until 10:10 a.m. At 10:10 a.m. R #1 was escorted to the therapy room and was engaged in therapy still sitting in her wheelchair until 10:33 a.m. At 10:33 a.m., R #1 was assisted to bed on a low air loss mattress. Blue Prevalon boots were applied to R #1's feet. Observation of R #1 on 03/29/17 at 10:45 a.m. revealed R #1 sat in her wheelchair in front of the television of the common area of the 300 Hall. Observation of R #1 on 03/29/17 at 11:15 a.m. revealed R #1 sat in her wheelchair in the dining room. Observation of R #1 on 03/29/17 at 1:50 a.m. revealed R #1 sat in her wheelchair in front of the television of the common area of the 300 Hall. Further interview with CNA M on 03/29/17 at 4:52 p.m. revealed she was caring for R #1. CNA M said R #1 was repositioned every hour when in bed. CNA M said she did not reposition R #1 when R #1 sat in her wheelchair. CNA M stated she had not been instructed to reposition/offload R #1 when sat sat up in the wheelchair or couch. CNA M said she changed R #1's brief at approximately 9:00 a.m. and again at approximately 2:00 p.m., when she put R #1 in bed. CNA M said she was fixing to go back to check if R #1 needed changing. R #1's Skin-Pressure Ulcer Report dated 03/29/17 at 5:01 p.m. documented: Initial Stage: Stage 2 Date first observed: 03/27/17, acquired in-house Body Location: Coccyx, moderate drainage amount- serous. Deepest Stage: Unstageable (slough and/or eschar prevents evaluation) Wound appearance: Intact/pink: No; Intact/Deep purple: No; Granulation (red): 0%; Eschar (grey/black/brown): 75-99%; Slough (moist yellow/grey): 25-49%; [MEDICATION NAME] (Stage 2): 25-49%; Surrounding tissue: mascerated, purple/maroon; Wound edges: distinct, diffuse, not clearly visible; Measurement: 8.5 X 9.5 X 0.4 centimeters Interventions: mattress- low air loss, turning program, and chair cushion. Observation of R #1 on 03/30/17 at 8:48 a.m. revealed R #1 sat in her wheelchair in the therapy room with the male therapist assisting her with exercises. Observation of R #1 on 03/30/17 at 10:08 a.m. revealed R #1 sat in her wheelchair in front of the television of the common area of the 300 Hall. Observation of R #1 on 03/30/17 at 10:28 a.m. revealed R #1 was taken to therapy while still seated in her wheelchair. R #1 was escorted back to the 300 Hall common area at 10:51 a.m. and remained seated in her wheelchair in front of the television. At 11:00 a.m., R #1 was assisted with transfer from her wheelchair to the couch in the same area in front of the television. R #1 was relieved from pressure of her buttocks for 10 seconds before she was again seated on the couch. At 11:03 a.m. R #1 was transferred from the couch to her wheelchair and was escorted to the therapy room. Again, pressure was relieved from her buttocks for approximately 10 seconds. At 12:00 p.m. R #1 was observed to be sitting in her wheelchair in the dining room. Interview with CNA's E and O on 03/30/17 at 12:14 p.m. revealed they both assisted R #1 out of bed at approximately 7:15 a.m. on 03/30/17. Observation of R #1 on 03/30/17 at 1:45 p.m. revealed R #1 was transferred from her wheelchair to her bed. LVNs A and L were redirecting R #1 to stay in bed since R #1 was attempting to get out of bed. LVN A said We layed her down but she does't want to stay in bed. Observation of R #1 on 03/30/17 at 1:50 p.m. revealed LVN L was preparing to provide R #1 treatment to her pressure ulcer. LVN L removed R #1's dressing dated 03/29/17; R #1's coccyx/sacrum presented with her per-wound extending further out compared to 03/29/17. The peri-wound also had dark maroon/purple discoloration. Some of the black tissue was seen to attach to the dressing. Approximately 85% of the wound bed contained yellow and black tissue. LVN L said, There is a difference from yesterday to today, a slight improvement is that the Santyl is working to remove the slough and some [MEDICATION NAME] and granulation tissue is evident in a small part of the wound. The peri-wound is deteriorating, the redness extending outward. There is now Deep Tissue Injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss) noticeable in the per-wound that was not there yesterday. Just the wound bed measures 9.0 X 7.0 centimeters, now measuring all the peri-wound included is 15 X 8.9 X 0.4 centimeters. LVN L said R #1 should be repositioned every two hours but had instructed staff to reposition her every hour yesterday. LVN L said she did not physically follow-up to ensure R #1 was frequently repositioned. LVN L said she knew the staff left R #1 sitting up at times because she frequently attempted to get out of bed and since she was a high fall risk, staff were trying to prevent her from falling. The surveyor informed LVN L of R #1's observations sitting up in her wheelchair and the couch. LVN L said It sounds like she is up too long without relieving pressure. We have to coordinate with therapy and other staff to come up with a better plan so we can offload her bottom. LVN L confirmed 10 seconds of offloading during a transfer was not enough time to relieve pressure to her buttocks. LVN L said prolonged pressure on the wound could contribute to her pressure ulcer deteriorating. R #1's Skin-Pressure Ulcer Report dated 03/30/17 at 2:42 p.m. documented: Initial Stage: Stage 2 Date first observed: 03/27/17, acquired in-house Body Location: Coccyx, moderate drainage amount- serous. Deepest Stage: Unstageable (slough and/or eschar prevents evaluation) Wound appearance: Intact/pink: No; Intact/Deep purple: No; Granulation (red): 0%; Eschar (grey/black/brown): 75-99%; Slough (moist yellow/grey): 25-49%; [MEDICATION NAME] (Stage 2): 25-49%; Surrounding tissue: mascerated, purple/maroon; Wound edges: distinct, diffuse, not clearly visible; Measurement: 8.5 X 9.5 X 0.4 centimeters Interventions: mattress- low air loss, turning program, and chair cushion. physician progress notes [REDACTED]. The wound is reported to have been 3 X 3 centimeters stage 2 on 03/28/17. It has progressed rapidly since then. Presently she is on an air mattress. Exam reveals a 9.5 X 8.5 centimeter butterfly shaped wound to sacrum. Wound is mostly slough with some eschar, and is thus unstageable. She is receiving Santyl on the slough and covered with a foam dressing Based on my exam noted above and her overall clinical picture, there is a Kennedy ulcer (Kennedy terminal ulcers are irregularly shaped and often resemble a pear, butterfly or horseshoe. They usually start as a blister or an abrasion, but quickly get deeper and turn different colors. It can start as reddish color, then turn yellow or black. Kennedy ulcers also tend to start out larger than a regular bedsore, occurs when someone is nearing the end of life), and she has a poor prognosis. Continue with the Santyl, offloading pressure, and optimize nutrition. Monitor this closely. *Record review of all of R #1's Progress Notes and physician's orders [REDACTED].#1 being in the dying process. The only [DIAGNOSES REDACTED]. There were no orders or referrals for hospice services. R #1 was ordered to receive skilled therapy services from Speech therapy, Occupational Therapy, and Physical Therapy on 03/20/17. Interview with the Assistant Director of Nurses (ADON) on 03/31/17 at 9:31 a.m. revealed she was aware of R #1's deteriorating pressure ulcer. The ADON stated the facility procedure was for every resident to be checked, changed, and repositioned, if needed, at least every two hours. The ADON said each resident had their own care plan and Kardex for individualized care. The ADON said if there was a change in condition of a resident or a change in intervention, then the care plan would be reviewed and revised if needed. The ADON said if the resident was up in the wheelchair a long period of time and could not independently reposition, then the care plan would specify repositioning while in the wheelchair. The ADON said she did not see an intervention in R #1's care plan to be repositioned while she sat in her wheelchair. The ADON stated R #1 received therapy services daily and would probably get up from her wheelchair during that time. The ADON said she would follow-up with R #1's care plan and review the interventions. Further interview with LVN L on 03/31/17 at 10:00 a.m. revealed she and the surveyor reviewed R #1's Skin-Pressure Ulcer report dated 03/30/17. The surveyor informed LVN L of the discrepancy of measurements from R #1's Skin-Pressure Ulcer Report compared to the measurements she called out to the surveyor during the treatment on 03/30/17. LVN L said Oh, these measurements were from 03/29/17, I'm sorry, I messed up, yours are correct, I will have to do an addendum. LVN L asked if the surveyor could provide her with the measurements she called out during the observation of R #1's treatment on 03/30/17. LVN L stated she used the National Pressure Ulcer Advisory Panel recommendations as a reference. LVN L said the facility procedure for identification and treatment of [REDACTED]. LVN L said every resident received a complete skin check on admission and then weekly. LVN L said if the resident had a wound, that wound was assessed and staged by her. LVN L said if a pressure ulcer was present, the resident's care plan was updated and the physician would be kept informed. LVN L explained that the turning program meant that a resident was to be turned every two hours. LVN L said R #1 was not diagnosed to be in the dying process, that she knew of. Interview with LVN A on 03/31/17 at 10:34 a.m. revealed she frequently cared for R #1 and was currently R #1's nurse. LVN A said R #1 was not in the stages of the dying process. LVN A reviewed R #1's clinical record and said R #1 was not on hospice and there was no documentation to suggest R #1 was in the dying process. Interview with Physician T on 03/31/17 at 10:37 a.m. revealed he confirmed he assessed R #1 on 03/30/17. Physician T said he diagnosed R #1 with a Kennedy Ulcer because of the rapid deterioration and the appearance of the wound. Physician T said the staff informed him that all preventative care, including offloading, was being provided and still her wound deteriorated. The surveyor informed Physician T of her observations of R #1's positioning for the past three days. Physician T said I was not told that, I was told they were offloading her. The surveyor informed Physician T of the staff transferring R #1 from her wheelchair to a couch was included in their offloading techniques. Physician T said 10 seconds or even one minute is not enough time to relieve pressure to an area, especially an impaired area. Physician T stated prolonged pressure could contribute to a pressure ulcer worsening but could not say definitively at this time that is what happened to R #1's wound. Physician T said R #1 was not in the active dying process and confirmed R #1 was being provided with skilled Physical, Occupational, and Speech Therapy. Interview with the Director of Rehabilitation (DOR) on 03/31/17 at 11:28 a.m. revealed R #1 received speech therapy five days a week for approximately 40-50 minutes. The DOR said R #1 remained seated in her wheelchair as she received her therapy. The DOR confirmed R #1 was not offloaded off her buttocks at any time during her therapy session. Interview with the Occupational Therapy Assistant (OTA) on 03/31/17 at 11:31 a.m. revealed R #1 received occupational therapy five days a week. The OTA stated R #1's therapy included grooming and hygiene, upper body dressing, dynamic sitting during activity of daily living care, and transfers. The OTA said the longest she had gotten R #1 to stand was three minutes, on a good day, which was rare. The OTA said the majority, if not all, of the therapy was done with R #1 in a sitting position. Interview with the Physical Therapy Assistant (PTA) on 03/31/17 at 11:33 a.m. revealed R #1 received physical therapy five times a week. The PTA said the longest he had gotten R #1 to stand was 20 minutes but those 20 minutes included several sitting breaks. The PTA said R #1 did not stand daily and it depended on her cognition each day. The PTA said the majority of R #1's therapy was done sitting in her wheelchair. According to the National Pressure Ulcer Advisory Panel website (http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/) searched on 04/05/17 revealed: Pressure Injury Prevention Points: Risk Assessment: 1 Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2 Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within 8 hours after admission). 3 Refine the assessment by including these additional risk factors: A. Fragile skin B. Existing pressure injury of any stage, including those ulcers that have healed or are closed C. Impairments in blood flow to the extremities from vascular disease, diabetes or tobacco use D. Pain in areas of the body exposed to pressure . 5 Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Skin Care: .Avoid positioning an individual on an area of [DIAGNOSES REDACTED] or pressure injury Repositioning and Mobilization: 1 Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 2 Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. 3 Consider lengthening t/e turning schedule during the night to allow for uninterrupted sleep/ 4 Turn the individual into a 30-degree side lying position, and use your hand to determine if the sacrum is off the bed 5 Avoid positioning the individual on body areas with pressure injury. 6 Ensure that the heels are free from the bed. 7 Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface. 8 Continue to reposition an individual when placed on any support surface. 9 Use a breathable incontinence pad when using microclimate management surfaces. 10 Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs. 11 Reposition weak or immobile individuals in chairs hourly Observation of R #1 on 04/13/17 at 10:10 a.m. revealed R #1 was asleep in bed on an inflated air mattress. R #1 had white compression stockings on each leg; R #1's heel rested on her bed. R #1 did not have on any pressure relieving devices on her feet nor any pillows under her feet. Prevalon boots were not visible anywhere in her room. Interview with LVN A on 04/13/17 at 10:42 a.m. revealed R #1's sacral wound developed E.Coli (Escherichia Coli: a bacteria that normally lives in the intestines) in the wound. LVN A said R #1 likely got E.Coli in her wound from her urine or feces contaminating the wound. LVN A said R #1 had lost approximately five pounds in one week from 04/01/17-04/07/17. LVN A stated it was a possibility that R #1 was not given her bolus feedings as ordered through her [DEVICE] because out of 26 cans of enteral feeding R #1 had in her room, only three cans were missing within that one week. LVN A said she informed the ADON of R #1's weight loss. Record review of R #1's April 2017 Medication Review Report documented Vital 1.5 bolus feeding/ one can after meals PRN if eats less than 50% of meal .Start date 01/13/17. Record review of R #1's Weight Summary Report dated 04/13/17 documented 03/27/17 = 105.0 pounds; 04/06/17 = 101.5 pounds; 04/11/17 = 98.0 pounds .Height 62.0 inches Ideal Body Weight: 110.0 pounds. Record review of R #1's April 2017 Medication Administration Record [REDACTED].Start date: 03/27/17. The MAR indicated [REDACTED]. There were no entries documented of percentage of food eaten or bolus feeding given or not, for the entire day of 04/03/17, for lunch or supper on 04/04/17, for the entire day on 04/05/17 or for supper on 04/06/17. Observation of R #1 on 04/13/17 at 12:31 p.m. revealed R #1 was asleep in her bed, on an air mattress. R #1's feet rested on the mattress. R #1 did not have any pressure relieving devices on her feet nor pillows under her feet. Prevalon boots were not visible anywhere in her room. CNA F entered the room and attempted to awaken R #1 to eat. R #1 refused. CNA F said he was not sure if R #1 was suppose to wear Prevelon boots. CNA F said he recalled R #1 using Prevalon boots sometime last week but did not know what happened to them. CNA F looked throughout R #1's room and found the Prevalon boots in her closet. Upon the surveyor's request, CNA F removed R #1's white compression stockings and presented R #1's feet; R #1 had dark brown and light marroon discoloration to three seperate areas of her left heel. Interview with LVN A on 04/13/17 at 12:37 p.m. revealed she stated R #1 should be wearing her Prevalon boots whenever she was in bed. LVN A said R #1 could not put the Prevalon boots on herself. LVN A said the nursing staff were responsible for ensuring R #1 had the Prevalon boots on when she was in bed. LVN A said she was not aware of R #1 having any pressure areas on her feet. LVN A said she did not know if R #1 had her Prevalon boots on. Interview with Physician T on 04/13/17 at 1:00 p.m. revealed this surveyor explained to Physicain T her observations of R #1 not being offloaded off her sacrum, not being provided with her Prevelon boots to offload her heels, the CNA not aware of R #1's order when to wear her Prevalon boots, of the seven pound weight loss R #1 had within 15 days due to possibly not receiving her bolus feedings as ordered, and R #1 developing new wounds on her left heel. Physician T said he was not aware of R #1 having any new pressure areas. Physician T said Not maintaining adequate nutrition and not providing offloading to pressure areas can contribute to lack of healing of pressure ulcers and development of new pressure ulcers. Physician T stated he was aware R #1 did not eat much of her meals therefore that was why he ordered the bolus feedings. Physician T did not provide an answer when asked if R #1's pressure ulcers could have been avoided but said This did not help. Physician T said R #1 was not in the terminal state. Physician T said he was going to order R #1 scheduled bolus enteral feedings. Interview with the ADON on 04/13/17 at 1:20 p.m. revealed she stated that the Treatment Nurse (LVN L) had to leave. The ADON said she was available to assess R #1. The ADON stated she was not aware of R #1 having any pressure areas to her feet.The surveyor accompanied the ADON into R #1's bedroom. There were two blue Prevalon boots on R #1's wheelchair. R #1 was lying in bed on her right side with her eyes closed. The ADON said R #1 probably took the boots off when asked if R #1 should be wearing the boots. Upon the surveyor's request, the ADON assessed R

Based on observation, interview, and record review the facility failed to ensure that respiratory care services provided by the facility, as outlined in the comprehensive care plan (Physician Orders), met professional standards of practice, for two Residents (R #4 and R #14) of three residents reviewed with orders for continuous oxygen and three residents (R #4, R #17, and R #19) of seven residents reviewed for oxygen concentrator filter and oxygen tubing maintenance. 1.) The facility staff did not follow R #4's Physician order [REDACTED]. R#4's oxygen concentrator setting was observed at 2 and 2.5 LPM on three occasions on [DATE]-[DATE], and during transfer to the shower room when R #4 was provided with no oxygen. 2.) The facility did not ensure that R #14 wore her oxygen during ambulation, she became short of breath and she fell , fracturing her right hip and hitting her head. The facility did not follow R #14's Physician order [REDACTED]. R #14 expired on [DATE], in the facility. 3.) The facility did not ensure R #4's most current oxygen therapy order of continuous Oxygen at 3 liters per nasal cannula was accurate on her Treatment Administartion Record and the oxygen therapy was consistently monitored. 4.) The facility did not ensure the oxygen tubings were changed weekly, as per the facility's policy and oxygen concentrator filters remained clean for R #4, R #17, and R #19. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This failure could place 22 residents who required oxygen therapy at risk for shortness of breath and respiratory distress. Findings included: R #4: R #4's Face Sheet dated [DATE] documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's [DATE] Treatment Administration Record (TAR) documented O2 (Oxygen) via NC (nasal cannula) @ (at) 2LPM as needed for SOB. Start date: [DATE]. R #4's physician's orders [REDACTED].@ 3 LPM via NC continuously. R #4's Care Plan dated [DATE] documented (R #4) exhibits a risk for complications of infection related to increased risk of reoccurence of aspiration pneumonia .Approaches: .O2 as ordered. R #4's Significant Change MDS dated [DATE] documented R #4: -Rarely made self understood and rarely understood others. -Had short and long-term memory problems and had severely impaired cognitive skills for daily decision making. -Had an active [DIAGNOSES REDACTED]. -Received oxygen therapy while not a resident and while a resident at the facility. Observation of R #4 on [DATE] at 8:50 a.m. revealed R #4 was sleeping and was receiving O2 @ 2 LPM via NC. Observation of R #4 on [DATE] at 10:51 a.m. revealed R #4 was receiving O2 @ 2.5 LPM per NC. At 10:54 a.m., Licensed Vocational Nurse (LVN) I and Certified Nurse Aides H and J assisted to transfer R #4 from the bed to the Geriatric chair. During this time, CNA H removed R #4's nasal cannula, leaving R #4 without any oxygen administration. Both CNAs escorted R #4 to the shower room, without any oxygen therapy. At 11:33 a.m., R #4 was escorted back to her bedroom in the Geriatric chair and transferred to bed with the assistance of LVN I and CNAs H and J. Once R #4 was in bed, LVN I replaced R #4's nasal cannula in R #4's nares at 11:45 a.m The oxygen concentrator was set at 2.5 LPM. -R #4 was not provided with oxygen therapy from 10:51 a.m.- 11:45 a.m. Observation of R #4 on [DATE] at 11:30 a.m. revealed R #4 was lying in bed receiving O2 @ 2.5 LMP via NC. LVN K entered the room and said R #4 had continuous O2 @ 3LPM ordered when asked how much oxygen R #4 should be receiving. Upon the surveyor's request, LVN K inspected R #4's oxygen concentrator and stated It is set at 2.5 liters, it should be at 3 liters. LVN K adjusted R #4's oxygen concentrator to 3 LPM and then checked R #4's oxygen saturation which was 92%. LVN K stated LVN I was currently R #4's nurse. Interview with LVN I on [DATE] at 11:35 a.m. revealed she stated R #4 was ordered to receive continuous O2 @3LPM via NC. LVN I was informed of R #4 only receiving O2 @ 2.5 LPM on [DATE] and [DATE]. At this time LVN K approached LVN I and the surveyor that R #4's concentrator was set at 2.5 LPM but was adjusted to 3LPM. LVN I verified she had not verified that R #4's oxygen concentrator was set at 3 liters. LVN I explained R #4 used to receive O2 at 2.5 LPM but her order was recently changed to 3 LPM. LVN I reviewed R #4's Treatment Administration Record and said It still say's 2 liters as needed, that's not right. After LVN I reviewed R #4's physician's orders [REDACTED]. The new order was not transcribed to the record, I will do it immediately. LVN I was informed of the surveyor's observation of R #4 not receiving any oxygen on [DATE] while being prepared and escorted to the shower room; LVN I verified she witnessed R #4 without any oxygen in the shower room then said R #4 should have had the oxygen since her order was to receive oxygen continuously. LVN I stated R #4 should have been provided with a portable oxygen tank. LVN I said she took responsibility for not ensuring R #4 had oxygen on and then said each nurse caring for R #4 was responsible to ensure R #4 received continuous oxygen. LVN I stated the procedure was that any nurse that received a new order, transcribed that order to the Medication Administration Record. LVN I said each nurse caring for R #4 should have referred to the Treatment Administration Record to document the prescribed treatment administered but that was not done. R #14: Review of the Admission Record (closed record) dated [DATE] revealed R#14 was initially admitted on [DATE] and readmitted on [DATE]. R#14's [DIAGNOSES REDACTED]. R#14 was [AGE] years old. R #14 expired on [DATE], in the facility. Review of R#14's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was clearly able to understand others and had good ability to express her ideas and wants. R#14 had no cognitive deficits and scored 15 out of 15 points on the Brief Interview for Mental Status (BIMS). R#14 had no mood or behavior problems. R#14 was able to walk independently using a walker in her room or corridor with supervision, could dress herself, toilet herself, but required physical help in part of the bathing activity with the help of one person. R#14 was not steady in her balance during transitions and walking but was able to stabilize herself without staff assistance. R#14 was continent of bowel and bladder. R#14 had frequent pain and was on scheduled pain medication. R#14 had shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat. R#14 received oxygen therapy. Review of R#14's Care Plan included the following: R#14 requires assistance/is dependent for ADL (Activities of Daily Living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: SOB (shortness of breath) with exertion secondary to [MEDICAL CONDITION]. Interventions included R#14 was independent with bed mobility and with transfers. There were no other interventions listed. Initiated [DATE] and revised [DATE]. R#14 is at nutritional risk and may gain or lose weight due to fluid retention as evidenced by [MEDICAL CONDITION] to lower extremities. Interventions included evaluating for proper consistency of diet, honoring food preferences within meal plan, weighing weekly and alerting dietitian and physician to any significant loss or gain, monitoring for changes in nutritional status, and monitoring intake at all meals. Initiated [DATE]. No interventions were noted regarding elevating BLE when [MEDICAL CONDITION] was present. R#14 has [MEDICAL CONDITION]. Interventions included administering oxygen as ordered/indicated, evaluating breath sounds and respiratory function for rate, rhythm, depth, rhonchi, wheezes q (every) shift and with a change of condition, notify physician of changes from baseline; observe patient at rest and exertion, notify physician of increased weakness and fatigue, and observe for worsening SOB, notify physician if unrelieved or new SOB at rest. Initiated [DATE] with no updates. Review of R#14's Order Summary Report printed on [DATE] for the date range [DATE] to [DATE] revealed the following physician orders [REDACTED]. [DATE]: [MEDICATION NAME] 2 puffs inhale two times a day related to [MEDICAL CONDITION] [DATE]: Oxygen at 2L(liters)/min (minute) via nasal cannula continuously, every shift related to [MEDICAL CONDITION] [DATE]: [MEDICATION NAME] ER Extended Release 30 mg two times daily for pain [DATE]: Duo Neb .5 mg (milligram)/3 mg one vial with Nebulizer every six hours as needed [DATE]: [MEDICATION NAME] Liquid 100 mg/5ML Give 10 ml by mouth every 6 hours as needed for cough [DATE]: Check O2 (oxygen) daily and prn (as needed) every day shift for dyspnea. [DATE]: [MEDICATION NAME] Solution XXX,[DATE].5 (3) mg/3ML (milliliters) 1 vial inhale orally every 6 hours related to [MEDICAL CONDITION] [DATE]: Daliresp Tablet 500 mcg (micrograms) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION] [DATE]: [MEDICATION NAME] Tablet 20 mg once daily for [MEDICAL CONDITION] Review of Interdisciplinary Team Notes dated [DATE] revealed After speaking with nurse verified that resident is on continuous O2 at 2 L/M per NC (two liters of oxygen per nasal canula). Review of R#14's Treatment Administration Record (TAR) for February, 2017 revealed the following oxygen levels when they were checked during the day shift 8:00 a.m. to 4:00 p.m.: [DATE]: 93 [DATE]: 95 [DATE]: 95 [DATE]: 93 [DATE]: 93 [DATE]: 96 [DATE]: 94 Review of Progress Notes from R#14's facility record revealed the following: [DATE]: R#14 was found on floor in front of her recliner. Cause of fall was slippery socks. Socks changed out. [DATE]: R#14 with increased occurrence of shortness of breath/cough. Administered nebulizer treatment with little results observed. Oxygen inspected and working properly. Oxygen sats = 84% and toes cyanotic. Oxygen increased to 3.5L via nasal canula. Oxygen sats were 90% after oxygen adjustment. [DATE]: R#14 slipped while ambulating to the restroom in her room. No injury sustained. Root cause was R#14 was wearing inappropriate footwear. [DATE]: Family member of R#14 expressed concern that R#14 had swelling in bilateral extremities (BLE). Nurse noted 2+ [MEDICAL CONDITION]. Nurse notified physician and physician gave no new orders but will see R#14 on [DATE]. [DATE]: physician progress notes [REDACTED]. Referral to Pulmonologist was pending since [DATE]. Cancel that referral and refer R#14 to a different physician. BLE Venous Doppler (blood flow test) ordered, as well as chest xray, an echocardiogram, and labs. For [MEDICAL CONDITION], change [MEDICATION NAME] 60 mg QD (daily) to [MEDICATION NAME] 60 mg BID (twice daily) and monitor fluid status. Review of Telephone Physician order [REDACTED]. Review of chest xray report dated [DATE] revealed R#14 had mild [MEDICAL CONDITIONS]. Review of Progress Notes from R#14's facility record revealed the following: [DATE]: Results from Ultrasound and Venous Doppler were negative at this time. [DATE] 02:25: R#14 resting quietly in bed with head of bed raised for comfort. Oxygen via nasal canula in place at this time. 3+ [MEDICAL CONDITION] to BLE noted. No cough observed or reported. Seems to tolerate increased [MEDICATION NAME] well. Denies pain. [DATE] 15:09: Nurse Practitioner (NP) Progress Note. NP seeing R#14 due to episode of [MEDICAL CONDITION] with sats dropping to 85%. Staff report she was walking to the bathroom without her oxygen and became very short of breath. ,[DATE]+ [MEDICAL CONDITION] to BLE. Chest xray showed mild [MEDICAL CONDITION]. [MEDICATION NAME] increased to 80 mg BID X 3days, then resume 60 mg BID. Prognosis: Guarded, worse today. Today with episode of [MEDICAL CONDITION]. [DATE]: Facility staff meeting, reviewed R#14's condition. Nursing, Social Services, Dietary Manager, ADON, and Administrator present. R#14 has gained 11 pounds in 30 days. R#14 has 2+ [MEDICAL CONDITION] to BLE, is sedentary and compliant with elevating her lower extremities. Started on weekly weights X 4 weeks to monitor fluid balance. [DATE] 10:37: Referral to Pulmonologist. Expected to be one to two weeks before appointment can be made but it would be made as soon as possible. [DATE] 12:25: physician progress notes [REDACTED]. Yesterday with episode of [MEDICAL CONDITION]. Follow up in a few days around ,[DATE]. [DATE] 12:16: R#14 had an unplanned transfer. [DATE] 17:55: Change in Condition. Per CNA F, R#14 was standing awaiting shower and fell against door, hitting head, arm and hip on floor upon landing. R#14 oxygen saturation 82 on room air at time of incident and 95% on 31 NC (nasal canula) upon return to room. Observations included labored breathing, shallow breathing crackles/rales present, right upper, right lower, left upper, left lower pitting right LE [MEDICAL CONDITION], pitting left LE [MEDICAL CONDITION], lower body right side weakness. Review of hospital History and Physical revealed R#14 was admitted to the hospital on [DATE] at 18:21. Review of R#14's present illness revealed she had [MEDICAL CONDITION] from diastolic dysfunction [MEDICAL CONDITION], hypertensive [MEDICAL CONDITION], type 2 diabetes, chronic [MEDICAL CONDITION] pacemaker defibrillator, dementia, history of [MEDICAL CONDITION] (rapid heart rate), [MEDICAL CONDITION], left carotid endarterectomy (surgery on neck artery), depression, history of back surgery, hysterectomy, and rotator cuff injury. Review of hospital Assessment and Plan dated [DATE] revealed R#14 had Pneumonia, right femoral neck fracture, [MEDICAL CONDITIONS] with exacerbation, and Chronic [MEDICAL CONDITION]. In an interview on [DATE] at 11:45 a.m., CNA E said on [DATE] she assisted R#14 out of her room to go to the shower room. CNA E said R#14 complained of being a little dizzy when she opened the shower room door and R#14 fell to the side. CNA E said R#14 fell right inside the shower room by the door. CNA E said R#14 said she was dizzy and could not breathe. CNA E said R#14 used her regular walker with a portable oxygen tank on it but she was not using oxygen when she was walking. CNA E said she had showered R#14 before and R#14 usually only needed help with washing her back and drying off. CNA E said R#14 usually had her portable oxygen on the other side of the wall from the shower and she wore the nasal canula in the shower. CNA E said R#14 told her she did not need her oxygen and sometimes did not wear her oxygen. CNA E said she was not given instructions about whether R#14 needed to wear her oxygen all of the time but she knew R#14 could not be left alone. CNA E said they just walked two doors down from R#14's room to the shower room when R#14 fell . In an interview at 11:55 a.m. on [DATE], Family Member (FM) BB, who also resided in the facility, said he was receiving therapy when R#14 fell on [DATE]. FM BB went to check on R#14 and found her sitting in a chair in bad pain. FM BB said R#14 told him she got out of her wheelchair and walked into the bathroom and fell . R#14 had a big knot on the right side of her head and broke the knob off of her hip. FM BB said R#14 returned to the facility after her hip was repaired, and passed away as he was talking to her on [DATE]. In an interview on [DATE] at 1:00 p.m., FM CC, a family member of R#14, said R#14 always had her oxygen on when he visited her, and when R#14 left the facility, she was always using her portable oxygen In an interview at 10:10 a.m. on [DATE] with CNA E, when asked if she had asked R#14 to put her oxygen on before they walked down the hall toward the shower room on [DATE], CNA E said she did not ask R#14 to put on her oxygen because she did not want to pressure her to wear her oxygen. CNA E said sometimes R#14 wore her oxygen and sometimes she did not wear it. In an interview at 10:20 a.m. on [DATE], the Assistant Director of Nurses (ADON), when asked how often R#14 wore her oxygen, said R#14 went without her oxygen sometimes and probably wore her oxygen about 50% of the time. The ADON said R#14 would go around the building without it sometimes. Surveyor asked the ADON if there was any change in R#14's breathing and need for oxygen the week before she fell , and the ADON replied that she did not know of any change. In an interview with the Administrator on [DATE] at 10:10 a.m., the Administrator said she did not report the incident with R#14's fall on [DATE] because it was a witnessed fall. The Administrator said they talked with staff and determined it was not a reportable incident. Review of Event Summary Report of incident with R#14 dated [DATE] at 11:30 a.m. revealed R#14 sustained an abrasion, bruise, fracture and skin tear. Emergency Medical was called and R#14 was transferred to the hospital at 12:15 p.m. Circumstances of the event and immediate actions taken: Resident (R#14) amb (ambulated) 30 ft (feet) to shower room. became dizzy and fell . CNA reported immediately to LVN who assessed. O2 Sat at 85%. Resident c/o (complained of) pain to head and right arm, skin tear noted. Neuro check complete and WNL (within normal limits). Full ROM (range of motion) to all extremities. Resident assisted back to room and requests to sit in recliner. O2 applied, SAT return to 95% (in less than) 1 min. (minute). Skin Tear cleansed and covered. The fall was related to ambulation status, resident was weak and stated she felt dizzy once arriving to shower area. R#14 had a change of condition in the last seven days with 3+ [MEDICAL CONDITION] to bilateral feet, with [MEDICATION NAME] increased to 80 mg. Current medication that may be causative to the fall included antihypertensives, diuretics, and narcotics. R#14 was administered [MEDICATION NAME] ER Tablet Extended Release 30 mg within eight hours prior to the fall. Review of Event Summary Report of incident with R#14 dated [DATE] revealed root cause to be Resident oxygen saturation decreased and caused resident become dizzy. O2 at 2L ordered continuous, but resident refuses to wear O2 while in bathroom in room and while showering. CNA was unable to effectively catch resident in time to prevent fall. Corrective actions included further education on use of oxygen continuous, standby assistance and s/s (signs/symptoms) of possible complications related to oxygen dependent residents. Resident needs to use her portable oxygen during bathing process to prevent desaturation. Resident c/o pain to right hip over one hour after being in chair and was sent out to hospital with a right [MEDICAL CONDITION]. Review of Witness Statements dated [DATE], attached to the facility Risk Management System report, revealed the following: I, (CNA E) did observe on [DATE] at 10:20 a.m. I went to (R#14's) room and told her it's her shower day. Let's go get your shower. She said okay. I have my clothes and stuff together lets go. I was walking her to the shower room. We opened the door. Right when she was entering the bathroom, (R#14) stood very still then she lost balance and fell over on the floor. I tried to catch her but she fell too quickly. She ended up falling on her shoulder and hit her head. I, (CNA G), did observe on (blank) at (blank). Have witnessed (R#14) to refuse to use her oxygen to the restroom or the shower room. On occasion. I, (CNA H), did observe on (blank) at (blank). In the past I have known (R#14) not to wear her o2 to bathroom or shower room. The facility's Oxygen: Transport of Patient on Continuous Oxygen Policy dated [DATE] documented The center will provide full (oxygen level at time of departure), portable oxygen equipment (concentrator, compressed oxygen, liquid portable oxygen) for patients requiring continuous oxygen .Portable oxygen will be set up by a licensed nurse, respiratory therapist, or rehabilitation therapist as appropriate. The duration begins . or allows for travel time to the destination where capability to continue to deliver oxygen exists. The facility's Oxygen Concentrator Procedure dated [DATE] documented 1. Verify order .11. Set liter flow per order. 12. Attach prescribed oxygen delivery device and apply oxygen delivery to the resident . R #17: R #17's [DATE] physician's orders [REDACTED].Oxygen at 3 LPNC continuously- start date: [DATE]. R #17's [DATE] TAR indicated the order for oxygen at 3 LPNC but did not indicate when her oxygen tubing should have been changed. Observation of R #17 on [DATE] at 9:48 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #17's oxygen tubing was dated [DATE]. On [DATE] at 9:50 a.m., the Administrator was informed an IJ situation was identified due to the above failures. Observation of R #16 on [DATE] at 9:51 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #16's oxygen concentrator filter had white dust covering the filter. R #16's oxygen tubing was dated [DATE]. R #19: R #19's Face Sheet dated [DATE] documented a [AGE] year-old female asmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #19's admission orders [REDACTED]. Observation of R #19 on [DATE] at 9:54 a.m. revealed she received oxygen at 3 liters per nasal cannula. R #19's oxygen tubing was not dated. Interview with LVN U on [DATE] at 10:14 a.m. revealed she did not know how many liters of oxygen R #19 should be receiving. LVN U reviews R #19's [DATE] Medication Administration Record [REDACTED]. I have to check her orders. LVN U consulted with LVN K then LVN K reviewed R #19's physician's orders [REDACTED]. On [DATE] at 11:08 a.m., LVN K informed the surveyor that she received orders for R #19 and provided a copy of the orders. R #19's physician's orders [REDACTED].@ 2LPNC PRN (as needed) for saturation level less than 90% for [DIAGNOSES REDACTED].#19's oxygen should have retrieved anorder from her physician for the oxygen. R #18: R #18's [DATE] physician's orders [REDACTED]. Review of R #18's [DATE] TAR indicated her oxygen concentrator filter was only cleaned on [DATE]. The TAR contained a signature on [DATE], indicating that the oxygen tubing was changed on that day. -However, observation on [DATE] revealed R #18's tubing was dated [DATE]. Observation of R #18 on [DATE] at 9:57 a.m. revealed she received oxygen at 4 liters per nasal cannula. R #18's oxygen concentrator filter was covered with white dust. R #18's oxygen tubing was dated [DATE]. Interview with LVN U on [DATE] at 10:09 a.m. revealed she stated she had recently started working in the facility approximately one week ago. LVN U said oxygen tubing should be changed weekly but did not know what the facility's policy and procedure was or who was responsible for cleaning them. LVN U stated she did not know anything about the maintenance of the filters. Interview with LVN I on [DATE] at 10:12 a.m. revealed she stated oxygen tubing should be changed and dated weekly, at the same time the concentrator filters were cleaned. LVN I said this was scheduled on Sundays and the night shift was responsible for ensuring it was done. LVN I said each resident's Treatment Administration Record should have address the cleaning of filters and changing of oxygen tubing. On [DATE] at 5:59 p.m., the facility was notified of the acceptance of the final Plan of Removal (POR). The final Plan of Removal documented: This Plan of Removal is in response to the alleged identification of Immediate Jeopardy communicated by the survey team on [DATE] during a return visit prompted by the annual survey with exit date of [DATE] at (the facility). The alleged Immediate Jeopardy findings were identified in the following areas: -Quality of Care -Neglect The facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of Immediate Jeopardy and/or any subsequent Statement of Deficiencies. Corrective Action and Identification: Review of orders identified 22 of 72, residents as having orders for Oxygen. This facility has put in place immediate corrective action as evidenced by: 1. On [DATE], nursing administration provided education on abuse and neglect to staff members. On [DATE], nursing administration reeducated staff members on abuse and neglect. 2. On [DATE] residents on oxygen therapy assessed and compliance with orders verified by nursing administration. 3. On [DATE], a complete audit of residents using oxygen was conducted by nursing administration and care plans were reviewed and revised accordingly. 4. On [DATE], nursing administration provided education to nursing staff regarding use of oxygen and maintenance of filter and tubing. 5. On [DATE], the MAR indicated [REDACTED]. MAR indicated [REDACTED]. 6. On [DATE] Kardexes were updated to reflect those residents receiving oxygen with the verbiage 'respiratory therapy'. A Kardex is a tool that is used by the CNAs and nursing to communicate what type of care the resident needs from the CNA perspective. The Kardex is located in the CNA electronic tablet that is used to document resident care and provides information regarding resident care and needs specific to the CNA level. It is the equivalent of a care plan. Examples of items on a Kardex are mobility, transfer, eating and oxygen status. 7. On [DATE], Kardexes were updated to reflect those residents that are on oxygen with the verbiage 'Continuous Oxygen therapy' or 'PRN oxygen therapy'. 8. On [DATE], nursing staff educated regarding the MAR updates that reflect the tubing and filter changing and the oxygen tubing/filter maintenance process. The tubing will be changed on Sunday by the charge nurse on the ,[DATE] shift. Charge nurse to remove and replace old tubing and date new tubing. Remove old filter and replace with new filter. Humidification bottles are to be removed and replaced as needed. Humidification bottles will be dated each time they are replaced. 9. CNAs on [DATE] received education provided regarding the updated Kardex that reflects the verbiage, 'Continuous Oxygen therapy' or 'PRN oxygen therapy'. 10. CNAs on [DATE] received education to alert charge nurses or nurse managers on all resident oxygen use refusals and changes of condition for appropriate intervention and documentation. Example: If the resident refuses oxygen the CNA will alert the charge nurse so that the charge nurse can come assess and speak to the resident to explain the importance of using the oxygen as ordered and check the residents oxygen saturation levels, level of consciousness, nail beds and fingers for cyanosis and encourage the resident to comply with the oxygen as ordered. The nurse will be sure to document the resident's status and concerns and communicate this to nurse management, the attending MD and family if needed. Charge nurse and CNA will ensure that resident is safe from falls or other injury related to refusal of oxygen. Changes of condition related to respiratory distress such as shortness of breath, dusky nail beds, increase in confusion, drowsiness CNA to alert charge nurse, charge nurse to perform respiratory assessment of resident including but not limited to oxygen saturation levels, vital signs, lung sounds and intervene and notify as appropriate, and document findings and outcomes. 11. Care Plans were reviewed and revised to ensure they reflect the current oxygen therapy orders. Care plans will be updated [DATE]. 12. Nursing staff to receive the above education before returning to the floor. The Administrator and other consultants re-assessed residents who were identified by the facility as having a need for oxygen thereapy Through this process, on [DATE], the facility provided an updated list of those residents on oxygen therapy. Four residents were identified as having physician orders [REDACTED]. The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: -eight CNA's were interviewed and confirmed they had been trained as to which residents required oxygen therapy, and could identify them. -five nurses were interviewed and said they had been trained as to which residents were identified with use of oxygen therapy, and could identify them. The nurses said they received instruction and were able to state and retrieve the current physician's orders [REDACTED]. -The updated resident Kardex's and Treatment Administration Record for all residents with ordered oxygen therapy were reviewed and it was found they contained the order for oxygen and when the oxygen tubing were to be changed and when the oxygen filter was to be cleaned. On [DATE] at 2:54 p.m., the Administrator and the Regional Vice President were informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure assessments and interventions for oxygen therapy were accurate for all residents. Review of List of Patients on Oxygen dated [DATE] and received on [DATE] identified four residents as requiring continuous oxygen; one resident as requiring continuous oxygen at night, and 17 residents requiring oxygen as needed, for a total of 22 residents requiring oxygen therapy.

Based on interview and record review the facility failed to immediately consult with the resident's Physician when there was a significant change in the resident's physical or psychosocial status or treatment and notify residents' legal representative or interested family member of treatment, status and room change and for five Residents (R #1, R #2, R #6, R #7 and R #10) of nine residents reviewed for abuse and neglect. The DON received report of R #7's left Humorous (upper arm bone) fracture on 02/16/16 after 11:00 p.m. and she said she would take care of it in the morning. Day shift LVN J notified R#7's physician on 02/17/16 at 11:30 a.m. of the fracture as the DON did not notify the physician nor did she give instruction to nursing staff to notify the physician The DON received report of R #10's femur (upper leg bone) fracture on 02/19/16 at 12:45 a.m. and said she would take care of it in the morning. Day shift LVN K notified R #10's physician on 02/19/16 at 8:00 a.m. of the fracture as the DON did not notify the physician nor did she give instruction to nursing staff to notify the physician R #1's legal representative was not notified her room changed because of reported incident of abuse and neglect with roommated R #2. R #2's physician was not consulted regarding inappropriate sexual behaviors was added to her Care Plan on 01/28/16. R #1 and #2's physician was not consulted regarding R #2 putting her hands down R #1's pajama pants. R #6's family was not notified timely after she was isolated and treated for [REDACTED]. These failures could affect 48 residents with a mental status of dementia by placing them at risk for abuse and neglect, delay in treatment and an avoidable decline in physical, mental, or psychosocial well-being. The findings were: R#7 Record review of R#7's Face Sheet dated 02/25/15 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. R#7 had the following Diagnoses: [REDACTED]. Ath. Usp. Graft, Chronic Asthma, [MEDICAL CONDITIONS] Reflux, [MEDICAL CONDITION], and Chronic Pain. Record review of R#7's Minimum Data Set ((MDS) dated [DATE] revealed R#7's [DIAGNOSES REDACTED]. R#7's MDS revealed she had clear speech, usually understood, and usually understood others. R#7 needed extensive assistance from one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R#7 was totally dependent on one person for physical assistance for bed mobility. Record review of R#7's Nurse's Notes by LVN Jdated 02/16/16 1200 revealed upon assessment resident (R#7) guarding left arm and complaining of pain. Swelling noted to left shoulder (refuses to move). Reported to physician. awaiting new orders. Medicated for pain . assisted to bed . Record review of R#7's Nurses Notes dated 02/16/16 2-10 pm revealed resident complained of severe left shoulder pain. Physician ordered x-ray. Taken at 8 pm ,no results yet. Resident observed for sleep in recliner in .area. Resident continues to hold left arm to her shoulder area. Record review of R#7's Nurses Notes( by LVN J) dated 02/17/16 1530 revealed discoloration noted to left arm measuring approximately 1.3 cm (centimeter) Asked in report of origin of injury. Informed resident had been hitting and grabbing at arm. Informed that X-ray of possible fracture had been reported to DON. Informed DON of discoloration and pain. Call to physician. N.O. (new order) to transfer to local hospital for evaluation and treatment. During a telephone interview on 02/17/16 at 3:30 p.m. ,LVN F (night nurse) stated -had called the DON on 02/15/16 at 11:45 p.m to report R#7 was not able to move her left arm to assist with her own toileting. - R#7 was screaming in pain and agitated but no bruising was noted - R#7's baseline was no reported pain in her left arm and R#7 was able to use both arms to assist in her own toileting with out pain R#7 was up all night her shift starting at 10:00 p.m. on 02/15/16 through 6:00 a.m on 02/16/16 and R#7 picked and grabbed at her left arm during that time -she (LVNF) retrieved an X-ray result after 11:00 p.m.for R#7 from the fax machine and called the DON at that time to report a positive X-ray for a fracture to R#7's left Humerus. -she (LVNF) stated the DON said she would call Physician (PHY) in the morning to report R#7's positive X-ray results. -she (LVNF ) was instructed to medicate R#7 for pain -LVNF stated the facility's policy is to call the Physician with changes in resident condition -she (LVNF) gave report to LVNJ at 6:00 a.m. on 02/17/16 regarding R#7's positive X-ray results and at that time the DON had not come to see R#7 and the Physician had not called with orders to treat R#7. On 02/17/16 at 12:25 p.m., LVN Jstated she was told yesterday (2/16/16) that R#7 had arm pain. She (LVNJ) noted swelling and advised R#7's physician. This morning (02/17/16) she was told the X-ray report had come for R#7 at 8:56 p.m.on 02/16/16. LVNJ replied the night nurse (LVNF) had called the DON about R#7's X-ray result. LVNJ replied it was reported to her that the DON did not call the Physician about R#7's X-ray result. LVNJ said she had spoken to the DON about 7:30 to 8:00 a.m. on 02/17/16/. LVN J said I called the physician on 02/17/16 at 11:30 a.m and asked if he (Physician) knew the results of R#7's X-ray report. LVNJ replied ,the Physician said no ;X-ray report was read to the Physician. Review of Physicians's t.o. (telephone order) dated 02/17/16 1130 revealed transfer to local hospital for evaluation and treatment fracture left arm. Review of R#7's Radiology Report with DOS (date of service) 02/16/16 (final report faxed to facility on 02/16/16 20:56 ) revealed Conclusion Subtle cortical disruption in left humeral neck suspicious of impacted non-displaced fracture, with modest inferior subluxation of left humeral head. F/U (follow -up) recommended. R #10 Record review of R #10's Face Sheet dated 02/03/16 revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #10's physician was PHY U, the Medical Director for the facility. Record review of R #10's current Minimum Data Set ((MDS) dated [DATE] revealed R #10's [DIAGNOSES REDACTED]. R #10's MDS revealed she was incapable of speech, rarely or never made herself understood and rarely or never understood others. R #10's MDS revealed her cognitive skills for daily decision making was coded as severely impaired and she never or rarely made decisions. R #10 was totally dependent on one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R #10 required extensive assistance from one person for bed mobility, locomotion in her wheelchair and eating. Record review of R #10's Care Plan dated 01/30/16 revealed R #10 exhibited symptoms of decline on cognitive function related to dementia. R #10 was at risk for falls due to cognitive loss, lack of safety awareness as she slid forward in her wheelchair and tipped wheelchair backward. Interventions included assess for changes in medical status, pain status, mental status and report to the physician as indicated. Record review of R #10's Nurses Notes dated 02/16/16 at 1:00 p.m. revealed R #10 had swelling and heat to the left lower extremity reported to and evaluated by Physician (PHY) U. Record review of R #10's Nurses Notes dated 02/16/15 from the 2:00 p.m. to 10:00 p.m. shift revealed PHY U ordered a Venous Doppler (ultrasound that uses sound waves to produce pictures of the body's veins) to R #10's left leg due to swelling and redness. Record review of R #10's Nurses Notes dated 02/17/16 at 7:00 a.m. revealed R #10 was assessed with [REDACTED]. Observation on 02/17/16 at 11:45 a.m. revealed R #10 sitting in her wheelchair in the dining room of the secured unit at a table with another resident. R #10 shifted in her wheelchair often and leaned on her right hip and the right arm rest of her wheelchair while she looked out the window. R # 10 pulled at and lifted the left corner of her shirt. Record review of R #10's Nurses Notes dated 02/17/16 from the 2:00 p.m. to 10:00 p.m. shift revealed R #10 was assessed and continued to have swelling and redness to her left leg. R # 10's left leg had a slight discoloration to the area. The Venous Doppler to R #10's left leg was performed at 4:00 p.m. on 02/17/16 and the technician who performed the ultrasound stated to the nurse that results could take 24 hours to receive. Observation on 02/18/16 at 7:45 a.m. revealed R #10 sitting in her wheelchair at a table in the dining room of the secured unit at a table with another resident. R #10 was able to feed herself and was restless as she shifted positions in her wheelchair. Record review of R #10's Nurses Notes dated 02/18/16 at 12:00 p.m. revealed the results of R #10's Venous Doppler were given to PHY U and the nurse reported to PHY U that R #10's left leg remained swollen with multiple areas of dark discoloration. Discolored areas of R #10's left leg included her left knee, left outer leg, left heel, left outer thigh, left calf and left inner knee. LVN J documented she showed the discolored areas of R #10's left leg to the Assistant Director of Nursing (ADON) and LVN J reported the multiple areas of discoloration to the Director of Nursing (DON.) Record review of R #10's physician's orders [REDACTED].#10 was to have X-rays of her left hip and left knee. Record review of R #10's Nurses Notes dated 02/18/16 from the 2:00 p.m. to 10:00 p.m. shift revealed a new order from PHY U for an X-ray to R #10's left leg including her knee, ankle and foot. The DON was to be notified with the results of the X-ray. R #10 was assessed to have swelling and redness with skin discoloration noted to her left leg that were warm to touch. Record review of R #10's Radiology Report faxed to the facility on [DATE] at 12:42 a.m. revealed R #10 had an acute left knee fracture that involved the left distal femur (long bone in the thigh close to the knee.) Record review of R #10's Nurses Notes dated 02/19/16 at 12:30 a.m. signed by LVN W revealed the results of R #10's X-ray were reported to the DON. The documented response from the DON was that she would take care of this in the morning. Record review of the facility Nursing Home to Hospital Transfer Form for R #10 dated 02/19/16 revealed R #10 was given two Tylenol Extra Strength 500 milligram (mg) tablets on 02/19/16 at 8:40 a.m. and her last set of vital signs was taken on 02/19/16 at 9:00 a.m. Record review of R #10's Nurses Notes dated 02/19/16 at 1:30 p.m. by LVN W revealed R #10 was sent out to the hospital and transported by Emergency Medical Services (EMS.) A telephone follow-up to the local hospital revealed R #10 was a probable admit. In an interview on 02/19/16 at 2:40 p.m. LVN K stated she worked in the secure unit 02/19/16 from 6:00 a.m. to 2:00 p.m. LVN K stated she took report this morning from LVN W that revealed that X-ray results received after midnight showed R #10 had a fractured left femur. LVN K stated she called PHY U at 8:00 a.m. on 02/19/16 as she had not been contacted by the DON regarding care for R #10. LVN K stated PHY U stated he was on call the night of 02/18/16 and early morning of 02/19/16 and he was not aware of the results of R #10's X-ray. LVN K stated PHY U ordered R #10 be sent to the hospital by EMS. LVN K stated she called R #10's family member and legal representative and they were not aware R #10 had a fractured femur. LVN K stated she saw the DON about 9:30 a.m. or 10:00 a.m. on 02/19/16 and informed the DON R #10 was sent out to the hospital as per PHY U orders. LVN K stated that the DON replied to her R #10 had pathological fractures (bone fracture caused by disease that led to weakness of the bone structure.) LVN K stated to the surveyor that regardless if it was one fracture or multiple fractures R #10 still needed to be treated because R #10 shouldn't have to hurt. In an interview on 02/19/16 at 3:30 p.m., the DON stated she was aware that PHY U had ordered an X-ray for R #10 on 02/18/16 at 3:00 p.m. The DON stated LVN W called her at home at 12:45 a.m. on 02/19/16 with the results of R #10's X-ray and said that we needed to call the doctor. The DON stated she did not call PHY U regarding results of R #10's X-ray showing a fractured femur but that the floor nurse called and notified PHY U in the morning. The DON stated PHY U was not on call at that time on 02/19/16 but another physician. The DON stated PHY U was particular that nursing staff call him and not the physician on call regarding his residents' medical conditions. In an interview on 02/17/16 at 3:30 p.m., LVN F stated PHY U will accept calls regarding his residents' change of condition while he is on call. LVN F stated PHY U did not want facility staff to call the on call physician for changes in his residents ' condition if PHY U was not on call. LVN F stated PHY U wanted to be the only physician to treat his residents. LVN F stated she used her nursing judgment to determine if a resident change of condition was an emergency and needed to be reported to the physician on call for PHY U. Record review of a written Physician order [REDACTED]. Call me with All med changes made to ANY of my patients. If I am not on call, wait to call ME personally when I am back on call. The order was delivered to the surveyor by the DON on 02/19/16 at 5:45 p.m. as requested documentation of PHY U orders to facility staff informing when staff were to notify PHY U of changes in condition or treatment for [REDACTED]. Record review of a written statement from PHY U dated 02/19/16 and received after 5:45 p.m. revealed PHY U was aware that R #10 had swelling in her left leg since 02/16/16 and he ordered a Venous Doppler to check if R #10 had a blood clot in her left leg. The Venous Doppler results revealed R #10 did not have a blood clot in her left leg on 02/18/16 so at that time he ordered an X-ray of R 10's left leg. PHY U stated R #10's X-ray report came in to the facility at 12:45 a.m. on 02/19/16 and he was called with the results at 8:00 a.m. on 02/19/16 regarding R #10's new [DIAGNOSES REDACTED]. PHY U stated he felt that R #10's X-ray represented a new [DIAGNOSES REDACTED]. PHY U stated he felt the notification he received at 8:00 a.m. on 02/19/16 was appropriate and timely and led to the proper treatment of [REDACTED]. In a telephone interview on 02/19/16 at 4:20 p.m., PHY U stated he was on call the night of 02/18/16 and morning of 02/19/16. PHY U stated when he is not on call he does not want facility staff to call the on call physician about his residents unless it is a true emergency. PHY U stated facility staff was to wait to notify him when he was back on call regarding changes in his residents' medical conditions or need for treatment changes. In an interview on 02/19/16 at 5:00 p.m., the Assistant Director of Nursing (ADON) stated the facility did not instruct her on a requirement to report changes of condition only to PHY U and not to the physician on call regarding his residents at the facility. The ADON stated the facility did not instruct her on what PHY U considered an emergency condition that would require the consultation of the on call physician. R #2 Record review of R #2's Face Sheet dated 12/05/15 revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of R #2's Care Plan revised on 01/28/16 revealed in a focus area that R #2 displayed inappropriate sexual behaviors at times. The goal for this behavior included R #2 would not exhibit at risk or inappropriate sexual behaviors that affected other patients, staff, or visitors. Facility staff interventions to meet this goal included the following: -Review behavioral expectations with patient. -Observe and report verbal and/or physical sexual behaviors exhibited and report to the licensed nurse immediately. -Notify physician if sexually inappropriate behavior is exhibited. -Observe and report change in mood state to licensed nurse immediately. -Remove from common areas when sexually inappropriate behavior is exhibited -Attempt to refocus the patient ' s behavior to something positive when he or she exhibits inappropriate sexual behavior. -Assist the patient in identifying problem causing stimuli. R #2's Care Plan included a focus area initiated and created on 01/14/16 by the Director of Nursing (DON) stating R #2 exhibited or was at risk for complications of infection related to a Urinary Tract Infection (UTI.) Facility staff intervention included facility staff was to assist resident with hand washing throughout the day as needed. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 resided in the Transitions Unit (secured unit) due to being at risk for elopement (leaving the facility.) Facility staff interventions included monitoring R #2 frequently to assure her safety. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 had poor safety awareness. Facility staff interventions included monitoring for changes in R #2's condition that may warrant increased supervision or assistance and notify the physician as needed. R #2's interventions included she needed adequate lighting to see at night. R #2's Care Plan included a focus area imitated on 07/16/13 that stated R #2 had difficulty making her own decisions. Facility staff interventions included assisting R #2 with decision making as needed and report any changes in R #2's level of consciousness to the physician. Record review of R #2's Minimum Data Set ((MDS) dated [DATE] revealed R #2 had a Brief Interview for Mental Status (BIMS) score of four out of a possible 15 points. R #2 understood others with clear comprehension and was able to make herself understood. R #2 spoke clearly and had adequate hearing and vision. R #2's MDS was coded as she had no behaviors, hallucinations or delusions. R #2 was independent and required not assistance from staff for bed mobility, transfer or ambulation. R #2 required supervision and setup help only for dressing, eating, personal hygiene and bathing. R #2 was able to toilet herself with supervision only. In a telephone interview on 02/17/16 at 3:10 p.m., LVN Fstated approximately one month prior at 5:00 a.m. she entered the room shared by R #1 and R #2 on the secured unit to give R #2 a scheduled medication. LVN F stated when she entered the room she saw R #2 standing beside R #1's bed with her hand in R #2's pajama bottoms. LVN F stated R #1's blankets were pulled down and she wore an incontinent brief. LVN F stated as soon as she entered the room shared by R #1 and R #2, R #2 removed her hand from R #1's pajama pants and crossed the room to sit on her bed and asked LVN F what do you have for me? LVN F stated she told R #2 that she had the [MEDICAL CONDITION] medication. LVN F stated R #2 said Oh yes, that one. LVN F stated she medicated R #2 and left the room with R #2 sitting on her bed and R #1 lying in her bed. LVN F stated she did not know how or where to document the incident she witnessed between R #2 and R #1 so at 5:15 a.m. on that morning she called the DON and informed the DON what she witnessed at 5:00 a.m. LVN F stated the DON told her to keep an eye on them and let me know if anything else happens. LVN F stated the DON did not tell her to write a report or call the physician. LVN F stated the DON told her We'll take care of it. LVN F stated she was not told nor was she aware that inappropriate sexual behaviors were added to R #1's Care Plan on 01/18/16. LVN F stated the facility staffing ratio for night shift; 10:00 p.m. to 6:00 a.m.; was to include two CNA's in the secure unit, one CNA for hall 200, one CNA for hall 300 and two nurses for the facility. LVN F stated they often only have one CNA in the secure unit, one CNA on hall 200, one CNA for hall 300 and two nurses to cover the entire facility during the 10:00 p.m. to 6:00 a.m. shift. In an interview on 02/18/16 at 12:05 p.m., Physician (PHY) U stated he was not aware and was not consulted by the facility regarding R #2's inappropriate sexual behaviors or that inappropriate sexual behaviors were added to R #2's Care Plan on 01/28/16. PHY U stated he expected to be notified within a couple of days of the change to add inappropriate sexual behaviors to one of his patients Care Plan. In an interview on 02/18/16 at 12:15 p.m., LVN D stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. LVN D stated that change in R #2's Care Plan should have been communicated to staff. LVN D stated R #1 was moved out of the room with R #2 last month in January 2016 but she was not informed the reason for the roommate change. In an interview on 02/18/16 at 3:25 p.m., the administrator (ADM) stated she was aware that R #2 had inappropriate sexual behaviors added to her Care Plan 02/18/16 but that she thought it needed to be reworded because it was misleading. The ADM stated the situation that prompted R #2's Care Plan to be changed was when a CNA witnessed R #2 assisting R #1 in their room. The ADM stated since R #1 did not appear distressed they added inappropriate sexual behaviors to R #2's Care Plan but I know it is wrong wording and should be interfere with care or over help other residents. The ADM stated that she added the inappropriate sexual behaviors to R #2's Care Plan to be better safe than sorry. The ADM stated the DON interviewed staff and determined the CNA did not see anything and R #1 was not distressed. The ADM stated the NPE went to the different halls of the facility with updates on care guides and the NPE was the mechanism the facility used to advise staff of changes necessary for resident care. In an interview on 02/18/16 at 3:40 p.m., the DON stated she received a call the next day regarding the situation between R #1 and R #2. The DON stated they moved R #1 to another room because she was sick and she notified R #1's Court Appointed Guardian regarding her room change. The DON stated she did an internal investigation and determined there was no reason to report an incident to DADS. In a telephone interview on 02/19/16 at 5:05 p.m., CNALstated she was in the hall of the secure unit at night in November and heard a noise in the room shared by R #1 and R #2. CNA L stated she entered the room and saw R #2 standing at R #1's bedside with her hand under R #1's covers. Record review of a piece of paper received from the DON on 02/18/16 at 4:50 p.m. revealed a piece of paper with the date 11/14/15 at the top that stated the following: I was contacted by (NPE) at 11:18 a.m. stated she was told (R #2) was touching roommate by (CNAL) 11:40 a.m. (NA G) - Reports (R #2) wakes up roommate throughout the night. No other behaviors noted 11:50 a.m. (LVN K) - states (R #2) is bossy tells other residents what to do but is re-directable. Sometimes paces. 11:50 a.m. (AA X) - states R #2 is affectionate with others no behaviors noted 12:10 p.m. (CNA L, LVN W, LVN Y) all interviewed with no sexual behaviors seen . (R #1) assessed for injury with none noted. (R #1) moved to another room to reduce risk of any behaviors and reassess at next care plan meeting. The paper was signed by the DON 02/18/16 Record review of R #1's Physician order [REDACTED].#1 was moved from bed A of the room she shared with R #2 into bed B of another room down the hall on 01/13/16 that was occupied by R #16. Record review of R #16's Physician order [REDACTED].#16 was moved from bed B of the room R #1 was moved to on 01/13/16. R #16 was moved into the A bed of the room with R #2 on 01/13/16. Record review of the facility daily census log for 01/08/16 revealed R #1 and R #2 shared a room. R #16 was listed as residing at the other end of the hall in bed B. Record review of the facility daily census log for 01/09/16 revealed R #2 and R #16 shared a room. R #1 was listed as residing in bed B of the room R #16 was listed on 01/08/16. In an interview on 02/18/16 at 4:50 p.m., the DON stated she did an internal investigation of the situation between R #1 and R #2 on 11/14/15 regarding R #2's behaviors and moved R #1 to another room on 11/14/15. The DON stated I moved R #1 in November 2015. I don ' t know why the Physicians Order says 01/13/16 because I moved her 11/14/15 .We moved (R #1.) Staff there helped me move her. Probably (LVN K) or (NA G.) I'm not sure. The DON stated she was notified of the situation between R #1 and R #2 on 11/14/15 and she had not received any other notifications from staff regarding R #1's behaviors toward R #2 since 11/14/15. The DON stated it was her decision to amend R #2's Care Plan for January 2016 to add sexually inappropriate behaviors on 01/28/16 but her decision was not related to the incident in November 2015. The DON stated I thought the inappropriate sexual behaviors were on (R #2's) old Care Plan so I added it from November (2015.) My thought it was a continuation we were not ready to resolve at that point. The DON stated she recalled the inappropriate sexual behaviors were in place on R #2's Care Plan prior to November 2015 on an old handwritten Care Plan so it was added in January 2016. The DON stated Now I advise it be taken off R #2's Care Plan. The DON stated staff had not notified her of any sexually inappropriate behaviors for R #2 since November 2015. Record review of R #1's Resident Notification of Room Change dated 11/14/15 with a Late entry 02/18/16 revealed R #1 was moved on 11/14/15 and the responsible party was notified. In an interview on 02/19/16 at 9:30 a.m., the ADM stated R #1 was moved from the room she shared with R #2 to another room on 11/14/15. The ADM stated the new computer system caused the change to not show up in the records until January 2016. The Facility Regional Vice President (RVP) was in the room and agreed that the new computer system caused the delay in recording R #1's move from 11/14/15 to January 2016. In an interview on 02/19/16 at 10:15 a.m., the Medical Records Coordinator (MR) stated the new facility computer system was implemented in August 2015. MR stated telephone orders for room change are written at the time of the room change and usually the rooms assignments are updated daily. In an interview on 02/19/16 at 10:30 a.m., LVN S stated the DON told her to update R #2's Care Plan and add inappropriate sexual behaviors in January 2016. LVN S stated there may have been an old hand written Care Plan from 2013 for R #2 that included inappropriate sexual behaviors. LVN S stated she would look through all of R #2's medical records. In an interview on 02/19/16 at 11:30 a.m., NA G stated she assisted the DON move R #1 from the room she shared with R #2 in January 2016. R #1 Record review of R #1's Face Sheet dated 12/23/15 revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of R #1's Care Plan initiated on 06/13/14 and created on 02/15/16 revealed in a focus area that R #1 exhibited aggressive behavior with Activities of Daily Living (ADLs.) Facility staff interventions included identifying causes for R #1's behavior and reduce factors that may provoke R #1. Facility staff was to monitor and document R #1's behavior. R #1's Care Plan included a focus stating R #1 was unable to remember names and faces and facility staff intervention included validating resident thoughts and feelings during daily care. R #1's Care Plan included a focus area that stated R #1 had feelings of restlessness and anxiety. Facility staff interventions included assisting R #1 to determine the source of her anxiety and encourage R #1 to verbalize when she was anxious. R #1 was to be referred for psychological consult as needed. Record review of R #1's most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #1 was coded that she understood others with clear comprehension and was able to make herself understood. R #1's MDS was coded that she spoke clearly and had adequate hearing and vision. R #1's MDS was coded as she did not display behaviors. R #1 totally dependent and required the assistance from one person for bed mobility, dressing, eating, personal hygiene and bathing. R #1 required extensive assistance from one person for transfer and ambulation. R #1's 12/25/15 MDS was not completed for Brief Interview for Mental Status or Cognitive Patterns (BIMS.) R #1's most recent annual MDS dated [DATE] revealed R #1 was unable to complete the BIMS and her Cognitive Patterns were coded as moderately impaired with poor decisions requiring cues and supervision. Record review of R #1's medical record did not reveal any entry for November 2015 through January 2016 regarding an assessment of R #1's urogenital area. There was no documentation regarding any incident between R #1 and R #2. R #1's medical record revealed R #1 had recurrent bladder infections and was admitted to the hospital 11/19/15 with the [DIAGNOSES REDACTED].) In a telephone interview on 02/18/16 at 2:30 p.m., R #1's Responsible Party Representative (RPR) stated their official record of notifications from the facility regarding R #1 did not include a change of room for November 2015 or January 2016. The RPR stated there was no notification of R #2's hand under R #1's sheet in November 2015 nor of R #2's hand in R #1's brief in January 2016 received from the facility. R #6 R #6's face sheet dated 04/23/15 revealed she was an 89 female admitted to the facility on [DATE]. R #6's [DIAGNOSES REDACTED]. Record review of R #6's quarterly MDS dated [DATE] revealed R #6 had a cognitive score of 3 which meant she was severely cognitively impaired. Observed R #6 on 02/17/16 at 12:00 noon up in a wheelchair in her room

Based on observation, interview and record review, the facility failed to implement their policy and procedure that prohibits neglect for four Residents (R #1, R #2, R#7,and R #10) of nine Residents reviewed for neglect. -The DON delayed treatment of [REDACTED]. -The DON delayed treatment of [REDACTED]. -The facility did not investigate, document, protect other residents or remove R #1 from the room she shared with R #2 when staff reported to the Director of Nursing (DON) that R #2 had her hand under R #1's sheet during the night shift in November 2015. -The facility did not investigate, document or protect other residents when staff reported to the Director of Nursing (DON) that R #2 had her hands in R #1's pajama pants during the night shift in January 2016. -The facility did not make staff aware that sexually inappropriate behaviors were added to R #2's Care Plan on 01/28/16 and staff did not know to monitor R #2 for those interventions. -The facility did not notify R #1 and R #2's physician of the reported incident of R #2's hand under R #1's sheet in November 2015 nor of the incident of R #2's hand in R #1's brief in January 2016. -The faiclity did not notify R #1's responsible party of R #1's room change in January 2016 nor of the reported incident of R #2's hand under R #1's sheet in November 2015 nor of the incident of R #2's hand in R #1's bried in January 2016. -The facility did not follow their policy to report to the Texas Department of Aging and Disability Services (DADS) suspected or alleged neglect reported to the DON regarding the incidents of R #2's hand under R #1's sheet in November 2015 and of R #2's hand in R #1's brief in January 2016. -The facility staffed the secure unit with one CNA on the night shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16 when their staffing schedule stated two CNAs were to be scheduled in the secure unit during the night shifts. -The facility Nursing Practice Educator (NPE) did not assess R #1 when she didn't look right and R #1 sustained a fall while ambulating in the hall. These failures could place 24 residents who resided in the secure unit of the facility at risk for neglect from the facility to not provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The findings were: R#7 Record review of R#7's Face Sheet dated 02/25/15 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. R#7 had the following Diagnoses: [REDACTED]. Ath. Usp. Graft, Chronic Asthma, [MEDICAL CONDITIONS] Reflux, [MEDICAL CONDITION], and Chronic Pain. Record review of R#7's Minimum Data Set ((MDS) dated [DATE] revealed R#7's [DIAGNOSES REDACTED]. R#7's MDS revealed she had clear speech, usually understood, and usually understood others. R#7 needed extensive assistance from one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R#7 was totally dependent on one person for physical assistance for bed mobility. Record review of R#7's Nurse's Notes by LVN Jdated 02/16/16 1200 revealed upon assessment resident (R#7) guarding left arm and complaining of pain. Swelling noted to left shoulder (refuses to move). Reported to physician. awaiting new orders. Medicated for pain . assisted to bed . Record review of R#7's Nurses Notes dated 02/16/16 2-10 pm revealed resident complained of severe left shoulder pain. Physician ordered x-ray. Taken at 8 pm ,no results yet. Resident observed for sleep in recliner in .area. Resident continues to hold left arm to her shoulder area. Record review of R#7's Nurses Notes( by LVN J) dated 02/17/16 1530 revealed discoloration noted to left arm measuring approximately 1.3 cm (centimeter) Asked in report of origin of injury. Informed resident had been hitting and grabbing at arm. Informed that X-ray of possible fracture had been reported to DON. Informed DON of discoloration and pain. Call to physician. N.O. (new order) to transfer to local hospital for evaluation and treatment. During a telephone interview on 02/17/16 at 3:30 p.m. ,LVN F (night nurse) stated -had called the DON on 02/15/16 at 11:45 p.m to report R#7 was not able to move her left arm to assist with her own toileting. - R#7 was screaming in pain and agitated but no bruising was noted - R#7's baseline was no reported pain in her left arm and R#7 was able to use both arms to assist in her own toileting with out pain R#7 was up all night her shift starting at 10:00 p.m. on 02/15/16 through 6:00 a.m on 02/16/16 and R#7 picked and grabbed at her left arm during that time -she (LVNF) retrieved an X-ray result after 11:00 p.m.for R#7 from the fax machine and called the DON at that time to report a positive X-ray for a fracture to R#7's left Humerus. -she (LVNF) stated the DON said she would call Physician (PHY) in the morning to report R#7's positive X-ray results. -she (LVNF ) was instructed to medicate R#7 for pain -LVNF stated the facility's policy is to call the Physician with changes in resident condition -she (LVNF) gave report to LVNJ at 6:00 a.m. on 02/17/16 regarding R#7's positive X-ray results and at that time the DON had not come to see R#7 and the Physician had not called with orders to treat R#7. On 02/17/16 at 12:25 p.m., LVN Jstated she was told yesterday (2/16/16) that R#7 had arm pain. She (LVNJ) noted swelling and advised R#7's physician. This morning (02/17/16) she was told the X-ray report had come for R#7 at 8:56 p.m.on 02/16/16. LVNJ replied the night nurse (LVNF) had called the DON about R#7's X-ray result. LVNJ replied it was reported to her that the DON did not call the Physician about R#7's X-ray result. LVNJ said she had spoken to the DON about 7:30 to 8:00 a.m. on 02/17/16/. LVN J said I called the physician on 02/17/16 at 11:30 a.m and asked if he (Physician) knew the results of R#7's X-ray report. LVNJ replied ,the Physician said no ;X-ray report was read to the Physician. Review of Physicians's t.o. (telephone order) dated 02/17/16 1130 revealed transfer to local hospital for evaluation and treatment fracture left arm. Review of R#7's Radiology Report with DOS (date of service) 02/16/16 (final report faxed to facility on 02/16/16 20:56 ) revealed Conclusion Subtle cortical disruption in left humeral neck suspicious of impacted non-displaced fracture, with modest inferior subluxation of left humeral head. F/U (follow -up) recommended. R #10 Record review of R #10's Face Sheet dated 02/03/16 revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #10's physician was PHY U, the Medical Director for the facility. Record review of R #10's current Minimum Data Set ((MDS) dated [DATE] revealed R #10's [DIAGNOSES REDACTED]. R #10's MDS revealed she was incapable of speech, rarely or never made herself understood and rarely or never understood others. R #10's MDS revealed her cognitive skills for daily decision making was coded as severely impaired and she never or rarely made decisions. R #10 was totally dependent on one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R #10 required extensive assistance from one person for bed mobility, locomotion in her wheelchair and eating. Record review of R #10's Care Plan dated 01/30/16 revealed R #10 exhibited symptoms of decline on cognitive function related to dementia. R #10 was at risk for falls due to cognitive loss, lack of safety awareness as she slid forward in her wheelchair and tipped wheelchair backward. Interventions included assess for changes in medical status, pain status, mental status and report to the physician as indicated. Record review of R #10's Nurses Notes dated 02/16/16 at 1:00 p.m. revealed R #10 had swelling and heat to the left lower extremity reported to and evaluated by Physician (PHY) U. Record review of R #10's Nurses Notes dated 02/16/15 from the 2:00 p.m. to 10:00 p.m. shift revealed PHY U ordered a Venous Doppler (ultrasound that uses sound waves to produce pictures of the body's veins) to R #10's left leg due to swelling and redness. Record review of R #10's Nurses Notes dated 02/17/16 at 7:00 a.m. revealed R #10 was assessed with [REDACTED]. Observation on 02/17/16 at 11:45 a.m. revealed R #10 sitting in her wheelchair in the dining room of the secured unit at a table with another resident. R #10 shifted in her wheelchair often and leaned on her right hip and the right arm rest of her wheelchair while she looked out the window. R # 10 pulled at and lifted the left corner of her shirt. Record review of R #10's Nurses Notes dated 02/17/16 from the 2:00 p.m. to 10:00 p.m. shift revealed R #10 was assessed and continued to have swelling and redness to her left leg. R # 10's left leg had a slight discoloration to the area. The Venous Doppler to R #10's left leg was performed at 4:00 p.m. on 02/17/16 and the technician who performed the ultrasound stated to the nurse that results could take 24 hours to receive. Observation on 02/18/16 at 7:45 a.m. revealed R #10 sitting in her wheelchair at a table in the dining room of the secured unit at a table with another resident. R #10 was able to feed herself and was restless as she shifted positions in her wheelchair. Record review of R #10's Nurses Notes dated 02/18/16 at 12:00 p.m. revealed the results of R #10's Venous Doppler were given to PHY U and the nurse reported to PHY U that R #10's left leg remained swollen with multiple areas of dark discoloration. Discolored areas of R #10's left leg included her left knee, left outer leg, left heel, left outer thigh, left calf and left inner knee. LVN J documented she showed the discolored areas of R #10's left leg to the Assistant Director of Nursing (ADON) and LVN J reported the multiple areas of discoloration to the Director of Nursing (DON.) Record review of R #10's physician's orders [REDACTED].#10 was to have X-rays of her left hip and left knee. Record review of R #10's Nurses Notes dated 02/18/16 from the 2:00 p.m. to 10:00 p.m. shift revealed a new order from PHY U for an X-ray to R #10's left leg including her knee, ankle and foot. The DON was to be notified with the results of the X-ray. R #10 was assessed to have swelling and redness with skin discoloration noted to her left leg that were warm to touch. Record review of R #10's Radiology Report faxed to the facility on [DATE] at 12:42 a.m. revealed R #10 had an acute left knee fracture that involved the left distal femur (long bone in the thigh close to the knee.) Record review of R #10's Nurses Notes dated 02/19/16 at 12:30 a.m. signed by LVN W revealed the results of R #10's X-ray were reported to the DON. The documented response from the DON was that she would take care of this in the morning. Record review of the facility Nursing Home to Hospital Transfer Form for R #10 dated 02/19/16 revealed R #10 was given two Tylenol Extra Strength 500 milligram (mg) tablets on 02/19/16 at 8:40 a.m. and her last set of vital signs was taken on 02/19/16 at 9:00 a.m. Record review of R #10's Nurses Notes dated 02/19/16 at 1:30 p.m. by LVN W revealed R #10 was sent out to the hospital and transported by Emergency Medical Services (EMS.) A telephone follow-up to the local hospital revealed R #10 was a probable admit. In an interview on 02/19/16 at 2:40 p.m. LVN K stated she worked in the secure unit 02/19/16 from 6:00 a.m. to 2:00 p.m. LVN K stated she took report this morning from LVN W that revealed that X-ray results received after midnight showed R #10 had a fractured left femur. LVN K stated she called PHY U at 8:00 a.m. on 02/19/16 as she had not been contacted by the DON regarding care for R #10. LVN K stated PHY U stated he was on call the night of 02/18/16 and early morning of 02/19/16 and he was not aware of the results of R #10's X-ray. LVN K stated PHY U ordered R #10 be sent to the hospital by EMS. LVN K stated she called R #10's family member and legal representative and they were not aware R #10 had a fractured femur. LVN K stated she saw the DON about 9:30 a.m. or 10:00 a.m. on 02/19/16 and informed the DON R #10 was sent out to the hospital as per PHY U orders. LVN K stated that the DON replied to her R #10 had pathological fractures (bone fracture caused by disease that led to weakness of the bone structure.) LVN K stated to the surveyor that regardless if it was one fracture or multiple fractures R #10 still needed to be treated because R #10 shouldn't have to hurt. In an interview on 02/19/16 at 3:30 p.m., the DON stated she was aware that PHY U had ordered an X-ray for R #10 on 02/18/16 at 3:00 p.m. The DON stated LVN W called her at home at 12:45 a.m. on 02/19/16 with the results of R #10's X-ray and said that we needed to call the doctor. The DON stated she did not call PHY U regarding results of R #10's X-ray showing a fractured femur but that the floor nurse called and notified PHY U in the morning. The DON stated PHY U was not on call at that time on 02/19/16 but another physician. The DON stated PHY U was particular that nursing staff call him and not the physician on call regarding his residents' medical conditions. In an interview on 02/17/16 at 3:30 p.m., LVN F stated PHY U will accept calls regarding his residents' change of condition while he is on call. LVN F stated PHY U did not want facility staff to call the on call physician for changes in his residents ' condition if PHY U was not on call. LVN F stated PHY U wanted to be the only physician to treat his residents. LVN F stated she used her nursing judgment to determine if a resident change of condition was an emergency and needed to be reported to the physician on call for PHY U. Record review of a written Physician order [REDACTED]. Call me with All med changes made to ANY of my patients. If I am not on call, wait to call ME personally when I am back on call. The order was delivered to the surveyor by the DON on 02/19/16 at 5:45 p.m. as requested documentation of PHY U orders to facility staff informing when staff were to notify PHY U of changes in condition or treatment for [REDACTED]. Record review of a written statement from PHY U dated 02/19/16 and received after 5:45 p.m. revealed PHY U was aware that R #10 had swelling in her left leg since 02/16/16 and he ordered a Venous Doppler to check if R #10 had a blood clot in her left leg. The Venous Doppler results revealed R #10 did not have a blood clot in her left leg on 02/18/16 so at that time he ordered an X-ray of R 10's left leg. PHY U stated R #10's X-ray report came in to the facility at 12:45 a.m. on 02/19/16 and he was called with the results at 8:00 a.m. on 02/19/16 regarding R #10's new [DIAGNOSES REDACTED]. PHY U stated he felt that R #10's X-ray represented a new [DIAGNOSES REDACTED]. PHY U stated he felt the notification he received at 8:00 a.m. on 02/19/16 was appropriate and timely and led to the proper treatment of [REDACTED]. In a telephone interview on 02/19/16 at 4:20 p.m., PHY U stated he was on call the night of 02/18/16 and morning of 02/19/16. PHY U stated when he is not on call he does not want facility staff to call the on call physician about his residents unless it is a true emergency. PHY U stated facility staff was to wait to notify him when he was back on call regarding changes in his residents' medical conditions or need for treatment changes. In an interview on 02/19/16 at 5:00 p.m., the Assistant Director of Nursing (ADON) stated the facility did not instruct her on a requirement to report changes of condition only to PHY U and not to the physician on call regarding his residents at the facility. The ADON stated the facility did not instruct her on what PHY U considered an emergency condition that would require the consultation of the on call physician. R #2 Record review of R #2's Face Sheet dated 12/05/15 revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review on 01/28/16 of R #2's Care Plan revised revealed in a focus area that R #2 displayed inappropriate sexual behaviors at times. The goal for this behavior included R #2 would not exhibit at risk or inappropriate sexual behaviors that affected other patients, staff, or visitors. Facility staff interventions to meet this goal included the following: -Review behavioral expectations with patient. -Observe and report verbal and/or physical sexual behaviors exhibited and report to the licensed nurse immediately. -Notify physician if sexually inappropriate behavior is exhibited. -Observe and report change in mood state to licensed nurse immediately. -Remove from common areas when sexually inappropriate behavior is exhibited -Attempt to refocus the patient's behavior to something positive when he or she exhibits inappropriate sexual behavior. -Assist the patient in identifying problem causing stimuli. on 01/14/16 R #2's Care Plan included a focus area initiated and created by the Director of Nursing (DON) stating R #2 exhibited or was at risk for complications of infection related to a Urinary Tract Infection (UTI.) Facility staff intervention included facility staff was to assist resident with hand washing throughout the day as needed. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 resided in the Transitions Unit (secured unit) due to being at risk for elopement (leaving the facility.) Facility staff interventions included monitoring R #2 frequently to assure her safety. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 had poor safety awareness. Facility staff interventions included monitoring for changes in R #2's condition that may warrant increased supervision or assistance and notify the physician as needed. R #2's interventions included she needed adequate lighting to see at night. R #2's Care Plan included a focus area imitated on 07/16/13 that stated R #2 had difficulty making her own decisions. Facility staff interventions included assisting R #2 with decision making as needed and report any changes in R #2's level of consciousness to the physician. Record review of R #2's current Minimum Data Set ((MDS) dated [DATE] revealed R #2 had a Brief Interview for Mental Status (BIMS) score of four out of a possible 15 points. R #2 understood others with clear comprehension and was able to make herself understood. R #2 spoke clearly and had adequate hearing and vision. R #2's MDS was coded as she had no behaviors, hallucinations or delusions. R #2 was independent and required no assistance from staff for bed mobility, transfer or ambulation. R #2 required supervision and setup help only for dressing, eating, personal hygiene and bathing. R #2 was able to toilet herself with supervision only. In a telephone interview on 02/17/16 at 3:10 p.m., LVN Fstated approximately one month prior at 5:00 a.m. she entered the room shared by R #1 and R #2 on the secured unit to give R #2 a scheduled medication. LVN F stated when she entered the room she saw R #2 standing beside R #1's bed. R #2 had her hand in R #1's pajama bottoms. LVN F stated R #1's blankets were pulled down and she wore an incontinent brief. LVN F stated as soon as she entered the room shared by R #1 and R #2, R #2 removed her hand from R #1's pajama pants and crossed the room to sit on her bed and asked LVN F what do you have for me? LVN F stated she told R #2 that she had the [MEDICAL CONDITION] medication. LVN F stated R #2 said Oh yes, that one. LVN F stated she medicated R #2 and left the room with R #2 sitting on her bed and R #1 lying in her bed. LVN F stated she did not know how or where to document the incident she witnessed between R #2 and R #1 so at 5:15 a.m. on that morning she called the Director of Nurses (DON) and informed the DON what she witnessed at 5:00 a.m. LVN F stated the DON told her to keep an eye on them and let me know if anything else happens. LVN F stated the DON did not tell her to write a report or call the physician. LVN F stated the DON told her We'll take care of it. LVN F stated she was not told nor was she aware that inappropriate sexual behaviors were added to R #1's Care Plan on 01/28/16. LVN F stated the facility staffing ratio for night shift; 10:00 p.m. to 6:00 a.m.; was to include two CNAs in the secure unit, one CNA for hall 200, one CNA for hall 300 and two nurses for the facility. LVN F stated they often only had one CNA in the secure unit, one CNA on hall 200, one CNA for hall 300 and two nurses to cover the entire facility during the 10:00 p.m. to 6:00 a.m. shift. On 02/18/16 record review of nurse's notes revealed there were no notes indicating LVN F called the DON to notify her of the situation. There were no notes indicating the physician or family had been notified. There were no incident reports, new assessments, or care plans updated. Observation on 02/18/16 at 5:50 a.m. revealed three residents ambulating in the hall of the secure unit and two residents seated in the dining room of the secure unit. CNA C was the only staff member on the secure unit. In an interview on 02/18/16 at 6:20 a.m., LVN D stated there was only one CNA scheduled on the secure unit during the shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16. LVN Dstated two CNAs were scheduled for the secure unit during the night shift because sometimes the residents wake up on the wrong side of the bed and start kicking at each other. In an interview on 02/18/16 at 6:30 a.m., CNA C stated she was the only CNA scheduled during the night shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16 in the secure unit. CNA C stated there were two CNAs scheduled in the secure unit about four to seven nights per week. CNA C stated one CNA could handle the secure unit when there were no problems. CNA C stated if she needed help at night on the secure unit she could press the call bell light or pull the call bell light from the wall and wait for help from staff in other parts of the facility. CNA C stated R #2 got up at night and was confused. CNA C stated she did not know that R #2 had inappropriate sexual behaviors or that it was added to her Care Plan on 01/28/16. In an interview on 02/18/16 at 8:45 a.m., LVN J stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. In an interview on 02/18/16 at 10:05 a.m., AA E stated she did not know R #2 had inappropriate sexual behaviors added to her Care Plan on 01/28/16. AA E stated she expected to be informed of any changes or new behaviors to monitor for resident. In an interview on 02/18/16 at 11:30 a.m., LVN K stated she was not informed that R #2 had inappropriate sexual behaviors or that it was added to her Care Plan on 01/28/16. LVN K stated that when Care Plans were updated direct care staff needed to be notified of new behaviors to monitor. In an interview on 02/18/16 at 12:05 p.m., Physician (PHY) U stated he was not aware and was not consulted by the facility regarding R #2's inappropriate sexual behaviors or that inappropriate sexual behaviors were added to R #2's Care Plan on 01/28/16. PHY U stated he expected to be notified within a couple of days of the change to add inappropriate sexual behaviors to one of his patient's Care Plan. In an interview on 02/18/16 at 12:15 p.m., LVN D stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. LVN D stated that change in R #2's Care Plan should have been communicated to staff. LVN D stated R #1 was moved out of the room with R #2 last month in January 2016 but she was not informed the reason for the roommate change. In an interview on 02/18/16 at 3:25 p.m., the administrator (ADM) stated she was aware that R #2 had inappropriate sexual behaviors added to her Care Plan 01/18/16 but that she thought it needed to be reworded because it was misleading. The ADM stated the situation that prompted R #2 ' s Care Plan to be changed was when a CNA witnessed R #2 assisting R #1 in their room. The ADM stated since R #1 did not appear distressed they added inappropriate sexual behaviors to R #2's Care Plan but I know it is wrong wording and should be interfere with care or over help other residents. The ADM stated that she added the inappropriate sexual behaviors to R #2's Care Plan to be better safe than sorry. The ADM stated the DON interviewed staff and determined the CNA did not see anything and R #1 was not distressed. The ADM stated the NPE went to the different halls of the facility with updates on care guides and the NPE was the mechanism the facility used to advise staff of changes necessary for resident care. In an interview on 02/18/16 at 3:40 p.m., the DON stated she received a call the next day regarding the situation between R #1 and R #2. The DON stated they moved R #1 to another room because she was sick and she notified R #1's Court Appointed Guardian regarding her room change. The DON stated she did an internal investigation and determined there was no reason to report an incident to DADS. In a telephone interview on 02/19/16 at 5:05 p.m., CNALstated she was in the hall of the secure unit at night in November and heard a noise in the room shared by R #1 and R #2. CNA L stated she entered the room and saw R #2 standing at R #1's bedside with her hand under R #1's covers. Record review of a piece of paper dated 11/14/15 received from the DON on 02/18/16 at 4:50 p.m. revealed the following: I was contacted by (NPE) at 11:18 a.m. stated she was told (R #2) was touching roommate by (CNA L) 11:40 a.m. (Nurse Aid NA G) - Reports (R #2) wakes up roommate throughout the night. No other behaviors noted 11:50 a.m. (LVN K) - states (R #2) is bossy tells other residents what to do but is re-directable. Sometimes paces. 11:50 a.m. (AA X) - states R #2 is affectionate with others no behaviors noted 12:10 p.m. (CNA L, LVN W, LVN Y) all interviewed with no sexual behaviors seen . (R #1) assessed for injury with none noted. (R #1) moved to another room to reduce risk of any behaviors and reassess at next care plan meeting. The paper was signed o 02/18/16 by the DON. Record review of R #1's Physician order [REDACTED].#1 was moved from bed A of the room she shared with R #2 into bed B of another room down the hall on 01/13/16 that was occupied by R #16. Record review of R #16's Physician order [REDACTED].#16 was moved from bed B of the room R #1 was moved to on 01/13/16. R #16 was moved into the A bed of the room with R #2 on 01/13/16. Record review of the facility daily census log for 01/08/16 revealed R #1 and R #2 shared a room. R #16 was listed as residing at the other end of the hall in bed B. Record review of the facility daily census log for 01/09/16 revealed R #2 and R #16 shared a room. R #1 was listed as residing in bed B of the room R #16 was listed in 01/08/16. In an interview on 02/18/16 at 4:50 p.m., the DON stated she did an internal investigation of the situation between R #1 and R #2 on 11/14/15 regarding R #2's behaviors and moved R #1 to another room on 11/14/15. The DON stated I moved R #1 in November 2015. I don't know why the Physicians Order says 01/13/16 because I moved her 11/14/15 .We moved (R #1.) Staff there helped me move her. Probably (LVN K) or (NA G.) I'm not sure. The DON stated she was notified of the situation between R #1 and R #2 on 11/14/15 and she had not received any other notifications from staff regarding R #1's behaviors toward R #2 since 11/14/15. The DON stated it was her decision to amend R #2's Care Plan for January 2016 to add sexually inappropriate behaviors on 01/28/16 but her decision was not related to the incident in November 2015. The DON stated I thought the inappropriate sexual behaviors were on (R #2's) old Care Plan so I added it from November (2015.) My thought it was a continuation we were not ready to resolve at that point. The DON stated she recalled the inappropriate sexual behaviors were in place on R #2's Care Plan prior to November 2015 on an old handwritten Care Plan so it was added in January 2016. The DON stated Now I advise it be taken off R #2 ' s Care Plan. The DON stated staff had not notified her of any sexually inappropriate behaviors for R #2 since November 2015. Record review of R #1's Resident Notification of Room Change dated 11/14/15 with a Late entry 02/18/16 revealed R #1 was moved on 11/14/15 and the responsible party was notified. In an interview on 02/19/16 at 9:30 a.m., the ADM stated R #1 was moved from the room she shared with R #2 to another room on 11/14/15. The ADM stated the new computer system caused the change to not show up in the records until January 2016. The Facility Regional Vice President (RVP) was in the room and agreed that the new computer system caused the delay in recording R #1's move from 11/14/15 to January 2016. In an interview on 02/19/16 at 10:15 a.m., the Health Information Coordinator (HIC) stated the new facility computer system was implemented in August 2015. Medical Records (MR) stated telephone orders for room change were written at the time of the room change and usually the rooms assignments were updated daily. In an interview on 02/19/16 at 10:30 a.m., LVN S stated the DON told her to update R #2's Care Plan and add inappropriate sexual behaviors in January 2016. LVN S stated there may have been an old hand written Care Plan from 2013 for R #2 that included inappropriate sexual behaviors. LVN S stated she would look through all of R #2's medical records. In an interview on 02/19/16 at 11:30 a.m., NA G stated she assisted the DON move R #1 from the room she shared with R #2 in January 2016. In an interview on 02/19/16 at 54:00 p.m., LVN S stated she could not find any other Care Plan for R #2 that included inappropriate sexual behaviors other than the one dated 01/28/16. R #1 Record review of R #1's Face Sheet dated 12/23/15 revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED].

Based on observation, interview and record review, the facility failed to implement their written policy and procedure that prohibits neglect for four Residents (R #1, R #2, R#7,and R #10) of nine Residents reviewed for neglect. -The DON delayed treatment of [REDACTED]. -The DON delayed treatment of [REDACTED]. -The facility did not investigate, document, protect other residents or remove R #1 from the room she shared with R #2 when staff reported to the Director of Nursing (DON) that R #2 had her hand under R #1's sheet during the night shift in November 2015. -The facility did not investigate, document or protect other residents when staff reported to the Director of Nursing (DON) that R #2 had her hands in R #1's pajama pants during the night shift in January 2016. -The facility did not make staff aware that sexually inappropriate behaviors were added to R #2's Care Plan on 01/28/16 and staff did not know to monitor R #2 for those interventions. -The facility did not notify R #1 and R #2's physician of the reported incident of R #2's hand under R #1's sheet in November 2015 nor of the incident of R #2's hand in R #1's brief in January 2016. -The facility did not notify R #1's responsible party of R #1's room change in January 2016 nor of the reported incident of R #2's hand under R #1's sheet in November 2015 nor of the incident of R #2's hand in R #1's brief in January 2016. -The facility did not follow their policy to report to the Texas Department of Aging and Disability Services (DADS) suspected or alleged neglect reported to the DON regarding the incidents of R #2's hand under R #1's sheet in November 2015 and of R #2's hand in R #1's brief in January 2016. -The facility scheduled the Activity Aid (AA) E in the secured unit to perform tasks outside the secured unit and left only two staff to manage the secure unit during the day on 02/17/18. While the Certified Nurse Aid (CNA) performed scheduled resident personal care one LVN was left on the floor to intervene in a resident altercation during morning medication pass. -The facility staffed the secure unit with one CNA on the night shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16 when their staffing schedule stated two CNAs were to be scheduled in the secure unit during the night shifts. -The facility Nursing Practice Educator (NPE) did not assess R #1 when she didn't look right and R #1 sustained a fall while ambulating in the hall. These failures could place 24 residents who resided in the secure unit of the facility at risk for neglect from the facility to not provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The findings were: Record review of the facility OPS333-TX Abuse Prohibition-State of Texas dated 01/22/16 received from the facility stated If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. The family and physician will be notified and any follow-up recommended will be completed. Options for room changes will be provided based on the situation .Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, injuries of unknown origin .the Administrator of designee will perform the following including immediately, not to exceed 24 hours, notify (DADS) .and provide with the following: -If special supervision was required -The person's level of cognition -The person's pertinent medical history -If there was a history of similar or prior incidents -The date and time you first learned of the incident and a brief narrative summary of the reportable incident -The names of any alleged perpetrators or witnesses -The date, time and results of any assessment conducted, including findings of injury or adverse effects noted -The immediate action taken to protect other people and to prevent occurrences of similar incidents while you conduct and complete your investigation. The facility policy also stated the following: - Provide staff with information on how they may report concerns and incidents without fear of retribution and provide feedback regarding the expressed concerns. - Notify the families and attending Physician about all reports of suspected abuse or neglect. R#7 Record review of R#7's Face Sheet dated 02/25/15 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. R#7 had the following Diagnoses: [REDACTED]. Ath. Usp. Graft, Chronic Asthma, [MEDICAL CONDITIONS] Reflux, [MEDICAL CONDITION], and Chronic Pain. Record review of R#7's Minimum Data Set ((MDS) dated [DATE] revealed R#7's [DIAGNOSES REDACTED]. R#7's MDS revealed she had clear speech, usually understood, and usually understood others. R#7 needed extensive assistance from one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R#7 was totally dependent on one person for physical assistance for bed mobility. Record review of R#7's Nurse's Notes by LVN Jdated 02/16/16 1200 revealed upon assessment resident (R#7) guarding left arm and complaining of pain. Swelling noted to left shoulder (refuses to move). Reported to physician. awaiting new orders. Medicated for pain . assisted to bed . Record review of R#7's Nurses Notes dated 02/16/16 2-10 pm revealed resident complained of severe left shoulder pain. Physician ordered x-ray. Taken at 8 pm ,no results yet. Resident observed for sleep in recliner in .area. Resident continues to hold left arm to her shoulder area. Record review of R#7's Nurses Notes( by LVN J) dated 02/17/16 1530 revealed discoloration noted to left arm measuring approximately 1.3 cm (centimeter) Asked in report of origin of injury. Informed resident had been hitting and grabbing at arm. Informed that X-ray of possible fracture had been reported to DON. Informed DON of discoloration and pain. Call to physician. N.O. (new order) to transfer to local hospital for evaluation and treatment. During a telephone interview on 02/17/16 at 3:30 p.m. ,LVN F (night nurse) stated -had called the DON on 02/15/16 at 11:45 p.m to report R#7 was not able to move her left arm to assist with her own toileting. - R#7 was screaming in pain and agitated but no bruising was noted - R#7's baseline was no reported pain in her left arm and R#7 was able to use both arms to assist in her own toileting with out pain R#7 was up all night her shift starting at 10:00 p.m. on 02/15/16 through 6:00 a.m on 02/16/16 and R#7 picked and grabbed at her left arm during that time -she (LVNF) retrieved an X-ray result after 11:00 p.m.for R#7 from the fax machine and called the DON at that time to report a positive X-ray for a fracture to R#7's left Humerus. -she (LVNF) stated the DON said she would call Physician (PHY) in the morning to report R#7's positive X-ray results. -she (LVNF ) was instructed to medicate R#7 for pain -LVNF stated the facility's policy is to call the Physician with changes in resident condition -she (LVNF) gave report to LVNJ at 6:00 a.m. on 02/17/16 regarding R#7's positive X-ray results and at that time the DON had not come to see R#7 and the Physician had not called with orders to treat R#7. On 02/17/16 at 12:25 p.m., LVN Jstated she was told yesterday (2/16/16) that R#7 had arm pain. She (LVNJ) noted swelling and advised R#7's physician. This morning (02/17/16) she was told the X-ray report had come for R#7 at 8:56 p.m.on 02/16/16. LVNJ replied the night nurse (LVNF) had called the DON about R#7's X-ray result. LVNJ replied it was reported to her that the DON did not call the Physician about R#7's X-ray result. LVNJ said she had spoken to the DON about 7:30 to 8:00 a.m. on 02/17/16/. LVN J said I called the physician on 02/17/16 at 11:30 a.m and asked if he (Physician) knew the results of R#7's X-ray report. LVNJ replied ,the Physician said no ;X-ray report was read to the Physician. Review of Physicians's t.o. (telephone order) dated 02/17/16 1130 revealed transfer to local hospital for evaluation and treatment fracture left arm. Review of R#7's Radiology Report with DOS (date of service) 02/16/16 (final report faxed to facility on 02/16/16 20:56 ) revealed Conclusion Subtle cortical disruption in left humeral neck suspicious of impacted non-displaced fracture, with modest inferior subluxation of left humeral head. F/U (follow -up) recommended. R #10 Record review of R #10's Face Sheet dated 02/03/16 revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #10's physician was PHY U, the Medical Director for the facility. Record review of R #10's current Minimum Data Set ((MDS) dated [DATE] revealed R #10's [DIAGNOSES REDACTED]. R #10's MDS revealed she was incapable of speech, rarely or never made herself understood and rarely or never understood others. R #10's MDS revealed her cognitive skills for daily decision making was coded as severely impaired and she never or rarely made decisions. R #10 was totally dependent on one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R #10 required extensive assistance from one person for bed mobility, locomotion in her wheelchair and eating. Record review of R #10's Care Plan dated 01/30/16 revealed R #10 exhibited symptoms of decline on cognitive function related to dementia. R #10 was at risk for falls due to cognitive loss, lack of safety awareness as she slid forward in her wheelchair and tipped wheelchair backward. Interventions included assess for changes in medical status, pain status, mental status and report to the physician as indicated. Record review of R #10's Nurses Notes dated 02/16/16 at 1:00 p.m. revealed R #10 had swelling and heat to the left lower extremity reported to and evaluated by Physician (PHY) U. Record review of R #10's Nurses Notes dated 02/16/15 from the 2:00 p.m. to 10:00 p.m. shift revealed PHY U ordered a Venous Doppler (ultrasound that uses sound waves to produce pictures of the body's veins) to R #10's left leg due to swelling and redness. Record review of R #10's Nurses Notes dated 02/17/16 at 7:00 a.m. revealed R #10 was assessed with [REDACTED]. Observation on 02/17/16 at 11:45 a.m. revealed R #10 sitting in her wheelchair in the dining room of the secured unit at a table with another resident. R #10 shifted in her wheelchair often and leaned on her right hip and the right arm rest of her wheelchair while she looked out the window. R # 10 pulled at and lifted the left corner of her shirt. Record review of R #10's Nurses Notes dated 02/17/16 from the 2:00 p.m. to 10:00 p.m. shift revealed R #10 was assessed and continued to have swelling and redness to her left leg. R # 10's left leg had a slight discoloration to the area. The Venous Doppler to R #10's left leg was performed at 4:00 p.m. on 02/17/16 and the technician who performed the ultrasound stated to the nurse that results could take 24 hours to receive. Observation on 02/18/16 at 7:45 a.m. revealed R #10 sitting in her wheelchair at a table in the dining room of the secured unit at a table with another resident. R #10 was able to feed herself and was restless as she shifted positions in her wheelchair. Record review of R #10's Nurses Notes dated 02/18/16 at 12:00 p.m. revealed the results of R #10's Venous Doppler were given to PHY U and the nurse reported to PHY U that R #10's left leg remained swollen with multiple areas of dark discoloration. Discolored areas of R #10's left leg included her left knee, left outer leg, left heel, left outer thigh, left calf and left inner knee. LVN J documented she showed the discolored areas of R #10's left leg to the Assistant Director of Nursing (ADON) and LVN J reported the multiple areas of discoloration to the Director of Nursing (DON.) Record review of R #10's physician's orders [REDACTED].#10 was to have X-rays of her left hip and left knee. Record review of R #10's Nurses Notes dated 02/18/16 from the 2:00 p.m. to 10:00 p.m. shift revealed a new order from PHY U for an X-ray to R #10's left leg including her knee, ankle and foot. The DON was to be notified with the results of the X-ray. R #10 was assessed to have swelling and redness with skin discoloration noted to her left leg that were warm to touch. Record review of R #10's Radiology Report faxed to the facility on [DATE] at 12:42 a.m. revealed R #10 had an acute left knee fracture that involved the left distal femur (long bone in the thigh close to the knee.) Record review of R #10's Nurses Notes dated 02/19/16 at 12:30 a.m. signed by LVN W revealed the results of R #10's X-ray were reported to the DON. The documented response from the DON was that she would take care of this in the morning. Record review of the facility Nursing Home to Hospital Transfer Form for R #10 dated 02/19/16 revealed R #10 was given two Tylenol Extra Strength 500 milligram (mg) tablets on 02/19/16 at 8:40 a.m. and her last set of vital signs was taken on 02/19/16 at 9:00 a.m. Record review of R #10's Nurses Notes dated 02/19/16 at 1:30 p.m. by LVN W revealed R #10 was sent out to the hospital and transported by Emergency Medical Services (EMS.) A telephone follow-up to the local hospital revealed R #10 was a probable admit. In an interview on 02/19/16 at 2:40 p.m. LVN K stated she worked in the secure unit 02/19/16 from 6:00 a.m. to 2:00 p.m. LVN K stated she took report this morning from LVN W that revealed that X-ray results received after midnight showed R #10 had a fractured left femur. LVN K stated she called PHY U at 8:00 a.m. on 02/19/16 as she had not been contacted by the DON regarding care for R #10. LVN K stated PHY U stated he was on call the night of 02/18/16 and early morning of 02/19/16 and he was not aware of the results of R #10's X-ray. LVN K stated PHY U ordered R #10 be sent to the hospital by EMS. LVN K stated she called R #10's family member and legal representative and they were not aware R #10 had a fractured femur. LVN K stated she saw the DON about 9:30 a.m. or 10:00 a.m. on 02/19/16 and informed the DON R #10 was sent out to the hospital as per PHY U orders. LVN K stated that the DON replied to her R #10 had pathological fractures (bone fracture caused by disease that led to weakness of the bone structure.) LVN K stated to the surveyor that regardless if it was one fracture or multiple fractures R #10 still needed to be treated because R #10 shouldn't have to hurt. In an interview on 02/19/16 at 3:30 p.m., the DON stated she was aware that PHY U had ordered an X-ray for R #10 on 02/18/16 at 3:00 p.m. The DON stated LVN W called her at home at 12:45 a.m. on 02/19/16 with the results of R #10's X-ray and said that we needed to call the doctor. The DON stated she did not call PHY U regarding results of R #10's X-ray showing a fractured femur but that the floor nurse called and notified PHY U in the morning. The DON stated PHY U was not on call at that time on 02/19/16 but another physician. The DON stated PHY U was particular that nursing staff call him and not the physician on call regarding his residents' medical conditions. In an interview on 02/17/16 at 3:30 p.m., LVN F stated PHY U will accept calls regarding his residents' change of condition while he is on call. LVN F stated PHY U did not want facility staff to call the on call physician for changes in his residents ' condition if PHY U was not on call. LVN F stated PHY U wanted to be the only physician to treat his residents. LVN F stated she used her nursing judgment to determine if a resident change of condition was an emergency and needed to be reported to the physician on call for PHY U. Record review of a written Physician order [REDACTED]. Call me with All med changes made to ANY of my patients. If I am not on call, wait to call ME personally when I am back on call. The order was delivered to the surveyor by the DON on 02/19/16 at 5:45 p.m. as requested documentation of PHY U orders to facility staff informing when staff were to notify PHY U of changes in condition or treatment for [REDACTED]. Record review of a written statement from PHY U dated 02/19/16 and received after 5:45 p.m. revealed PHY U was aware that R #10 had swelling in her left leg since 02/16/16 and he ordered a Venous Doppler to check if R #10 had a blood clot in her left leg. The Venous Doppler results revealed R #10 did not have a blood clot in her left leg on 02/18/16 so at that time he ordered an X-ray of R 10's left leg. PHY U stated R #10's X-ray report came in to the facility at 12:45 a.m. on 02/19/16 and he was called with the results at 8:00 a.m. on 02/19/16 regarding R #10's new [DIAGNOSES REDACTED]. PHY U stated he felt that R #10's X-ray represented a new [DIAGNOSES REDACTED]. PHY U stated he felt the notification he received at 8:00 a.m. on 02/19/16 was appropriate and timely and led to the proper treatment of [REDACTED]. In a telephone interview on 02/19/16 at 4:20 p.m., PHY U stated he was on call the night of 02/18/16 and morning of 02/19/16. PHY U stated when he is not on call he does not want facility staff to call the on call physician about his residents unless it is a true emergency. PHY U stated facility staff was to wait to notify him when he was back on call regarding changes in his residents' medical conditions or need for treatment changes. In an interview on 02/19/16 at 5:00 p.m., the Assistant Director of Nursing (ADON) stated the facility did not instruct her on a requirement to report changes of condition only to PHY U and not to the physician on call regarding his residents at the facility. The ADON stated the facility did not instruct her on what PHY U considered an emergency condition that would require the consultation of the on call physician. R #2 Record review of R #2's Face Sheet dated 12/05/15 revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review on 01/28/16 of R #2's Care Plan revised revealed in a focus area that R #2 displayed inappropriate sexual behaviors at times. The goal for this behavior included R #2 would not exhibit at risk or inappropriate sexual behaviors that affected other patients, staff, or visitors. Facility staff interventions to meet this goal included the following: -Review behavioral expectations with patient. -Observe and report verbal and/or physical sexual behaviors exhibited and report to the licensed nurse immediately. -Notify physician if sexually inappropriate behavior is exhibited. -Observe and report change in mood state to licensed nurse immediately. -Remove from common areas when sexually inappropriate behavior is exhibited -Attempt to refocus the patient's behavior to something positive when he or she exhibits inappropriate sexual behavior. -Assist the patient in identifying problem causing stimuli. on 01/14/16 R #2's Care Plan included a focus area initiated and created by the Director of Nursing (DON) stating R #2 exhibited or was at risk for complications of infection related to a Urinary Tract Infection (UTI.) Facility staff intervention included facility staff was to assist resident with hand washing throughout the day as needed. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 resided in the Transitions Unit (secured unit) due to being at risk for elopement (leaving the facility.) Facility staff interventions included monitoring R #2 frequently to assure her safety. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 had poor safety awareness. Facility staff interventions included monitoring for changes in R #2's condition that may warrant increased supervision or assistance and notify the physician as needed. R #2's interventions included she needed adequate lighting to see at night. R #2's Care Plan included a focus area imitated on 07/16/13 that stated R #2 had difficulty making her own decisions. Facility staff interventions included assisting R #2 with decision making as needed and report any changes in R #2's level of consciousness to the physician. Record review of R #2's current Minimum Data Set ((MDS) dated [DATE] revealed R #2 had a Brief Interview for Mental Status (BIMS) score of four out of a possible 15 points. R #2 understood others with clear comprehension and was able to make herself understood. R #2 spoke clearly and had adequate hearing and vision. R #2's MDS was coded as she had no behaviors, hallucinations or delusions. R #2 was independent and required no assistance from staff for bed mobility, transfer or ambulation. R #2 required supervision and setup help only for dressing, eating, personal hygiene and bathing. R #2 was able to toilet herself with supervision only. In a telephone interview on 02/17/16 at 3:10 p.m., LVN Fstated approximately one month prior at 5:00 a.m. she entered the room shared by R #1 and R #2 on the secured unit to give R #2 a scheduled medication. LVN F stated when she entered the room she saw R #2 standing beside R #1's bed. R #2 had her hand in R #1's pajama bottoms. LVN F stated R #1's blankets were pulled down and she wore an incontinent brief. LVN F stated as soon as she entered the room shared by R #1 and R #2, R #2 removed her hand from R #1's pajama pants and crossed the room to sit on her bed and asked LVN F what do you have for me? LVN F stated she told R #2 that she had the [MEDICAL CONDITION] medication. LVN F stated R #2 said Oh yes, that one. LVN F stated she medicated R #2 and left the room with R #2 sitting on her bed and R #1 lying in her bed. LVN F stated she did not know how or where to document the incident she witnessed between R #2 and R #1 so at 5:15 a.m. on that morning she called the Director of Nurses (DON) and informed the DON what she witnessed at 5:00 a.m. LVN F stated the DON told her to keep an eye on them and let me know if anything else happens. LVN F stated the DON did not tell her to write a report or call the physician. LVN F stated the DON told her We'll take care of it. LVN F stated she was not told nor was she aware that inappropriate sexual behaviors were added to R #1's Care Plan on 01/28/16. LVN F stated the facility staffing ratio for night shift; 10:00 p.m. to 6:00 a.m.; was to include two CNAs in the secure unit, one CNA for hall 200, one CNA for hall 300 and two nurses for the facility. LVN F stated they often only had one CNA in the secure unit, one CNA on hall 200, one CNA for hall 300 and two nurses to cover the entire facility during the 10:00 p.m. to 6:00 a.m. shift. On 02/18/16 record review of nurse's notes revealed there were no notes indicating LVN F called the DON to notify her of the situation. There were no notes indicating the physician or family had been notified. There were no incident reports, new assessments, or care plans updated. Observation on 02/18/16 at 5:50 a.m. revealed three residents ambulating in the hall of the secure unit and two residents seated in the dining room of the secure unit. CNA C was the only staff member on the secure unit. In an interview on 02/18/16 at 6:20 a.m., LVN D stated there was only one CNA scheduled on the secure unit during the shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16. LVN Dstated two CNAs were scheduled for the secure unit during the night shift because sometimes the residents wake up on the wrong side of the bed and start kicking at each other. In an interview on 02/18/16 at 6:30 a.m., CNA C stated she was the only CNA scheduled during the night shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16 in the secure unit. CNA C stated there were two CNAs scheduled in the secure unit about four to seven nights per week. CNA C stated one CNA could handle the secure unit when there were no problems. CNA C stated if she needed help at night on the secure unit she could press the call bell light or pull the call bell light from the wall and wait for help from staff in other parts of the facility. CNA C stated R #2 got up at night and was confused. CNA C stated she did not know that R #2 had inappropriate sexual behaviors or that it was added to her Care Plan on 01/28/16. In an interview on 02/18/16 at 8:45 a.m., LVN J stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. In an interview on 02/18/16 at 10:05 a.m., AA E stated she did not know R #2 had inappropriate sexual behaviors added to her Care Plan on 01/28/16. AA E stated she expected to be informed of any changes or new behaviors to monitor for resident. In an interview on 02/18/16 at 11:30 a.m., LVN K stated she was not informed that R #2 had inappropriate sexual behaviors or that it was added to her Care Plan on 01/28/16. LVN K stated that when Care Plans were updated direct care staff needed to be notified of new behaviors to monitor. In an interview on 02/18/16 at 12:05 p.m., Physician (PHY) U stated he was not aware and was not consulted by the facility regarding R #2's inappropriate sexual behaviors or that inappropriate sexual behaviors were added to R #2's Care Plan on 01/28/16. PHY U stated he expected to be notified within a couple of days of the change to add inappropriate sexual behaviors to one of his patient's Care Plan. In an interview on 02/18/16 at 12:15 p.m., LVN D stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. LVN D stated that change in R #2's Care Plan should have been communicated to staff. LVN D stated R #1 was moved out of the room with R #2 last month in January 2016 but she was not informed the reason for the roommate change. In an interview on 02/18/16 at 3:25 p.m., the administrator (ADM) stated she was aware that R #2 had inappropriate sexual behaviors added to her Care Plan 01/18/16 but that she thought it needed to be reworded because it was misleading. The ADM stated the situation that prompted R #2 ' s Care Plan to be changed was when a CNA witnessed R #2 assisting R #1 in their room. The ADM stated since R #1 did not appear distressed they added inappropriate sexual behaviors to R #2's Care Plan but I know it is wrong wording and should be interfere with care or over help other residents. The ADM stated that she added the inappropriate sexual behaviors to R #2's Care Plan to be better safe than sorry. The ADM stated the DON interviewed staff and determined the CNA did not see anything and R #1 was not distressed. The ADM stated the NPE went to the different halls of the facility with updates on care guides and the NPE was the mechanism the facility used to advise staff of changes necessary for resident care. In an interview on 02/18/16 at 3:40 p.m., the DON stated she received a call the next day regarding the situation between R #1 and R #2. The DON stated they moved R #1 to another room because she was sick and she notified R #1's Court Appointed Guardian regarding her room change. The DON stated she did an internal investigation and determined there was no reason to report an incident to DADS. In a telephone interview on 02/19/16 at 5:05 p.m., CNALstated she was in the hall of the secure unit at night in November and heard a noise in the room shared by R #1 and R #2. CNA L stated she entered the room and saw R #2 standing at R #1's bedside with her hand under R #1's covers. Record review of a piece of paper dated 11/14/15 received from the DON on 02/18/16 at 4:50 p.m. revealed the following: I was contacted by (NPE) at 11:18 a.m. stated she was told (R #2) was touching roommate by (CNA L) 11:40 a.m. (Nurse Aid NA G) - Reports (R #2) wakes up roommate throughout the night. No other behaviors noted 11:50 a.m. (LVN K) - states (R #2) is bossy tells other residents what to do but is re-directable. Sometimes paces. 11:50 a.m. (AA X) - states R #2 is affectionate with others no behaviors noted 12:10 p.m. (CNA L, LVN W, LVN Y) all interviewed with no sexual behaviors seen . (R #1) assessed for injury with none noted. (R #1) moved to another room to reduce risk of any behaviors and reassess at next care plan meeting. The paper was signed o 02/18/16 by the DON. Record review of R #1's Physician order [REDACTED].#1 was moved from bed A of the room she shared with R #2 into bed B of another room down the hall on 01/13/16 that was occupied by R #16. Record review of R #16's Physician order [REDACTED].#16 was moved from bed B of the room R #1 was moved to on 01/13/16. R #16 was moved into the A bed of the room with R #2 on 01/13/16. Record review of the facility daily census log for 01/08/16 revealed R #1 and R #2 shared a room. R #16 was listed as residing at the other end of the hall in bed B. Record review of the facility daily census log for 01/09/16 revealed R #2 and R #16 shared a room. R #1 was listed as residing in bed B of the room R #16 was listed in 01/08/16. In an interview on 02/18/16 at 4:50 p.m., the DON stated she did an internal investigation of the situation between R #1 and R #2 on 11/14/15 regarding R #2's behaviors and moved R #1 to another room on 11/14/15. The DON stated I moved R #1 in November 2015. I don't know why the Physicians Order says 01/13/16 because I moved her 11/14/15 .We moved (R #1.) Staff there helped me move her. Probably (LVN K) or (NA G.) I'm not sure. The DON stated she was notified of the situation between R #1 and R #2 on 11/14/15 and she had not received any other notifications from staff regarding R #1's behaviors toward R #2 since 11/14/15. The DON stated it was her decision to amend R #2's Care Plan for January 2016 to add sexually inappropriate behaviors on 01/28/16 but her decision was not related to the incident in November 2015. The DON stated I thought the inappropriate sexual behaviors were on (R #2's) old Care Plan so I added it from November (2015.) My thought it was a continuation we were not ready to resolve at that point. The DON stated she recalled the inappropriate sexual behaviors were in place on R #2's Care Plan prior to November 2015 on an old handwritten

Based on observation, interview, and record review, the facility Director of Nursing failed to provide services that met professional standards of quality for four Residents (R #1, R #2, R #7 and R #10) of nine Residents reviewed for neglect. -The Director of Nursing (DON) delayed treatment of [REDACTED]. -The DON delayed treatment of [REDACTED]. -The DON did not investigate, document, protect other residents or remove R #1 from the room she shared with R #2 when staff reported to the DON that R #2 had her hand under R #1's sheet during the night shift in November 2015. R #1 was hospitalized in November 2015 for Urosepsis (a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream.) -The DON did not investigate, document or protect other residents when staff reported that R #2 had her hands in R #1's pajama pants during the night shift in January 2016. -The DON did not make staff aware that sexually inappropriate behaviors were added to R #2's Care Plan on 01/28/16 and staff did not know to monitor R #2 for those interventions. -The DON did not notify R #1 and R #2's physician of the reported incident of R #2's hand under R #1's sheet in November 2015 nor of the incident of R #2's hand in R #1's brief in January 2016. -The DON did not notify R #1's responsible party of R #1's room change in January 2016 nor of the reported incident of R #2's hand under R #1's sheet in November 2015 nor of the incident of R #2's hand in R #1's brief in January 2016. -The DON did not follow the facility policy to report to the Texas Department of Aging and Disability Services (DADS) suspected or alleged neglect reported to the DON regarding the incidents of R #2's hand under R #1's sheet in November 2015 and of R #2's hand in R #1's brief in January 2016. These failures could place 24 residents who resided in the secure unit of the facility at risk for neglect from the facility to not provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The findings included: Texas Administrative Code, Title 22, Part 11, Chapter 217, Standards of Nursing Practice: 217.11 The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document; . (ii) nursing care rendered; . (iv) administration of medications and treatments; 217.12. Unprofessional Conduct. The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (1) Unsafe Practice - actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered or advanced practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11; (B) Carelessly or repeatedly failing to conform to generally accepted nursing standards in applicable practice settings; . (4) Careless or repetitive conduct that may endanger a client's life, health, or safety. Actual injury to a client need not be established R#7 Record review of R#7's Face Sheet dated 02/25/15 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. R#7 had the following Diagnoses: [REDACTED]. Ath. Usp. Graft, Chronic Asthma, [MEDICAL CONDITIONS] Reflux, [MEDICAL CONDITION], and Chronic Pain. Record review of R#7's Minimum Data Set ((MDS) dated [DATE] revealed R#7's [DIAGNOSES REDACTED]. R#7's MDS revealed she had clear speech, usually understood, and usually understood others. R#7 needed extensive assistance from one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R#7 was totally dependent on one person for physical assistance for bed mobility. Record review of R#7's Nurse's Notes by LVN Jdated 02/16/16 1200 revealed upon assessment resident (R#7) guarding left arm and complaining of pain. Swelling noted to left shoulder (refuses to move). Reported to physician. awaiting new orders. Medicated for pain . assisted to bed . Record review of R#7's Nurses Notes dated 02/16/16 2-10 pm revealed resident complained of severe left shoulder pain. Physician ordered x-ray. Taken at 8 pm ,no results yet. Resident observed for sleep in recliner in .area. Resident continues to hold left arm to her shoulder area. Record review of R#7's Nurses Notes( by LVN J) dated 02/17/16 1530 revealed discoloration noted to left arm measuring approximately 1.3 cm (centimeter) Asked in report of origin of injury. Informed resident had been hitting and grabbing at arm. Informed that X-ray of possible fracture had been reported to DON. Informed DON of discoloration and pain. Call to physician. N.O. (new order) to transfer to local hospital for evaluation and treatment. During a telephone interview on 02/17/16 at 3:30 p.m. ,LVN F (night nurse) stated -had called the DON on 02/15/16 at 11:45 p.m to report R#7 was not able to move her left arm to assist with her own toileting. - R#7 was screaming in pain and agitated but no bruising was noted - R#7's baseline was no reported pain in her left arm and R#7 was able to use both arms to assist in her own toileting with out pain R#7 was up all night her shift starting at 10:00 p.m. on 02/15/16 through 6:00 a.m on 02/16/16 and R#7 picked and grabbed at her left arm during that time -she (LVNF) retrieved an X-ray result after 11:00 p.m.for R#7 from the fax machine and called the DON at that time to report a positive X-ray for a fracture to R#7's left Humerus. -she (LVNF) stated the DON said she would call Physician (PHY) in the morning to report R#7's positive X-ray results. -she (LVNF ) was instructed to medicate R#7 for pain -LVNF stated the facility's policy is to call the Physician with changes in resident condition -she (LVNF) gave report to LVNJ at 6:00 a.m. on 02/17/16 regarding R#7's positive X-ray results and at that time the DON had not come to see R#7 and the Physician had not called with orders to treat R#7. On 02/17/16 at 12:25 p.m., LVN Jstated she was told yesterday (2/16/16) that R#7 had arm pain. She (LVNJ) noted swelling and advised R#7's physician. This morning (02/17/16) she was told the X-ray report had come for R#7 at 8:56 p.m.on 02/16/16. LVNJ replied the night nurse (LVNF) had called the DON about R#7's X-ray result. LVNJ replied it was reported to her that the DON did not call the Physician about R#7's X-ray result. LVNJ said she had spoken to the DON about 7:30 to 8:00 a.m. on 02/17/16/. LVN J said I called the physician on 02/17/16 at 11:30 a.m and asked if he (Physician) knew the results of R#7's X-ray report. LVNJ replied ,the Physician said no ;X-ray report was read to the Physician. Review of Physicians's t.o. (telephone order) dated 02/17/16 1130 revealed transfer to local hospital for evaluation and treatment fracture left arm. Review of R#7's Radiology Report with DOS (date of service) 02/16/16 (final report faxed to facility on 02/16/16 20:56 ) revealed Conclusion Subtle cortical disruption in left humeral neck suspicious of impacted non-displaced fracture, with modest inferior subluxation of left humeral head. F/U (follow -up) recommended. R #10 Record review of R #10's Face Sheet dated 02/03/16 revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #10's physician was PHY U, the Medical Director for the facility. Record review of R #10's current Minimum Data Set ((MDS) dated [DATE] revealed R #10's [DIAGNOSES REDACTED]. R #10's MDS revealed she was incapable of speech, rarely or never made herself understood and rarely or never understood others. R #10's MDS revealed her cognitive skills for daily decision making was coded as severely impaired and she never or rarely made decisions. R #10 was totally dependent on one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R #10 required extensive assistance from one person for bed mobility, locomotion in her wheelchair and eating. Record review of R #10's Care Plan dated 01/30/16 revealed R #10 exhibited symptoms of decline on cognitive function related to dementia. R #10 was at risk for falls due to cognitive loss, lack of safety awareness as she slid forward in her wheelchair and tipped wheelchair backward. Interventions included assess for changes in medical status, pain status, mental status and report to the physician as indicated. Record review of R #10's Nurses Notes dated 02/16/16 at 1:00 p.m. revealed R #10 had swelling and heat to the left lower extremity reported to and evaluated by Physician (PHY) U. Record review of R #10's Nurses Notes dated 02/16/15 from the 2:00 p.m. to 10:00 p.m. shift revealed PHY U ordered a Venous Doppler (ultrasound that uses sound waves to produce pictures of the body's veins) to R #10's left leg due to swelling and redness. Record review of R #10's Nurses Notes dated 02/17/16 at 7:00 a.m. revealed R #10 was assessed with [REDACTED]. Observation on 02/17/16 at 11:45 a.m. revealed R #10 sitting in her wheelchair in the dining room of the secured unit at a table with another resident. R #10 shifted in her wheelchair often and leaned on her right hip and the right arm rest of her wheelchair while she looked out the window. R # 10 pulled at and lifted the left corner of her shirt. Record review of R #10's Nurses Notes dated 02/17/16 from the 2:00 p.m. to 10:00 p.m. shift revealed R #10 was assessed and continued to have swelling and redness to her left leg. R # 10's left leg had a slight discoloration to the area. The Venous Doppler to R #10's left leg was performed at 4:00 p.m. on 02/17/16 and the technician who performed the ultrasound stated to the nurse that results could take 24 hours to receive. Observation on 02/18/16 at 7:45 a.m. revealed R #10 sitting in her wheelchair at a table in the dining room of the secured unit at a table with another resident. R #10 was able to feed herself and was restless as she shifted positions in her wheelchair. Record review of R #10's Nurses Notes dated 02/18/16 at 12:00 p.m. revealed the results of R #10's Venous Doppler were given to PHY U and the nurse reported to PHY U that R #10's left leg remained swollen with multiple areas of dark discoloration. Discolored areas of R #10's left leg included her left knee, left outer leg, left heel, left outer thigh, left calf and left inner knee. LVN J documented she showed the discolored areas of R #10's left leg to the Assistant Director of Nursing (ADON) and LVN J reported the multiple areas of discoloration to the Director of Nursing (DON.) Record review of R #10's physician's orders [REDACTED].#10 was to have X-rays of her left hip and left knee. Record review of R #10's Nurses Notes dated 02/18/16 from the 2:00 p.m. to 10:00 p.m. shift revealed a new order from PHY U for an X-ray to R #10's left leg including her knee, ankle and foot. The DON was to be notified with the results of the X-ray. R #10 was assessed to have swelling and redness with skin discoloration noted to her left leg that were warm to touch. Record review of R #10's Radiology Report faxed to the facility on [DATE] at 12:42 a.m. revealed R #10 had an acute left knee fracture that involved the left distal femur (long bone in the thigh close to the knee.) Record review of R #10's Nurses Notes dated 02/19/16 at 12:30 a.m. signed by LVN W revealed the results of R #10's X-ray were reported to the DON. The documented response from the DON was that she would take care of this in the morning. Record review of the facility Nursing Home to Hospital Transfer Form for R #10 dated 02/19/16 revealed R #10 was given two Tylenol Extra Strength 500 milligram (mg) tablets on 02/19/16 at 8:40 a.m. and her last set of vital signs was taken on 02/19/16 at 9:00 a.m. Record review of R #10's Nurses Notes dated 02/19/16 at 1:30 p.m. by LVN W revealed R #10 was sent out to the hospital and transported by Emergency Medical Services (EMS.) A telephone follow-up to the local hospital revealed R #10 was a probable admit. In an interview on 02/19/16 at 2:40 p.m. LVN K stated she worked in the secure unit 02/19/16 from 6:00 a.m. to 2:00 p.m. LVN K stated she took report this morning from LVN W that revealed that X-ray results received after midnight showed R #10 had a fractured left femur. LVN K stated she called PHY U at 8:00 a.m. on 02/19/16 as she had not been contacted by the DON regarding care for R #10. LVN K stated PHY U stated he was on call the night of 02/18/16 and early morning of 02/19/16 and he was not aware of the results of R #10's X-ray. LVN K stated PHY U ordered R #10 be sent to the hospital by EMS. LVN K stated she called R #10's family member and legal representative and they were not aware R #10 had a fractured femur. LVN K stated she saw the DON about 9:30 a.m. or 10:00 a.m. on 02/19/16 and informed the DON R #10 was sent out to the hospital as per PHY U orders. LVN K stated that the DON replied to her R #10 had pathological fractures (bone fracture caused by disease that led to weakness of the bone structure.) LVN K stated to the surveyor that regardless if it was one fracture or multiple fractures R #10 still needed to be treated because R #10 shouldn't have to hurt. In an interview on 02/19/16 at 3:30 p.m., the DON stated she was aware that PHY U had ordered an X-ray for R #10 on 02/18/16 at 3:00 p.m. The DON stated LVN W called her at home at 12:45 a.m. on 02/19/16 with the results of R #10's X-ray and said that we needed to call the doctor. The DON stated she did not call PHY U regarding results of R #10's X-ray showing a fractured femur but that the floor nurse called and notified PHY U in the morning. The DON stated PHY U was not on call at that time on 02/19/16 but another physician. The DON stated PHY U was particular that nursing staff call him and not the physician on call regarding his residents' medical conditions. In an interview on 02/17/16 at 3:30 p.m., LVN F stated PHY U will accept calls regarding his residents' change of condition while he is on call. LVN F stated PHY U did not want facility staff to call the on call physician for changes in his residents ' condition if PHY U was not on call. LVN F stated PHY U wanted to be the only physician to treat his residents. LVN F stated she used her nursing judgment to determine if a resident change of condition was an emergency and needed to be reported to the physician on call for PHY U. Record review of a written Physician order [REDACTED]. Call me with All med changes made to ANY of my patients. If I am not on call, wait to call ME personally when I am back on call. The order was delivered to the surveyor by the DON on 02/19/16 at 5:45 p.m. as requested documentation of PHY U orders to facility staff informing when staff were to notify PHY U of changes in condition or treatment for [REDACTED]. Record review of a written statement from PHY U dated 02/19/16 and received after 5:45 p.m. revealed PHY U was aware that R #10 had swelling in her left leg since 02/16/16 and he ordered a Venous Doppler to check if R #10 had a blood clot in her left leg. The Venous Doppler results revealed R #10 did not have a blood clot in her left leg on 02/18/16 so at that time he ordered an X-ray of R 10's left leg. PHY U stated R #10's X-ray report came in to the facility at 12:45 a.m. on 02/19/16 and he was called with the results at 8:00 a.m. on 02/19/16 regarding R #10's new [DIAGNOSES REDACTED]. PHY U stated he felt that R #10's X-ray represented a new [DIAGNOSES REDACTED]. PHY U stated he felt the notification he received at 8:00 a.m. on 02/19/16 was appropriate and timely and led to the proper treatment of [REDACTED]. In a telephone interview on 02/19/16 at 4:20 p.m., PHY U stated he was on call the night of 02/18/16 and morning of 02/19/16. PHY U stated when he is not on call he does not want facility staff to call the on call physician about his residents unless it is a true emergency. PHY U stated facility staff was to wait to notify him when he was back on call regarding changes in his residents' medical conditions or need for treatment changes. In an interview on 02/19/16 at 5:00 p.m., the Assistant Director of Nursing (ADON) stated the facility did not instruct her on a requirement to report changes of condition only to PHY U and not to the physician on call regarding his residents at the facility. The ADON stated the facility did not instruct her on what PHY U considered an emergency condition that would require the consultation of the on call physician. R #2 Record review of R #2's Face Sheet dated 12/05/15 revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review on 01/28/16 of R #2's Care Plan revised revealed in a focus area that R #2 displayed inappropriate sexual behaviors at times. The goal for this behavior included R #2 would not exhibit at risk or inappropriate sexual behaviors that affected other patients, staff, or visitors. Facility staff interventions to meet this goal included the following: -Review behavioral expectations with patient. -Observe and report verbal and/or physical sexual behaviors exhibited and report to the licensed nurse immediately. -Notify physician if sexually inappropriate behavior is exhibited. -Observe and report change in mood state to licensed nurse immediately. -Remove from common areas when sexually inappropriate behavior is exhibited -Attempt to refocus the patient's behavior to something positive when he or she exhibits inappropriate sexual behavior. -Assist the patient in identifying problem causing stimuli. on 01/14/16 R #2's Care Plan included a focus area initiated and created by the Director of Nursing (DON) stating R #2 exhibited or was at risk for complications of infection related to a Urinary Tract Infection (UTI.) Facility staff intervention included facility staff was to assist resident with hand washing throughout the day as needed. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 resided in the Transitions Unit (secured unit) due to being at risk for elopement (leaving the facility.) Facility staff interventions included monitoring R #2 frequently to assure her safety. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 had poor safety awareness. Facility staff interventions included monitoring for changes in R #2's condition that may warrant increased supervision or assistance and notify the physician as needed. R #2's interventions included she needed adequate lighting to see at night. R #2's Care Plan included a focus area imitated on 07/16/13 that stated R #2 had difficulty making her own decisions. Facility staff interventions included assisting R #2 with decision making as needed and report any changes in R #2's level of consciousness to the physician. Record review of R #2's current Minimum Data Set ((MDS) dated [DATE] revealed R #2 had a Brief Interview for Mental Status (BIMS) score of four out of a possible 15 points. R #2 understood others with clear comprehension and was able to make herself understood. R #2 spoke clearly and had adequate hearing and vision. R #2's MDS was coded as she had no behaviors, hallucinations or delusions. R #2 was independent and required no assistance from staff for bed mobility, transfer or ambulation. R #2 required supervision and setup help only for dressing, eating, personal hygiene and bathing. R #2 was able to toilet herself with supervision only. In a telephone interview on 02/17/16 at 3:10 p.m., LVN Fstated approximately one month prior at 5:00 a.m. she entered the room shared by R #1 and R #2 on the secured unit to give R #2 a scheduled medication. LVN F stated when she entered the room she saw R #2 standing beside R #1's bed. R #2 had her hand in R #1's pajama bottoms. LVN F stated R #1's blankets were pulled down and she wore an incontinent brief. LVN F stated as soon as she entered the room shared by R #1 and R #2, R #2 removed her hand from R #1's pajama pants and crossed the room to sit on her bed and asked LVN F what do you have for me? LVN F stated she told R #2 that she had the [MEDICAL CONDITION] medication. LVN F stated R #2 said Oh yes, that one. LVN F stated she medicated R #2 and left the room with R #2 sitting on her bed and R #1 lying in her bed. LVN F stated she did not know how or where to document the incident she witnessed between R #2 and R #1 so at 5:15 a.m. on that morning she called the Director of Nurses (DON) and informed the DON what she witnessed at 5:00 a.m. LVN F stated the DON told her to keep an eye on them and let me know if anything else happens. LVN F stated the DON did not tell her to write a report or call the physician. LVN F stated the DON told her We'll take care of it. LVN F stated she was not told nor was she aware that inappropriate sexual behaviors were added to R #1's Care Plan on 01/28/16. LVN F stated the facility staffing ratio for night shift; 10:00 p.m. to 6:00 a.m.; was to include two CNAs in the secure unit, one CNA for hall 200, one CNA for hall 300 and two nurses for the facility. LVN F stated they often only had one CNA in the secure unit, one CNA on hall 200, one CNA for hall 300 and two nurses to cover the entire facility during the 10:00 p.m. to 6:00 a.m. shift. On 02/18/16 record review of nurse's notes revealed there were no notes indicating LVN F called the DON to notify her of the situation. There were no notes indicating the physician or family had been notified. There were no incident reports, new assessments, or care plans updated. Observation on 02/18/16 at 5:50 a.m. revealed three residents ambulating in the hall of the secure unit and two residents seated in the dining room of the secure unit. CNA C was the only staff member on the secure unit. In an interview on 02/18/16 at 6:20 a.m., LVN D stated there was only one CNA scheduled on the secure unit during the shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16. LVN Dstated two CNAs were scheduled for the secure unit during the night shift because sometimes the residents wake up on the wrong side of the bed and start kicking at each other. In an interview on 02/18/16 at 6:30 a.m., CNA C stated she was the only CNA scheduled during the night shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16 in the secure unit. CNA C stated there were two CNAs scheduled in the secure unit about four to seven nights per week. CNA C stated one CNA could handle the secure unit when there were no problems. CNA C stated if she needed help at night on the secure unit she could press the call bell light or pull the call bell light from the wall and wait for help from staff in other parts of the facility. CNA C stated R #2 got up at night and was confused. CNA C stated she did not know that R #2 had inappropriate sexual behaviors or that it was added to her Care Plan on 01/28/16. In an interview on 02/18/16 at 8:45 a.m., LVN J stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. In an interview on 02/18/16 at 10:05 a.m., AA E stated she did not know R #2 had inappropriate sexual behaviors added to her Care Plan on 01/28/16. AA E stated she expected to be informed of any changes or new behaviors to monitor for resident. In an interview on 02/18/16 at 11:30 a.m., LVN K stated she was not informed that R #2 had inappropriate sexual behaviors or that it was added to her Care Plan on 01/28/16. LVN K stated that when Care Plans were updated direct care staff needed to be notified of new behaviors to monitor. In an interview on 02/18/16 at 12:05 p.m., Physician (PHY) U stated he was not aware and was not consulted by the facility regarding R #2's inappropriate sexual behaviors or that inappropriate sexual behaviors were added to R #2's Care Plan on 01/28/16. PHY U stated he expected to be notified within a couple of days of the change to add inappropriate sexual behaviors to one of his patient's Care Plan. In an interview on 02/18/16 at 12:15 p.m., LVN D stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. LVN D stated that change in R #2's Care Plan should have been communicated to staff. LVN D stated R #1 was moved out of the room with R #2 last month in January 2016 but she was not informed the reason for the roommate change. In an interview on 02/18/16 at 3:25 p.m., the administrator (ADM) stated she was aware that R #2 had inappropriate sexual behaviors added to her Care Plan 01/18/16 but that she thought it needed to be reworded because it was misleading. The ADM stated the situation that prompted R #2 ' s Care Plan to be changed was when a CNA witnessed R #2 assisting R #1 in their room. The ADM stated since R #1 did not appear distressed they added inappropriate sexual behaviors to R #2's Care Plan but I know it is wrong wording and should be interfere with care or over help other residents. The ADM stated that she added the inappropriate sexual behaviors to R #2's Care Plan to be better safe than sorry. The ADM stated the DON interviewed staff and determined the CNA did not see anything and R #1 was not distressed. The ADM stated the NPE went to the different halls of the facility with updates on care guides and the NPE was the mechanism the facility used to advise staff of changes necessary for resident care. In an interview on 02/18/16 at 3:40 p.m., the DON stated she received a call the next day regarding the situation between R #1 and R #2. The DON stated they moved R #1 to another room because she was sick and she notified R #1's Court Appointed Guardian regarding her room change. The DON stated she did an internal investigation and determined there was no reason to report an incident to DADS. In a telephone interview on 02/19/16 at 5:05 p.m., CNALstated she was in the hall of the secure unit at night in November and heard a noise in the room shared by R #1 and R #2. CNA L stated she entered the room and saw R #2 standing at R #1's bedside with her hand under R #1's covers. Record review of a piece of paper dated 11/14/15 received from the DON on 02/18/16 at 4:50 p.m. revealed the following: I was contacted by (NPE) at 11:18 a.m. stated she was told (R #2) was touching roommate by (CNA L) 11:40 a.m. (Nurse Aid NA G) - Reports (R #2) wakes up roommate throughout the night. No other behaviors noted 11:50 a.m. (LVN K) - states (R #2) is bossy tells other residents what to do but is re-directable. Sometimes paces. 11:50 a.m. (AA X) - states R #2 is affectionate with others no behaviors noted 12:10 p.m. (CNA L, LVN W, LVN Y) all interviewed with no sexual behaviors seen . (R #1) assessed for injury with none noted. (R #1) moved to another room to reduce risk of any behaviors and reassess at next care plan meeting. The paper was signed o 02/18/16 by the DON. Record review of R #1's Physician order [REDACTED].#1 was moved from bed A of the room she shared with R #2 into bed B of another room down the hall on 01/13/16 that was occupied by R #16. Record review of R #16's Physician order [REDACTED].#16 was moved from bed B of the room R #1 was moved to on 01/13/16. R #16 was moved into the A bed of the room with R #2 on 01/13/16. Record review of the facility daily census log for 01/08/16 revealed R #1 and R #2 shared a room. R #16 was listed as residing at the other end of the hall in bed B. Record review of the facility daily census log for 01/09/16 revealed R #2 and R #16 shared a room. R #1 was listed as residing in bed B of the room R #16 was listed in 01/08/16. In an interview on 02/18/16 at 4:50 p.m., the DON stated she did an internal investigation of the situation between R #1 and R #2 on 11/14/15 regarding R #2's behaviors and moved R #1 to another room on 11/14/15. The DON stated I moved R #1 in November 2015. I don't know why the Physicians Order says 01/13/16 because I moved her 11/14/15 .We moved (R #1.) Staff there helped me move her. Probably (LVN K) or (NA G.) I'm not sure. The DON stated she was notified of the situation between R #1 and R #2 on 11/14/15 and she had not received any other notifications from staff regarding R #1's behaviors toward R #2 since 11/14/15. The DON stated it was her decision to amend R #2's Care Plan for January 2016 to add sexually inappropriate behaviors on 01/28/16 but her decision was not related to the incident in November 2015. The DON stated I thought the inappropriate sexual behaviors were on (R #2's) old Care Plan so I added it from November (2015.) My thought it was a continuation we were not ready to resolve at that point. The DON stated she

Based on observation, interview and record review, the facility failed to be administered in a anner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for four Residents (R #1, R #2, # 7 and R #10) of nine Residents reviewed for neglect. The facility Administrator did not: - Implement policies and procedures that prohibit abuse, neglect and injuries of unknown origin. - Supervise the Director of Nurses to ensure she reported suspected abuse or neglect of R #1 and R #2 within 24 hours to officials in accordance with state law. - Notify the families and attending Physician (PHY) U about suspected abuse or neglect regarding R#1 and R#2. - Notify the Texas Department of Aging and Disability Services within 24 hours upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect or injury of unknown origin. - Take immediate action to protect R #1 and prevent occurrences of similar incidents. - Initiate an investigation within 24 hours of an allegation of abuse or neglect that focused on whether abuse or neglect occurred and to what extent; clinical examination for sign of injuries, if indicated; causative factors and interventions to prevent further injury. - Ensure that documentation of witnessed interviews was conducted and included conduct interview using the Alleged Perpetrator Victim Interview Record and Witness Interview Record. The facility DON did not: - Implement policies and procedures that prohibit abuse, neglect and injuries of unknown origin. - Initiate an investigation within 24 hours of an allegation of abuse or neglect that focused on whether abuse or neglect occurred and to what extent; clinical examination for sign of injuries, if indicated; causative factors and interventions to prevent further injury. - Provide staff with information on how they may report concerns and incidents without fear of retribution and provide feedback regarding the expressed concerns. - Notify the families and attending Physician (PHY) U about suspected abuse or neglect regarding R #1 and R #2. - Take immediate action to protect R #1 and prevent occurrences of similar incidents. - Ensure that documentation of witnessed interviews was conducted and included conduct interview using the Alleged Perpetrator Victim Interview Record and Witness Interview Record. - Immediately consult R #2's attending physician of behavior changes that required increased Physician and staff monitoring. - Promptly notify R #1's legal representative that R #1 changed rooms and the reason for the move. - Promptly notify R #10's physician herself or provide staff instructions to promptly notify R #10's physician of X-ray results of a new fracture in R #10's femur (bone in upper leg.) These failures could place 24 residents who resided in the secure unit of the facility at risk for neglect from the facility to not provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The findings were: R#7 Record review of R#7's Face Sheet dated 02/25/15 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. R#7 had the following Diagnoses: [REDACTED]. Ath. Usp. Graft, Chronic Asthma, [MEDICAL CONDITIONS] Reflux, [MEDICAL CONDITION], and Chronic Pain. Record review of R#7's Minimum Data Set ((MDS) dated [DATE] revealed R#7's [DIAGNOSES REDACTED]. R#7's MDS revealed she had clear speech, usually understood, and usually understood others. R#7 needed extensive assistance from one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R#7 was totally dependent on one person for physical assistance for bed mobility. Record review of R#7's Nurse's Notes by LVN Jdated 02/16/16 1200 revealed upon assessment resident (R#7) guarding left arm and complaining of pain. Swelling noted to left shoulder (refuses to move). Reported to physician. awaiting new orders. Medicated for pain . assisted to bed . Record review of R#7's Nurses Notes dated 02/16/16 2-10 pm revealed resident complained of severe left shoulder pain. Physician ordered x-ray. Taken at 8 pm ,no results yet. Resident observed for sleep in recliner in .area. Resident continues to hold left arm to her shoulder area. Record review of R#7's Nurses Notes( by LVN J) dated 02/17/16 1530 revealed discoloration noted to left arm measuring approximately 1.3 cm (centimeter) Asked in report of origin of injury. Informed resident had been hitting and grabbing at arm. Informed that X-ray of possible fracture had been reported to DON. Informed DON of discoloration and pain. Call to physician. N.O. (new order) to transfer to local hospital for evaluation and treatment. During a telephone interview on 02/17/16 at 3:30 p.m. ,LVN F (night nurse) stated -had called the DON on 02/15/16 at 11:45 p.m to report R#7 was not able to move her left arm to assist with her own toileting. - R#7 was screaming in pain and agitated but no bruising was noted - R#7's baseline was no reported pain in her left arm and R#7 was able to use both arms to assist in her own toileting with out pain R#7 was up all night her shift starting at 10:00 p.m. on 02/15/16 through 6:00 a.m on 02/16/16 and R#7 picked and grabbed at her left arm during that time -she (LVNF) retrieved an X-ray result after 11:00 p.m.for R#7 from the fax machine and called the DON at that time to report a positive X-ray for a fracture to R#7's left Humerus. -she (LVNF) stated the DON said she would call Physician (PHY) in the morning to report R#7's positive X-ray results. -she (LVNF ) was instructed to medicate R#7 for pain -LVNF stated the facility's policy is to call the Physician with changes in resident condition -she (LVNF) gave report to LVNJ at 6:00 a.m. on 02/17/16 regarding R#7's positive X-ray results and at that time the DON had not come to see R#7 and the Physician had not called with orders to treat R#7. On 02/17/16 at 12:25 p.m., LVN Jstated she was told yesterday (2/16/16) that R#7 had arm pain. She (LVNJ) noted swelling and advised R#7's physician. This morning (02/17/16) she was told the X-ray report had come for R#7 at 8:56 p.m.on 02/16/16. LVNJ replied the night nurse (LVNF) had called the DON about R#7's X-ray result. LVNJ replied it was reported to her that the DON did not call the Physician about R#7's X-ray result. LVNJ said she had spoken to the DON about 7:30 to 8:00 a.m. on 02/17/16/. LVN J said I called the physician on 02/17/16 at 11:30 a.m and asked if he (Physician) knew the results of R#7's X-ray report. LVNJ replied ,the Physician said no ;X-ray report was read to the Physician. Review of Physicians's t.o. (telephone order) dated 02/17/16 1130 revealed transfer to local hospital for evaluation and treatment fracture left arm. Review of R#7's Radiology Report with DOS (date of service) 02/16/16 (final report faxed to facility on 02/16/16 20:56 ) revealed Conclusion Subtle cortical disruption in left humeral neck suspicious of impacted non-displaced fracture, with modest inferior subluxation of left humeral head. F/U (follow -up) recommended. R #10 Record review of R #10's Face Sheet dated 02/03/16 revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #10's physician was PHY U, the Medical Director for the facility. Record review of R #10's current Minimum Data Set ((MDS) dated [DATE] revealed R #10's [DIAGNOSES REDACTED]. R #10's MDS revealed she was incapable of speech, rarely or never made herself understood and rarely or never understood others. R #10's MDS revealed her cognitive skills for daily decision making was coded as severely impaired and she never or rarely made decisions. R #10 was totally dependent on one person for physical assistance for dressing, toilet use, personal hygiene and bathing. R #10 required extensive assistance from one person for bed mobility, locomotion in her wheelchair and eating. Record review of R #10's Care Plan dated 01/30/16 revealed R #10 exhibited symptoms of decline on cognitive function related to dementia. R #10 was at risk for falls due to cognitive loss, lack of safety awareness as she slid forward in her wheelchair and tipped wheelchair backward. Interventions included assess for changes in medical status, pain status, mental status and report to the physician as indicated. Record review of R #10's Nurses Notes dated 02/16/16 at 1:00 p.m. revealed R #10 had swelling and heat to the left lower extremity reported to and evaluated by Physician (PHY) U. Record review of R #10's Nurses Notes dated 02/16/15 from the 2:00 p.m. to 10:00 p.m. shift revealed PHY U ordered a Venous Doppler (ultrasound that uses sound waves to produce pictures of the body's veins) to R #10's left leg due to swelling and redness. Record review of R #10's Nurses Notes dated 02/17/16 at 7:00 a.m. revealed R #10 was assessed with [REDACTED]. Observation on 02/17/16 at 11:45 a.m. revealed R #10 sitting in her wheelchair in the dining room of the secured unit at a table with another resident. R #10 shifted in her wheelchair often and leaned on her right hip and the right arm rest of her wheelchair while she looked out the window. R # 10 pulled at and lifted the left corner of her shirt. Record review of R #10's Nurses Notes dated 02/17/16 from the 2:00 p.m. to 10:00 p.m. shift revealed R #10 was assessed and continued to have swelling and redness to her left leg. R # 10's left leg had a slight discoloration to the area. The Venous Doppler to R #10's left leg was performed at 4:00 p.m. on 02/17/16 and the technician who performed the ultrasound stated to the nurse that results could take 24 hours to receive. Observation on 02/18/16 at 7:45 a.m. revealed R #10 sitting in her wheelchair at a table in the dining room of the secured unit at a table with another resident. R #10 was able to feed herself and was restless as she shifted positions in her wheelchair. Record review of R #10's Nurses Notes dated 02/18/16 at 12:00 p.m. revealed the results of R #10's Venous Doppler were given to PHY U and the nurse reported to PHY U that R #10's left leg remained swollen with multiple areas of dark discoloration. Discolored areas of R #10's left leg included her left knee, left outer leg, left heel, left outer thigh, left calf and left inner knee. LVN J documented she showed the discolored areas of R #10's left leg to the Assistant Director of Nursing (ADON) and LVN J reported the multiple areas of discoloration to the Director of Nursing (DON.) Record review of R #10's physician's orders [REDACTED].#10 was to have X-rays of her left hip and left knee. Record review of R #10's Nurses Notes dated 02/18/16 from the 2:00 p.m. to 10:00 p.m. shift revealed a new order from PHY U for an X-ray to R #10's left leg including her knee, ankle and foot. The DON was to be notified with the results of the X-ray. R #10 was assessed to have swelling and redness with skin discoloration noted to her left leg that were warm to touch. Record review of R #10's Radiology Report faxed to the facility on [DATE] at 12:42 a.m. revealed R #10 had an acute left knee fracture that involved the left distal femur (long bone in the thigh close to the knee.) Record review of R #10's Nurses Notes dated 02/19/16 at 12:30 a.m. signed by LVN W revealed the results of R #10's X-ray were reported to the DON. The documented response from the DON was that she would take care of this in the morning. Record review of the facility Nursing Home to Hospital Transfer Form for R #10 dated 02/19/16 revealed R #10 was given two Tylenol Extra Strength 500 milligram (mg) tablets on 02/19/16 at 8:40 a.m. and her last set of vital signs was taken on 02/19/16 at 9:00 a.m. Record review of R #10's Nurses Notes dated 02/19/16 at 1:30 p.m. by LVN W revealed R #10 was sent out to the hospital and transported by Emergency Medical Services (EMS.) A telephone follow-up to the local hospital revealed R #10 was a probable admit. In an interview on 02/19/16 at 2:40 p.m. LVN K stated she worked in the secure unit 02/19/16 from 6:00 a.m. to 2:00 p.m. LVN K stated she took report this morning from LVN W that revealed that X-ray results received after midnight showed R #10 had a fractured left femur. LVN K stated she called PHY U at 8:00 a.m. on 02/19/16 as she had not been contacted by the DON regarding care for R #10. LVN K stated PHY U stated he was on call the night of 02/18/16 and early morning of 02/19/16 and he was not aware of the results of R #10's X-ray. LVN K stated PHY U ordered R #10 be sent to the hospital by EMS. LVN K stated she called R #10's family member and legal representative and they were not aware R #10 had a fractured femur. LVN K stated she saw the DON about 9:30 a.m. or 10:00 a.m. on 02/19/16 and informed the DON R #10 was sent out to the hospital as per PHY U orders. LVN K stated that the DON replied to her R #10 had pathological fractures (bone fracture caused by disease that led to weakness of the bone structure.) LVN K stated to the surveyor that regardless if it was one fracture or multiple fractures R #10 still needed to be treated because R #10 shouldn't have to hurt. In an interview on 02/19/16 at 3:30 p.m., the DON stated she was aware that PHY U had ordered an X-ray for R #10 on 02/18/16 at 3:00 p.m. The DON stated LVN W called her at home at 12:45 a.m. on 02/19/16 with the results of R #10's X-ray and said that we needed to call the doctor. The DON stated she did not call PHY U regarding results of R #10's X-ray showing a fractured femur but that the floor nurse called and notified PHY U in the morning. The DON stated PHY U was not on call at that time on 02/19/16 but another physician. The DON stated PHY U was particular that nursing staff call him and not the physician on call regarding his residents' medical conditions. In an interview on 02/17/16 at 3:30 p.m., LVN F stated PHY U will accept calls regarding his residents' change of condition while he is on call. LVN F stated PHY U did not want facility staff to call the on call physician for changes in his residents ' condition if PHY U was not on call. LVN F stated PHY U wanted to be the only physician to treat his residents. LVN F stated she used her nursing judgment to determine if a resident change of condition was an emergency and needed to be reported to the physician on call for PHY U. Record review of a written Physician order [REDACTED]. Call me with All med changes made to ANY of my patients. If I am not on call, wait to call ME personally when I am back on call. The order was delivered to the surveyor by the DON on 02/19/16 at 5:45 p.m. as requested documentation of PHY U orders to facility staff informing when staff were to notify PHY U of changes in condition or treatment for [REDACTED]. Record review of a written statement from PHY U dated 02/19/16 and received after 5:45 p.m. revealed PHY U was aware that R #10 had swelling in her left leg since 02/16/16 and he ordered a Venous Doppler to check if R #10 had a blood clot in her left leg. The Venous Doppler results revealed R #10 did not have a blood clot in her left leg on 02/18/16 so at that time he ordered an X-ray of R 10's left leg. PHY U stated R #10's X-ray report came in to the facility at 12:45 a.m. on 02/19/16 and he was called with the results at 8:00 a.m. on 02/19/16 regarding R #10's new [DIAGNOSES REDACTED]. PHY U stated he felt that R #10's X-ray represented a new [DIAGNOSES REDACTED]. PHY U stated he felt the notification he received at 8:00 a.m. on 02/19/16 was appropriate and timely and led to the proper treatment of [REDACTED]. In a telephone interview on 02/19/16 at 4:20 p.m., PHY U stated he was on call the night of 02/18/16 and morning of 02/19/16. PHY U stated when he is not on call he does not want facility staff to call the on call physician about his residents unless it is a true emergency. PHY U stated facility staff was to wait to notify him when he was back on call regarding changes in his residents' medical conditions or need for treatment changes. In an interview on 02/19/16 at 5:00 p.m., the Assistant Director of Nursing (ADON) stated the facility did not instruct her on a requirement to report changes of condition only to PHY U and not to the physician on call regarding his residents at the facility. The ADON stated the facility did not instruct her on what PHY U considered an emergency condition that would require the consultation of the on call physician. R #2 Record review of R #2's Face Sheet dated 12/05/15 revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review on 01/28/16 of R #2's Care Plan revised revealed in a focus area that R #2 displayed inappropriate sexual behaviors at times. The goal for this behavior included R #2 would not exhibit at risk or inappropriate sexual behaviors that affected other patients, staff, or visitors. Facility staff interventions to meet this goal included the following: -Review behavioral expectations with patient. -Observe and report verbal and/or physical sexual behaviors exhibited and report to the licensed nurse immediately. -Notify physician if sexually inappropriate behavior is exhibited. -Observe and report change in mood state to licensed nurse immediately. -Remove from common areas when sexually inappropriate behavior is exhibited -Attempt to refocus the patient's behavior to something positive when he or she exhibits inappropriate sexual behavior. -Assist the patient in identifying problem causing stimuli. on 01/14/16 R #2's Care Plan included a focus area initiated and created by the Director of Nursing (DON) stating R #2 exhibited or was at risk for complications of infection related to a Urinary Tract Infection (UTI.) Facility staff intervention included facility staff was to assist resident with hand washing throughout the day as needed. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 resided in the Transitions Unit (secured unit) due to being at risk for elopement (leaving the facility.) Facility staff interventions included monitoring R #2 frequently to assure her safety. R #2's Care Plan included a focus area initiated on 07/16/13 that stated R #2 had poor safety awareness. Facility staff interventions included monitoring for changes in R #2's condition that may warrant increased supervision or assistance and notify the physician as needed. R #2's interventions included she needed adequate lighting to see at night. R #2's Care Plan included a focus area imitated on 07/16/13 that stated R #2 had difficulty making her own decisions. Facility staff interventions included assisting R #2 with decision making as needed and report any changes in R #2's level of consciousness to the physician. Record review of R #2's current Minimum Data Set ((MDS) dated [DATE] revealed R #2 had a Brief Interview for Mental Status (BIMS) score of four out of a possible 15 points. R #2 understood others with clear comprehension and was able to make herself understood. R #2 spoke clearly and had adequate hearing and vision. R #2's MDS was coded as she had no behaviors, hallucinations or delusions. R #2 was independent and required no assistance from staff for bed mobility, transfer or ambulation. R #2 required supervision and setup help only for dressing, eating, personal hygiene and bathing. R #2 was able to toilet herself with supervision only. In a telephone interview on 02/17/16 at 3:10 p.m., LVN Fstated approximately one month prior at 5:00 a.m. she entered the room shared by R #1 and R #2 on the secured unit to give R #2 a scheduled medication. LVN F stated when she entered the room she saw R #2 standing beside R #1's bed. R #2 had her hand in R #1's pajama bottoms. LVN F stated R #1's blankets were pulled down and she wore an incontinent brief. LVN F stated as soon as she entered the room shared by R #1 and R #2, R #2 removed her hand from R #1's pajama pants and crossed the room to sit on her bed and asked LVN F what do you have for me? LVN F stated she told R #2 that she had the [MEDICAL CONDITION] medication. LVN F stated R #2 said Oh yes, that one. LVN F stated she medicated R #2 and left the room with R #2 sitting on her bed and R #1 lying in her bed. LVN F stated she did not know how or where to document the incident she witnessed between R #2 and R #1 so at 5:15 a.m. on that morning she called the Director of Nurses (DON) and informed the DON what she witnessed at 5:00 a.m. LVN F stated the DON told her to keep an eye on them and let me know if anything else happens. LVN F stated the DON did not tell her to write a report or call the physician. LVN F stated the DON told her We'll take care of it. LVN F stated she was not told nor was she aware that inappropriate sexual behaviors were added to R #1's Care Plan on 01/28/16. LVN F stated the facility staffing ratio for night shift; 10:00 p.m. to 6:00 a.m.; was to include two CNAs in the secure unit, one CNA for hall 200, one CNA for hall 300 and two nurses for the facility. LVN F stated they often only had one CNA in the secure unit, one CNA on hall 200, one CNA for hall 300 and two nurses to cover the entire facility during the 10:00 p.m. to 6:00 a.m. shift. On 02/18/16 record review of nurse's notes revealed there were no notes indicating LVN F called the DON to notify her of the situation. There were no notes indicating the physician or family had been notified. There were no incident reports, new assessments, or care plans updated. Observation on 02/18/16 at 5:50 a.m. revealed three residents ambulating in the hall of the secure unit and two residents seated in the dining room of the secure unit. CNA C was the only staff member on the secure unit. In an interview on 02/18/16 at 6:20 a.m., LVN D stated there was only one CNA scheduled on the secure unit during the shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16. LVN Dstated two CNAs were scheduled for the secure unit during the night shift because sometimes the residents wake up on the wrong side of the bed and start kicking at each other. In an interview on 02/18/16 at 6:30 a.m., CNA C stated she was the only CNA scheduled during the night shift from 10:00 p.m. on 02/17/16 to 6:00 a.m. on 02/18/16 in the secure unit. CNA C stated there were two CNAs scheduled in the secure unit about four to seven nights per week. CNA C stated one CNA could handle the secure unit when there were no problems. CNA C stated if she needed help at night on the secure unit she could press the call bell light or pull the call bell light from the wall and wait for help from staff in other parts of the facility. CNA C stated R #2 got up at night and was confused. CNA C stated she did not know that R #2 had inappropriate sexual behaviors or that it was added to her Care Plan on 01/28/16. In an interview on 02/18/16 at 8:45 a.m., LVN J stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. In an interview on 02/18/16 at 10:05 a.m., AA E stated she did not know R #2 had inappropriate sexual behaviors added to her Care Plan on 01/28/16. AA E stated she expected to be informed of any changes or new behaviors to monitor for resident. In an interview on 02/18/16 at 11:30 a.m., LVN K stated she was not informed that R #2 had inappropriate sexual behaviors or that it was added to her Care Plan on 01/28/16. LVN K stated that when Care Plans were updated direct care staff needed to be notified of new behaviors to monitor. In an interview on 02/18/16 at 12:05 p.m., Physician (PHY) U stated he was not aware and was not consulted by the facility regarding R #2's inappropriate sexual behaviors or that inappropriate sexual behaviors were added to R #2's Care Plan on 01/28/16. PHY U stated he expected to be notified within a couple of days of the change to add inappropriate sexual behaviors to one of his patient's Care Plan. In an interview on 02/18/16 at 12:15 p.m., LVN D stated she did not know that R #2 had inappropriate sexual behaviors or that they were added to her Care Plan on 01/28/16. LVN D stated that change in R #2's Care Plan should have been communicated to staff. LVN D stated R #1 was moved out of the room with R #2 last month in January 2016 but she was not informed the reason for the roommate change. In an interview on 02/18/16 at 3:25 p.m., the administrator (ADM) stated she was aware that R #2 had inappropriate sexual behaviors added to her Care Plan 01/18/16 but that she thought it needed to be reworded because it was misleading. The ADM stated the situation that prompted R #2 ' s Care Plan to be changed was when a CNA witnessed R #2 assisting R #1 in their room. The ADM stated since R #1 did not appear distressed they added inappropriate sexual behaviors to R #2's Care Plan but I know it is wrong wording and should be interfere with care or over help other residents. The ADM stated that she added the inappropriate sexual behaviors to R #2's Care Plan to be better safe than sorry. The ADM stated the DON interviewed staff and determined the CNA did not see anything and R #1 was not distressed. The ADM stated the NPE went to the different halls of the facility with updates on care guides and the NPE was the mechanism the facility used to advise staff of changes necessary for resident care. In an interview on 02/18/16 at 3:40 p.m., the DON stated she received a call the next day regarding the situation between R #1 and R #2. The DON stated they moved R #1 to another room because she was sick and she notified R #1's Court Appointed Guardian regarding her room change. The DON stated she did an internal investigation and determined there was no reason to report an incident to DADS. In a telephone interview on 02/19/16 at 5:05 p.m., CNALstated she was in the hall of the secure unit at night in November and heard a noise in the room shared by R #1 and R #2. CNA L stated she entered the room and saw R #2 standing at R #1's bedside with her hand under R #1's covers. Record review of a piece of paper dated 11/14/15 received from the DON on 02/18/16 at 4:50 p.m. revealed the following: I was contacted by (NPE) at 11:18 a.m. stated she was told (R #2) was touching roommate by (CNA L) 11:40 a.m. (Nurse Aid NA G) - Reports (R #2) wakes up roommate throughout the night. No other behaviors noted 11:50 a.m. (LVN K) - states (R #2) is bossy tells other residents what to do but is re-directable. Sometimes paces. 11:50 a.m. (AA X) - states R #2 is affectionate with others no behaviors noted 12:10 p.m. (CNA L, LVN W, LVN Y) all interviewed with no sexual behaviors seen . (R #1) assessed for injury with none noted. (R #1) moved to another room to reduce risk of any behaviors and reassess at next care plan meeting. The paper was signed o 02/18/16 by the DON. Record review of R #1's Physician order [REDACTED].#1 was moved from bed A of the room she shared with R #2 into bed B of another room down the hall on 01/13/16 that was occupied by R #16. Record review of R #16's Physician order [REDACTED].#16 was moved from bed B of the room R #1 was moved to on 01/13/16. R #16 was moved into the A bed of the room with R #2 on 01/13/16. Record review of the facility daily census log for 01/08/16 revealed R #1 and R #2 shared a room. R #16 was listed as residing at the other end of the hall in bed B. Record review of the facility daily census log for 01/09/16 revealed R #2 and R #16 shared a room. R #1 was listed as residing in bed B of the room R #16 was listed in 01/08/16. In an interview on 02/18/16 at 4:50 p.m., the DON stated she did an internal investigation of the situation between R #1 and R #2 on 11/14/15 regarding R #2's behaviors and moved R #1 to another room on 11/14/15. The DON stated I moved R #1 in November 2015. I don't know why the Physicians Order says 01/13/16 because I moved her 11/14/15 .We moved (R #1.) Staff there helped me move her. Probably (LVN K) or (NA G.) I'm not sure. The DON stated she was notified of the situation between R #1 and R #2 on 11/14/15 and she had not received any other notifications from staff regarding R #1's behaviors toward R #2 since 11/14/15. The DON stated it was her decision to amend R #2's Care Plan for January 2016 to add sexually inappropriate behaviors on 01/28/16 but her decision was not related to the incident in November 2015. The DON stated I thought the inappropriate sexual behaviors were on (R #2's) old Care Plan so I added it from November (2015.) My thought it was a continuation we were not ready to resolve at that point. The DON stated she recalled the inappropriate sexual behaviors were in place on R #2's Care Plan prior to November 2015 on an old handwritten Care Plan so it was added in January 2016. The DON stated Now I advise it be taken off R #2 ' s Care Plan. The DON stated staff had not notified her of any sexually inappropriate behaviors for R #2 since November 2015. Record review of R #1's Resident Notification of Room Change dated 11/14/15 with a Late entry 02/18/16 revealed R #1 was moved on 11/14/15 and the responsible party was notified. In an interview on 02/19/16 at 9:30 a.m., the ADM stated R #1 was moved from the room she shared with R #2 to another room on 11/14/15. The ADM stated the new computer system caused the change to not show up in the records until January 2016. The Facility Regional Vice President (RVP) was in the room and agreed that the new computer system caused the delay in recording R #1's move from 11/14/15 to January 2016. In an interview on 02/19/16 at 10:15 a.m., the Health Information Coordinator (HIC) stated the new facility computer system was implemented in August 2015. Medical Records (MR) stated telephone orders for room change were written at the time of the room change and usually the rooms assignments were updated daily. In an interview on 02/19/16 at 10:30 a.m., LVN S stated the DON told her to update R #2's Care Plan and add inappropriate sexual behaviors in January 2016. LVN S stated there may have been an old hand written Care Plan from 2013 for R #2 that included inappropriate sexual behaviors. LVN S stated she would look through all of R #2's me