Every finding on record at Sabal Palms Health & Rehabilitation

Based on interviews and record review the facility failed to provide medical records to the resident/resident representative in accordance with guidelines, within two working days, for one resident (#1) out of three sampled residents.Findings included:Resident #1 was admitted to the facility on [DATE] with a diagnoses of Traumatic Brain Injury (TBI), seizures, tracheostomy (trach), gastrostomy tube (g-tube), oxygen, vision loss, cramps and spasms, ventilator (vent) dependent.A family member (FM) was listed on the Facility Profile as the emergency contact and member who provides consent for care.A review of a hospital admission note, dated 8/11/2026, revealed Resident #1 had an acute hypoxic event and cardiac arrest. Resident #1 was transferred to the hospital for a higher level of care.Review of an Authorization to Release Protected Health Information filed on behalf of Resident #1 by the FM revealed the following:-On 8/18/2026 at 11:30:25 a.m. a request for the entire medical record was filed electronically with the medical records department of the facility.On 8/27/2026 at 12:50 p.m. an interview was conducted with the Director of Medical Records (DOM). She stated a request for the medical records was received on 8/18/2026 by the family of Resident #1 electronically. She said she had received several request for medical records on 8/18/2026 and it took her a while to work through them all. She stated she called the requestor on 8/21/2026 to clarify the request. She said the FM wanted records from 8/4/2026 to 8/11/2026 right away. She said she verified what email to send the records to after they were ready and approved to be released by legal on 8/25/2026. She said she was currently working on getting the 10 years' worth of records ready to get to them. She said all records are sent in a folder via a drop box link, and the first records were sent on 8/25/2026. She said she had 14 days for current patients, and 30 days for discharged residents to get the records to them. She said they do not charge people records.A review of the facility policy titled Medical Records-HIPAA, reviewed on 2/15/2026, revealed the following:.Access rights to medical information are as follows:1. the resident's record will be accessible to him/her within 14 working days for current residents and up to 30 days for discharged residents notice, following an oral or written request.The resident may have designated a legal representative who can exercise the same rights as the resident. The resident or his/her legal representative may receive a copy of his/her record within 14 days after the request has been made.

Based on observations, interviews and record reviews the facility failed to ensure the identified needs for residents at high risk for fall interventions was effective and prevented falls with major injuries for two vulnerable residents (#7 and #8) out of eight residents sampled.Findings included:Review of the facility's Daily Census report provided on 9/22/25 at 6:12 a.m. showed 700 Unit had a census of 26.Review of the facility's Minimum Data Set (MDS) Resident Matrix dated 9/23/25 at 8:59 AM showed the 700 Unit 50% (13) of the residents had a fall and 34% (9) experience fall related injuries including fractures. 1. Review of Resident #8's admission record showed an admission to the facility on 7/1/2025 with diagnoses including dementia, fracture of left pubis, insomnia and displaced fracture of the olecranon process.Review of Resident #8's nursing admission evaluation, dated 7/1/25 showed a fall prevention interventions was started of Hi/low bed, anticipate needs as able and call light within reach when in room.Review of Resident #8's MDS dated [DATE], Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) summary score of 0, indicating severe cognitive impairment. Section GG, Functional Abilities shows the resident needs a helper to complete all self-care activities and when transferring from bed to chair.Review of Resident #8's care plan showed a focus on the resident had an actual fall and a pubis ramus fracture, initiated on 7/2/25 interventions included adequate lighting, anticipate needs, call light and frequently used items within reach, wearing nonskid footwear and glasses, fall risk assessments, 4p's rounding (check resident for any pain concerns, positioning needs, personal items are within reach and personal needs are being met), keep bed in low position. Floor mats x2, scoop air mattress, medication and laboratory review and started medication for sleep aid initiate on 7/31/25. Psychology/Psychiatry evaluation and therapy screening and evaluation on 9/1/25. Encourage resident to remain in a common area if restless/agitated, start antianxiety medications and the use of a pommel cushion on 9/1/25. Anti-tippers to wheelchair and hip protector's interventions added on 9/11/25. A care plan for left elbow fracture was initiated on 9/10/25. Review of Resident #8's Order summery report, dated 9/22/25 included the following orders neuro checks after a fall - 7/31/25, 9/1/25 and 9/7/25, left elbow skin tear wound care- 9/1/25, buspirone HCL 5mg two times daily for anxiety- 9/6/25, send to the emergency department for evaluation and possible treatment after a fall- 9/7/25, Naproxen 500 mg every 12 hours for left elbow fracture - 9/7/25, Tylenol extended release (ER) 650 mg every six hours for left elbow fracture- 9/7/25, lorazepam 0.5mg every 8 hours for anxiety 9/8/25, ice pack to left elbow status post (s/p) open reduction and internal fixation (ORIF) - 9/16/25 and lorazepam 0.5mg every 6 hours for anxiety and agitation - 9/17/25.Review of Resident #8's emergency department discharge instructions dated 9/7/25 showed acute displaced fracture of the olecranon with intra-articular involvement. The discharge instructions include ice to affected area, maintain splint and arm immobilizer, and elevate affected area for 24 hours and follow-up with orthopedic surgeon in 3-5 days. Review of Resident #8's progress notesOn 7/31/25 at 11:10 p.m., a post fall progress note showed injury was noted at the time of the fall right elbow and right knee bruise . Current .measures in place include call light education, 4P's, Hi/Lo bed, room close to the nurses' station, therapy evaluation, frequent checks On 9/6/25 at 11:49 a.m. a system note showed current preventative safety measures in place: call light education, 4P's, Hi/Lo bed, room close to the nurses' station, mat next to bed, activities/exercise, frequent checks; scoop mattress.On 9/6/25 at 12:11 p.m. an order note showed buspirone 5mg tab one tablet two times daily for anxiety, monitor for .dizziness, .insomnia, . anxiety . On 9/7/25 at 1:42 p.m., an incident SBAR note showed CNA (Certified Nursing Assistant) found resident sitting up on bedside mat with back against the bed in lowest position. [wearing] only brief and non-skid socks . No apparent injuries.On 9/7/25 at 1:48 p.m. an incident SBAR note showed .alerted by CNA that resident was on the floor near nurses' station. Patient was noted to be on her back on the floor holding her left wrist. Resident left in place supervised while 911 called.left at approximately 10:45 a.m.On 9/7/25 at 7:11 p.m. a clinical note showed Resident #8 returned to the facility, . acute displaced fracture of olecranon w/intra-articular involvement. Left elbow fiberglass splint .On 9/14/25 a system note showed the Interdisciplinary Team (IDT) met regarding falls from 8/31/25, and 9/7/25, laboratory results reviewed, melatonin started, therapy to screen, psych visit started with anti-anxiety medications, encourage resident to be placed in the common area if seem restless/ agitation and pommel cushion .On 9/16/25 at 8:41 PM a clinical note showed Resident #8 returned from the hospital after ORIF procedure.On 9/18/25 Primary Care Physician (PCP) note showed Resident #8 's history included an unwitnessed ground level fall with left inferior pubic ramus fracture, no surgical intervention. On 9/16/25 left elbow ORIF due to left elbow fracture from a ground level fall. Post-operative expectations will be non-weight bearing to operative extremity and wear cast for approximately 2 weeks.Review of Resident #8's documentation survey report, dated September 2025, flow sheet documentation showed for fall risk, encourage resident in common areas if seem restless/agitated, fall mats x2 and, hip protector as tolerated, flow sheet documentation started on 9/9/25.During an interview on 9/22/25 at 3:10 p.m. Resident #8's representative (RR) said, there are only so many caregivers for the number of residents. The RR spends nine hours daily in the facility and assists with feeding lunch and dinner. The RR reminds staff to toilet Resident #8 after meals.During an interview on 9/22/25 at 6:30 a.m. Staff A, Licensed Practical Nurse (LPN) said during the 11:00 p.m. -7:00 a.m. the 700UUnit is staffed with two Certified Nursing Assistants (CNA) and one nurse. Staff A, LPN described post fall interventions and did not mention there was a post fall huddle.During an interview on 9/22/25 at 6:48 a.m. Staff B, CNA described post fall interventions and did not mention there was a post fall huddle.During an interview and review on 9/22/25 at 1:07 PM with the Risk Manager (RM), Director of Nursing (DON), Assistant Director of Nursing (ADON) about Resident #8's fall incidents and the facility investigations, the RM said the resident has had four falls since admission. During the review of Resident #8's falls the RM said on 9/7/25 at 7:40 a.m. Resident #8 was found beside her bed. The DON said in the common areas staff can keep an eye on her. On 9/7/25 at 10:26 a.m. Resident #8 was found on the floor in the hallway by the nurse's station the resident complained of left arm pain and was sent to the emergency room (ER). Resident #8 sustained a left elbow fracture and required surgery. After the investigation the facility did not verify allegations of serious bodily injury and neglect because Resident #8's plan of care was followed and adequate supervision was provided. In discussion of Resident #8's additional falls the RM said on 8/31/25 at 8:80 p.m. Resident #8 was found sitting on the mat next to her bed and on 7/30/25 at 8:00 a.m. was found lying on the floor next to her bed, both incidents were unwitnessed, and the resident did not sustain any injuries.During an interview on 9/23/25 at 9:19 a.m. with the Director of Rehabilitation (DOR) said Resident #8 had been on the therapy case load since admission to the facility. Resident #8 had transitioned to a platform walker, due to left elbow fracture the resident is unable to weight bear and was transitioned to hand hold assistance. 2. Review of Resident #7's admission record showed an admission date on 6/16/25 with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and anxiety.Review of Resident #7's admission evaluation, dated 8/29/25 showed a history of falling in the past 1-6 months and the current fall preventative measures in place are 4P's as appropriate, Hi/Lo bed, anticipate needs as able and call light within reach.Review of Resident #7's MDS admission, dated 6/22/25, Section C, Cognitive Patterns showed a BIMS summary score of 1 indicating severe cognitive impairment. Section GG, Functional Abilities showed the resident needs partial/moderate assistance with toileting and chair to bed transfers. Review of Resident #7's care plan had a focus of an actual fall, initiated on 6/17/25, interventions included adequate lighting, non-skid socks/well-fitted shoes, therapy screen/evaluation routine rounding schedule i.e. 4P's rounding, bed on safe transfer height (just below the knee, call light and frequently used items are within reach. The fall reduction program was initialed on 6/18/25 and the anti-roll back wheelchair. Medication and laboratory review was completed on 7/18/25. The next intervention was for staff to offer toileting after lunch and Resident #7's representative was educated about light use and providing activities of daily living (ADL) as assistance on 8/4/25. Encourage the resident to be in common area during meals and when seen awake at night was initiated on 8/12/25. The use of a helmet and hip protector as tolerated was added on 9/3/25 and floor mats x2 and scoop mattress initiated on 9/8/25.Review of Resident #7's order summary report showed orders including, order dated 6/16/25 PT evaluation and treatment, order dated 7/18/25 neuro checks after a fall, order dated 8/4/25 neuro checks after a fall, order dated 8/11/25 neuro checks after a fall, on 8/25/25 increase trazodone from 50mg to 100 mg at bedtime, order dated 9/1/25 monitor .skin tear left forearm (LFA) after a fall ., order dated 9/2/25 neuro checks and send to the emergency room (ER) after fall, order dated 9/4/25 [NAME] Program consult, comfort measures only and morphine sulfate 20mg/ml give 0.25 ml every 8 hours, order dated 9/5/25 follow -up x-ray lumbar spine history of compression fractures and pain and tramadol 25 mg give 1 tablet every six hours as needed, order dated 9/8/25 floor mats x2 and scoop mattress.Review of Resident #7's hospital discharge instructions, dated [DATE] Impression: Lumbar (L)1 compression fracture, new from 8/27/25. Follow-up with neurosurgery for further evaluation treatment of L1 compression fractureReview of Resident #7's progress notes showed the following:Review of a behavior note, dated 8/25/25 showed Resident #7 .out of bed (OOB) and self-propels in wheelchair .Review of a system note, dated 8/25/25, showed current fall measures in place are call light education, room close to the nurses' station, anti-rollback for wheelchair, activities/exercises, frequent checks, scoop mattress. No new interventions required at this time.Review of a system note, dated 8/25/25, Fall IDT met regarding resident falls from 7/18, 8/3, and 8/11- staff offering toileting after lunch, staff educated [family] call light use/ assistance of activities of daily living (ADL. PCP to adjust Trazodone, staff to encourage resident in common area during meals.Review of a clinical note dated 8/30/25 at 12:30 PM Resident observed barefoot walking down the hallway. Resident observed yelling and fell onto the floor right before writer can get to her Small skin tear noted to left forearm measuring approx. 0.5cm X 0.2cm with minimal bleeding.Review of a clinical note dated 8/30/25 at 12:30 PM Resident observed barefoot walking down the hallway. Resident observed yelling and fell onto the floor right before writer can get to her Small skin tear noted to left forearm measuring approx. 0.5cm X 0.2cm with minimal bleeding.Review of a system note dated 9/9/25, Fall IDT met regarding resident falls from 7/18/25, 8/3/25, 8/11/25 and 8/21/25- staff to encourage resident in common area during meals, therapy, staff to encourage resident in common area when seen awake at night, helmet and hip protector as tolerated .Review of an incident note dated 9/2/25 at 11:43 p.m. showed Resident was found lying on the dining room floor, few steps from her wheelchair holding her head .Called EMS [emergency medical services] for transfer resident was unable to say if she hit her head.Review of note dated 9/3/26 at 2:13 a.m. showed Resident #7 returned from the Emergency Department at 1:00 a.m.Review of palliative care note dated 9/13/25 showed follow-up for comfort measure .she has been hospitalized 3x since 8/3/25 for recurrent falls.During an interview on 9/23/25 at 12:40 p.m. the Life Enrichment Director (LED) provided a one-page memo titled,Fall Reduction Program, undated. The memo includes the name of the participants 16 participants with an asterisk (indicating previous fall) in front of six names. The memo also contained the participants' room numbers, diet and a 4:00 p.m.to 10:00 p.m. scheduled tasks. The LED said the Fall Reduction Program is provided in the 200 Unit dining area. He had one designated LE staff assigned to the 700 Unit during the day shift.On 9/23/25 at approximately 1:40 p.m. the LED presented an updated fall reduction program memo, listing the names of 14 participants, he said this is the second memo provided by the nursing team. He started the LED role on 5/14/25 and received the first updated memo two weeks ago. The LED signed and dated the memo he provided. During an interview on 9/23/25 at 12:20 p.m. with Staff F, CNA, 700 Unit Life Enrichment staff (LE) said during the evening shift a designated nursing staff member's focus was primarily one on one with residents who are agitated. The activities include touch therapy techniques (hand and back massages, fidget [devices], coloring, etc.) Staff F, CNA, LE said when residents are positioned in front of the nurses' stations, nurses get busy.On 9/23/25 at 1:59 p.m. During a discussion of the Fall Reduction program, Staff G, LPN said the program is usually on the 3:00 p.m.-11:00 p.m. shift, an extra CNA who does not have an assignment, calms residents down, sometimes residents are gathered in the common area to watch TV, they have dolls, offer coloring, go to the patio or medication. Staff G, LPN said she does not know anything about compassionate touch techniques to calm residents. On 9/23/25 at 2:10 p.m. during a follow-up interview Staff F, CNA, LE in reference to staff knowledge of the compassionate touch technique to calm residents said I was teaching it and haven't had a class in a while. The new aides probably don't know how to do it.During an interview and review on 9/22/25 at 1:07 PM with the Risk Manager (RM), Director of Nursing (DON), and Assistant Director of Nursing (ADON). The DON said the 700 Unit is the secured unit and has various types of activities and therapeutic intervention to alleviate anxiety. The ADON said there is Fall Reduction Program with intervention including aromatherapy, Compassionate Touch Program and post fall huddles. The RM said the facility meets with RR of residents with multiple fall incidents to discuss the plan of care including the need for a companion or sitter, if the family can afford the services. At the conclusion of the meeting a negotiated risk agreement is completed. The RM said the facility has not completed a negotiated risk agreement for Resident #8 .On 9/23/25 at 2:41 p.m. during a follow up interview and review of the facility's Fall Reduction Program with the DON and ADON. The DON said the Fall Reduction Program is being developed and currently does not have a facility policy or procedure. The program was started in April, trying to identify things we can improve on. The DON said she is not aware all staff members on the 700 Unit have not received compassionate touch technique training and clarified the intervention to consult Physical Therapy (PT) after each fall does not apply for residents who are currently on the therapy case load. The DON said the 700 Unit hall monitor walks the hall during the evening meal. During the fall huddle the Unit Manager, DON/ ADON or supervisor, therapy and the risk manager meet where the incident occurred. Review of a facility policy titled, Fall Prevention Program, reviewed on 1/23/25 showed-Policy: An individualized fall prevention program is implemented for each resident to ensure the safest environment possible. Even though the facility cannot prevent falls, each resident will be assessed-for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Policy-Explanation and Compliance -Guidelines:The facility utilizes a standardized risk assessment for determining a resident's fall risk. 1a) The risk assessment categorizes residents according to low, moderate, or high risk. 1b) For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment.Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk and individual needs.The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions.High Risk Protocols i. Indicate fall risk on care plan. ii. Implement interventions from Low/ Moderate Risk Protocols. iii. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. iv. Provide additional interventions as directed by the resident's admission, quarterly or significant change assessment. v. Appropriate interventions will be individualized to the safety needs of the resident.b. Low, Moderate Risk Protocols:i. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to:1. A clear pathway to the bathroom and bedroom doors.2. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bee3. Call light and frequently used items are within reach.4. Adequate lighting.5. Wheelchairs and assistive devices are in good repair.6. Implement routine rounding schedule.7. Monitor-for changes in resident's cognition, gait, ability to rise/sit, and balance.8. Encourage residents to wear shoes or slippers with non-slip soles when ambulating.9. Ensure eyeglasses, if applicable, are clean and the resident wears them when ambulating.10. Monitor-vital signs in accordance with facility policy.11. Complete a fall risk assessment every 90days. Update care plan interventions as needed as resident's condition changes.Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness.b. The-plan of care will be revised as needed.When any resident experiences a fall, the facility will:Assess the resident.Complete-a-Post-Fall Incident-report.Place the resident on the Falling Star program for a period of 30 days or longer if determined.Notify physician and family.Review the resident's care plan and update as indicated.Document all assessments and actions.Obtain witness statements in the case of injury.Review of a facility policy titled, Post Fall assessment policy, reviewed on 10/14/24 showed the following:Policy: All residents will be assessed immediately who fall to identify causative factors that may be related to the fall. Upon this assessment, actions will be taken to decrease the potential for future falls.Procedure:The nurse will respond to the resident sustaining a fall.The nurse will perform a head-to-toe assessment and notify the physician as needed.The nurse will document in the medical record.The family will be notified.The DON or Supervisor on duty will be notified should there be a severe injury enough to require transportation to the hospital.The nurse will initiate an incident/accident report.All falls will be reviewed by the Interdisciplinary team who will make additional recommendations as needed for the resident's safety and document in the medical records. Changes as appropriate will be made on the resident's care plan and communicated to the nursing staff.Nursing will implement the recommendations and monitor that preventive measures are consistently followed.

Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (#10) out of three sampled residents.Findings included:Review of Resident #10's concern/grievance form dated 7/29/25, with a date of occurrence on 7/29/25 and a time of occurrence 3:00 p.m.-11:00p.m. revealed a grievance with the following documentation, . 7/29/25 [Resident #10] detail of complaint/grievance: Resident complaint that nurse is constantly mocking her when in room. Resident asked for inhaler and nurse stated she had to wait another 20 mins now that she is already in room, even though med [medication] cart is right outside room. Stating nurse called her crazy with finger mocking in her face to hers and [family member]. by twirl finger like we were crazy, and reported nurse is condescending and not helpful.,. Further review of the grievance revealed a follow up dated 8/5/25 revealed, [Resident #10] reports nurse is rude and not what she considers abusive in anyway. Nurse will not provide services moving forward and DON [Director of Nursing] to address nurse behaviors. Documentation of the resolution of the grievance revealed the following, . Nurse was reassigned on 8/5/25 and [Resident #10] signed the grievance form on 8/6/25. A review of the education attached to the grievance revealed the following . Resident also stated nurse constantly mocking resident. Education counseling instructions given to employee to correct action & performance improvement: Platinum service approach, reviewed. Customer service, reviewed. Staff Verbalized understanding. Employee performance improvement and progress results: No complaints concern since education. Signed by Department Director on 7/30/25 and Executive Director on 7/30/25.On 9/23/25 at 3:00 p.m., an interview was conducted with Resident #10. She said she remembered the grievance. Resident #10 stated, The nurse wouldn't give me my medication and when she came in the room and I was talking with her, and my [family member] was here as well, she called me crazy with the motion you make when you put your finger up to your ear and twirl it around. She thought we were crazy. I got very upset and was disgusted. She mocked me and my [family member]. The nurse made me feel angry. It's just so petty; she acted like we were stupid. It's very unprofessional and just uncaring. We need to be treated right and with dignity. She said no facility staff completed a follow-up with her after the incident. Resident #10 said the social worker came by a day or so later but didn't say anything about it.Review of Resident #10's admission record revealed an admission date of 03/07/2019. Further review of the admission record revealed diagnoses to include chronic atrial fibrillation, angina pectoris, hypertension, chronic obstructive pulmonary disease, diabetes, generalized anxiety, atherosclerotic heart disease of native coronary artery, atrial fibrillation, chronic kidney disease stage 3, heart failure.Review of Resident #10's quarterly Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact.Review of Resident #10's progress notes revealed the following:On 7/30/25, Quarterly assessment completed for [Resident#10]. Speech and communication skills remain stable. Cognitive status is stable. No report on changes in social interactions. No changes in mood noted. Residents' ability to make adjustments to situations remain stable. No new behaviors report. Resident is compliant with care. Resident is agreeable to current plan of care. No psychological/psychiatric services indicated at this time.Review of the facility's REPORT TRACKING LOG, dated 6/1/25 to 8/31/25, revealed there was no allegation of abuse, neglect, exploitation reported to state agencies for Resident #10.An interview was conducted on 9/23/25 at 12:48 p.m. with the Risk manager (RM) who stated, My expectations are they would report it to me; abuse; physical and verbal abuse and mental abuse. Mental abuse could be anything like making a resident feel bad by their actions. if you make a resident feel bad, I guess it would be the response that the resident had to determine if they were affected by it. She was asked if Resident #10's grievance would be a reportable event, and the RM stated, If it was a change in the psychosocial. Did the residents wellbeing change due to the event? Did it affect the resident? If yes, then we would report it. The RM stated, in reviewing it [Resident #10's grievance] now I should have reported it. The RM said the facility completed a thorough investigation and education with the staff. The RM said they interviewed the resident, received statements from the nurses, interviewed staff, and completed abuse training and education. The RM said the grievance was looked at in terms of lack of good customer service and not abuse.An interview was conducted with the DON and the RM on 9/23/25 at 1:30 p.m. They DON and the RM said Resident #10 had behavioral issues before and there was a care plan in place for confabulation as well as her behaviors. The DON reviewed Resident #10's care plans and confirmed there were no care plans in place for behaviors or confabulation.Review of the facility's policy titled Abuse, Neglect, and Exploitation, with a review date of 1/11/2025 revealed Policy:Each resident has the right to be free from abuse, including verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. This prohibition applies to everyone, including, but not limited to, facility staff (employees, consultants, contractors, volunteers and other caregivers who provide care and services to residents on behalf of the facility) .I. DefinitionsThe definitions herein are supplemented by Any definitions set forth in state law or regulation that pertain to abuse or any of the terms defined below. abuse is the willful infliction of.intimidation, or punishment with resulting.mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain .mental, psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause.pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Mental- Abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation.III TrainingFacility shall develop, implement, and maintain an effective training program for all new and existing staff, individuals providing serves under a contractual arrangement, and volunteers consistent with their expected roles. Training shall include at a minimum: activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse.dementia management and resident abuse prevention.Annual education and training is provided to all existing employees and other individuals as applicable. Training, at least annually, shall also include staffs' obligation to report to the relevant state agency and to one or more local law enforcement agencies any reasonable suspicion of a crime against residents of the facility either immediately, but no later than two hours after formulating the suspicion if the resident suffers serious bodily harm, or no later than 24 hours after forming the suspicion if the resident does not suffer serious bodily harm. IV Prevention of Abuse, Neglect, Exploitation of Residents, and Misappropriation of Resident PropertyThe facility will utilize the following techniques for prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property: Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents.recognize signs of burnout, frustration and stress in employees that may lead to abuse.React to all allegations or questions from residents, family members, employees or visitors. Take appropriate actions when abuse, neglect, exploitation or misappropriation is suspected. Provide feedback to residents, staff and family members who voice grievances. Provide instructions to staff on care needs of residents. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, . Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect.VII Response and reporting of Abuse, Neglect, Exploitation, and MisappropriationAnyone with knowledge or concerns about the care of a resident int eh facility must report suspected abuse to the Facility Administrator, abuse agency hotline or file a complaint with the state agency and adult protective services.immediately (but not alter than 2 hours after an allegation is made if the events that lead to the allegation involve abuse or results in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury. Reporting and investigation should be in accordance with state law/regulation.

Based on record review, interviews, and review of facility policy, the facility failed to immediately notify a resident's primary care provider to receive instructions for a change in condition for one resident (Resident # 2) out of three residents sampled for changes in condition. Findings included: Review of an admission record revealed Resident # 2 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and history of falling. Review of an order summary dated 3/1/2025 showed, apply steri strips to wounds on right forehead. Monitor every shift until healed. Review of a clinical note dated 3/1/2025 at 12:53 a.m. showed, Resident found lying on the floor in [room number]. Laceration noted to right forehead and right shoulder, steri strips applied, [physician] notified. daughter to be notified in the morning. Review of an eINTERACT Change in Condition Evaluation dated 3/1/2025 at 5:32 a.m. revealed under Section A. Signs and Symptoms Identified, Resident # 2 had a fall in the morning and obtained a skin wound or ulcer. Review of section B6. Skin Status Evaluation showed Resident # 2 skin changes were a laceration and skin tear on the right shoulder and above the right eye. Review of a System Note dated 3/1/2025 at 6:23 a.m. showed Resident #2 was sent to the hospital on 3/1/2025 at 6:15 a.m. for a head injury. During an interview on 4/22/2025 at 1:25 p.m. with the Nursing Home Administrator (NHA), Risk Manager (RM), and Director of Nurses (DON), the RM stated Resident # 2 had a fall on 3/1/2025 at 12:54 a.m. The resident was found lying on the floor next to the air conditioner in the room next door to her room. She sustained a laceration on her right forehead and on her shoulder. The nurse assessed the resident, conducted neurological checks, and steri-strips were applied. The nurse documented the resident did not have any signs of pain, mood, or behavior after the fall. Her vital signs were in normal limits before the resident went out to the hospital. The nurse documented she notified the on-call physician and noted she would notify the daughter in the morning. The RM stated when she asked the nurse why she waited four hours later to notify the daughter, the nurse stated she did not feel there was anything critical going on with the resident that she needed to wake the daughter up at the time. The RM stated when the daughter was notified about the fall, she came to the facility to see her mother and requested her mother be sent out to the hospital because she was concerned about the bruise she saw on her mother. The RM stated the daughter was very upset she was not notified about her mother at the time of the incident. The RM stated when she called the nurse to interview her, the nurse stated she never spoke to the resident doctor that night, but she left a voice message on the doctor's phone. The nurse stated she called the on-call number and left a message with the on-call service. The RM stated the nurse's story kept changing, so they reported her license to the board and she was terminated because she would not cooperate with the investigation. The DON stated the nurse documented in her progress note she notified the doctor, but she did not notify the doctor and the on-call doctor services said they did not have a record of a message from that night. The DON stated when she reached out to the resident's provider, he said he was on call that night and he would have gotten the message but he did not receive a call or have a message from the facility about Resident #2's fall. Review of the facility policy titled Incidents and Accidents, last reviewed on 10/14/2024, showed the following: Compliance Guidelines: 9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies).

Based on record review, interviews, and review of facility policy, the facility failed to immediately notify a resident representative about a change in condition for one resident (Resident # 2) out of three residents sampled for changes in condition. Findings included: Review of an admission record revealed Resident # 2 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and history of falling. Review of an order summary dated 3/1/2025 showed, apply steri strips to wounds on right forehead. Monitor every shift until healed. Review of a clinical note dated 3/1/2025 at 12:53 a.m. showed, Resident found lying on the floor in [room number]. Laceration noted to right forehead and right shoulder, steri strips applied, [physician] notified. daughter to be notified in the morning. Review of an eINTERACT Change in Condition Evaluation dated 3/1/2025 at 5:32 a.m. revealed under Section A. Signs and Symptoms Identified, Resident # 2 had a fall in the morning and obtained a skin wound or ulcer. Review of section B6. Skin Status Evaluation showed Resident # 2 skin changes were a laceration and skin tear on the right shoulder and above the right eye. Review of a System Note dated 3/1/2025 at 6:23 a.m. showed Resident #2 was sent to the hospital on 3/1/2025 at 6:15 a.m. for a head injury. During an interview on 4/22/2025 at 1:25 p.m. with the Nursing Home Administrator (NHA), Risk Manager (RM), and Director of Nurses (DON), the RM stated Resident # 2 had a fall on 3/1/2025 at 12:54 a.m. The resident was found lying on the floor next to the air conditioner in the room next door to her room. She sustained a laceration on her right forehead and on her shoulder. The nurse assessed the resident, conducted neurological checks, and steri-strips were applied. The nurse documented the resident did not have any signs of pain, mood, or behavior after the fall. Her vital signs were in normal limits before the resident went out to the hospital. The nurse documented she notified the on-call physician and noted she would notify the daughter in the morning. The RM stated when she asked the nurse why she waited four hours later to notify the daughter, the nurse stated she did not feel there was anything critical going on with the resident that she needed to wake the daughter up at the time. The RM stated when the daughter was notified about the fall, she came to the facility to see her mother and requested her mother be sent out to the hospital because she was concerned about the bruise she saw on her mother. Review of the facility policy titled Incidents and Accidents, last reviewed on 10/14/2024, showed the following: Compliance Guidelines: 11. The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital.

Based on observations, interviews, and record review, the facility failed to ensure the positive end-expiratory pressure (PEEP), a pressure applied by the ventilator at the end of each breath to prevent the collapse of the tiny air sacs in the lung, alarm was audible in accordance with professional standards for four residents (#61, #184, #101, and #130) out of thirteen residents requiring mechanical ventilation support. Findings Included: 1. On 7/22/24 at approximately 9:55 a.m. Resident #61 was observed lying in bed with a tracheostomy tube connected to a LTV 1150 mechanical ventilator. A red-letter sign displaying PEEP OFF was observed on the front panel screen. According to the ventilator manufacturer the PEEP display on the LTV 1150 mechanical ventilator shows the pressure in the airway circuit at the end of expiration. Resident #61 was admitted to the facility on [DATE]. Resident #61's active diagnoses included metachromatic leukodystrophy (a rare genetic disorder that affects the brain and nervous system), cerebral palsy, and seizures. Resident #61's Minimum Data Set (MDS) assessment, dated 7/1/2024, revealed the following: -Section GG, Functional Abilities and Goals, showed impairment to both arms and legs, severely cognitively impaired and uses a wheelchair for mobility. Resident #61 required a helper for all activities of daily living, including rolling in bed and transferring from bed to wheelchair. -Section O, Special Treatments, Procedures, and Programs showed Resident # 61 requires oxygen therapy, invasive mechanical ventilation, tracheostomy care and suctioning. Review of Resident # 61's orders, active as of 7/24/24, showed the following: -End-tidal carbon dioxide (ETCO 2), (adequacy with which carbon dioxide (CO 2) is carried in the blood back to the lungs and exhaled), check once per shift and as needed. -Fraction of inspired oxygen (FiO2), (the concentration of oxygen to maintain sat [oxygen saturation], a measurement of how much oxygen is in the blood) greater than 92%. -Lavage and suction every shift for increased secretions, pressure alarm on when in room for respiratory care, dated 11/5/22. -Ventilator heater on when in room every shift for vent care, dated 11/05/22. -Ventilator settings Tidal Volume (VT) 330, respiratory rate (RR) 12, pressure Support (PS) 10, PEEP 6, check and document every four hours what actual settings six times per day for respiratory care, dated 4/27/22. -Ventilator alarm six times a day for monitor alarms [sic], dated 7/22/24. -PEEP alarm set at (+) 10, (-) 3 every shift, dated 7/23/24. Review of Resident # 61's care plan, dated 4/21/22, focused on potential impaired gas exchange due to dependence tracheostomy and ventilator. The goal was to maintain a patent airway and oxygen saturation levels greater than 94%. The interventions included monitor for signs and symptoms of respiratory infections/ distress, ventilator orders per medical doctor (MD) orders. 2. On 7/22/24 at 10:10 a.m. Resident #184 was observed lying in bed with a tracheostomy tube connected to an LTV 1150 mechanical ventilator. A red-letter sign displaying PEEP OFF was observed on the front panel screen. According to the ventilator manufacturer the PEEP display on the LTV 1150 mechanical ventilator shows the pressure in the airway circuit at the end of expiration. Resident #184 was admitted to the facility on [DATE]. Resident #184's active diagnoses included respiratory failure with hypoxia (low blood oxygen), Hypoxic ischemic encephalopathy (HIE) (brain injury that happens around birth when oxygen or blood flow to the brain is reduced or stopped), cerebral palsy, epilepsy, and intellectual disabilities. Resident #184's MDS, dated [DATE], revealed the following: Section C, cognitive patterns, showed cognitive skills for daily living is severely impaired, Section GG, Functional Abilities and Goals, showed impairment of both arms. A helper does all the effort with all activities of daily living including rolling in bed. Resident #184 uses a wheelchair for mobility. Section O, Special Treatments, Procedures, and Programs showed Resident # 184 requires oxygen therapy, invasive mechanical ventilation, tracheostomy care and suctioning. Review of Resident #184's active orders as of 7/1/24 showed orders to include: -ETCO2 check once each shift and as needed, -Fi02 to maintain sats greater than 92% every shift, -give cough assist for three cycles every six hours, -lavage and suction every shift as needed for increased secretions, -pressure alarm on when in room every shift, dated 1/4/24, -respiratory treatments two times per day, -vent heater when in room, -ventilator settings check and document six times per day what actual settings are RR 10, PC 15, inspiratory time 1.0, PS 10, PEEP 12 -Fi02 to maintain sats greater than 92% six times per day for respiratory care. Review of Resident # 184's care plan, undated, focused on tracheostomy, the goal is Resident #184 will not have signs or symptoms of infection. The interventions include lavage and suction for increased secretions. A second care plan focused on Resident #184's oxygen therapy. The goal is Resident #184 will not have signs or symptoms of poor oxygen absorption. The interventions include monitor for signs and symptoms of respiratory distress and report to the medical doctor. During an interview on 7/22/24 at 11:00 a.m. Staff L, Licensed Practical Nurse (LPN) said she did not know why the ventilator PEEP alarms were turned off. During an interview on 7/22/24 at 11:05 a.m. Staff I, LPN, Unit Manager (UM), referred the question to the respiratory therapist. During an interview on 7/22/24 at 11:18 a.m. Staff E, Respiratory Therapist (RT) confirmed the PEEP alarms were off. Staff E, RT said the alarm is triggered when resident's hiccups or when there is water in the high pressure tubing and pointed to a clear plastic tubing connected to the blue corrugated ventilator tubing. Staff E said the RT checks the ventilators every four hours. During an interview on 7/22/24 at 1:06 p.m. with the Director of Nursing (DON), Regional Nurse Consultant (RNC) and the Nursing Home Administrator (NHA), the NHA said the facility's leadership team is aware of the concerns related to the PEEP alarms and they are in discussions and will implement corrective measures today. During an interview on 7/22/24 at 3:18 p.m. with the Pediatric Medical Director, Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Nurse Consultant (RNC) and Assistant Nursing Home Administrator ANHA). The Pediatric Medical Director stated, If the PEEP alarm is the only thing off, other alarms would trigger. He said, The PEEP is an extra caution alarm, if disconnected other alarms would alert staff. The Pediatric Medical Director said he expects RTs to follow orders and adjust per orders. He said alarms are there for a reason To protect the patient. During an interview on 7/23/24 at 12:45 p.m. with Staff H, Respiratory Therapist (RT), said he is familiar with the LTV 1150 mechanical ventilator, and it is the only ventilator currently in use at the facility. Staff H, RT said the low PEEP alarm indicates the resident is losing pressure, this affects oxygenation and may be triggered by disconnection from the machine, a mucus plug or improper seal of the tracheostomy tube cuff. He stated the high PEEP alarm may indicate there is air trapping which could be caused by a mucus plug, coughing, hiccups or high inspiratory pressure. He stated when the PEEP alarm is triggered by the ventilator the resident is assessed to identify issues with the resident, tracheostomy tube or the ventilator. The RT stated the resident may require suctioning, check the cuff, or administer a breathing treatment. Staff H, RT said, I would never turn off alarms, not my practice unless there is a doctor's order, this is for safety. He said the Florida Board of Respiratory Care does not endorse turning off ventilator alarms without a physician's order. 51062 3. Resident #101 was admitted to the facility on [DATE] with diagnoses to include sleep apnea and acute tracheitis without obstruction. An observation was conducted on 7/22/2024 at 10:56 a.m. revealed Resident #101 was lying in bed, with the ventilator display reading PEEP OFF. A review of Resident #101's physician orders for July 2024 revealed the following: -7/22/2024 1:00 p.m. for ventilator alarms on, six times a day for alarm check. -7/22/2024 for PEEP (positive end expiratory pressure) alarm set at +20 and -20 (high and low setting at which the alarm will activate) every day and night shift for monitor settings. -7/23/2024 7:00 a.m. for PEEP alarm set at +11 and -6 every day and night shift for monitor settings. (Photographic Evidence Obtained) A review of Resident #101's progress notes revealed: -7/23/2024 6:43 p.m., Incident SBAR (situation, background, assessment, and recommendation) Nurse's Description: On 7/22/2024 noted PEEP alarm reading off on the ventilator, setting in place. Resident's description of what happened: n/a Witnesses? Yes/No: Staff K, Respiratory Therapist (RT) Injuries?: None Immediate Actions taken: Assessment of child complete, vital signs stable, oxygen saturation 99%. No noted Respiratory distress. No ill effects noted. Alarm turned on. Predisposing factors: Notifications: Medical Director notified. Family member notified. During an interview on 7/23/23 at 10:00 a.m. with Staff H, Respiratory Therapist, he stated that ventilator alarms go off frequently. He stated if he is with another child, the nurses check on the child that has the alarm and notify him if they need any further assistance. Staff H stated most alarms reset themselves and can be caused by movement, coughing, or sometimes mucous obstructions. He stated an alarm can be flashing on the ventilator screen but does not indicate it is a current alarm. The previous alarm will flash on the screen until it is cleared. Staff H stated this way; anyone can tell what alarm the child had last. He stated he did not know if there was any memory on the ventilator that stored previous alarms. Staff H stated he would not turn off any alarm unless ordered by a doctor because every alarm has a reason. 4 Resident #130 was admitted to the facility on [DATE] with diagnoses to include pneumothorax, other chronic respiratory diseases originating from perinatal period, paralysis of vocal cords and larynx, disturbances of salivary secretion, tracheostomy, and dependence on respirator (ventilator). An observation was conducted on 7/22/2024 at 10:56 a.m. Resident #130 was lying in bed. Resident #130's ventilator display read PEEP OFF. A review of Resident #130's physician orders for July 2024 revealed: -7/22/2024 1:00 p.m. for ventilator alarms on, six times a day for monitor alarms. -7/23/2024 7:00 a.m. for PEEP alarm set at +11 and -3. A review of Resident #130's progress notes revealed: -7/23/2024 7:02 p.m., Incident SBAR Nurse's Description: On 07/22/2024 noted PEEP alarm reading off on the ventilator, settings in place. Resident's description of what happened: N/A Witnesses? Yes/No: Staff K, RT Injuries?: NONE Immediate Actions taken: Assessment of child complete, vital signs stable, oxygen saturations 99%, no noted respiratory distress, no ill effects noted. Peep alarm turned on. Predisposing factors: Notifications: Medical Director notified. Family member notified. Review of the facility's policy titled Mechanical Ventilator, dated 7/22/24, revealed the following: Policy Residents who require mechanical ventilation will be cared for in accordance to Federal, State and local guidance and with current standards of practice. Definition: Mechanical Ventilation may be defined as a life support system designed to replace or support normal ventilator lung function . Compliance Guidelines: 1. The facility will ensure that there is sufficient numbers of trained, competent, qualified staff, consistent with State practice acts/laws when providing mechanical ventilation. 2. The facility will identify who is responsible for the following: c. Setting the ventilator: d. Monitoring the ventilator; e. Response to ventilator alarms; 3. The physician/ practitioner will write an order for the mechanical ventilation to include at a minimum the mode, rate, tidal volume, oxygen concentration, and desired level of positive end expiratory pressure (PEEP), and pressure support, if applicable. (Include any other pertinent information for the order.) 5. Appropriate staff will be trained and maintain competency in the use of mechanical ventilation to include: c. Use and maintenance of the ventilator system according to manufacturer's instructions g. Responding to alarms .

Based on interviews and record review, the facility failed to provide physician follow-up for catheter care and recurrent urinary tract infection (UTI) in a timely manner for two residents (#165 and #60) out of three residents sampled. Findings include: On 7/25/2024 at 4:24 p.m., an interview was conducted with the facility's Infection Control Preventionist (ICP) regarding antibiotic stewardship related to antibiotics as a prophylaxis. The ICP stated there were a few residents in the facility on long term prophylaxis antibiotics and there is a justification in the resident's chart to indicate the rationale. The ICP stated the residents' urologists are the primary physicians who will place the orders. 1. Resident #165 was admitted on [DATE] with a primary diagnosis of nontraumatic subarachnoid hemorrhage from unspecified intracranial artery. Secondary diagnoses included Type 2 Diabetes without complications, obstructive and reflux uropathy unspecified, Benign Prostatic Hyperplasia with lower urinary tract symptoms, cystitis unspecified without hematuria, and major depressive disorder recurrent unspecified. A review of the July 2024 physician orders showed the following: -catheter change every month and as needed (PRN), -Foley care every shift and PRN, -irrigate Foley catheter PRN every 24 hours as needed for catheter blockage or leakage, -Methenamine Hippurate tablet five 1 gram by mouth two times a day for recurrent UTIs. A review of Resident #165's Minimal Data Set (MDS) dated [DATE] under Section C- Cognitive Patterns has a Brief Interview for Mental Status (BIMS) of 15 indicating cognition is intact. Section H- Bladder and Bowel has resident with an indwelling catheter. Section H0200 Urinary Toileting Program marked as NO for trial of a toileting program. A review of Resident #165's 3008, dated 8/25/2022, showed the resident had urinary retention requiring intermittent catheterization's. A review of a urology note, dated 12/02/2022, for Resident #165 showed the following: He had a stroke and was unable to void, he was supposed to be straight catheterized but they were not doing this at his facility and he ended up hospitalized with retention and Urosepsis from Klebsiella. I will write an order to change his catheter at his facility now and once a month with a 16 French Foley. I will also start him on prophylactic Methenamine to prevent further infections. Follow up in three months to reassess. A review of Resident 165's medical record revealed no further follow up to a urologist was noted until 7/17/2024. A review of Resident 165's physician progress notes, dated 7/17/2024, showed the following: Urology F/U [follow up] [physician name]: Retention, Void trial Resident #165 had three positive urinary tract infections (12/07/2024,10/07/2023 and 12/01/2022) for Proteus Mirabilis (a member of the bacterial family Enterobacteriaceae or E. coli). A search from the NIH (National Institute for Health), National Library of Medicine at (https://www.ncbi.nlm.nih.gov/books/NBK442017/) states proteus mirabilis is a gram-negative bacterium which is well known pathogen of the urinary tract, particularly in patients undergoing long-term catheterization [photographic evidence of article]. 2. Resident #60 was admitted to the facility on [DATE] with a primary diagnosis of urinary tract infection site not specified. Secondary diagnoses included atrial fibrillation, nonrheumatic aortic valve stenosis, peripheral vascular disease, fall, Type 2 Diabetes Mellitus with diabetic neuropathy, depression, and flaccid neuropathic bladder not elsewhere classified. A review of the July 2024 physician orders showed the following: -catheter change every month and PRN for malfunction or dislodgement -irrigate Foley catheter with 30-60 milliliters of normal saline as needed for blocked catheter A review of Resident #60's MDS, dated [DATE], revealed: -Section C- Cognitive Patterns a BIMS of 14 indicating cognition was intact. -Section H- Bladder and Bowel resident with an indwelling catheter. -Section H0200 Urinary Toileting Program marked as NO for trial of a toileting program. On 7/25/2024 at 2:00 p.m., an interview was conducted with Staff A, Registered Nurse (RN)/Unit Manager. Staff A stated a family member makes the arrangements for a resident to follow-up with doctor appointments. She stated follow-up appointments had not been arranged with a urologist regarding Resident #60's indwelling catheter. A review of the facility's policy titled Resident Rights, dated 1/22/2024, revealed the following: Policy: The resident has a right to a dignified existence self-determination, and communication with and access to persons and services inside and outside the facility. Planning and implementing care: The resident has the right to be informed of, and participate in, his or her treatment, including the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. A review of the facility's policy titled Urinary Catheters, dated 10/24/2023, revealed the following: Policy explanation and compliance guidelines: .4. Physician should document within the order for the use of the catheter, the diagnosis or clinical conditions making catheterization necessary. i. Documentation is the medical record should reveal attempts to manage the incontinence and increase bladder function without the use of an indwelling catheter; Bladder training programs, prompted voiding schedules or external catheters ii. Documentation in the medical record should reveal continual assessment for use of the catheter. iii. The plan of care should address catheter use, hydration programs and strategies to prevent urinary tract infections.

Based on observations, interviews, and record review, the facility failed to assess and monitor a dialysis catheter per facility policy for one resident (#191) out of one resident sampled for dialysis. Findings included: On 07/24/24 at 11:48 a.m. Resident #191 was observed sitting in a bedside chair in the room. The resident's shirt was protruding on the upper right chest wall area. The resident lifted his shirt up to show surveyor his dialysis catheter site located on the upper right chest wall. The resident stated he has been off dialysis for a couple weeks and was supposed to get his shunt out soon. A review of the medical record revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD), urinary tract infection, and Type II Diabetes Mellitus with diabetic neuropathy. A review of the Form 3008, dated 04/23/24, showed the following: -Section V treatment devices IV [Intravenous Therapy]/PICC [Peripherally Inserted Central Catheter]/ Portacath. Access box is check-marked with type listed as right subclavian D.L [double lumen] dialysis site. Review of the physician orders for July 2024 revealed: - No Blood Draws or BP[Blood Pressures] on RUE[Right Upper Extremity] due (Dialysis port). - Change dressing (RU [Right Upper] chest dialysis port). every day shift every Wed [Wednesday]for (RU chest dialysis port) Dressing change protocol. AND as needed for (RU chest dialysis port) Dressing change protocol. When soiled or dislodged. Dated 07/24/24 at 1:08 p.m. - Monitor area (RU chest dialysis port) for s/s [signs and symptoms] of infection (redness, heat, drainage or bleeding). every shift for (RU chest dialysis port). Dated 07/24/24 at 1:02 p.m. Review of the Minimum Data Set (MDS), dated [DATE], revealed: - Section O showed special treatments, procedures and programs section J1. Dialysis marked yes, section 01. IV marked yes. - Section M showed the application of nonsurgical dressing marked yes. - Section C showed a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Review of the nurse's progress notes, for July 1, 2024, through July 23, 2024, revealed no daily assessment or monitoring documentation of a dialysis shunt site. Review of the nurse progress note on 07/24/24 at 1:12 p.m. showed Order for site being monitored q [every] shift for s/s of infection obtained and weekly dressing change and PRN if is soiled or dislodged. Orders entered in [electronic health system]. Staff will monitor. Review of the care plan, dated 04/25/24, revealed: - A focus of Resident has potential for spread of MDRO [multidrug-resistance organism] related to presence of dialysis port (an indwelling medical device; chronic wound, infection or colonization with a CDC targeted MDRO when Contact Precautions do not apply) Date Initiated: 04/29/2024 Revision on: 07/24/2024. - A focus of RESOLVED: Receives dialysis r/t [related to]: ESRD [End stage Renal Disease] Date Initiated: 04/25/2024 Revision on: 07/24/2024 Resolved Date: 07/24/2024. An interview was conducted on 07/24/24 at 12:43 P.M. with Staff A, Registered Nurse (RN). She stated Resident #191's dialysis catheter was still in place. She stated she would expect an order in place to check the port site until it is removed and stated there was no order currently in place. An interview was conducted on 07/24/24 at 1:24 PM with the Director of Nursing (DON). She stated Resident #191 was last dialyzed on 07/01/24 and his dialysis catheter was still in place. She stated her expectation would be a physician's order in place for monitoring the dialysis site and a dressing change order for the duration of the dialysis catheters presence. Review of the facility policy titled Dialysis Communication and Site monitoring, dated 11/28/2016 and reviewed on 10/24/2023, revealed the following: .Procedure #6 The shunt site is to be assessed daily and documented in the clinical chart. If there is any change or problems noted with the shunt site, these are to be documented in the medical record with a nurse note and the MD is to be notified for follow up. Procedure #7 If dialysis does not occur for any reason, the facility will: notify MD for further orders.

Based on observations, interviews, and policy review, the facility failed to ensure clean and sanitary equipment and floors for two of two units and eleven of seventeen rooms where tracheostomy residents reside. Findings included: An observation was conducted on 4/22/24 at 1:14 p.m. in room [ROOM NUMBER] of an oxygen concentrator that had dried liquid splatter on it as well as dust. The suction canister base and motor had debris and dust. There was a fan clipped to a pole at the bedside that was covered in dust. (Photographic evidence obtained.) An observation was conducted on 4/22/24 at 1:18 p.m. in room [ROOM NUMBER] of a IV (Intravenous) pole that had dried splatter on the base. The suction canister and motor set up had dust and debris on it. (Photographic evidence obtained.) An observation on 4/23/24 at 9:56 a.m. revealed the equipment in rooms [ROOM NUMBERS] remained in the same condition as they were on 4/22/24 at 1:14 p.m. Additional rooms of residents that had tracheostomies were toured on 4/23/24 from 11:30 a.m. to 12:00 p.m. with the following observations: -room [ROOM NUMBER] had an IV pole with dried splatter on the base. (Photographic evidence obtained.) -room [ROOM NUMBER] had a fan at the bedside with dust on it and black marks on the floors. (Photographic evidence obtained.) -room [ROOM NUMBER] had black spots and stains on the floor, a dirty IV pole, a crib bed with dust and debris on the railings, a plastic crib covering with dried liquid, brown splatter on the wall. (Photographic evidence obtained.) -The floor outside the 600 Unit nurses' station was dirty with black marks and spills. (Photographic evidence obtained.) -room [ROOM NUMBER] had a fan at the bedside with dust on it, a piece of tape attaching two pieces of flooring, dirty/stained floors, a dirty IV pole base, trash on the floor, a call light cord that had visible dirty, and a side table with spots/stains and a pink liquid spilled. (Photographic evidence obtained.) -room [ROOM NUMBER] had a dresser with broken drawers and a suction canister base and motor that had dust and debris. (Photographic evidence obtained.) -room [ROOM NUMBER] had a tablet and black stand on wheels that was visibly soiled. (Photographic evidence obtained.) -room [ROOM NUMBER] had a black stand on wheels that was visibly soiled. (Photographic evidence obtained.) -room [ROOM NUMBER] had a basin with towel under a ventilator hose to catch dripping water. The towel had black dirt partially covering the top, an IV pump had dried splatter, and there was another basin catching water dripping from a ventilator hose. -room [ROOM NUMBER] had a cough assist machine that had dried splatter and debris on the top. An interview was conducted on 4/23/24 at 12:12 p.m. with Staff D, Licensed Practical Nurse (LPN). Staff D identified herself as a unit manager (UM) on the 300 unit. Staff D said housekeeping wiped down all the surfaces of equipment in resident rooms. She said nurses should also wipe equipment down if they see that it is dirty. Staff D said nurses also change ventilator tubing and suction canisters weekly and should clean soiled items. She said IV poles were swapped out when they were obviously soiled and the dirty ones were taken out back and sprayed down. She added that housekeeping wiped the poles down and nurses or certified nursing assistants (CNA) could also wipe the poles down if they were soiled. Staff D was observed going to room [ROOM NUMBER] and looking at the fan at the bedside and the suction canister set up. Staff D said, it is disgusting. She said it was not acceptable to have equipment in this condition in resident rooms. She removed the fan and said it needed to go in the trash it was so dirty. An interview was conducted on 4/23/24 at 12:19 p.m. with the interim Director of Nursing (DON.) She stated she did not know who was responsible for cleaning the equipment in resident rooms and she would look into it. She agreed the medical equipment in resident rooms should not have splatters and dust on it. At 12:46 p.m. the DON said nursing and respiratory should be cleaning the suction and IV equipment in the resident rooms. An interview was conducted on 4/23/24 at 12:59 p.m. with the Environmental Services (EVS) Director. She said when it came to medical equipment housekeeping was hesitant to touch it because they did not want to mess anything up, especially if it was being used by a resident. A follow-up interview was conducted on 4/23/24 at 1:01 p.m. with Staff D, LPN/UM. Staff D agreed with the EVS Director and said she believed housekeeping thought nursing cleaned the equipment and nursing thought housekeeping cleaned it. She said it fell through the cracks but was being cleaned now. A follow-up interview was conducted on 4/23/24 with the EVS Director. She said the facility did not have a policy on floor maintenance. She said they rotate doing deep cleaning on the floors in each room. She said the black marks on the floors were stains and she could not get them up. She agreed it did not look good and was not acceptable in resident areas. She was shown the area by the 600 unit nurses station, she said she would try to deep clean that area. Review of a facility policy titled Maintaining a Safe, Clean, Comfortable, and Homelike Environment, reviewed 3/20/24, showed the following: Policy This facility will accommodate, to the extent possible, a personalized, homelike environment that recognizes the individuality and autonomy of each resident. Policy Explanation and Compliance Guidelines . 6. Report any furniture disrepair to Maintenance promptly. 7. Maintain a clean, comfortable, and homelike environment (i.e. ceiling tiles, wallpaper, floor times.) 8. Report any unresolved environmental concerns to the Administrator. Review of a facility policy titled Cleaning and Disinfection of Resident-Care Equipment, reviewed 10/25/23, showed the following: Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. Policy Explanation and Compliance Guidelines: 1. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to facility protocol.

Based on interviews and record review, the facility failed to identify, assess, and respond in a timely manner to a resident's change in condition related to a wound for one (Resident #1) of four residents reviewed. Findings included: Resident #1 was admitted to the facility on [DATE] with a primary diagnosis of nondisplaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing. Review of a care plan dated 03/15/24 showed Resident #1 had alteration in skin integrity related to incontinence, impaired mobility, a sacrum pressure ulcer, and a left heel skin tear posterior right lower leg. Interventions included to assist with transfers and positioning during rounds as resident allows cushion in wheelchair, dermatology consult, dietary consult as ordered, educate resident on the importance of offloading and pressure reduction as appropriate, encourage fluid intake with and between meals and increase protein in diet, and float heels while in bed as resident will allow. Observe and assess skin for signs/symptoms of redness, drainage, blisters, or evidence of skin breakdown. Observe and assess wound/ulcer for signs/symptoms of increased redness, swelling, warmth or purulent drainage. Apply skin prep heels x 21 days. Follow treatment per MD (Medical Doctor) orders and weekly skin checks. A focus in the care plan dated 10/13/23 showed Resident #1 was receiving an anti-coagulant with interventions to evaluate for bruising. On 04/22/24 at 11:59 p.m., an interview was conducted with Resident #1's family member/ POA (Power of Attorney). He stated on 03/12/24 he was at the facility visiting Resident #1. He stated while visiting with the resident in the dining room, he had noticed the resident had a wound that was weeping at the back of her right leg. He stated he reported his concerns to the nurses, and they did not respond. He said, they were not aware, they did nothing. They did not even attempt to come and see what the issue was. The wound on the back of her leg was filled with puss and was draining to her socks. Her socks were soaking wet. The family member said, We are not trying to be adversarial. It was neglectful. The draining fluid was running down to her socks. This didn't occur overnight. They said this was happening because of the Velcro on her left boot. They don't analyze or accept anything. It's systemic. We notified Staff A, Registered Nurse (RN)/ Unit Manager. My partner went to the desk and notified her. The family member stated Staff B, RN was also at the desk. He stated they never came to look at the resident's leg. The family member stated they were at the facility until after 6 p.m. and the nurses never came to assess the resident. The family stated this was not the first time they failed to identify a concern. He stated sometime in February he had notified the facility of an infection to the resident's right thumb. He stated no one was aware and no one had done anything about it. On 04/23/24 at 11:47 a.m., an interview was conducted with Staff B, RN. She stated she remembered the family coming up to the desk. She said, it must have been a Tuesday night I believe the 12th between 3 p.m. and 4 p.m. The family brought her [Resident #1] to the desk. She was in her wheelchair and reported there was some drainage on her leg. At the time [Staff A, RN] was going to be coming on shift. She said she would look at the leg when she got the resident in bed or as soon as possible . The family was still visiting when I left. Staff B stated the next day [03/13/24], she did rounds and noticed the resident had redness, serious drainage and weeping from the back of her leg. She stated she discussed this with Staff A. She stated Staff A was not going to pick up the resident for wound care, but she was going to put her on antibiotics. Staff B confirmed there were no notes indicating this conversation and course of treatment. She said, I do not see it under progress notes, we discussed it with the wound care nurse who no longer works at the facility.[Staff A] was to obtain orders. On 04/23/24 at 1:02 p.m., an interview was conducted with Staff A, RN/UM. She stated early in March the family was visiting. She stated they had reported Resident #1 had a skin tear to the right calf, and it was weeping. She stated the resident caused the injury. Staff A said, I was walking down the hall, there was another person with the family member. They said, [Resident #1] had something on her foot. I went and looked at her leg, she was in a wheelchair, she was wet. I asked the CNA [Certified Nursing Assistant] to change her and put her in bed. [Staff B, RN] was with me, we both looked at her. Staff A stated the resident crossed her foot with the boot she was wearing at that time and caused the injury. Staff A stated she obtained an order for wound care and doxycycline for 10 days. Review of a progress note documented by Staff A, RN on 03/14/24, showed Nurse's Description: CNA on duty notified writer that resident has an area that it look little red and is moist, writer went into the resident's room and skin tear is observed in the posterior part of the right lower leg, area looks little red, moist, mild clear drainage with no odor noted. MD [Medical Doctor] made aware about the new skin area and order to clean are with NS (Normal Saline) pad and dry, apply xeroform and cover with bordered gauze was given. Also, to monitor site for s/s (signs or symptoms) of infection and ABT (antibiotic) BID (two times daily) x 10 days was given due to the little redness and the clear drainage. All the orders are placed in [a software documentation program]. Wound care performed and well tolerated. Resident observed on daily basis to try to cross the right leg over the left leg. Resident uses a Podus boot on the left foot and the Velcro part touches and rubs the same area that was reported as per CNA on duty. POA made aware and no questions or concerns were expressed at this time. Staff will continue to monitor. Resident's description of what happened: None. Witnesses? Yes/No: None. Injuries: Skin tear posterior right lower leg. Immediate Actions taken: Assessment performed. MD made aware, new orders obtained and placed in PCC. Wound care performed. POA made aware. Predisposing factors: Resident has active wounds. Resident is on diuretics, cardiac meds, and anticoagulants. Assist x 1 for transfers and ADLs (Activities of Daily Living). Resident seen by therapy for wheelchair positioning. Resident observed in daily basis to try to cross the right leg over the left leg. Resident uses a Podus boot on the left foot and the Velcro part touches and rubs the same area that was reported as per CNA on duty. Notifications: MD made aware and POA notified. This documentation confirmed Staff A,RN responded to the change in condition on 03/14/24 and not 03/12/24 when she was first notified. Review of Resident #1's skin assessment dated [DATE] revealed there were no concerns documented related to the right foot infection. Review of a progress note documented by Staff A, RN, dated 02/01/24 showed, Clinical Note Text: Resident's son approached writer regarding his mom right thumb being red close the nail. Area looks little red, no open area, no drainage or bleeding. Resident denied pain and stated it just bothered when it's being touch. Finger nail observed to start having slight change in color and texture. MD made aware and new orders were given to start ABT and Dermatology consult. New orders placed in [a software documentation program]. POA made aware and no questions or concerns were expressed at this time. Staff will continue to monitor. A progress note dated 02/01/24 showed, Infection note: Note Text: Abt/Rt thumb in progress. First dose pulled via EDK (Emergency Drug Kit). No adverse effects noted. C/o (complaint of) pain this shift, Tramadol given + effect. VS WNL (vitals within normal limits). All safety measures in place with call light within reach. On 04/23/24 at 2:10 p.m. an interview was conducted with Staff A, RN, The Director of Nursing (DON) and the Regional Nurse Consultant (RNC). The DON stated when the thumb incident was reported they educated all staff about monitoring and assessing residents. She stated if the CNAs found any concerns with the skin, they should document in the task log. She stated the task log asks the question if there are new changes. This would mean a new change to the staff documenting. If they answer Yes, the system will send a notification to some key staff members such as the DON and the Unit Managers. She confirmed the family had notified them of the two incidents. On 04/23/24 at 2:15 p.m., The DON reviewed a document titled, Follow -up Question Report, dated 02/01/24 to 02/07/24 and 03/10/24 to 03/15/24. The DON confirmed the CNA's had not reported any changes to the resident's skin. She confirmed they had not received any alerts on changes to the resident. On 4/23/24 at 10:02 a.m., an interview was conducted with Staff C, RN QIC (Quality Infection Control) nurse. She stated she had started education for the nursing staff on identifying change in condition, addressing family concerns in a timely manner. She stated she understood the family's concern. She said, What might have appeared normal to a nurse would be perceived differently by a family member. I understand. The nurse should have taken the time to go see the resident. An interview was conducted with the Nursing Home Administrator (NHA) on 04/23/24 at 11:02 a.m. She stated they will address the change in condition concerns. The nurse should have contacted the family. The nurse should have responded to the family in a timely manner. We will educate about assessing resident's needs. Review if a facility policy titled, Change in a resident's condition, dated 10/22/23, showed a change noted in a resident's condition is reported as soon as practical to charge nurse. The procedure showed A. notify the charge nurse when any condition occurs in the resident including but not limited to (1.) anything that seems different than usual. (11.) change in skin color or condition; red areas on skin, skin tears, bruises. C. Evaluate reported changes in resident condition performed by a licensed nurse. D. Report findings to Health Care Provider and resident representative, as indicated.

Based on observations, record reviews, and interviews the facility failed to provide social services for one (#8) out of 18 sampled residents related to not following up with family regarding the transferring to another facility and not following up on the resident request for replacing lower dentures. Findings included: Resident #8 was admitted on [DATE]. The Admission Record included diagnoses not limited to epileptic seizures related to external causes not intractable without [CONDITION(S)], unspecified visual loss, mild recurrent major depressive disorder, and unspecified [CONDITION(S)] not due to a substance or known physiological condition. The Admission record identified that the resident was the financial responsible party and sister was the next of kin and emergency contact #1. The quarterly Minimum Data Set (MDS) , dated 8/9/22, identified Resident #8's Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS also assessed the resident for not having broken or loosely fitting full or partial dentures. The care conference, held on 8/17/22, was attended by Staff Member N (Social Service Assistant, SSA), Staff Member C (Nursing Supervisor), the Dietitian, Life Enrichment staff, and Resident #8. The conference indicated that Emergency contact, Life Enrichment, dental services needed or desired at this time were reviewed, and that no issues or concerns were identified at that time. An interview was conducted, on 10/10/22 at 12:50 p.m., with Resident #8. The resident was observed with top dentures in place and dressed appropriately. The resident reported that Staff Member N had been asked if the facility was going to assist in the move (to another state) and that the staff member had stated no. The resident stated the desired discharge came down to money and the family did not have the money for transporting. Resident #8 stated she did not know if there were programs to help people in this case. A continuing interview was conducted, on 10/11/22 at 10:05 a.m., with Resident #8. She stated that one of her sons was trying to get her bottom dentures since she had not been eating well but the facility had not been helping, telling her that no provider is able to do them. The resident asked for assistance in obtaining bottom dentures. The resident reported that the entire family (sister, ex-husband, and sons) were working on getting her out of the facility to live in a facility in the other state. An interview was conducted, on 10/01/22 at 2:41 p.m., with Staff Member N. The staff member reported that Resident #8's sister was assisting in relocating the resident to a facility in Ohio but the resident did not have any income in Ohio or Florida and she was getting Supplemental Security Income (SSI) in the community. The staff member reported to having talked to the resident's sister and ex-husband but the resident was doing better and able to make her own decisions. Staff N reported that as the resident was visually impaired, an escort would be needed for the discharge and the sister could come to Florida and escort. The staff member stated and reiterated that most of the conversations have been with the sister and ex-husband but confirmed she had not spoken with the sister in over a month. The staff member reported that the sister had been looking into transferring the resident to one facility but had decided to look elsewhere if the first facility would not accept the resident. On 10/11/22 at 10:49 a.m., Staff Member N stated that there was no discharge care plan because there was not an actual discharge plan, just that the sister was looking for a place as I told you yesterday. The staff member stated that Resident #8 was offered dental services and that the program did not provide dentures as it had to be out of pocket. Staff N reported that the resident did not have lower dentures and an email was received from the dental provider who stated that dentures would have to be paid for out of pocket. The SSA stated she had last spoken to the resident's sister in July or August. A psychologist note, dated 9/21/22, indicated that Resident #8 had reported that she was trying to work with her sister to get to Ohio to be with family and the plan was to work on setting things up for the resident to go up to Ohio. A psychologist note, dated 8/31/22, indicated that the resident continued to talk about moving to Ohio but did not know the status of that situation. The note indicated that the resident was encouraged to keep in touch with her sister to find out the status of being able to move to Ohio. A review was completed of the dental provider email that was sent to the facility's Social Service Department on 7/5/22. The email identified that Resident #8 was not eligible to enroll due to income requirements. She is interested in a lower denture. We have left a voicemail for her sister (name) but our records indicate she may be self-responsible. On 10/11/22 at 11:37 a.m., Staff Member N stated she had left voicemail (regarding dental) with Resident #8's sister but had to follow up and was thinking last week after talking with the resident that she might be able to find something (dental) in the community for low-income residents. A review of the Inventory of Personal Effects identified that the resident was admitted with upper and lower dentures. The recent dental service report, dated 6/14/22, reported Patient presents for screening. Upper and Lower edentulous. Patient has upper denture, fits well. Patient interested in lower denture. (Local) Dental Services office will follow up for approval. The Resident Care Summary, dated 12/16/21, indicated resident had upper and lower dentures. The Social Service notes included the following: - a note, dated 6/7/22, indicated that the Staff Member N and the resident had discussed plans to discharge to Ohio closer to family. The note reported that the resident's sister was attempting to make arrangements with a facility in Ohio and that the Social Service would continue to monitor and assist as needed. - the next Social Service note was dated 8/8/22 and indicated that a call to the resident's son had been attempted. - A care conference note, dated 8/17/22, indicated that the physician was made aware of the discharge plan of care but did not indicate what the discharge plan of care consisted of. - approximately two months later, on 10/10/22, Social Services noted that the resident and Staff Member N had discussed placing an order for a government phone. The note did not include information related to the resident's desire to discharge to be closer to family. A review of the Social Service notes, dated 1/31/22 to 10/10/22 did not indicate that Social Services had addressed the resident's request for dentures or that the resident's wish to discharge to an out of state facility had been discussed other than on 2/24 and 6/7/22. The care plan for Resident #8 did not include a focus related to the resident and family's wish to be discharged to a facility in Ohio to be closer to the family. The resident's care plan identified that the resident had no natural teeth or tooth fragments and wore dentures, initiated and revised on 2/18/22. The related interventions indicated that the facility was to assist with dental care and cleaning as needed, dentures would be well-fitting, to schedule dental evaluation and arrange for follow up care as indicated. During an interview, on 10/12/22 at 8:29 a.m., Staff Member N stated that she had spoken with the resident after the email had been received from the dental provider (7/5/22) and that the resident stated she did not want the dentures due to finances. She stated that the sister had told her she could come to Florida and pick her up but did not have the resources to take care of the resident herself. The SSA confirmed that the conversation with Resident #8's sister had not been documented. The staff member reported that she had searched Resident #8's room today and had been unable to locate the resident's lower dentures, stating that the resident had reported that the dentures had come up missing from the previous facility and the hospital. She confirmed that she should have looked for the dentures prior to 10/12/22 and that she had contacted another dental provider but they were unable to assist, and was going to reach out to the resident's insurance service to see if they could assist with getting the resident lower dentures. The Director of Nursing (DON) stated, on 10/12/22 at 8:35 a.m., that discharge planning should begin at the time of admission and be included in the resident's care plan. The DON stated that if Social Services were having conversations with family regarding possible discharge plans it should be documented. He reviewed the dental providers report dated 6/14/22 and the email sent on 7/5/22. The DON stated that Social Services should have been looking to outside sources for other dental companies sooner than last week. He reviewed documentation and confirmed there wasn't documentation of conversations with family as there should be and it was a lack of follow up. The Social Service Director stated, on 10/12/22 at 12:00 p.m. that they had spoken with the resident and the resident was now wanting dentures and that they had spoken with the resident's health service company and that they do have a dental benefit and Resident #8 had been scheduled for an denture evaluation. The SSD reported that years ago the resident wanted to go to Ohio with family but the sister did not feel she could take care of the resident. The SSD confirmed there was no documentation with family members related to an ongoing discharge plan or dental needs and that documentation could be better. The policy - Social Service Referral, created 10/7/2012 and reviewed 4/10/2022 identified It is the policy of the facility to assist residents in accessing needed services and information, including translator services for residents who do not speak English. The procedure portion included that: - 3. Social Service will document in resident record the services provided and the outcome. - 4. Social Services will follow up with the resident on the request and document this in the resident's chart. The policy - Discharge Planning Policy, effective November 2016 and reviewed/revised January 2020, January 2021, and January 2022, identified It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The procedure included the following: - 1. The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. - 2. The facility will determine the resident's expected goals an d outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle, and as needed. - 3. If discharge to community is determined to not be feasible the facility will document in the clinical record who made the determination and why. - 4. if discharge to community is a goal, an active discharge plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. - 7. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community. - 8. the facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. - 10. The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis sin the clinical record. The job description, Social Service Assistant, identified the following: - 3. Develop a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident and the goals to accomplished for each problem/need identified. - 7. Participate in discharge planning, development, and implementation of social care plans and resident assessments. - 8. Provide information to resident/families as to medicare/medicaid, and other financial assistance programs available to the resident. - 10. Assist in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required. - 12. Assist in obtaining resources from community social, health and welfare agencies to meet the need of the resident. - 13. Ensure that all charted progress notes are informative and descriptive of the services provided and of the resident's response to the services.

Based on observation, resident and staff interview, and record review the facility failed to provide timely care and services for a resident after a reported accident with pain for one resident (#2) out of fourteen sampled residents. Resident #2 reported to nursing staff on 06/24/2022 her right foot had been caught under the wheelchair, while being transported without the foot rests in place, and Resident #2 reported new pain in her right leg. The physician was not notified and no new orders were implemented. On 07/09/2022, Resident #2 was documented to have unrelieved pain in her leg, the physician was notified, an X-ray was ordered which identified an acute fracture of the right proximal tibia. On 07/10/20, Resident #2 was transferred to an acute care facility for treatment of the fracture. Findings included: On 08/18/2022 at 9:55 a.m., an observation was conducted of Resident #2. She was observed in bed and agreed to answer questions. She reported she had fractured her right leg recently. She stated the cast was just removed, last Friday. She stated an aide was pushing her and should have had the leg rests on, and they did not. She stated her right leg fell under the wheelchair. She stated it took 2 weeks before she was able to go to the hospital. She stated they (the facility staff) thought I was faking it. She stated her whole leg was in a cast. She stated she thought the man who pushed her in the wheelchair was a volunteer. She reported she currently had pain level of 10 on a scale of 1-10, with 10 being the most severe pain. On 08/18/2022, at 11:30 a.m., Resident #2 was observed with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated she was familiar with Resident #2. She stated the resident fractured her right tibia. She stated she was really not sure what happened because she had heard several stories. She stated one version was a volunteer was pushing the resident and the resident's leg went under the wheelchair. A review of Resident #2's admission Record revealed the resident was admitted on 01/2013 with diagnoses including: Diabetes Mellitus due to underlying condition with diabetic nephropathy, acute ischemic heart disease, heart failure, and chronic obstructive pulmonary disease. A review of Resident #2's Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Function, a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section B: Hearing, Vision, and Speech revealed the resident had no impairment and assessed the resident with clear speech-distinct intelligible words; makes self-understood; and understands others-clear comprehension. Section G: Functional Status, revealed Resident #2 required support of two persons for transfer, bed mobility, and dressing. A review of Resident #2's Care Plan revealed the following: Focus: Self-care deficit: Requires assist with ADL's (Activity of Daily Living) due to decreased mobility, initiated on 03/08/2022. Interventions included: Extensive to total, 2 person assist for bed mobility, initiated on 03/11/2022, revision on 08/01/2022. Extensive to total assist with transfers; 2 persons, initiated on 03/11/2022, revision on 08/01/2022. Leg rests are to be on when she is up in w/c, initiated 08/03/2022 Uses a full body mechanical lift for transfers, initiated on 03/11/2022. Uses a manual wheelchair, initiated on 03/11/2022. Focus: Resident has potential for falls related to: unable to bear weight and non-ambulatory, initiated 03/08/2022. Interventions included: 4P's rounding (Check resident for any pain concerns, positioning needs, that personal items are within reach and that personal needs are being met), initiated 03/08/2022. A review of Resident #2's Medication Administration Record (MAR) for 06/2022, reflected a physician order for Tramadol HCL (Hydrochloride) 50 mg (milligram) tablet, give 50 mg orally every 4 hours as needed for pain. A review of the MAR reflected from 06/01/2022 through 06/23/2022, Resident #2's daily administration of the Tramadol fluctuated between 0 to 2 pills daily for pain levels ranging between 4 and 7 out of 10. On 06/24/2022, the resident was administered Tramadol 4 times at 5:12 a.m. for a pain level of 5, at 9:50 a.m. for a pain level of 4, at 4:42 p.m. for a pain level of 8, and at 9:11 p.m. for a pain level of 0. Resident #2 was administered Tramadol for pain on: 6/26, 6/27, 6/28, 6,29, and 6/30 once daily with a pain rating of between 4 and 6. A review of the MAR for 07/2022 revealed Resident #2 continued to receive Tramadol 50 mg for pain as follows: 7/1--at 6:31 a.m. pain level of 7, at 10:37 a.m. pain level of 5, at 4:13 p.m. pain level of 3, at 11:40 p.m. pain level of 7 7/2-at 4:29 a.m. pain level of 10, at 9:30 a.m. pain level of 4, at 4:30 p.m. for pain level of 3 7/3-at 9:37 a.m. pain level of 4, at 7:38 p.m. for pain level of 7, 7/4-at 9:55 a.m. pain level of 4 7/5-at 9:32 a.m. pain level of 4 7/6-at 6:36 a.m. pain level of 3, at 9:29 p.m. pain level of 6 7/7-at 5:29 a.m. pain level of 6, at 10:44 a.m. pain level of 4 7/8-at 6:32 a.m. pain level of 6, at 8:29 p.m. pain level of 6 7/9-at 5:02 a.m. pain level of 6, at 10:04 a.m. pain level of 4 7/10-at 10:06 a.m. pain level of 4 (then sent out to hospital) A review of Resident #2's Progress notes was conducted for the time period of 06/01/2022 to 08/15/2022 which revealed the following: 06/24/2022 9:25 p.m.: [Staff J, Registered Nurse RN]: While completing Tx [treatment] to buttocks Resident stated when being pushed out of her room earlier, the foot rests were not put on, and her R [right] foot went under the w/c [wheelchair]; unable to determine exact situation as resident changing situation if asked multiple times; checked R knee/leg and no swelling, dis-alignment, or redness; able to turn without pain; provided pain medication at resident request. Will have following nurse continue to monitor. 06/27/2022 5:58 a.m. [Staff K, LPN]: C/O [complaint of] Right leg pain. 06/29/2022 2:38 p.m. Psychotherapy progress note .Stated she is still having a lot of leg, foot, and back pain 07/5/2022 2:35 a.m. Tramadol HCL 50 mg given for pain per resident request for bilateral leg pain. 07/06/2022 2:09 p.m. Psychotherapy progress note .Indicated she is having trouble with her legs and has pain when being changed . 07/09/2022 7:22 a.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. Tramadol HCL 50 mg given. 07/09/2022 4:49 p.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. Tramadol HCL 50 mg given 07/09/2022 5:39 p.m. [Staff L, LPN] Resident c/o rt lower leg pain. Call placed to [doctor]. Per call on call obtain x-ray rt knee, rt tibia/fibula, rt foot. Portable x-ray required resident is non ambulatory. 07/10/2022 1:07 p.m. Radiology Results: Results of Right knee, tib/fib and foot x-ray returns with findings of acute proximal tibia fracture. Called on call provider, LM [left message] on personalized VM [voice mail] requesting return call to writer. 07/10/2022 1:32 p.m. Called [Doctor] on call provider number . no answer, left message on personalized voice mail requesting return call to writer regarding radiology results and orders. 07/10/2022 2:33 p.m. Called on call provider for [Doctor] .Left message on personalized voice mail to report tibial fx findings and to obtain orders. 07/10/2022 3:26 p.m. [Doctor] on call ARNP [Advanced Registered Nurse Practitioner] returned call, new orders given to send to ED [Emergency Department] for further eval and Tx of tibial fx. Guardian numbers called x 2 each with no answer. No voicemail set up to leave message. 07/10/2022 3:40 p.m. Resident was sent to [local Hospital] at 07/10/2022 4:00 p.m. for tibial fx 07/10/2022 10:26 p.m. (Incident note) At approx. 8:45 p.m. resident returned to facility with a ½ brace wrapped with ace bandage to RT leg. Resident denies pain at time of arrival. Resident states, I'm so glad I am back. Discharge instructions: No weight bearing to Rt Leg. Follow-up with Dr [Orthopedic] .address within 3-5 days. Script for Norco 5/325 mg every 6 hours as needed for acute pain x 3 days. MD and Guardian aware of resident's return. A review of a Resident #2's X-Ray, Radiology Interpretation, date of exam 07/10/2022, reflected the following significant findings: Right Knee, 3 views: Findings: Multiple views of the right knee show a fracture of the proximal tibia. Diffuse osteopenia is present. Moderate osteoarthritis is seen in the tri-compartment joint spaces. There are no joint bodies. There is no knee region soft tissue swelling. There is no joint effusion. There are no radiopaque foreign bodies. Impression: Acute fracture of the proximal tibia. Right Tibia and Fibula, two views: Findings: A fracture of the proximal tibia is visualized. Diffuse osteopenia is present. The joint spaces are preserved. No radiopaque foreign body is seen in the soft tissues. The soft tissues are unremarkable. Impression: Acute fracture of the proximal tibia. On 09/01/2022 at 12:00 p.m. an interview was conducted with the Radiologist. He stated the fracture for Resident #2 was acute and unlikely to be over three weeks old due to no callus formation. He stated on an older person with a lot of osteopenia, like Resident #2, makes a fracture slow to heal and he confirmed the fracture would have occurred within a three-week time period prior to the xray. On 08/18/2022 at 2:29 p.m., an interview was conducted with Staff A, LPN, UM (Unit Manager). She stated if a resident complains of leg pain the nurses are to find out what the pain is from, medicate for pain, let the doctor know, and let the family know. She stated if there are no other signs and it does not continue the nurse would do an assessment and go from there. A review of Resident #2's progress notes was conducted with Staff A, LPN, UM, the 06/24/2022 nurse note and the 06/27/2022 nurse note. Staff A, LPN confirmed both entries were missed opportunities to notify the physician. She said, the resident would complain of pain, but the right leg pain was unusual. On 08/19/2022 at 10:05 a.m. an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She reported she was familiar with Resident #2 and she normally had the same assignment which included Resident #2. She stated before Resident #2 broke her leg they would get her out of bed a lot and she would be put in the manual wheelchair. She stated the chair had regular foot rests. She stated she would always put the leg rests on and sometimes she would put a pillow on because her feet would dangle and angle out. She stated the resident was not able to self-propel and she would need someone to push her. She stated the wheelchair leg rests are extended now since the resident had a broken leg. She said she was not working on 06/24/2022. She stated during a Hoyer lift transfer, she did not recall a date, the resident complained about her leg hurting. She stated the resident was crying, I mean crying. She stated she told the nurse, who was an agency nurse, but she did not know the name of the nurse. She stated after the leg event, Resident #2 did not want to get out of bed. On 08/19/2022 at 11:05 a.m., an interview was conducted with Staff H, CNA. He recalled 06/24/2022, and he recalled Resident #2 that day. He said it was his first day in the facility and Resident #2 was going out of the building that day. Staff H stated she had taken a shower and he described what she was wearing, and stated the resident left before or around lunch time. He stated he was not assigned to care for the resident, but he did help with her care that day. He stated the resident was happy to be going out. He stated another aide, he could not remember her name, asked for his assistance with the wheelchair and he got it for her. He could not recall whether leg rests were placed on the wheel chair. On 08/19/2022 at 3:28 p.m., Staff I, CNA was interviewed by phone. She confirmed she was working on 06/24/2022 on the 7 a.m.- 3 p.m. shift and was assigned to care for Resident #2. She stated she assisted Resident #2 on 06/24/22 with care and getting the resident ready to go out of the building. Staff I, CNA, stated she did not take the resident to the main lobby, but recalled one of the people who come and get the residents for the activities came down. She stated it was either a younger guy or the young lady with blond hair but she did not know them. She stated the people just come around and get the residents to take them where they are going. She stated she remembered asking the resident if she needed her leg rests because she always asks. The person said, she will be ok and took her. I do not recall putting the leg rests on the wheelchair. On 08/19/2022 at 2:55 p.m. an interview was conducted with the NHA. The NHA stated Resident #2 indicated during her interview about the fracture, it was an accident where she put her foot down while being pushed by a volunteer. The NHA confirmed no one had witnessed the event. The NHA stated however, we were unable to validate any volunteer pushing her on said day, 06/24. The NHA stated she was notified on 07/10/2022 at 2:27 p.m. by Staff M, LPN, House Supervisor who called her. She stated it was a Sunday and she immediately came in. The NHA said, she called the Director of Operations and the Regional Clinical Nurse to let them know there was an allegation and a fracture with Resident #2. She stated she told them she going to the building to investigate. The NHA said Staff M, LPN and I went in to interview Resident #2 together. She stated during the interview with the resident, even though she has a BIMS of 11, she appeared quite lucid at the interview. The NHA stated the resident appeared alert and oriented with no nonsensical conversation. She stated Resident #2 reported she had an incident on 06/24/2022, and she remembered this because it was her special day. The NHA said Resident #2 told her she put her right foot down while being transported to the reception area by a volunteer and she did not think anything serious about it, but, as time has gone on, it had started to hurt more. The NHA stated the resident told her it was her fault for putting her foot down, and when she told the pusher to stop, he did. The NHA stated she thought the resident's right leg had fallen to the bar under the wheel chair. The NHA stated the resident described the male as short and blond and said he could be a volunteer. On 08/19/2022 at 2:21 p.m., a phone interview was conducted with Resident #2's Physician. He confirmed he was familiar with Resident #2. He confirmed Resident #2 had an X-Ray on 07/09/2022, was sent to the hospital on [DATE], and she returned with a soft cast to the right leg. He stated he was driving and did not have the medical record in front of him, so specifics, he would have to review in the medical record. He stated he did not recall being notified of the event on 06/24/2022 with Resident #2, the report of the resident's pain, or the allegation her right foot had gone under the wheelchair. He stated, they [facility staff] are instructed to call about ALL problems, we are in the building 2-3 times per week, we are very responsive. He confirmed an X-ray could have been ordered for Resident #2's leg for her pain at the time of the event on 06/24/2022. He confirmed it was a missed opportunity to order the x-ray to identify the fracture at that time. A review of the facility policy and procedure: Accidents and Incidents, effective August 2000, last reviewed January 2022, documented the policy: A. An Accident or Incident Report Form must be completed on the shift that the accident/incident occurred-or was discovered. B. An accident or incident is any unusual event or circumstances that may include but are not limited to: Falls; Injuries which may or may not involve equipment; Assaults; Abuse, neglect, mistreatment, or exploitation; and Poison incidents. C. Inform the charge nurse of all accidents or incidents to provide medical attention. D. Steps for witnessed accidents: Render immediate assistance. Do not move the victim .; If assistance is needed, summon help . E. The charge nurse will: Examine all accident or incident victims; Notify the victims personal or attending physician and inform the physician of the accident or incident during the shift of occurrence; Notify the responsible party; Initiate the facility specific investigation report; If necessary, transfer the injured person to hospital; If necessary or appropriate, designate an employee to accompany the victim. F. The charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident. G. The following data as it may apply, must be included on the Accident Investigation Report form: 1. The date, time, and accident or incident took place; 2. The circumstances surrounding the accident or incident. 3. Where the accident or incident took place. 4. Names) of any witness and their account of the accident or incident. 5. The injured person's account of the accident or incident. 6. The time the injured persons attending, or personal physician was notified as well as the time the physician responded and his/her instructions. 7. The date and time the injured person's next of kin was notified and by whom. 8. The condition of the injured person, to include his/her vital signs. 9. Disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.) 10. Corrective action taken 11. Other pertinent data as necessary or required. 12. Signature and title of the person completing the report. H. The DON/Representative will: 1. Examine A/I (Accident/Incident) victims. 2. Complete the investigation form for all residents. 3. Complete the Employee A/I Form. 4. Offer emergency medical services at designated medical care center to all A/I victims who are employees or visitors. If necessary or appropriate, an employee shall be designated to accompany the victim to hospital. 5. Ensure that appropriate medical care has been provided for resident involved in A / Is. 6. A / I are logged for quality assurance. 7. Informs DPH of any reportable A/Is as required. 8. Informs the Executive Director and/or DON of all reportable A/Is immediately by phone. I. The Unit Manager will: 1. Ensure the measures to prevent reoccurrence are addressed on the Interdisciplinary Care Plan. 2. Consults with other disciplines and adjusts care plan according to need. 3. Reports effectiveness of any new interventions. J. Staff education as needed.

Based on observation, resident and staff interview, and record review the facility failed to provide timely care and services for a resident after a reported accident with pain for one resident (#2) out of fourteen sampled residents. Resident #2 reported to nursing staff on 06/24/2022 her right foot had been caught under the wheelchair, while being transported without the foot rests in place, and Resident #2 reported new pain in her right leg. The physician was not notified and no new orders were implemented. On 07/09/2022, Resident #2 was documented to have unrelieved pain in her leg, the physician was notified, an X-ray was ordered which identified an acute fracture of the right proximal tibia. On 07/10/20, Resident #2 was transferred to an acute care facility for treatment of the fracture. Findings included: On 08/18/2022 at 9:55 a.m., an observation was conducted of Resident #2. She was observed in bed and agreed to answer questions. She reported she had fractured her right leg recently. She stated the cast was just removed, last Friday. She stated an aide was pushing her and should have had the leg rests on, and they did not. She stated her right leg fell under the wheelchair. She stated it took 2 weeks before she was able to go to the hospital. She stated they (the facility staff) thought I was faking it. She stated her whole leg was in a cast. She stated she thought the man who pushed her in the wheelchair was a volunteer. She reported she currently had pain level of 10 on a scale of 1-10, with 10 being the most severe pain. On 08/18/2022, at 11:30 a.m., Resident #2 was observed with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated she was familiar with Resident #2. She stated the resident fractured her right tibia. She stated she was really not sure what happened because she had heard several stories. She stated one version was a volunteer was pushing the resident and the resident's leg went under the wheelchair. A review of Resident #2's Admission Record revealed the resident was admitted on ,d+[DATE] with diagnoses including: Diabetes Mellitus due to underlying condition with diabetic [CONDITION(S)], acute [CONDITION(S)], heart failure, and chronic obstructive pulmonary disease. A review of Resident #2's Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Function, a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section B: Hearing, Vision, and Speech revealed the resident had no impairment and assessed the resident with clear speech-distinct intelligible words; makes self-understood; and understands others-clear comprehension. Section G: Functional Status, revealed Resident #2 required support of two persons for transfer, bed mobility, and dressing. A review of Resident #2's Care Plan revealed the following: Focus: Self-care deficit: Requires assist with ADL's (Activity of Daily Living) due to decreased mobility, initiated on 03/08/2022. Interventions included: Extensive to total, 2 person assist for bed mobility, initiated on 03/11/2022, revision on 08/01/2022. Extensive to total assist with transfers; 2 persons, initiated on 03/11/2022, revision on 08/01/2022. Leg rests are to be on when she is up in w/c, initiated 08/03/2022 Uses a full body mechanical lift for transfers, initiated on 03/11/2022. Uses a manual wheelchair, initiated on 03/11/2022. Focus: Resident has potential for falls related to: unable to bear weight and non-ambulatory, initiated 03/08/2022. Interventions included: 4P's rounding (Check resident for any pain concerns, positioning needs, that personal items are within reach and that personal needs are being met), initiated 03/08/2022. A review of Resident #2's Medication Administration Record (MAR) for 06/2022, reflected a physician order for [MEDICATION(S)] ([MEDICATION(S)]) 50 mg (milligram) tablet, give 50 mg orally every 4 hours as needed for pain. A review of the MAR reflected from 06/01/2022 through 06/23/2022, Resident #2's daily administration of the [MEDICATION(S)] fluctuated between 0 to 2 pills daily for pain levels ranging between 4 and 7 out of 10. On 06/24/2022, the resident was administered [MEDICATION(S)] 4 times at 5:12 a.m. for a pain level of 5, at 9:50 a.m. for a pain level of 4, at 4:42 p.m. for a pain level of 8, and at 9:11 p.m. for a pain level of 0. Resident #2 was administered [MEDICATION(S)] for pain on: 6/26, 6/27, 6/28, 6,29, and 6/30 once daily with a pain rating of between 4 and 6. A review of the MAR for 07/2022 revealed Resident #2 continued to receive [MEDICATION(S)] 50 mg for pain as follows: 7/1--at 6:31 a.m. pain level of 7, at 10:37 a.m. pain level of 5, at 4:13 p.m. pain level of 3, at 11:40 p.m. pain level of 7 7/2-at 4:29 a.m. pain level of 10, at 9:30 a.m. pain level of 4, at 4:30 p.m. for pain level of 3 7/3-at 9:37 a.m. pain level of 4, at 7:38 p.m. for pain level of 7, 7/4-at 9:55 a.m. pain level of 4 7/5-at 9:32 a.m. pain level of 4 7/6-at 6:36 a.m. pain level of 3, at 9:29 p.m. pain level of 6 7/7-at 5:29 a.m. pain level of 6, at 10:44 a.m. pain level of 4 7/8-at 6:32 a.m. pain level of 6, at 8:29 p.m. pain level of 6 7/9-at 5:02 a.m. pain level of 6, at 10:04 a.m. pain level of 4 7/10-at 10:06 a.m. pain level of 4 (then sent out to hospital) A review of Resident #2's Progress notes was conducted for the time period of 06/01/2022 to 08/15/2022 which revealed the following: 06/24/2022 9:25 p.m.: [Staff J, Registered Nurse RN]: While completing Tx [treatment] to buttocks Resident stated when being pushed out of her room earlier, the foot rests were not put on, and her R [right] foot went under the w/c [wheelchair]; unable to determine exact situation as resident changing situation if asked multiple times; checked R knee/leg and no swelling, dis-alignment, or redness; able to turn without pain; provided pain medication at resident request. Will have following nurse continue to monitor. 06/27/2022 5:58 a.m. [Staff K, LPN]: C/O [complaint of] Right leg pain. 06/29/2022 2:38 p.m. Psychotherapy progress note .Stated she is still having a lot of leg, foot, and back pain 07/5/2022 2:35 a.m. [MEDICATION(S)] 50 mg given for pain per resident request for bilateral leg pain. 07/06/2022 2:09 p.m. Psychotherapy progress note .Indicated she is having trouble with her legs and has pain when being changed . 07/09/2022 7:22 a.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. [MEDICATION(S)] 50 mg given. 07/09/2022 4:49 p.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. [MEDICATION(S)] 50 mg given 07/09/2022 5:39 p.m. [Staff L, LPN] Resident c/o rt lower leg pain. Call placed to [doctor]. Per call on call obtain x-ray rt knee, rt tibia/fibula, rt foot. Portable x-ray required resident is non ambulatory. 07/10/2022 1:07 p.m. Radiology Results: Results of Right knee, tib/fib and foot x-ray returns with findings of acute proximal tibia fracture. Called on call provider, LM [left message] on personalized VM [voice mail] requesting return call to writer. 07/10/2022 1:32 p.m. Called [Doctor] on call provider number . no answer, left message on personalized voice mail requesting return call to writer regarding radiology results and orders. 07/10/2022 2:33 p.m. Called on call provider for [Doctor] .Left message on personalized voice mail to report tibial fx findings and to obtain orders. 07/10/2022 3:26 p.m. [Doctor] on call ARNP [Advanced Registered Nurse Practitioner] returned call, new orders given to send to ED [Emergency Department] for further eval and Tx of tibial fx. Guardian numbers called x 2 each with no answer. No voicemail set up to leave message. 07/10/2022 3:40 p.m. Resident was sent to [local Hospital] at 07/10/2022 4:00 p.m. for tibial fx 07/10/2022 10:26 p.m. (Incident note) At approx. 8:45 p.m. resident returned to facility with a ½ brace wrapped with ace bandage to RT leg. Resident denies pain at time of arrival. Resident states, I'm so glad I am back. Discharge instructions: No weight bearing to Rt Leg. Follow-up with Dr [Orthopedic] .address within 3-5 days. Script for [MEDICATION(S)] 5/325 mg every 6 hours as needed for acute pain x 3 days. MD and Guardian aware of resident's return. A review of a Resident #2's X-Ray, Radiology Interpretation, date of exam 07/10/2022, reflected the following significant findings: Right Knee, 3 views: Findings: Multiple views of the right knee show a fracture of the proximal tibia. Diffuse osteopenia is present. Moderate [CONDITION(S)] is seen in the tri-compartment joint spaces. There are no joint bodies. There is no knee region soft tissue swelling. There is no joint effusion. There are no radiopaque foreign bodies. Impression: Acute fracture of the proximal tibia. Right Tibia and Fibula, two views: Findings: A fracture of the proximal tibia is visualized. Diffuse osteopenia is present. The joint spaces are preserved. No radiopaque foreign body is seen in the soft tissues. The soft tissues are unremarkable. Impression: Acute fracture of the proximal tibia. On 09/01/2022 at 12:00 p.m. an interview was conducted with the Radiologist. He stated the fracture for Resident #2 was acute and unlikely to be over three weeks old due to no callus formation. He stated on an older person with a lot of osteopenia, like Resident #2, makes a fracture slow to heal and he confirmed the fracture would have occurred within a three-week time period prior to the xray. On 08/18/2022 at 2:29 p.m., an interview was conducted with Staff A, LPN, UM (Unit Manager). She stated if a resident complains of leg pain the nurses are to find out what the pain is from, medicate for pain, let the doctor know, and let the family know. She stated if there are no other signs and it does not continue the nurse would do an assessment and go from there. A review of Resident #2's progress notes was conducted with Staff A, LPN, UM, the 06/24/2022 nurse note and the 06/27/2022 nurse note. Staff A, LPN confirmed both entries were missed opportunities to notify the physician. She said, the resident would complain of pain, but the right leg pain was unusual. On 08/19/2022 at 10:05 a.m. an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She reported she was familiar with Resident #2 and she normally had the same assignment which included Resident #2. She stated before Resident #2 broke her leg they would get her out of bed a lot and she would be put in the manual wheelchair. She stated the chair had regular foot rests. She stated she would always put the leg rests on and sometimes she would put a pillow on because her feet would dangle and angle out. She stated the resident was not able to self-propel and she would need someone to push her. She stated the wheelchair leg rests are extended now since the resident had a broken leg. She said she was not working on 06/24/2022. She stated during a Hoyer lift transfer, she did not recall a date, the resident complained about her leg hurting. She stated the resident was crying, I mean crying. She stated she told the nurse, who was an agency nurse, but she did not know the name of the nurse. She stated after the leg event, Resident #2 did not want to get out of bed. On 08/19/2022 at 11:05 a.m., an interview was conducted with Staff H, CNA. He recalled 06/24/2022, and he recalled Resident #2 that day. He said it was his first day in the facility and Resident #2 was going out of the building that day. Staff H stated she had taken a shower and he described what she was wearing, and stated the resident left before or around lunch time. He stated he was not assigned to care for the resident, but he did help with her care that day. He stated the resident was happy to be going out. He stated another aide, he could not remember her name, asked for his assistance with the wheelchair and he got it for her. He could not recall whether leg rests were placed on the wheel chair. On 08/19/2022 at 3:28 p.m., Staff I, CNA was interviewed by phone. She confirmed she was working on 06/24/2022 on the 7 a.m.- 3 p.m. shift and was assigned to care for Resident #2. She stated she assisted Resident #2 on 06/24/22 with care and getting the resident ready to go out of the building. Staff I, CNA, stated she did not take the resident to the main lobby, but recalled one of the people who come and get the residents for the activities came down. She stated it was either a younger guy or the young lady with blond hair but she did not know them. She stated the people just come around and get the residents to take them where they are going. She stated she remembered asking the resident if she needed her leg rests because she always asks. The person said, she will be ok and took her. I do not recall putting the leg rests on the wheelchair. On 08/19/2022 at 2:55 p.m. an interview was conducted with the NHA. The NHA stated Resident #2 indicated during her interview about the fracture, it was an accident where she put her foot down while being pushed by a volunteer. The NHA confirmed no one had witnessed the event. The NHA stated however, we were unable to validate any volunteer pushing her on said day, 06/24. The NHA stated she was notified on 07/10/2022 at 2:27 p.m. by Staff M, LPN, House Supervisor who called her. She stated it was a Sunday and she immediately came in. The NHA said, she called the Director of Operations and the Regional Clinical Nurse to let them know there was an allegation and a fracture with Resident #2. She stated she told them she going to the building to investigate. The NHA said Staff M, LPN and I went in to interview Resident #2 together. She stated during the interview with the resident, even though she has a BIMS of 11, she appeared quite lucid at the interview. The NHA stated the resident appeared alert and oriented with no nonsensical conversation. She stated Resident #2 reported she had an incident on 06/24/2022, and she remembered this because it was her special day. The NHA said Resident #2 told her she put her right foot down while being transported to the reception area by a volunteer and she did not think anything serious about it, but, as time has gone on, it had started to hurt more. The NHA stated the resident told her it was her fault for putting her foot down, and when she told the pusher to stop, he did. The NHA stated she thought the resident's right leg had fallen to the bar under the wheel chair. The NHA stated the resident described the male as short and blond and said he could be a volunteer. On 08/19/2022 at 2:21 p.m., a phone interview was conducted with Resident #2's Physician. He confirmed he was familiar with Resident #2. He confirmed Resident #2 had an X-Ray on 07/09/2022, was sent to the hospital on 07/10/2022, and she returned with a soft cast to the right leg. He stated he was driving and did not have the medical record in front of him, so specifics, he would have to review in the medical record. He stated he did not recall being notified of the event on 06/24/2022 with Resident #2, the report of the resident's pain, or the allegation her right foot had gone under the wheelchair. He stated, they [facility staff] are instructed to call about ALL problems, we are in the building 2-3 times per week, we are very responsive. He confirmed an X-ray could have been ordered for Resident #2's leg for her pain at the time of the event on 06/24/2022. He confirmed it was a missed opportunity to order the x-ray to identify the fracture at that time. A review of the facility policy and procedure: Accidents and Incidents, effective August 2000, last reviewed January 2022, documented the policy: A. An Accident or Incident Report Form must be completed on the shift that the accident/incident occurred-or was discovered. B. An accident or incident is any unusual event or circumstances that may include but are not limited to: Falls; Injuries which may or may not involve equipment; Assaults; Abuse, neglect, mistreatment, or exploitation; and Poison incidents. C. Inform the charge nurse of all accidents or incidents to provide medical attention. D. Steps for witnessed accidents: Render immediate assistance. Do not move the victim .; If assistance is needed, summon help . E. The charge nurse will: Examine all accident or incident victims; Notify the victims personal or attending physician and inform the physician of the accident or incident during the shift of occurrence; Notify the responsible party; Initiate the facility specific investigation report; If necessary, transfer the injured person to hospital; If necessary or appropriate, designate an employee to accompany the victim. F. The charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident. G. The following data as it may apply, must be included on the Accident Investigation Report form: 1. The date, time, and accident or incident took place; 2. The circumstances surrounding the accident or incident. 3. Where the accident or incident took place. 4. Names) of any witness and their account of the accident or incident. 5. The injured person's account of the accident or incident. 6. The time the injured persons attending, or personal physician was notified as well as the time the physician responded and his/her instructions. 7. The date and time the injured person's next of kin was notified and by whom. 8. The condition of the injured person, to include his/her vital signs. 9. Disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.) 10. Corrective action taken 11. Other pertinent data as necessary or required. 12. Signature and title of the person completing the report. H. The DON/Representative will: 1. Examine A/I (Accident/Incident) victims. 2. Complete the investigation form for all residents. 3. Complete the Employee A/I Form. 4. Offer emergency medical services at designated medical care center to all A/I victims who are employees or visitors. If necessary or appropriate, an employee shall be designated to accompany the victim to hospital. 5. Ensure that appropriate medical care has been provided for resident involved in A / Is. 6. A / I are logged for quality assurance. 7. Informs DPH of any reportable A/Is as required. 8. Informs the Executive Director and/or DON of all reportable A/Is immediately by phone. I. The Unit Manager will: 1. Ensure the measures to prevent reoccurrence are addressed on the Interdisciplinary Care Plan. 2. Consults with other disciplines and adjusts care plan according to need. 3. Reports effectiveness of any new interventions. J. Staff education as needed.

Based on observation, interview, record review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey, on [DATE] and was cited at F759. On [DATE] a revisit survey was conducted and the facility was recited at F759. The facility had developed a Plan of Correction with a completion date [DATE]. The facility had not comprehensively implemented the plan of correction for the identified quality deficiencies. Findings Included: A review of the facility's policy and procedure for Quality Assurance & Performance Improvement Program (QAPI), effective [DATE], last reviewed [DATE], revealed the following: Our Quality Assurance and Performance Improvement Program (QAPI) represent our facility's commitment to continuous quality improvement. The program ensures a systematic performance evaluation, problem analysis and implementation of improved strategies to achieve our performance goals. The Policy Explanation and Compliance Guidelines: A. The facility shall implement a QAPI Program designed to ensure the provisions required by The Patient Protection and Affordable Care Act of 2010, section 6102( c ). B. The facility shall establish an interdisciplinary QAPI Committee. The committee shall consist of at a minimum, a chairperson, director of nursing services, physician, and three other facility staff members. Additional staff members may be included when their expertise is needed. C. The QAPI Committee shall select additional members to participate in various subcommittees based upon the Performance Improvement Project (POP) topic and participant expertise. These projects may include clinical and non-clinical opportunities to improve. D. The QAPI Committee shall communicate its activities, and the progress of its subcommittee PIPs, to the administrator or executive director a minimum of quarterly by formal meeting. Additional team communication may occur via email or conference call. E. The QAPI Committee shall meet at least quarterly to review facility data, identify opportunities for improvement, and review the activities of its PIP sub-committees. The committee shall maintain written meeting agendas, minutes, and periodically provide activity reports upon request to the administrator. F. The QAPI Committee's oversight responsibilities shall include, but are not limited to the following: 1. Annual review of the facility QAPI Program. 2. Establishment of PIP subcommittees. 3. Ensure the subcommittee has the adequate resources to conduct their project. 4. Submit findings of performance improvement projects to the chairperson that includes a summary of QAPI performance improvement project activities and findings. 5. Utilize facility data to identify opportunities to improve systems and care. Data may include, but is not limited to: grievance logs, medical record review, skilled care claims, fall log, pressure ulcer log, treatment logs, staffing trends, incident and accident reports, quality measures, survey outcomes, etc. Procedure: Establishment of Facility QAPI Plan: The QAPI Committee shall establish an initial facility plan in its first QAPI meeting. Revision of Facility QAPI Plan: The QAPI Committee will review the plan annually and make necessary revisions. Revisions shall reflect the findings, discussions, meeting, surveys, interaction with executive leadership, etc. of the previous year. The plan may be modified during the year, with expanded executive committee approval as needed. Annual Report to the Executive Director: The committee chair (if other than the executive director or administrator) shall submit an annual summary report of the QAPI activities to the administrator or executive director. The report may be requested more frequently. QAPI Sub-Committees: Each Sub-committee shall be guided by a QAPI Committee member who will facilitate coordination of the PIP and ensure each Subcommittee is adequately resourced. Upon conclusion of the PIP, the Sub-committee shall provide the QAPI Committee with a report, which contains a summary and analysis of activities and recommendations for improvement. Clinical and Non-Clinical Performance Improvement Projects: The facility shall conduct PIPs designed to achieve and sustain performance improvement over time. PIPs shall be designed to have an expected favorable outcome. The QAPI Sub-committee shall implement PIPs using relevant data collection and analysis with appropriate intervention strategies to improve facility performance. The QAPI Committee will review the outcome of the PIP and may recommend further assessment of problem areas or corrective systemic interventions. The QAPI Committee shall maintain written documentation of meetings, findings, and progress, and make recommendations. A review of the policy entitled Medication Administration Skilled Nursing Facility (SNF), reviewed [DATE], revealed the following: . medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner . 3. Medications are administered in accordance with the written orders of the attending physician. The facility plan of correction identified an In-service education to licensed staff on [DATE] with ongoing instruct on medication administration guidelines per facility protocols along with a Medication Administration Competency. 1) On [DATE] at 9:30 a.m. an observation of medication administration was conducted alongside Staff N, Licensed Practical Nurse (LPN). Staff N stated she just started and she was not scheduled to work at the facility today and stated, I was just called in. Staff N prepared the following medications for Resident #9: one Ferrous Sulfate 325 mg (milligrams), one Cilostazol 100 mg, one Amlodipine 2.5 mg, two Lisinopril 10 mg, one Loratadine 10 mg, one Buspar 150 mg ER, and a Novolog flex pen. The Novolog (insulin) pen dose selector was set to 5 units. Staff N, LPN confirmed a total of seven pills. The oral medications were administered to the resident and the insulin pen was administered to the resident in the left upper arm. A medication reconciliation was conducted which revealed the following Physician orders: Cholecalciferol 25 mcg (micrograms) 1000 Units give 1 tablet by mouth one time a day for weakness and fatigue start date [DATE], due at 0900. The medication was not observed to have been administered.; Novolog (insulin aspart) flex pen solution Pen-Unit/ML (milliliters) inject 5 units subcutaneously with meals for Diabetes Melilites (DM) start date [DATE]. The inulin was scheduled to be administered at 7:30 a.m. An interview was conducted with Staff N, LPN on [DATE] who confirmed the inulin was late because the resident had already eaten his breakfast. A review of the manufacturer's instructions for the Novolog Insulin flex pen revealed the following: Giving the air shot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin: G. Turn the dose selector to select 2 units. H. Hold your Novolog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. the dose selector returns to 0, A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. 2) On [DATE] at 10:05 a.m. a medication administration was observed with Staff O, LPN as he prepared the following medications for Resident #8. Staff O, LPN stated, I'm running late, and said it was related to computer issues. He stated I was here on time this morning but my password for the computer system had expired. It took over two hours to reset my password. Staff O prepared the following medications: one Multivitamin with mineral, one Vitamin D 5000 units, one Ferrous Sulfate 325 mg, one Tamsulosin 0.4 mg, one Metoprolol 25 mg, one Norco 10/325 mg. Staff 0 stated the next dose of Ferrous Sulfate is already due at noon and then confirmed an order for Pro-Stat was not available on the medication cart. Staff O entered Resident #8's bedroom and administered the oral medications. Staff O performed a blood glucose reading with a result of 298. Staff O stated the order for blood glucose reading was scheduled at 8:00 a.m. Staff O returned to the resident room and administered Novolog (insulin) 65 units to the resident at 10:22 a.m. Staff O confirmed the inulin was given late. Resident #8 was overheard telling Staff O,LPN, I haven't received my IV yet. Staff O told the resident he would be getting it ready next. At 10:41 a.m. Staff O, reentered Resident #8's bedroom and placed a bag of solution on the IV pole. The tubing was connected to the bag and then attached to the resident's right upper arm peripherally inserted central catheter (PICC). The bag of solution read Vancomycin 1000 mg. The resident dressing on the PICC was not dated, Resident #8 stated out loud they don't like to put dates on it. Then they'll have to change it more often. Staff O stated, I'll be back later and change the dressing. A medication reconciliation was conducted which revealed the following Physician orders: Novolog N suspension 100 units inject 65 units subcutaneously two times a day for DM dated [DATE] scheduled at 7:00 a.m.; Vancomycin HCL solution 1000 mg/ml use 1 gram intravenously two times a day for gram positive bacteria for 4 weeks dated [DATE] scheduled at 8:00 a.m.; Pro-Stat sugar free one time a day for hypoalbuminemia 30 ml one time a day (1x/day) dated [DATE] scheduled at 9:00 a.m. On [DATE] at 1:37 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated, it is getting better now as were trying to use less agency. When informed of the concerns related to the observations during the administration of medications he stated, That is a problem, that would be a concern if that was what you saw. The DON said he uses an insulin pen. He said he doesn't prepare his pen with an air shot. He stated, the air shot is only performed when the pen is first used. On [DATE] at 2:32 p.m. Staff P, Supervisor confirmed training was provided on the insulin flex pen. She stated they had a tutorial a while back. Staff N was present and confirmed she did not perform the air shot prior to administering Resident #8's insulin. Twenty-six medication administration opportunities were observed, and six errors were identified for two (#8 and 9) of three residents sampled. These errors constituted a 21.43% medication error rate. On [DATE] at 3:40 p.m. an interview was conducted with the Nursing Home Administrator (NHA) to review the Quality Assurance and the facility Plan of Correction. The NHA confirmed they conduct monthly QA meetings. The meetings include discussions on the survey results, and the plan of correction. The NHA stated the committee discussed how they are progressing with the monitoring and if there any need to change the plan in any way. The NHA stated We felt we had substantial compliance.

Based on observation, interview, and record review the facility failed to ensure an allegation of abuse and neglect was reported to the governing agency in accordance with the State law for one resident (#2) out of fourteen residents sampled regarding a resident who reported their foot had been caught under a wheelchair and was reporting new onset of pain in that leg. Findings included: On 08/18/2022 at 9:55 a.m., an observation was conducted of Resident #2. She was observed in bed and agreed to answer questions. She reported she had fractured her right leg recently. She stated the cast was just removed, last Friday. She stated an aide was pushing her [on 06/24/2022] and should have had the leg rests on, and they did not. She stated her right leg fell under the wheelchair. She stated it took 2 weeks before she was able to go to the hospital. She stated they (the facility staff) thought I was faking it. She stated her whole leg was in a cast. She stated she thought the man who pushed her in the wheelchair was a volunteer. She reported she currently had pain level of 10 on a scale of 1-10, with 10 being the most severe pain. On 08/18/2022, at 11:30 a.m., Resident #2 was observed with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated she was familiar with Resident #2. She stated the resident fractured her right tibia. She stated she was really not sure what happened because she had heard several stories. She stated one version was a volunteer was pushing the resident and the resident's leg went under the wheelchair. A review of Resident #2's Admission Record revealed the resident was admitted on ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Function, a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section B: Hearing, Vision, and Speech revealed the resident had no impairment and assessed the resident with clear speech-distinct intelligible words; makes self-understood; and understands others-clear comprehension. Section G: Functional Status, revealed Resident #2 required support of two persons for transfer, bed mobility, and dressing. A review of Resident #2's Care Plan revealed the following: Focus: Self-care deficit: Requires assist with ADL's (Activity of Daily Living) due to decreased mobility, initiated on 03/08/2022. Interventions included: Extensive to total, 2 person assist for bed mobility, initiated on 03/11/2022, revision on 08/01/2022. Extensive to total assist with transfers; 2 persons, initiated on 03/11/2022, revision on 08/01/2022. Leg rests are to be on when she is up in w/c, initiated 08/03/2022 Uses a full body mechanical lift for transfers, initiated on 03/11/2022. Uses a manual wheelchair, initiated on 03/11/2022. Focus: Resident has potential for falls related to: unable to bear weight and non-ambulatory, initiated 03/08/2022. Interventions included: 4P's rounding (Check resident for any pain concerns, positioning needs, that personal items are within reach and that personal needs are being met), initiated 03/08/2022. A review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/24/2022, the resident was administered [MEDICATION(S)] 4 times at 5:12 a.m. for a pain level of 5, at 9:50 a.m. for a pain level of 4, at 4:42 p.m. for a pain level of 8, and at 9:11 p.m. for a pain level of 0. Resident #2 was administered [MEDICATION(S)] for pain on: 6/26, 6/27, 6/28, 6,29, and 6/30 once daily with a pain rating of between 4 and 6. A review of the MAR for 07/2022 revealed Resident #2 continued to receive [MEDICATION(S)] 50 mg for pain as follows: 7/1--at 6:31 a.m. pain level of 7, at 10:37 a.m. pain level of 5, at 4:13 p.m. pain level of 3, at 11:40 p.m. pain level of 7 7/2-at 4:29 a.m. pain level of 10, at 9:30 a.m. pain level of 4, at 4:30 p.m. for pain level of 3 7/3-at 9:37 a.m. pain level of 4, at 7:38 p.m. for pain level of 7, 7/4-at 9:55 a.m. pain level of 4 7/5-at 9:32 a.m. pain level of 4 7/6-at 6:36 a.m. pain level of 3, at 9:29 p.m. pain level of 6 7/7-at 5:29 a.m. pain level of 6, at 10:44 a.m. pain level of 4 7/8-at 6:32 a.m. pain level of 6, at 8:29 p.m. pain level of 6 7/9-at 5:02 a.m. pain level of 6, at 10:04 a.m. pain level of 4 7/10-at 10:06 a.m. pain level of 4 (then sent out to hospital) A review of Resident #2's Progress notes was conducted for the time period of 06/01/2022 to 08/15/2022 which revealed the following: 06/24/2022 9:25 p.m.: [Staff J, Registered Nurse RN]: While completing Tx [treatment] to buttocks Resident stated when being pushed out of her room earlier, the foot rests were not put on, and her R [right] foot went under the w/c [wheelchair]; unable to determine exact situation as resident changing situation if asked multiple times; checked R knee/leg and no swelling, dis-alignment, or redness; able to turn without pain; provided pain medication at resident request. Will have following nurse continue to monitor. 06/27/2022 5:58 a.m. [Staff K, LPN]: C/O [complaint of] Right leg pain. 06/29/2022 2:38 p.m. Psychotherapy progress note .Stated she is still having a lot of leg, foot, and back pain 07/5/2022 2:35 a.m. [MEDICATION(S)] 50 mg given for pain per resident request for bilateral leg pain. 07/06/2022 2:09 p.m. Psychotherapy progress note .Indicated she is having trouble with her legs and has pain when being changed . 07/09/2022 7:22 a.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. [MEDICATION(S)] 50 mg given. 07/09/2022 4:49 p.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. [MEDICATION(S)] 50 mg given 07/09/2022 5:39 p.m. [Staff L, LPN] Resident c/o rt lower leg pain. Call placed to [doctor]. Per call on call obtain x-ray rt knee, rt tibia/fibula, rt foot. Portable x-ray required resident is non ambulatory. 07/10/2022 1:07 p.m. Radiology Results: Results of Right knee, tib/fib and foot x-ray returns with findings of acute proximal tibia fracture. Called on call provider, LM [left message] on personalized VM [voice mail] requesting return call to writer. 07/10/2022 1:32 p.m. Called [Doctor] on call provider number . no answer, left message on personalized voice mail requesting return call to writer regarding radiology results and orders. 07/10/2022 2:33 p.m. Called on call provider for [Doctor] .Left message on personalized voice mail to report tibial fx findings and to obtain orders. 07/10/2022 3:26 p.m. [Doctor] on call ARNP [Advanced Registered Nurse Practitioner] returned call, new orders given to send to ED [Emergency Department] for further eval and Tx of tibial fx. Guardian numbers called x 2 each with no answer. No voicemail set up to leave message. 07/10/2022 3:40 p.m. Resident was sent to [local Hospital] at 07/10/2022 4:00 p.m. for tibial fx 07/10/2022 10:26 p.m. (Incident note) At approx. 8:45 p.m. resident returned to facility with a ½ brace wrapped with ace bandage to RT leg. Resident denies pain at time of arrival. Resident states, I'm so glad I am back. Discharge instructions: No weight bearing to Rt Leg. Follow-up with Dr [Orthopedic] .address within 3-5 days. Script for [MEDICATION(S)] 5/325 mg every 6 hours as needed for acute pain x 3 days. MD and Guardian aware of resident's return. On 08/18/2022 at 2:29 p.m., an interview was conducted with Staff A, LPN, UM (Unit Manager). She stated if a resident complains of leg pain the nurses are to find out what the pain is from, medicate for pain, let the doctor know, and let the family know. A review of Resident #2's progress notes was conducted with Staff A, LPN, UM, specifically the 06/24/2022 nurse note and the 06/27/2022 nurse note. Staff A, LPN confirmed both entries were missed opportunities to notify the physician and complete an assessment. She said, the resident would complain of pain, but the right leg pain was unusual. On 08/19/2022 at 10:05 a.m. an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She reported she was familiar with Resident #2 and she normally had the same assignment which included Resident #2. She stated before Resident #2 broke her leg they would get her out of bed a lot and she would be put in the manual wheelchair. She stated the chair had regular foot rests. She stated she would always put the leg rests on and sometimes she would put a pillow on because her feet would dangle and angle out. She stated the resident was not able to self-propel and she would need someone to push her. She stated the wheelchair leg rests are extended now since the resident had a broken leg. She said she was not working on 06/24/2022. She stated during a Hoyer lift transfer recently, she did not recall a date, the resident complained about her leg hurting. She stated the resident was crying, I mean crying. She stated she told the nurse, who was an agency nurse, but she did not know the name of the nurse. She stated after the leg event, Resident #2 did not want to get out of bed. Staff B, CNA stated no one had interviewed her or asked her for a statement related to the 6/24/2022 incident involving Resident #2. She denied any additional training related to the incident. On 08/19/2022 at 3:28 p.m., Staff I, CNA was interviewed by phone. She confirmed she was working on 06/24/2022 on the 7 a.m.- 3 p.m. shift and was assigned to care for Resident #2. She stated she assisted Resident #2 on 06/24/22 with care and getting the resident ready to go out of the building. Staff I, CNA, stated she did not take the resident to the main lobby, but recalled one of the people who come and get the residents for the activities came down. She stated it was either a younger guy or the young lady with blond hair but she did not know them. She stated the people just come around and get the residents to take them where they are going. She stated she remembered asking the resident if she needed her leg rests because she always asks. The person said, she will be ok and took her. I do not recall putting the leg rests on the wheelchair. She stated no one had called her about any event on 06/24/2022, this was the first time anyone had reached out. On 08/19/2022 at 2:21 p.m., a phone interview was conducted with Resident #2's Physician. He confirmed he was familiar with Resident #2. He confirmed Resident #2 had an X-Ray on 07/09/2022, was sent to the hospital on 07/10/2022, and she returned with a soft cast to the right leg. He stated he was driving and did not have the medical record in front of him, so specifics, he would have to review in the medical record. He stated he did not recall being notified of the event on 06/24/2022 with Resident #2, the report of the resident's pain, or the allegation her right foot had gone under the wheelchair. He stated, they [facility staff] are instructed to call about ALL problems, we are in the building 2-3 times per week, we are very responsive. He confirmed an X-ray could have been ordered for Resident #2's leg for her pain at the time of the event on 06/24/2022. He confirmed it was a missed opportunity to order the x-ray to identify the fracture at that time. A review of a Resident #2's X-Ray, Radiology Interpretation, date of exam 07/10/2022, reflected the following significant findings: Right Knee, 3 views: Findings: Multiple views of the right knee show a fracture of the proximal tibia. Diffuse osteopenia is present. Moderate [CONDITION(S)] is seen in the tri-compartment joint spaces. There are no joint bodies. There is no knee region soft tissue swelling. There is no joint effusion. There are no radiopaque foreign bodies. Impression: Acute fracture of the proximal tibia. Right Tibia and Fibula, two views: Findings: A fracture of the proximal tibia is visualized. Diffuse osteopenia is present. The joint spaces are preserved. No radiopaque foreign body is seen in the soft tissues. The soft tissues are unremarkable. Impression: Acute fracture of the proximal tibia. On 09/01/2022 at 12:00 p.m. an interview was conducted with the Radiologist. He stated the fracture for Resident #2 was acute and unlikely to be over three weeks old due to no callus formation. He stated on an older person with a lot of osteopenia, like Resident #2, makes a fracture slow to heal and he confirmed the fracture would have occurred within a three-week time period prior to the xray. A review of the facility Report Tracking Log for June 2022 listed no entries. A review of the facility Report Tracking Log, for July 2022 listed the following entries: Resident #2, abuse, date of event 07/10/2022; date of AHCA 1 day 07/10/2022; date of the AHCA 5-day report 07/14/2022. On 08/19/2022 at 12:01 p.m. and again at 2:55 p.m. an interview was conducted with the NHA. The NHA confirmed she was the Abuse Coordinator and Risk Manager for the faciltiy. The NHA stated she was notified of the incident with Resident #2, that occurred on 06/24/2022, on 07/10/2022 at 2:27 p.m. by Staff M, LPN, House Supervisor who called her. She stated it was a Sunday and she immediately came in. The NHA said, she called the Director of Operations and the Regional Clinical Nurse to let them know there was an allegation and a fracture with Resident #2. She stated she told them she going to the building to investigate. The NHA said Staff M, LPN and I went in to interview Resident #2 together. The NHA stated Resident #2 indicated during her interview about the fracture, it was an accident where she put her foot down while being pushed by a volunteer. The NHA confirmed no one had witnessed the event. The NHA stated however, we were unable to validate any volunteer pushing her on said day, 06/24. She stated during the interview with the resident, even though she has a BIMS of 11, she appeared quite lucid at the interview. The NHA stated the resident appeared alert and oriented with no nonsensical conversation. She stated Resident #2 reported she had an incident on 06/24/2022, and she remembered this because it was her special day. The NHA said Resident #2 told her she put her right foot down while being transported to the reception area by a volunteer and she did not think anything serious about it, but, as time has gone on, it had started to hurt more. The NHA stated the resident told her it was her fault for putting her foot down, and when she told the pusher to stop, he did. The NHA stated she thought the resident's right leg had fallen to the bar under the wheel chair. The NHA stated the resident described the male as short and blond and said he could be a volunteer. The NHA confirmed the facility had surveillance cameras, and said I did not check the cameras, I think the cameras only go back one week. A review of the facility policy and procedure, Abuse, Neglect & Exploitation, effective November 2017, revised January 2022, documented the policy: Each resident has the right to be free from abuse, including verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. This prohibition applies to everyone, including, but not limited to, facility staff (employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility), other residents, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. This includes mental abuse that is facilitated or caused by facility staff using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, use, or distribute photographs, videos, or other recordings, including posting on social media, or in any manner that demean or humiliate a resident(s). Anytime that the nursing facility receives an allegation of abuse, including those involving the posting of an unauthorized photograph or recording of a resident on social media, the facility must comply with the reporting and investigation procedures set forth in this policy and with any state-specific policy and take steps to prevent further potential abuse. Compliance with reporting the reasonable suspicion of a crime must also be followed. Definitions included: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Mental Abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility abuse prohibition plan included: Training: Facility shall develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers consistent with their expected roles . Prevention of Abuse, Neglect, Exploitation of Residents and Misappropriation of Resident Property. The facility will utilize the following techniques for prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property included: . React to all allegations or questions from residents, family members, employees, or visitors. Take appropriate actions when abuse, neglect, exploitation, or misappropriation is suspected. Provide instructions to staff on care needs of residents. Assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, . residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. Identification of Abuse, Neglect, Exploitation and Misappropriation included: The facility will identify factors indicating possible abuse, neglect, exploitation of residents, or misappropriation of resident property, including, but not limited to, the following possible indicators: Resident, staff, or family report of abuse. Physical injury of a resident, of unknown source. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning. Resident Protection after Alleged Abuse, Neglect, Exploitation, or Misappropriation: The facility will make reasonable efforts to protect any and all residents after alleged abuse, neglect exploitation, or misappropriation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect, and exploitation may include, but are not limited to: Evaluate resident and ensure necessary medical care or treatment is provided and notify treating physician as appropriate. Response and Reporting of Abuse, Neglect, Exploitation, and Misappropriation: Anyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility administrator, abuse agency hotline, or file a complaint with the state survey agency and adult protective services (if applicable under state law) immediately (but not later than 2 hours after an allegation is made if the events that lead to the allegation involve abuse or result in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury. Reporting and investigation should be done in accordance with state law/regulation. When abuse, neglect, or exploitation is suspected, the Administrator or designee should: Respond to the needs of the resident and protect them from further incident (document); Notify the Director of Nursing and Administrator (document); Initiate an investigation immediately; Notify the attending physician, resident's family/legal representative and Medical Director. Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from the resident care areas immediately. Contact the state agency and local Ombudsman office to report the alleged abuse. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions, and document actions taken in steps above in the medical record. Investigation of Alleged Abuse, neglect, Exploitation, and Misappropriation: When suspicion of abuse, neglect, exploitation, or misappropriation or reports of abuse, neglect, exploitation, or misappropriation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation shall be conducted. Components of an investigation shall include when appropriate; Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically. After completion of the investigation, the results of the investigation and any reports or witness statements shall be provided to the facility's Quality Assurance and performance Improvement Committee for further evaluation.

Based on observations, staff interviews, and record review, the facility failed to develop care planning problem areas with goals and interventions related to 1. hand covers for one (Resident #58) of three sampled residents related to hand devices; 2. anticoagulant use for one (Resident #107) of five sampled residents; 3. padded side rails for one (Resident #16) of one sampled resident ; and 4. nebulizer medications for one (Resident #175) of three sampled residents for nebulizer use. Findings included: 1. On 6/5/2022 at 10:00 a.m., Resident #58 was observed seated and positioned in his wheelchair at the 300 unit nurses' station. He was observed dressed for the day and well groomed. On 6/5/2022 at 10:03 a.m., Resident #58 started shaking his hands and arms up over his head and making loud grunting noises. The resident had cognitive impairments and he could not speak and or communicate with conversation. Both of his hands and fingers were covered with what appeared to be white socks. On 6/5/2022 at 10:08 a.m., while Resident #58 was still waiving his hand and grunting, Staff B, Registered Nurse (RN) was observed standing at a medication cart about five feet across from him. After about two to three minutes of the resident shaking his hands and grunting, Staff B was heard saying, Oh you want those off, I'm sorry honey; I can't take them off. Resident #58 was not observed trying to take off the hand coverings, but continued to shake his hand and arms over his head. About a minute after Staff B spoke to Resident #58, he stopped waiving his hands and became quiet. On 6/5/2022 at 11:15 a.m. and 12:00 p.m., Resident #58 was observed seated in his wheelchair in the same position at the 300 unit nurse station. He was not wearing the socks or hand covers on either of his hands. Resident #58 was not touching his face or head, and was not presenting with any other type of behaviors, pain or discomfort. On 6/6/2022 at 2:55 p.m., Resident #58 was observed in his room and in an enclosed netted bed. He was observed dressed for the day and was resting with his eyes closed. The resident was not wearing sock/ hand coverings on either of his hands. On 6/7/2022 at 7:30 a.m., Resident #58's room was entered and he was noted in his enclosed netted bed, dressed for the day and lying on his side with his eyes closed. The room was generally dark. Staff A, CNA was in the room assisting Resident #58's roommate. Upon interview with Staff A, she revealed she had Resident #58 routinely on her assignment and knew him well. Staff A confirmed Resident #58 was not wearing socks or hand coverings and did not know he ever wore hand covers that resembled socks. She revealed at times, they gave him things to hold on to and grip, but had never seen socks placed on his hands and fingers. On 6/7/2022 at 8:00 a.m., the 300 unit manager Staff C was interviewed. She revealed Resident #58 wore hand coverings on both hands at times and that they were tube socks. She revealed they had placed the socks on him so he did not bite his hands. She said Resident #58's mother and physician were both aware and consented to this trial to see if it helped. Staff C stated the socks/hand coverings were not Restraints. She said, the resident could and had been educated and observed removing them either by wiping his upper chest area to roll the socks off, or using his mouth to pull them off. She revealed Resident #58 had gone through a recent [CONDITION(S)] medication change, and he had not been presenting with biting behaviors. Staff C could not remember exactly when they started using the socks/hand covers for both of his hands, but did indicate it had been at least two weeks. Staff C confirmed there was no actual order or care plan for use of the sock/hand covers and expressed they had been doing a trial run. Staff C confirmed most of the other direct care staff on the 300 unit had not been made aware of the use of the socks nor had they been made aware of who was responsible to put them on and monitor him with them on. Review of Resident #58's electronic medical record revealed he was admitted to the facility on [DATE]. Review of the admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Quarterly assessment, dated 3/18/2022 revealed Cognition - Brief Interview for Mental Status BIMS score = Not assessed. However, the assessment revealed resident was severely impaired with decision making skills; Behaviors - behavior symptoms not directed towards others e.g. physical symptoms such as hitting, scratching; this behavior was documented as occurred daily; Activities of Daily Living ADL - Total dependence with two person assist with Bed Mobility, Transfers, Dressing, Eating, Toilet use and Personal Hygiene; Restraints - Documented as none used, to include limb restraint. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was an order with a start date of 6/3/2022 which indicated to target anxiety behaviors (restless, unable to focus, difficulty sleeping), note biting hands when anxious (has formed callous area to knuckles), note if target behaviors were present every shift; every shift for anti-anxiety medication use. Review of the nurses' progress notes dated from 3/1/2022 through 6/7/2022, revealed the following notes related to biting behaviors: 3/31/2022 12:53 p.m. - Behavior note: Reported to staff resident noted with increased aggression, spoke with Unit Manager, Social Services then notified, spoke with MD for new order for Psych eval. and treat. There was nothing in the note that indicated resident was biting his hands. 4/7/2022 10:59 a.m., - Behavior note: Alert, up in wheelchair, resident grabbing staffs clothing while feeding him. Grabbing stethoscope and glasses. As needed [MEDICATION(S)] given with relief. Taken to activities where he remains alert, calm, and cooperative. There was nothing in the note that indicated resident was biting his hands. 5/20/2022 14:36 (2:36 p.m.), - Behavior note: Noted resident biting hand more so today, along with kicking leg. Reported yesterday resident had been yelling out, and physically destroyed his own keyboard in room. Psych contacted today, informed of increased behaviors. New orders for [MEDICATION(S)] twice daily, continue Valporic acid, and as needed [MEDICATION(S)]. Resident had been given Tylenol earlier this a.m. for possible discomfort without effect. This was the only note from progress notes dated 3/1/2022 through to 6/7/2022 that identified resident was biting his hand. 5/26/2022 15:25 (3:25 p.m.), - Clinical note: MD in to see resident regarding behavior and of [MEDICATION(S)] effectiveness, writer discussed with MD if we could remove the previous benzodiazepine ([MEDICATION(S)]) so resident is not on both Medications. MD agreed and gave [MEDICATION(S)] 5 mg q 8 hour as need for breakthrough behavior. Mother notified. This note did not indicate what type of behaviors the MD was evaluating for. On 6/7/2022 8:22 a.m., - Behavior note: Resident has behaviors i.e., biting hands, scratching self, throwing objects, kicking and can be resistive to care rendered, when resident becomes agitated and scratching self and or biting hands. May apply socks/hand protectors bilaterally on resident to prevent harm. Family and MD has been made aware. On 6/7/2022 8:32 a.m., Behavior note: Called resident's mother regarding behaviors and hand protectors. Mother stated nurse called her several days ago and informed her. On 6/7/2022 at 10:30 a.m., an interview with the 300 Unit Manager, Staff C confirmed she had put in Behavior notes related to Resident #58 biting his hands, and other behaviors on 6/5/2022, after Resident #58 was observed wearing socks/hand covers. Review of the 5/2022 monthly Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 6/2022 monthly Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's current Care Plans with the next review date of 6/20/2022, revealed the following areas to include but not limited to: 1. Focus area: Behaviors, self abusive, biting self, banging feet on the bedrails and wheelchair, initiated on 4/4/2022, with interventions to include: Administer and monitor effectiveness and side effects of medications as per MD orders; Intervene as needed to protect the rights and safety of others. Approach calmly. Divert attention, remove from situation and take to another location; On 6/5/2022, this intervention was developed: May apply hand protectors that can be removed by the resident i.e (socks) to prevent physical injury to self, resident may remove. 2. Focus area:Resident is resistive to care related to anxiety, initiated on 6/5/2022, with interventions to include but not limited to when resident is causing self injury due to anxiety i.e. biting, scratching, etc. may apply hand protectors that can be removed by resident (may use socks). On 6/7/2022 at 1:00 p.m., an interview with the 300 Unit Manager and review of the medical record revealed a new care plan was developed with interventions to include: Use of hand protectors/socks if resident is biting hands or scratching self, initiated 6/7/2022, with interventions to include but not limited to: Nurse to apply hand protectors/socks as needed. On 6/8/2022 at 11:00 a.m., an interview with the MDS/Care Plan Coordinator confirmed they (the facility) did not develop a care plan problem area with goals and interventions related to socks/hand coverings when Resident #58 presented with hand biting behaviors. She revealed she was aware of the behavior, but was not aware staff were using socks/hand covers to prevent him from biting his hands 2. A review of the Resident #107's Admission Record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #107 had moderately impaired cognition. Section N: Medications revealed Resident #107 received anticoagulant medications six times a week. A review of the care plan dated 04/12/22 revealed no focus area, goals, or interventions related to the use of anticoagulants. A review of Resident #107's current Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/07/22 at 9:25 a.m., Resident #107 was observed in bed. There was no bruising or skin discoloration noted. On 06/08/22 at 10:39 a.m., an interview was conducted with Staff R, Licensed Practical Nurse (LPN) and the Nursing Supervisor. They confirmed Resident #107 received [MEDICATION(S)], and monitoring was not completed related to the use of it. They stated that there was no specific reason to monitor for the use of [MEDICATION(S)]. On 06/08/22 at 12:25 p.m., an interview was conducted with the MDS Coordinator. She confirmed the resident did not have a focus area in the care plan for anticoagulant use and he should have had one. She stated the care plan should have been updated upon admission. She confirmed if a new order was received for the medication, a nurse should have added it to the care plan. 3. On 6/7/2022 at 11:00 a.m., 12:00 p.m., and 1:00 p.m. Resident #16 was observed in her room and lying flat in bed pushing her left foot and leg between the space of the bottom left side rail and rubbing her left foot and lower leg against the metal frame of the left side rail. The bed was observed to have both lower and upper side rails up in position with only the right-side rail blue pad attached and the left side rail pad removed. Review of the Admission Record revealed Resident #16 was admitted to the facility for long term care on 10/23/2000. Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Order Summary Report, as of 6/8/2022, revealed the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/7/2022 at 12:59 p.m., Staff E, Certified Nursing Assistant (CNA) was interviewed. He confirmed when he received his assignment to care for Resident #16 the left blue pad was not attached to Resident #16's left side rail. He also confirmed he did not know where the left blue side rail pad was, and he did not know why the blue pads should be attached to Resident #16's side rails. Staff E confirmed he was not made aware of the expectation of the blue pads on the side rails for Resident #16. On 6/7/2022 at 1:15 p.m. Staff D, Licensed Practical Nurse (LPN) was interviewed and confirmed he took care of Resident #16 frequently. He confirmed he was aware of Resident #16's needs and the expectation regarding the blue pads for the side rails. Staff D confirmed whenever Resident #16 was in bed both left and right blue side rail pads must be attached to the side rails for the resident's safety. He confirmed it was the nurses' and CNAs' responsibility to ensure both blue pads were attached to Resident #16's side rails on each shift every day. Staff D revealed at the start of his shift the left blue pad was on Resident #16's bed, and he was not aware that the pad was missing. Staff D went to Resident #16's room and confirmed the blue left pad was not on Resident #16's side rail. Review of the current care plans with a next review date of 9/3/2022, revealed the following problem areas: a. At risk for injury related to involuntary movement in bed R/T (related to) TBI (traumatic brain injury), date initiated 3/11/2022. Goal: will have no injury to involuntary movements, date initiated 3/11/2022, revision on 6/6/2022, target date, 9/3/2022. Interventions: daily observation by CNA, padded side rails, date initiated 3/11/2022. b. Resident has potential for alteration in skin integrity related to incontinence, dependent with bed mobility, date initiated 2/25/2022. Goal: resident's skin will remain intact, date initiated 2/25/2022, revision on 6/6/2022, target date 9/3/2022. Intervention: pads/bolsters (bolsters) on bed to protect from injury related to [CONDITION(S)] and involuntary movement. 4. On 06/08/2022 at 8:59 a.m., an observation was made of Resident #175's room. During the observation respiratory equipment of a blue nebulizer and facemask were noted to be placed in a plastic storage bag. A record review for Resident # 175 indicated she was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 175's Brief Interview For mental Status (BIMS) score was 0, (indicating severe cognitive impairment). On 06/06/2022 at 11:10 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN)/Unit Manager (UM). Staff H, (LPN/UM) confirmed Resident #175 received respiratory nebulizer treatments. Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Both medications are used via respiratory (nebulization) facemask device. Resident #175's comprehensive care-plan dated 02/18/2022 was reviewed and did not reveal a focus area or intervention related to receiving respiratory nebulizer breathing treatments for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 06/07/2022 at 4:06 p.m., with the Director of Minimum Data Set (MDS) who was responsible for updating care plans. During the interview, she confirmed Resident #175 was not care-planned for nebulizer usage. During the interview she revealed it was every staff's job to update the care plan, and the intervention should go under the Focus area of [CONDITION(S)]. The Director of (MDS) updated the resident's care plan. The intervention read meds as ordered. On 6/8/2022 at 1:00 p.m. the Director of Nursing provided the Comprehensive Care Plans policy and procedure with last review date January 2022, for review. The policy stated: The resident has the right to participate in care planning and treatment and changes in care and treatment. The procedure section of the policy revealed: 1. Initial care plans are opened upon admission 2. Start care planning process with the resident during the initial care conference to include IDT and resident and or representative. Continue care planning with the resident after comprehensive assessment and as changes in resident status or resident goals may occur. 6. Review care plans ongoing after each MDS assessment and as indicated with change in the resident's status. 7. Periodically review care plans by the interdisciplinary team after each assessment and as indicated with change in the resident's status. The protocol section of the policy revealed the following: 2. Other care plans that may need to be initiated on admission could include the following: a. Behaviors b. Medications c. Safety concerns 5. The care plan is reviewed with the first comprehensive MDS assessment and is revised towards a goal, changes in goals, revision of interventions or other pertinent updates.

Based on observations, record reviews, and interviews, the facility failed to accurately assess and document the presence of one pressure ulcer and two areas of deep tissue injury for one (Resident #1) of sixteen residents with pressure ulcers. Findings included: Resident #1 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/5/22 at 11:48 a.m., an observation was conducted of Resident #1 as he laid in bed. The resident did not acknowledge verbal stimuli, was receiving breathing assistance from ventilator, and extremities were covered with blankets. On 6/6/22 at 9:18 a.m., Resident #1 did open his eyes in response to verbal stimuli. His extremities were covered with blankets. On 6/7/22 at 1:10 p.m., the resident was sitting up in a wheelchair, a television was playing and the resident was covered with blankets. During an interview, on 6/7/22 at 1:51 p.m., Staff J, Licensed Practical Nurse (LPN) stated that staff used to do weekly skin assessments on paper but now they did them electronically and it was incorporated with a daily (progress) note. The LPN stated if any skin condition was noted, staff were to complete an incident report and notify the supervisor. The following progress notes were documented in regards to Resident #1: - A progress note dated 5/1/22 at 8:37 a.m., identified Resident #1 was hospitalized . - On 5/11/22 at 3:41 p.m., a note identified wound care was completed and included areas not limited to an unstageable grey hard blistered to left toes and abrasion to the top of left foot. - On 5/11/22 at 4:20 p.m., a note written by a LPN indicated skin is intact and was admitted due to [CONDITION(S)] of left foot. - On 5/13/22 at 3:02 p.m., staff noted that the physician was notified regarding bilateral swelling to lower extremities and an order was obtained for [brand name] wraps - A Skin/Wound note, on 5/14/22 at 5:13 p.m., identified Reddened/purple discoloration on crease of patient's right front ankle appears to be from [brand name] wrap. Not open at this time, skin prep applied. Blister present on end of patient's left great toe, skin intact. Skin prep applied to area. [brand name] wrap in place to bilateral legs, circulation good, capillary refill brisk less than 2 seconds on all toes. The note did not indicate that the physician or responsible party was notified of a change in the residents' skin condition. - A physician note, dated 5/15/22 at 12:35 p.m., indicated that the resident was admitted to the acute care facility for bilateral lower extremity [CONDITION(S)] left greater than right, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note did not identify that the physician was aware of a change in the residents' skin condition. A review was conducted of the Skin Issue Identification form that was completed on 5/20/22 at 12:25 p.m., by the Unit Manager, Staff K. The form identified the resident had a tracheotomy, gastrostomy (G-tube), and bilateral [CONDITION(S)] - [brand name] wraps in place. The form did not identify any further skin issues. The system note, dated 5/20/22 at 10:36 a.m., did not indicate Resident #1 had bilateral lower extremity (BLE) [CONDITION(S)] or any other skin conditions. On 5/22/22 at 10:48 a.m., a system note written by nursing did not indicate Resident #1 had BLE [CONDITION(S)] and that skin intact and clear. On 5/23/22 at 10:48 a.m. and 7:51 p.m., nursing staff documented Skin intact and clear. Neither note identified if the resident had BLE [CONDITION(S)]. On 5/24/22 at 11:51 a.m., Staff J documented Skin intact and clear and did not indicate if the resident had BLE [CONDITION(S)]. On 5/25/22 at 3:51 p.m., nursing staff documented Skin warm and pink. Normal turgor noted. The note did not identify if the skin was intact or if there was evidence of BLE [CONDITION(S)]. On 5/25/22 at 7:23 p.m., a clinical note indicated that Resident #1's [brand name] wrap was removed from right foot and a 5 centimeter (cm) x 3.5 cm discoloration wound was noted and orders were received. The note did not indicate if any other skin condition or BLE [CONDITION(S)] was present. An administration note, on 5/25/22 at 10:09 p.m., identified [brand name] wraps for compression both lower extremities two times a day for compression. A review of the clinical progress notes and assessments from 5/15 to 5/25/22 did not indicate any further documentation regarding Resident #1's reddened/purple discoloration on the right front ankle or blister on the end of left great toe. A review of nursing documentation indicated that an assessment was completed, on 5/27/22 at 1:06 a.m., on Resident #1. The assessment did not identify if the resident had any BLE [CONDITION(S)] and noted skin warm and pink. On 5/27/22 at 11:06 a.m., nursing documentation indicated skin intact and clear. On 5/28/22 at 1:22 p.m. and 8:19 p.m., nursing staff noted that Resident #1's skin intact and clear. A system note, dated 5/29/22 at 7:37 p.m., identified that the residents' skin intact and clear. The Wound Care providers' Initial Evaluation note, dated 5/30/22 at 11:54 a.m., identified an unstageable area to Resident #1's right dorsal proximal foot, which measured 3.6 cm x 5.4 cm x 0.1 cm. The tissue contained 20% granulation, 30% slough, 30% necrotic, and 20% dark. The treatment was for Santyl and a dry clean dressing every day. The note instructed to offload area aggressively and no ace wraps. The note did not identify any pressure ulcer to the residents left great toe. On 6/1/22 and 6/2/22 nursing staff continued to document that Resident #1's skin was intact and clear. Neither 6/1/22 or 6/2/22 notes indicated the status of Resident #1's BLE [CONDITION(S)]. A provider note, on 6/3/22 at 10:00 p.m., indicated that the physician was aware of Resident #1 developing an ulcerative lesion on the right foot which was being treated with [brand name] and that Compression stockings on both lower extremities are noted and extremities are spastic swelling of the lower extremities are also improved. A review of progress notes from 6/4, 6/5, 6/6, and 6/7/22 identified that nursing staff had documented that Resident #1's skin was intact and clear. The Wound Care providers' note, dated 6/6/22, identified that the unstageable wound to Resident #1's dorsal proximal right foot was smaller but wound base declined. The wound measured 3.2 cm x 4.6 cm x 0.1 cm. The tissue was 20% granulation, 20% slough, and 60% necrotic. The provider instructed offload area aggressively, absolutely NO [brand name] wraps. On 6/8/22 at 8:54 a.m., an interview was conducted with Staff K, Registered Nurse/Unit Manager (RN/UM). The UM reported Resident #1 had been recently hospitalized and [brand name] wraps ordered on bilateral lower extremities for [CONDITION(S)]. Staff K reviewed the progress notes and assessments and stated she was unaware that the progress notes were generated by the daily assessments. The UM reviewed nursing notes from 6/6 and 6/7/22 that indicated skin intact and confirmed the information was incorrect. She said her expectation was after the nurse completed daily wound care a note would be produced indicating what the wound looked like and that the dressing change had been done. Staff K identified that the Wound Care nurse did weekly wound assessments and the floor nurse was responsible for daily wound care. On 6/8/22 at 9:32 a.m., during an interview with Staff L, Wound Care Nurse (WCN), she reported wound care rounds were completed with the wound care provider on Mondays. In regards to Resident #1, the wound to the right ankle was discovered on 5/25/22 when staff removed the elastic wrap from the area. The WCN described the area as unstageable pressure ulcer that was darkened and open. The nurse reiterated the pressure ulcer on the resident's ankle was discovered on 5/25/22 was assessed by the provider on the following Monday (May 30, 2022). Staff L reported the facility process was Certified Nursing Assistants (CNA) did a skin assessment tool and when an issue was observed they notified the nurse. The nurse notified the family (if a new area), the physician, and sometimes will notify her, the WCN. She stated she received a weekly skin list if anything new, she compared it to the previous week. The WCN stated she was notified on the 5/25/22 of a reddened area. The staff member reviewed the written note from 5/14/22 that identified Reddened/purple discoloration on crease of patient's right front ankle appears to be from [brand name] wrap. Not open at this time, skin prep applied. Blister present on end of patient's left great toe, skin intact. Skin prep applied to area. [brand name] wrap in place to bilateral legs, circulation good, capillary refill brisk less than 2 seconds on all toes. She stated she would not have necessarily been notified of the area. The WCN confirmed that the blister to the residents left great toe should have been on her weekly skin list. An observation was conducted, on 6/8/22 at 11:35 a.m., with the WCN of Resident #1's bilateral lower pedal areas. The left lower extremity was wrapped with an elastic bandage with a corner of the bandage covering the great toe. The WCN moved the bandage away from the great toe and an area of purplish/black discoloration approximately the size of a nickel was observed. The WCN palpitated the area and stated it was hard. The observation revealed that both feet of the resident was extremely edematous and non weeping. The right foot had a white border dressing to the top of the ankle. The observation identified a dark purple area to the residents' right fifth toe, approximately a size of a dime. This area had not been identified in any documented assessment or progress note. The WCN confirmed that the areas on the right fifth toe and the left great toe should have been noted and a treatment in place for them. The staff member stated that the resident moved both feet back and forth on the bed sheets and that the areas should be noted. A review of the Weekly Facility Pressure Ulcer Tracking Report, dated 5/30/22, indicated that Resident #1 acquired an unstageable ulcer on 5/25/22 to the right dorsal proximal foot. The report did not identify any other pressure-related areas for the resident. The Weekly Facility Skin Report, dated 6/3/22, indicated the resident had a dark scabbed area to the right dorsal foot that was in-house acquired. The report did not identify any other altered skin integrity areas for the resident. A review of policy 01B039 - Pressure Ulcer/Pressure Injury Prevention and Management, reviewed 10/24/2021, indicated that The purpose of this procedure is to provide guidelines for prevention of avoidable pressure ulcers/pressure injury and the promotion of healing of existing pressure ulcer(s)/pressure injury(s). The procedure identified that the facility should establish and utilize a systemic approach for pressure ulcer/pressure injury(s) prevention and promotion of pressure ulcer/pressure injury healing that includes efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. The policy indicated that staff were to Conduct a weekly full body skin assessments by a licensed or registered nurse and conducted a full body skin inspection by nursing assistants during bathing and any concerns reported to the resident's nurse immediately after the task. Nursing assistants also inspect skin during AM/HS cares and report any concerns to nurse immediately after the task, and Measure the wound upon identification of a new pressure ulcer/pressure injury and initiate a weekly wound monitoring sheet and implement initial treatment per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - a. Differentiate the type of ulcer/injury (pressure related versus non-pressure related - arterial, venous, diabetic). - b. Determine the ulcer/injury stage (I, II, III, IV, deep tissue injury, unstageable due to slough or eschar). - c. Describe and monitor the ulcer's/injury's characteristics. - d. Monitor the progress weekly towards healing. - e. Determine if infection is present. - f. Assess, treat, and monitor pain, if present. - g. Monitor dressings and treatments weekly. - h. Evaluating the effectiveness of current interventions. - i. Modify or replace interventions as needed. - j. Evaluate the effectiveness of new interventions.

Based on observations, record reviews, and interviews, the facility failed to ensure respiratory equipment was stored in a sanitary manner for three (Residents #194, #175 and #90), and failed to have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: 1. On 06/05/2022 at 9:35 a.m., an observation of Resident #194's room included a nasal cannula and oxygen tubing on the bedside table, attached to a portable oxygen tank, and not stored appropriately. (photographic evidence obtained) On 06/05/2022 at 12:31 p.m., an observation revealed Resident # 194 was receiving 3 liters of oxygen via a nasal cannula and an oxygen concentrator in the 800 Hall dining room. On 06/06/2022 at 8:53 a.m., Resident # 194's room was observed. During the observation a nasal cannula and oxygen tubing were seen on the bedside table, and not stored appropriately. Immediately after the observation, Resident #194 was seen in the dining room seated in a wheelchair. The resident was receiving 3 liters of oxygen via a nasal cannula and an oxygen concentrator. On 6/7/2022 at 8:03 a.m., Resident # 194 was observed sleeping in bed, she was receiving 3 liters of oxygen via a nasal cannula and an oxygen concentrator. Review of active Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's care plan with revision date of 03/11/2022 read, under interventions, to Administer O2 [oxygen] as ordered for SATS of 90% or less. On 6/7/2022 at 4:05 p.m., an interview conducted with Staff H, Unit Manager (UM) for the 800 Hall. She confirmed Resident #194 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. On 6/5/2022 at 2:24 p.m., an observation of Resident #175's room revealed an unbagged nebulizer face mask on the resident's bedside table. The resident was asleep in her wheelchair. A record review for Resident # 175 indicated she was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 175's Brief Interview for Mental Status (BIMS) score was 0, (indicating severe cognitive impairment). On 06/06/2022 at 11:10 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN)/Unit Manager (UM). Staff H confirmed Resident #175 received respiratory nebulizer treatments. She verified respiratory devices were changed every week and stored in a plastic bag. 3. An observation conducted on 06/05/2022 at 9:26 a.m., revealed Resident #90's respiratory facemask was left unbagged on top of the nebulizer machine. On 6/6/2022 at 8:38 a.m., an observation and interview was conducted with Resident #90. An unbagged nebulizer facemask was observed on top of the nebulizer machine, not stored appropriately. During the interview with the resident, she said the staff did not store the facemask in a plastic bag. During an observation conducted on 6/7/2022 at 3:51 p.m., with Staff H she verified resident #90's face mask was on top of the nebulizer machine and was not stored appropriately. Staff H stated It's supposed to be in a plastic infection control bag. Record review of Resident #90's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Director of Nursing on 6/7/2022 at 4:41 p.m. During the interview, the DON was informed of all observations made for Residents #90, #194,and #175 and was shown Photographic Evidence Obtained from the observations. The DON stated, We need to do in-servicing of the staff on how they need to store nebulizer respiratory devices when not in use. I am going to go speak to the UM and figure out what has been going on with the order for oxygen for [Resident # 194]. A request was made for a policy related to the storage of Respiratory Equipment of Nebulizer Equipment, the facility provided a policy, titled Nebulizer Treatments, Dated 10/25/2021, Version #1: one page, read as follows Policy: To provide residents with appropriate nebulizer treatments administered in a safe, effective manner in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] According to the NIH (National Heart, Lung and Blood Institute) NIH Publication no. 21-HL-8163, Dated October 2021, Pages 01-02, How to Use a Nebulizer (nih.gov), reads A nebulizer is a machine that delivers a fine steady mist of medication through a mouthpiece or mask. Between Uses: Store nebulizer parts in a dry, clean plastic storage bag.

Based on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and five errors were identified for one (Resident #110) of six residents observed. These errors constituted a 15.63% medication error rate. Findings included: On 6/7/22 at 2:24 p.m., an observation of medication administration with Staff M, Licensed Practical Nurse (LPN), was conducted with Resident #110. The staff member dispensed the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - Vitamin D3 125 microgram/5000 unit tablet - Famotidine 20 milligram (mg) tablet - [MEDICATION(S)] 100 mg/milliliter (mL) liquid - 2.5 mL (250 mg) - [MEDICATION(S)] 20 mg/5 mL [MEDICATION(S)] - 7.5 mL (30 mg) - [MEDICATION(S)] 1 mg tablet - [MEDICATION(S)] 1450 powder - 17 grams - diluted in approximately 4 ounces of water The staff member identified that the medications other than [MEDICATION(S)] were late (as evidence by the patient profile being colored red). Staff M reported she was not used to the unit and was recently moved from night shift to day shift. A review of Resident #110's June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 5000 unit tablet - Give 1 one tablet via G-tube one time a day for Vitamin D deficiency. - Famotidine 20 mg tablet - Give 1 tablet via G-tube every 12 hours for GERD. - [MEDICATION(S)] 100 mg/mL solution - Give 250 mg via G-tube two times a day for Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)] 20 mg/5 mL with sugar - Give 7.5 mL via G-tube every 12 hours for seizures. - [MEDICATION(S)] 1450 powder - Give 17 gram via G-tube every 12 hours for constipation - Hold for loose stools. On 6/7/22 at 3:04 p.m., the staff member completed the administration of medications and the start of Resident #110's nutrition. Staff M confirmed the physician was not notified that Resident #110's medication was late. The staff member stated the procedure was to call the physician prior to administration of late medications. The facility provided a copy of a Clinical note, dated 6/7/22 at 3:10 p.m. (after the observation) that Resident #110's Medications given late, the physician was notified, and orders were to received to monitor for [CONDITION(S)] activity. The policy - Medication Administration Skilled Nursing Facility (SNF), reviewed 10/21/21, identified that medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner. The procedure indicated that If a dose of a regularly scheduled medication is held, refused, or given at a time other than the prescribed time documentation in the electronic record will be done. The documentation is to include a reason for refusal (no reason given is adequate if applicable), as well as evidence to show that education was completed as appropriate.

Based on observation, interview, and record review the facility failed to ensure an allegation of abuse and neglect was reported to the governing agency in accordance with the State law for one resident (#2) out of fourteen residents sampled regarding a resident who reported their foot had been caught under a wheelchair and was reporting new onset of pain in that leg. Findings included: On 08/18/2022 at 9:55 a.m., an observation was conducted of Resident #2. She was observed in bed and agreed to answer questions. She reported she had fractured her right leg recently. She stated the cast was just removed, last Friday. She stated an aide was pushing her [on 06/24/2022] and should have had the leg rests on, and they did not. She stated her right leg fell under the wheelchair. She stated it took 2 weeks before she was able to go to the hospital. She stated they (the facility staff) thought I was faking it. She stated her whole leg was in a cast. She stated she thought the man who pushed her in the wheelchair was a volunteer. She reported she currently had pain level of 10 on a scale of 1-10, with 10 being the most severe pain. On 08/18/2022, at 11:30 a.m., Resident #2 was observed with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated she was familiar with Resident #2. She stated the resident fractured her right tibia. She stated she was really not sure what happened because she had heard several stories. She stated one version was a volunteer was pushing the resident and the resident's leg went under the wheelchair. A review of Resident #2's admission Record revealed the resident was admitted on 01/2013 with diagnoses including: Diabetes Mellitus due to underlying condition with diabetic nephropathy, acute ischemic heart disease, heart failure, and chronic obstructive pulmonary disease. A review of Resident #2's Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Function, a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section B: Hearing, Vision, and Speech revealed the resident had no impairment and assessed the resident with clear speech-distinct intelligible words; makes self-understood; and understands others-clear comprehension. Section G: Functional Status, revealed Resident #2 required support of two persons for transfer, bed mobility, and dressing. A review of Resident #2's Care Plan revealed the following: Focus: Self-care deficit: Requires assist with ADL's (Activity of Daily Living) due to decreased mobility, initiated on 03/08/2022. Interventions included: Extensive to total, 2 person assist for bed mobility, initiated on 03/11/2022, revision on 08/01/2022. Extensive to total assist with transfers; 2 persons, initiated on 03/11/2022, revision on 08/01/2022. Leg rests are to be on when she is up in w/c, initiated 08/03/2022 Uses a full body mechanical lift for transfers, initiated on 03/11/2022. Uses a manual wheelchair, initiated on 03/11/2022. Focus: Resident has potential for falls related to: unable to bear weight and non-ambulatory, initiated 03/08/2022. Interventions included: 4P's rounding (Check resident for any pain concerns, positioning needs, that personal items are within reach and that personal needs are being met), initiated 03/08/2022. A review of Resident #2's Medication Administration Record (MAR) for 06/2022, reflected a physician order for Tramadol HCL (Hydrochloride) 50 mg (milligram) tablet, give 50 mg orally every 4 hours as needed for pain. A review of the MAR reflected from 06/01/2022 through 06/23/2022, Resident #2's daily administration of the Tramadol fluctuated between 0 to 2 pills daily for pain levels ranging between 4 and 7 out of 10. On 06/24/2022, the resident was administered Tramadol 4 times at 5:12 a.m. for a pain level of 5, at 9:50 a.m. for a pain level of 4, at 4:42 p.m. for a pain level of 8, and at 9:11 p.m. for a pain level of 0. Resident #2 was administered Tramadol for pain on: 6/26, 6/27, 6/28, 6,29, and 6/30 once daily with a pain rating of between 4 and 6. A review of the MAR for 07/2022 revealed Resident #2 continued to receive Tramadol 50 mg for pain as follows: 7/1--at 6:31 a.m. pain level of 7, at 10:37 a.m. pain level of 5, at 4:13 p.m. pain level of 3, at 11:40 p.m. pain level of 7 7/2-at 4:29 a.m. pain level of 10, at 9:30 a.m. pain level of 4, at 4:30 p.m. for pain level of 3 7/3-at 9:37 a.m. pain level of 4, at 7:38 p.m. for pain level of 7, 7/4-at 9:55 a.m. pain level of 4 7/5-at 9:32 a.m. pain level of 4 7/6-at 6:36 a.m. pain level of 3, at 9:29 p.m. pain level of 6 7/7-at 5:29 a.m. pain level of 6, at 10:44 a.m. pain level of 4 7/8-at 6:32 a.m. pain level of 6, at 8:29 p.m. pain level of 6 7/9-at 5:02 a.m. pain level of 6, at 10:04 a.m. pain level of 4 7/10-at 10:06 a.m. pain level of 4 (then sent out to hospital) A review of Resident #2's Progress notes was conducted for the time period of 06/01/2022 to 08/15/2022 which revealed the following: 06/24/2022 9:25 p.m.: [Staff J, Registered Nurse RN]: While completing Tx [treatment] to buttocks Resident stated when being pushed out of her room earlier, the foot rests were not put on, and her R [right] foot went under the w/c [wheelchair]; unable to determine exact situation as resident changing situation if asked multiple times; checked R knee/leg and no swelling, dis-alignment, or redness; able to turn without pain; provided pain medication at resident request. Will have following nurse continue to monitor. 06/27/2022 5:58 a.m. [Staff K, LPN]: C/O [complaint of] Right leg pain. 06/29/2022 2:38 p.m. Psychotherapy progress note .Stated she is still having a lot of leg, foot, and back pain 07/5/2022 2:35 a.m. Tramadol HCL 50 mg given for pain per resident request for bilateral leg pain. 07/06/2022 2:09 p.m. Psychotherapy progress note .Indicated she is having trouble with her legs and has pain when being changed . 07/09/2022 7:22 a.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. Tramadol HCL 50 mg given. 07/09/2022 4:49 p.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. Tramadol HCL 50 mg given 07/09/2022 5:39 p.m. [Staff L, LPN] Resident c/o rt lower leg pain. Call placed to [doctor]. Per call on call obtain x-ray rt knee, rt tibia/fibula, rt foot. Portable x-ray required resident is non ambulatory. 07/10/2022 1:07 p.m. Radiology Results: Results of Right knee, tib/fib and foot x-ray returns with findings of acute proximal tibia fracture. Called on call provider, LM [left message] on personalized VM [voice mail] requesting return call to writer. 07/10/2022 1:32 p.m. Called [Doctor] on call provider number . no answer, left message on personalized voice mail requesting return call to writer regarding radiology results and orders. 07/10/2022 2:33 p.m. Called on call provider for [Doctor] .Left message on personalized voice mail to report tibial fx findings and to obtain orders. 07/10/2022 3:26 p.m. [Doctor] on call ARNP [Advanced Registered Nurse Practitioner] returned call, new orders given to send to ED [Emergency Department] for further eval and Tx of tibial fx. Guardian numbers called x 2 each with no answer. No voicemail set up to leave message. 07/10/2022 3:40 p.m. Resident was sent to [local Hospital] at 07/10/2022 4:00 p.m. for tibial fx 07/10/2022 10:26 p.m. (Incident note) At approx. 8:45 p.m. resident returned to facility with a ½ brace wrapped with ace bandage to RT leg. Resident denies pain at time of arrival. Resident states, I'm so glad I am back. Discharge instructions: No weight bearing to Rt Leg. Follow-up with Dr [Orthopedic] .address within 3-5 days. Script for Norco 5/325 mg every 6 hours as needed for acute pain x 3 days. MD and Guardian aware of resident's return. On 08/18/2022 at 2:29 p.m., an interview was conducted with Staff A, LPN, UM (Unit Manager). She stated if a resident complains of leg pain the nurses are to find out what the pain is from, medicate for pain, let the doctor know, and let the family know. A review of Resident #2's progress notes was conducted with Staff A, LPN, UM, specifically the 06/24/2022 nurse note and the 06/27/2022 nurse note. Staff A, LPN confirmed both entries were missed opportunities to notify the physician and complete an assessment. She said, the resident would complain of pain, but the right leg pain was unusual. On 08/19/2022 at 10:05 a.m. an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She reported she was familiar with Resident #2 and she normally had the same assignment which included Resident #2. She stated before Resident #2 broke her leg they would get her out of bed a lot and she would be put in the manual wheelchair. She stated the chair had regular foot rests. She stated she would always put the leg rests on and sometimes she would put a pillow on because her feet would dangle and angle out. She stated the resident was not able to self-propel and she would need someone to push her. She stated the wheelchair leg rests are extended now since the resident had a broken leg. She said she was not working on 06/24/2022. She stated during a Hoyer lift transfer recently, she did not recall a date, the resident complained about her leg hurting. She stated the resident was crying, I mean crying. She stated she told the nurse, who was an agency nurse, but she did not know the name of the nurse. She stated after the leg event, Resident #2 did not want to get out of bed. Staff B, CNA stated no one had interviewed her or asked her for a statement related to the 6/24/2022 incident involving Resident #2. She denied any additional training related to the incident. On 08/19/2022 at 3:28 p.m., Staff I, CNA was interviewed by phone. She confirmed she was working on 06/24/2022 on the 7 a.m.- 3 p.m. shift and was assigned to care for Resident #2. She stated she assisted Resident #2 on 06/24/22 with care and getting the resident ready to go out of the building. Staff I, CNA, stated she did not take the resident to the main lobby, but recalled one of the people who come and get the residents for the activities came down. She stated it was either a younger guy or the young lady with blond hair but she did not know them. She stated the people just come around and get the residents to take them where they are going. She stated she remembered asking the resident if she needed her leg rests because she always asks. The person said, she will be ok and took her. I do not recall putting the leg rests on the wheelchair. She stated no one had called her about any event on 06/24/2022, this was the first time anyone had reached out. On 08/19/2022 at 2:21 p.m., a phone interview was conducted with Resident #2's Physician. He confirmed he was familiar with Resident #2. He confirmed Resident #2 had an X-Ray on 07/09/2022, was sent to the hospital on [DATE], and she returned with a soft cast to the right leg. He stated he was driving and did not have the medical record in front of him, so specifics, he would have to review in the medical record. He stated he did not recall being notified of the event on 06/24/2022 with Resident #2, the report of the resident's pain, or the allegation her right foot had gone under the wheelchair. He stated, they [facility staff] are instructed to call about ALL problems, we are in the building 2-3 times per week, we are very responsive. He confirmed an X-ray could have been ordered for Resident #2's leg for her pain at the time of the event on 06/24/2022. He confirmed it was a missed opportunity to order the x-ray to identify the fracture at that time. A review of a Resident #2's X-Ray, Radiology Interpretation, date of exam 07/10/2022, reflected the following significant findings: Right Knee, 3 views: Findings: Multiple views of the right knee show a fracture of the proximal tibia. Diffuse osteopenia is present. Moderate osteoarthritis is seen in the tri-compartment joint spaces. There are no joint bodies. There is no knee region soft tissue swelling. There is no joint effusion. There are no radiopaque foreign bodies. Impression: Acute fracture of the proximal tibia. Right Tibia and Fibula, two views: Findings: A fracture of the proximal tibia is visualized. Diffuse osteopenia is present. The joint spaces are preserved. No radiopaque foreign body is seen in the soft tissues. The soft tissues are unremarkable. Impression: Acute fracture of the proximal tibia. On 09/01/2022 at 12:00 p.m. an interview was conducted with the Radiologist. He stated the fracture for Resident #2 was acute and unlikely to be over three weeks old due to no callus formation. He stated on an older person with a lot of osteopenia, like Resident #2, makes a fracture slow to heal and he confirmed the fracture would have occurred within a three-week time period prior to the xray. A review of the facility Report Tracking Log for June 2022 listed no entries. A review of the facility Report Tracking Log, for July 2022 listed the following entries: Resident #2, abuse, date of event 07/10/2022; date of AHCA 1 day 07/10/2022; date of the AHCA 5-day report 07/14/2022. On 08/19/2022 at 12:01 p.m. and again at 2:55 p.m. an interview was conducted with the NHA. The NHA confirmed she was the Abuse Coordinator and Risk Manager for the faciltiy. The NHA stated she was notified of the incident with Resident #2, that occurred on 06/24/2022, on 07/10/2022 at 2:27 p.m. by Staff M, LPN, House Supervisor who called her. She stated it was a Sunday and she immediately came in. The NHA said, she called the Director of Operations and the Regional Clinical Nurse to let them know there was an allegation and a fracture with Resident #2. She stated she told them she going to the building to investigate. The NHA said Staff M, LPN and I went in to interview Resident #2 together. The NHA stated Resident #2 indicated during her interview about the fracture, it was an accident where she put her foot down while being pushed by a volunteer. The NHA confirmed no one had witnessed the event. The NHA stated however, we were unable to validate any volunteer pushing her on said day, 06/24. She stated during the interview with the resident, even though she has a BIMS of 11, she appeared quite lucid at the interview. The NHA stated the resident appeared alert and oriented with no nonsensical conversation. She stated Resident #2 reported she had an incident on 06/24/2022, and she remembered this because it was her special day. The NHA said Resident #2 told her she put her right foot down while being transported to the reception area by a volunteer and she did not think anything serious about it, but, as time has gone on, it had started to hurt more. The NHA stated the resident told her it was her fault for putting her foot down, and when she told the pusher to stop, he did. The NHA stated she thought the resident's right leg had fallen to the bar under the wheel chair. The NHA stated the resident described the male as short and blond and said he could be a volunteer. The NHA confirmed the facility had surveillance cameras, and said I did not check the cameras, I think the cameras only go back one week. A review of the facility policy and procedure, Abuse, Neglect & Exploitation, effective November 2017, revised January 2022, documented the policy: Each resident has the right to be free from abuse, including verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. This prohibition applies to everyone, including, but not limited to, facility staff (employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility), other residents, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. This includes mental abuse that is facilitated or caused by facility staff using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, use, or distribute photographs, videos, or other recordings, including posting on social media, or in any manner that demean or humiliate a resident(s). Anytime that the nursing facility receives an allegation of abuse, including those involving the posting of an unauthorized photograph or recording of a resident on social media, the facility must comply with the reporting and investigation procedures set forth in this policy and with any state-specific policy and take steps to prevent further potential abuse. Compliance with reporting the reasonable suspicion of a crime must also be followed. Definitions included: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Mental Abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility abuse prohibition plan included: Training: Facility shall develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers consistent with their expected roles . Prevention of Abuse, Neglect, Exploitation of Residents and Misappropriation of Resident Property. The facility will utilize the following techniques for prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property included: . React to all allegations or questions from residents, family members, employees, or visitors. Take appropriate actions when abuse, neglect, exploitation, or misappropriation is suspected. Provide instructions to staff on care needs of residents. Assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, . residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. Identification of Abuse, Neglect, Exploitation and Misappropriation included: The facility will identify factors indicating possible abuse, neglect, exploitation of residents, or misappropriation of resident property, including, but not limited to, the following possible indicators: Resident, staff, or family report of abuse. Physical injury of a resident, of unknown source. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning. Resident Protection after Alleged Abuse, Neglect, Exploitation, or Misappropriation: The facility will make reasonable efforts to protect any and all residents after alleged abuse, neglect exploitation, or misappropriation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect, and exploitation may include, but are not limited to: Evaluate resident and ensure necessary medical care or treatment is provided and notify treating physician as appropriate. Response and Reporting of Abuse, Neglect, Exploitation, and Misappropriation: Anyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility administrator, abuse agency hotline, or file a complaint with the state survey agency and adult protective services (if applicable under state law) immediately (but not later than 2 hours after an allegation is made if the events that lead to the allegation involve abuse or result in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury. Reporting and investigation should be done in accordance with state law/regulation. When abuse, neglect, or exploitation is suspected, the Administrator or designee should: Respond to the needs of the resident and protect them from further incident (document); Notify the Director of Nursing and Administrator (document); Initiate an investigation immediately; Notify the attending physician, resident's family/legal representative and Medical Director. Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from the resident care areas immediately. Contact the state agency and local Ombudsman office to report the alleged abuse. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions, and document actions taken in steps above in the medical record. Investigation of Alleged Abuse, neglect, Exploitation, and Misappropriation: When suspicion of abuse, neglect, exploitation, or misappropriation or reports of abuse, neglect, exploitation, or misappropriation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation shall be conducted. Components of an investigation shall include when appropriate; Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically. After completion of the investigation, the results of the investigation and any reports or witness statements shall be provided to the facility's Quality Assurance and performance Improvement Committee for further evaluation.