Every finding on record at Sandia Ridge Center

Based on record review and interviews, the facility failed to ensure the environment was free of accident hazards for 1 (R #1) of 1 (R #1) residents, when the facility staff failed to:Use a Hoyer lift (equipment used to move residents who have limited mobility) and two staff members to safely transfer R #1 as required. This deficient practice is likely to result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and harm. The findings are: A. Record review of R #1's face sheet revealed an admission date of 02/23/22 with following diagnoses:Cerebral infarction with stenosis or left cerebral artery (stroke caused by narrowing (stenosis) leading to reduced blood flow and tissue death).Fracture of lumbosacral (the lower spine where the lumbar spine meets the sacrum) spine and pelvis.Failure to thrive (progressive decline marked by weight loss, poor nutrition, decreased activity, and often cognitive or emotional impairment). Rheumatoid Arthritis (chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness). B. Record review of R #1's electronic health record (EHR) revealed R #1 was receiving hospice services since 05/12/22. C. Record review of R #1's physician orders, dated 04/02/25, revealed R #1 requires a Hoyer lift with two staff members for transfers out of bed. D. Record review of R #1's Kardex (documentation system that enables nurses to write, organize, and easily reference key patient information), dated 06/02/26, revealed the following:R #1 requires two-staff assistance when transferring with a total lift divided-leg sling (a patient transfer sling designed for safe lifting, with a split-leg design for comfort, support, and toileting access, compatible with most patient lifts). R #1 must be transferred by two staff using the Hoyer lift for safety and comfort. E. Record review of R #1's care plan, dated 03/26/26, revealed the following:R #1 requires one-staff assistance for activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating).R #1 requires two-staff assistance for transfers using a Hoyer lift with a divided-leg sling. F. Record review of R #1's nursing progress notes, dated 04/23/26, revealed R #1 obtained a skin tear (a type of injury where the skin is torn from the body) while staff were showering R #1. G. Record review of R #1's nursing progress notes, dated 04/24/26, revealed a flat purple discoloration on R #1's chest and both forearms (the part of a person's arm extending from the elbow to the wrist or the fingertips), along with a skin tear to R #1's right forearm. H. Record review of R #1's wound and skin assessment notes, dated 04/24/26, revealed the following wounds were identified for R #1:New skin tear acquired on 04/23/26 to R #1's right forearm. The skin tear length is 1.11 centimeters (cm), width is 1.41 cm, and the depth is 0.1 cm. New skin issue with bruising to R #1's chest. The bruising length is 3.43 cm, the width is 3.6 cm, and the depth is 0 cm. New skin Issue with bruising to R #1's left forearm. The bruising length is 1.02 cm, the width is 1.02 cm, and the depth is 0 cm. New skin Issue with bruising to R #1's right forearm. The bruising length is 4.83 cm, the width is 4.19 cm, and the depth is 0 cm. I. Record review of R #1's nursing progress notes, dated 04/24/26, revealed R #1 was found to have skin discoloration to the upper chest area and both arms. The Medical Director (MD) visualized R #1's skin and determined R #1 has senile purpura (a skin condition characterized by recurrent purple bruises on sun-exposed areas, primarily the forearms and hands, due to fragile blood vessels in aging skin). J. On 06/02/26 at 11:30 am, during an interview, the Administrator stated R #1's bruising and skin tear was brought to her attention on 04/24/26. She stated R #1 was showered on 04/23/26 by the facility staff. The Administrator stated a Hoyer lift is used to transfer R #1 with the appropriate sling. K. On 06/02/26 at 11:50 am, during an interview, Certified Nursing Assistant (CNA) #4 stated she gave R #1 a shower on 04/23/26. She stated that she and another CNA brought the shower chair into R #1's room and transferred R #1 into the shower chair. She stated R #1 sustained a skin tear to her right forearm at some point during the shower. CNA #4 stated she reported the skin tear to the nurse right away. CNA #4 stated after R #1's shower, they transferred R #1 back to bed without using the Hoyer lift because R #1 was not heavy. CNA #4 stated she lifted R #1 under the arms (arm pits) while the other CNA moved R #1's feet, and together they lifted her from the shower chair. L. On 06/02/26 at 1:45 pm, during an interview, the Director of Nursing (DON) stated she found out about R #1's bruising on 04/24/26 when the hospice CNA was upset and alleged the facility was abusing R #1. She stated she observed purple discoloration on R #1's chest and arms, along with a skin tear. She stated staff should have used a Hoyer lift when transferring R #1. She stated she was not aware that CNA #4 and another CNA transferred R #1 without using a Hoyer lift. The DON stated transferring a resident by the underarms could have caused some of the bruising and discoloration observed on R #1, and that should not have happened.

Based on observation and interview, the facility failed to provide snacks at night for all residents who wanted an evening snack. This deficient practice is likely to cause resident to be at risk of unnecessary hunger and frustration. The findings are: A. On 04/23/26 at 2:26 pm during observation and interview, R #1 stated he would like snacks to be offered to him. He stated staff did not offer snacks to him very often, and he would like them especially at night. R #1 stated he had to ask the staff for a snack, and he has been told there is none. B. On 04/23/26 at 3:30 pm during observation, the locked unit nourishment refrigerator contained a sandwich labeled with a resident's name and dated 04/22/26. Further observation revealed some unlabeled and undated yogurts, sandwich items in a white shopping bag, and two undated and unlabeled metal tumblers on the refrigerator door. C. On 04/23/26 at 3:32 pm during an interview, Registered Nurse (RN) #1 stated the snacks in the refrigerator in the white shopping bag were for all residents that wanted a snack. D. On 04/25/26 at 9:43 am during an interview, Certified Nurse Aide (CNA) #1 stated there were not any snacks at night. CNA #1 stated the concern was that the kitchen was locked at night, and there were not snacks for the residents who wanted them or needed them due to diabetes. CNA #1 stated the snacks available at night were five milk cartons, a few yogurts, and a few supplement shakes. The CNA stated she did not think it was enough for all the residents that would like a snack. CNA #1 stated the staff would go out and buy snacks to keep for those residents. E. On 04/27/26 at 5:00 pm during an interview, CNA #2 stated they do not have many snacks to be delivered to the residents. The CNA stated there were five shakes and four to five sandwiches available. CNA #2 stated there were about 22 residents in each hall. CNA #2 stated they have requested more snacks. CNA #2 stated there were residents that asked for snacks all the time, and sometimes staff will buy snacks at the vending machine in the facility for the residents. F. On 04/27/26 at 5:35 pm during an interview, the Dietary Manager (DM) stated he put snacks out three times a day. He stated the snacks were put out according to the Registered Dietician's orders and not everybody got a snack. The DM stated it was based on recommendations for weight gain or specific purposes. The DM stated snacks are not left in the refrigerator for residents. The DM stated staff were not able to access the kitchen at night. G. On 04/28/26 at 12:49 pm during an interview, CNA #3 stated there were not enough snacks sent out during snack times or on weekends. CNA #3 stated residents with labeled snacks get a snack. CNA #3 stated the other residents ask for snacks, and staff tell them there is not enough snacks for them. H. On 04/28/26 at 2:19 pm during an interview, the Director of Nursing (DON) stated the kitchen used to put out a lot of snacks, but they got left out. The DON stated the facility lost money, because they had to throw away the left over snacks. The DON stated they put together a snack list, and they put out snacks for those prescribed by the Registered Dietician. I. On 04/29/26 at 9:02 am during an interview, the Activities Assistant (AA) stated residents asked her for snacks, because they know where she kept them. The AA stated she gave snacks to whomever asked for them. The AA stated the dietary department used to bring snacks for everyone and individual labeled snacks for residents with an order. She stated the dietary department recently send out snacks only for the prescribed resident snacks and did not send enough for everyone. The AA stated she will buy snacks to have on hand for those residents wanting a snack.

Based on observations and interviews, the facility failed to ensure staff properly stored and secured medications for all residents residing on the 200, 300, and 400 hallway when medication carts were left unlocked and unattended. This deficient practice is likely that resident have unauthorized access to medications that could result in injury or illness. The findings are: A. On 03/17/26 at 9:38 am, during an observation of the 300 unit, a medication cart was left unlocked and unattended outside of room [ROOM NUMBER]. B. On 03/17/26 at 9:40 am, during an interview with License Practical Nurse (LPN) #1, she confirmed her medication cart was unlocked and unattended. LPN #1 stated she should have locked her cart.C. On 03/17/26 at 9:42 am, during an observation of the 400 unit, a medication cart was left unlocked and unattended outside of room [ROOM NUMBER].D. On 03/17/26 at 9:43 am, during an interview with Certified Nursing Aide (CNA) #1, she confirmed medication cart was left unlocked and unattended. E. On 03/17/26 at 9:49 am, during an observation of the 200 unit, a treatment cart was left unlocked and unattended outside of room [ROOM NUMBER].F. On 03/17/26 at 9:50 am, interview with Registered Nurse (RN) #1, she confirmed treatment cart was left unlocked and unattended. RN #1 stated nurse should have locked the cart prior to leaving the area.G. On 03/19/26 at 11:07 am, interview with the Director of Nursing (DON), she stated medication carts should be always locked when nurses are away from the medication cart. The DON further stated it is also an expectation for nurses to keep medication carts and treatment carts locked at all times when not in use.

Based on observation, and interview, the facility failed to protect residents' personal health information (PHI) by leaving a document unattended containing multiple residents' information (such as names, diagnoses, treatment plans, or room numbers) on top of a nursing cart in hallway. This deficient practice is likely to result in passerby's to have unauthorized access to sensitive information, putting residents' privacy at risk.The findings are:A. On 03/17/26 at 9:40 am, during an observation of the medication cart outside of room [ROOM NUMBER], a stack of CNA shower list with complete resident information was laying on top of the treatment cart unattended and exposed to public view. B. On 03/17/26 at 9:42 am, during an interview Licensed Practical Nurse (LPN) #1 confirmed that the shower list for CNA's was exposed for public view and unattended. LPN #1 stated residents identifiable information should not be left unattended. C. On 03/19/26 at 8:38 am, during an observation of the medication cart outside of room [ROOM NUMBER] a stack of patient face sheets with resident information was laying on top of the treatment cart was left unattended and exposed to public view. D. On 03/19/26 at 8:40 am, during an interview with Registered Nurse (RN) #2, RN#2 confirmed that a face sheet was left exposed to public view and unattended. RN #2 confirmed that personal health information should not be left unattended. E. On 03/18/26 at 8:46 am, during an observation of the medication cart outside on the 400 wing, a stack of resident vital sign list resident information was laying on top of the treatment cart unattended and exposed to public view. F. On 03/18/26 at 8:52 am, during an interview Certified Medication Aide (CMA) #1, he confirmed resident vitals list was exposed for public view and unattended. CMA #1 confirmed resident identifiable information should not be left unattended.

Based on observation, and interviews, the facility failed to store and serve food under sanitary conditions when staff failed to ensure:Food items were labeled and dated.Dietary Aides are preparing food with no beard restraints.These deficient practices are likely to cause foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are:A. On 03/18/26 at 10:13 am, during an observation of the drink and snack cart outside room [ROOM NUMBER] revealed a pitcher with Milk sitting on a bucket of ice and is unlabeled and undated.B. On 03/18/26 at 10:15 am, interview with the Certified Nursing Aide (CNA) #1, confirmed milk is unlabeled and undated.C. On 03/18/26 at 12:13pm, during an observation in the facility kitchen revealed two kitchen aides preparing food with no beard restraints.D. On 03/18/26 at 1:55 pm, during an interview with the Dietary Manager (DM), he stated he expects the kitchen aides to label and date every item leaving the kitchen and it did not happen in this case. DM also confirmed two kitchen aides were not wearing beard restraints in the kitchen. DM also stated kitchen aides are to wear beard restrains when inside the kitchen, if applicable and they were not.

Based on record review and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for baseline care plans. This deficient practice is likely that residents will not receive the appropriate care needed causing harm or worsening of current condition. The findings are: A. Record review of R #1's admission Record revealed the following: 1. R #1 was admitted into the facility on [DATE] and was discharged on 10/13/26. 2. R #1 had the following diagnoses (including but not limited to): a. Encounter for orthopedic aftercare following surgical amputation (healthcare provided after a surgical removal of a limb or other body used to control pain or a disease process in the affected limb). b. Acquired absence of other right toe(s). c. Kidney transplant status (post-survey, residents will need to take immunosuppressive medication [a drug that suppresses the immune response of an individual] to prevent rejection of the new kidney). d. Difficulty in walking. e. Other reduced mobility. f. Other acute osteomyelitis (a serious bone infection), right ankle and foot.B. Record review of R #1's physician's orders revealed the following: 1. 10/09/26: Azathioprine (immunosuppressive medication) 50 milligrams (mg) tablet, give 1 tablet by mouth one time a day for immunosuppressant. 2. 10/09/26: Eliquis (anticoagulant, blood thinner) 5 mg tablet, give 1 tablet by mouth two times a day for blood thinner. 3. 10/09/26: Gabapentin (pain medication) 100 mg, give 1 tablet by mouth three times a day for neuropathic pain (chronic condition caused by damage in the nervous system). 4. 10/09/26: Insulin (used to lower blood sugar levels), inject 7 units one time a day for diabetes (DM; a disease in which the body cannot make or properly use insulin). 5. 10/09/26: Linezolid (antibiotic) 600 mg / 300 milliliters (ml), use 600 mg intravenously every twelve hours for Vancomycin-resistant enterococcus (VRE). 6. 10/09/26: Meropenem (antibiotic) 1 gram, use 1 gram intravenously every eight hours for anti-effective agents.C. Record review of R #1 baseline care plan dated 10/10/25 did not address pain management, antibiotic use, weight bearing status, anticoagulant use, and hypoglycemic (low blood sugar).D. On 03/19/26 at 11:40 am, interview with the Director of Nursing (DON), she confirmed baseline care plan did not address pain management, antibiotic use, weight bearing status, anticoagulant use and hypoglycemic. The DON also stated baseline care plan should be done in the first 48 hours upon admission and it did not happen.

Based on record review and interview the facility failed to obtain physicians orders for Hospice Services for 1 (R #'s 3) of 3 (R #'s 1, 2, and 3) residents reviewed for Hospice Services. This deficient practice is likely to result in residents not receiving the care need to maintain their optimal health as planned by their medical provider.The findings are:A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's physician orders revealed an order for admission to hospice services was not found. C. Record review of R #3's Electronic Health Record (EHR) revealed a signed hospice documents dated 02/24/26.D. On 03/18/26 at 3:11 pm, during an interview with the Social Services Director (SSD), he stated R #3 was admitted to (name of hospice agency) on 02/24/26. E. On 03/19/26 at 3:44 pm, during an interview with the Director of Nursing (DON), she stated R #3 should have physician orders for hospice service and there were no orders available or present in R #3's medical record.

Based on record review and interview the facility failed to provide showers for1 (R #2) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for Activities of Daily Living (ADL). This deficient practice is likely to result in residents feeling dirty and neglected resulting in isolation. The findings are:R #2: A. Record review of R #2's face sheet revealed resident was admitted to facility on 10/13/25 and discharged on 01/07/26B. Record review of R #2's shower schedule revealed R #2 should be offered a bath/shower twice per week; Tuesday and Thursday and as needed.C. Record review of R #2's Electronic Health Record (EHR) dated 09/01/25 through 11/30/25, revealed the following:10/13/25 through 10/31/25: R #2 was offered/received 2 baths/showers out of 6 opportunities.11/01/25 through 11/30/25: R #2 was offered/received 0 baths/showers out of 2 opportunities. D. On 03/19/26 at 11:54 am during an interview with the Unit Manager (UM). He confirmed that the showers for R #2 did not occur as scheduled. The UM further stated the expectation is for Certified Nurse Aides (CNA)'s to shower residents on scheduled days and document showers in the EHR after each opportunity weather they were given/missed/refused.

Based on interview and record review, the facility failed to ensure that the physician orders regarding weight bearing status and isolation needs from the transferring hospital were accurately transferred and implemented for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for admission's orders. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider.The findings are:A. Record review of R #1's admission Record revealed the following: 1. R #1 was admitted into the facility on [DATE] and was discharged on 10/13/25. 2. R #1 had the following diagnoses (including but not limited to): a. Encounter for orthopedic aftercare following surgical amputation (healthcare provided after a surgical removal of a limb or other body used to control pain or a disease process in the affected limb). b. Acquired absence of other right toe(s). c. Kidney transplant status (post-survey, residents will need to take immunosuppressive medication [a drug that suppresses the immune response of an individual] to prevent rejection of the new kidney). d. Difficulty in walking.B. Record review of R #1's hospital discharge orders dated 10/09/25 revealed the following: 1. An order for non weight bearing to right lower extremity (no weight or force can be applied through the injured limb, limb must not touch the ground). 2. An order for requires private room due to immunocompromised status (a weakened immune system that cannot effectively fight infections) from kidney transplant. No roommates/shared room.C. Record review of R #1's physician orders revealed an order for non-weight bearing status to right lower leg and isolation precaution due to immunosuppressive medication were not found.D. On 03/19/26 at 10:40 am, interview with the Director of Nursing (DON), she stated R #1 should have physician orders for non-weight bearing status to right lower extremity and isolation precaution due to immunosuppressive medication use per the hospital orders. The DON stated that her expectation were that all hospital admissions orders be reviewed and clarified before resident arriving to the facility and it did not happen. The DON confirmed these admissions orders for R #1 were not reviewed and clarified by the admission nurse therefore they were not implemented.

Based on observations and interviews, the facility failed to ensure a safe, clean, and homelike environment for 4 (Room #'s 210, 305, 307, and 405) out of 4 (Room #'s 210, 305, 307, and 405) resident rooms on the 200, 300, and 400 halls, when: The facility failed to ensure resident restrooms were maintained in good repair (a condition in which something is properly maintained, fully functional, and free from significant defects or damage) and did not have damaged baseboards (a narrow wooden board running along the base of an interior wall).If the facility does not ensure resident restrooms are maintained in good repair, then residents are likely to experience a decreased quality of life, pest infestation, and injury due to unsafe environmental conditions. The findings are: A. On 03/09/26 during random room observations, the following was observed: At 2:00 pm in room [ROOM NUMBER], the vinyl baseboard covering (a strip of flexible plastic material installed along the bottom of the wall where it meets the floor to protect the wall, conceal gaps, and provide a finished appearance) was in disrepair. Gaps measuring approximately six inches in length were present along the bottom left portion of the wall, extending through the corner and continuing onto the wall behind the toilet. A gap measuring approximately seven inches in length was present along the right side of the wall, continuing onto the wall behind the toilet.At 2:13 pm in room [ROOM NUMBER], the vinyl baseboard covering was in disrepair. A hole measuring approximately one and a half inches in length was present in the corner to the right of the toilet, and an additional hole measuring approximately two inches in length was present on the wall to the left of the toilet.At 2:31 pm in room [ROOM NUMBER], the vinyl baseboard covering was in disrepair. A gap measuring approximately two inches in length was present on the wall to the left of the toilet, and a gap measuring approximately one inch in length was present on the wall to the right of the toilet.At 2:34 pm in room [ROOM NUMBER], the vinyl baseboard covering was in disrepair. A gap measuring approximately four inches in length was present on the wall to the left of the toilet. B. On 3/10/26 at 3:09 pm during an interview, the Maintenance Director (MD) confirmed there are gaps and holes in the vinyl baseboard coverings in the restrooms of rooms #210, #305, #307, and #405. The MD stated the vinyl baseboards should be repaired immediately to prevent insects and pests from entering through the gaps and holes.

Based on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment (to prevent the development and transmission of communicable diseases and infections) for 1 (R #1) of 3 (R #1, #2 and #3) residents, when: The facility failed to post the required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage for R #1.This deficient practice is likely to result in repeated and ongoing exposure of residents to increased risk of infection, cross-contamination, and injury. The findings are: A. Record review of R #1's face sheet revealed an admission date of 12/17/25 and included a diagnosis of gastronomy status (when a person has a surgically created opening in their abdominal wall that leads directly into the stomach which allows for nutrition, hydration, and medication administration). B. Record review of R #1's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/26/26 revealed the following: R #1 has an indwelling catheter (a hollow tube inserted through your lower abdomen into your bladder to drain it of urine). R #1 has a swallowing disorder and requires a feeding tube (a soft, flexible tube that is surgically inserted through the skin of the abdomen, directly into the stomach and is used to provide nutrition, liquids, and medications when a person is unable to eat or drink). R #1 has unhealed pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and was at a continued risk for developing pressure ulcers, and R #1 required wound care for pressure ulcers. C. Record review of R #1's physicians' orders revealed the following: Dated 03/07/26: Enteral feed order (feeding tube), every day and night shift.Dated 03/07/26: Change indwelling catheter when occluded or leaking, as needed. Dated 03/07/26: Cleanse site (PU) with wound cleanser, pat dry, apply Medi-Honey (wound and burn gel), apply calcium alginate (a highly absorbent wound gel), cover with foam dressing, daily and as needed if dressing becomes soiled or removed. D. On 03/09/26 at 9:12 am during an observation, R #1 was observed utilizing an indwelling foley catheter and a feeding tube. Observation of this room revealed there was no signage posted indicating R #1 required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). E. On 03/09/26 at 2:08 pm during an observation, signage was not posted at the entrance of R #1's room indicating R #1 required EBP. F. On 03/10/26 at 11:15 am during an observation, signage was not posted at the entrance of R #1's room indicating R #1 required EBP. G. On 03/10/26 at 3:45 pm during an interview, the Administrator (ADM) stated R #1 required EBP because she has an indwelling catheter as well as a feeding tube. She verified there was no signage posted on the door indicating R #1 required EBP and stated there should be a sign indicating R #1 required EBP. H. On 03/10/26 at 3:56 pm during an interview, the Director of Nursing (DON) stated R #1 required EBP for direct care. She stated the signage lets staff know if there are precautions required and what type of precautions are required.

Based on interview, observation, and record review, the facility failed to ensure meals were palatable and served at an appetizing temperature for 6 (R #1, R #2, R #3, R #4, R #5, and R #6) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed. This failed practice had the potential to affect all 128 residents identified on the resident census list provided by the Administrator on 02/19/26. If meals are not appetizing, then residents may not eat meals and lose weight. The findings are: A. On 02/19/26 at 3:12 p.m., during an interview, Resident #1 stated their meals were consistently cold. R #1 stated they ate only what they could tolerate because the food often arrived too cold to enjoy. B. On 02/19/26 at 3:17 p.m., during an interview, Resident #2 stated their meals were often cold when they were supposed to be hot. The resident stated the room trays sometimes took a long time to reach the rooms. C. On 02/19/26 at 3:24 p.m., during an interview, Resident #3 stated their meals were often not warm enough, and the food was sometimes already cold by the time the tray reached them.D. On 02/19/26 at 3:30 pm during an interview, R #4 stated the food is horrible. I don't ask to warm it up anymore. It's always cold.E. On 02/19/26 at 3:30 p.m., during an interview, Resident #4 stated their meals were consistently served cold. The resident stated they did not ask staff to reheat the food anymore, because it did not help in the past. R #4 stated the meals continued to arrive cold. F. On 02/20/26 at 10:15 a.m., during an interview, Resident #6 stated their meals were inconsistent in temperature. R #6 stated some meals arrived cold while others did not. G. On 02/20/26 at 11:55 a.m., observation revealed staff delivered the lunch meal trays delivered to Unit 500. Further observation revealed the plates for Residents #1 and #2 were cool to the touch. H. On 02/20/26 at 11:45 am during an interview, the Dietary District Manager stated he was aware of residents' complaints about the cold food served at the facility. I. On 02/20/26 at 11:52 am, during an interview, the Administrator stated the facility utilized plate bases and plate warmers to help keep the hall tray meals warm. The Administrator stated they were aware there was a problem with food temperatures.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for 4 (R #'s 1, 41, 85 and 114) of 4 (R #'s 1, 41, 85 and 114) residents reviewed for ADL care by not: Providing baths/showers per the schedule for R #'s 1, 41, and 85. Providing nail care for R #114. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's shower schedule revealed R #1's baths/showers were scheduled for Mondays, Wednesdays, and Fridays. C. Record review of R #1's care plan dated 05/16/25 revealed R #1 is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing. eating, bed mobility, transfer, locomotion & toileting related to physical and cognitive impairments. R #1's interventions included staff monitoring for ADL decline and engagement in resident ADL activity and planning. D. Record review of R #1's Documentation Survey Report (ADL tracking form located in Electronic Health Record; EHR) dated 04/01/25 through 04/30/25 revealed, R #1 was offered/given 9 showers/baths out of 13 opportunities. Shower sheets were not provided by the facility for the timeframe. E. Record review of R #1's Documentation Survey Report dated 05/01/25 through 05/31/25 revealed, R #1 was offered/given 11 showers/baths out of 13 opportunities. Shower sheets were not provided by the facility for the timeframe. F. Record review of R #1's Documentation Survey Report dated 06/01/25 through 06/26/25 revealed, R #1 was offered/given 8 showers/baths out of 11 opportunities Shower sheets were not provided by the facility for the timeframe. G. On 06/24/25 at 3:46 pm during an interview, R #1 has difficulty communicating due to a Traumatic Brain Injury (TBI). R #1 did confirm that he was not receiving enough bed baths/showers per week. H. On 06/24/25 at 4:10 pm during an interview with R #1's Power of Attorney (POA; medical decision maker), she stated R #1's family will go into the facility to visit R #1, and they will tell her that R #1 was visibly dirty and had a foul odor present. R #1's POA confirmed her biggest concerns for R #1 involved the number of baths/showers that R #1 is given. I. On 06/27/25 at 4:09 pm during an interview with Certified Nursing Assistant (CNA) #4, he stated R #1 enjoys receiving baths/showers and R #1 will seldomly refuse one. CNA #4 confirmed all baths/showers and bath/showers refusal should be documented in shower sheets of the residents EHR. J. On 06/30/25 at 3:00 pm during an interview with Licensed Practical Nurse (LPN) #2, she confirmed R #1 enjoyed receiving baths/showers and R #1 liked to be clean. LPN #2 confirmed R #1 should be offered baths/showers per the schedule. K. On 07/01/25 at 12:06 pm during an interview with the Director of Nursing (DON), she confirmed R #1 was not offered or given enough baths/showers as scheduled and R #1 should have. R #41:L. Record review of R #41's face sheet revealed R # 41 was admitted into the facility on [DATE].M. On 06/23/25 at 12:31 during an interview, R #41 stated I do not receive hair care or nail care until my children come and pick me up. I would go outside of my room, but they don't offer. N. On 06/25/25 at 2:53 pm during interview with Licensed Practical Nurse (LPN) #5, she confirmed that residents are supposed to receive 2-3 offers for showers per week whether they are on hospice or not. O. Record review of R #41's Documentation Survey report (DSR) revealed a lack of documentation between hospice and facility regarding bathing for R #41 since October of 2024. There is one refusal documented for June 5th, out of 12 opportunities for the month.R #85:P. Record review of R #85's face sheet reveled R #85 was admitted to facility on 06/22/23.Q. On 06/25/25 at 12:56 pm during an interview with R #85's mother she stated, he wasn't getting his baths. He gets them Monday Wednesday and Fridays, and he said he doesn't get them on Friday.R. 06/23/25 03:14 PM during an interview with R #85, he stated They're supposed to change it [catheter] every 30 days but they don't. They don't change my urine bag often, and sometimes it overflows. I'm supposed to get a shower three times a week but they missed it. They were doing good for a while but now they're starting to slack. It frustrates me. S. Record review of R #125's EHR revealed only one shower-sheet (facility documentation of showers for residents) for the month of June. T. On 07/01/25 at 11:05 am during an interview with the DON, she stated resident's baths and showers should be documented on shower sheets and in the EHR. The DON confirmed three Documentation Survey Reports (DSR) showed staff did not offer and /or give R #85, R #41 enough baths and showers. R #114:U. On 06/23/25 at 11:35 an during an interview with R #114, she stated she has asked staff to trim her fingernails because they are getting a little too long. I would do it myself, but they will not allow me to have a nail clipper. V. On 06/30/25 at 3:02 am during an interview with CNA #1, he stated R #114 had not asked him to cut her nails. He further stated he would go into her room after this interview and trim her nails.W. On 07/01/25 at 10:17 am during an interview with R #114, she stated she is still waiting for her nails to be trimmed or for someone to give her a manicure. X. On 07/01/25 at 10:25 am during an interview with Activities Assistant (AA) #2, she stated no one has told her that R #114 wants a manicure. “We usually do manicures on Saturday or Sunday. We keep a list of residents that have asked for a manicure, and we will also make an announcement.”Y. On 07/01/25 at 11:25 am during an interview with the DON, she stated the expectation is to cut residents' nails when they ask you to. She further stated if the CNA, nurse, whoever the resident asked could not cut their nails right away I would expect them to give the resident a timeframe of when they are going to go back and cut them.

Based on record review and interview the facility failed to protect 1 (R #2) of 1 (R #2) resident reviewed from the use of a physical restraint that was not required to treat a resident's medical condition. This deficient practice could likely result in resident feeling trapped and hopeless. The findings are: A. Record review of R #2's face sheet dated 03/26/25 revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a chronic progressive decline of mental abilities and memory). -Need for assistance with personal care. -History of Traumatic Brain Injury (an injury of the brain that may cause a decline in memory, thought, personality or motor skill). -Homelessness The face sheet further revealed R #2 was discharged on [DATE]. B. Record review of R #2's Elopement (to leave or exit without permission or knowledge of staff) Risk Evaluation dated 02/17/25 revealed he was not a risk of elopement. C. Record review of R #2's daily care note dated 02/27/25, stated R #2 was found in the parking lot and was brought back in by staff. A Wander Guard was being placed on his wheelchair. R #2 stated he is going to leave and doesn't want to be here D. Record review of the provider order dated 03/12/25 revealed an order for staff to place a Wander Guard elopement device due to poor safety awareness. E. Record review of R #2 care plan reviewed on 03/26/25 revealed the care plan did not contain any documentation for risk of elopement or the use of a Wander Guard. F. On 03/25/25 at 12:15 PM during interview with the Assistant Director of Nursing, he stated he could recall that R #2 had a Wander Guard placed on him starting in February. He reviewed and confirmed the daily care note dated 02/27/25 and agreed that a Wander Guard had been placed on R #2 at that time. ADON confirmed that he could remember R #2 had a Wander Guard on his person or on his wheelchair beginning in February 2025. He could not explain who placed the Wander Guard on R #2 and he confirmed that the order for placement of a Wander Guard was not entered until 03/12/25. ADON stated all the nurses have access to Wander Guards and a nurse would be able to place a Wander Guard any time with or without a provider order.

Based on record review and interview the facility failed to revise the care plan for 1 (R #2) of 1 (R #2) resident reviewed for care planning. This deficient practice has the potential for staff to fail to identify resident as an elopement risk. The findings are: A. Record review of R #2's face sheet dated 03/26/25 revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a chronic progressive decline of mental abilities and memory). -Need for assistance with personal care. -History of Traumatic Brain Injury (an injury of the brain that may cause a decline in memory, thought, personality or motor skill). -Homelessness The face sheet further revealed R #2 was discharged on [DATE]. B. Record review of R #2's provider order dated 03/12/25 revealed an order for staff to place a Wander Guard elopement device due to poor safety awareness. C. Record review of R #2 care plan reviewed on 03/26/25 , revealed the care plan did not contain any documentation to include the risk of elopement and the order to place and use a Wander Guard on the resident. D. On 03/26/25 at 12:10 PM during interview with Assistant Director of Nursing, he confirmed R #2 had no care plan for being an elopement risk and no care plan for the placement of a Wander Guard.

Based on record review and interview the facility failed to ensure staff provided care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident. Nursing staff failed to maintain the scene of a suspcious death before calling the New Mexico Office of Medical Investigator. (OMI) (a New Mexico state agency that reviews and determines the need for investigation and autopsy when a person dies in a facility). This deficient practice could disturb the scene of a suspicious death so that it cannot be thoroughly assessed and reviewed by proper authorities. The findings are: A. Record review of OMI web page (hsc.unm.edu/omi/about/faq/reportable.html) reviewed on 03/27/25 at 11:30 am revealed the expectation to report any death suspected to be due to violence (suicidal, accidental or homicidal) and any death of a person in a nursing home should be reported to OMI. B. Record review of R #1 face sheet dated 03/28/25 revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: -Fracture (break) of upper end of left Humorous (upper arm bone) -Anterior (front) Dislocation of Tibia (lower leg bone), Left Knee -Displaced Fracture of left Tibia -Dislocation of left Patella (knee bone) -Fracture of Left Clavicle (collar bone) -Aortic (large artery carrying blood from the heart) Aneurysm (weak spot in an artery) The face sheet further revealed R #1 had been discharged from the facility on 03/18/25 at 5:02 am for other reasons. C. Record review of R #1's daily care note dated 03/18/25 at 9:43 am revealed R #1 was found in his room at 4:50 am with a bag over his head and tied at the neck. The nurse observed no signs of life and asked for help. At 5:00 am the bag was removed from his head and R #1 was pronounced dead. The nurse notified the health provider, facility administrator, director of nursing, and supervisor of the incident. R #1's sister was contacted and message left. At 5:20 am the nurse notified the Office of Medical Investigator. At 5:45 am R #1's body was moved, cleaned and his Foley Catheter (a tube placed into the bladder to allow free flow of urine) was removed. D. Record review of the local police report number 250021249 dated 03/18/25 revealed police were called and arrived at the facility at 5:43 am. Upon arrival the officer found R #1 in his room where R #1 was covered with a line cloth sheet from head to toe. Staff reported they had removed the plastic bag and string from R #1 and thrown it away, they had washed, cleaned the body, and changed sheets prior to police or OMI arrival. The report further revealed that the arriving officer called and informed OMI of the death of R #1. E. On 03/27/25 at 12:10 PM, during interview with the facility Assistant Director of Nursing (ADON), he stated the expectation is that nurses would contact OMI before moving or disturbing the body. He confirmed that in this case, the nurses did not act according to expectations and the nurses should have waited for OMI or the police to release the body of R #1 before they moved and cleaned him. F. On 03/31/25 at 11:15 am ,during interview, the OMI investigator stated the facility did contact the OMI office to report the death of R #1. OMI investigator stated that the nurse was told to leave the scene untouched and contact the police immediately. OMI investigator stated he was called later by police at about 6:00 am. OMI investigator arrived at the facility about 6:30 am.

Based on observation record review and interview, the facility failed to provide adequate supervision for 1 (R #2) of 1 (R #2) resident reviewed who were identified as a risk for elopement (leave facility without authorization or supervision potentially endangering themselves or others.) This deficient practice likely resulted in the resident being able to eloped from the facility for over 24 hours likely putting himself at serious risk of adverse outcomes. The findings are: A. On 03/26/25 at 11:00 am, during observation of the facility entrance the front door was locked. To enter the building required a doorbell be pushed and staff within the facility would then activate and unlock the door. Once inside the building there was a lounge area with a nurses station directly across from the entrance. There were chairs and multiple residents sitting in the area. Multiple staff sat at the nurses station. Staff, visitors and residents were further observed to walk up to the front door where they pushed a green button that unlocked the front door allowing them to exit the building. B. Record review of R #2's face sheet dated 03/26/25 revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a chronic progressive decline of mental abilities and memory). -Need for assistance with personal care. -History of Traumatic Brain Injury (an injury of the brain that may cause a decline in memory, thought, personality or motor skill). -Homelessness C. Record review of Elopement Risk assessment for R #2 revealed the following: 1. 11/13/24 was not identify R #2 as an elopement risk. 2. 02/17/25 was not identify R #2 as an elopement risk. D. Record review of R #2 care plan revealed the following: -11/29/24 Impaired/decline in cognitive function or impaired thought. Observe and evaluate types of changes in cognitive status-confusion, orientation, forgetfulness, decision making, impulsivity. -The care plan did not include a plan regarding elopement risk (to leave or exit without permission or knowledge of staff) and the placement and use of a Wander Guard or requirement for increased supervision. E. Record review of R #2's provider order dated 03/12/25, revealed an order for staff to place a Wander Guard elopement device due to R #2's poor safety awareness. There was no previous provider order that had been entered for a Wander Guard to be placed on R #2 F. Record review of R #2's daily nursing notes revealed the following: -02/27/25 2:23 pm, R #2 was found in the parking lot and brought back in the facility by staff. A Wander Guard is being placed on his wheelchair. R #2 stated he is going to leave and doesn't want to be here. He stated he wants to go back to the streets to do his drugs. -02/27/25 2:34 pm, R #2 refused to have a Wander Guard on his person and on his wheelchair. -02/27/25 3:59 pm, R #2 seen by unit manager and the Director of Nursing seeking to leave the facility without permission and seeking for drugs. -03/24/25 11:00 pm, R #2 approached the nurses station where the provider sat and stated to the provider that he wanted to get out. Provider informed resident he should remain in the facility and continue care .Assistant Director of Nursing (ADON) was aware of R #2's desire to discharge and leave the facility. -03/24/25 11:26 pm, resident is missing in the room and dinning. Nurse announced all staff to assemble at nursing station. Staff divided and checked into each room and toilet in all units. Checked all backyards and around the building. Resident not found. Staff called 911 (emergency services). Police enter resident as a missing person. G. On 03/25/25 at 8:15 PM during phone interview with ADON, he described R #2 as a man who was wheelchair bound who was alert and oriented but due to his traumatic brain injury he was impulsive and made poor choices. ADON stated that on 03/24/25 at 5:15 PM, he was notified that R #2 was missing and could not be found. ADON stated R #2 probably left late afternoon (due to staff were unsure when he was last seen following lunch and was not around for the dinner meal) on 03/24/25, and he had been gone for 24 hours at this time and had not been located. H. On 03/26/25 at 12:00 PM, during interview with ADON, he stated R #2 had been located and had been taken to the hospital. ADON stated he had met with and interviewed R #2 since being found. ADON stated R #2 had informed him that he cut his Wander Guard off and left it somewhere unknown. R #2 had then exited the building at the front door by pressing the button that unlocked the door and exited. ADON stated the Wander Guards activate an alarm as they approach the front door. He stated the alarm was loud and would alert staff that a resident wearing a Wander Guard was near the front door. ADON stated this did not happen when R #2 left because he had cut his alarm off prior to approaching the door. ADON further stated that all residents with a Wander Guard are checked daily to assure that the Wander Guard was properly placed and functioning. He further stated that staff was aware that R #2 was an elopement risk, R #2 had cut her wander guard off before, and that he required close observation and monitoring. He also stated R #2 had a habit of sitting in the front area next to the nurses station throughout the day and evening hours and that he had told several staff that he wanted to leave the building and return to the streets.

Based on record review and interview the facility failed to ensure that 1 (R #1) of 1 (R #1) resident received prescribed intravenous (IV) (medications administered directly into the vein) medications on time in accordance with professional standards of practice. The facility failed to provide and administer antibiotic (antibacterial) medications as ordered by the prescriber. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: -Acute (sudden onset) Infective Endocarditis (a serious, potentially life threatening bacterial infection of the heart) -Bacteremia (a serious bacterial infection of the blood stream) and was transferred to a local hospital on 11/14/24 and was discharged the same day. B. Record review of R #1's provider orders revealed the following: -10/19/24 Ampicillin (antibiotic medication used to treat bacterial infections) 2 GM (grams). Use 100 ml (milliliter) intravenously every four hours for Enterococcus faecalis (a specific bacteria) Bacteremia until 11/25/24. -10/19/24 Ceftriaxone Sodium (antibiotic medication used to treat bacterial infections) 2 GM use 100 ml intravenously every 12 hours for Enterococcus faecalis bacteremia. No end date. C. Record review of R #1's Daily Notes revealed the following: -10/20/24 at 8:18 am Ampicillin Intravenous solution. Awaiting med (medication) delivery. -10/20/24 at 8:18 am Ceftriaxone intravenous solution. Awaiting med delivery. -10/20/24 at 10:38 am Ampicillion Intravenous Solution. Awaiting med delivery. -10/20/24 at 3:15 pm Ampicillin intravenous solution. Awaiting med delivery. -10/20/24 at 5:27 pm Family concerned about IV antibiotic administration and having medication available. Reassured family that pharmacy had been called and IV antibiotics were to arrive STAT (immediately). -10/20/24 10:01 pm Ampicillin intravenous solution. Awaiting pharmacy delivery. -10/20/24 at 10:01 pm Ceftriaxone intravenous solution. Awaiting pharmacy delivery. -10/21/24 at 1:07 am Change in Condition-Transferred to hospital. -10/21/24 at 11:04 pm Ampicillin intravenous solution. Awaiting pharmacy delivery. -10/22/24 at 4:18 am Ampicillin intravenous solution. Awaiting pharmacy delivery. D. Record review of R #1's hospital emergency room care note dated 10/21/24 revealed R #1 was received at the emergency room due to not receiving prescribed antibiotic medications and R #1's son's concern that she had not been administered any antibiotic medications for three days. E. Record review of R #1's Medication Administration Record (MAR) for the month of October 2024 revealed the following: -Ampicillin Intravenous Solution was administered on 10/19/24 at 11:00 pm and on 10/20/24 at 3:00 am. -Ampicillin Intravenous Solution was due but not administered on 10/20/24 at 7:00 am, 10/20/24 at 11:00 am, 10/20/24 at 3:00 pm, 11/20/24 at 7:00 pm, 10/20/24 at 11:00 pm, and on 10/20/24 at 3:00 pm. -Ampicillin Intravenous Solution was due but not administered on 10/21/24 at 7:00 am and on 10/21/24 at 11:00 am due to R #1 being at hospital. -Ampicillin Intravenous Solution was administered on 10/21/24 at 3:00 pm and at 7:00 pm. -Ampicillin Intravenous Solution was due but not administered on 10/21/24 at 11:00 pm and on 10/21/24 at 3:00 pm. -Ceftriaxone intravenous solution was due but not administered on 10/20/24 at 8:00 am and 10/20/24 at 8:00 pm. F. On 01/29/25 at 10:50 am during interview with the Assistant Director of Nursing (ADON) 2, he confirmed R #1 was admitted to the facility with orders to administer antibiotics intravenously. He confirmed that R #1's IV antibiotics were ordered but not available for multiple doses because to the pharmacy did not deliver the medications. ADON #2 stated that the ordered IV antibiotics must be administered on time to maintain a therapeutic level (an expected blood level of the medication so that the medication is effective) of the antibiotic medication. ADON 2 stated that this administration schedule would be especially critical for R #1 due to her diagnosis of Endocarditis.

Based on record review and interview, the facility failed to ensure that resident injuries of unknown sources were reported to the State Agency within 24 hours to the state agency for 1 (R #4) of 2 (R #4 and R #5) residents reviewed. If the facility is not immediately investigating and reporting injuries of unknown sources residents are likely to be at risk of further injuries. The findings are: R #4 A. Record review of R #4's face sheet revealed R #4 was admitted to the facility on [DATE] with multiple diagnoses including: -Pain in Left Hip. -Dementia (a progressive disease that affects memory). -Lack of Coordination. Face sheet further revealed she was readmitted to the facility on [DATE] with new diagnoses including: -Fracture of Left Femur (large upper leg bone) with routine healing. -Fracture of left Patella (knee bone) B. Record review of R #4's X-ray report of the left leg dated 10/29/24 stated no acute fracture or dislocation. Prior fixation hardware (surgically placed metal supports and screws used to repair fractured bones) present. C. Record review of R #4's hospital H & P (history and physical) report revealed R #4 was admitted to hospital for leg pain on 11/03/24. R #4 reported she fell a few days ago landing on her left hip and today (11/03/24) she began having pain. Record continues to state History of Present Illness R #4 was brought to hospital for evaluation of left hip pain after mechanical fall. It further stated R #4 sustained a mechanical fall on the afternoon before (11/02/24) landed on her left hip. There was no head trauma or loss of consciousness. D. Record review of R #4's daily progress notes dated 11/03/24 at 10:31 am reported R #4 pain issue: Location Left Hip. Note dated 11/03/24 at 12:39 pm reported R #4 was transferred to [name of hospital] and listed reason for transfer edema (swelling) new or worsening. E. Record review of R #4's facility pre-admission note dated 11/06/24 stated patient's hospital diagnoses for hospital admission was for evaluation of left hip pain after mechanical fall. Note further stated R #4 had incisions (surgical cuts) from surgery. F. Record review of R #4's daily progress note dated 11/06/24 at 6:36 pm reported that R #4 had been returned to the facility with new skin issue described dot-like wound present on admission. Front left trochanter (upper end of leg bone-hip bone)-surgical site closed with staples. Left patella (Knee Bone) -surgical site closed with staples. G. On 01/29/25 at 2:59 pm during interview with Administrator (ADM), she stated that she was not aware that R #4 had fallen on 11/03/24 and was not aware of the extent of her injuries. She stated that had she known, she would have conducted an investigation and reported to the state agency as required. ADM acknowledged that neither she nor any other staff investigated these reported changes on 11/03/24 or upon R #4's return from the hospital on 11/06/24. ADM stated there had been no initial report of the incident to the state agency and no five day follow up report submitted to the state agency. 47031

Based on record review and interview, the facility failed to investigate and report within five working days, injuries of unknown origin for 1 (R #4) of 2 (R #4 and R #5) residents reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: R #4 A. Record review of R #4's face sheet revealed R #4 was admitted to the facility on [DATE] with multiple diagnoses including: -Pain in Left Hip. -Dementia (a progressive disease that affects memory). -Lack of Coordination. Face sheet further revealed she was readmitted to the facility on [DATE] with new diagnoses including: -Fracture of Left Femur (large upper leg bone) with routine healing. -Fracture of left Patella (knee bone) B. Record review of R #4's X-ray report of left leg dated 10/29/24 stated no acute fracture or dislocation. Prior fixation hardware (surgically placed metal supports and screws used to repair fractured bones) present C. Record review of R #4's daily progress note dated 11/03/24 at 12:39 pm reported that R #4 was transferred to (name of hospital) and listed reason for transfer edema (swelling) new or worsening. D. Record review of R #4's facility pre-admission note dated 11/06/24 stated patient's hospital diagnoses for hospital admission was for evaluation of left hip pain after mechanical fall. Note further stated R #4 has incisions (surgical cuts) from surgery. E. Record review of R #4's hospital H & P Notes (history and physical) revealed R #4 was admitted to hospital for leg pain. R #4 reported she fell a few days ago landing on her left hip and today (11/03/24) she began having pain. Record continues to state History of Present Illness that R #4 was brought to hospital for evaluation of left hip pain after mechanical fall. It further states R #4 sustained a mechanical fall on the afternoon before (11/02/24) landed on her left hip. There was no head trauma or loss of consciousness. F. Record review of R #4's daily progress note dated 11/06/24 at 6:36 pm reported that she had been returned to the facility with new skin issue described dot-like wound present on admission. Front left trochanter (upper end of leg bone-hip bone)-surgical site closed with staples. Left patella-surgical site closed with staples. G. On 01/29/25 at 10:15 am during interview with Assistant Director of Nursing (ADON) #2 he confirmed that R #4 was transferred to hospital on 11/03/24 and returned on 11/06/24. He stated the daily progress notes indicated that R #4 had returned from hospital with surgical sites and orders to provide wound care. He stated there was no indication of any fall within the facility prior to 11/03/24 and no fall was reported to staff. H. On 01/29/25 at 2:59 pm during interview with Administrator (ADM), she stated that she was not aware that R #4 had fallen on 11/03/24 and was not aware of the extent of her injuries. She stated that had she known, she would have conducted an investigation and reported to the state agency as required. ADM acknowledged that neither she nor any other staff investigated these reported changes on 11/03/24 or upon R #4's return from the hospital on 11/06/24. ADM stated there had been no initial report of the incident to the state agency and no five day follow up report submitted to the state agency. 47031

Based on record review and interview the facility failed to prevent resident to resident abuse for [R #1] of 3 [R #1, R #2 and R #9] residents reviewed for sexual abuse by R #2 sexually assaulting R #1. This deficient practice likely resulted in psychosocial harm to residents. The findings are. A. Record review of the facesheet for R #1 indicated the following, R #1 was admitted on [DATE] for the following Diabetes Mellitus Type 2 (your body doesn't use insulin properly) right carotid artery occlusion (occurs when fatty deposits (plaques) clog the blood vessels that deliver blood to your brain and head), major depressive disorder (clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), insomnia (sleep disorder that makes it hard to fall asleep), Irritable bowel syndrome (IBS) (is a common disorder that affects the stomach and intestines, also called the gastrointestinal tract) and hypertension (high blood pressure). Unspecified dementia with behavioral disturbance (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life). This is not an all inclusive list. B. Record review of the Minimum Data Set (MDS) dated [DATE] indicated that R #1 had a BIMS (Brief Interview for Mental Status) score of 4 (0-7 severely Impaired cognition, 8-12 moderately impaired, 13 -15 intact cognition) and resided on the locked unit for wandering behavior. C. Record review of the care plan revised on 12/06/22 indicated the following: R #1 has a tendency to exhibit sexually inappropriate behavior R/T (related to): Cognitive Loss/Dementia. (name of R #1) has consent from R #1's POA (Power of Attorney) to have an intimate relationship with R #2. R #2's POA provided consent. D. Record review of the facesheet for R #2, indicated that R #2 was admitted on [DATE] and had the following diagnosis of extradural and subdural abscess (infections in the brain), dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), dysphagia (difficulty in swallowing food or liquid may interfere in a person's ability to eat and drink), chronic hepatitis C (viral infection that causes liver inflammation, sometimes leading to serious liver damage) and Wernike's encephalopathy (or wet brain is the presence of neurological symptoms caused by biochemical lesions of the central nervous system). This is not all inclusive list. E. Record review of the Minimum Data Set (MDS) dated [DATE] indicated that R #2 had a BIMS score of 5 (0-7 severely Impaired cognition, 8-12 moderately impaired, 13 -15 intact cognition) and resided on the locked unit for elopement (leaving) and wandering behavior. F. Record review of the care plan for R # 2 revised on 12/06/22 indicated the following: R #2 has a tendency to exhibit sexually inappropriate behavior R/T: Cognitive Loss/Dementia (name of R #2) has consent from R #2's POA to have an intimate relationship with R #1. R #1's POA provided consent. G. On 04/05/23 at 10:00 am during an interview with Licensed Practical Nurse (LPN) #1, she stated that R #2 could be touchy feely and at times aggressive. He was on the locked unit because would sought to exit all the time. LPN #1 stated that just last week he got out the backdoor of this unit and kicked the wooden gate and started running down the street. She stated that he had a plan and had a bag with him. She stated that as of last week his behaviors had been escalating. She stated that R #2 hit another resident after the elopement incident, and then the sexual assault incident with R #1. LPN #1 stated that she witnessed this incident. LPN #1 said that on Monday 04/03/23, that she heard R #1 scream stop you're hurting me. LPN #1 was around the corner at the mediation cart when she heard R #1 say this. When she walked around into the dayroom she saw R #2 with his hands under R #1's dress. LPN #1 stated that R #2 was being forceful and aggressive with R #1 and wouldn't stop. They tried to pull his arm away from R #1 but they couldn't. Finally he (R #2) got mad and stopped, and started threatening and calling them fucking bitches. LPN #1 stated that she took her (R #1) to her room to make sure she was physically alright and changed her dress to a pair of sweatpants. At that point LPN #1 stated that she notified everyone and the investigation started. She stated that after this incident she saw in the care plan where it indicated in both R #1's and R #2's Power of Attorneys had stated that these two residents were allowed to be in an intimate relationship. LPN #1 stated that when she spoke to POA (daughter) of R #1, she was very upset about this, indicating that she had no idea that the care plan stated she had given permission for them to have an intimate relationship. H. Record review of the nursing progress notes indicated the following: On 4/3/2023 20:09 (8:09 pm. Today, the Administrator met with the (name of) Police Department, SANE (Sexual Assault Nurse Examiners), and (name of) Detective regarding the sexual abuse incident that took place earlier in the day. (name of detective), along with SANE, strongly advised against (name of resident #2) returning to the facility due to the potential danger he poses to both the abused resident (R #1) and other residents. As such, they recommended a restraining order be put in place for the facility and family. The son of the abused resident (R #1) worked closely with Detectives and SANE to complete the restraining order, which was received at approximately 5 pm. SANE also conducted an evaluation of the abused resident (R #1), and results are currently pending. The facility promptly notified Adult Protective Services (report number 301988) and the state Ombudsman of the incident. I. Record review of the progress note dated 12/05/22 indicated the following: At the beginning of the night shift around 6:35, the nurse was summoned by the CNA (Certified Nurse Assistant) to go and witness the resident (R #2) and (name of R #1) in his room. Upon assessment the resident was lying in his bed naked half covered by his blanket and (name of R #1) was sitting leaning on the residents' waist her legs suspended on her wheel chair. (name of R #1) had her black slack, printed shirt and her brief on. When the nurse asked the resident why (name of R #1) was in his room, he replied she is my girl friend and we are watching TV. The residents were accompanied to the dining for close monitoring . J. Record review of the progress notes dated 09/05/22 indicated the following: resident continuously trying to take a female resident into a vacant room. When told he cant be alone with her in the room resident is becoming aggressive with staff calling CNA's and nurses bitches, throwing finger. Stating you guys are a bunch of snitches your always telling on me. K. Record review of the progress notes dated 06/09/22 for R #2 indicated that he is experiencing impulsive behavior and often holds hands of female Pt's (patient) and sits with female Pt's exhibits behavior: seeking companionship (e.g. looking for a loved one). Additional mental health/behavior comments: Pt will hold female Pt's hands while sitting in dining room. Will sometimes kiss a female Pt and has to be told to stop. Pt is currently resting in bed. Pt is a 1:1 watch for sexual behaviors exhibited on day shift. No behaviors noted so far this shift. L. On 04/05/23 at 1:15 pm, during an interview with the Ombudsman she stated that she had not been made aware that the facility was allowing these two residents to be intimate with each other. M. On 04/05/23 at 1:30 pm, during an interview with R #1, she stated that she had a friend, that was her friend, but weren't those kind of friends and he hadn't touched her. She also had a friend like that and he touched her in a way she didn't like at least one time. R #1 was unable to give any other details of the names, places, or events. N. On 04/05/23 at 2:26 pm, during an interview with R #1's daughter and Power of Attorney (POA) she stated that the facility called her on Monday 04/03/23 and told her about the incident between her mother R #1 and R #2. She stated that she was aware that her mother R #1 and R #2 would hold hands and had seen this while she was at the facility visiting her mother. She stated that when she had become aware of the care plan stating it was ok for them to be in an intimate relationship she stated that she never said that or would have ever allowed that. O. On 04/05/23 at 4:15 pm, during an interview with R #2's brother (not the power the attorney), he stated that to his awareness no one consented to an intimate relationship. It was only ok for them to hold hands. P. On 04/05/23 at 4:31 pm, during an interview with Center Executive Director (CED), he stated that when he first got here R #1 and R #2 would hold hands with each other but nothing more. He stated once the incident happened on 04/03/23, he contacted everyone, the police, SANE, he reported it to the state and contacted the families. The CED stated that R #2 has had a few incidents, one was last Friday (03/31/23) when he pushed a resident and the other on the 03/28/23, he left through the back door and exited the building kicking the outside wooden gate open. Staff followed him out the door and never lost sight of him. He had a meeting with R #1's family members and they were upset about what was noted in the care plan indicating that she had given consent for her mother to have an intimate relationship R #2. He stated that he had the assistant director of nursing remove the parts of the care plan that the family was unhappy with. The son of R #1 filed a restraining order on R #2. Q. On 04/05/23 at 4:51 pm, during an interview with the Social Services Director (SSD), he stated that he met with R #1's family after the incident on 04/03/23, and he stated that during the meeting the daughter of R #1 stated that she never gave permission for a relationship to occur and was upset that her mother was assaulted. He stated that when R #2 tried to elope recently and got out the back door and kicked open the gate, this was the red flag. He stated that something could have been done at that time and maybe this incident wouldn't have occurred. R. On 04/06/23 at 8:17 am, during an interview with Certified Nursing Assistant (CNA) #3, she stated that on Monday 04/03/23 she was passing refreshments in the dining room. She heard R #1 state Stop you are hurting me. She said that when she turned around she didn't see anything so she went back to passing snacks. Then she heard R #1 say again I told you stop you're hurting me. She said that the nurse came in and saw right away what was going on. She stated that her and the nurse both tried to get him to stop and he wouldn't. She stated that R #2 got really mad and then finally stopped and then started calling them names. She stated that there has been a lot of issues of concern with what is acceptable and what isn't acceptable for R #1 and R #2. She stated that to her understanding Dementia residents aren't able to consent to having a relationship with each other. She stated that she had been told that they are allowed to have a relationship and to not discipline him. She stated that she hadn't been made aware of this information and wouldn't have understood what that meant anyway (referring to the care plans that stated that both residents were allowed to have a relationship with each other). CNA #3 stated that she was educated and trained that if a resident is in their right mind then they can make those decisions. She said that she would point out that R #2 would inappropriately touch R #1 but was told that they are allowed to be in a relationship. CNA #3 stated that she would stop it (inappropriately touch) every time she saw it. S. On 04/06/23 at 10:10 am, during an interview with Social Services Assistant (SSA), she stated that to her awareness R #1 and R #2 were in a relationship with each other. They would hold hands and wanted to be by each other. She stated that it was care planned that they could be girlfriend and boyfriend. She stated that staff were always trying to keep them separated and she told them to stop, that it was care planned for them to be boyfriend and girlfriend and said that to her that included holding hands, and not going into each others rooms. The SSA stated that R #2 could be vulgar and he was escalating the past two weeks. She stated that with the elopement that happened for R #2 and he was exit seeking and cussing at the nurses this should have been taken more seriously then she thinks it was.

Based on record review, observation, and interview, the facility failed to provide the necessary behavioral health services for 1 (R #3) of 1 (R #3) resident reviewed. This deficient practice likely resulted in worsening anxiety and depression for R #3. The findings are: A. Record review of R #3's face sheet revealed that she was admitted to the facility on [DATE] with the following diagnoses: recurrent major depressive disorder with severe psychotic symptoms (a medical condition that causes you to experience psychotic symptoms plus the sadness and hopelessness associated with depression such as seeing, hearing, smelling, or believing things that aren't real), unspecified psychosis (a condition that affects the way your brain processes information; it causes you to lose touch with reality) and anxiety disorder (a medical condition that affects the mind and body's reaction to stressful, dangerous, or unfamiliar situations; it is a sense of uneasiness, distress, or dread you feel before a significant event). B. On 04/05/23 at 11:35 am, during an interview and observation, R #3 reported a man named [first and last name of R #4] has been making passes at me (to flirt or make advances to someone, especially of a sexual nature). First in January (2023) and then in February (2023), he would look at me and try to touch me and kiss me and he would follow me around (the facility) and would go down my hall and look in my room too. I told him (R #4) stop, don't touch me and leave me alone, but he does not listen to me. The police come over here (to the facility) when [First name of R #4] does that (stalking, touching and attempted kissing) to me. I was raped a few years ago, so I think about that time (getting raped) every time [first name of R #4] comes near me. I hate talking about it (the rape) and him (R #4), it just makes me so upset. I don't want to talk about it anymore. I have let all of the nurses and [first name of the Social Services Director (SSD)] know about it so a pretty pink whistle was given to me by the tall guy (the facility Administrator) that works here and he told me, 'if he (R #4) goes near you or tries to touch you, just blow the whistle and we (staff) all know about your whistle and we will all come to help you.' Having my whistle makes me feel safe. R #3 was observed crying throughout the interview and appeared visibility shaken when describing her past rape experience and the incidents (of January & February 2023) involving R #4. C. Record review of R #3's care plan revealed: 1. Initiated on 01/19/23 [first name of R #3] to get a whistle and will educate to use it when resident feels unsafe, insecure, or feels sexual advances are occurring. 2. Revised on 03/15/23 [First name of R #3] has a history of sexual abuse. D. On 04/05/23 at 12:14 pm, during an observation and interview, R #3 was crying and stated I wish I could see a counselor to talk to, like I used to do before I came here (to the facility), it helped me a lot and I've asked them (staff), but nobody here gets me one (a counselor). E. On 04/05/23 at 12:16 pm, during an observation, as soon as R #3 was able to see Licensed Practical Nurse (LPN) #2 down the hall, she started to cry harder. LPN #2 asked R #3 what's wrong are you ok? R #3 reported no, I'm upset about what happened to me in February (2023-when R #4 touched R #3's back, grabbed her right forearm and tried to kiss her) and I can't stop worrying about it. LPN #2 said lets help calm you down. R #3 reported I don't know why I have to be worrying about him (R #4), this is my home, I should feel comfortable here. F. On 04/05/23 at 12:19 pm, during an interview, LPN #2 reported that R #3 has had 2 or 3 episodes a week of heightened anxiety since January (2023) due to the unwanted advances of [first name of R #4]. She reported we (staff) just try to calm her (R #3) down as soon as we can and give her anxiety meds as directed by the orders. G. Record review of R #3's order summary dated 12/14/22 Buspirone HCI (hydrochloride-medication used to treat anxiety) tablet 5 mg (milligrams) Give 1 tablet by mouth two times per day for anxiety. H. On 04/05/23 at 1:10 pm, during an observation and interview, R #3 was observed crying outside of the Social Services Directors' (SSD) office. R #3 reported I am still worried about R #4 doing something bad to me so I need my phone so I can call for help, in case I need to. I. On 04/05/23 at 1:35 pm, during an interview, the SSD reported [First name of R #3] is upset, because we have ordered her a cell phone, but it has not come in yet; she has been anxious about this for that last week or so and has spent a lot of time in my office crying; I always let the nurses know (when R #3 is having behaviors) and there is often times a nurse in here (in office) with me trying to calm her down. J. On 04/06/23 at 11:09 am, during an interview, the SSD reported Back in January (2023) [first name of R #3] reported that R #4 was following her, stalking her and looking in her room and had told me and other staff that she was not feeling safe. [First name of R #3] has had a lot of trauma (a deeply disturbing experience) in her past and is hypervigilant (an increased alertness where the individual is constantly assessing potential threats around) in her space. [First name of R #3] got (provided by the Administrator) a whistle to protect her, if in danger at any time. I worked with her (R #3) when she got the whistle to help her understand what it should used for. She (R #3) has meltdowns (outburst of severe emotional distress also known as a nervous breakdown) sometimes several times a week, it just depends and it (having meltdowns) is typical (having distinctive qualities). No one else (other residents) has a whistle, just [First name of R #3]. She (R #3) has never blown it (the whistle), but she has threatened to blow it. R #4 was placed on a behavioral contract (a contract between two or more parties that sets boundaries and is designed to hold the person it is issued to accountable for their actions/behavior) due to this issue (stalking, making physical contact and unwanted advances towards R #3). I discussed the behavioral contract with R #4 and laid out the expectations and he (R #4) is very aware that he needs to stay off of unit 300 (where R #3 resides) and he (R #4) cannot have any interaction with [First name of R #3]. [First name of R #3] is pretty aware of what is going on around her and makes us (staff) aware when she is not comfortable or is upset about anything. SSD confirmed that there have been no recent incidents/contact between R #4 and R #3. K. On 04/12/23 at 1:55 pm, during an interview, the SSD reported that R #3 was in his office upset and crying again this morning when she learned that they still have not received her cell phone. The SSD reported I think she (R #3) would benefit from seeing a therapist on a weekly basis and I have suggested that to the nurses, but that is not happening. L. On 04/12/23 at 2:29 pm, during an interview, the Activities Director (AD) reported [First name of R #3] has psychological (behavioral health related such as those listed in Finding A) issues and the whistle makes her feel safe. She does have episodes of outbursts (anxiety attacks) and the last one I saw her have was on Sunday (04/02/23) when we were playing BINGO. [First name of R #4] said something, I can't remember what, to [First name of R #3] and she stood up and yelled at him, the words they said to each other went over me, but all we can do is keep them separated and calm her down. M. Record review of R #3's order summary dated 10/20/21 revealed Was resident free from behaviors? If no, document behavior, intervention and outcome in PN (progress notes) every day shift and every night shift. N. Record review of R #3's progress notes date range 12/01/22 thru 04/06/23 revealed no documented behaviors and no outreach to Behavioral Health Providers/Specialists. O. Record review of R #3's care plan revised on 03/15/23 revealed Monitor for changes in mental status and functional level and report to MD (Medical Director) as indicated. P. Record review of R #3's care plan revised 03/15/23 revealed [First name of R #3] exhibits distressed/fluctuating mood symptoms R/T (related to) sadness/depression anxieties/fears caused by past trauma & loss of her husband. Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. Refer to Behavioral Health Specialist as needed. Q. Record review of R #3's progress notes date range 12/01/22 thru 04/06/23 revealed no documented behaviors and no outreach to the Medical Director or any of the Behavioral Health Specialists. R. On 04/25/23 at 1:22 pm, during an interview, Behavioral Health Physician Assistant (BHPA) reported Prior to 04/13/23, we would only see patients (residents) at this facility when we would get a referral for an evaluation, we would then put them (residents) on our caseload and anyone (residents) on psychiatric meds stays on our caseload. R #3 has been on our caseload since she was admitted to the facility. She (R #3) has reported complaints in January and February 2023 of a male touching her, but we don't document names of alleged perpetrators in our notes. She has chronic PTSD (Post Traumatic Stress Disorder) [The First and last name of the Psychiatrist] last saw her (R #3) on 04/02/23, no one saw her from 04/05/23 - 04/12/23 as no one notified us from the facility that she (R #3) was having behaviors. We have a hot list, the facility calls our office and leaves us a message that a resident is in need of BH (Behavioral Health) support and they get added to the hot list and when a patient (resident) gets added to the hot list we go in (to the facility) to see them (residents) right away. I do not remember [First name of R #3] being on the hot list for the month of April (2023). The BHPA confirmed that since R #3 is on psych meds they should have been seeing her at least monthly prior to 04/13/23 and weekly after 04/13/23 and there were no BH visits conducted for R #3 between 02/14/23 and 04/02/23 and does not know the reason for that. S. Record review of R #3's Electronic Medical Record (EMR) revealed no Behavioral Health Progress Notes (also known as SOAP notes-subjective, objective, assessment plan) on file between 02/14/23 and 04/02/23. T. On 04/12/23 at 4:28 pm, during an interview, the Regional Nurse Manager confirmed no Behavioral Health Visits were conducted for R #3 between 02/14/23 and 04/02/23. U. On 04/12/23 at 4:35 pm, during an interview, the Director of Nursing (DON) reported that the Behavioral Health Specialists have not been coming to the facility as often as they should be (at least monthly) and they are difficult to reach and she does not know why there were no Behavioral Health Visits between 02/14/23 and 04/03/23 for R #3.

Based on interviews, record review, and review of facility policy, the facility failed to immediately notify/report to the physician a change of condition for two residents (Resident (R)75 and R53) out of 28 sampled residents. The facility's failed practice likely resulted in R75's death at the facility on [DATE]. Findings include: Review of facility-provided policy titled Change of Condition, [DATE], revealed .A Center must immediately inform .the patient's physician a significant change in patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status) in either life-threatening conditions or clinical complications .to provide appropriate and timely information relevant to the patient's condition . 1. Review of R75's undated ADMISSION RECORD, located in the Electronic Medical Record (EMR) revealed R75 was initially admitted to the facility on [DATE], readmitted on [DATE] and discharged (expired) on [DATE] with multiple diagnosis to include type 2 diabetes, acquired absence of left above the knee, dementia, and delusional (firmly held beliefs not set in reality) disorder. Review of R75's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in her EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not conducted and indicated R75 was severely cognitively impaired. Review of R75's Progress Note under the Notes tab in the EMR, revealed the following: [DATE] at 8:33 PM .Note: This writer received report from . [Licensed Practical Nurse LPN 1] the night nurse, that this resident was heard moaning while asleep most of the time during the night. Sternum [sic] done by night nurse and resident was observed crying. This writer saw this resident between the hours of 0630 AM and 0700 AM. Resident was observed lying in bed in a supine position, had eyes closed and was heard making some moaning/snoring sound. Sternum rub (A sternal rub is the application of painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) was done and resident (R75) partially opened her eyes. Between the hours of about 0800 AM and 0815 AM . the CNA (Certified Nursing Assistant 4) called this writer to resident's room that this resident was nonresponsive. Resident was in a supine position. Sternum rub done and was nonresponsive. No pulse felt. Body was warm to the touch. CPR (Cardiopulmonary Resuscitation) was started. 911 was called and came to assist. Resident was pronounced dead at 0853 AM. Resident's husband was notified and came to the facility with resident's two sons. Resident's body was picked up by [name of mortuary] at about 1314 (1:14) PM. Resident's husband and two sons picked up all resident's belongs During an interview on [DATE] at 1:19 PM, LPN3 confirmed R75 was difficult to arouse (awaken) on [DATE]. LPN3 confirmed LPN1 reported to her R75 required a sternum rub to be arouse. LPN3 confirmed she performed a sternum rub and R75's fluttered her eye lids. LPN3 confirmed she did not notify the physician of R75's change in condition. LPN3 confirmed R75 expired at the facility, over an hour later. During an interview on [DATE] at 4:55 PM, the Wound Care-Registered Nurse (WC) confirmed she would expect the nursing staff to assess R75 for her change of condition. WC confirmed difficult to arouse was considered a change in condition. WC confirmed she expected the nursing staff, who had to perform a sternum rub to arouse R75, to report R75's change in condition to her physician. WC confirmed R75 expired at the facility on [DATE]. During an interview on [DATE] at 6:38 PM, Registered Nurse (RN) 2 confirmed nurses were expected to call the resident's provider of a change of a condition. During an interview on [DATE] at 6:47 PM, the Unit Manager-Licensed Practical Nurse (UM) 1 confirmed she expected the nursing staff to call and report R75's change in condition to her (R75) physicians. UM1 confirmed R75 expired hours after the nursing staff had difficulty arousing on [DATE]. During an interview [DATE] at 9:14 AM, the facility Medical Director confirmed her expectation for the facility's clinical staff was to notify the resident's provider immediately of the change of condition of difficulty arousing R75 on [DATE]. The Medical Director confirmed her expectation for the facility's clinical staff was to assess R75 (upon the change of condition) on [DATE] not limited to but to include obtaining vital signs and checking her fingerstick blood sugar. The Medical Director stated physician's immediate notification of resident's change of condition was time sensitive and important because R75's change of condition could be life threatening and require life sustaining treatment, and omittance could cause death. The Medical Director confirmed she had reviewed R75's case with her Nurse Practitioner/Medical Doctor and had concerns R75 did not receive medical treatment because the physician's/providers were not notified of her change of condition. The Medical Director stated the facilities clinical staff had a history of not following policies and procedures. The Medical Director confirmed the facility's clinical staff not following policies and procedures was dangerous for residents. During an interview on [DATE] at 10:11 AM the Medical Doctor (MD) confirmed he was a provider for residents at the facility including R75. MD confirmed he expected the facility staff to inform the medical provider of a resident's change in condition within 15 minutes of the change including (difficult to arouse and sternum rubs). MD confirmed provider notification was important for the facility to receive orders from the physician for diagnostic testing and treatment for the change in condition. During an interview on [DATE] at 8:47 PM, LPN 1 confirmed she provided care for R75 on [DATE] night shift through the morning of [DATE] and reported off to LPN3. LPN1 confirmed she did not notify R75's physician of her difficulty to arouse. 25490 Findings for R53 2. Review of R53's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included but not limited to diabetes and Acute Systolic Congestive Heart Failure (CHF-buildup of fluid in the lungs). CHF often results in rapid weight gain due to the retention of fluid. Review of R53's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R53 was cognitively intact. Review of R53's Care Plan, located in the EMR under the Care Plan tab and dated [DATE], revealed . [R53] is at high nutrition risk d/t (due to) uncontrolled T2DM (Type 2 Diabetes Mellitus). BMI (Body Mass Index) Class III obesity range. Under Interventions indicated, weigh per protocol and alert dietitian and physician to any significant weight loss or gain. Review of a physician order of R53's diabetes medication, dated [DATE] and located in the EMR under Clinical Physician Orders, indicated NovoLog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/M (Insulin As part) revealed, Inject as per sliding scale: . 401 - 450 = 12 give 12 units and notify provider . Review of the physician order, dated [DATE] and located in the EMR under Clinical Physician Orders, indicated, change weights to 3 times a week. Call MD (Medical Director) if over 285 [pounds]. Review of R53's Blood Sugar Summary, located in the EMR under the Weights and Vitals tab dated from [DATE] until [DATE], indicated the following blood sugar readings above 401 mg/dl (milligrams/deciliter). [DATE]- 450, [DATE]-427, [DATE]-416, [DATE]-423, [DATE]-447, [DATE]-402, [DATE]-435, [DATE]-440, [DATE]-439, [DATE]-419, [DATE]-419 and [DATE]-435, [DATE]-420, [DATE]-441 and [DATE]-437, [DATE]-442, [DATE]-421 and [DATE]-444, [DATE]-423, [DATE]-405, [DATE]-401 and [DATE]-403, [DATE]-432 and [DATE]-431, [DATE]-437 and [DATE]-442, [DATE]-433, [DATE]-423, and [DATE]-439, [DATE]-445, [DATE]-428, and [DATE]-441, [DATE]-435, [DATE]-415, [DATE]-450, [DATE], and [DATE]-416, [DATE]-407, and [DATE]-468. From the order date of [DATE] through [DATE], R53's blood sugars were between the range of ,d+[DATE] mg/dl thirty-nine times. The physician was not notified per order of these elevated blood sugar levels. Review of R53's Weight Summary, located in the EMR under the Weights and Vitals tab and dated from [DATE] until [DATE] indicated the following weights above 285: [DATE]- 285.3, [DATE]-286.1, [DATE]-285.4, [DATE]-289. [DATE]-288.6, [DATE]-290.6, [DATE]- 290.7, [DATE]-291.3, [DATE]-287.1, [DATE]-287.6, [DATE]-287.1, [DATE]-288.1, [DATE]-285.3, [DATE]-287.1, [DATE]-288.9, [DATE]-289.7, [DATE]-288.9, and [DATE]-288.8. From the order date of [DATE] until [DATE] R53's weights were 285 or over on seventeen incidents. The physician was not notified of these weights that could indicate fluid buildup. During an interview on [DATE] at 11:20 AM, Registered Nurse (RN)3 stated, The order dated [DATE] states, to change weights to 3 times per week and call MD [medical doctor] if over 285 along with an order dated on [DATE] to contact the doctor if R53's blood sugars are over 401. RN3 further stated, there were many opportunities that the doctor should have been notified but the doctor was not notified. Surveyor asked RN3 to share some complications of high blood sugar levels. RN3 stated, if the insulin becomes too high there can be complications. The resident may have confusing, acetone breath, respiratory issues, and uncontrolled blood sugar levels could lead to death. During an interview with the Director of Nursing (DON) on [DATE] at 12:16 PM, this surveyor asked the DON what the order note written for R53 on [DATE] stated. DON stated, the order states, the doctor should be notified when R53's blood sugars are between ,d+[DATE], give 12 units and notify provider. Surveyor asked, how many opportunities were there from [DATE] until [DATE] to notify the doctor? DON stated, too many times. Surveyor asked, What is your expectation of your staff? The DON stated, it is expected that all staff always follow the doctor's order and complete a progress note. Surveyor asked DON what are complications of elevated blood sugars? The DON stated, there can be multiple areas of decline from diabetes, there is fatigue, jitteriness, sweating, skin tissue breaks down, confusion, agitation, increased behaviors, diabetic neuropathy, and vision damage. During this same interview, the DON confirmed R53's elevated blood sugars, elevated body weight, and/or changes with R53's medical condition were not reported to the doctor per orders dated [DATE] and [DATE]. During an interview with the Clinical Lead Corporate (CLC) on [DATE] at 5:25 PM revealed, the facility does not have a policy for what staff should do if a resident has a high blood sugar reading. The expectation is for the facility staff to follow doctor's orders. During an interview on [DATE] at 12:25 PM, the Administrator stated, when a change of condition is identified, it is the facility's expectation that staff notify the family, notify the physician and notify the DON and that all physicians orders are followed. On [DATE] at 6:28 PM, the Administrator, the Clinical Lead Corporate, and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) at F580-L: Notify of Changes. The Immediate Jeopardy began on [DATE] when the nursing staff failed to notify the physician of their difficulty in arousing R75 with a sternal rub through the night and into the next day ([DATE]). In addition, the nursing staff failed to notify the physician of elevated blood sugar levels and increased weight for R53 who had diagnoses of diabetes and congestive heart failure (CHF-buildup of fluid in the lungs and extremities). The facility provided an acceptable removal plan on [DATE] at 4:29 PM. The removal plan included Licensed nurses would complete assessments on current residents residing in the center to determine presence of a medical change in condition. Identified issues were reported to the physician. Registered nurses would review resident's blood glucose and weights. Identified changes in conditions not reported to MD would be reported and medical orders would be followed, with monitoring. The Director of Nursing would educate current staff and auxiliary staff regarding the policy for resident change in condition. The survey team verified implementation of the Removal Plan. The Administrator, the Clinical Lead Corporate, and Director of Nursing (DON) were notified that the IJ at F580-L was removed on [DATE] at 7:35 PM.

Based on interviews, record review, and policy review, the facility failed to ensure residents were protected from further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and failed to have evidence that all alleged violations were thoroughly investigated for one resident (Resident (R) 25) out of one resident reviewed for abuse in a total sample of 28 residents. Specifically, the two alleged perpetrators, Certified Nursing Assistant (CNA)1 and CNA2 were not removed from the facility but were reassigned and remained in the facility working with other residents the evening of the alleged abuse and the Administrator failed to thoroughly investigate conflicting verbal and written statements by the CNAs. This deficient practice could likely result in residents being at risk of abuse. Findings include: Review of the facility investigation report revealed the facility failed to follow facility policy titled Abuse Prohibition, dated 10/24/22. The policy reads, the employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Review of R25's Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included but not limited to unspecified Dementia, unspecified severity, with other behavioral disturbances. Review of R25's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/03/22, revealed R25's Brief Interview for Mental Status (BIMS) score of a 15 out of 15 indicating R25 was cognitively intact. During an interview on 01/09/23 at 3:16 PM, R25 stated that she was abused in the facility by two CNA's on 12/27/22 while receiving incontinent care. R25 shared a picture of a bruise on an unidentifiable location of the body. The photo was located on R25's phone. Further interview revealed on 12/27/22 during incontinent care two CNAs lowered R25's blankets to the foot of the bed to provide care. R25 stated you see these two blankets? I received them for Christmas and did not want them to be touched. I reached for them, and the CNA grabbed my arm. During an interview on 01/09/23 at 5:21 PM, the Abuse Coordinator/Administrator stated, I reported the allegation to the Department of Health, started an internal investigation to determine if substantiated or not, we removed staff members involved and started conducting our own interviews. The Administrator stated, on the following day [12/28/22] the unit manager received some information that CNA1 was involved. Their agency was immediately notified via phone and the agency replied by email. The email stated, 'Please keep us posted on her investigation. The Administrator further stated, later on, that day [12/28/22], I found out that CNA2 was also involved, and I notified the agency that CNA2 was also mentioned in this allegation. Administrator shared with the Surveyor an email correspondence from the CNA agency which stated, I have canceled all of her shifts. During an interview with CNA1 (the CNA alleged to have held down the hands of R25) on 01/09/23 at 6:25 PM CNA1 stated, On 12/27/22, I was working with another CNA (CNA2) for the first time. We started our rounds, vitals and passing trays. The resident (R25) was pressing the call button and said, 'I need to be changed.' when we pulled down her blankets, R25 started cursing and said, 'don't touch my blanket'. We apologized and started care again. CNA1 continued to state, The resident became more aggravated again and started hitting us and I never held down the resident's hands. I only tried to block her from hitting me and we removed ourselves from the room. During this same interview CNA1 further stated that at no point did CNA1 or CNA2 hold down the hands of R25. CNA1 further stated, on the night of the incident CNA1 attempted to explain to R25's daughter what occurred and that R25's daughter pushed and shoved the CNA out of the room. Surveyor was unable to interview CNA2 due to the CNA being hospitalized . Review of CNA1 and CNA2's time sheets, provided by the facility, indicated CNA1 clocked in on 12/27/22 at 6:03 PM and clocked out on 12/28/22 at 5:59 AM. Further review of the time sheets revealed CNA2 clocked in on 12/27/22 at 5:58 PM and clocked out on 12/28/22 at 5:59 AM. The facility timesheets indicated that the CNA's were not removed from the facility per facility policies. During an interview with the facility Abuse Coordinator/Administrator on 01/10/23 at 1:47 PM, this Surveyor asked, why weren't the CNA's removed at the time of the incident? The Administrator stated, the CNA's were not immediately suspended at the time of the allegation because we were unable to identify the CNA's involved. The daughter just said the mother (R25) was being abused and that was all the information I had. The Administrator continued to state, When staff attempted to talk with the resident (R25) the resident refused to speak to staff in reference to this incident. Surveyor asked the Administrator the policy regarding an allegation of abuse. The Administrator stated, alleged perpetrators should be removed from the facility for the safety of the resident. Interview with the facility Director of Nursing (DON) on 01/10/23 at 1:52 PM revealed, at the time of the incident the alleged CNA's were not known by me. I acted off of what information I had and the reason we did not suspend anyone on that day was because I did not know who the perpetrators were until the next day. The Registered Nurse (RN) on the floor did not tell me who the perpetrators were on the evening of the incident. I found out the next day by the scheduling staff and reading the witness statements left under my door. Once we realized who the alleged perpetrators were their agency was contacted and the CNA's were suspended. Surveyor asked the DON what is the facility policy once the alleged perpetrators are identified? The DON stated, to suspend the alleged perpetrators. During this same interview, this surveyor shared the written statement by RN1 dated 12/27/22 at 8:00 PM. RN1's written statement revealed, the CNA walked into the room to explain what had happened and R25's daughter pushed her out . The DON was informed of the incident and a new aide was assigned to take care of the resident for the night. The written statement by RN1 contradicted the DON recollection of the incident which occurred on 12/27/22. Surveyor asked the DON, Was the RN on duty the night of the incident aware of the facility Abuse Policy [to remove the alleged perpetrators]? The DON stated, They should know. During an interview on 01/11/23 at 7:32 PM, RN1 stated, on the night of 12/27/22 I was passing medication on the hall. A CNA approached me after leaving R25's room and reported that the resident was very agitated. RN1 further stated, It was time for the resident's night medications, so I prepared the medications. At this same time the daughter stormed into the hall and stated, 'I got a call from my mother saying she is being abused.' RN1 stated to the daughter, 'Oh, I didn't know that I only heard she was agitated' and they proceeded to R25's room. RN1 expressed once they got to R25's room the resident shared with the RN1 and daughter that two CNA's abused her by holding down her hands. RN1 stated that while R25 was telling the daughter what had occurred, CNA1 came back into R25's room to explain their side of the incident and R25's daughter pushed the CNA out of the room. Surveyor asked RN1 how were you able to identify the alleged perpetrators. RN1 stated, there were only two CNA's working the hall that evening. Surveyor asked RN1 was the facility Administrator notified of the incident and the alleged perpetrators. RN1 stated, yes. Interview on 01/09/23 5:21 PM, the Abuse Coordinator/Administrator stated, The staff were trying to get away from the resident because the resident was pulling their hair. This surveyor shared the witness statement written by CNA2 dated 12/27/22 which stated, So, my coworker just hold her (R25) hands she wouldn't atack[sic] us, she was trying to bite us . The Administrator stated, We read the witness statements the next morning, what stood out to me was the CNA said, they held her hands. I took it as they were trying to protect themselves because the resident was being combative. English is this CNA's second language and what she said is not what is written. When asked if he investigated further the disparity between the CNA's written statement and verbal statement before concluding the abuse was unsubstantiated, the Administrator verified that he took the verbal statement as the accurate statement and did not investigate further. On 01/10/2023 at 6:40 PM, the Administrator, Director of Nursing (DON), and the Clinical Lead Corporate (CLC) were notified of the Immediate Jeopardy (IJ) at F610-L: Investigate, protect, correct Alleged Violation. The Immediate Jeopardy began on 12/27/22 when R25 and her daughter told Registered Nurse (RN)1 that CNA1 and CNA2 abused her by holding down her hands while providing incontinence care. The facility provided an acceptable removal plan on 01/11/23 at 9:39 AM. The removal plan included education to facility staff on the Abuse policy along with special training to the facility Director of Nursing and Abuse Coordinator/Administrator. The Survey team interviewed facility staff and verified that 100% of staff in the facility had received the Abuse policy training. The survey team verified all elements of the facility's IJ Removal Plan and removed the IJ on 01/11/23 at 5:35 PM.

Based on interviews, record review, and review of the facility's policy, the facility failed to complete a change of condition assessment when the nursing staff had difficulty arousing with a sternal rub (A sternal rub is the application of painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimulit) through the night and into the next day for one resident (Resident (R) 75) out of a total sample of 28 residents. The facility's failed practice likely resulted in R75's death at the facility on [DATE]. Findings include: Review of facility-provided policy titled, Change of Condition, dated [DATE], revealed .A Center must immediately inform .the patient's physician a significant change in patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .to provide appropriate and timely information relevant to the patient's condition . Review of facility-provided policy titled, Assessment: Nursing, ,d+[DATE], revealed .The assessment process must include direct observation and communication with the patient, as well as communication with licensed and non-licensed direct care staff members on all shifts .To determine patient's condition and clinical needs .Conduct a change in condition assessment as needed using the eInteract Change in Condition Evaluation .Notify physician/advanced practice provider .of assessment results as indicated .Document physician .notification and response if indicated . Review of R75's undated ADMISSION RECORD, located in the Electronic Medical Record (EMR) revealed she was initially admitted to the facility on [DATE], readmitted on [DATE], and discharged (expired) on [DATE] with multiple diagnosis to include type 2 diabetes, acquired absence of left above knee, dementia, and delusional disorder (firmly held beliefs not based on reality). Review of R75's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in her EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not conducted and indicated R75 was severely cognitively impaired. Review of R75's Progress Note, under the Notes tab in the EMR revealed the following: [DATE] at 8:33 PM .Note: This writer [Licensed Practical Nurse 3] received report from the night nurse [LPN1], that this resident was heard moaning while asleep most of the time during the night. Sternum [sic] done by night nurse and resident was observed crying. This writer saw this resident between the hours of 0630 AM and 0700 AM. Resident was observed lying in bed in a supine position, had eyes closed and was heard making some moaning/snoring sound. Sternum rub was done and resident partially opened her eyes. Between the hours of about 0800 AM and 0815 AM . the CNA [Certified Nursing Assistant 4] called this writer to resident's room that this resident was non responsive. Resident was in a supine position. Sternum rub done and was nonresponsive. NO pulse felt. Body was warm to the touch. CPR (Cardiopulmonary Resuscitation) was started. 911 was called and came to assist. Resident was pronounced dead at 0853 AM. Resident's husband was notified and came to the facility with resident's two sons. Resident's body was picked up by [name of mortuary] at about 1314 (1:14) PM. Resident's husband and two sons picked up all resident's belongs . During an interview on [DATE] at 1:19 PM, LPN3 confirmed R75 was difficult to arouse (awaken) on [DATE]. LPN3 confirmed LPN1 reported to her R75 required a sternum rub to arouse. LPN3 confirmed she performed a sternum rub and R75 fluttered her eye lids. LPN3 confirmed when a resident was difficult to arouse that was something that should have been assessed further. LPN3 confirmed staff should assess everything from head to toe. LPN3 confirmed signs or symptoms for hypo (low blood sugar) or hyper glycemia (high blood sugar) could be difficult to arouse. LPN3 verified R75 had interventions on her care plan for medications that cause sedation. LPN3 confirmed R75 expired at the facility, over an hour later after LPN3 had applied a sternal rub and R75 fluttered her eye lids. During an interview on [DATE] at 4:55 PM, the Wound Care-Registered Nurse (WC) confirmed she would expect the nursing staff to assess R75 for her change of condition. WC confirmed difficult to arouse was considered a change in condition. RN confirmed R75 expired at the facility on [DATE]. During an interview on [DATE] at 6:38 PM, Registered Nurse (RN) 2 confirmed nurses were expected to assess residents with a change of condition. During an interview on [DATE] at 6:47 PM, the Unit Manager-Licensed Practical Nurse (UM) 1 confirmed she expected the facility staff to complete the steps on the change of condition assessment for a resident that was difficult to arouse and required a sternum rub to arouse. UM1 confirmed she expected her staff to follow through with change of condition assessment, including checking the blood sugar level, when R75 was initially found difficult to arouse by the night shift nurse (LPN1) and when the day shift nurse (LPN3) also had difficulty arousing R75. UM1 confirmed the facility failed to ensure R75 was provided quality of care. UM confirmed R75 expired on [DATE], hours after LPN1 and LPN3 had difficulty arousing her. During an interview [DATE] at 9:14 AM, the Medical Director confirmed her expectation for the facility's clinical staff was to assess R75 (upon the change of condition) on [DATE] not limited to but to include obtaining vital signs and checking her fingerstick blood sugar. The Medical Director stated R75's change of condition assessment was time sensitive, could be life threatening, required life sustaining treatment, and omittance could cause death. The Medical Director stated the facilities clinical staff had a history of not following policies and procedures. The Medical Director confirmed the facility's clinical staff not following policies and procedures was dangerous for residents. During an interview on [DATE] at 10:11 AM, the Medical Doctor (MD) confirmed he was a provider for residents at the facility including R75. MD confirmed he expected the facility staff to inform the medical provider of a resident's change in condition within 15 minutes of the change including (difficult to arouse and sternum rubs). MD confirmed provider notification was important for the facility to receive orders from the physician for diagnostic testing and treatment for the change in condition. During an interview on [DATE] at 08:47 PM LPN1 confirmed she provided care for R75 on the [DATE] night shift and reported to LPN3. LPN1 stated she did not check R75's blood sugar because it was not ordered by the physician. On [DATE] at 6:28 PM, the Administrator, the Clinical Lead Corporate, and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) at F684-L: Quality of Care. The Immediate Jeopardy began on [DATE] when the nursing staff failed to complete an assessment for R75's change in condition. The facility provided an acceptable removal plan on [DATE] at 4:29 PM. The removal plan included Licensed nurses would complete assessments on current residents residing in the center to determine presence of a medical change in condition. Identified issues were reported to the physician. Identified changes in conditions that were not reported to MD (Medical Director) would be reported and medical orders would be followed, with monitoring. The Director of Nursing would educate current and auxiliary staff regarding the policy for resident change in condition. The survey team verified implementation of the Removal Plan and removed the IJ at F684 on [DATE] at 7:35 PM. The Administrator, the Clinical Lead Corporate, and DON were notified that the IJ was removed.

Based on record review and interview, the facility failed to provide pain management for 1 (R #3) of 2 (R #3 and 4) residents reviewed for pain by: 1. Not providing available PRN (as needed) pain medication even though numerous progress notes and interviews identified resident was in constant pain throughout her stay. 2. Delaying in sending resident to hospital and providing pain medication following an unwitnessed fall for over 12 hours despite immediate identification that resident was in pain. This deficient practice likely resulted in R #3 experiencing pain without appropriate relief. The findings are: A. Record review of R #3's face sheet revealed she was admitted to the facility on [DATE] with the following diagnosis (not all inclusive): pulmonary embolism (arteries in the lung become blocked), muscle weakness, idiopathic [CONDITION(S)] ([CONDITION(S)]) and epileptic syndromes with seizures (sudden uncontrolled electrical disturbance in the brain), [CONDITION(S)] (wearing down of protective tissue at end soft bones), fracture of sacrum (triangular bone below lumbar vertebrae), [CONDITION(S)] (chronic [CONDITION(S)] disease) and dementia (impairment of brain function). B. On 08/11/22 at 11:28 am during interview with R #3's daughter she stated, My mother suffered neglect at [Name of facility]. They [staff] said she wasn't in pain when she had pain from a sacral fracture. I never saw her move herself at all. She was in pain and unable to mover herself. The therapist said she couldn't touch her skin without her yelling. I couldn't even imagine her turn on her side, she would yell in pain. Anytime she would move her hips, she would be in pain. They would put her in a wheelchair but decided it was torture. R #3's daughter reported that she had to ask the doctor to increase her mother's pain medication. R #3's daughter further stated, They [facility] reported she had an unwitnessed fall. They said they weren't sure what happened and they didn't know if she had fractures. She was only assessed by nurses, not the doctor. I called the doctor and told them to take her to the ER (emergency room ). C. Record review of Progress Notes revealed: 06/06/22 Satisfaction with current level of pain is UTD (Unable to be determined)/unable to be communicated. No change to current plan-pain goals met. 06/10/22: Daughter here to visit resident requesting code status to be changed to DNR (Do not resuscitate) .Comfort measures only [Name of Physician #1] notified of change in code status and family requested to speak to her, provided phone number to daughter. D. Record review of Therapy Notes revealed the following: 06/07/22: Patient displays pain with bed mobility often screaming due [to] pain. 06/07/22: Pt frequently screams with mobility 06/08/22: Pt (patient) demos (demonstrates) limited ROM (range of motion)/strength and moans with minimal movement. 'Wait, wait, please stop. E. Record review of progress notes for R #3 dated 06/11/22 at 3:17 pm revealed Resident was notified to have fallen around 0400 (4:00 am) this morning. Pt (patient) presents currently w/(with) non verbal c/o (complaint of) pain with any movement of hips or upper extremities. Per report, member was overdue for her infusion treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Member was started on PRN (as needed) [MEDICATION(S)] (medication used to help relieve moderate to severe pain) .Nurse called on call provider .provider ordered pt to go to hospital for CT/Xray s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] F. Record review of the Physical Therapist service notes dated 06/11/22 revealed, Patient screams with movement. Patient is unable to verbally respond to questions or follow commands today. The note was signed at 12:24 pm. G. On 08/11/22 at 4:16 pm during interview with Physical Therapist (PT) #1, she stated that R #3 was in a lot of pain during therapy and she thought R #3 was offered pain medication before treatment was provided. She was very confused and very reactive. If you touch the bedding, she would scream. She was dependent for all mobility. I never saw her move on her own. When asked how R #3 could have ended up on the floor on 06/11/22 if she barely ever moved, she said, I'm not sure. Maybe it was during a transfer. H. Record review of staffing scheduled identified that CNA #4 worked the evening shift on R #3's hallway from 6:00 pm on 06/10/22 until 6:00 am on 06/11/22. I. On 08/16/22 at 3:52 pm during interview with CNA #4, he confirmed that he did not remember the resident or her fall. J. Record review of the facility self report dated 06/12/22 regarding R #3's fall on 06/11/22 revealed found lying on floor next to bed head at foot on r (right) side of bed and r side awake and yelling if touch anywhere including hair able to move all extremities no bruises swelling or lacerations noted had small abrasion on lower jaw Assessment completed VS (vital signs) and neuros, complaints of generalized pain, resident was transferred to [name of hospital] for further evaluation. K. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Pain monitoring each shift. Documented included check mark confirming it was done but did not indicate a pain scale. 2. Received scheduled [MEDICATION(S)] (treat arthritis) 7.5 mg (milligrams) one time a day for pain. 3. Acetaminophen 325 mg every 4 hours prn (as needed for fever over 100 degrees) was administered on 05/26/22 at 11:40 am and 06/09/22 at 11:03 pm and documented relief as E (effective) 4. [MEDICATION(S)] (pain reliever) 5 mg (ordered 06/10/22) was administered once on 06/11/22 at 12:16 am and documented relief as E 5. No other pain medication was available or administered during R #3's stay. L. Record review of the hospital history and Physical dated 06/12/22 at 5:51 am revealed Per EMS report to ED, the patient fell ,d+[DATE] and brought to ED after she screamed all night.There was scant documentation of what actually happened before and after the fall. He reported the fall happened the morning of 06/11/22 . When asked where she is in pain she says all over. Report also identified Chronic Pain, Patient received [MEDICATION(S)] infusions (used for Arthritis pain) every 8 weeks Patient 05/20 (2022) dose was canceled because her hospitalization , patient is now 3 weeks overdue. Per [Name of R #3's daughter], pt shows she's in pain by recoiling from touch, will curl her wrists close to her and yell if anyone touches her. M. On 08/12/22 at 11:34 am during interview with the Director of Nursing (DON), he reviewed R #3's medical record including the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . N. On 08/18/22 at 10:15 am during interview with Physician #1, she reported that she remembers R #3 being in pain and she never saw her move due to all assessments were conducted while resident was in bed. Physician #1 didn't remember the circumstances in which she ordered the [MEDICATION(S)] on 06/10/22.

Based on record review, and interview the facility failed to prevent resident to resident abuse for 2 [R #16 and 224] of 5 [R #s 16, 42, 60, 224 and 265] residents reviewed for abuse and neglect by not providing enough supervision for a resident with known sexually inappropriate behaviors and not implementing additional interventions to protect residents. This deficient practice likely resulted in psychosocial harm to residents. The findings are A. Record review of the hospital records for R #265 dated 03/19/21 indicated the following: per CM [Case Manager] note: in process to apply to Office of Guardianship .Recommended discharge to skilled nursing facility. He would not be a safe discharge to his home where he lives alone. He would not be able to identify and or resolve any unsafe situations, or hazards in the home. Like forget the stove was on, burn himself while cooking or take medications wrong. B. Record review of R #265's Care Plan dated 04/20/21 revealed Resident/patient has a tendency to exhibit sexually inappropriate behavior related to: Psychiatric Disorder (s): [CONDITION(S)] (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Interventions included :Monitor conditions that may contribute to inappropriate sexual behaviors, including: psychiatric disorder(s), cognitive loss/dementia, [CONDITION(S)] (Cerebralvascual Accident, ie. stroke), [CONDITION(S)], delusions, hallucinations, head injury, etc. and Monitor medications for potential contribution to sexually inappropriate behaviors There were no additional events or interventions added. C. Record review of the nursing progress notes for R #265 dated 04/06/21, indicated the following, Received report from CNA [Certified Nursing Assistant] this morning that resident was in his room with his pants down and his hands on his penis playing with himself. He was spraying his bodily fluids on the floor and on the wall. Resident [R #265] came to the entry way of the room and was trying to lure female residents in the room. He was immediately redirected by nursing staff to pull up his pants and clean himself up. This nurse went in to speak to resident regarding situation. It was discussed that his behavior was inappropriate in the hallway. Resident became angry started calling me [staff] a [OBSCENITY] and flipping me off . D. Record review of the nursing progress notes for R #265 dated 04/19/21, Resident refusing medications. Cussing at staff. Stated you girls are mad because your husbands are f'ing other women. E. Record review of the nursing progress notes dated 04/20/21, This morning R #265 was in his room with another female resident [R #224] laying on his bed and R #265 was holding her around her waist. When staff entered the room and assisted the female resident out of the room the male resident became irate began to curse at nursing staff. Stated Leave her in my room or I'm going to say that you guys are pushing her. And let's see who gets in trouble. F. Record review of the nursing progress notes dated 05/11/21, Last pm (evening) pt (patient) was seen with pants and underwear off lying in female bed, he was asked to leave but refused, male CNA came got pt dressed and escort him to his room. Pt settled and slept throughout the night. G. Record review of a nursing progress note dated 05/15/21 indicated the following Resident [#16] stated that male resident [R #265] touched her in front and back resident pointed to the area where she was touched .This nurse noticed her brief and pj (pajama) pants were half on and tisted (twisted) [sic] . H. On 10/18/21 at 2:52 pm, during an interview with Family Member [FM] #1, she stated that there was a resident [R #265] to resident [R #16] abuse on May 2021. She stated that resident [R #265] sexually assaulted her mother [R #16] back on May 15, 2021. She stated that R #265 was known to the facility to have sexually inappropriate behaviors by the staff. She stated that the staff told her that they keep an eye on him but at some point they got busy and lost track of him. FM #1 stated that a staff member was checking on the residents and that R #265 peeked out of a female's room and slammed the door when he saw the staff member. The staff member wasn't able to immediately gain entrance into the room because the facility investigation revealed that R #265 was blocking the door. The staff member did get into the room and the resident threw a chair at the staff member [not hitting the staff]. R #265 was asked to leave, and they did get him out of the room. They asked R #16 if he had hurt her, and she indicated that he had sexually touched her. She stated that R #16 was taken to the emergency room and checked out. The hospital staff stated that they did not see any indication of penetration and thought that doing a SANE [sexual abuse nursing exam] evaluation on her would just be traumatizing for her. FM #1 stated she decided not to have a SANE exam done and that she does not believe that her mother suffered any harm from the incident. I. Record review of the nursing progress notes dated 05/15/21, Was called to Dementia unit by the nurse on duty to assist with this resident with behaviors. Upon entering the unit the resident was in the hallway this resident was educated on the ladies can not consent to being touch in any way he ask why not attempted to explain to this resident that it's inappropriate to touch. J. On 10/20/21 at 12:35 pm, during an interview with Certified Nursing Assistant #5 [CNA], she stated that she does remember R #265 and he did have really bad behaviors. R #265 would grab people, both staff and residents. He would stand in the doorway naked, touching himself. She stated that his behavior started right away. When there are three CNA's back here on this unit it helps a lot, they don't have three CNA's back on this unit anymore. She stated that it makes it hard to keep an eye on everyone. CNA #5 stated that R #265 was tall and very strong, he intimidated the staff. She did not like working with him and felt like she needed to protect the other residents from him. She was not working the evening [05/15/21] that the incident with R #265 and R #16 occurred. K. On 10/20/21 at 1:30 pm, during an interview with Licensed Professional Nurse [LPN] #7, she stated, R #265 was young, he was in his 50's. He didn't have any family and had memory issues, that is why he was on the unit. He was very perverted, from the day he got here. He would make nasty comments to staff. At first it was directed to staff, then he directed it to residents. She stated that he would stand in his door way naked, he would pee in trash cans. LPN #7 stated that he had expressed a couple of times that he knew what he was doing and was going to do it anyway. LPN #7 stated that she on multiple occasions spoke to the Unit Manager about this and the Center Nursing Executive [CNE] about the behaviors and not being appropriate for that unit. The day of incident 05/15/21 with R #16 he was sent out and was not accepted back to the facility. L. On 10/20/21 at 2:15 pm, during an interview with Unit Manager #1 she stated that she was told about R #265's behaviors. She told the staff to document it. She stated that he was appropriate to be on this unit because he had exit seeking behaviors with some memory issues and that was really the only criteria that a resident would need to meet to be on this unit. She stated that CNA #1 and #5 did come to her with their concerns. She told them to document it. M. On 10/20/21 at 2:23 pm, during an interview with CNA #1, she stated that she does remember R #265. We [the staff] had lots of problems with him. He was aggressive and intimidating. N. On 10/21/21 at 3:02 pm, during an interview with Physician #1, he stated that he saw R #265 in April 2021. R #265 was in his fifties and he did have some dementia and inappropriate sexual behaviors. Physician #1 stated behaviors like this are hard to treat. Can't treat his disinhibition [disinhibition is a lack of restraint manifested in disregard of social conventions, impulsivity, and poor risk assessment. Hypersexuality, hyperphagia, and aggressive outbursts are indicative of disinhibited instinctual drives]. He stated that there are no good medications to treat those that display these types of behaviors. He stated that he searches for medications all the time that might be effective. He stated that this is the best situation you are going to get. There isn't a hospital that you can send him to. You can send him out to places like [mental health hospital] because they will send him right back. He stated that yes at that point you have to monitor and watch him at all times, that would be the only way to ensure other residents safety. O. On 11/23/21 at 8:34 am, during an interview with Admissions, she stated that if they aren't sure about bringing in a resident for the secure unit they will have a meeting about it. The nurse will have input and so will the Center Executive Director and Center Nursing Executive. She stated that the only criteria for for being admitted to the secure unit is that they have to have exit seeking behaviors and memory issues. P. On 11/23/21 at 11:46 am, during an interview with UM #1, it was stated that they [staff] moved him to the unlocked behavioral unit on 04/20/21 for a few days to see how he would do on that unit. He was exiting seeking so they tried a WanderGuard on him, that didn't work because he knew how to push the green button to get out of the facility. So, they put R #265 back on the secure unit. Having more staff on that unit monitoring would have helped and may have prevented the incident.

Based on observation, record review, and interview, the facility failed to provide a sufficient amount of nursing staff to meet the needs of 5 (R #14, 16, 115, 224 and 271) of 5 (R #14, 16, 115, 224 and 271) resident reviewed for ADLs (Activities of Daily Living) and abuse by not having enough licensed nursing staff and Certified Nursing Assistants (CNA's) to: 1. Provide showers per resident preference and need. 2. Provide required supervision on the secured unit needed to prevent resident to resident sexual abuse. This deficient practice could likely resulted in residents not receiving their required care and likely resulted in psychosocial harm on the secured unit. The findings are: Findings related to bathing: Findings for R #14 A. Record review R #14's face sheet revealed, admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review R #14's care plan dated 07/12/21 revealed, Focus: [name of resident] is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to: recent illness with hospitalization resulting in fatigue, activity intolerance and confusion. C. Record review of shower/bath report for R#14 dated from 10/07/21 to 10/20/21 revealed R #14 did not receive shower or bed bath on their scheduled days 10/07/21 and 10/18/21. D. On 10/18/21 at 9:48 am, during an interview and observation of R #14, she was wearing a bed gown with old food stains and hair was dirty, greasy, and uncombed. During an interview with R #14, she stated, I have not had my gown changed for a couple of days. I cannot remember when I last received a bed bath. I should have a bed bath twice a week. Findings for R #115 E. Record review R #115's face sheet revealed, admitted [DATE], and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . F. Record review R #115 care plan dated 10/04/21 revealed, Focus: [name of resident] is at risk for decreased ability to perform ADLs in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. Resident recent illness with hospitalization resulting in fatigue, activity intolerance, and confusion. G. Record review of shower/bath report for R #115 dated from 10/07/21 to 10/20/21 revealed, R #115 did not receive scheduled showers or bed-baths on 10/09/21, 10/13/21, 10/16/21, and 10/20/21. H. On 10/18/21 at 10:14 am, during an interview and observation of R #115, she was wearing a bed gown, hair was greasy, and uncombed. R #115, she stated, They (staff) did not have time to bathe me on Saturday (10/16/21) telling me they (staff) are doing 25 showers a day. They do not have time to shower me. I am a Hoyer lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) resident and prefer to be in the shower. I do not like bed baths. I am not really sure when I last had a shower. Findings for R #271 I. Record review of R #271's face sheet, revealed admitted [DATE]. Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . J. Record review of R #271 care plan dated 10/14/21 revealed, Focus: [name of resident] requires assistance is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, related to: recent hospitalization impaired balance/dizziness. K. Record review of shower/bath report for R #271 dated from 10/14/21 to 10/20/21 revealed R #271 did not receive showers or bed baths on Thursday 10/14/21, and Monday 10/18/21. L. On 10/18/21 at 10:42 am, during an interview and observation of R #271, she was wearing a bed gown, hair had not been combed and her hair is matted together and greasy looking. During an interview with R #271, she stated, I have been wondering about when my shower would be. I have asked when it would be and the CNAs (Certified Nursing Assistance) are not sure when it will be, that is what they told me when I came into the facility. Then I found out my showers are on Wednesday and Saturday. Saturday night (10/16/21) the CNA was on her own and she said only one CNA on the floor, one called in (not coming to work) and she did not know where the other CNA was. M. On 10/20/21 at 01:45 pm, during an interview with CNA #2, she stated, It is chaotic on Monday and Tuesdays. We did give somebody a bed bath today. There is only 2 CNA's assigned on this skilled hall (400). I have been working here for about 3 weeks and have asked yesterday (10/19/21) for more help on this hall and we were given a shower aid today. We have 5 room changes (residents to be moved to another room) today and was able to do one so far. N. On 10/20/21 at 03:30 pm, during an interview with CNA #4, she stated, We have 5 to 6 showers to do a day on this hall. If we don't get them the showers/bed baths done we make a note. We try to do the best we can. Does not always happen that we can get the showers/bed baths completed. I have been working for 3 weeks that's about 10 days in the facility. We need 2 people to use the Hoyer lift which limits us to answer the call lights. We have 4 to 5 residents requiring the Hoyer lift. I did not have a lunch break yesterday and have only one 15 minute break today. Our nurse do not pay attention to us (CNA). The nurse is not in the hallway and does not help with the call lights. She mainly sits up at the nurse's station. The med techs are too busy is help us. We have residents that are wanderers (residents trying to leave) on our hall and we don't get any help getting them out of other resident's rooms. The resident on the end is a new admit and we have to keep the door closed because he is in quarantine and he does not know how to use the call button. We are supposed to check on him every 15 minutes but how are we supposed to do that? We do not have the time for him, he is a fall risk, and we can't hear him. We are scared for him. Right now, you see all the lights on and we have 2 people waiting to be put back to bed. They (residents) are both a 2-person transfer. O. On 10/21/21 at 03:37 pm, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that R #14, 115 and 271, have not been receiving showers/bed baths on their scheduled days. P. On 10/22/21 at 11:34 am, during an interview, CNA #6 stated There are usually two CNA's per hall. I don't think that's enough CNA's because we have some residents who are one-on-one [requiring 1 staff member to provide constant supervision/assistance per resident] or need a lot of attention. Everybody is busy and its hard to get to the residents on time. We have requested more CNA's and they claim to be training some. Q. On 10/22/21 at 12:07 pm, during an interview, LPN (Licensed Practical Nurse) #1 stated Staffing is sometimes short. Yesterday, there were three admissions, and I had a patient who needed a wound vac [a method of decreasing air pressure around a wound to assist the healing by placing a vacuum pump to create negative pressure around the wound] so I had to ask the manager to help me care for the other residents. R. On 10/25/21 at 1:05 pm, during an interview, LPN #2 stated There are times that you have to assist with other units, and there are times where there is only one CNA on the floor, like weekends or the night shift. This makes it hard . When there is 1 CNA, it makes it difficult to do showers and dining. This slows the process of getting drinks and feeding. It's been a consistent issue. A lot of times, the staff call in. S. On 10/26/21 at 4:09 pm, during an interview, CNA #7 stated I'm all over the building, I fill in a lot. On this hall, 400, there's one other CNA helping. It's a heavy hall. I wish there were more of us but I go where I can, I can't be in 2 places at once. It's tough to provide quality care. T. On 10/26/21 at 4:26 pm, during an interview with the Staffing Coordinator, when asked how the number of CNA's to schedule on each hall is determined, she replied, There are usually two CNA's per hall. They [administration] have started talking about putting three people instead of two on 100 and 400. In the last couple of days, they requested more help for the 100 hall and the 400 hall. The 400 needs more care to deliver. The need for the additional person on the 400 hall came to my attention about late last week. Honestly, its either [NAME] or famine [alternating, extremely high and low degrees of prosperity, success, volume of business, etc.]. When asked to explain the process for call-in's [when a staff member who is scheduled to work is unable to work as scheduled], she stated, If someone calls-in, I call the people who are off. I put the staffer link into our agency platform and then reach out to our people who are off. Then I usually will find out who [which staff members] I can move where [within the halls] to best accommodate our patients. The residents [and their needs] are always going to be different. When asked to describe how the acuity (level of intensity of care required by the resident's condition) of the hall effects the amount of staff on the schedule, she stated nursing will let me know, we have our two daily meetings, and we are informed of what needs to be done or if other halls need more help. Findings related to supervision on the secured unit: U. Record review of R #265's Care Plan dated 04/20/21 revealed Resident/patient has a tendency to exhibit sexually inappropriate behavior related to: Psychiatric Disorder (s): [CONDITION(S)] (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Interventions included :Monitor conditions that may contribute to inappropriate sexual behaviors, including: psychiatric disorder(s), cognitive loss/dementia, [CONDITION(S)] (Cerebralvascual Accident, ie. stroke), [CONDITION(S)], delusions, hallucinations, head injury, etc. and Monitor medications for potential contribution to sexually inappropriate behaviors There were no additional events or interventions added. V. Record review of the nursing progress notes for R #265 dated 04/06/21, indicated the following, Received report from CNA [Certified Nursing Assistant] this morning that resident was in his room with his pants down and his hands on his penis playing with himself. He was spraying his bodily fluids on the floor and on the wall. Resident [R #265] came to the entry way of the room and was trying to lure female residents in the room. He was immediately redirected by nursing staff to pull up his pants and clean himself up. This nurse went in to speak to resident regarding situation. It was discussed that his behavior was inappropriate in the hallway. Resident became angry started calling me [staff] a [OBSCENITY] and flipping me off . W. Record review of the nursing progress notes dated 04/20/21, This morning R #265 was in his room with another female resident [R #224] laying on his bed and R #265 was holding her around her waist. When staff entered the room and assisted the female resident out of the room the male resident became irate began to curse at nursing staff. Stated Leave her in my room or I'm going to say that you guys are pushing her. And let's see who gets in trouble. X. Record review of the nursing progress notes dated 05/11/21, Last pm (evening) pt (patient) was seen with pants and underwear off lying in female bed, he was asked to leave but refused, male CNA came got pt dressed and escort him to his room. Pt settled and slept throughout the night. Y. Record review of a nursing progress note dated 05/15/21 indicated the following Resident [#16] stated that male resident [R #265] touched her in front and back resident pointed to the area where she was touched .This nurse noticed her brief and pj (pajama) pants were half on and tisted (twisted) [sic] . Z. On 10/18/21 at 2:52 pm, during an interview with Family Member [FM] #1, she stated that there was a resident [R #265] to resident [R #16] abuse on May 2021. She stated that resident [R #265] sexually assaulted her mother [R #16] back on May 15, 2021. She stated that R #265 was known to the facility to have sexually inappropriate behaviors by the staff. She stated that the staff told her that they keep an eye on him but at some point they got busy and lost track of him. FM #1 stated that a staff member was checking on the residents and that R #265 peeked out of a female's room and slammed the door when he saw the staff member. The staff member wasn't able to immediately gain entrance into the room because the facility investigation revealed that R #265 was blocking the door. The staff member did get into the room and the resident threw a chair at the staff member [not hitting the staff]. R #265 was asked to leave, and they did get him out of the room. They asked R #16 if he had hurt her, and she indicated that he had sexually touched her. She stated that R #16 was taken to the emergency room and checked out. The hospital staff stated that they did not see any indication of penetration and thought that doing a SANE [sexual abuse nursing exam] evaluation on her would just be traumatizing for her. FM #1 stated she decided not to have a SANE exam done and that she does not believe that her mother suffered any harm from the incident. AA. On 10/20/21 at 12:35 pm, during an interview with Certified Nursing Assistant #5 [CNA], she stated that she does remember R #265 and he did have really bad behaviors. R #265 would grab people, both staff and residents. He would stand in the doorway naked, touching himself. She stated that his behavior started right away. When there are three CNA's back here on this unit it helps a lot, they don't have three CNA's back on this unit anymore. She stated that it makes it hard to keep an eye on everyone. CNA #5 stated that R #265 was tall and very strong, he intimidated the staff. She did not like working with him and felt like she needed to protect the other residents from him. She confirmed that she was not working the evening [05/15/21] that the incident with R #265 and R #16 occurred. BB. On 10/20/21 at 1:30 pm, during an interview with Licensed Professional Nurse [LPN] #7, she stated, R #265 was young, he was in his 50's. He didn't have any family and had memory issues, that is why he was on the unit. He was very perverted, from the day he got here. He would make nasty comments to staff. At first it was directed to staff, then he directed it to residents. She stated that he would stand in his door way naked, he would pee in trash cans. LPN #7 stated that he had expressed a couple of times that he knew what he was doing and was going to do it anyway. LPN #7 stated that she on multiple occasions spoke to the Unit Manager about this and the Center Nursing Executive [CNE] about the behaviors and not being appropriate for that unit. The day of incident 05/15/21 with R #16 he was sent out and was not accepted back to the facility. CC. On 10/20/21 at 2:23 pm, during an interview with CNA #1, she stated that she does remember R #265. We [the staff] had lots of problems with him. He was aggressive and intimidating. You had to watch him. DD. On 10/21/21 at 3:02 pm, during an interview with Physician #1, he stated that he saw R #265 in April 2021. R #265 was in his fifties and he did have some dementia and inappropriate sexual behaviors. Physician #1 stated behaviors like this are hard to treat. Can't treat his disinhibition [disinhibition is a lack of restraint manifested in disregard of social conventions, impulsivity, and poor risk assessment. Hypersexuality, hyperphagia, and aggressive outbursts are indicative of disinhibited instinctual drives]. He stated that there are no good medications to treat those that display these types of behaviors. He stated that he searches for medications all the time that might be effective. He stated that this is the best situation you are going to get. There isn't a hospital that you can send him to. You can send him out to places like [mental health hospital] because they will send him right back. He stated that yes at that point you have to monitor and watch him at all times, that would be the only way to ensure other residents safety. EE. On 11/22/21 at 11:46 am, during an interview with UM (Unit Manager) #1 regarding the secured unit, They need more staff back there. The staff on that unit are great but having one more CNA on that unit would cover all the areas on that unit. After a meal the residents will wander out of the dining room and start walking up and down the hall and this can be the time when altercations can occur. There needs to be someone monitoring the hallway when the other two CNA's are assisting with eating, but it isn't just at meal time, the CNA's working back there could use the help with showering, ADL's [activities of daily living] changing briefs and just keeping on eye on everyone. Most of them are mobile and wander around a lot. Having more staff on that unit monitoring would have helped and may have prevented the incident on 05/15/21 with R #16 and R #265. Findings related to observations on the secured unit: FF. On 10/21/21 at 9:30 am, an observation was made of one CNA #8 hall. CNA #8 was in the dining room with most of the residents. The nurse was at the front desk, RN #10. The other CNA was taking a break. The CNA was observed around 10 minutes later taking a resident down the shower room for their shower. At this time the other CNA assigned to the hall was not back from break and the nurse was still at the front desk. The residents were left unattended at this time. GG. On 10/22/21 at 12:50 pm, observation was made of the dining room. Lunch time was occuring and most of the residents were finished eating. Two residents were being assisted with eating in the dining room and many of the other residents were up and walking around. Residents were wandering up and down the halls. Several residents were observed to go into rooms that were not their room. The hall was very congested with people wandering in and out of the dining room and up and down the hall. HH. On 11/23/21 at 8:22 am, during an interview with CNA #5, she stated that the majority of the residents here [on the secured unit] are incontinent, so they need to change them. The dayshift has all three meals. They have three residents that need assistance with eating and several others that need prompting with meals. They have to get them up and get them dressed and there are 10 showers to get done today. She stated that what is lacking is keeping an eye on all the residents. She stated that when you are that busy, you can't watch and monitor all the residents. She stated that they used to have three CNA's back here on this unit and that is what they need now. These residents can't really express themselves in the normal way so they have to constantly address new behaviors and frustration that the residents have, like what they need, are they in pain, are they hungry, do they need to be changed or toileted.

On 10/19/20 at 9:20 am, observations were made of R #8 being served diced (not pureed) potatoes for breakfast, at 1:10 pm during the lunch meal R #8 was observed to have received a chicken sandwich and hash browns (not pureed). R #8's roommate R #110 notified staff that she (R #8) did not get the proper meal texture for lunch. R #8 is not able to advocate for herself and likely would have eaten the non-pureed meal that was delivered to her if the roommate had not intervened. On 10/19/20 at 1:10 pm, observations of the lunch meal were being made. Conversations between the Dietary Aides indicated that there were issues with getting lunch out timely today. There had also been issues with the breakfast meal (some residents receiving an inadequate meal). At approximately 1:25 pm, an Occupational Therapist (OT) was observed stating to the Dietary Aide that R #38 received a regular meal and not the puree meal that she is supposed to receive. Upon observation, the plate of food revealed a chicken sandwich with some potatoes. None of the food on the tray was pureed. The meal ticket on R #38's tray stated that she is to receive a puree meal. It was later confirmed in an interview with the cook that he was upset and someone should have been checking the tickets for accuracy. This resulted in an immediate jeopardy (IJ) at a scope and severity of K (immediate jeopardy to more than one residents health and safety) being called on 10/19/20 at 6:32 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 10/20/20 at 4:16 pm. Implementation of the POR was verified onsite. Based on the Plan of Removal, the interventions included: 1. October 19, 2020 all kitchen staff education was begun for meal ticket and tray accuracy. 2. October 19, 2020 an audit was completed of all residents with Dysphagia (difficulty or discomfort in swallowing) puree diets to determine who was at risk. 14 residents identified. 3. Nursing staff to observe residents who are able to feed themselves will be conducted to observe for any issues with choking on Dysphagia pureed diet. 4. ST (Speech Therapist) will re-assess residents who do not have a current evaluation that are on a Dysphagia pureed diet, to determine continued need for that texture 5. October 19, 2020 education was begun with current staff in the center on meal service delivery. 6. Investigation of event began on October 19, 2020. Staff statements and interviews of those who had contact with resident prior and during event obtained. 7. Audit to be completed to ensure ordered diet matches, diet entered into meal tracker. 8. Menu reviewed to ensure correct meal was served at dinner on October 19,2020. 9. Ongoing audit to ensure staff compliant with safety plan for residents who are on Dysphagia Puree diets. Scope and Severity was reduced from the level K to a level E. Based on observation, record review and interview the facility failed to serve the appropriate, and physician ordered diet of puree consistency for 2 (R#'s 8 and 38) of 2 (R#'s 8 and 38) residents reviewed during dining observations. This defiecienct practice could likely result in aspiration and death. The findings are: A. On 10/19/20 at 1:20 pm, during observation of the lunch trays being made; a conversation was heard. Dietary Aide (DA) #1 was heard speaking loudly to the other dietary staff, stating that all they could serve for breakfast this morning was potatoes and oatmeal but nothing else. He stated that they didn't even have any ham. They had nothing else to serve. A dietary aide (unknown) asked DA #1 if any of the dishes had come back yet. It had been stated earlier during observation, that they didn't have enough dishes to continue to serve until some came back. The dietary staff are laughing and joking around. DA #1 is throwing condiment packets at Cook #1 who was making the trays. Continued observation revealed a staff member, Occupational Therapist (OT) #1 came in with a tray of food. Stated to Cook #1 that she needed another puree meal for R #38. B. On 10/19/20 at 1:35 pm, during an interview with Occupational Therapist OT #1, she stated that she needed a puree meal for R #38 because she was served a regular meal, which consisted of chicken sandwich on a bun with condiments and potatoes. OT #1 stated that R #38 can't eat this because she is on puree diet. She stated that R #38's call light was on so she went in to see if she could help R #38. That is when R #38 told her about the meal. C. Record review of the face sheet for R #38 indicated that R #38 was admitted to the facility on [DATE]. She currently has a [DIAGNOSES REDACTED].(brain disorder that causes problems with memory, thinking and behavior), Dysatharia (condition in which the muscles you use for speech are weak or you have difficulty controlling them), this is not an all inclusive list. D. Record review of the physician's orders [REDACTED].>E. Record review of the nutritional assessment dated [DATE] indicated that R #38 requires a puree diet. R #38 could be assessed for an upgrade to advanced Dysphagia if they (staff) could get her to eat in the dining room with supervision, but she refuses to do that. F. Record review of the Minimum Data Set ((MDS) dated [DATE] indicated that R #38 was independent with eating. G. On 10/19/20 at 1:42 pm, during an interview with the Dietary Manager (DM), she stated that a resident who is supposed to receive a puree meal and got a regular meal is not acceptable. She stated that the person serving the tray is supposed to be reading every ticket on every tray. She stated that the tickets are on the trays and R #38 states puree so it should not have been a problem. She stated that he must not have been paying attention. H. Record review of the meal ticket dated 10/19/20 indicated that R #38 has DYS (Dysphagia) Puree on the top of the ticket. The ticket also indicated DYS Puree Sausage, Pepper and Onion, DYS Puree Herb Bread, DYS Puree Pan Fried Potatoes. I. On 10/19/20 at 2:42 pm, during an interview with R #38 she stated that she got the wrong meal twice today. Two times it was not pureed. Record review of R #38 's meal ticket indicated that she is to receive for lunch meal, sausage, pepper and onion, pan fried potatoes, bread with parsley sprinkle and chocolate ice cream. Her meal indicates that it should be pureed. She received a chicken sandwich with potatoes and none of it was pureed. J. On 10/19/20 at 3:13 pm, during an interview with the cook, he stated that he was upset from this morning meal and that the DM knew he was upset. He stated that the DM should have been checking his trays to make sure they were right. He stated that he was upset from the morning meal when they only had three cartons of liquid eggs, that is not enough to serve everyone in the building. So, he improvised and served potatoes and oatmeal to around 38 to 40 of the residents. He stated that they were already short on eggs and breakfast items. So, the DM brought in three cartons of eggs and one bone in ham. He stated that for the number of residents they have at the facility this was not going to feed them all. He stated that for lunch they did not have sausage and peppers, so he chose the chicken to serve. The cook stated again that someone else should have had eyes on the tickets because they knew he was upset. K. On 10/20/20 at 8:52 am, during an observation of the breakfast meal a plate food was placed on the top rack of the cart for R #111. L. On 10/20/20 at 9:03 am, during an interview with CNA #8 she stated that they placed the meal on top of the cart because resident is fed through tube feeding and is not supposed to receive a tray; but they were aware of this and placed it on top because it wasn't going to be served. He (R #111) is NPO (nothing by mouth). CNA #8 stated that he never received the meal because everyone on this hall knew that he was NPO. She stated that he had come back into the facility late last evening and the diet of NPO had not been submitted yet. She stated that there is a form that the nurse fills out and gives it to the kitchen. M. On 10/20/20 at 9:20 am, during an interview with the DM, she stated that there is a system failure with the (facility) system and the system that the kitchen uses. She stated that the two systems don't synch together. She stated that the system has a default, if you don't enter in a meal type and specify what it should be then it defaults to regular meal with regular texture. So, in the case of R #111, it just defaulted for him to receive a regular meal. She stated that until she receives a form from the nursing staff that indicates what the diet is, it will default to regular. N. On 10/20/20 at 11:15 am, during an interview with Center Executive Director (CED) she stated that the Certified Nursing Assistants (CNA)'s are also supposed to be checking the tickets against the plate of food to make sure they were getting the right diet. Findings for R #8: O. Record review of facility Admission Record, revealed, resident admitted [DATE], with [DIAGNOSES REDACTED]. Short term memory loss, change in behavior and reduction in concentration are the commonly observed symptoms) without behavioral disturbance (behaviors such as wandering and delusions). P. Record review of provider orders for diet revealed, 1. On 05/04/20, Dysphagia (difficulty swallowing) puree texture (finely mashed) 2. On 09/14/20, Bread and cake okay with supervision. Q. On 10/19/20 at 9:20 am, during observation, the resident who is sitting up in a chair at her bedside, was served oatmeal and diced (not pureed) potatoes for her breakfast. The Certified Nursing Assistant (CNA) who delivered the food has left the room. R. On 10/19/20 at 9:25 am the residents roommate, R #103, calls in the CNA and reminds him the resident must have pureed food. He takes away the potatoes and leaves the oatmeal. Resident eats the oatmeal. Later she is asked if she is hungry by a nurse and she says she is not. S. On 10/19/20 at 1:10 pm, received a chicken sandwich and hash browns on her lunch tray (not pureed). She is sitting up to eat it the CNA that delivered it is no longer in the room . The residents roommate calls out into hall for staff to notify them that her roommate does not have her pureed diet. They come and take the food away. In approximately 10 minutes they brought her a pureed meal. T. On 10/19/20 at 6:40 PM The resident was served a pureed meal with the addition of a non pureed roll. The food was set up for her and the staff member was leaving the room when he was reminded resident was on a puree diet, he removed the roll and left the room. U. On 10/20/20 at 3:18 pm, during telephone interview with two of the residents daughters they reveal the resident's not able to express her needs at times, will not recall to use the call light, will eat what is put in front of her at meals.

On 10/19/20 at 9:20 am, observations were made of R #8 being served diced (not pureed) potatoes for breakfast, at 1:10 pm during the lunch meal R #8 was observed to have received a chicken sandwich and hash browns (not pureed). R #8's roommate R #110 notified staff that she (R #8) did not get the proper meal texture for lunch. R #8 is not able to advocate for herself and likely would have eaten the non-pureed meal that was delivered to her if the roommate had not intervened. On 10/19/20 at 1:10 pm, observations of the lunch meal were being made. Conversations between the Dietary Aides indicated that there were issues with getting lunch out timely today. There had also been issues with the breakfast meal (some residents receiving an inadequate meal). At approximately 1:25 pm, an Occupational Therapist (OT) was observed stating to the Dietary Aide that R #38 received a regular meal and not the puree meal that she is supposed to receive. Upon observation, the plate of food revealed a chicken sandwich with some potatoes. None of the food on the tray was pureed. The meal ticket on R #38's tray stated that she is to receive a puree meal. It was later confirmed in an interview with the cook that he was upset and someone should have been checking the tickets for accuracy. This resulted in an immediate jeopardy (IJ) at a scope and severity of K (immediate jeopardy to more than one residents health and safety) being called on 10/19/20 at 6:32 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 10/20/20 at 4:16 pm. Implementation of the POR was verified onsite. Based on the Plan of Removal, the interventions included: 1. October 19, 2020 all kitchen staff education was begun for meal ticket and tray accuracy. 2. October 19, 2020 an audit was completed of all residents with Dysphagia (difficulty or discomfort in swallowing) puree diets to determine who was at risk. 14 residents identified. 3. Nursing staff to observe residents who are able to feed themselves will be conducted to observe for any issues with choking on Dysphagia pureed diet. 4. ST (Speech Therapist) will re-assess residents who do not have a current evaluation that are on a Dysphagia pureed diet, to determine continued need for that texture 5. October 19, 2020 education was begun with current staff in the center on meal service delivery. 6. Investigation of event began on October 19, 2020. Staff statements and interviews of those who had contact with resident prior and during event obtained. 7. Audit to be completed to ensure ordered diet matches, diet entered into meal tracker. 8. Menu reviewed to ensure correct meal was served at dinner on October 19,2020. 9. Ongoing audit to ensure staff compliant with safety plan for residents who are on Dysphagia Puree diets. Scope and Severity was reduced from the level K to a level E. Based on observation, record review and interview the facility failed to: 1. Serve the appropriate, and physician ordered diet of puree consistency 2. Communicate and maintain menu options 3. Update resident preferences for 9 (R#'s 8, 38, 41, 96, 103, 111, 120, 324, and 325) of 9 (R#'s 8, 38, 41, 96, 103, 111, 120, 324, and 325) residents reviewed during dining observations. Due to the inaccuracy of tray preparation, this deficient practice could likely cause aspiration and death, and a decline in the psychosocial health of the residents as the residents develop feelings of frustration, anxiety, and disappointment. A. On 10/19/20 at 1:20 pm, during observation of the lunch trays being made; a conversation was heard. Dietary Aide (DA) #1 was heard speaking loudly to the other dietary staff, stating that all they could serve for breakfast this morning was potatoes and oatmeal but nothing else. He stated that they didn't even have any ham. They had nothing else to serve. A dietary aide (unknown) asked DA #1 if any of the dishes had come back yet. It had been stated earlier during observation, that they didn't have enough dishes to continue to serve until some came back. The dietary staff are laughing and joking around. DA #1 is throwing condiment packets at Cook #1 who was making the trays. Continued observation revealed a staff member, Occupational Therapist (OT) #1 came in with a tray of food. Stated to Cook #1 that she needed another puree meal for R #38. B. On 10/19/20 at 1:35 pm, during an interview with Occupational Therapist OT #1, she stated that she needed a puree meal for R #38 because she was served a regular meal, which consisted of chicken sandwich on a bun with condiments and potatoes. OT #1 stated that R #38 can't eat this because she is on puree diet. She stated that R #38's call light was on so she went in to see if she could help R #38. That is when R #38 told her about the meal. C. Record review of the face sheet for R #38 indicated that R #38 was admitted to the facility on [DATE]. She currently has a [DIAGNOSES REDACTED].(brain disorder that causes problems with memory, thinking and behavior), Dysatharia (condition in which the muscles you use for speech are weak or you have difficulty controlling them), this is not an all inclusive list. D. Record review of the physician's orders [REDACTED].>E. Record review of the nutritional assessment dated [DATE] indicated that R #38 requires a puree diet. R #38 could be assessed for an upgrade to advanced Dysphagia if they (staff) could get her to eat in the dining room with supervision, but she refuses to do that. F. Record review of the Minimum Data Set ((MDS) dated [DATE] indicated that R #38 was independent with eating. G. On 10/19/20 at 1:42 pm, during an interview with the Dietary Manager (DM), she stated that a resident who is supposed to receive a puree meal and got a regular meal is not acceptable. She stated that the person serving the tray is supposed to be reading every ticket on every tray. She stated that the tickets are on the trays and R #38 states puree so it should not have been a problem. She stated that he must not have been paying attention. H. Record review of the meal ticket dated 10/19/20 indicated that R #38 has DYS (Dysphagia) Puree on the top of the ticket. The ticket also indicated DYS Puree Sausage, Pepper and Onion, DYS Puree Herb Bread, DYS Puree Pan Fried Potatoes. I. On 10/19/20 at 2:42 pm, during an interview with R #38 she stated that she got the wrong meal twice today. Two times it was not pureed. Record review of R #38 's meal ticket indicated that she is to receive for lunch meal, sausage, pepper and onion, pan fried potatoes, bread with parsley sprinkle and chocolate ice cream. Her meal indicates that it should be pureed. She received a chicken sandwich with potatoes and none of it was pureed. J. On 10/19/20 at 3:13 pm, during an interview with the cook, he stated that he was upset from this morning meal and that the DM knew he was upset. He stated that the DM should have been checking his trays to make sure they were right. He stated that he was upset from the morning meal when they only had three cartons of liquid eggs, that is not enough to serve everyone in the building. So, he improvised and served potatoes and oatmeal to around 38 to 40 of the residents. He stated that they were already short on eggs and breakfast items. So, the DM brought in three cartons of eggs and one bone in ham. He stated that for the number of residents they have at the facility this was not going to feed them all. He stated that for lunch they did not have sausage and peppers, so he chose the chicken to serve. The cook stated again that someone else should have had eyes on the tickets because they knew he was upset. K. On 10/20/20 at 8:52 am, during an observation of the breakfast meal a plate food was placed on the top rack of the cart for R #111. L. On 10/20/20 at 9:03 am, during an interview with CNA #8 she stated that they placed the meal on top of the cart because resident is fed through tube feeding and is not supposed to receive a tray; but they were aware of this and placed it on top because it wasn't going to be served. He (R #111) is NPO (nothing by mouth). CNA #8 stated that he never received the meal because everyone on this hall knew that he was NPO. She stated that he had come back into the facility late last evening and the diet of NPO had not been submitted yet. She stated that there is a form that the nurse fills out and gives it to the kitchen. M. On 10/20/20 at 9:20 am, during an interview with the DM, she stated that there is a system failure with the (facility) system and the system that the kitchen uses. She stated that the two systems don't synch together. She stated that the system has a default, if you don't enter in a meal type and specify what it should be then it defaults to regular meal with regular texture. So, in the case of R #111, it just defaulted for him to receive a regular meal. She stated that until she receives a form from the nursing staff that indicates what the diet is, it will default to regular. N. On 10/20/20 at 11:15 am, during an interview with Center Executive Director (CED) she stated that the Certified Nursing Assistants (CNA)'s are also supposed to be checking the tickets against the plate of food to make sure they were getting the right diet. Findings for R #8: O. Record review of facility Admission Record, revealed, resident admitted [DATE], with [DIAGNOSES REDACTED]. Short term memory loss, change in behavior and reduction in concentration are the commonly observed symptoms) without behavioral disturbance (behaviors such as wandering and delusions). P. Record review of provider orders for diet revealed, 1. On 05/04/20, Dysphagia (difficulty swallowing) puree texture (finely mashed) 2. On 09/14/20, Bread and cake okay with supervision. Q. On 10/19/20 at 9:20 am, during observation, the resident who is sitting up in a chair at her bedside, was served oatmeal and diced (not pureed) potatoes for her breakfast. The Certified Nursing Assistant (CNA) who delivered the food has left the room. R. On 10/19/20 at 9:25 am the residents roommate, R #103, calls in the CNA and reminds him the resident must have pureed food. He takes away the potatoes and leaves the oatmeal. Resident eats the oatmeal. Later she is asked if she is hungry by a nurse and she says she is not. S. On 10/19/20 at 1:10 pm, received a chicken sandwich and hash browns on her lunch tray (not pureed). She is sitting up to eat it the CNA that delivered it is no longer in the room . The residents roommate calls out into hall for staff to notify them that her roommate does not have her pureed diet. They come and take the food away. In approximately 10 minutes they brought her a pureed meal. T. On 10/19/20 at 6:40 PM The resident was served a pureed meal with the addition of a non pureed roll. The food was set up for her and the staff member was leaving the room when he was reminded resident was on a puree diet, he removed the roll and left the room. U. On 10/20/20 at 3:18 pm, during telephone interview with two of the residents daughters they reveal the resident's not able to express her needs at times, will not recall to use the call light, will eat what is put in front of her at meals. Findings for R# 96: V. On 10/19/20 at 02:46 pm, during an interview with R# 96, when asked to describe the food served by the facility, R# 96 stated they refuse to serve correct food to people. They served us French Toast and a cube of ham about an inch and a half big. They never toast the bread. Once they served me chicken and it hurt my tooth when I bit into it. It snapped like a piece of wood. They don't serve nutritious meals. I have repeatedly talk to the dietician and 2 dietary managers. They had a poor attitude about my concerns. The nutritionist believes that the residents do not deserve snacks. There was a time when they didn't have bread for sandwiches. They say that sausage and bacon are too expensive to serve to us. Not every breakfast meal is served with a breakfast meat. They always serve us a goo which is oatmeal, which is always cold. I do not like veggies. I requested not to be served veggies. They don't do it (honor his request). I have requested double protein because I am a [MEDICAL TREATMENT] resident. they don't give me double protein. The tickets do not match what's on the tray. I primarily worry about the people who cannot advocate for themselves. The primary issue with this facility is nutrition. Nothing has improved since I have been here. We do they not have a set menu of alternative options. They don't have an alternative menu at all. My alternative from yesterday was a 'sandwich', it was a couple of slices of pepperoni and a slice of cheese. That was their serving of double protein for a [MEDICAL TREATMENT] resident. W. On 10/19/20 at 2:54 pm, during an observation of the room tray for R# 96, the following items were served; a chicken sandwich with cheddar cheese, hash browns, chocolate ice cream, juice, and 7 ketchup packets. Observation of the tray ticket read Renal, double protein. Grilled Swiss sandwich-1 ea, parsley garnish- 1 each, sliced peaches- 1/2 cup, 2% milk. The tray did not have a serving of double protein, parsley, peaches, or 2% milk. X. Record review of physician's orders [REDACTED]. (brand of protein shake) 1 container 2x a day as a protein supplement - two times a day for supplement Y. Record review of nursing notes, dated 09/13/20, reveal the following Resident was not happy with his meal this evening. He requested to speak with kitchen supervisor who asked what he wanted instead of what was prepared. He requested to speak with the unit manager who went and spoke to pt (patient), pt remained dissatisfied. Still requesting to speak with kitchen staff. 18:45, kitchen staff came and spoke with resident then offered ham and cheese sandwich, pt still refused meal Z. Record review of nursing notes, dated 08/14/20, demonstrate the resident's feelings as follows Resident reported feeling anger . Resident stated he does not like the food . Resident was able to identify needs. Resident struggled to manage his irritability and stated, 'I just want to punch someone'. Resident stated he would continue to advocate for himself. Resident agreed he would reach out to staff if he had more concerns. AA. Record review of SOAP notes (a method of documentation for healthcare professionals which include points of review; Subjective, Objective, Assessment, and Plan) dated 10/05/20, document the resident's expression; I am very [***] ing pissed. I spoke to the kitchen manager, and they still screw up my food. The food sucks here. I want to speak to the manager, but she won't talk to me. The author of the SOAP note then documented I spoke to the admin for him. She did not seem concerned. In a hurry to close her door. BB. On 10/26/20 at 4:01 pm, during an interview with R# 96, he stated The dietician, he didn't have much to say. In the end, it was all about what the kitchen can afford and what they can and will do. Today, I received lime Jello, mashed potatoes, and turkey, and I think some kind of veggie. I didn't eat it. On the ticket, supposedly it said ham. the CNA said it was ham. I didn't eat it. I ate breakfast. Ever since state showed up I have been getting French toast, eggs, and cold cereal, which is what I prefer instead of oatmeal. Sometimes they screw up- the other day they sent me bacon with no eggs, and sausage with no eggs. CC. On 10/28/20 at 3:48 pm, during an interview with CNA# 8 when asked if R# 96 eats his food, she stated It's hard to say for him. He sometimes likes his food, he sometimes doesn't. He doesn't like fish or veggies. I often return his tray for a sandwich or something else. DD. On 10/28/20 at 3:20 pm, during an interview with the Dietary Manager, when asked to review her software for the preferences of R# 96, the following items were listed: cold cereal, French toast, scrambles eggs with cheese, milk, hamburger, hamburger on a roll, Italian meat and cheese sandwich. Dislikes: potatoes, fish and sea food, banana, spicy foods, OJ, powdered sugar, vegetables. She then stated, He loves potatoes but we listed it as a dislike because there's so much potassium. Findings for R# 120: EE. On 10/19/20 at 12:07 pm, during an interview with R #120, when asked to describe the food, he stated, The food is horrible. it causes me anxiety. I feel like I have no help. They never give me what is on my ticket. They serve pancakes and French toast without syrup. They never serve toast, but they serve bread. They do not send butter or sugar. They give you coffee and oatmeal without sugar. This morning the coffee was horrible, like always. They didn't serve us any meat for breakfast. It was cold and so was the coffee. When asked if the resident receives a menu to inform the kitchen of his preference or what to expect for the day, he stated I do not get notified of what meal is to be expected. I don't get an option for my meals. Something is going on where they are just taking too long to get the food out. I have a picture of a tray they served me, look! The bacon is burnt, and the pancakes were horrible. FF. On 10/20/20 at 9:33 am, during an interview with R# 120, he stated This is the first day I've seen toast. looking at my ticket, this is the first time its correct. My ticket matches except I did not get milk. The coffee was warm today and my oatmeal is still warm. It's usually cold. Sometimes we don't get silverware. GG. Record review of nurse's notes dated 09/22/20 state 20-minute Check in with patient by phone. Patient sounded frustrated due to poor quality of meals. Resident reported he felt out of control and frustration due to not wanting to eat. Resident was able to ground and utilize grounding techniques such as positive thinking to manage his emotions. HH. Record review of the SOAP notes, date not observed, for R# 120 indicate that he has stated The food here is horrible and it gives me anxiety II. On 10/28/20 at 3:18 pm, during an interview with the Dietary Manager, when asked what has been saved in her software for R# 120, she stated I don't have any notes on likes or dislikes. I know that he likes fish. JJ. On 10/28/20 at 8:57 am, during an interview with the Mental Health Recovery Director, when asked if R# 120 has mentioned the food, she stated, He doesn't like the food. He says it's cold. They were not getting what was on the menu. One morning, they had pancakes on the menu, I don't know what happened with the pancakes, but they ended up getting bread with syrup on it. Residents were told not to take pictures of the food. When asked why they were taking pictures of the food, she stated It was horrible or not a lot, they received small portions. Or they didn't get double protein. Findings for R# 325 KK. On 10/19/20 at 10:38 am, during an interview with R# 325, when asked her opinion of the food, she stated, The food is not good. it is overwhelmingly starchy. we get very little protein and sometimes its swimming in fat. There is no access to water. I don't know how these people (other residents) are surviving. If you ask the nurse for water, they give you a little container of water, the one that holds meds. the only liquids we get are paper cups with juice at dinner. They give us juice with meals and water with meds but never to have. I fill up my water bottle with water from the bathroom sink. LL. On 10/28/20 at 3:19 pm, during an interview with the Dietary Manager, when asked what her preferences are, she stated that she likes soup of any kind. Findings for R# 41 MM. On 10/22/20 at 2:51 pm, during an interview with R# 41, when asked to discuss the food, he stated They don't give us a choice. We never see the menu. When we receive the trays, they forget to send proper utensils. NN. On 10/28/20 at 3:20 pm, during an interview with the Dietary Manager, when asked what is saved in her software for his preferences, she stated He has 3 special requests for soy milk for breakfast, lunch, and dinner. Findings for R# 324 OO. Record review of a complaint submitted to the state Department of Health, intake number NM 349 reads (I) told them numerous times I cannot eat wheat or dairy, so it was served to me daily. My last morning there, they served breakfast. I saw a large scoop of what appeared to be eggs and hash browns. I smashed it to examine and found bits and pieces of veggies that had been served previously during the week. I don't know what they charge for meals but it's not worth it. Oatmeal is the bottom of the barrel, cheapest stuff you can find. Not even a resemblance of one single oat. PP. On 10/28/20 at 3:20 pm, during an interview with the Dietary Manager, when asked what is saved in her software for her preferences, the resident was unable to locate in her software. Findings for R# 103 QQ. On 10/28/20 at 3:04 pm, during an interview with R# 103, the Resident Council President, stated From this month's council, I asked the activities director to go to different rooms and ask the residents what concerns they have. The concerns that are trending is the issue of food. Food that is cold, food that takes a long time to come out, and not having any options. I have made copies of the minutes and sent them out to the residents. I also sent the minutes to the administration and asked for a reply within 72 hours. I have not yet received any response. I wanted to go to each resident and present them with our complaints and hope that they see a change in the kitchen. I have 5 meal tickets that I have placed an X next to the item on the tray that I did not receive on my tray. As a resident, I am feeling very beat up- I feel guilty requesting a hot tray, I feel bad trying to advocate, I try to calm down other residents. General findings: RR. On 10/26/20 at 1:38 pm, during an interview with the Dietary Manager, when asked if a menu is distributed for residents to select the main dish or an alternative, the Dietary Manager stated that she utilizes meal tracker in place of menus. She stated It is my software that accounts for dislikes, preferences, allergies and it modifies the choice for the resident. My software automatically calculates what the resident would like or dislike. I am relying heavily on my software, with COVID-19, I don't like sending tickets out to residents and bringing them back, I didn't want to contaminate the kitchen. SS. On 10/28/20 at 3:24 pm, during an interview with the Dietary Manager, when asked how the preferences are updated in the software, she stated They (the residents) either file a grievance and we go meet with them or for new admits, the dietician meets with the resident and goes over their preferences. He would then update their preferences in the software.

Based on record review and interview the facility failed to ensure that there was a system in place for the nursing staff to immediately recognize the resident's code status in the electronic medical record; and to also ensure that the paper chart was on the same unit as the resident. This deficient practice affected 1 resident (R #1) out of 10 (R #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) residents residing in the facility, causing confusion among the nursing staff who was not aware of what R #1's code status was and made an assumption of resident being on hospice resulting in staff not initiating any life saving efforts when R #1 was found to not be breathing. The findings are: A. Record review of the face sheet revealed that resident had been diagnosed with [REDACTED]. (This is not a complete list of diagnosis). B. Record review of a History and Physical (H and P) dated [DATE], indicated the following: The chief complaint indicated that R #1 had failure to thrive. R #1 had returned from the hospital with lower lobe pneumonia and chronic on acute kidney failure along with refusing to eat and drink, and refusing medications. Guardianship for R #1 was also in progress. C. Record review of the nursing progress notes dated [DATE] indicated that R #1 needed to have a guardian in place so the facility could pursue Hospice. R #1 had been her own POA (power of attorney) and there was a full code status that the resident had signed in 2016, before she was unable to make decisions about her medical care. R #1 did not have any family to make those decisions. R #1 had not been eating and was declining. R #1 had been sent to the hospital and returned [DATE] for refusing to eat and drink. D. Record review of the dashboard/facesheet in the EMR (electronic medical record) indicated that no advance directives were listed for R #1. E. On [DATE] at 5:00 pm during an interview with Certified Nursing Assistant (CNA) #1, he stated that (on [DATE]) he went into R #1's room and he saw that she was not breathing. He asked the other CNA, CNA #3 to check to see if she was breathing, and CNA #3 confirmed that she was not. He then went and told the nurse that R#1 was not breathing. Registered Nurse (RN) #2 went down to check and confirmed that she was not breathing and continued to check other vitals. RN #2 asked him if he would go find another nurse who could help her with the process for the paperwork because she wasn't familiar. CNA #1 went up front and found another nurse. LPN #2 came down and was told that R #1 had passed away and that RN #2 needed help with the paperwork. LPN #2 started to look for R #1's chart and they could not find it. He stated that they looked for her chart for a long time and he did not know if they found it. During a follow up interview on [DATE] at 10:55 am with CNA #1, he stated that he is Cardio [MEDICAL CONDITION] Resuscitation (CPR) trained and he would have started CPR for R #1 if he knew her code status. He stated he didn't want to start a code because he wasn't clear what it was. F. On [DATE] at 2:20 pm, during an interview with CNA #3, she stated that the first time she worked that unit, and she had worked on the evening shift. She stated that she could not remember specific times but that she had checked in on R #1 and she was fine, this was sometime after dinner she remembers. CNA #3 had been told that R #1 was on palliative care and had been declining. Then towards shift change around 10 :00 am for CNA's, CNA #1 looked in on her again and he came out of the room and asked me to go check on R #1 because he didn't think she was breathing. CNA #3 stated she went and checked and she wasn't breathing. So they went and told RN #2. RN #2 came down and checked her breathing and vitals and pronounced her dead. CNA #3 stated she did not know R #1's code status and CNA #1 wasn't sure if she was on hospice or not, so they went and got the nurse. G. On [DATE] at 5:39 pm, during an interview with RN #2, she stated that she was told during shift change that R #1 was on palliative care. RN #2 stated that she assumed that R #1 was a DNR. RN #2 stated that when she went to check on R #1 around 10 pm, to see if she was breathing, she wasn't exactly hot or cold, but slightly warm to the touch. She felt like R #1 had not just passed away, that it had been a little awhile. Going down to do vitals on her and to check her pupils etc. She did ask for another nurse to come and assist her because she didn't know the process of how they handled a resident death. She stated LPN #2 came down and asked her about her code status and RN #2 stated that she was already dead and that she had already pronounced her. RN #2 stated that LPN #2 identified that R #1 was a full code and asked her if she had started CPR on her. RN #2 told LPN #2 that she thought that she was on palliative care and was a DNR. RN #2 also stated that she felt like R #1 had not just passed away, that it had been awhile. H. On [DATE] at 1:28 pm, during an interview with Licensed Professional Nurse (LPN) #2, she stated that on the evening (around shift change at 10:00 pm, that R #1 passed, CNA #1 had come to her and asked for her to help the nurse on the back unit. He stated that the nurse in the back needed help. LPN #2 stated that she went right away to the back. When she arrived on the unit she was asked about paper work and the forms that needed to be filed out when there is a death. LPN #2 stated that she went to get R #1's chart but they could not find it. She looked in the EMR at the dashboard and the advance directive was not there either. She had to look further into the EMR to find the code status and when she realized that R #1 was a full code she asked RN #2 whether or not she did CPR on her. LPN #2 stated that RN #2 told her no she didn't because she assumed she was a DNR because she was on palliative care. LPN #2 then stated that she instructed RN #2 to call the CNE to tell him what happened. LPN #2 stated that so much time had passed at this point that there would be no need to start CPR. I. On [DATE] at 4:30 pm, interviews with Center Executive Director (CED), she stated that when she interviewed Registered Nurse (RN) #2 during her investigation, RN #2 stated that she was under the impression that R #1 was on palliative care/hospice (an approach that improves the quality of life of patients who are facing the challenges associated with life-threatening illness). The CED stated that R #1 was not on palliative care or hospice at that time, however, that was something they were looking into for her. The CED confirmed that the paper chart for R #2 was not on the hall that she had been readmitted to on [DATE]. The CED also stated that the advance directive was not on the dashboard/face sheet in the electronic medical record (EMR) for R #1. The CED stated that making an assumption about R #1's code status, the fact that the paper chart was not on the proper hall, and that the code status was not available in Electronic Medical Record (EMR) dashboard was inappropriate and a fail on the part of the facility. She also stated that they immediately started a Program Improvement Plan (PIP) and began making changes right away. J. On [DATE] at 2:15 pm, during an interview with the Interim Center Nurse Executive (CNE), he stated that the code status or advance directive was discontinued when R #1 left the facility to go to the hospital. When R #1 arrived back to the facility on [DATE] she was placed on an admission quarantine unit, not the unit she had been on prior to going to the hospital. A new order was never put in place for her advanced directive upon return to the facility, and because there was no order, then it was never put back on the dashboard/face sheet in the EMR. The Interim CNE also stated that if there is no code status available then it goes back to being a full code. K. On [DATE] at 5:15 pm, during an interview with interim CNE, he stated that from a nursing standpoint RN #2 should have started the code. If you don't know someone's code status, if the chart is not available then it becomes full code. He stated that the CNA's also could have and should have started the code. The CNE also stated that there is no excuse to say I thought this resident was on palliative care and assume they were a do not resuscitate (DNR). At the time of the incident on [DATE] the resident had an advance directive which was full code. The nursing staff at the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) when resident was discovered not breathing. The facility investigated this death to find where the failure occurred. The facility implemented changes to prevent another incident like this from occurring again. These changes include the following: 1. Audit for accuracy of all resident records with the Medical Orders for Scope of Treatment, (MOST) form and physician order. 2. Monitor clinical dashboard progress notes for change in condition. 3. Validate current advanced directive with responsible party if discrepancy is found. 4. Validate that care plan is updated. 5. Educate nursing staff to validate code status if there is a decline in condition . 6. Educate staff on documentation form for code situations . 7. Educate licensed nurse staff to check crash cart daily. 8. Validate licensed nurses CPR status and review annually. 9. Medical records and Social Services Department to validate that advanced directives are loaded into Point Click Care (PCC) on same day as admission or change in directive. 10. Medical records to ensure physical chart is on appropriate unit where resident resides. (residents need to quarantine when returning to facility on different unit than unit they reside) 11. Nursing staff are to carry on their person the list of residents and advance directives for the hall they are working on for that shift. During onsite investigation of this complaint it was found that this deficiency had been corrected based upon the following: 1. Confirmation that every current resident had an accurate MOST form, physician orders, care plan updates and monitoring of resident dashboards. 2. Nursing staff were educated on Cardiac/Respiratory Arrest, Carts, AED, and MOST forms. The Inservice covered [MEDICAL CONDITION] P and P's AED checklist, Emergency Cart checklist. MOST forms and code status and the training indicated the following: Must be completed upon admission and readmission. After patient signs MOST form, needs to be placed in Physician's bin which is located in the copy room. Orders must immediately be put into PCC (even without provider signature), Anytime family/resident change MOST form, SSD must be notified and PCC order updated. All staff need to have list of Resident's code status on their person at all times. 3. Surveyors reviewed audit sheets for advance directive admission or readmission. It covered the following areas of resident code status such as: reviewed on admission with responsible party, what the code status is, physician order, DNR consent form if applicable, social services documentation of code status, plan of care code status and if the code status alert was in place. 4. Surveyors confirmed that new admits and LTC residents had code status in chart, on dashboard, uploaded in system and physician order [REDACTED].>5. Surveyors interviewed and observed that current staff had their papers on them to verify code status for residents on the halls they are working on and if they knew what to do if they encountered a resident who was not breathing/unresponsive.

The facility failed to ensure that accident hazards were minimized on the locked Dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life) unit, by failing to provide residents with the correct consistency snack. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being identified on 03/06/18. The facility was notified on 03/06/18 at 4:21 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/06/18 at 4:23 pm. Based on the Plan of Removal, interventions included: 1. Snack lists have been reviewed for correct diet by CNE (Center Nurse Executive) and Dietician on 03/06/18. 2. Diet orders have been provided to the nursing stations for quick review for staff on 03/06/18. 3. Staff currently working were educated on the diet order notebooks on 03/06/18, other staff will be re-educated prior to working their next shift. 4. Daily checks will be conducted for residents on snacks for correct diet by the unit manager or designee for 1 week, and then weekly for 4 weeks, and then monthly thereafter. 5. The daily checks will be brought to QAPI (Quality Assurance Performance Improvement) monthly for three months. Based on the Plan of Removal, the IJ was lifted on 03/06/18 at 4:25 pm. This resulted in the scope and severity being reduced from level J to level D. Based on observation, record review, and interview, the facility failed to ensure that residents received the correct consistency of snacks and that the resident environment was free of tripping hazards for 3 (R #s 35, 81, 97) of 3 (R #s 35, 81, 97) residents reviewed for accident hazards. This deficient practice increases the risk for falls, choking, aspiration, and/or death. The findings are: Findings for R #81 A. Record review of R #81's Diet Order and Communication Form dated 11/06/17, revealed R #81's diet was changed to dysphasia puree (diet where all food has been ground, pressed, and/or strained to a consistency of a soft smooth paste) by the Speech Therapist. B. On 03/06/18 at 11:06 am, during observation in the locked Dementia Unit, R #81 was given a whole banana as a snack. C. On 03/06/18 at 2:07 pm, during observation in the locked Dementia Unit, R #81 was given half of a peanut butter and jelly sandwich as a snack. D. On 03/06/18 at 2:16 pm, during interview CNA (Certified Nursing Assistant) #1 stated that he believed R #81 was on a mechanical soft diet (foods that are chopped or soft). After checking, CNA #1 verified that R #81 is dysphasia pureed and confirmed that he did give her a peanut butter and jelly sandwich. CNA #1 also stated that residents' diet orders are communicated three ways: 1. on the diet sheets kept in the medical charts, 2. the nurses tell CNAs, 3. On the diet order slips. E. On 03/06/18 at 2:19 pm, during interview RN (Registered Nurse) #1 stated that a peanut butter and jelly sandwich is not appropriate on a pureed diet. RN #1 confirmed that CNAs should know which residents are on a pureed diet, stating that most of the CNAs are regulars, so they are well aware. F. On 03/06/18 at 2:30 pm, during interview the Dietary Director confirmed that a peanut butter and jelly sandwich is not acceptable on a pureed diet. The Dietary Director stated that the snacks will have a nutrition label put on it from the kitchen and then staff take them down to the Dementia unit. He stated that diet orders are inputted into the labeling system by either himself, the dietician or via a request from physical therapy. G. On 03/06/18 at 2:40 pm, observations in the refrigerator on the Dementia Unit, showed that the information on the peanut butter and jelly sandwiches included the name of the resident, the date, and what the snack is. During interview with the Dietary Director and Dietitian on the unit, they both verified that the nutrition label does not state the diet type, stating that if staff are not familiar with the residents, they could pass the wrong snacks. H. On 03/06/19 at 2:52 pm, during interview the Dietary Director stated that R #81's diet change to a puree diet was not updated in the Resident Diet System (RDS) which prints out the nutrition labels for the snacks. He stated R #81 has been getting non-pureed snacks for about a year and a half. He stated that he did not know who put the order in for her pureed diet. I. On 03/06/18 at 3:27 pm, during interview the Speech Therapist stated that in (MONTH) (2017) she put R #81 on a pureed diet because of excessive chewing and pocketing of her food, not because of choking. She stated that excessive chewing could cause her to pocket her food, which could lead to aspiration. The Speech Therapist was asked if a banana was appropriate, she stated No, I don't trust her with a banana. I wouldn't clear it until I cleared it. I consider it (a banana) more regular diet. Unless it's mashed up, I wouldn't feel comfortable with her eating a whole banana. J. On 03/06/18 at 3:37 pm, during interview CNA #2 stated that she believes R #81 gets a peanut butter and jelly sandwich as a snack. When asked which residents were on a pureed diet, CNA #2 did not indicate R #81 was on a pureed diet. CNA #2 stated that the snacks come from the kitchen with nutrition labels and she just hands them out to residents. CNA #2 stated that she would give R #81 a banana because she is on a regular diet. She also stated that when she passes out meals, she looks at the meal ticket and the food to make sure they match, but could not remember if R #81 was on a pureed diet. CNA #2 also stated that the bananas come from the kitchen with no nutrition labels. During the interview, CNA #2 looked at R #81's Kardex (a summary of all the resident's care needs which includes diet consistency) which showed her diet as regular/liberalized and mechanical. K. On 03/06/18 at 4:07 pm, during interview the Unit Manager stated that she just looked up R #81's diet and stated it was dysphasia pureed. She stated that on the meal tickets and CNA Kardex, it says what diet residents are on. The Unit Manager stated that as far as she knew, the snacks come from the kitchen labeled, so CNAs know who to give the snacks to. When asked if a peanut butter and jelly sandwich was appropriate, she stated, I had to clarify that too. No, it's not, unless they have been evaluated by speech therapy. The Unit Manager stated that she did not recall seeing R #81 eating a sandwich or a banana. She verified that if CNAs are passing meals with pureed food, they should see that the snacks are not appropriate. L. Record review of the Nutritional Snack Label provided by the Dietary Director dated 03/06/18, showed R #81's name, room number, and ½ peanut butter and jelly sandwich. M. Record review of R #81's Care Plan, revealed it was updated on 03/06/18 with the focus, goal, and interventions related to impaired swallowing. R #81 was not care planned for swallowing issues or a pureed diet prior to 03/06/18. N. Record review of the Nutritional assessment dated [DATE], revealed diet is Dysphagia puree. O. On 03/06/18 at 5:20 pm, during interview the Administrator stated that she talked to the CNA working day shift on 03/06/18 and confirmed that at around 11:00 am, she gave R #81 a whole banana and she did not mash it. Findings for R #97 P. Record review of the Physician order [REDACTED]. Q. On 03/06/18 at 3:37, during observations of the fridge on the Dementia Unit, revealed a small sealed cup of fruit chunks with R #97's name written on the top. R. On 03/06/18 at 2:19 pm, during interview with RN #1 she stated that R #97 was on a pureed diet. S. On 03/06/18 at 3:37 pm, during interview with CNA #2 she stated that R #97 was on a pureed diet. She stated that R #97 gets yogurt, soft foods or the health shake for snacks. CNA #2 did not know why the fruit cup with his name on it was in the fridge. She also stated that she has not seen him eat a sandwich or a banana. T. Record review of the 1:1 (one on one) Monitoring sheets for R #97, dated 2/16/18 to 03/06/18, revealed the following: 1. On 02/16/18 at 10:20 pm, states had a snack (banana and milk shake). 2. On 02/21/18 at 4:35 am, states he woke up and ate snack (cracker) then went back to bed asleep. 3. On 02/23/18 at 11:30 am, states still watching. Health shake, juice, sandwich. 4. On 02/23/18 at 1:12 am, states I gave him some snacks i.e. sandwich, yogurt, and shake. He went back to bed after snacking. At 5:19 am, states the resident came out of his room to the dining room, offered him some snacks, shake, sandwich and yoplait (yogurt). 5. On 02/25/18 at 7:00 am, states he's in DR (dining room) got his coffee and a cookie while waiting calmly for breakfast. 6. At 1:00 am (not dated), states resident got up, used restroom, ate a cookie went back to bed. 7. On 03/05/18 at 1:15 am, states rsd (resident) gets a cookie and milk. U. On 03/09/18 at 10:22 am, during interview the Speech Therapist stated that she was not aware that R #97 was getting non-pureed snacks. She stated I was not aware, because I would have intervened. The Speech Therapist stated that at the request of the family she evaluated R #97, and is now being monitored for a dysphagia advanced diet (mechanical soft). She confirmed that a whole banana is not appropriate on a pureed diet, stating that if the banana was mashed up it would be acceptable. The Speech Therapist stated It makes me nervous, when she said that she would expect staff to notify her if residents receive inappropriate snacks. She stated that it never occurred to her that staff who work with residents every day, that if they pass their meals why they would given them snacks that are not appropriate. She stated It's common sense to not give a resident a cookie, if they don't get one at meals, if every one else gets one with regular diets. She stated that she is going to be spending more time on the locked unit, because she didn't know staff were giving residents non-pureed snacks. Findings related to R #35: V. On 03/07/18 at 9:20 am, observation of R #35's room revealed an area on the floor between the resident's bed and the bathroom approximately 3 feet by 3 feet where several of the rectangular floor pieces were warped. The floor was slightly raised at the places where the ends of two floor pieces met creating small humps approximately half an inch in height. There were several humps across this area which made the floor an uneven surface. W. On 03/08/18 at 10:46 am, during an interview with the Maintenance Director, he stated that R #35 tends to flush items down the toilet such as wipes, towels and underwear. He stated that his toilet got clogged about 3 weeks ago and the water overflowed from the toilet and flooded part of the resident's room. He stated the wooden floor pieces were warped by the water damage which then created the uneven surface in his room. He stated he ordered new vinyl flooring and is waiting for them to arrive. X. Record review of the facility's purchase order dated 03/02/18 revealed that new vinyl flooring was ordered on [DATE]. Y. Record review of the facility's list of incidents that occurred from (MONTH) (YEAR) to (MONTH) (YEAR) revealed that R #35 had the following falls/incidents: 1. On 06/22/17 resident stated he hit his head on the bathroom door when he tried to open it. 2. On 07/03/17 resident was found sitting on the floor with no injuries. 3. On 12/24/17 resident fell trying to get into his bed while it was in the high position. 4. On 01/09/18 resident was found on the floor in his room with a bruise on his forehead. Z. Record review of R #35's most recent MDS assessment dated [DATE] revealed that his vision is moderately impaired and does not wear corrective lenses. AA. On 03/08/18 at 10:45 am, during an interview with the Director of Nursing, she verified that R #35 has a history of falling but that all his previous falls occurred in his previous room. She stated that he was moved into his current room in (MONTH) (YEAR) and has not had a fall since. She stated they are planning on replacing the floor once the new floor pieces arrive. She stated she does not know the exact day as to when the flooding occurred but thinks it was a few weeks ago. The DON verified that R #35 has poor vision and that the uneven floor is a potential tripping hazard for him.

Based on record review and interview, the facility failed to ensure that residents residing on the Dementia (a decline in mental ability severe enough to interfere with daily life) Unit were free from physical abuse for 8 (R #s 4, 33, 62, 71, 79, 87, 93, and 108) of 8 (R #s 4, 33, 62, 71, 79, 87, 93, and 108) residents reviewed for abuse by failing to prevent R #97 from pushing, slapping, grabbing, and pulling a resident out of bed onto the floor. This deficient practice subjected vulnerable residents to assaults, which are likely to cause serious injury, feelings of fear, distress and humiliation. The findings are: A. Record review of R # 97's Admission record, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. B. Record review of R # 97's Resident Management System Summary Reports revealed the following resident to resident altercations with/alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident, (who was not identifed in report), unknown what triggered resident to hit another resident. He sustained a skin tear on in (sic) right bridge nose area. The (unidentified) resident would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (who was not identifed in report), who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and Certified Nurses Aide (CNA) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim (victim) was lying on the floor. 5. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was sitting in. This resident then stood up and pushed (R #33) causing him to fall on the floor. This resident then reached down grabbing (R #33's) shirt trying to pull him up off floor. 6. On 01/12/18, Resident (R #97) hit (R #108) while he was eating his dinner. (R #108) then hit him back with his cane causing a laceration on this resident's (R #97) forehead. 7. On 01/14/18, Resident (R #97) was sitting at dining room table with a male resident (who was not identifed in report), (un readable) heard calling out. Upon entering room, both residents (R #97 and the unidentified male resident), (unreadable), was pulling on a female resident's (not identifed in report) hand. Resident's (R #97 and unidentifed male resident) hands were separated and (unidentifed) female resident was asked if she would like to move to another seat. Unidentifed female resident replied yes and was assisted to another table in a different section of the dining room. Each resident (all three) was examined for injury. Upon visual inspection of hands, a skin tear upon the back of (unidentifed) male resident's hand was located between thumb and index finger. 8. On 01/22/18, Resident (R #97) was found by CNA in a neighboring room. Resident was witnessed pulling on the arm of another male resident (R #93) who was on the floor. 9. On 01/31/18, Resident (R #62) was found on the floor on his back in room [ROOM NUMBER] (R #97's room). (R #97) had his hand on resident's wrist. 10. On 02/09/18, I heard (R #93) yell out in fear. I ran down to room and found (R #97) standing above (R #93), holding his left leg, jerking it, pulling him off the bed onto the floor, onto the mat next to the bed. (R #93) yelling out in fear. No physical injury noted, but Pt (patient # 93) is very upset. 11. On 02/13/18, Per nurse report, nurse heard yelling from nurses station and when (sic) to check noted this resident (R #79) being pushed by another resident (R #97) into the hall from his room causing her to fall on floor in hallway, nurse noted the other resident, R #97 then attempting to pull her to standing position. C. Record review of R # 97's Psychiatry Note dated 02/05/18, revealed Patient has shown improvement in behaviors with [MEDICATION NAME] (used to treat high blood pressure). Continues to have some agitation with certain residents. He is more easily redirected. D. Record review of R #97's Minimum (MDS) data set [DATE], revealed that he has Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring 4 to 6 days, in the 7 day look back period. R #97 has wandered 4 to 6 days in the 7 day look back. He requires limited assistance with walking and locomotion (how resident moves between locations). He has no physical impairments to his upper and lower extremities (arms and legs) and he does not use any mobility devices (wheelchair, walker, cane). E. Record review of R # 97's Physician order [REDACTED]. Every shift for resident to resident abuse. The orders indicate the following medications are in the process of being gradually reduced or were discontinued: [MEDICATION NAME] (an anticonvulsant) for Dementia and behaviors, [MEDICATION NAME] for agitated behavior related to Dementia, [MEDICATION NAME] for Dementia, agitation, and behaviors, [MEDICATION NAME] (antipsyhotic) for violent psychiatric behavior, severe agitation, restlessness, and [MEDICATION NAME] (antipsychotic) for agitation. F. Record review of the Progress Notes dated 03/19/17 through 03/08/18, revealed the following incidents with R #97: was physically aggressive and/or attempting to hit, choke, push, grab, slap both residents and staff members; 1. On 03/03/18 at 2:18 am, Pt (R #97) was awoken by another Pt. (resident unidentifed) going in his room yelling and looking for her husband. He (R #97) came out with a jolt to his room door. Following the other Pt. (resident unidentifed) into the dining room. 2. On 2/25/18, Resident tried grabbing another resident's (resident unidentifed) arm who sat down at the same table. 3. On 02/21/18, Resident got up to go to the bathroom, CNA assisted him to the bathroom. (R #97) pushed CNA up against the wall when returning to bed. 4. On 02/13/18, during a meeting with (R #97) family, states (R #97) was sent to (name of hospital) to try and have the eval (evaluation ) done, but they were unable to do a med (medication) eval due to his severe dementia. (R #97) has been aggressive with all the family members at one time or another. They understand that he can hurt someone and they don't want him to hurt anyone. His meds will be adjusted so that he is unable to hurt anyone. 5. On 02/06/18, While attempting to redirect resident to his room, he attempted to strike and choke the CNA. Once assisted to his room, resident again attempted to strike and push both nurse and CNA inside resident room. 6. On 02/01/18, Resident with aggressive behaviors throughout afternoon. Not hard to divert but persistent in his attempts to threaten other residents with body language or reaching out with both hands. 7. On 01/28/18, Resident sitting in dining room when he stood up from his chair and attempted to slap another male resident (resident unidentifed) walking by. 8. On 01/16/18, Resident observed standing up to strike another male resident (resident unidentifed) in the face. 9. On 01/15/18, (Name of a behavioral health hospital) called and said that (R #97's) dementia is too severe and he wouldn't be able to participate in their program. 10. On 01/14/18, Female resident (resident unidentifed) had entered resident's room at 5:15 am. Female was overheard stating that she was looking for the restroom. Upon entering the room to direct female resident, the patient charged at her with hands out as if preparing to push her. 11. On 01/11/18, Female resident (resident unidentifed) was standing near sink in dining room when this resident (R #97) walked in and up to her raising his hands towards her. 12. On 01/11/18, Resident attempted to become physically aggressive with (R #4) twice today. Both times (R #4) was just passing by in hallway and (R #97) went after him attempting to grab him while staring him in face. Both times resident (R #97) was intercepted from hitting resident (R #4). (R #4) did nothing to bring on (R #97's) anger. 13. On 01/10/18, Resident in hall at approximately 3:30 am. As I (RN #2) went to investigate the resident had reentered his room and was sitting on the edge of the bed. I entered the room to check on his needs when the resident stood from the edge of the bed and charged at this nurse. Using my hands to fend him off the resident grabbed both my hands in a crushing grip, and started to push wildly at me, and backed me out of the room and into the hall. Where he momentarily stopped his attack. The resident walked back into his room turned around, spotted me in the doorway, and charged at me again. Further review of the progress notes revealed between (MONTH) (YEAR) and (MONTH) (YEAR), R #97 has had 24 attempted incidents of physical aggression such as hitting, choking, pushing, grabbing, and slapping both residents and staff members and 10 incidents of actual physical contact between R #97, other residents, or staff. G. Record review of the care plan updated on 02/09/18, indicated that interventions were being added to the care plan. Some of the new interventions were: 1. Add 1:1 2. Guide resident through the task at hand 3. Make eye contact prior to starting care 4. Provide outdoor activities 5. Monitor medications, especially new/changed/discontinued 6. Observe for non-verbal signs of physical aggression, e.g.,rigid body position, clenched fists H. On 03/08/18 at 9:36 am, during interview the Director of Nursing (DON) stated R #97 Has spatial issues, if you get too close he gets angered more. At night he was roaming more, so we put the 1:1 (one on one/staff to resident) at night. The DON stated that staff should be arms length away at all times a night. I. On 03/08/18 at 9:48 am, during interview the Corporate Compliance Nurse (CCN) stated that R #97 is territorial and reacts when residents get too close. She stated that R #97 used to be able to communicate, but he has declined. She stated that his behaviors are communicating his needs and that R #97 was reacting to situations were he was provoked by other residents. She stated that R #97 was not intending to hurt other residents, but from the reports it seemed like he was concerned for the other person and was trying to help them up. The CCN confirmed that R #97 would push residents away if they got to close to him, went in his room, or sat at the same table. She stated that they increased his behavior management and feels like it has been successful in reducing his behaviors. J. On 03/08/18 at 11:49 am, during an interview the Administrator stated that R #97 reacts because he is usually provoked by residents getting in his space. She stated that if somebody is at his table trying to do something with him, he'll push them. The Administrator stated that his Dementia was increasing, he was no longer verbal. She stated that the interventions they have in place are: to give him space in the dining room, they put a stop sign across his door and another residents door, medication adjustments, put him on extra monitoring, one on one, and stated that she has seen a decrease in his behaviors. The Administrator stated that R #97 has no place else to go and that the residents on the unit are as safe as they can be. The Administrator stated that R #97 does not posses the cognition to have the intention to cause harm to other residents, but that he is reacting to situations were he feels like his space is being invaded. The Administrator verified that R #97 has made physical contact with residents, but that it is not intentional when he pushes them, it is him reacting to the situation. K. On 03/08/18 at 2:09 pm, during an interview the DON stated that she made the decision after discussing with the doctor to put R #97 on one to one monitoring at night because his behaviors were worse. She stated that during the day, she has enough staff working on the unit to monitor him during the day. The DON stated that R #97 hasn't always been aggressive, but that his Dementia is worse and his speech and understanding has declined over the last few months. She stated that she sent him out for an evaluation and has a referral to see a psychiatrist off site and is working to reduce his medications. L. On 03/08/18 at 2:27 pm, during an interview Certified Nursing Assistant (CNA) #10 stated that R #97 will usually get upset when it's meal time and he gets his food. CNA #10 stated that if somebody touches his food, he reacts and pushes people. She stated that he has behaviors at every meal, so they try to pay attention to make sure no one goes around him. She stated that R #97 is tall and strong and states that when he pushes or hits residents, that it's deliberate. M. On 03/09/18 at 10:04 am, during an interview Licensed Practical Nurse (LPN) #1 stated that R #97 has behaviors if people intrude on his space. LPN #1 stated that about a month ago he got confused and pulled another resident out of bed. LPN #1 also stated that it was reported to her that a female resident went into his room and R #97 pushed her out of his room into the hall. She stated there are a lot of other incidents where other residents will approach him, try to hover over him, or take his drinks and that is when he gets defensive. N. On 03/09/18 at 10:56 am, during an interview Registered Nurse (RN) #3 stated, that he thinks R #97 only responds to things in his field of vision. RN #3 stated that he does not see a purpose with any of R #97's behaviors, it's more of a reflex, not intent. RN #3 stated that R #97 Can no longer form the intent. Other than him pushing residents from his bubble, there is no intent involved. He does not have spasms, he does not jerk. When asked if R #97 pushes residents accidentally, RN #3 stated No, it's not that he brushed them accidentally, it's deliberate but not intentional. When asked if R #97 is a danger to other residents, RN #3 stated that was a hard question to answer, but stated He is still very strong. He physically ejected me from his room. RN #3 stated the potential for R #97 to hurt someone is there. O. On 03/12/18 at 4:07 am, during observation and interview CNA #11, was observed in R #97's room doing 1:1 care. CNA #11 stated that she is a little scared because R #97 tries to grab her when he gets up. She stated that when he goes after her, she gets scared but she tries not to show fear because she doesn't want him to become more aggressive. P. On 03/12/18 at 6:05 am, during an interview CNA #12 stated that R #97 was going into other resident rooms and that before the 1:1 he would go straight to R #93's room and pull him off the bed. She stated that R #97 was pulling R #93 off the bed or going into his room often enough that one on one was started. Nobody is safe. We don't know what triggers him. If you happen to be passing by, you're the one that's gonna get it. If you are in his face, it will be faster. She was asked if R #97 was appropriate on the unit, she stated No. She was asked if R #97 is dangerous, she stated To staff and residents. (Name of R #97) is pretty strong. A lot of female staff are afraid of him. He mostly attacks the girly women. Some people (staff doing 1:1) sit in his room, I don't. If it's dark and you startle him, he's going to attack you. He tends to go for strangers. I stay in the hallway because I know he is going to two places, he goes to R #93's room or the dining room. Q. On 03/12/18 6:18 am, during a second interview CNA #11 stated He was really aggressive, so when he comes at you, if you don't run away he will assault you. Since he doesn't speak you don't know what's going on. He stares and he frightens you. When they decided to put him on 1:1 that was when he was always going to one room and pulling the resident out of bed. That was scary, we didn't know what happened. More than two times he was going to the room of a particular resident. I witness (sic) it twice, he (R #93) was yelling and crying and R #97 was standing over him. I was in a room, I just find (sic) the resident on the floor with the bed sheets on the floor. The second time, (R #97) was pulling on his foot. It was scary because you don't know what can happen. CNA #11 was asked if R #97 is dangerous, she stated Yes, because in the dining room, if you leave him alone, he will go and slap all the people. I saw four times (sic) this week already with one woman (R #79). R. Record review of the Abuse Prohibition Policy dated 09/01/16, stated Centers will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following; prevention of occurrences, identification of possible incidents or allegations which need investigation. Purpose: to ensure that center staff are doing all that is within their control to prevent occurrences of abuse and mistreatment for [REDACTED].

Based on record review and interview the facility failed to adequately monitor (through skin assessments) and prevent skin breakdown that led to pressure sores for 1 (R #38) of 1 (R #38) residents looked at for pressure injury/sores and skin breakdown. This deficient practice contributed to R #38 having multiple pressure sores (areas of damaged skin caused by staying in one position for too long) which commonly form where your bones are close to your skin, such as your ankles, back, elbows, heels and hips due to (MASD) Moisture Associated Skin Damage (which is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus), creating more issues with nutrition and requiring wound treatment that creates pain. The findings are: A. Record review of the Shower sheets indicated that during a shower dated 01/29/18 that R #38 had redness/rash and there was an open area. B. Record review of the Weekly Skin Check Assessments for R #38 indicated that a skin check was done on 12/22/17 and 12/29/17 and there was not another Skin Assessment completed until 02/28/18. C. Record review of the Skin Integrity Report that the DON fills out, indicated that on 01/28/18 and 02/06/18 that R #38 had Moisture Associated Skin Damage (MASD). D. Record review of the Nursing Progress Notes dated 02/04/18, indicated that Resd (resident) appeared very weak and dehydrated. Fluids encouraged and 3 cups taken during shift . [MEDICATION NAME] (a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers) intact on coccyx area for protection. Very red open areas on groin areas with clear fluid drainage. Cleansed with warm soapy water and barrier cream applied. E. Record review of the Nursing Progress Notes dated 02/08/18, indicated that . Open area/redended (sic) area noted to coccyx. Dressing applied. Barrier cream applied to groin (sic) and buttocks area. Repositioned on side. F. Record review of the (name of the hospital) History and Physical Addendum by (name of person) for R #38 dated 02/10/18, indicated that Nursing notes severe skin breakdown in groin and pressure ulcer at heel. Will have wound care evaluate. G. Record review of the (name of hospital) Wound Care/Ostomy Forms, Plan of Care: indicated that on 02/11/18 the head to toe skin assessment determined that R #38 had Noted R (right) lateral heel unstageable pressure injury. Wound over heel with tan slough (a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, a sore, or an inflammation) throughout. Foam dressing in place, peeled back to assess . Positioned patient off wound using pillow. Bilateral (affecting both sides) inner thigh, labia majora, Please define perineum (the area between the anus and the scrotum or vulva) and inner buttocks denuded (Denuded means skin gone via chemical means (urine, feces, sweat)). MASD likely from urine leakage .L (left) inferior and superior coccyx (tail bone) with unstageable pressure injuries. Circular wounds over bony prominence. Tan slough throughout both. Non blanching (to cause to become pale, by using digital pressure). No s/s of infection. Blancable redness over entire sacrococcoygeal (pertaining to both the sacrum and coccyx (the tailbone)) area . H. Record review of the care plan dated 12/25/17 indicated that one of the interventions for skin breakdown was to do Weekly Skin Assessments by the licensed nurse. I. On 03/08/18 at 2:32 pm, during an interview with Director of Nursing (DON), she stated that R#38 was originally admitted for a right non surgical leg fracture. She stopped eating for three days so she was sent out to psych (psychiatric) services. Psych services sent her to (name of hospital) and they performed surgery on her right leg fracture and sent her back to this facility. After the surgery she thought that R #38 was in a cast and that it was not removable, but it was a removable cast. When asked if the right heel was being checked, the DON stated that she was not looking at it and that there was a failure on the part of the facility. J. On 03/08/18 at 4:42 pm, during an interview with Licensed Practical Nurse (LPN) #4, she stated that R #38 wouldn't drink enough. She stated that she knew R #38 was dehydrated because of the dry skin, poor skin turgor and cracked lips. She also stated that her pulse was often times high. She stated that R #38 was incontinent and had diarrhea. LPN #4 also stated that if R #38 was having diarrhea she would not give R #38 her stool softeners. LPN #4 also stated that R #38 did have an open area on her Coccyx (referred to as the tailbone), and they were putting cream and a foam dressing on it. When LPN #4 was asked about R #38's heel she stated that she did not have an open area on her heel. K. On 03/12/18 at 9:12 am, during an interview with the Director of Nursing (DON), she confirmed that on the Activities of Daily Living (ADL) flowsheet R #38 was having constant watery stools for (MONTH) (YEAR). She also stated that if a resident was having constant watery stools they should not be getting stool softeners. This could cause skin breakdown and diarrhea depending on fluid intake. The reason that stool softeners are usually prescribed is for residents on opiod (drugs that act on the nervous system to relieve pain) pain medications. L. On 03/12/18 at 9:47 am, during a second interview with the DON, she stated that R #38 had a removable boot but she thought it was a cast. It was removable but she wasn't looking at it. She stated that R #38 did have Moisture Associated Damage and because of this R #38 could have been raw, maybe bloody, because of the wiping when she was incontinent. The DON also stated that the dehydration can contribute to Urinary Tract Infection (UTI's). [MEDICAL CONDITION] (potentially life-threatening complication of an infection) could have been caused by the [MEDICAL CONDITION] but I can't say the UTI is what caused it. The Uropethay (occurs when urine cannot drain through a ureter) could have caused [MEDICAL CONDITION]. It's hard to know and the hospital didn't know either. M. On 03/14/18 at 9:10 am, during an interview with Certified Nursing Assistant (CNA) #14, she stated that R #38 had a red bottom with severe diarrhea 3 or 4 times per shift. She also stated that R #38 was not drinking enough fluids and not eating. CNA #14 stated that they apply cream and put on a foam dressing over that area. She stated that they (the CNAs) were telling the nurses about the poor food and fluid intake, the redness and the diarrhea. N. On 03/14/18 at 9:10 am, during an interview with RN #3, he stated that the incontinence could have contributed to R #38 having an open area. He also stated that the day that R #38 went out to the emergency room (ER), she had lost a lot of weight in a short period of time. Like 14 pounds in ten days or two weeks. He stated that R #38 wasn't eating or drinking on and off since admission. O. On 03/14/18 at 10:27 am, during an interview with the DON, she stated that she had a conversation with the Power of Attorney (POA) sometime after 02/09/18. The POA reported to her that R #38 had an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) pressure ulcer to the right heel. The DON stated that R #38 did not get any of the pressure ulcers at the facility, that R #38 got the pressure ulcers while at the hospital. The DON stated that she was aware of the Moisture Associated Damage on her Coccyx and she was actively looking at this area. When asked about the lack of assessments for R #38, the DON indicated that the nurses are supposed to be doing skin assessments and that probably when R #38 returned from the hospital the first time (early (MONTH) (YEAR)) she is not sure that she triggered for skin assessments and that this is probably why they weren't done.

Based on record review and interview, the facility failed to provide a drug regimen that was free from unnecessary medication, duplicate medication, or medication that had an appropriate [DIAGNOSES REDACTED].#38) of 6 (R#s 38, 9, 18, 38, 104, 119) residents reviewed for unnecessary medication. This deficient practice likely contributed to R #38's dehydration and malnourishment and caused R #38 to have moisture associated skin breakdown, eventually returning to the hospital and prolonging and complicating her recovery. The findings are: A. Record review of the Admission Record indicated that R #38 had a [DIAGNOSES REDACTED]. B. Record review of the R #38's physician's orders [REDACTED]. C. Record review of R #38's physician's orders [REDACTED]. D. Record review of the Medication Administration Record [REDACTED]. E. Record review of the MAR for the month of the (MONTH) (YEAR) indicated that R #38 received 16 out of 18 doses of the [MEDICATION NAME] medication and 15 out of 18 of the Sennosides medication. R #38 refused one dose of [MEDICATION NAME] on 02/03/18 and refused again on 02/09/18. On 02/03/18 R #38 refused both doses of the Sennosides medication and refused one dose on 02/09/18. F. Record review of the Activities of Daily Living (ADL) flowsheet dated 01/29/18 indicated that R #38 had several days of loose stools, some entries are noted as soft formed and some are watery. Entries from the ADL flowsheet from 02/01/18 to 02/09/18 indicated that R #38 had watery stools daily. G. Record review of the Minimum Data Set ((MDS) dated [DATE], section I, indicated that R #38 had a [DIAGNOSES REDACTED]. H. Record review of the care plan dated 12/25/17 and revised on 01/17/18 indicated that there was not a care plan focus or intervention for R #38's diarrhea and malnutrition. I. Record review of the (Name of Healthcare Facility), History and Physical Report indicated that R #38 was admitted to the emergency room (ER) on 02/09/18 for softball sized abdominal mass, a 14 pound weight loss, altered mental status. While in the ER, R #38 was noted to have an Acute Kidney Injury (AKI) [MEDICAL CONDITION] (an infection) from a Urinary Tract Infection [MEDICAL CONDITION]. The History and Physical also indicated that R #38 had a past medical history to include Chronic Diarrhea. J. On 03/08/18 at 4:42 pm, during an interview with Licensed Practical Nurse (LPN) #4, she stated that R #38 wasn't eating or drinking fluids. Or at least not enough fluids. LPN #4 stated that she did appear dehydrated due to dry skin, lips were cracked, poor skin turgor. She was incontinent and had diarrhea. She stated that when R #38 was incontinent she would hold her [MEDICATION NAME]. She also stated that R #38 had an open wound on her coccyx (tailbone) because of the incontinence. A foam dressing was being placed along with barrier cream. K. On 03/09/18 at 8:26 am, during an interview with CNA #13, he stated that R #38 never ate or drank much. He stated that her stools weren't loose all the time but that she did have loose stools. They would offer her drink supplements and she would drink a little of that. L. On 03/09/18 at 10:15 am, during an interview with Director of Nurses (DON), she stated that the pharmacist had not reviewed R #38 since she arrived on 12/22/17. She stated that the pharmacist had not been in for this month (March (YEAR)) but he would be conducting a Medication Regimen Review for R #38. M. On 03/12/18 at 9:12 am, during an interview with the DON, she confirmed that on the ADL flowsheet R #38 was having constant watery stools for (MONTH) (YEAR). She also stated that if a resident was having constant watery stools they should not be getting stool softeners. This could cause skin breakdown and diarrhea depending on fluid intake. The reason that stool softeners are usually prescribed is for those residents on opiod (are primarily used for pain relief) medications. N. On 03/14/18 at 9:10 am, during an interview with CNA #14, she stated that R #38 had a red bottom with severe diarrhea 3 or 4 times per shift. She also stated that R #38 was not drinking any fluids and not eating. She stated that they (the CNAs) were telling the nurses about the poor intake, the redness and the diarrhea.

Based on record review and interview, the facility failed to provide necessary treatment and services to heal pressure ulcers for 1 (R #13) of 1 (R #13) residents reviewed for wounds when they failed to notify the healthcare provider of the development of bilateral heel ulcers. This deficient practice likely resulted in the resident not receiving the care and services necessary to promote healing which resulted in worsening of the bilateral pressure ulcers. The findings are: A. Record review of the Nursing Assessment-Initial (Admission) dated 12/15/16 revealed Integumentary (skin) assessment describing skin as occasionally moist, normal for ethnicity skin color, warm, and without skin impairment present. B. Record review of the Progress Notes revealed: 1. Entry dated 12/23/16 revealed resident had a new onset/change in skin integrity as evidenced by ulcer-pressure. The location is identified as skin breakdown to bilateral heels noted. 2. Entry dated 12/28/16 revealed the resident had a skin injury/wound that was previously identified and described the area as pressure area location bilateral wounds to heels. 3. Entry dated 01/04/17 revealed the resident had previously identified injury/wound and described the wounds as located on bilateral heels. 4. Entry dated 01/23/17 revealed Res (resident) heels improved. Scab is beginning to peel away with pink healing. Dressing applied to protect scab from ripping away. 5. Entry dated 01/26/17 revealed a skin injury was present that had previously been identified and was evaluated and the location was pressure area. 6. Entry dated 03/02/17 revealed a previously identified skin injury/wound was present located on bilateral heels. 7. Entry dated 03/13/17 stated This nurse called to resident's room by CNP (certified nurse practitioner) to assess diabetic ulcers on bilateral heels .100 % eschar (dead tissue) bilateral heels, heels are boggy (abnormal texture of tissue) and surrounding area is calloused (hardened). C. Record review of the Skin Check documentation revealed: 1. Skin check documentation dated 12/28/17, 01/04/17, 01/26/17, and 03/02/17 revealed a skin injury/wound was identified, the wound was not new, was a pressure type wound, and was located on bilateral heels. 2. Skin check documentation dated 01/11/17, 01/18/17, 02/02/17, 02/09/17, 02/16/17, 02/23/17, and 03/09/17 revealed no skin injury identified. 3. Skin check documentation dated 3/13/17 revealed a skin injury/wound was identified, the wound was not new, and described the wound as diabetic ulcers bilateral heels. D. Record review of the Skin Integrity Report revealed one entry dated 03/13/17 regarding bilateral heel ulcers. 1. Left Heel described wound as diabetic, 100 % (percent) necrotic eschar (dead tissue), measuring 3.2 cm (centimeters) length, 4.0 cm width, < (less than) 0.2 cm depth, surrounding tissue boggy, wound edges calloused, and odor present. 2. Right Heel described wound as diabetic, 100 % necrotic eschar (dead tissue), measuring 3.5 cm length, 3.7 cm width, < 0.2 cm depth, surrounding tissue boggy, wound edges calloused, and odor present. E. Record review of the physician orders, Medication Administration Record, [REDACTED]. F. Record review of the Care Plan dated 05/08/16 revealed no care plan focus, goals, or interventions related to R #13's actual bilateral heel ulcers. G. Record review of the physician progress notes [REDACTED].> 1. On 01/23/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 2 .On 02/16/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 3. On 03/13/17 physical exam Skin: Bilateral wounds on heels, L (left) heel with drainage and foul smelling. H. On 03/16/17 at 4:14 pm, during interview with UM #3 (unit manager) she verified she was the facility wound care nurse. She stated R #13's bilateral heel ulcers are considered in house acquired. I. On 03/16/17 at 8:35 am, during interview with the UM #3, she confirmed she was not notified of R # 13's initial documentation of bilateral heel ulcers by facility nursing staff. She stated she was notified of the bilateral heel ulcers by the CNP on 03/13/17. The wound care nurse verified there were no physician orders related to wound care until the CNP notified her of the wounds on 03/13/17 nor were there care plans in place related to the actual wounds prior to that. J. On 3/20/17 at 08:36 am, during interview with the CNP, she confirmed she is R # 13's primary medical provider. She stated staff did not notify her of R #13's bilateral heel ulcers and she found them herself on 03/13/17. She described the left heel wound as moist and smelled bad. She described the right heel wound as mostly dry and about the same size. When asked if she would call his wounds pressure ulcers, she replied yes. She stated she observed the resident without a heels up cushion (a cushion that lifts the heels up off the bed to alleviate pressure) and went to the UM #3 to notify her the staff needed education. K. Record review of emergency room Discharge report revealed R #13 sent to emergency room regarding bilateral heel ulcers on 03/19/17. The discharge [DIAGNOSES REDACTED]. L. Record review of the facility policy and procedure Skin Integrity Management revealed: 1. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. 2. Include all patients who have newly identified skin impairments on the Center's 24 hours summary report. 3. Perform skin inspection on admission/re-admission and weekly. Document on treatment administration record (TAR) or in Point click care (PCC). 4. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. 5. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. 6. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. 7. Document daily monitoring of ulcer site, with or without dressing.

Based on record review and interview the facility failed to ensure that residents were free from neglect for 1 (R #13) of 1 (R #13) residents reviewed for wounds by not notifying the HCP (healthcare provider) of the development of R #13's bilateral (both) heel ulcers. This deficient practice resulted in inconsistent and inaccurate monitoring of bilateral heel ulcers and lack of physician orders for treatment which allowed for R # 13's bilateral heel ulcers to worsen. The findings are: A. Record review of the Nursing Assessment-Initial (Admission) dated 12/15/16 revealed Integumentary (skin) assessment describing skin as occasionally moist, normal for ethnicity skin color, warm, and without skin impairment present. B. Record review of the Progress Notes revealed the following: 1. On 12/23/16 resident had a new onset/change in skin integrity as evidenced by ulcer-pressure. The location is identified as skin breakdown to bilateral heels noted. 2. On 12/28/16 the resident had a skin injury/wound that was previously identified and described the area as pressure area location bilateral wounds to heels. 3. On 01/04/17 the resident had previously identified injury/wound and described the wounds as located on bilateral heels. 4. On 01/26/17 a skin injury was present that had previously been identified and was evaluated and the location was pressure area. 5. On 03/02/17 a previously identified skin injury/wound was present and located on bilateral heels. 6. On 03/13/17, bilateral heel wounds were found by the CNP (certified nurse practitioner). C. Record review of the Skin Check documentation revealed: 1. Skin check documentation dated 12/28/16, 01/04/17, 01/26/17, and 03/02/17 revealed a skin injury/wound was identified, the wound was not new, was a pressure type wound, and was located on bilateral heels. 2. Skin check documentation dated 01/11/17, 01/18/17, 02/02/17, 02/09/17, 02/16/17, 02/23/17, and 03/09/17 revealed no skin injury identified. 3. Skin check documentation dated 03/13/17 revealed a skin injury/wound was identified, the wound was not new, and described the wound as diabetic ulcers bilateral heels. D. Record review of the Skin Integrity Report revealed 1 entry dated 03/13/17 regarding bilateral heel ulcers indicated the following: 1. Left Heel described wound as diabetic, 100 % necrotic eschar (dead tissue), measuring 3.2 cm (centimeters) length, 4.0 cm width, < (less than) 0.2 cm depth, surrounding tissue boggy (painful, firm, mushy, warmer or cooler to the touch than surrounding tissue), wound edges calloused, and odor present. 2. Right Heel described wound as diabetic, 100 % necrotic eschar (dead tissue), measuring 3.5 cm length, 3.7 cm width, <0.2 cm depth, surrounding tissue boggy, wound edges calloused, and odor present. E. Record review of the physician orders, Medication Administration Record, [REDACTED]. F. Record review of the Care Plan dated 05/08/16 revealed no care plan focus, goals, or interventions related to R #13 actual bilateral heel ulcers. G. Record review of the physician progress notes [REDACTED].> 1. On 01/23/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 2 .On 02/16/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 3. On 03/13/17 physical exam Skin: Bilateral wounds on heels, L (left) heel with drainage and foul smelling. H. On 03/16/17 at 8:35 am, during interview with the Unit Manager (UM) #3, she confirmed she was not notified of R # 13's initial documentation of bilateral heel ulcers by facility nursing staff. She stated she was notified of the bilateral heel ulcers by the CNP on 03/13/17. The UM #3 verified there were no physician orders related to wound care until the CNP notified her of the wounds on 03/13/17 nor were there care plans in place related to the actual wounds prior to that. I. On 03/20/17 at 8:36 am, during interview with the CNP, she confirmed she is R # 13 primary medical provider. She stated staff did not notify her of R #13 bilateral heel ulcers and she found them herself on 03/13/17. She described the left heel wound as moist and smelled bad. She described the right heel wound as mostly dry and about the same size. When asked if she would call his wounds pressure ulcers, she replied yes. She stated she observed the resident without a heels up cushion (a cushion used to lift heels up off the bed to alleviate pressure) and went to the UM #3 to notify her that the staff needed education regarding wounds. J. Record review of emergency room Discharge report dated 03/19/17 revealed R # 13 sent to emergency room regarding bilateral heel ulcers. K. Record review of the facility policy and procedure Skin Integrity Management revealed: 1. Identify patient's skin integrity status and need for prevention, intervention or treatment modalities through review of all appropriate assessment information. 2. Include all patients who have newly identified skin impairments on the Center's 24 hours summary report. 3. Perform skin inspection on admission/re-admission and weekly. Document on treatment administration record (TAR) or in Point click care (PCC). 4. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. 5. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. 6. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. 7. Document daily monitoring of ulcer site, with or without dressing.

Based on record review and interview, the facility failed to ensure that each resident received adequate supervision and assistive devices to avoid falls and elopement (unsupervised exit from the facility) for 2 (R #s 4 and 128) of 6 (R #s 4, 73, 79, 128, 156 and 160) residents reviewed for accident hazards. R #4 was not fitted with a Wanderguard device (an electronic monitoring bracelet), allowing her to exit the facility without detection. After R #128 sustained a fall which resulted in a fractured hip, the facility failed to provide adequate supervision, which resulted in the resident falling 2 mores times resulting in skin tears and another fractured hip. These deficient practices likely caused R #128's injuries, and could jeopardize residents at risk for elopement through exposure to street traffic, temperature extremes, or other environmental hazards. The findings are: Findings related to R #4: A. Record review of a Risk Management System document dated 3/19/17 found that it pertained to an elopement event of R #4 on 03/17/17. The document indicated The resident exited the center with another resident at 7:12 pm. The staff was informed of the resident outside at 7:21 pm. The resident was brought back into the center and was assessed for injury and none was noted. B. Record review of R #4's care plan dated 08/02/16 found a focus area stating Resident/Patient is at risk for elopement related to: Cognitive Loss (thinking impairment) / Dementia. Among the listed interventions was Utilize and monitor security bracelet per protocol. All later versions of R #4's care plan were found to have continued this focus area and intervention. C. Record review of R #4's Minimum Data Set Assessment (a tool for reporting on resident characteristics) found a section stating Wandering - Presence & Frequency. To the question Has the resident wandered?, a response of Behavior of this type occurred daily was documented and signed by the Social Services Director on 01/27/17. D. Record review of R #4's progress notes found: 1. A nurse's note dated 07/25/16 stating Res (resident) up through much of shift wandering Tries doors and attempts to enter residents' rooms. Redirected multiple times. 2. A Social Services Dept. (SSD) note dated 07/26/16 stating She is exit seeking and has tried to get out the doors on hall 500. She is wearing a wanderguard bracelet as she does wander around the facility. 3. A Social Services Dept. note dated 08/03/16 stating SSD also spoke to (resident's family member/power-of-attorney) about how (R #4) is wandering around the facility and that she has been exit seeking. Again they refused to have her in the secured unit. The family believes she will adjust and that it will just take her time. SSD explained that we are worried for her safety as she tries to go out the side doors that do not have the wanderguard alarm system. Family wants to keep her in the general area. 4. An Administrator's note dated 08/10/16 stating . She continues to wander and is exit seeking. Family denies her needing a locked unit. Will continue to educate family that she would be safer in a locked unit. Resident has a wander guard . 5. A Social Services Dept. note dated 11/01/16 stating She does have a wanderguard. 6. A nurse's note dated 03/18/17, related to the elopement incident on 03/17/17, stating Resident left facility with another resident this evening at shift change. Residents both found at sign attempting to return. Resident no longer has a wanderguard. Requesting orders for renewal of wanderguard order. Spoke with family, and family wants resumption of wanderguard order. E. On 03/20/17 at 12:35 pm, during interview with the Administrator, she stated that R #4 was on a trial of not having a Wanderguard. She stated that she would look for documents supporting her assertion that a planned, intentional trial was taking place. She did not provide any such documentation by survey's end. F. On 03/20/17 at 12:52 pm, during interview with Unit Manager #3, she stated that R #4 was discharged to a hospital on [DATE], and returned on 03/14/17. She stated that EMTs (Emergency Medical Technicians) routinely cut off Wanderguards when transporting patients, and confirmed that R #4's Wanderguard was not replaced upon her return to the facility. She confirmed that the resident was not wearing a Wanderguard when she eloped through the facility's front door on 03/17/17. G. On 03/20/17 at 12:55 pm, during interview with R #4's family member/power-of-attorney, she stated that R #4 is supposed to have a Wanderguard. She stated that R #4 had had a Wanderguard prior to being discharged to the hospital on [DATE], but that when she returned from the hospital on [DATE], she no longer had it on. She indicated that facility staff had advised her that a new physician's orders [REDACTED].#4 eloped. Findings Related to R #128: H. Record review of R #128's Nurse's Note dated 07/01/16 stated, This day an Agency nurse worked on hall 500. Reported that resident was found on the floor at 7am during breakfast, lying down and a pillow on the back of his head. Nurse stated assessed resident and was in pain. (Name of Nurse Practitioner) was informed and assessed Resident and gave new orders to transport resident to the ER (emergency room ) for evaluation. Efforts to reach the nurse for pertinent details fruitless. I. Record review of R #128's Nurse's Note dated 07/06/16 stated, Resident was re-admitted [DATE] from the hospital due to a hip fx (fracture). J. Record review of the facility's investigative report regarding R #128's incident on 07/01/16 concluded by saying, His care plan has been updated with new fall interventions. K. Record review of the Fall Risk Assessment portion of R #128's Nursing assessment dated [DATE] indicated he scored 19.0 which was considered High Risk for falls. L. Record review of R #128's Nurse's Note dated 10/26/16 stated, Resident self-reported to me @ (at) around 1500 (3:00 pm), that he had tripped in his room; time unknown. He sustained 2 skin tears; one to his left outer elbow and one to his left knee. M. Record review of the facility's RMS (Risk Management System) Event Summary Report regarding R #128's fall on 10/21/16 stated Preventative measures in place prior to fall: n/a. The report also stated Interventions added immediately after fall and care plan updated: VS (vital signs) taken; woundcare. N. Record review of R #128's Nurse's Note dated 02/15/17 stated, Received call back from on call (Name of on call physician) for Radiology Report on (Name of R #128). Results are right intertrochanteric fracture (hip fracture) with minimal displacement. Keep patient comfortable and let (Name of R #128's physician) know in the morning. Message was left for family member during day shift. No call back. O. Record review of the facility Follow-up Summary of R #128's incident on 02/15/17 revealed The resident did have a surgical repair of his hip and has returned back to the center. Although the center could not conclude the causation of the fracture, it is possible the resident fell in his room and got himself back up. Per the hospital records, the ortho (orthopedic, the branch of medicine dealing with the correction of deformities of bones or muscles) notes stated his fracture was acute and was probably due to a fall as they found a laceration (a deep cut or tear in skin or flesh) to his scalp. P. Record review of R #128's History and Physical completed by his physician on 03/02/17 indicated his past medical history of [REDACTED]. It also indicated his subsequent surgeries related to those fractures: Left Hip ORIF (An Open Reduction Internal Fixation surgery which involves realigning the bone or joint and then using steel rods, screws and/or plates to keep the fracture stable) July 2015, Right Hip ORIF February 16, 2017. Q. Record review of R #128's care plan revealed he did not have a focus related to fall prevention or any fall related interventions prior to 02/16/17. R. On 03/15/17 at 2:53 pm, during an interview with LPN #4, she stated R #128 did not have a fall when he was on the 100 unit in February 2017. She stated he complained of pain and was eventually sent out for an x-ray which confirmed a hip fracture however since nobody saw him fall she stated she did not consider that he fell . LPN #4 stated R #128 was unsteady on his feet, but did not consider him to be a fall risk. She also stated she was not sure whether R #128 had any interventions in place related to fall prevention. S. On 03/15/17 at 3:33 pm, during an interview with the DON, he stated that a resident is considered a fall risk after they have their first fall. The DON verified that R #128's first fall at the facility occurred on 07/01/16 which resulted in his left hip being fractured. The DON stated that after a fall, the resident's care plan should be updated with new interventions added to prevent future falls. The DON failed to provide an updated care plan for R #128 after his fall on 07/01/16 and after his fall on 10/21/16 which resulted in 2 skin tears. T. On 03/16/17 at 8:47 am, during an interview with the Administrator, she verified that R #128 did not have his care plan updated after his fall on 07/01/16 or after his fall on 10/21/16. She verified that his care plan was not updated until 02/16/17 after his fall on 02/15/17. The Administrator was unable to provide an answer as to what interventions were in place to prevent R #128's second and third falls.

Based on record review and interview the facility failed to develop and revise comprehensive care plans with individualized goals and interventions for 2 (R #s 57 and 128) of 2 (R #s 57 and 128) residents reviewed for care plan issues. After R #128 sustained a fall which resulted in a [MEDICAL CONDITION], the facility failed to update his care plan and did not create any new interventions to prevent future falls, which resulted in the resident falling 2 more times acquiring multiple skin tears and another [MEDICAL CONDITION]. This deficient practice resulted in staff failing to identify and create new interventions that were necessary to prevent avoidable falls which resulted in serious injury to R #128. The findings are: Findings related to R #57: A. Record review of R #57's electronic record revealed he was admitted to the facility on [DATE]. B. Record review of R #57's current care plan dated [DATE] revealed only 2 entries: one related to pain inititated on [DATE] and one related to [MEDICAL CONDITION] drugs (drugs that change brain function and results in alterations in perception, mood, or consciousness) initiated on [DATE]. C. On [DATE] at 2:36 pm, during an interview with the MDS (Minimum Data Set) Coordinator, she stated that back on [DATE] an MDS (Minimum Data Set) Asssessment was accidentally submitted that indicated the resident had died . She stated the mistake was corrected the same day however the error caused R #57's care plan to be deleted from his eletronic record. The MDS Coordinator stated she would have to contact the IT (Information Technology) department to see if they can recover his full care plan. D. On [DATE] at 11:51 am, during an interview with the Administrator, she verified that R #57's care plan was accidentally deleted and that none of the staff had access to it from [DATE] up until today ([DATE]). Findings related to R #128: E. Record review of R #128's Nurse's Note dated [DATE] stated, This day an Agency nurse worked on hall 500. Reported that resident was found on the floor at 7am during breakfast, lying down and a pillow on the back of his head. Nurse stated that assessed resident and was in pain. (Name of Nurse Practitioner) was informed and assessed Resident and gave new orders to transport resident to the ER (emergency room ) for evaluation. Efforts to reach the nurse for pertinent details fruitless. F. Record review of R #128's Nurse's Note dated [DATE] stated, Resident was re-admitted [DATE] from the hospital due to a hip fx (fracture). G. Record review of the facility's investigative report regarding R #128's incident on [DATE] concluded by saying, His care plan has been updated with new fall interventions. H. Record review of the Fall Risk Assessment portion of R #128's Nursing assessment dated [DATE] indicated he scored of 19.0 which was considered High Risk for falls. I. Record review of R #128's Nurse's Note dated [DATE] stated, Resident self-reported to me @ around 1500, that he had tripped in his room; time unknown. He sustained 2 skin tears; one to his left outer elbow and one to his left knee. J. Record review of the facility's RMS (Risk Management System) Event Summary Report regarding R #128's fall on [DATE] stated Preventative measures in place prior to fall: n/a. The report also stated Interventions added immediately after fall and care plan updated: VS (vital signs) taken; woundcare. K. Record review of R #128's Nurse's Note dated [DATE] stated, Received call back from on call (Name of on call physician) for Radiology Report on (Name of R #128). Results is right intertrochanteric fracture ([MEDICAL CONDITION]) with minimal displacement. keep patient comfortable and let (Name of R #128's physician) know in the morning. message was left for family member during day shift. No call back. L. Record review of the facility Follow-up Summary of R #128's incident on [DATE] revealed The resident did have a surgical repair of his hip and has returned back to the center. Although the center could not conclude the causation of the fracture, it is possible the resident fell in his room and got himself back up. Per the hospital records, the ortho (orthopedic, the branch of medicine dealing with the correction of deformities of bones or muscles) notes stated his fracture was acute and was probably due to a fall as they found a laceration (a deep cut or tear in skin or flesh) to his scalp. M. Record review of R #128's History and Physical completed by his physician on [DATE] indicated his past medical history of [REDACTED]. It also indicated his subsequent surgeries related to those fractures: Left Hip ORIF (An Open Reduction Internal Fixation surgery which involves realigning the bone or joint and then using steel rods, screws and/or plates to keep the fracture stable.) [DATE], Right Hip ORIF February 16, 2017. N. Record review of R #128's care plan revealed he did not have a focus related to fall prevention or any fall related interventions prior to [DATE]. O. On [DATE] at 2:53 pm, during an interview with Licensed Practical Nurse (LPN) #4, she stated R #128 did not have a fall when he was on the 100 unit in February 2017. She stated he complained of pain and was eventually sent out for an x-ray which confirmed a [MEDICAL CONDITION] however since nobody saw him fall she stated she did not consider that he fell . LPN #4 stated R #128 was unsteady on his feet but did not consider him to be a fall risk. She also stated she was not sure whether R #128 had any interventions in place related to fall prevention. P. On [DATE] at 3:33 pm, during an interview with the Director of Nurses (DON), he stated that a resident is considered a fall risk after they have their first fall. The DON verified that R #128's first fall at the facility occurred on [DATE] which resulted in his left hip being fractured. The DON stated that after a fall, the resident's care plan should be updated with new interventions added to prevent future falls. The DON failed to provide an updated care plan for R #128 after his fall on [DATE] and after his fall on [DATE] which resulted in 2 skin tears. Q. On [DATE] at 8:47 am, during an interview with the Administrator, she verified that R #128 did not have his care plan updated after his fall on [DATE] or after his fall on [DATE]. She verified that his care plan was not updated until [DATE] after his fall on [DATE]. The Administrator was unable to provide an answer as to what interventions were in place to prevent R #128's second and third falls.

Based on observation, record review, and interview, the facility failed to prevent the development of avoidable pressure ulcers for 2 (R #s 9 and 154) of 2 (R #s 9 and 154) residents reviewed for pressure ulcers by failing to: 1. Monitor and document wound for changes in color, odor, size, and severity, 2. Complete weekly skin assessments, 3. Provide wound care treatments as ordered by the physician, 4. Develop a plan of care with interventions to promote healing and prevent worsening of a pressure ulcer. This deficient practice resulted in inaccurate wound assessments, inconsistent documentation and noncompliance with standards of practice resulting in miscommunication and directly affected the health and well being of residents. The findings are: Findings for R #154 A. Record review of the Interdisciplinary Discharge Summary dated 03/25/16, revealed R #154 was admitted to facility on 02/08/16 for rehab (rehabilitation services) and under progress it states, St (stage) II coccyx ulcer (outer layer of skin and part of the underlying layer of skin is damaged on the lower area of the back). Summary revealed R #154 was able to make her needs known, received a BIMS (Brief Interview for Mental Status) score of 15 (a score of 13-15 indicates cognitively intact), AAO x 4 (alert and oriented times four-resident is alert to person, place, time, and event). Weight was 85.0 pounds, height was 64 inches (5 feet 4 inches), note stated Wt (weight) loss over 30 days present. R #154 was discharged from facility 03/21/16. B. Record review of Physician Orders, revealed orders for barrier cream with each brief change, every shift and prn (as needed) ordered on [DATE], air mattress for skin protection, physical therapy-evaluation and treatments as recommended, pressure-redistribution cushion to chair, pressure-redistribution mattress to bed, heel up pillow when in bed to prevent skin breakdown, skin check weekly every night shift every Mon (Monday). The order for barrier cream does not specify the [DIAGNOSES REDACTED]. C. Record review of Treatment Administration Record (TAR) dated 02/01/16 to 02/29/16, indicated Skin check weekly on 10-6 (night shift) every night shift every Mon. Documentation shows a skin check was completed on 02/15/16. On 02/22/16 and 02/29/16, no documentation showing R #154's skin was checked. Further review of the TAR, revealed no treatments for R #154's wound. D. Record review of TAR dated 03/01/16 to 03/31/16, revealed no documentation that R #154's skin was checked on 03/07/16 and 03/14/16. Further review of the TAR, revealed no treatments for R #154's wound. E. Record review of Physician's History & Physical dated 03/03/16, indicated under chief complaint, Nursing reports a new Stage II pressure sore that should heal quickly. History: states R #154 was admitted on [DATE] for PT (physical therapy) and OT (occupational therapy). She is SBA (stand by assist) with her FWW (front wheeled walker) and she is walking about 150 feet. F. Record review of Braden Scale (tool used to predict pressure sore risk) dated 02/09/16, indicated a score of 17. A total score of 12 or less represents high risk. R #154 was at low risk for development of a pressure ulcer. G. Record review of Admission Resident (MDS) data set [DATE], indicated R #154 is alert and independent with decision making. She makes herself understood and understands others. She is limited assist with bed mobility, and other ADLs (activities of daily living), with one person assist. She is frequently incontinent of bladder. She received a score of 15 for risk of pressure ulcers, a total score of 16 or below deems resident at risk for pressure ulcers. Implement plan of care. Nurses note states Alert and oriented x 3 (person, place, and time). No hx (history) of pressure ulcers. Is on very limited activity and requesting briefs. Skin warm, dry, no [MEDICAL CONDITION] noted. H. Record review of Interdisciplinary Team Notes dated 03/03/16, revealed Resident is being reviewed for wound to R (right) buttock, stage 2, 0.5 cm (centimeter) by 0.5 cm. Resident is being evaluated by therapy. She has a ROHO cushion (used to prevent skin breakdown) to wc (wheel chair), air mattress and wound care Q (every) day. Will continue daily wound care. Review in one week. On 03/09/16, note states Resident is being reviewed for a f/u (follow up) to wound to R buttock, resident has air mattress, being evaluated by PT/OT, has ROHO cushion to wc, wound care Q day. Plan: Continue to monitor wound and apply barrier cream as needed. Will review in one week. I. Record review of Licensed Nurses Notes with various dates between 02/08/16 to 03/02/16, revealed there was no documentation indicating that R #154 had a wound to her coccyx (tailbone) or right buttock, that wound care was completed Q day, skin assessments were completed weekly, and no measurements indicating the wound was healing or resolved. J. Record review of Skilled Nursing Notes with various dates between 02/12/16 to 03/20/15, revealed there was no documentation indicating that R #154 had a wound to her coccyx or right buttock, that wound care was completed Q day, skin assessments were completed weekly, and no measurements indicating the wound was healing or resolved. K. Record review of the Wound Management Tracking Tool dated February 2016, revealed R #154 was not identified as having a wound, indicating R #154 did not receive wound care and monitoring of her stage II sore. L. Record review of the Wound Management Tracking Tool dated March 2016, revealed R #154 was not identified as having a wound, indicating R #154 did not receive wound care and monitoring of her stage II sore. M. Record review of the Minimum Data Set ((MDS) dated [DATE], indicated R #154 has one stage II pressure ulcer, identified on 02/29/16. N. Record review of Care Plan dated 02/22/16, revealed resident is at risk for skin breakdown as evidenced by shear/friction risks, limited mobility, incontinence. Interventions include: apply barrier cream with each cleansing, assist resident in repositioning q 2 hrs (hours) and prn (as needed), evaluate for skin risk factors per protocol, monitor skin for signs/symptoms of skin breakdown i.e. (in example) redness, cracking, blistering, decrease sensation, and skin that does not blanche (a whitish appearance as blood flow to the region is prevented) easily, observe skin condition with ADL care daily and report abnormalities, provide pericare/incontinence care as needed, and utilize positioning devices as appropriate to prevent pressure over boney prominences. O. On 04/14/16 at 9:29 am, during interview with the DON regarding R #154, he stated According to admission note, nothing was marked that she had any stage II. She is not listed as having any wounds in February (2016). I also checked the treatment record and didn't see any orders for wound treatment. It's a discrepancy of information. The discharge says she had a stage II pressure ulcer. The DON was asked when did she develop the wound, he stated I don't know what to tell you, because she is not on the wound report. She was here for 35 days. According to IDT (interdisciplinary team) notes she had a wound. They were just applying barrier cream to the wound. My guess is it wasn't open, but I don't know the criteria they used to stage it. The DON confirmed no wound treatment was done. The DON also confirmed staff needs a physician's orders [REDACTED]. The only order I see is for an air mattress. I don't see any order for wound treatment. The DON was asked if skin checks were completed, he confirmed they were not, stating According to March (2016) (TAR) it wasn't done. In February (2016) it was done once on the 15th. Regarding the licensed nurses notes, the DON stated, From the time she got here all they (staff) were talking about was her pain. There is no mention of a wound any where. Regarding the skilled nurses notes, the DON stated They are not complete. It's not mentioned about anybody doing a dressing change. The whole month of March from the 14th of February, it (R #154's skin) was documented as intact. I don't see it mentioned she had any type of wound, just the skin intact and just her pain management. I don't see any documentation of when she developed it (wound) and the discharge note doesn't say if she had a wound at discharge or not. P. On 04/14/16 at 10:15 am, during interview Registered Nurse (RN) #2 stated She (R #154) came in for skilled, she had a hip fx (fracture). She was here for PT/OT. She was healthy otherwise. RN #2 confirmed R #154 had a small opening to her skin, measuring 0.5 cm by 0.5 cm. Q. On 04/14/16 at 1:25 pm, during interview the Regional Medical Corporate Officer, stated that after talking with the DON regarding the lack of documentation in the chart for R #154's stage II, she did a quality review call to the resident. R #154 confirmed she did develop a wound while in the facility, stating that a day or two into her stay, she felt she was getting a sore. R #154 stated it was a small split on her coccyx. Findings related to R #9: R. Record review of the physician's orders [REDACTED]. S. Record review of the Pressure Wound Assessment sheet dated February 2016 revealed only one entry dated 02/29/16 documenting a pressure wound to R #9's Lt. (left) foot measuring 3 centimeters (cm) by 3cm and was noted as being unstageable (blackened outer tissue present and unable to determine depth of wound). No further measurements were recorded or wound descriptions noted for the month of February from information provided. The wound onset date was 02/05/16. T. Record review of the Wound Management Tracking Tool dated March 2016 revealed one entry dated 03/22/16 documenting R #9's wound was now noted to be on the right foot and measured 4cm by 3cm and 0.3cm deep. There was no documentation indicating what stage the wound was identified at, at this time. Under follow up plan it was noted; Continue wound care and assess q (every) week. No further documentation on R #9's wound was found in the medical records for the month of March 2016. U. Record review of the Wound Management Tracking Tool dated April 2016 revealed R #9's right foot wound measured 1cm by 1cm on 04/05/16. No wound depth was recorded. This was the only entry documented and no further wound assessments were noted for the month of April as of 04/20/16. V. Record review of the TAR dated April 2016 revealed no documentation that wound care was performed from 04/01/16 to 04/14/16. The TAR indicated the wrong foot where the wound was located. W. Record review of the March 2016 TAR could not be done because the TAR was not available for review. X. Record review of the TAR (not dated but other dates on record were noted 02/16) revealed an order for [REDACTED]. Y. On 04/14/16 at 10:31 am, during observation of wound care for R #9, being performed by Licensed Practical Nurse LPN #1, stated there is no wound on the left foot, it must have healed. LPN #1 was unaware that the wound was actually on the right foot until it was brought to her attention and wound care was then performed as ordered. LPN#1 then stated, the The Treatment Administration Record (TAR)says the wound is on the left foot. After wound care was performed LPN #1 confirmed that the TAR dated April 2016 for R #9 indicated the wound was on the wrong foot (the left foot instead of the right foot). During observation LPN #1 did not measure the wound and stated, the Unit managers measure the wounds. After wound care was performed LPN #1 applied a new dressing to the wound that was neither dated, timed or initialed by LPN #1. Z. Record review of the Nutritional assessment dated [DATE] for R #9 stated, L (left) foot healed per nursing report. Recommendations - D'c (discontinue)prostat r/t(related to) wound healed- product no longer appears warranted AA. On 04/18/16 at 8:18 am, interview with Registered Dietician (RD), stated she (RD) did not know R #9 still had a wound because per nursing report R #9's wound to her left foot had healed so she (RD) discontinued the ProStat (a liquid protein supplement used to promote wound healing). RD then stated she(RD) R # 9's wound was on her right foot and not the left. BB. On 04/15/16 at 10:25 am, during interview with Registered Nurse (RN) #1/ Nurse Practice Educator / Infection Control stated, the unit managers are responsible for measuring the wounds once a week. When asked what documentation should be included in a wound assessment, RN #1 stated, wound location, description , measurements and Stage. RN #1 then stated, if a resident is admitted with a wound off hours the unit nurses will assess, measure and Stage the wound. CC. Record review of the Pressure Ulcer Management Policy, referenced from the facility wide Nursing Operations Manual states, `Licensed nurses/treatment nurse will document the status of ulcer sites and effectiveness of treatment for [REDACTED]. Documentation should address the following areas: 1. Site/location- indicate specific body location - draw pictures if needed. 2. Size; include length, width and depth measurements in centimeters -use measuring device. 3. Stage- document Stage I-IV (Stages refer to the severity level of the wound) 4. Undermining/tunneling (meaning wound has tunneled under the skin to another area). 5. Drainage- describe amount, color,odor f(following specific guidelines noted in text). 6. Describe surrounding tissue. 7. Describe the wound base and kind of tissue presently. 8. Wound Status - improved, no change or deteriorating 9. Treatment/dressing - describe type and include documentation on the TAR. 10. Make sure the pressure ulcer/sore is identified on the body diagram in addition to the written documentation describing the ulcer. 11. Document when the area is resurfaced and continue to monitor. DD. Record review of the Skin Integrity management policy dated 07/01/01 revision date 03/15/16 states the following; 1. Perform skin inspection on admission/re-admission and weekly- Document on Treatment Administration Record. 2. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly and with anticipated decline of wound. 3. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. EE. Record review of the Wound Dressings policy dated 06/01/96, revision date 01/02/14 states, the dressing must be labeled with the date and the initials of the caregiver.

The facility failed to ensure that residents were free from physical battery and sexual abuse on two locked dementia (group of thinking and social symptoms that interferes with daily functioning) units. Residents known to exhibit abusive behaviors were not monitored to ensure that vulnerable residents were not abused. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of K being identified on 11/13/15. The facility Administrator was notified on 11/13/15 at 4:55 pm. The facility took corrective action by providing an acceptable Plan of Removal on 11/13/15 at 5:49 pm. The Plan of Removal interventions included: 1. One-on-one supervision for residents identified for inappropriate touching. 2. Inservice of staff on interventions and reporting requirements if these behaviors are observed. 3. Interview the affected and random residents to assess for psychological effects of the identified incidents. Based on the Plan of Removal and interviews, the IJ was lifted on 11/13/15 at 5:49 pm. This resulted in the scope and severity being reduced from level K to level H. Based on observation, interview, and record review, the facility failed to keep residents free from physical and sexual abuse by other residents with a known history of battery or sexual assault, for 3 (R #s 5, 6 and 9) of 43 residents on the locked units as identified on the Roster/Sample Matrix provided by the facility on 11/13/15. Severely impaired residents on two locked dementia units, who were incapable of giving consent, were subject to touching by other residents. This deficient practice subjected vulnerable residents to assaults, which were likely to cause feelings of fear, distress and humiliation. The findings are: A. On 11/13/15 at 8:15 am, during observation in the 200-unit dining room, Resident (R) #4 was observed to be sitting in his wheelchair, behind R #5. R #4 was noted to be massaging R #5's back and shoulders, a behavior which occurred periodically over 12 minutes. During this time, the 3 Certified Nurse Aides (CNA #s 3, 6 and 7) assigned to the 200-unit were frequently in and out of the dining room. None of the CNAs addressed R #4's behavior. B. On 11/13/15 at 10:42 am, during interview with the Director of Nursing, she stated that the facility was currently evaluating residents on the locked 100- and 200-units to determine if the residents were properly placed. She stated I really don't believe there has been any real monitoring of behaviors here (at this facility). C. On 11/13/15 at 12:20 pm, during observation in the 200-unit dining room, R #4 was noted to propel his wheelchair to behind R #6. R #4 reached under R #6's right arm, and began stroking his right chest. This behavior was noted twice within 5 minutes. On the second occasion, R #4 moved his hand down R #6's torso, reaching below R #6's waist, before withdrawing it. R #6 appeared oblivious to the touch. CNA #2 was not observed to intervene. D. Record review of the medical record of R #4 found a nurse's note dated 10/19/15 stating that R #4 had been medicated after becoming verbally and physically abusive, chasing another resident down a hallway, and hitting a nurse. E. On 11/13/15 at 2:29 pm, during interview with CNA #2, he stated that he had seen R #4 touching other residents' torsos on several occasions in the past. He stated that R #8 was frequently the subject of R #4's physical advances. He stated that when he sees the behavior, he attempts to redirect the resident. F. On 11/13/15 at 3:44 pm, during interview with the Director of Nursing, she stated that she was advised of an episode of inappropriate contact between residents that day (11/13/15). She stated that R #7, had been found in a resident room on the 100-unit with a female resident with his face near her breasts. She stated that R #7 has a history of sexual inappropriateness with female residents. She stated that, as a result, R #7 was being moved to the 200-unit, an all-male unit, that day (11/13/15). The Director of Nursing stated that her expectation of nursing staff would be that they would intervene if they observed inappropriate contact between residents. She again stated that she was not sure whether or not the facility had a system for monitoring problematic resident behaviors. G. On 11/13/15 at 4:04 pm, during interview with the Nurse Practice Educator, he stated that LPN #1 had told him about an episode of physical contact between R #5 and R #6 that morning (11/13/15). He stated that physical contact between residents on the locked dementia units is never appropriate, unless it was shaking hands or something like that. H. On 11/13/15 at 4:35 pm, during interview with LPN #1, she stated that she had witnessed an episode of physical contact between residents that day (11/13/15), between breakfast and lunch. She stated that she witnessed R #5 with his hand on R #6's lap, and saw him run his hand down R #6's leg. She stated that she saw R #6 spread his legs a bit more in response, and that she separated the residents. I. On 11/13/15 at 4:43pm, during interview with CNA #1, she stated that R #7 has engaged in inappropriate contact with female residents on multiple occasions, often with R #9. She stated that she doesn't redirect R #7 when she sees this behavior because he looks like he would hit me. He has hit me before. So I redirect (R #9) instead. She recalled a situation in which she found R #9 with her head between R #7's legs. She stated I worry about the ladies back there. She stated that R #7 had inappropriately touched male residents in the past as well. J. Record review of a psychiatric evaluation for R #7 dated 08/25/15 found the statements: 1. The patient is a [AGE] year-old retired male, referred from (the facility) with the chief complaint of aggressive [MEDICAL CONDITION] 2. The patient is reported to have had prior hospitalization s for dementia with behavioral disturbances including inappropriate behavior. He was found with another resident in his room, embracing each other and 'undressed from the waist down.' He also had grabbed one of the female resident's breast. His behaviors had been progressively worsening, becoming highly inappropriate and threatening the safety of other residents. He became (sic) aggressive when attempts were made to redirect him. K. Record review of an Abuse, Neglect and Exploitation or Report of Death Form, submitted to the State Survey Agency and dated 11/02/15, found statements that: 1. R #7 had been observed lifting the shirt of a demented female resident on 11/01/15, and moving his face toward her breasts. 2. The facility had filed a police report about the incident. L. Record review of the facility's Policy and Procedure document related to Behavior Management, created on 03/01/04 and revised on 03/30/07, found nothing to address keeping other residents safe from residents' abusive behaviors. M. Record review of the facility's Policy and Procedure document related to Abuse Prevention, dated 08/31/07, found that, while it primarily addressed prevention of resident abuse by employees, some statements were applicable to resident-on-resident abuse: 1. It is the policy of this Center to do all within its control (to) maintain the residents' right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property, through implementation of seven components . 2. In the Training section, Specific instructions on how to respond (appropriate interventions) to deal with aggressive and/or catastrophic reactions of residents . as well as emergency procedures to follow. and The importance of protecting residents from potentially abusive situations. 3. In the Prevention section, the statement Deployment of staff on each shift in sufficient number to meet the needs of the residents, and then assure that the staff assigned have knowledge of the individual care needs .

Based on observation, interview, and record review, the facility failed to implement their policies and procedures designed to keep residents free from physical and sexual abuse by other residents with a known history of battery or sexual assault, for 3 (R #s , 5, 6 and 9) of 43 (R #s 1-43) residents on the locked units as identified on the Roster/Sample Matrix provided by the facility on 11/13/15. Severely impaired residents on two locked dementia units, who were incapable of giving consent, were subject to touching by other residents. The facility also failed to implement their policies and procedures designed to keep residents free from neglect for 1 (R #1) of 1 (R #1) residents reviewed for neglect. This deficient practice subjected vulnerable residents to assaults, which were likely to cause feelings of fear, distress and humiliation and resulted in a resident being left unattended in the facility van for approximately 30 minutes in temperatures in excess of 90 degrees Fahrenheit, caused the resident to become dehydrated and caused the resident anxiety due to being left alone in the heat. The findings are: A. On 11/13/15 at 8:15 am, during observation in the 200-unit dining room, Resident (R) #4 was observed to be sitting in his wheelchair, behind R #5. R #4 was noted to be massaging R #5's back and shoulders, a behavior which occurred periodically over 12 minutes. During this time, the 3 Certified Nurse Aides (CNA #s 3, 6 and 7) assigned to the 200-unit were frequently in and out of the dining room. None of the CNAs addressed R #4's behavior. B. On 11/13/15 at 10:42 am, during interview with the Director of Nursing, she stated that the facility was currently evaluating residents on the locked 100- and 200-units to determine if the residents were properly placed. She stated I really don't believe there has been any real monitoring of behaviors here (at this facility). C. On 11/13/15 at 12:20 pm, during observation in the 200-unit dining room, R #4 was noted to propel his wheelchair to behind R #6. R #4 reached under R #6's right arm, and began stroking his right chest. This behavior was noted twice within 5 minutes. On the second occasion, R #4 moved his hand down R #6's torso, reaching below R #6's waist, before withdrawing it. R #6 appeared oblivious to the touch. CNA #2 was not observed to intervene. D. Record review of the medical record of R #4 found a nurse's note dated 10/19/15 stating that R #4 had been medicated after becoming verbally and physically abusive, chasing another resident down a hallway, and hitting a nurse. E. On 11/13/15 at 2:29 pm, during interview with CNA #2, he stated that he had seen R #4 touching other residents' torsos on several occasions in the past. He stated that R #8 was frequently the subject of R #4's physical advances. He stated that when he sees the behavior, he attempts to redirect the resident. F. On 11/13/15 at 3:44 pm, during interview with the Director of Nursing, she stated that she was advised of an episode of inappropriate contact between residents that day (11/13/15). She stated that R #7, had been found in a resident room on the 100-unit with a female resident with his face near her breasts. She stated that R #7 has a history of sexual inappropriateness with female residents. She stated that, as a result, R #7 was being moved to the 200-unit, an all-male unit, that day (11/13/15). The Director of Nursing stated that her expectation of nursing staff would be that they would intervene if they observed inappropriate contact between residents. She again stated that she was not sure whether or not the facility had a system for monitoring problematic resident behaviors. G. On 11/13/15 at 4:04 pm, during interview with the Nurse Practice Educator, he stated that LPN #1 had told him about an episode of physical contact between R #5 and R #6 that morning (11/13/15). He stated that physical contact between residents on the locked dementia units is never appropriate, unless it was shaking hands or something like that. H. On 11/13/15 at 4:35 pm, during interview with LPN #1, she stated that she had witnessed an episode of physical contact between residents that day (11/13/15), between breakfast and lunch. She stated that she witnessed R #5 with his hand on R #6's lap, and saw him run his hand down R #6's leg. She stated that she saw R #6 spread his legs a bit more in response, and that she separated the residents. I. On 11/13/15 at 4:43pm, during interview with CNA #1, she stated that R #7 has engaged in inappropriate contact with female residents on multiple occasions, often with R #9. She stated that she doesn't redirect R #7 when she sees this behavior because he looks like he would hit me. He has hit me before. So I redirect (R #9) instead. She recalled a situation in which she found R #9 with her head between R #7's legs. She stated I worry about the ladies back there. She stated that R #7 had inappropriately touched male residents in the past as well. J. Record review of a psychiatric evaluation for R #7 dated 08/25/15 found the statements: 1. The patient is a [AGE] year-old retired male, referred from (the facility) with the chief complaint of aggressive [MEDICAL CONDITION] 2. The patient is reported to have had prior hospitalization s for dementia with behavioral disturbances including inappropriate behavior. He was found with another resident in his room, embracing each other and 'undressed from the waist down.' He also had grabbed one of the female resident's breast. His behaviors had been progressively worsening, becoming highly inappropriate and threatening the safety of other residents. He became (sic) aggressive when attempts were made to redirect him. K. Record review of an Abuse, Neglect and Exploitation or Report of Death Form, submitted to the State Survey Agency and dated 11/02/15, found statements that: 1. R #7 had been observed lifting the shirt of a demented female resident on 11/01/15, and moving his face toward her breasts. 2. The facility had filed a police report about the incident. L. Record review of the facility's Policy and Procedure document related to Behavior Management, created on 03/01/04 and revised on 03/30/07, found nothing to address keeping other residents safe from residents' abusive behaviors. M. Record review of the facility's Policy and Procedure document related to Abuse Prevention, dated 08/31/07, found that, while it primarily addressed prevention of resident abuse by employees, some statements were applicable to resident-on-resident abuse: 1. It is the policy of this Center to do all within its control (to) maintain the residents' right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property, through implementation of seven components . 2. In the Training section, Specific instructions on how to respond (appropriate interventions) to deal with aggressive and/or catastrophic reactions of residents . as well as emergency procedures to follow. and The importance of protecting residents from potentially abusive situations. 3. In the Prevention section, the statement Deployment of staff on each shift in sufficient number to meet the needs of the residents, and then assure that the staff assigned have knowledge of the individual care needs . N. Record review of the complaint intake dated 09/09/15 indicated the following: Resident was left in the facility's transport van awaiting transportation to the (Name of Hospital) for 30 minutes. The temperature that day was between 94 and 99 degrees Fahrenheit. Once the resident was strapped in and the wheelchair locked in place, the driver left the van without the motor or air conditioning running, to reenter the building. Video footage clearly shows the driver preparing a plate of food in the facility conference room and eating while standing. O. Review of the facility Incident Follow Up Report dated 08/12/15 indicated the following: Conclusion: The facility substantiates that allegation of neglect. The resident was left in the mid-day heat without water or air conditioning while the employee ate her meal in the building and socialized at a farewell party for a fell ow employee. Interviews with the resident, family and witnesses, as well as video footage, substantiate the allegation. P. Record review of physician progress notes [REDACTED]. Seen today at request of resident who states he was left in the facility van for 35 mins (minutes) yesterday. Felt a bit dizzy when exited but made sure he drank plenty of fluids last noc (night). Also requesting a PRN (as needed) pain medication that he could have. Meds (medications) reviewed. States he uses [MEDICATION NAME] occasionally with some success. Take [MEDICATION NAME] QID (four times a day) with the last dose at 8 pm. Dehydration potential exposure. Monitor. Q. On 11/13/15 at 9:05 am, during interview with R #1's spouse, she stated that her husband had an appointment on the day of the incident at the (Name of Hospital). R #1's Spouse stated that on the day of the incident, her husband was taken outside to the front of the facility to the van and that when the aide asked if he needed an escort for the appointment, he answered that he did, so the aide left him alone in the van to go look for another aide to escort him to the appointment. R #1's spouse stated that the wife of another resident was sitting on the patio and witnessed her husband being left alone in the van and that the temperature at the time was in the high 90s and that the other resident's wife brought R #1 some water when she saw him alone in the van. R #1's spouse stated that while her husband was unattended in the van, the door to the van was open but the air conditioner was not running. R #1's spouse stated that her husband informed her of the incident as soon as he returned from his appointment and that, as a result she spoke to the Administrator and Director of Nursing who were upset to learn of the events. R #1's spouse stated that the Administrator informed her that after the incident was reviewed, it was determined that her husband sat unattended in the van for at least 25 minutes. R. On 11/13/15 at 10:00 am, during phone interview with Witness #1, she stated that she observed R #1 sitting in the van alone for at least 20 minutes and that she saw him fanning himself so she brought him some water. Witness #1 stated that the van door was open but that the van was not running. S. On 11/13/15 at 10:57 am, during a telephone interview with CNA (Certified Nursing Aide) #5, she stated she was taking R #1 to an appointment on 08/12/15 and that as she secured R #1 in the van, he informed her that he needed an escort for his appointment. CNA #5 stated that it was unusual that he needed an escort since all the previous trips he hadn't needed one. CNA #5 stated that she left R #1 in the van unattended while she went back into the facility to find an escort. CNA #5 stated that before leaving him, she rolled down several van windows, left the passenger side van door open and left the van's air conditioning on. CNA #5 stated that after speaking with the Assistant Director of Nursing about needing an escort she went to the unit to talk to CNA #4. CNA #5 stated she told CNA #4 to come with her to serve as R #1's escort. CNA #5 stated that on her way back from the unit, she grabbed a sandwich from the dining area and continued back to the van. CNA #5 denied that she ate her food at the facility despite the allegation that she was video taped by the facility eating her lunch in the dining area that day. CNA #5 could not give a general estimate of how much time elapsed from when she left R #1 in the van and when she returned to the van. When asked whether she thought it was appropriate to leave R #1 in the van unattended while she got food for herself she stated, I don't think so. That was my mistake. CNA #5 verified that the facility terminated her employment due to this incident. T. On 11/13/15 at 1:20 pm, during interview with CNA #4, she stated that at the time that R #1 was left in the facility van, CNA #5 approached her and asked her to escort R #1 to his appointment. CNA #4 stated that she was in the middle of showering a resident at the time, so she told CNA #5, No, I need to finish what I'm doing. CNA #4 stated that about ten minutes later, when she finished with the resident she was assisting, she went to look for CNA #5 and found her in the break room eating and that it took CNA #5 another 10 minutes to finish eating. CNA #4 stated that was not aware that R #1 was in the van at this time. CNA #4 stated that while she was at the appointment with R #1, she remembered having to get him some water because he kept stating that he was thirsty. U. On 11/13/15 at 1:26 pm, during interview with the Manager of Clinical Operations (MCO), she stated that she was unable to find documentation of the employee's suspension but that she was able to locate the employee's time card that indicated that the employee clocked out on 08/12/15 and did not return to the facility. The MCO stated that CNA #5 was terminated after the investigation relating to R #1 being left unattended in the facility van. V. On 11/13/15 at 1:55 pm, during an interview with R #1, he stated that on the day of the incident (08/12/15), CNA #5 loaded him into the van, secured him and then went to go find an escort for him. R #1 stated that he almost always had an escort when going to appointments. R #1 stated the only time he did not have an escort was when he went to go get his wheelchair repaired. R #1 stated CNA #5 only left one van door open, that all the windows were closed and the air conditioning was not left on. R #1 stated I was very hot. It was 90 plus degrees and with MS ([MEDICAL CONDITION]) I was starting to get a little woozy. He stated that Witness #1 happened to be sitting on the front porch area of the facility and that she noticed that he had been sitting in the van for a while and brought him a glass of water. R #1 stated that he was upset that he was left in the van for about 30 to 35 minutes alone. W. Record review of the Termination Form dated 08/16/15 indicated that CNA #5 was terminated for Poor performance/conduct. X. Record review of the facility Abuse Prevention Policy dated 08/31/07 indicated that, It is the policy of this center to do all within its control to maintain the resident's right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misapplication of property, through the implementation of seven components.

Based on observation, record review and interview, the facility failed to immediately report, investigate and submit a follow-up investigation to the State survey and certification agency for 2 (R #1, 2) of 2 (R #1, 2) residents who sustained injuries of unknown origin to include (old bruises found to the forehead and bruises to the right and left eye for R #1 and a unidentified bruise to the nose for R #2). This deficient practice presents a risk of potential harm to resident safety. If injuries of unknown origin are not reported or investigated, the state agency is not aware of the incident or investigation, therefore, the state agency is not able to follow up with the facility to ensure resident safety. The findings are: A. On 01/10/12, review of the medical record for R #1 revealed the following: 1. Face Sheet dated 07/08/11 indicated [DIAGNOSES REDACTED]. 2. Quarterly Minimum Data Set ((MDS) dated [DATE] states the resident has a short term memory problem, and cognitive skills for daily decision making are severely impaired. 3. Comprehensive Care Plan (no date indicated) states "Visual function impaired." Care Plan further states "Cognitive loss/dementia. Short term and long term memory problem, Impaired Cognitive skills in daily decision making, altered ability to understand others, altered level of consciousness, dementia, depression, and anxiety." The Care plan further states, "[MEDICAL CONDITION], disorganized thinking...behavioral symptoms and wandering behaviors." 4. Licensed Nurses Notes revealed the following: a. Entry dated 09/11/11 indicated, "Noted old bruise to left forehead." b. Entry dated 09/12/11 indicated, "Darkening of bruise to R (right) forehead...Continuing to monitor bruising to R eye black/purple at outer corner of R eye." c. Entry dated 09/13/11 indicated, "No c/o (complaints of) pain to left eye with bruise and left forehead... resident walking to right side, bruising no change to right side of head and eye." d. Entry dated 09/14/11 indicated, "Continues to lean to right side. No discomfort noted...from bruise to left side of forehead." e. Entry dated 09/15/11 indicated, "Right outer eyelid discoloration continues. Complains of tenderness when palpated." B. The following interviews were conducted with R #1 and facility staff: 1. On 01/10/12 at 11:45 am the Surveyor attempted to interview R #1 but was unable to due to her confusion. When the Surveyor asked her "How are you doing today?" R #1 replied by saying, "Oh honey you do remember me. When are they coming back home." 2. On 01/11/12 at 12:35 pm, during interview, the Director of Nursing (DON) stated, "I don't have an incident report regarding the bruising. I don't find anything. There was no incident report for the bruising to the forehead that I can see. The September nurse manager was responsible for reporting this. She (referring to R #1) tends to lean her head on the table so that's where I think she got the bruises from." 3. On 01/11/12 at 12:55 pm, during interview, the MDS Coordinator stated, "To me it would be an injury of unknown origin to her forehead and eye. I don't recall this one. But I believe there should have at least been an incident report because I would think it was a injury of unknown origin." 4. On 01/11/12 at 2:15 pm, during interview, the Administrator stated, "The process for any bruise of unknown origin is reported, that should be the procedure. I believe the nurse saw this as an old bruise and assumed there was an incident report. Unless it comes through our Interdisciplinary Team (IDT) Meetings then I wouldn't know. It was noted to be an older bruise and I'm assuming the nurse probably knew how she (the resident) received it and therefore didn't report it. But yes, you would expect there to be an incident report." 5. On 01/11/12 at 2:25 pm, during interview, Registered Nurse (RN) Staff #1 stated, "Regarding her bruising in September, there was no incident report that was done. It would be my expectation though if I notice any bruising that I didn't know where it came from then to report to the doctor. My understanding is that if you notice a bruise, monitor it for the first day, then if it worsens with neurological checks, immediately notify the Dr." 6. On 01/11/12 at 2:30 pm, during interview, the Certified Nurse Practioner stated, "I think they should have at least checked neurosigns in September when they saw bruising." 7. On 01/12/12 at 9:00 am, during interview, the Assistant Director of Nursing stated, "Regarding the bruising in September, I know she had a bruise, but I don't really recall the details. She just wanders everywhere. The staff are supposed to be reporting to the on call Dr. for any injuries or bruising. I really don't know what happened." 8. On 01/12/12 at 9:45 am, during interview, the DON stated, "I wasn't aware of the incident. It was based on my assumption that it was due to her behaviors. This is why we don't have a incident report on that." 9. On 01/12/12 at 2:30 pm during interview, Licensed Practical Nurse (LPN) Staff #2 stated, "I wrote orders in the chart to monitor the bruising. The bruising did look old. I recall telling our charge nurse and she said the bruises were from before. I don't remember getting anything in report as far as an incident that occurred. The resident would not have been able to remember what happened." 10. On 01/12/12 at 2:45 pm, during interview, LPN Staff #3 stated, "Regarding the bruising in September, the resident would not be able to recall what happened. I don't recall what happened. If there was no incident report then I would have no idea. The first person that identified it was supposed to notify the Dr. I just assumed that the Dr. was notified." C. Review of the medical record for R #1 revealed no physician order to "monitor for bruising." The medical record revealed no documentation of neurochecks that were being done when the bruising to the forehead was identified. D. Review of the facilities Monthly Incident/Accident Log and Analysis document for the month of September 2011 revealed no documentation of an Incident Report, or any documentation of any bruises to the forehead or eyes for R #1. E. On 01/11/12, review of the medical record for R #2 revealed the following: 1. Face Sheet dated 07/08/11 indicated [DIAGNOSES REDACTED]. 2. Quarterly MDS assessment dated [DATE] indicated R #2 needs extensive assistance for bed mobility and transfers. 3. Comprehensive Care Plan dated 05/11/11 indicated R #2 has altered cognitive function as manifested by short term and long term memory problem, Impaired cognitive skills in daily decision making and altered ability to understand others. The Care Plan further indicated the resident has a bruise to the nose from an unknown origin. 4. Licensed Nurses Notes dated 01/01/12 indicated, "At change of shift CNA noted (name of R #2) bruised nose and asked what happened...resident is unaware of bruise and does not remember...discoloration extends length of nose." 5. Licensed Nurses Notes dated 01/02/12 indicated, "Nose with discoloration." F. Review of the facilities Monthly Incident/Accident Log and Analysis document dated 01/01/12 indicated, "Resident #2 found with bruise covering front of nose by staff. Unknown how or when resident bruised nose. Resident unaware of bruise." G. The following interviews were conducted with the facility staff: 1. 01/12/12 at 12:00 pm, during interview, LPN Staff #4 stated, "She is a total assist for transferring. She probably could not remember what happened to her regarding her nose." 2. 01/12/12 at 12:38 pm, during interview, Certified Nursing Assistant (CNA) Staff #5 stated, "When I came in to work I noticed the bruise to her nose. I figured it was already reported. Nothing was reported to me during change of shift as to what happened." 3. 01/12/12 at 12:55 pm, during interview, the Administrator stated, "With (name of R #2) we did not report this one. We certainly could have. There was nothing preventing us from reporting this. I'm not seeing a rationale as to what happened on our Incident report either." 4. 01/12/12 at 1:15 pm, during interview, the DON stated, "In this case, we don't know exactly what happened." 5. 01/12/12 at 3:00 pm, during interview, CNA Staff #6 stated, "When I came on shift I noticed she (referring to R #2) was coming down the hall and the bridge of her nose was very off color. I took it at face value that is was reported. In my opinion, it would have been an injury of unknown origin." 6. 01/12/12 at 3:15 pm, during interview, RN Staff #1 stated, "When I looked at her it looked like a faint bruise on her nose. I believe this would have been considered an injury of unknown origin if you don't know where it came from." H. Review of the facilities policy and procedures revealed the following: 1. Unexplained Injury-Investigation Policy and Procedure dated 04/04 indicated, Standard: "An investigation of all unexplained injuries including bruises is conducted..." Policy: "Licensed nursing personnel are responsible for the initiation and completion of Accident/Incident reports and Licensed Nurse's notes when unexplained injuries occur." 2. Incident/Accident Reporting Policy and Procedure dated 04/04 indicated, "An accident is defined as an unexpected, unintended event that can cause a resident bodily injury...An investigation as well as an incident report is initiated...The Administrator is responsible for notifying the appropriate State department within 24 hours and by submitting investigation within 5 days." 3. Abuse Prevention Manual dated 08/31/07 indicated, "The facility shall...report injuries of unknown origin..." Section V. Investigation indicated, "The investigation will include witness statements from employees. In cases of bruises and/or abrasions of unknown origin, interview employees who worked on the unit...Physician will be notified of alleged incidents and findings." Section VII. Reporting indicated, "Reporting of incidents, investigations, related to injury of unknown origin."