Every finding on record at Serenity Estates of Lena

Based on interview and record review the facility failed to ensure residents had access to petty cash. This applies to 4 of 4 residents (R29, R32, R41 & R46) reviewed for resident funds in the sample of 15. The findings include:The facility provided current trial balance of resident funds being managed by the facility shows, R29, R32, R41 & R46 have money in an account at the facility. On 4/28/26 at 1:17 PM, V4 Business Office Manager stated, she was new to the position and wasn't sure how resident's received their money in their accounts. She did not have any petty cash or access to the resident's accounts. The Resident Personal Funds policy dated 4/28/26 shows, Policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Deposit of Funds: .2. The facility will maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest bearing account, or petty cash fund.

Based on interview and record review the facility failed to ensure residents and/or Power of Attorney's (POA's) received quarterly statements for funds managed by the facility. This applies to 4 of 4 residents (R29, R32, R41 & R46) reviewed for resident funds in the sample of 15. The findings include: The facility provided current trial balance of resident funds being managed by the facility shows, R29, R32, R41 & R46 have money in an account at the facility. 1. On 4/28/26 at 1:28 PM, V5 R29's sister/POA stated, she was aware of the account from the previous owners but has not received any statements. He should not be getting any statements from the facility about money. He is not cognitively able to understand what it is or what to do. R29's face sheet lists diagnoses to include: dementia and a moderate intellectual disability. The same face sheet also shows, V5 is his primary Guardian and responsible party. R29's current balance is $2,744.77 in the account managed by the facility. 2. On 4/28/29 at 1:45 PM, R32 was not aware she had any money in account at the facility and has not received any statements about the account. Her sister V7 manages her finances. R32 called her sister, V7 during the interview to ask about the account. V7 R32's sister stated, she was not aware of the account and has not received any statements from the facility. R32's face sheet lists diagnoses to include: progressive multiple sclerosis, cognitive communication deficit and altered mental status. The same face sheet shows, V7 as her responsible party. R32's current balance is $88.49 in the account managed by the facility. 3. On 4/29/26 at 10:58 AM, V8 R41's daughter/POA stated, she was not aware of an account with any money in it. She has not received any statements. R41's face sheet list his diagnoses to include vascular dementia. The same face sheet lists V8 as his responsible party. R41's current balance is $991.91 in the account managed by the facility. 4. On 4/29/26 at 11:04 AM, V9 R46's son/POA stated, he gets a bill from the facility but never a statement for any money in an account for R46. He was not aware of an account with any money in it. She should not get that information because she wouldn't know what to do with it. R45's face sheet lists her diagnoses to include: bipolar disorder and hallucinations. The same face sheets lists V9 as her responsible party and POA for financial. R46's current balance is $2,572.37 in the account managed by the facility. On 4/28/26 at 3:16 PM, V4 Business Office Manager (BOM) stated, she has only been the BOM for a couple of months and is still learning. She has not received training on what to do. She does not send out any statements to residents or families (POAs). She was not aware or told she needed too. The Resident Personal Funds policy dated 4/28/26 shows, Policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Accounting and Records: .3. The individual financial record must be available to the resident through quarterly statements and upon request.

Based interview and record review the facility failed to ensure Power of Attorney's (POA's) of deceased residents were reimbursed money from accounts being managed by the facility. This applies to 2 of 2 residents (R56 & R57) reviewed for resident funds in the sample of 15. The findings include:The facility provided current trial balance of resident funds shows, R56 has $648.54 in an account at the facility. The same form shows, she expired (died) on [DATE] (54 days ago). The facility provided current trial balance of resident funds shows, R57 has $28.00 in an account at the facility. The same form shows, he expired on [DATE] (78 days ago).R56's face sheet shows, she was discharged from the facility on [DATE]. R57's face sheet shows, he was discharged from the facility on [DATE]. On [DATE] at 1:17 PM, V4 Business Office Manager (BOM) stated, she was new to the position and was still learning. They have a company managing the money outside of the facility. When they provided the list for the survey, V4 BOM noticed R56 and R57 had money in accounts and needed to be re-imbursed to them. The Resident Personal Funds policy dated [DATE] shows, Policy: The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Conveyance upon Discharge, Eviction, or Death: 1. Upon the discharge eviction, or death of a resident with a personal fund deposited with the facility, the facility will convey withing 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.

Based on observation, interview, and record review the facility failed to provide sufficient staffing and to address staffing concerns of the facility's Resident Council for 5 of 25 residents (R9,R33,R37,R38,R45) reviewed for staffing in the sample of 25.The findings include:1.On 04/27/2026 at 11:06 AM, R33 did not have the physician ordered pressure reduction interventions in the wheelchair to treat a current pressure ulcer to the sacrum and right posterior thigh. V10 CNA-Certified Nursing Assistant failed don PPE-Personal Protective Equipment according to R33's posted infection control guidance when providing ADL-Activity of Daily Living care.2. On 04/27/2026 at 9:57AM, R9 said, I wait a long time for care. I had dirtied myself and wet myself; I posted the incident on my social media. The staff did not like that; I was asked to take it down. Meals are not hot half the time.R9's Resident Grievance/Complaint Form dated 04/07/2026 shows, Not enough staff for CNA's.3.On 04/27/2026 at 10:00AM, R45's Significant Weight change on 04/12/2026 was not identified or reported to the physician.4.On 04/27/2026 at 10:45AM, R37 and R38 were sitting in the hallway, in their wheelchairs together talking.On 04/27/2026 at 10:46 AM, R37 said, we have one CNA, we have to wait a long time. We lost 2 CNAs, not sure what happened. They went to different facilities. On 04/27/2026 at 10:16 AM, R38 said, on the night shift, I have an appointment with the CNA every 2 hours. It did not work last night; they wanted to put a diaper on me. My skin cannot take that. It takes so long for the call light to be answered. I called out the door from my bed to the CNA, the CNA had forgot to do something, it was quick to complete, I knew the call light would take a long time and the CNA was right by the door. The nurse heard me and told me not to yell. I was not yelling, I do not know what caused the nurse to act that way. I needed assistance not attitude.R38's Nursing Home Resident/Family Grievance Form dated 02/06 shows, call light not being answered.5. The Resident Council minutes Dated February 23, 2026 shows, 18 residents attended the meeting. New Business, Nursing Department, Concerns: Staffing concerns. Call light concerns. No documents showing V1 Administrator addressed the Resident Council Concerns regarding Nursing staff and Call Light wait times.The Resident Council Dated March 23, 2026 shows, 23 residents attended the meeting. Staffing was again addressed under Nursing Department Concerns: Staffing Concerns. No documents showing V1 Administrator addressed the Resident Council Concerns regarding Nursing Staff for February or March Resident Council.On 04/29/26 at 11:55AM, V2 DON-Director of nursing said, the facility used to have 4-5 CNA's and 1-2 CNA's supervisors on the day shift, we had a lot of staff. When the new owners came in, after budgeting, they cut back on the CNAs. It has been an adjustment. The ombudsmen brought the concern to me after the resident council meeting. V23 Activity Director writes up the concerns and presents them to the Administrator. I have not received any specific reports that the resident care is not up to par. There are longer call light times.On 04/29/2026 at 12:08PM, V23 Activity Director said, in the meetings the residents felt the facility is working the staff too much. There is not enough help. Sometimes I write a concern form out, it depends on what it is. March 2026, I talk to the Administrator about the issue. I do not have anything showing V1 Administrator addressed the Resident Council. The residents invited V1 Administrator to the Resident Council meeting, some residents feel V1 Administrator should go to every Resident Council meeting. I explained it is not reasonable for the administrator to attend every meeting.On 04/29/2026 at 12:18PM, V25 Restorative CNA said, it was a cut in staffing. It is different. The care is the same, the staff is less. Some of the CNAs feel the ratio is off. This is what all healthcare facilities are doing.On 04/29/2026 at 12:22PM, V16 CNA said, with the staffing changes I am providing baseline care. I do not have time to go over and above. The residents want more staff; the residents complain about having to wait too long.On 04/29/2026 at 3:00PM, V1 Administrator said, the restorative CNA has been given a resident care assignment to meet the staffing ratio.The facility assessment dated 2025-2026 shows, our expectation is to exceed the minimum staffing for optimal resident outcomes.

Based on observation, interview and record the facility failed to ensure a Gradual Dose Reduction (GDR) for psychotropic medications was completed. This applies to 1 of 5 residents (R26) reviewed for unnecessary medications in the sample of 15. The findings include:R26's face sheet lists her diagnoses to include: dementia, cognitive communication deficit, major depressive disorder and generalized anxiety disorder. On 4/27-4/29/26 at multiple different times, R26 was observed in her room, in bed and up in her wheelchair. She was not cognitively intact and could not answer any questions.The consultant pharmacist medication regimen review for recommendations created between 8/1/2025 and 8/15/25 shows, For R26: As a reminder, per CMS (Centers for Medicare & Medicaid Services) guidelines, this patient is due for GDR for the following medication(s) to ensure that he/she is using the lowest possible effective/optimal dose: escitalopram (antidepressant) 20 mg (milligrams) daily and mirtazapine (antidepressant) 15 mg daily. The psychiatry note dated 9/15/2025 for R26 shows, Plan: Most recent GDR: 9/3/25 decreased escitalopram to 15 mg PO (by mouth) q AM (every morning) per Pharm (pharmacy) recs. 4/21/24- contraindicated GDR for mirtazapine due to increased risk of depressive symptoms. The note to attending physician/prescriber dated 3/1/2026 (7 months later) for R26 shows, As a reminder, per CMS (Centers for Medicare & Medicaid Services) guidelines, this patient is due for GDR for the following medication(s) to ensure that he/she is using the lowest possible effective/optimal dose: escitalopram (antidepressant) 20 mg (milligrams) daily and mirtazapine (antidepressant) 15 mg daily. The note is signed by the psychiatry NP (nurse practitioner) to decrease escitalopram 15 mg daily. The psychiatry notes between August 2025-March 2026 were reviewed. They all showed, R26 was taking escitalopram 20 mg daily and mirtazapine 15 mg daily. They did not address the original pharmacy request to GDR both medications in August 2025. R26's February 2026 medication administration record (MAR) showed, escitalopram 20 mg daily with a start date of 11/19/2024 and D/C (discontinued) date of 3/3/2026. The same record also shows mirtazapine 15 mg daily with a start date of 11/18/2024 and D/C date of 3/19/2026. The escitalopram 20 mg was never changed in August/September 2025 per pharmacy and psychiatry recommendations. The mirtazapine was never addressed in August 2025 for any GDR. R26's current order summary report shows, escitalopram 20 mg was decreased to 15 mg on 4/23/2026. The mirtazapine 15 mg was decreased to 7.5 mg on 3/19/2026. On 4/29/26 at 10:52 AM, V2 Director of Nursing (DON) confirmed, R26 was supposed to have a GDR of both medications in August 2025 and it was missed. The psychiatry notes showed it was done but it was not. When the pharmacy asked for it again in February they saw it was never done and both medications were changed/decreased in March 2026. The facility's gradual dose reduction of psychotropic drugs dated 3/14/26 shows, Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs. Compliance Guidelines: 2. After the first year, a GDR will be attempted annually, unless clinically contraindicated.

Based on observation, interview and record review the facility failed to ensure pressure ulcer prevention interventions were in place for a resident at risk for pressure ulcers for 1 of 4 residents (R33) reviewed for pressure ulcers in the sample of 15.The findings include:R33's Wound Evaluation and Management Summary dated 4/27/26 shows that she has a pressure wound to her sacrum and a pressure wound to her right posterior thigh. R33's Physician's Order Sheet shows an order dated 11/13/24 for, Cushion at edge of seat for wound prevention.On 4/27/26 at 11:06 AM, V10, Certified Nursing Assistant (CNA) went into R33's room to bring her to the toilet. R33's stood up from her bariatric sized wheel chair and there was a small padded cushion on middle of the her wheel chair seat. The cushion was not near the edge of her chair and there was no other padding on the edge of her chair. On 4/28/26 at 12:30 PM, V12 (Wound Nurse) said that R33 currently has a pressure wound to her sacrum and right posterior thigh that was facility acquired. V12 said that R33's posterior thigh pressure ulcer is a re-occuring wound for her. V12 said that she should have a cushion on her wheelchair that covers the front edge of her wheelchair because her wound is from her thighs pressing on the edge of the wheel chair. V12 said that she did notice that she had the wrong type of cushion on her wheelchair and has replaced it with the appropriate sized one. V12 said that staff could also use a pad to cushion the edge of the wheel chair if they did not have a cushion of appropriate size. R33's Braden assessment dated [DATE] shows that she is at high risk for developing pressure ulcers.The facility's Pressure Injury Prevention and Management Policy shows, Interventions for Prevention and to Promote Healing.Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include.Redistribute pressure.Provide appropriate, pressure-redistributing, support surfaces.

Based on observation and interviews, the facility failed to ensure safe hot water temperatures in resident care areas for 1 of 25 residents (R2) reviewed for safety and supervision in the sample of 25.The findings include:On 04/29/2026 at 9:32AM, V22 Maintenance provided a glass of ice water to check the thermometer's calibration. The reading was 31.6 degrees Fahrenheit.On 04/29/2026 at 9:50 AM, V22 Maintenance Director said, the residents have different opinions about water temperature; what it is too hot or too cold. I am good if the hot water does not go over 110 degrees Fahrenheit.On 04/29/2026 at 10:32AM, V22 Maintenance said, the sink in the activity area is connected to the kitchen's water supply. The kitchen's hot water needs to be at a higher temperature. On 04/29/2026 at 11:00 AM, R2 said, I use the sink all the time to wash my hands, the glue and stuff.On 04/29/2026 at 11:06 AM, V24 Activity Aid said, the residents use the sink to clean up after messy activities. On 04/29/2026 at 11:13 AM, the water in the activity area was 129.6 degrees Fahrenheit.On 04/29/2026 the facility did not provide a policy or guidelines for protecting residents from hot water burns.The regulator guidance from the Centers for Medicare and Medicaid in the State Operations [NAME] 08/08/2024 shows, the time required for a third degree burn to the skin is 15 seconds when the hot water is 133 degrees Fahrenheit, one minute when the hot water is 127 degrees Fahrenheit. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding.

Based on observation, interview, and record review, the facility failed to ensure a resident experiencing significant weight loss was identified and the physician was notified. This resulted in a delay in evaluation and intervention of a significant, unplanned weight loss of 5.88% for one of five (R45) residents reviewed for weight loss in the sample of 15.R45's Face Sheet printed 4/28/2026 documents R45 was admitted to the facility with multiple diagnoses that include influenza, acute respiratory failure, and unspecified protein-calorie malnutrition.On 4/27/2026 at 10:00AM, R45 was in bed, not dressed for the day, blinds closed and lights off, with breakfast (appeared to be oatmeal, eggs, toast and coffee and milk) on bedside table that appeared to be untouched. R45 stated that R45 was tired, had not yet been out of bed, and was not hungry.R45's Weights and Vitals Summary dated 4/28/2026 documents the following weights which represent a 7.2lb (pound), 5.88% unplanned weight loss over approximately 8 days, meeting criteria for significant weight loss:-4/4/2026: 122.4lbs-4/5/2026: 122.6lbs-4/6/2026: 120.2lbs-4/7/2026: 122.0lbs-4/8/2026: 121.8lbs-4/9/2026: 121.2lbs-4/10/2026: 117.6lbs-4/11/2026: 116.6lbs-4/12/2026: 115.2lbs with noted warning of -5% changeAdditional weights (4/15, 4/17, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27) noted warning of 5% weight loss.R45's Meal Consumption Task sheets (4/3/2026-4/28/2026) noted that the majority of R45's meal intake is between 0-25%.R45's medical record (nurse, provider, dietician progress notes) was reviewed and did not note that a provider or the registered dietician was notified of significant weight loss.V17's Registered Dietician Progress Notes note that V17 documented twice, on 4/9/2026 and 4/27/2026, with the 4/27/2026 noting that R45 had a -5.0% weight loss and recommended an appetite stimulant if medically appropriate. The notes did not include that a provider was notified.On 4/28/2026 at 8:56AM, V20 Dietary Aide stated that staff track residents' intake to determine if they are losing or gaining weight, and if additional interventions are needed such as supplements or alternative meals. V20 stated that intake information is notified to the nurses. On 4/28/2026 at 9:43AM, V19 Licensed Practical Nurse stated that V19 is unsure of who reviews and monitors nutritional intakes. V19 stated that there are no current residents (E hall) on a fluid restriction, and no resident is being monitored for weight loss. V19 stated that a provider should be notified of a significant change in weight.R45's Order Summary Report printed 4/29/2026 notes that an appetite suppressant was ordered on 4/28/2026.On 4/29/2026 at 10:56, V17 Registered Dietician stated that V45's initial assessment, a dietary supplement, TwoCal, was recommended as V45's history of malnutrition. V17 stated that V17 did not assess R45's weight again until 4/22/2026. V17 stated that V17 typically assesses residents' weights at the beginning and the end of the month. V17 stated that when staff enter residents' weights into the computer, a warning note will present if there is a significant weight loss of five or more percent. V17 stated that when R32's weight loss was assessed, intake was identified to be low, and an appetite stimulant was recommended to the Director of Nursing (DON) and that the DON would notify the provider. V17 stated that V17 does not recall receiving notification from staff that R45 was experiencing weight loss. On 4/29/2026 at 11:43AM, V18 Nurse Practitioner stated that V18 first assessed R32 on 4/7/2026 and recommended intervention of Ensure (protein supplement). V18 stated that V18 was not notified of V18's significant weight loss and that on 4/28/2026 the Director of Nursing asked V18 to review R32's weight. V18 stated that upon DON notification and review of R32's weight loss, an appetite stimulant was ordered as an intervention to promote weight gain. V18 stated that a provider should be notified of a change in resident's status, including weight loss.On 4/29/2026 at 12:30PM, V2 Director of Nursing stated that R45's medical status including weight loss has been discussed and reviewed by the care team, including a provider, but confirmed that R45's medical record does not reflect such.The facility's Weight Monitoring (reviewed/revised 3/14/2026) policy documents that the facility will ensure that all residents maintain acceptable parameters or nutritional status, weight can be an indicator of nutritional status, identify and assess each resident's nutritional status, and interventions will be identified, implemented, monitored and modified. The policy also notes weight analysis, that a newly recorded weight should be compared to the previous recorded weight and a 5% change in weight within 30 days is defined as a significant change in weight. Furthermore, the policy notes that the physician should be informed of significant weight change and the registered dietician should be consulted to assist with interventions.

Based on observation, interview, and record review, the facility failed to ensure urgent/emergent dental services were provided, failed to modify the diet of a resident with chewing difficulty due to dental concerns, and failed to notify the physician regarding dental concerns for 1 of 15 residents (R12) in the sample of 15 reviewed for dental care.The findings include:On 4/27/26 at 12:29 PM, R12 was sitting in the dining room during lunch. V14, Registered Nurse (RN), came in and began looking at R12's teeth. After V14 left, R12 said he was having trouble eating due to his tooth. R12 said it is almost falling out; it's been a couple of days, and he can tell it's been dead. R12 said the facility did not offer him a dentist appointment, only that the nurse asked him if he had a dentist.On 4/28/26 at 9:23 AM, R12 said his tooth is still loose and showed how his top, front, right tooth was wiggling freely. It appeared to barely be connected to his gums. R12 said he can only eat softer foods, no meat. R12 said his wife was here yesterday and said their dentist is out of network, so no dentist has been set up. On 4/28/26 at 1:07 PM, V14 said R12 has a loose tooth which he said just started getting loose the other day. V14 said she was able to wiggle it a little bit, but it's still in his mouth. V14 said she told R12's wife about it and she was going to look into a dentist. V14 said she doesn't think it's infected because it didn't look red. V14 said we were going to look into a dentist, but there has been no dentist available since the new company took over in November (2025). V14 said she did not report R12's tooth problem to anyone else. V14 said R12 is still eating, but some of the meat is too tough and she doesn't want him to choke on the tooth. V14 said she is waiting to see if R12's wife can find a dentist. V14 said she doesn't know if R12's tooth could be salvaged or not; he needs to see a dentist.On 4/28/26 at 1:20 PM, V2, Director of Nursing (DON), said if there was an urgent/emergent dental problem, the nurse would tell the resident's provider (nurse practitioner or physician) and have the resident evaluated. The resident would possibly need to go to the emergency room. V2 said no dentist would come to the facility for an urgent (dental) condition. V2 said it is not the family's responsibility to find a dentist. V2 said if a resident she was caring for had a dental concern, she would offer to schedule an appointment with a dentist, or let them choose their own provider, if it's safe to wait. If a resident is having trouble eating or can possibly choke on a loose tooth, she would want to make sure they were safe. V2 said they meet with the nurses and certified nursing assistants (CNAs) every morning to discuss any resident concerns; that's where an issue with a resident with a tooth problem would be brought to their attention.V1, Administrator, said the Interdisciplinary Team (IDT) meets every morning and resident concerns are brought up and they discuss it as a team. If there is a dental concern, they would notify the provider, discuss the residents' needs, possibly get a speech evaluation due to a possible need to change the resident's diet, and ask the resident/family if they would like to go to a dentist. If they agree, they would put out a referral to a dentist. V1 said she would want this process to be done within 24 hours.On 4/28/26 at 2:11 PM, V16, CNA, said she knew about R12's loose tooth yesterday (4/27/26). V16 said R12 reported that he had a loose tooth, and he wiggled it. V16 said she reported it to V19, Licensed Practical Nurse (LPN), but she was not R12's nurse, so she reported it to V14 right away yesterday.On 04/29/2026 at 11:48 AM R12 was sitting in the dining room. R12 said he still has his right front tooth at this time; nothing has been done.R12's Minimum Data Set, dated [DATE] shows R12 has no broken or loosely fitting full or partial denture (chipped, cracked, uncleanable or loose), and no mouth or facial pain, discomfort or difficulty with chewing. R12's Progress Notes dated 4/28/26 at 11:14 AM show R12's top, front tooth is very loose, the nurse tried to wiggle it out, but the resident did not want it pulled. The resident is eating soft foods at this time. The nurse notified R12's wife who will look into making a dental appointment. There was no other documentation regarding R12's tooth concern prior to or after the above entry as of 4/29/26 at 3:00 PM. R12's Order Summary Report dated 4/28/26 shows R12 is on a regular texture diet and has a current, active order for Apixaban (a blood thinner) twice a day. R12's admission Record dated 4/28/26 shows his diagnoses include, but are not limited to, acute osteomyelitis of the right ankle and foot, methicillin resistant staphylococcus aureus (MRSA) infection of unspecified site, sleep apnea, cardiac arrhythmia, and atrial fibrillation.The facility's Dental Services Policy (reviewed 3/14/26) shows it is the policy of the facility to assist residents in obtaining routine and emergency dental care. Emergency dental services includes services needed to treat broken or otherwise damaged teeth that requires immediate attention by a dentist. The facility will assist the resident with making dental appointments and arranging transportation to and from the dental services location. In the case of an acute dental condition, the facility will take measures to ensure residents are still able to eat and drink while awaiting dental services. Interventions include, but are not limited to, notify physician of pain or other needs, modifying diet consistency, referral to speech therapist for chewing problems. For residents/representatives who do not wish to be referred for dental services, the physician shall be notified. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.

Based on observation, interview and record review the facility failed to serve a resident chopped meat as ordered for 1 of 15 residents (R33) reviewed for diets in the sample of 15.The findings include:R33's Physician's Order Sheet shows an active order for a regular texture diet with chopped meats.On 4/27/26 at 12:15 PM, R33 was in the main dining room eating lunch. R33's meal ticket showed that she is supposed to have chopped meats. R33 had a whole pork chop on her plate. R33 ate half of the pork chop by picking it up and taking bites of it. On 34/27/26 at 12:30 PM, V13 (Dietary Aide) reviewed R33's meal ticket and said that R33 should have been served a chopped up pork chop for the noon meal and should not have been served a full pork chop. The facility's Therapeutic Diet Orders Policy shows, The facility provides all residents with foods in the appropriate form.as prescribed by a physician.Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.

Based on observation, interview and record review the facility failed to ensure Personal Protective Equipment (PPE) was donned prior to providing direct resident care to a resident on Enhanced Barrier Precautions (EBP) for 1 of 15 residents (R33) reviewed for infection control in the sample of 15. The findings include: R33's Wound Evaluation and Management Summary dated 4/27/26 shows that she has a pressure wound on her sacrum, right posterior thigh and left upper ear.On 4/27/26 at 11:06 AM, there was a sign on R33's door that said that she was on EBP and staff should apply a gown and gloves when performing direct resident care activities including transferring and providing hygiene. On 4/27/26 at 11:06 AM, V10, Certified Nursing Assistant (CNA) went into R33's room to bring her to the toilet. V10 did not apply a gown. V10 assisted R33 up from her wheelchair and into the bathroom. V10 then provided perineal care to R33 and assisted her back to her wheel chair. On 4/27/26 at 2:45 PM, V11 (CNA) said that R33 is on EBP due to having wounds and staff should apply a gown and gloves when providing care to her including taking her to the bathroom. The facility's Enhanced Barrier Precautions Policy shows, Enhanced Barrier Precautions (EBP) refer to infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following.wound.High-contact resident care activities include:.Transferring .Providing hygiene.

Based on interview and record review, the facility failed to ensure effective implementation of its Infection Prevention and Control Program was effectively implemented to include identification and surveillance of one of one (R32) resident reviewed for prophylactic antibiotic therapy in the sample of 15.R32's Face Sheet printed 4/28/2026 documents R32 was admitted to the facility with multiple diagnoses that include progressive multiple sclerosis and urinary tract infection.R32's Order Summary Report printed 4/28/2026 documents that R32 has an order for Trimethoprim (antibiotic) 100 milligrams one time a day for prophylaxis of urinary tract infection that started on 1/25/2025.On 4/29/2026 at 10:49 AM, V3 Infection Prevention Nurse/Assistant Director of Nursing stated that V3 is the individual who monitors the resident's antibiotic use, which includes the clinical reason for the antibiotic, who ordered it, when the antibiotic should be discontinued, monitor signs and symptoms, if any, and the medication effectiveness. V3 stated I did not know that I had anyone on prophylactic antibiotics and confirmed that R32's antibiotic use has not been evaluated at this time.The facility's Antibiotic Stewardship plan (revised 3/7/2026) policy documents that the IP (Infection Preventionist) monitor all antibiotic stewardship activities and the facility shall track antibiotic use.

Based on interview and record review the facility failed to investigate an injury of unknown origin as possible abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 3.The findings include:R1's Face Sheet printed on 2/25/26 showed he had the diagnosis of dementia and right above the elbow arm amputation.On 2/24/26 at 10:45 AM, V3 (R1's Daughter In-Law) said R1 had a black eye and the facility was unable to explain how R1 got the black eye.R1's Progress Note dated 9/18/25 at 2:08 PM, entered by V10 (Licensed Practical Nurse) showed R1 had bruising to the corner of his left eye that was dark purple in color and approximately 3 centimeters (CM) x 0.5 CM. The same note showed R1 was alert and oriented times one and was unable to explain how the bruising occurred.R1's Progress Note dated 9/18/25 at 11:50 PM showed R1 also had bruising to his left upper arm measuring 10 CM x 5 CM that was light purple/blue in color. The note indicated R1 was unable to explain how the bruising occurred.On 2/25/26 at 12:06 PM, V10 said she was taking care of R1 when the bruising was found. V10 said R1 was confused and could not explain how he got the bruising. V10 added that she was not sure how R1 sustained the bruising, and no one witnessed how R1 got the bruising. V10 said she treated the bruising like an injury of unknown origin and possible abuse. V10 said she notified V2 (Director of Nursing) of the bruising and filled out a Risk Management form. An Incident Form (undated) entered by V10 showed R1 had bruising to the left eye about 3 CM x 0.5 CM that was dark purple and bruising to the left upper arm that was 10 CM x 5 CM. The same form showed R1 was unable to explain the bruising. The form showed R1 was alert to place only, confused, and with impaired memory. According to the form, V2 was notified of the bruising on 9/18/25 at 1:56 PM. On 2/25/26 at 12:38 PM, V2, Director of Nursing, DON, said a Risk Management form was filled out regarding R1's bruising. V2 said R1's bruising was explainable therefore not treated as abuse. V2 added that R1 had a behavior of going to the end of the hallway and grabbing the door handle. V2 said it was plausible that the resident sustained the bruise while trying to open the door. V2 clarified that no one saw R1 swinging or forcefully pulling on a door handle, grab bar, or wheelchair component that caused the bruising. R1's Risk Management/Incident Report dated 9/18/25 signed by V2 showed R1 was noted with bruising to the corner of the left eye in an area accessible by the resident's functional left arm. Based on behavioral observations it is plausible that the resident sustained the bruise while swinging or forcefully pulling the door handle, grab bar, or wheelchair component. No signs of staff-to-resident or resident-to-resident altercation noted. Skin is otherwise intact with no additional injuries or abnormalities observed. The resident is a poor historian and unable to recall or report the cause of the bruise and there were no witnesses to the injury. There were no prior or current safety alerts specific to this area.On 2/25/26 at 1:20 PM, V2 Director of Nursing, DON, said there was no behavior noted that corresponded with the behaviors mentioned in the Risk Management/Incident Report.On 2/25/26 at 1:25 PM, V11 (Social Service) said her office was next to the door R1 would try to open. V11 said R1 would hold onto the door handle and at times flail his arms when staff tried to remove his hands from the door handle. V11 said she never witnessed R1 hit himself. On 2/26/26 at 11:54 PM, V1 (Administrator) said if a resident had bruising to the corner of their eye and the resident could not explain it and there were no witnesses to the injury an injury of unknown origin abuse investigation should be done. V1 said there was no abuse investigation for R1's bruising. The facility's Abuse policy dated 2/17/20 showed the facility must report any suspicious injuries of unknown sources. Injury of unknown origins were defined as an injury where the source of the injury was not observed, and the resident could not explain the injury. Also, that the injury was suspicious because of the extent of the injury or location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma). An example of suspicious injury of unknown origin is a resident who is unable to communicate has a black eye and no one witnessed the source of the injury. The same document showed the administration will conduct an investigation for suspected abuse.

Based on interview and record review the facility failed to ensure a resident wasn't administered the wrong medications resulting in a significant medication error. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 5. The findings include:On 2/9/26 at 10:37 AM, R1 stated, an agency nurse gave her the wrong medications. She tried to tell her the medications weren't her pills but the nurse told her they were, so she took them. The nurse did not ask her name or anything else to confirm it was her. She said she had a real hard headache and didn't know how to explain how she felt after taking the medication. They told her one of the medications was risperidone. She wrote it down on a piece of paper. She has never been prescribed that medication or taken it before. The facility's medication error report form for R1 dated 1/29/26 shows, the medication error happened on 1/29/26 at 8:30 AM. V4 agency Licensed Practical Nurse (LPN) gave R1 another residents (R5) medications. R1 received, Norvasc 5 mg (milligram) (blood pressure), iron 325 mg, fiber tablet, Lasix 10 mg (water pill), multivitamin, potassium 10 mEq (milliequivalent), vit D3 and risperidone 2 mg (antipsychotic). The contributing factors were inexperienced staff and an old photo of R1. R1's symptoms were none immediately, has gotten sleepy. R1 remained alert and oriented x 4. On 2/9/26 at 11:32 AM, V3 Assistant Director of Nursing (ADON) stated, R1 did receive the wrong medications from V4 agency LPN. V4 agency LPN recognized it right after R1 took the medications. Both her and V2 Director of Nursing (DON) confirmed nurses should be verifying the residents prior to giving medications by using the photo in their medical records. R1 and R5's electronic medical records show, R1 received amlodipine besylate (Norvasc) 5 mg, ferrous sulfate (iron) 325 mg, fiber tablet, Lasix 10 mg, multivitamin, potassium chloride 10 mEq, vitamin D3 25 mcg (micrograms), florastor (probiotic), liquid protein and risperidone 2 mg at 8:30 AM on 1/29/26 that were prescribed to R5. R1 is not prescribed any of those medications. The facility's medication administration policy dated 1/25/26 shows, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards or practice, in a manner to prevent contamination or infection. Policy explanation and compliance guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation.

Based on observation, interview, and record review the facility failed to prevent staff-to-resident physical and verbal abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of the 3. The findings include:The facility's Final Report to the local health department (date submitted not provided in report) showed, on 11/8/25 at 4:45 PM, V4 and V5 Certified Nursing Assistants (CNAs) entered R1's room, an incontinent resident, to provide cares.and get him ready for dinner. [R1] is resistant often to care, including yelling out when being provided peri care. The report showed V4 indicated V5 became frustrated with [R1's] reluctance of care and quickly pulled the blankets and sheet off him. [R1] then reacted negatively by yelling, again. [V5] then pinched the resident's nose and told [R1] to 'shut up and be quiet' and 'shut the f*** up.' The report showed, Allegations made by [V4] against [V5] are founded. [V5] will not be returning to work at [the facility].The facility's investigation included V4's Employee Statement (handwritten note signed by V4 on 11/8/25) which showed, .We (V4 and V5) walked into his room and right off the bat [R1] was a little irritated and did not want to get up for dinner. We told him that he did have to get up because he needs to eat. [V5] then proceeds to throw the blankets off of [R1] and [R1] grunts because she did it aggressively and she then tells [R1] to 'Shut up. Be quiet.' We start to change him and get his pants on and he's still grunting, kind of screeching at this point so I tell [R1] 'I'm sorry. We're not trying to hurt you, just get you changed.' [V5] goes on to say 'shut the f*** up!' and grabs his nose hard and twists it and pulls on his nose. After we are done getting him up, I immediately go to tell [V10] and [V1] about the situation. The investigation showed V5 had received abuse training. On 11/18/25 at 10:10 AM, R1 was alert but pleasantly confused. R1 did not recall the incident on 11/8/25. R1 began speaking about a man helping him downtown. R1 had no injuries to his nose or face. On 11/18/25 at 11:19 AM, V4 CNA stated she has worked at the facility for a year, and she has been a CNA for two years. V4 stated she had only worked with V5 CNA one other day prior to 11/8/25. V4 said on that training day (V5 was a new employee to the facility) V5 was telling residents to be quiet and she doesn't want to hear them. V4 stated these statements were reported to a supervisor. V4 stated the next day she worked with V5 was on the afternoon of 11/8/25. V4 stated on that afternoon she went to assist V5 with getting R1 ready for supper. V4 stated R1 moans and groans while the staff provide care and get him up. V4 stated all of the staff are aware of R1's behaviors during care and she believes it is due to his catheter, which irritates him. V4 stated V5 kept telling R1 to be quiet and to shut the f**** up. V4 stated, She did actually use that word. I'm not a confrontational person. I was very shocked when she said that. I should have stopped her at that time. V4 stated, after that statement they continued to get R1 ready and transfer him out of bed with a mechanical lift. V4 said V5 was operating the mechanical lift, R1 was continuing to moan, V5 reached around the mechanical lift and grabbed his nose, twisted it, pulled it, and told him to be quiet. V4 said, there is no question in my mind as to what [V5] was doing (when she grabbed R1's nose). She was trying to get him to be quiet through twisting and pulling his nose. When she did that he squealed. V4 said after the physical abuse she separated R1 from V5, reported the incident, and then V5 was escorted from the building. On 11/18/25 at 10:21 AM, V5 CNA stated R1 .cussed me out V5 stated she is used to racial slurs, and it does not affect her ability to provide care. V5 denied the incident and stated the facility is lying. On 11/18/25 at 11:52 PM, V10 CNA Supervisor stated, I've never had a problem (with V4). She is respectful and quiet. She has never made an allegation against another staff member that I know of. V10 said V5 has very poor customer service. V10 said her demeanor and speech came off as lacking compassion; she would talk to them (residents) like children.I did hear her tell a resident that they should not be using their call light constantly because she had things to do. I pulled her aside and told her that we need to encourage the residents to use the call lights for safety and she cannot say that to the residents.She said she felt like she was going to get fired and she was fired from her previous job. She actually told me that. V10 stated V5 told her at her previous facility herself and other CNAs would turn off the call light system when residents would continue to use the call light. V10 said that 11/8/25 was V5's first day off training. V10 said it is known by the staff that R1 does not like to be repositioned and he moans during care. V10 said V4 reported to her that V5 had told R1 to shut the h*ll up and that V5 pinched and pulled his nose. V10 said R1 and V5 were separated then V5 was escorted from the building. V10 said R1 was upset and riled up following the incident; however, by the time supper was over he was at his baseline. V10 said she did not see any facial trauma on R1.On 11/18/25 at 12:10 PM, V11 Registered Nurse (RN) stated she escorted V5 from the facility on 11/8/25. V11 stated she had not worked with V5. V11 stated, .[V4] is a sweet girl. She does her job. V11 stated R1 does moan and groan during care due to his catheter. V11 stated R1 is receiving an ointment for his catheter discomfort. V11 stated she assessed R1 after the incident and he was aggravated. On 11/18/25 at 9:41 AM, V6 R1's Power of Attorney/R1's Daughter stated she did not see R1 until the following Wednesday. (11/8/25 was a Saturday). V6 stated, her brother, R1's Son, was in the facility shortly after the incident and R1 reported to him there had been a ruckus. V6 stated she did not see any injuries to R1's face. V6 said if this incident had occurred to R1 and he was cognitively intact, he would have been upset; however, there would not have been any lasting consequences to his behavior or mood. V6 said R1 has been experiencing a recent decline in cognition and health. On 11/18/25 at 9:59 AM, V7 R1's Son stated he saw R1 on Monday, 11/10/25. V7 stated, R1 reported there had been a ruckus but could not provide any further details. V7 stated R1 had no injuries to his face, and he would have shrugged off an incident like this if he was cognitively intact. V7 stated R1 has started to experience a recent decline in his health and cognition. On 11/18/25 at 8:33 AM, V1 Administrator stated V4 was a trusted and valued staff member. V1 stated he believed V4's statement and substantiated the abuse. On 11/18/25 at 12:10 PM, V2 Director of Nursing stated V4 .is one of our best. R1's admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia, psychosis, and pain. R1's 9/2/25 Quarterly Minimum Data Set showed, during the assessment period, he had moderate cognitive impairment. The facility's Abuse policy (Dated 2/17/2020) showed, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.It included verbal abuse, sexual abuse, physical abuse and [NAME] abuse. The policy continued, Employees are required to report all incidents of possible abuse, mistreatment or neglect of any resident. The policy showed accused staff should be removed from the facility and suspended.

Based on observation, interview, and record review the facility failed to ensure cooked foods were cooled in a manner to limit the growth of potentially dangerous pathogens. The failure has the potential to affect all residents in the facility. The findings include: The CMS 671, dated 3/25/25, showed 52 residents reside in the facility. On 3/25/25 at 9:05 AM, the facility's reach-in freezer had several left-over food items to include but not limited to: 1.) Spaghetti Sauce prepared on 3/18/25 and use by date of 4/18/25 2.) Taco meat prepared on 3/3/25 and use by date of 4/3/25 3.) Beef Barley soup prepared on 3/25/25 and use by date of 3/27/25 4.) Meat Balls prepared on 3/19/25 and use by date of 4/19/25. The facility's reach-in refrigerator had leftover chicken noodle soup with a prepared date of 3/24/25. On 3/27/25 at 11:35 AM, V9 (Dietary Manager) stated the facility does serve leftover foods to the residents. V9 said the leftover chicken noodle soup in the refrigerator and the leftovers in the freezer are for all the residents. V9 said the soups are on the alternative menu and served to the residents per their request. V9 said the leftovers, like the pasta sauce and taco meat, will be used the next time that food item is on the menu. On 3/26/25 at 8:59 AM, V9 Dietary Manager stated the cooling logs for the leftover items in the freezer should be posted on the reach-ins. (V9 pointed to the doors of the reach-ins in the kitchen.) V9 said, We don't have any cooling logs for the leftovers. V9 said the leftovers must be cooled quickly enough so the food does not linger in the danger zone, which is a temperature range where pathogens will grow more rapidly. The facility's General HACCP (Hazard Analysis and Critical Control Points) Guidelines for Food Safety policy showed, .Limit the time that food is in the temperature danger zone. The policy showed the danger zone is 135 degrees Fahrenheit (F) to 41 F. The policy showed cooked food should be cooled from 135 F to 70 F in 2 hours then from 70 F to 41 F within 4 hours. The policy showed if these times and temperatures were not met, then the food should be reheated to 165 F and the process restarted.

Based on interview and record review, the facility failed to perform interdisciplinary care plan conferences for 1 of 1 residents (R44) reviewed for care plans in the sample of 26. The findings include: R44's electronic face sheet printed on 3/26/25 showed R44 has diagnoses including but not limited to cerebral infarction, hemiplegia & hemiparesis affecting left dominant side, dementia with anxiety, and dementia with behaviors. R44's facility assessment dated [DATE] showed R44 has severe cognitive impairment. On 3/25/25 at 10:10AM, V13 (R44's power of attorney) stated, I have been leaving voicemails for about 3 weeks at the facility to figure out (R44's) finances and I am getting very angry because you can never reach anyone. When they call me, I answer or call back. A few weeks ago, I went to see (R44), and I wanted to be able to sit down with someone and ask questions about his care. I have never heard of a care plan meeting, and we have never had one. R44's care plan attendance records showed, 6/18/24 no family attendance, 9/11/24 no family attendance, and 12/18/24 no family attendance. On 3/26/25 at 1:33PM, V12 (Social Service Director) stated, (R44) is a tough situation because he was kind of just dropped off here, so he didn't have a lot of family involvement but now his (family) have been coming around more to see him, so they'll begin to be invited to care plan meetings. R44's nursing progress notes showed the facility has contacted the family 6 times since R44's admission to the facility on [DATE] and have never invited R44's family to a care plan meeting. On 3/26/25 at 2:05PM, V12 stated, (R44's) power of attorney is (V13). She became his power of attorney in December 2024. Invitations for care plan meetings are not documented, we just call families. There is a lot of family drama with (R44), but someone should still be invited to the meetings. (R44) is due for a care plan meeting by the end of the month but I have not reached out to his family yet to invite them. I typically reach out at least a week prior to when the meeting is scheduled. (Only 5 days are left in the month) The facility was unable to provide a policy regarding family/healthcare power of attorney attendance at care plan meetings or documentation of invitations to care plan meetings.

Based on observation, interview, and record review the facility failed to perform incontinence care and activities of daily living care for 1 of 1 residents (R35) reviewed for activities of daily living in the sample of 26. The findings include: R35's electronic face sheet printed on 3/27/25 showed R35 has diagnoses including but not limited to need for personal care, muscle wasting and atrophy, morbid obesity, and edema. R35's facility assessment dated [DATE] showed R35 has mild cognitive impairment and requires partial/moderate assistance with toileting hygiene. R35's care plan dated 7/27/22 showed, I have an ADL (activities of daily living) self-care performance deficit related to activity intolerance, limited mobility .personal hygiene: limited assist x 1 at times. On 3/25/25 at 10:46AM, R35 was walking down the hallway and had wet marks on the back of his pants. V14 (Certified Nursing Assistant) took R35 to his bathroom and removed his wet pants and incontinence brief. V14 confirmed R35's incontinence brief was wet with urine. V14 applied a clean incontinence brief and pants onto R35 without performing incontinence care. After V14 left R35's room, V14 stated, He will usually ask for incontinence care but since he didn't then I didn't provide it. I guess I could have offered to him, but he probably would have said no. Sometimes he doesn't like us to help him. On 3/26/25 at 11:10AM and 3/27/25 at 9:42AM, R35 continued to wear the same shirt and pants that he was wearing on 3/25/25. R35's nursing progress notes were reviewed and showed no documentation that R35 refused to change his clothes or receive incontinence care on 3/25, 3/26, or 3/27. On 3/27/25 at 11:29AM, V2 (Director of Nursing) stated, (R35) needs assistance with personal care. When a resident has a brief that is wet with urine it should be removed and followed up with incontinence care to prevent skin breakdown and provide cleanliness. Staff should be offering and trying to do incontinence care and asking him to change his clothes and if he refuses, it should be documented. The facility's policy titled, Incontinent Care-with or without a catheter dated 1/1/23 showed, It is the policy of this center to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination .

Based on observation, interview and record review the facilty failed to ensure a healed pressure injury did not reopen for 1 (R40) of 6 residents reviewed for pressure injury in the sample of 26. The findings include: R40's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including congestive heart failure, and need for assistance with personal care. His 2/18/25 resident assessment and care screening documents moderate cognitive impairment. The same assessment documents he requires partial to moderate assistance with rolling side to side, sitting to stand, and transfers. He is occasionally incontinent of urine, and he was admitted with a Stage 3 pressure wound. R40's Wound evaluation and management summary of 2/24/25 documents a Stage 3 pressure wound to the left upper medial buttock was resolved. The 3/10/25 wound evaluation and management summary documents the same Stage 3 wound re-opened and the initial measurements were 2.2 cm (centimeters) (length) x 1.4 cm (width) x 0.2 cm (depth). On 3/26/25 at 12:51 PM, V3 RN (Registered Nurse) stood R40 up with a walker, and pulled down his incontinence brief. At the top of his left inner buttock was an open irregular shaped wound with a white paste covering. V3 said the wound originally was 2 open areas that became one. She said R40 was incontinent of urine, mostly at night, during the day he will ask for assistance with the bathroom. On 3/27/25 at 11:51 AM, V2 DON (Director of Nursing) said the nurses do weekly skin checks, and the aides should be doing skin checks for redness and open areas when providing care. After consulting with V8 Wound nurse, V2 said the current wound is a re-opening of the prior Stage 3, and it should have been noted and reported prior to becoming open again at that size. The facility's 1/2025 policy for pressure ulcers documents 3. The facility will ensure that all residents at risk for pressure ulcers are identified to be at risk and given care to prevent the development of pressure ulcers. 4. The facility will ensure that a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for 1 of 3 residents (R19) reviewed for safety and supervision in the sample of 26. The findings include: R19's electronic face sheet printed on 3/27/25 showed R19 has diagnoses including but not limited to femur fracture, dysphagia, osteoarthritis, dementia with behaviors, and major depressive disorder. R19's facility assessment dated [DATE] showed R19 has severe cognitive impairment and utilizes a bed and chair alarm daily. R19's physician's orders dated 3/25/25 showed, Ensure bed/chair alarm in place & functioning at all times. R19's care plan dated 9/22/23 showed, I had an actual fall 2/17/25 .utilize bed/chair alarms, bolstered mattress, (non-slip pad) when up in wheelchair. R19's care plan dated 10/16/23 showed, I require bed/chair alarm related to I have a history of falls with attempted independent transfers and ambulation. On 3/25/25 at 9:18AM, R19 was laying in her bed with her bed alarm cord laying in a basin. The alarm box was sitting out in plain view with no cord attached to it and no blinking light showing any function on the alarm. On 3/25/25 at 9:32AM, V10 (Licensed Practical Nurse) stated, (R19's) orders do not show that she needs a bed alarm, so I don't think she uses one. If it's in her room, I would think she uses it though and it should be plugged in. If it is not plugged in, then it is not on and will not alert us if she tries to get up on her own. On 3/25/25 at 10:59AM, V11 (Certified Nursing Assistant) stated R19 uses a bed alarm and is unsure of why it was not plugged in. On 3/27/25 at 11:29AM, V2 (Director of Nursing) stated, (R19) uses a bed and chair alarm and they should be plugged in at all times. We re-instated her alarms after her fall last month because we weren't sure if she slid out of her chair or was trying to get up. The facility's policy titled, Fall Management-Evaluation dated 1/1/23 showed, It is the policy of this center to evaluate residents for their fall risk and develop interventions for prevention .

Based on interview and record review, the facility failed to perform safe bed mobility for 1 resident (R1) reviewed for safety and supervision. This failure resulted in R1 sustaining a nasal bone fracture, a femoral neck fracture, and a 4x4cm (centimeter) laceration to her forehead that was repaired with 9 sutures. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 3. The findings include: R1's electronic face sheet printed on 8/1/24 showed R1 has diagnoses including but not limited to intracapsular fracture of right femur, localization-related idiopathic epilepsy and epileptic syndrome with seizures, laceration of head, dementia with agitation, and osteoporosis. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and requires 2+ staff assist for bed mobility. R1's ADL (Activities of Daily Living) assessment dated [DATE] showed R1 requires 2+ staff physical assist for bed mobility. R1's local hospital records dated 7/28/24 showed, Patient is bedridden at baseline and lives at (facility), was getting bed bath done today by staff with bed raised high, patient rolled out of bed resulting in a 3x3cm laceration to forehead, blood from nares, right leg pain with hip flexion .Head exam- 4x4cm linear laceration over the frontal area of the skull through the epidermis .patients imaging studies were reviewed .there is questionable chip fracture of the nasal bone, a displaced sub capital fracture of the right femoral neck .Procedures: laceration wound explored, irrigated extensively, deep structures intact, size: 4cm, number of sutures: 9. On 8/1/24 at 8:57AM, V6 (Certified Nursing Assistant) stated, (R1) has a hip fracture, a broken nose, a cut on her forehead and some bruising. I don't know what happened to her. She has always been a 2 assist for bed mobility because she doesn't help very much so if you were to use one person you would really have to give some momentum to get her over on her side. She can be very unpredictable and she has had seizures before so you have to have 2 people with her no matter what. On 8/1/24 at 9:35AM, V4 (Certified Nursing Assistant) stated, I was giving (R1) cares and washing her buttocks and had her rolled on her side with one of my hands on her hip and cleaning her with the other hand. She had a jerking movement and the momentum flung her forward and she landed on the floor on her stomach. I had the bed at about my waist level so it wasn't all the way up but it definitely wasn't low to the floor. I immediately went and got the nurse and she had me hold pressure on (R1's) forehead while she called 911 and we stayed with her until the ambulance arrived. I was scheduled on the hall by myself but I know to ask for help, I just didn't. This was so scary and I never anticipated anything like this would happen. I was just trying to get her cleaned up by myself and I didn't know she would jerk forward like that. I know she is supposed to be a 2 person assist for bed mobility but I did it by myself anyway. On 8/1/24 at 11:23AM, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) stated, (V4) definitely should have had another aide helping her with (R1's) bed mobility. There were several other aides in the building at the time and we all have walkie talkies to call someone for help when we need it. Even the nursing administration has the walkie talkies so we can help when needed. If a resident requires 2 people for bed mobility then it's obviously not safe to use 1 person because they have been assessed as needing 2 people. This was a bad judgement call for (V4) and we have in-serviced her and the other aides on bed mobility assistance. This could have been prevented if she would have asked another aide for help. The facility's policy titled, Activities of Daily Living dated 2/17/20 showed, It is the policy of this center to assure residents have their activities of daily living needs met in a person-centered manner. The center will strive to assure residents maintain and or improve their current level of ADL function.

Based on observation, interview, and record review the facility failed to provide supervision to a resident with repeated falls (R55). This resulted in R55 having an two unwitnessed falls, the first fall resulted in a left femur fracture requiring surgical intervention and the second fall resulting in a right humerus fracture. The facility failed to ensure a resident at risk for falls was supervised (R59). This resulted in R59 experiencing an unwitnessed fall and fracturing her lumbar one, spinal vertebrae (lower back fracture). The facility failed to implement their fall protocol and assess a resident for falls (R40), resulting in an unwitnessed fall in R40's room. The facility failed to ensure residents with a history of falls were supervised (R34, R10) and failed to transfer a resident with a gait belt (R11). This applies to 6 of 11 residents (R55, R59, R40, R34 , R10, R11) reviewed for falls in the sample of 20. The findings include: 1. On 05/23/23 at 9:28 AM, R55 was sleeping in a low recliner, in her room, with a sling to her right arm. R55 did not recall what happened to her arm. The facility's Incident Report dated 12/24/22 to 5/24/23 showed R55 had six unwitnessed falls (3/17, 3/31, 4/16, 4/24, 4/26 and 5/13). The facility's Fall Report dated 5/19/23 showed R55 fell on [DATE], around 4:30 AM. A noise was heard by nursing staff in the hallway. Upon entering R55's room, R55 was observed on her right side. R55 was unable to stated how she fell when asked by V20 and V22 (CNAs - Certified Nursing Assistants). V25 (LPN - Licensed Practical Nurse) assessed R55. R55 had pain to her right shoulder. R55 was sent to the emergency room for evaluation and R55 had a fractured right shoulder (humerus). The facility Fall Report dated 3/27/23 showed, R55 was found next to her bed on 3/17/23, around 1:30 AM (during rounds). R55 was unable to provide details of the fall. R55 was incontinent of stool and had a bruise to her right chest. R55 denied pain and her ROM (range of motion) was within normal limits, so R55 was assisted back to bed by staff. Around 8:15 AM, R55 reported pain with movement and pain medication was administered. R55 had increased confusion, incontinence, and pain. An order was obtained to send R55 to the emergency room . R55 was admitted to the hospital for a left femoral neck fracture and had surgery on her left hip. R55's Face sheet dated 5/24/23 showed diagnoses to include, but not limited to: muscle wasting and atrophy; lack of coordination; need for assistance with personal care; generalized muscle weakness; difficulty walking; hypertension; history of falling; left femur fracture; hypothyroidism; and dementia. R55's facility assessment dated [DATE] showed R55 had severe cognitive impairment; had no behaviors; required extensive assistance of 2 or more staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene; was not steady without staff to stabilize and was frequently incontinent of urine. R55's Care Plan initiated 10/02/22 showed R55 was at risk for falls due to deconditioning and gait/balance problems. The interventions included, Anticipate and meet my needs; and Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. R55's Care Plan initiated 3/17/23 showed, I had an actual fall d/t (due to) poor balance, poor communication/comprehension, and unsteady gait . The interventions included, Continue interventions on the at-risk plan; educate me regarding risk for falls; make sure I'm wearing non slip/gripper socks while in bed; make sure my call light is within reach . Remind me that I am in a different room and reiterate the call light use for assistance; and remind me to use my call light. R55's Fall Risk Evaluation dated 3/23/23 showed R55 was At Risk with a score of 15. This document showed R55 had intermittent confusion and had 1-2 falls in the past 3 months. This document showed R55 had 1-2 predisposing disease. R55's Incident Audit Report dated 5/13/23 showed, R55 was found lying on her right side and complained of right shoulder pain. R55 was unable to describe what happened, but denied she hit her head. R55 was transferred to the emergency room for evaluation. This document showed R55 was alert and oriented to person and situation and was ambulatory with an assistive device. This document showed the following predisposing factors: a wet floor, gait imbalance, impaired memory, incontinent, and recent room change. The facility's Employee Statement dated 5/13/23 for V22 (CNA) showed, At about 4 AM, I was doing bed checks. I heard a crash noise and went to see what it was. I saw [R55's] door almost all the way shut, which I keep them all open, so when I went in the room she was laying on the floor. She said she was trying to get up, to get dressed. Prior to this I had observed her lying in bed sleeping and had assisted her to the bathroom [ROOM NUMBER] times, previously. The facility's Employee Statement dated 5/14/23 by V20 (CNA) showed, Approximately 4:00 AM on 5/13 I was coming from A hall to B hall when [V22] asked me if I heard something. I had not, but I started helping her check rooms where we found [R55] on the floor. Resident was laying flat on her back and there was liquid all over the floor. Initially we thought it was urine but it turned out to be a spilled water pitcher, which is most likely the loud noise [V22] heard. [V22] stayed to assess and assist the resident while I went to get the nurse. The nurse rushed back to assess and assist. The resident wasn't able to move her right arm and was in a great deal of pain. Nurse instructed us to leave resident on the floor as she was calling the ambulance . R55's Hospital records dated 5/13/23 showed R55 was seen for a humeral neck fracture. R55's Hospital X-ray report dated 5/13/23 showed, Impacted comminuted displaced humeral head fractures as above . R55's Skin Only Evaluation dated 5/13/23 at 10:55 AM, showed R55 had 4 cm x 4 cm bruise to her right deltoid; a 7 cm x 4 cm bruise to her right forearm; and a 11.2 cm x 3 cm bruise to her right wrist. R55's Orthopedic Office Visit dated 5/16/23 showed R55 was seen for discussion of her Right Proximal Humerus Fracture. This document showed that the family and orthopedic surgeon discussed R55's fracture and decided to treat in a non-operative manner. R55 was provided gentle exercises, but instructed not to lift anything over 1 pound and no over-head activities. R55's 5/13/22 Progress Note showed R55 returned to the facility at 8:25 AM with orders for pain medications and a sling to her right arm. R55 rated her pain at a 5 on a 1-10 scale (10 is worst pain ever felt). R55's 5/22/23 Progress Note showed R55's right had was very swollen with +1 pitting edema, yellow bruising was noted to right hand, sling was on her right arm, and Tylenol was given for shoulder pain. R55's right hand was elevated on a pillow. R55's 5/20/23 Progress Notes showed R55 stayed in her room for all activities and complained of right shoulder pain. On 5/24/23 at 2:47 PM, V18 (RN - Registered Nurse) said R55 fell a couple weeks ago and fractured her right shoulder. She was in the hospital for a few hours, but didn't have surgery. R55 returned to the facility with a sling on her right arm. Now she has yellow bruising, that is fading and swelling in her right hand. R55 has an appointment with Ortho next week. I wasn't here for the fall or when she fell and broke her hip. V18 stated, I believe both falls happened on night shift. V18 said R55 was ambulatory prior to the first fall in March 2023. Now R55 is mostly in a wheelchair because of the shoulder fracture. R55 can transfer with one assistance, but she can't put weight on her arm to use the walker. On 5/25/23 at 9:16 AM, V31 (RN) said R55's confusion, impulsivity, and getting up without assistance makes her a fall risk. On 5/25/23 at 9:48 V25 (LPN) said R55 was able to ambulate without a walker, before she fell and broke her hip. Then she needed a walker, but she wouldn't always use it. R55 insisted on wearing these sloppy, floppy shoes. V25 continued to stated, Sometimes she would use her call light, but that night (5/13/23) she didn't turn on her call light. I tried to encourage her to use the call light, but she'd forget and needed constant reminders. I encouraged the CNAs to leave the doors open, so they can look in on her, every time the pass by her room. That night we heard a loud noise. The CNAs went to investigate. They told me that [R55] had fallen. By the time I got in the room, she (R55) was on her back. I'm not sure what her initial position was. I think one of the CNA statements said she was on her right side. So she might have rolled over, before I got to the room. She was in obvious pain. She kept saying, It hurts! It hurts! and complained of right shoulder pain. There was no bruising at that time, maybe a little swelling. I called 911 and sent her out. She was in big time pain, so I was sure there was a fracture there. She (R55) fell around 4:00 AM, but she didn't return from the hospital during my shift. The emergency room did find a fracture in her right shoulder. On 5/25/23 at 10:30 AM, V22 (CNA/Scheduler) said she does pick up shifts when needed. V22 stated, I was here when [R55] fell . I was doing bed checks and was in another resident's room, when I heard a crash. I went in the hall to see what it was. R40 was up and moving around his room, but he hadn't fallen. I kept walking down the hall and noticed [R55's] door was almost closed and I usually keep it open, so I can keep an eye on her. When I tried to go in the room, her overbed table was up against the door, I think that's why it was almost shut. I noticed [R55] on the floor and she said she was trying to get up and get dressed. Her water pitcher had spilled all over the floor. [R55] was lying between the two beds, across (perpendicular to the direction of the beds). The overbed table was at the end of the bed, up against the door. I think she must have gotten up, leaned against the overbed table, it moved, and she fell . I had been toileting her throughout the evening. This happened during my last rounds, around 4:00 AM. She was complaining about right shoulder pain. I yelled down for help and V25 (LPN) came to check her. [V25] told us not to get [R55] up, so I put a pillow under hear head and got a blanket to keep her comfortable. The ambulance came and took her to the hospital. She really doesn't use the call light. She thinks she can still do things on her own, but she does have a lot of shoulder pain. On 5/25/23 at 11:38 AM, V2 (DON - Director of Nursing) said she understood that the facility's efforts to prevent falls, an actual fall, and fall risk assessments must be documented in the EMR (Electronic Medical Record). V2 stated, I understand. If it's not there, then it didn't happen. It sucks that the documentation isn't there. All falls should be documented in the facility assessments and the care plans should be resident-centered and updated with each change in condition or fall. The facility's Fall Management Evaluation Policy dated 1/1/2023 showed, It is the policy of this center to evaluate residents for their fall risk and develop interventions for prevention . Residents should be evaluated for their fall risk: on admission/re-admission to the center; following any change of status that may affect balance, mobility, or safety; following a fall; and quarterly. Risk Factors Associated with a Fall: .Gait and balance disorders, muscular weakness (particularly of the lower extremities); dizziness or vertigo; confusion; incontinence; . Previous falls; Current medications such as: Antipsychotics, Sedatives and hypnotics, tricyclic antidepressants, anxiolytics, and certain antihypertensives . and The use of 5 or more different medications . Procedure: Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls . 2. On 5/23/23 at 9:49 AM, R59 was sitting up in bed and stated, I'm not feeling the best today. I just fell blah and I don't know why. I thought today was my boyfriend's birthday and we were supposed to go out. I was worried I wasn't going to feel up to it, but the nurse told me that I have the days messed up. So, I'm going to rest today. R59's head of the bed is elevated all the way and she was leaning forward in a tripod position. R59 had oxygen in place, via nasal cannula, with long tubing coiled on the bed and on the floor beside the bed. At 12:30 PM, R59 was in her room. V5 (CNA) delivered R59's lunch tray to her room, spoke with R59 briefly and left the room. The surveyor saw R59 self-transfer from the bed to her wheelchair. R59's wheelchair was parked next to the bed, between her bed and her roommates bed. R59's lunch tray was sitting on her overbed table, in front of her wheelchair. R59 stood slowly, reached down to the arm of the wheelchair with her right, shaky hand, and slowly shuffled over to the wheelchair. R59's legs and arms were shaking during the transfers and she was not picking up her feet, but shuffled them across the floor. R59 sighed loudly and stated, Whew, that was harder than usual. R59 had two chicken legs, cheesy potatoes, and mixed veggies on her lunch tray. On 5/24/23 at 11:07 AM, R59 was sleeping in bed with her legs hanging over the side of the bed. R50 awakened to name, but was lethargic and kept falling asleep mid-sentence. R59's pupils were pinpoint and her eyes were glassy. The surveyor asked her how she was feeling. R59 replied, I've been better. I just feel a little off. It's hard to explain. R59 denied pain and said she wasn't sure if she had pain medication recently. R59 did not recall speaking to the surveyor on 5/23/23. R59 stated, I talked to you? I don't remember you. I don't know what's going on with me. I thought about asking to go to the hospital last night, but I didn't. R59 fell asleep again with her legs still hanging over the edge of the bed. The surveyor walked directly to the nurses' station and reported concerns to V18 (RN). V18 said she had already called the Nurse Practitioner and she ordered a UA and some labs. R59's Face Sheet dated 5/24/23 showed diagnoses to include, but not limited to: COPD (Chronic Obstructive Pulmonary Disease), lack of coordination, need for assistance with personal cares, generalized muscle weakness, difficulty walking, sacral pressure ulcer, wedge compression fracture of the first lumbar vertebra, colon cancer, lung cancer, acute respiratory failure, dysphagia, and abnormalities of gait and mobility. The Facility Fall Report dated 12/24/23 to 5/24/23 showed an unwitnessed fall on 2/3/23 at 3:45 PM. R59's facility assessment showed she had moderate cognitive impairment; had no behaviors; required extensive assistance of one staff member for transfers; and required staff assistance to stabilize. R59's EMR Kardex dated 5/24/23 showed R59 required one assist with a gait belt and walker for transfers. R59's Incident Report dated 2/3/23 showed the nurse walked by room and saw the resident was falling. R59 landed on her left hip and shoulder, but did not hit her head. R59's Hospital H&P dated 2/5/23 showed R59 fell at the facility and was having low back pain since. R59 had not been able to ambulate without assistance since she fell on [DATE]. R59 was given pain medications (oxycodone 5 mg and toradol 30 mg). The MRI of Lumbar Spine showed: Moderate, acute to subacute vertebral body compression fracture deformity of L1 with approximately 40% vertebral body height loss, new since 1/22/2023. Pt continued to complain of lower back pain and was given fentanyl intravenously (IV). R59's undated Facility Report showed on 2/3/23 at 3:45 PM, V26 (Nurse) reported witnessing R59 falling to the floor onto the left lateral recumbent position. The resident reported she was reaching forward to try to lift something off the floor. The initial assessments showed no evidence of injury or pain. However, during night shift R59's pain increased to the low back and Tylenol was not effective. The provider was notified and an X-ray was completed at the facility. The results concluded no acute fracture or dislocation seen by plain film examination. On 2/5/23 R59 was transported to the emergency room and an MRI was completed. This showed an acute fracture of the first lumbar vertebra. R59's Safety Care Plan initiated 1/30/23 does not provide any resident specific information. The interventions for this care plan are: encourage use of prescribed assistive devices (not resident specific devices); perform safety risk evaluation on admission and as needed and upon changes in condition; and safety measures - including strategies to reduce the risk of infection, falls, injury initiated as appropriate. (This care plan does not include what R59's needs are). R59's Fall Care Plan imitated 2/3/23 showed, I had an actual fall with injury d/t poor balance and unsteady gait. The interventions include: continue interventions for at-risk plan; remind me to ask for assistance when wanting to pick up objects from the floor; and remind me to use my call light for assistance. On 5/24/23 at 2:58 PM, V18 (RN) said I think R59 is feeling a little better now. I think the pain medication was getting to her when you talked to her earlier. R59 is usually pretty alert and oriented. She normally knows the date and month, but today she struggled a little with that. She's been having a lot of pain under her right breast and her lower back. I'm not sure what it's from. R59 has a wheelchair and transfers with assistance. Today she's a little more weak and needs more help. On 5/25/23 at 9:36 AM, V31 (RN) said she works the night shift and R59 will get up and ambulate by herself. R59 is usually pretty steady, but had been declining and went to the hospital yesterday. She's had some changes over the last couple of days. She's been short of breath, lethargic, and confused. This morning when I tried to wake her up, she was still very confused. Normally she is pretty with it and independent. R59 is not normally lethargic and shaky. If she was, then she shouldn't have been self-transferring. She could fall and get hurt. R59 should have been a fall risk because she had a fall prior to admission to the facility. On 5/25/23 at 9:48 AM, V25 (LPN) said R59 could be a fall risk because she has the long oxygen tubing and she could get tangled up in it. R59 would get up at night and walk out into the hallway with no oxygen or she'd walk in the bathroom with her oxygen, and that tubing is long. On 5/25/23 at 10:30 AM, V22 (CNA/Scheduler) said R59 should not be getting up by herself. R59 needs one staff assist with a gait belt. If she's lethargic and shaking, then she could fall and get injured. On 5/25/23 at 11:38 AM, V2 (DON) said the facility does use agency staff. R59's Care Plan should be individualized and explain the care that R59 needs. R59 has been declining this week and should not have been self-transferring. She already fell and fractured her lumbar spine. She could get hurt again if she falls. 3. On 5/23/23 at 9:32 AM, R40 was sitting in his recliner with his shoes on. R40 said he fell and was pointing in the direction of the window and his closet. At first R40 said he was trying to get away from the Indians. Later he said he was trying to kill some ants. R40 said he was over by his closet. There was a single chair sitting over between the window and his closet door. R40 said he was trying to kill some ants and lost his balance. He said he fell backwards onto his butt. R40 is pleasant, but confused. During this interview, V18 (RN) entered R40's room with medications. V18 confirmed that R40 was trying to kill ants, lost his balance, and fell by the closet. V18 stated, I'm just coming in to do his follow-up assessments. V18 obtained vital signs and performed a Neuro check on R40. V18 stated, He denies pain; his VS and neurochecks are normal, but he said his neck was hurting a little and he bumped the back of his head. I don't feel any bumps or bruises on his head. V18 finished her assessment and left the room. R40 started talking about his previous job, stood up and walked to the pictures under his TV. R40 did not use his walker. There was a rolling walker parked, next to R40. V19 (CNA) saw R40 standing and came in the room to assist him back to the recliner. The facility fall list showed that R40 had an unwitnessed fall on 5/23/23 at 9:00 AM. R40's Face Sheet dated 5/24/23 showed diagnoses to include: dementia, stroke, osteoarthritis, benigh prostatic hypertrophy, anxiety, insomnia, unsteadiness on feet, lack of coordination, CHF (Congestive Heart Failure), respiratory failure, and fall. R40's facility assessment dated [DATE] showed he had severe cognitive impairment; no behaviors; required supervision for bed mobility; and required setup and supervision for transfers and walking in his room. R40's only Fall Risk Evaluation was completed on 7/22/22. This document showed R40 was to have Fall Risks completed upon admission and quarterly. This document showed that R40 was disoriented; had fallen 1-2 times in the past 3 months; required assistive devices; and had 1-2 predisposing conditions. R40's Progress Notes dated 5/23/23 showed, resident was in room, bending over to kill a few ants on the floor. He lost balance and sat on floor. Resident got up himself before the nurse got to the room and was sitting in the recliner. R40 reported his neck twisted and hit back on the wall. He denies pain and is able to move neck without difficulty. On 5/24/23 at 2:47 PM, V18 (RN) said R40 was doing good. Normally he walks to the bathroom himself and gets dressed himself. He hasn't had any falls recently. R40 did not have any injuries and is doing well. On 5/25/23 at 9:41 AM, V31 (RN) said R40 had some behaviors in the past, but had been adjusting well. He's supposed to use a wheelchair when he's out of his room. He's another resident that should ask for help, but doesn't and takes himself to the bathroom. He should ask for help, so he doesn't fall and get hurt. On 5/15/23 at 9:48 AM, V25 (LPN) said she wasn't sure who completed the Fall Risk Assessments or how often they should be completed. R40 normally ambulates by himself, without the walker. He has a walker in his room, but the won't use it. He's supposed to. On 5/25/23 at 11:38 AM, V2 (DON) said the facility does use agency staff. R59's Care Plan should be individualized. V2 said the only Fall Risk she saw for R40 was dated 7/22/22, but he was supposed to have a quarterly completed. V2 observed the red font on the computer that showed R40's Fall Risk Assessment was due in March 2023 and had not been completed. These risk assessments are important to ensure we have the most up to date interventions in place for the resident's safety. 41639 4. R10's electronic face sheet printed on 5/25/23 showed R10 has diagnoses including but not limited to dementia without behaviors, unsteadiness on feet, restlessness & agitation, hypertension, generalized anxiety disorder, and depression. R10's facility assessment dated [DATE] showed R10 has moderate cognitive impairment and requires 2+ staff assist for transfers. R10's care plan dated 5/16/22 showed, Risk for injury- a bed alarm is being used while I am in bed due to I don't always use my call light for assistance and have had falls related to self-transferring. Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Make sure my alarm is in place and turned on when in use. R10's fall risk assessment dated [DATE] showed R10 is a fall risk. On 5/23/23 at 1:22PM, V9 (Certified Nursing Assistant) had assisted R10 onto the toilet. V9 told R10 she had to leave to get another staff member to help her get him up. V9 then left R10 on the toilet unattended, closed the door to his room and was gone for 3 minutes. V9 then came back into the room, told R10 she was still trying to find help and again left R10 on the toilet unsupervised. V9 stated R10 is a fall risk but he doesn't try to get up on his own and hasn't had falls that she is aware of. On 5/25/23 at 9:53AM, V8 (Certified Nursing Assistant) stated, Residents that are a fall risk should not be left on the toilet alone. (R10) is a fall risk so I wouldn't leave him by himself because if he tries to stand up he could fall and get injured. On 5/25/23 at 10:38AM, V2 (Director of Nursing) stated, (R10) is a high fall risk and he's declining so he definitely should not be left on the toilet by himself. 5) R34's electronic face sheet printed on 5/25/23 showed R34 has diagnoses including but not limited to seizures, anxiety disorder, intellectual disabilities, personal history of healed traumatic fracture, and muscle weakness. R34's facility assessment dated [DATE] showed R34 has mild cognitive impairment, is a 1 person transfer assist and has had falls since her admission to the facility. R34's nursing progress notes showed R34 has sustained 5 falls within the past 5 months. R34's incident reports showed, 1/14/23 slid out of recliner after attempting to stand up on her own. 1/27/23 resident sitting on floor in doorway of her bathroom in her room with wheelchair behind her. 3/30/23 Resident was ambulating with her walker in her room and fell backwards onto her buttocks. 4/17/23 Patient found on floor in her room screaming and crying with bleeding to the scalp above left ear. Nickel sized skin tear noted with heavy bleeding. She was next to her wheelchair that had the lock on only on the right side. 5/17/23 Resident trying to self-transfer from recliner to wheelchair and slid out on floor. Urine & stool on floor. R34's care plan dated 1/23/23 showed, The resident has had actual falls due to gait imbalance and history of hip fracture. 1/23/23 remind me to use my call light. 4/3/23 remind and encourage me to walk even when I want to be in the wheelchair. On 5/25/23 at 10:38AM, V2 (Director of Nursing) stated, We discuss falls in morning meeting after any fall. The interventions we put in place depends on the situation and who it is. (R34's) sister says falling is a behavior for her and then all of a sudden she pretends she doesn't know how to walk. She knows how to call for assistance and will when she wants to. We don't have any specific interventions in place for her but we try to keep an eye on her as much as we can. 20042 6. On 5/23/23 at 9:36 AM, V11 CNA took R11 in her wheelchair to the bathroom. V11 had a gait belt around her waist but did not apply the belt around R11. R11 was attempting to grab onto the bars in front of her and V11 brought R11 to a standing position by pulling upwards on the back of the resident's pants. V11 guided R11 to the toilet. R11 flopped down on the toilet seat. V12 CNA walked into R11's room and V11 stated she was going to need help with peri care and the transfer. V11 and V12 provided incontinence care for R11. No gait belt was applied to R11 prior to a stand pivot transfer back to her wheelchair. On 5/24/23 at 12:25 PM, V2 DON (Director of Nursing) stated the girls will look at the resident's kardex to see how they transfer. V2 looked in R11's electronic medical record and stated R11 was a 1-2 assist for transfers. V2 stated staff can look at the kardex and report hand off sheet for a resident's transfer status. V2 stated staff were supposed to use gait belts when transferring residents for the resident's safety. V2 stated it was not okay to use the back of a resident's pants to help them stand. On 5/25/23 at 10:18 AM, V13 CNA stated gait belts were to be used when transferring or walking residents that need assistance. V13 stated it was for the safety of staff and residents. The Face Sheet dated 5/24/23 for R11 showed medical diagnoses including type 2 diabetes mellitus, dysphagia, second degree burn of the trunk, major depressive disorder, anxiety disorder, atherosclerosis, hyperlipidemia, osteoporosis, macular degeneration, insomnia, muscle weakness, rectal polyp, diverticulosis, constipation, bilateral hearing loss, hemorrhage of anus and rectum, hypertension, urinary incontinence, amnesia and sleep disorder. The MDS (Minimum Data Set) dated 4/26/23 for R11 showed severe cognitive impairment; extensive assistance of two or more people required for bed mobility, transfer, dressing, toilet use, and personal hygiene. The Care Plan dated 5/4/23 for R11 showed she is at risk for falls and to follow the facility's fall protocol. The activity of daily living and mobility care plan for R11 showed she has deficits related to weakness and cognition. Limited assistance of one person for transfers and extensive assistance for toileting. The facility's Gait Belt policy (1/1/23) showed, It is the policy of this center that when the gait belt is used with a resident, the correct procedure will be followed to promote safety for the resident and employee. Apply the gait belt: Always use the gait belt when the resident requires hands on assistance to ambulate or transfer.

Based on observation, interview, and record review the facility failed to ensure a residents nutritional caloric needs were met and failed to notify the physician for a continued weight loss for a resident with enteral feeding who had a significant weight loss this applies to 1 of 3 (R50) reviewed for weight loss in the sample of 20. This failure resulted in R50 losing 14.8 pounds in 3 months. The findings include: On 5/2/22 at 11:50 AM, R50 was lying in his bed. He appeared thin and frail his sternum bones were protruding from under his skin. The tube feeding was in his room was not connected. V10 (Certified Nursing Assistant) fed R50 his noon meal. R50 took one bite of the puree meal and said, that's enough. R50's diet card showed he was on a puree meal with pleasure feeding. On 5/3/22 at 8:31 AM, R50 was lying in his bed with his eyes closed. V8 (CNA) said we tried to feed him breakfast and he's not eating. The Nutritional Assessment Consultant dated 1/26/22 documents R50 was readmitted to the facility on [DATE] he was out in the hospital for COVID. R50 is on puree diet with pleasure feeding with poor intake and is fed by staff. R50 is receiving enteral (intake of food via the GI tract) feeding. (Tube Feeding liquid #1) 1200 cc daily at 65 cc/hr. Tube feeding estimated needs = 1800 calories. R50's Nutrition/Dietary Note dated 3/22/22 documents R50 is on a puree diet with pleasure feeding. R50 has a peg (percutaneous endoscopic gastrostomy tube allows nutrition directly through stomach) of Tube Feeding #1 at 1200 cc at 65 cc/hr. R50's current weight at 140 lbs with no weight loss desired. R50's weight should be maintained at or above 140 lbs. Tube feeding provides 1800 calories and 99 grams of protein. R50 is tolerating the enteral feeding and will continue to adjust tube feeding as needed with monthly assessments at minimum. R50 did not have a Nutrition Assessment for April 2022. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The P.O.S. shows order date of 1/25/22 for enteral feed order to start at 9:00 PM and end at 5:00 AM, may use Tube Feeding #2 in place of Tube Feeding #1 with the same directions. (The P.O.S. shows R50's enteral feeding being infused at 9:00 PM to 5:00 AM is 8 hours @ 65cc/hr. is equal to 520 cc being infused. R50 did not receive 680 cc of 1200 cc of his nutritional caloric needs as recommended daily from January 25, 2022, to May 3, 2022 = 98 days). R50's weight report: January 13, 2022= 147.2 lbs. (pounds) February 10, 2022 = 139 lbs. March 1, 2022 = 140 lbs. April 7, 2022 = 138.2 lbs. April 21, 2022= 132. 4 lbs. (14.8 lbs. pounds lost in 3 months = 10%) On 5/3/22 at 12:26 PM, V2 (DON) said weights should be monitored monthly by the dietitian. V2 said they have had several different dietitians at the facility, and she has been trying to get a hold of V16 (Dietitian) but she has not returned her calls. V2 said R50 was not seen by V16 in April and should have been. V2 confirmed R50's tube feeding was not being infused long enough to meet his nutritional needs. V2 said R50's tube feeding should have been infused for a total of 18.5 hours to equal 1200cc to meet his nutritional caloric needs. This surveyor called and left a message for V16 (dietitian) she did not return the call. The facility did not provide a policy regarding Significant Weight loss and Interventions.

Based on interview and record review the facility failed to ensure weekly assessment and monitoring of pressures were completed for residents (R1 & R2). The facility failed to ensure pressure ulcer treatments were being done as ordered for residents (R1 & R7) and a care plan was in place for a resident with pressure (R2). These failures resulted in R1 developing a sacral abscess and [CONDITION(S)]. This applies to 3 of 3 residents (R1, R2 & R7) reviewed for pressure ulcers in the sample of 8. The findings include: 1. The MDS (Minimum Data Set) dated 12/12/21 for R1 showed extensive cognitive impairment; limited assistance required for bed mobility, transfers, toilet use, and personal hygiene. The Nurse's Notes for R1 showed, 12/17/21 - Shower given this morning. Buttocks remain macerated. R1 resting in recliner at this time; 12/22/21 - Shower given. No new skin issues observed. Open area to buttocks remains. The wound consultant's Visit Report dated 1/4/22 for R1 showed, Wound #1 is a Stage 3 pressure and has received the status of not closed. Initial wound encounter measurements are 5 cm (centimeters) x 1 cm x 0.1 cm Tunneling has been noted at 1:00 (o'clock position) with a maximum distance of 3 cm. No sinus tract has been noted. No undermining has been noted. Wound bed has 1-25% slough, no granulation; no eschar and no epithelialization present. Plan- Wound orders: sacral pressure ulcer; apply collagen powder 1 gram to the wound every day for 21 days. Border dressing 4.3 x 4.3, pad 3 x 3 every other day for 21 days. Cleanse wound with wound cleanser or normal saline per facility, apply collagen, cover with bordered dressing. Change every other day. The January 2022 TAR (Treatment Administration Record) for R1 did not show the wound orders from the wound consultant's Visit Report dated 1/4/22 entered as an order or the treatment being done after the order was given from 1/4/22 through 1/20/22 when the wound care order was changed. The facility did not have weekly wound measurements or wound assessments completed for R1 after 1/4/22 through 1/24/22 (20 days) when the next Skin/Wound Note was documented. The January 2022 TAR for R1 showed, 1/20/22 - Treatment to coccyx - cleanse outer wound with wound wash, pat dry, gently pack with [MEDICATION(S)]. Change twice a day, days, and nights with skin prep to the peri-wound and cover with a 3 x 3 foam dressing. Re-evaluate in one week. On 1/22/22 at 8:00 AM the dressing change was not documented as being completed. R1's Nurse's Notes did not show that R1 was out of the facility or refused care on 1/22/22. The Skin/Wound Note dated 1/24/22 for R1 showed, Open area present and measures 2 cm x 1 cm x 1 cm. Wound Consultation with wound provider. Treatment orders after consultation = calcium alginate, collagen, and bordered dressing. Change daily and PRN (as needed). The facility did not have weekly wound measurements or wound assessments documented as being completed for R1 between 1/27/22 through 2/14/22 (a seventeen-day time period). On 3/20/22 at 3:20 PM, V3 DON (Director of Nursing) stated that they were unable to locate weekly wound assessments for R1. V3 stated V7 was the wound nurse but she quit on 1/27/22. Wound Measurements are to be done weekly and assessments are to be done with each dressing change. Assessments were supposed to be on the Wound - Weekly Observation Tool or in the progress notes. On 3/20/22 at 3:30 PM, V3 DON stated, The last time I saw R1's wound it was macerated and that was in December 2021. On 1/4/22 they put down R1's wound was acquired then because it was macerated before. R1's TAR dated January 2022 showed, 1/26/22 - Wound orders to coccyx - calcium alginate, collagen, bordered dressing. Change daily and as needed in the evening. The wound treatment was not documented as being completed on 1/28/22 at 9:00 PM. The Nurse's Note dated 1/29/22 for R1 showed, Treatment to coccyx completed. R1 had no packing and no dressing on the wound. Unsure of how long the wound was exposed but there was a large amount of musty smelling drainage light to faint green color and thin in consistency. The February 2022 TAR (Treatment Administration Record) for R1 showed the facility was doing the following wound orders: to open macerated area on gluteal cleft/coccyx - cleanse daily, apply skin prep to the peri wound. Put a small piece of calcium alginate in the wound bed, cover with a piece of gauze and secure with tape every evening. The order was dated 9/8/21 and showed that it was marked off as being completed on the 3-11 shift on 2/1/22 and 2/2/22; 2/4/22 through 2/10/22; 2/12/22 - 2/15/22; and 2/18/22. The current wound order to be completed by the facility was entered under the wound order dated 9/8/21 on R1's 2/2022 TAR and showed, wound orders to coccyx - calcium alginate, collagen, bordered dressing. Change daily and as needed in the evening with a start date of 1/27/22. The treatment was marked as being completed at 9:00 PM on 2/1/22 and 2/2/22; 2/4/22 through 2/10/22; 2/12/22 - 2/15/22; and 2/18/22. The Nurse's Note dated 2/16/22 for R1 showed she was transferred to the hospital on that date and never returned to the facility. The February 2022 TAR showed both treatments were documented as being completed on 2/18/22 and R1 was not in the facility. On 3/30/22 at 1:04 PM, V3 DON (Director of Nursing) stated when a treatment is done it is marked on the TAR (Treatment Administration Record). If the box on the TAR is not checked then the treatment was not done. V3 stated it is important to do wound care treatments as ordered otherwise the wound will not get better. The Order Summary Report for R1 showed, 2/12/22 - Observe wound dressing to ensure placement and integrity of the dressing. Location of dressing to coccyx, every day and night shift related to pressure ulcer of sacral region, unstageable. Please note if dressing required replacement. The Wound-Weekly Observation Tool dated 2/14/22 for R1 showed R1 had a facility acquired stage 4 pressure ulcer to her coccyx, infection was suspected and there was a green slimy exudate noted. The evaluation of the wound progress showed a worsening wound bed with increase in size, purulent drainage, odor, and fecal matter noted in the wound from stooling. The wound consultant's Visit Report dated 2/15/22 for R1 showed, Wound #1 sacral is an unstageable pressure injury; obscured full-thickness skin and tissue loss pressure ulcer and has received the status of not closed. There is a heavy amount of purulent drainage noted which has a strong odor. Possible infection due to fecal matter invasion of the wound bed. Green discharge noted in the wound bed. Plan: apply collagen sheet 2 x 2 silver to the wound every day for 30 days. Apply gel fiber silver rope 18 to the wound every day for 30 days. Cover the wound with bordered foam dressing 4 x 4 every day for thirty days. Cover the wound with a bordered super absorbent 3.5 x 4 every day for 30 days. Cleanse wound with wound cleanser of normal saline, gently pat dry, apply collagen to wound bed, apply ropes into all undermined areas of wound snuggly, dress with a bordered dressing. Change daily. The order was not entered into the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Hospital Assessment and Plan History & Physical dated 2/16/22 showed, Stage 3 pressure ulcer of the sacral region. Infected decubitus ulcer. The Hospital Wound Care Progress Note dated 2/16/22, Abscess, sacrum. [CONDITION(S)] of vertebra, sacral and sacrococcygeal region. Suggest follow up with general surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Care Plan initiated 2/18/21 and revised 2/21/22 showed, Risk for impaired skin integrity. Consult wound, ostomy and continence nurse as appropriate. Evaluate for bowel continence. Evaluate for urinary continence. Evaluate skin areas for blanching or redness. Monitor for moisture, apply barrier product as needed. Monitor resident's nutritional intake. Documented pressure ulcer - sacral. Encouraged resident to frequently shift weight. Monitor nutritional status. Monitor ulcer for signs of progression or declination. Provide skin care per facility guidelines and as needed. Provide wound care per treatment order. The facility's Skin Treatment - Guidelines for Pressure Injuries (3/2020) policy showed, Identify the underlying cause as pressure, sheer, friction, maceration, or a combination of these factors. Confirm the physician has been notified that the resident has a pressure injury and is aware of the current status. Document in the progress notes. Indicate dressing change date, time and initials on dressing. Complete this (Weekly Pressure Injury Evaluation) form in the clinical software weekly until the injury is resolved. Document dressing completion on the TAR. On 3/30/22 at 5:00 PM, V14 NP (Nurse Practitioner) stated, On 1/19/22 I got a text about R1's wound from them. I told them to send R1 to the wound clinic. It was the first I had heard of the wound; it was on her bottom. I told V7 LPN (Licensed Practical Nurse/Wound Nurse) to get R1 to the wound clinic. I told the facility four times to take R1 to the wound clinic and I considered that an order. I still have the text on my phone to show I ordered it. R1 ended up with a good wound infection. R1's wound really needed better care, proper dressings and to get R1 off her butt. R1 never went to the wound center for her sacral wound. Every time I went to the facility R1 was up in a chair. I saw a picture of R1's wound on 1/24/22. I told the facility to lay R1 down more. I saw R1's wound on Superbowl Sunday when I walked down the hall and the CNA (Certified Nursing Assistant) was putting R1 into bed. R1 was soiled and having loose stools. I helped her clean R1 and she had feces in the wound. There wasn't a dressing on the wound. The wound should have been assessed weekly and should be documented. R1 had an [CONDITION(S)]; it can happen to sacral wounds. I was never alerted about dressing change orders or that there was brown drainage. R1 needed more expert care. Nurse's complained to me that dressing changes were not being done the way they are supposed to be. On 3/31/22 at 3:01 PM, V8 LPN stated, I wasn't doing all of R1's dressing changes. R1's dressings were supposed to get changed more frequently, get packed, and have a dressing on it. When I started a couple of months ago, I put some of R1's treatment orders in. The wound care consultant would put recommendations in, but I don't know where she would write them. If I saw the recommendations, I would turn them into an order. The latest order takes priority. 2. On 3/30/22 at 9:57 AM, R7 was lying on her back in her bed. The air mattress was not turned on or plugged in. At 12:36 PM, R7's air mattress was unplugged. R7 stated her bed mattress felt different and that it had been like that for a while. The Order Summary Report dated March 2022 for R7 showed: 2/7/22 - Pressure relieving device (air mattress/pump) is plugged in and working properly every shift for preventative - skin. The Wound - Weekly Observation Tool dated 3/20/22 for R7 showed a facility acquired stage 2 pressure ulcer to her left buttock. On 3/30/22 the facility did not provide any information for a pressure ulcer to R7's right buttock. The wound consultant's Wound Orders dated 3/30/22 for R7 showed she has a stage 2 pressure ulcer to her left buttock and an unstageable pressure ulcer to the right buttock. The wound orders for the right buttock pressure ulcer were to apply collagen powder 1 gram to the wound every day for thirty days. Cover with an allevyn bordered dressing every day for 30 days. Cover with a bordered super absorbent dressing for 30 days. Apply triad cream to the wound every day for 30 days. The wound orders for the right buttock showed to apply collagen powder 1 gram to the wound every day for 30 days. Apply a cool border pad dressing to the wound every day for 30 days. On 3/30/22 at 1:04 PM, V3 DON (Director of Nursing) stated, Having the nurses check off the TAR for the air mattresses is on there as a part of a plan of correction. R7's bed should be plugged in because it is a preventative measure for pressure. It is important to do wound treatments as ordered because how will it get better unless you do it. On 3/31/22 at 2:25 PM V9 CNA (Certified Nursing Assistant) and V10 CNA were in R7's room and transferred her back to her bed. V9 and V10 provided incontinence care because R7's catheter was leaking. They turned R7 onto her side and the resident had a slit to her right buttock and open areas to her left buttock. both buttocks were reddish-purple in color. There were no dressings in place to her buttocks. On 3/31/22 at 3:01 PM, V8 LPN (Licensed Practical Nurse) stated, I come in on Mondays and try to see everyone for wound care. Another nurse and I split up wound care. We each have a list. R7 is my resident, and she has a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's bottom looks the best that it has. R7 has been noncompliant in the past. R7 has totally changed now and is more compliant. The wound care consultant would put recommendations in, but I don't know where she would write them. If I saw the recommendations, I would turn them into an order. The latest order takes priority. The wound care consultant and I had done wounds, and I would measure, and she would document. We would then enter those. When the wound care consultant left, she took my notebook and I never got it back. The facility's Skin Treatment - Guidelines for Pressure Injuries (3/2020) policy showed, Indicate dressing change date, time and initials on dressing. Complete this (Weekly Pressure Injury Evaluation) form in the clinical software weekly until the injury is resolved. Document dressing completion on the TAR. R7's Care Plan dated 12/21/21 showed, The resident has pressure ulcers, 2 stage 2 pressure ulcers of the buttocks and 1 venous stasis ulcer of the left lower extremity. Administer treatments as ordered and monitor for effectiveness. Educate me/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; frequent repositioning. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The Nurse's Notes for R2 showed, 12/14/21 - Received a shower. No new skin concerns noted. Slight redness to buttocks. Barrier cream applied; 12/19/21 - coccyx wound clean with no drainage - skin prep reapplied and optifoam; 12/29/21 - Shower given this shift. Open area remains to coccyx. Dressing changed; 1/11/22 - new dressing to buttocks early this AM per nurse. No measurements, staging or assessments of R2's coccyx wound were documented in these Nurse's Notes. The Nurse's Notes didn't have staging, measurements or assessments of the wound from 12/19/21 through 1/11/22. R2's medical record did not have any other weekly assessments completed to includ the stage, measurement, and description of the wound. The Skin/Wound Notes dated 1/12/22 for R2 showed, Open area to coccyx remains, dressing applied per orders. No wound measurements, staging of the wound, or description of the wound were documented. The next wound assessment was 12 days later on 1/24/22. The Skin Only Evaluation dated 1/24/2 for R2 showed a stage 2 pressure ulcer/injury to the coccyx. The Skin/Wound Note dated 1/24/22 for R2 showed, Assessment to coccyx wound, area measures 2.1 cm x 1.4 cm x 0.2 cm. Wound consultation; treatment orders after consultation - collagen powder, triad cream and bordered dressing. Change daily and as needed. The Wound - Weekly Observation Tool dated 2/2/22 for R2 showed the status of the form as still in progress for a coccyx wound that was facility acquired with no date given when it was acquired. Pressure was marked on the form, but no stage was given. The current treatment plan was documented as collagen powder, triad cream, bordered dressing. Change daily and as needed. R2's Care Plan was closed on 2/7/22 after her death. R2's Care Plan that was closed and then printed on 3/31/22 did not show that she had a focused care area with interventions in place for pressure ulcers. On 3/30/22 at 2:56 PM, V3 DON (Director of Nursing) stated, Our previous wound nurse (V7) worked here from 9/28/21 to sometime in December. V7 LPN (Licensed Practical Nurse/Wound Nurse) did not use the skin notes or weekly wound observation tool in the computer. V7 did a spreadsheet and binder. At 3:20 PM, V3 came back and stated there was only one wound assessment per resident with wounds in the binder and it is the same as what is in the computer. V3 stated they could not find the weekly assessments. V3 then stated V7 quit on 1/27/22 after being cited related to wound measurements. V3 stated the wound assessments will pop up for the nurse's to do. V3 stated, Measurements are to be done weekly. Assessments are to be done with each dressing change and should be documented on the wound - weekly observation tool or in the progress notes. On 3/30/22 at 5:00 PM, V14 NP (Nurse Practitioner) stated, I saw R2 for her monthly visit and she had a bad wound to her bottom. I think the pressure ulcers get so bad there (facility) because I don't think the residents get turned the way they should be. The preventative measures could be better. The MDS (Minimum Data Set) dated 2/2/22 for R2 showed impairment of memory and cognition; extensive assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene; stage 2 pressure ulcer. The facility's Skin Treatment - Guidelines for Pressure Injuries (3/2020) policy showed, Identify the underlying cause as pressure, sheer, friction, maceration, or a combination of these factors. Confirm the physician has been notified that the resident has a pressure injury and is aware of the current status. Document in the progress notes. Indicate dressing change date, time, and initials on dressing. Complete this (Weekly Pressure Injury Evaluation) form in the clinical software weekly until the injury is resolved. Document dressing completion on the TAR.

Based on interview and record review the facility failed to follow their policies and procedures related to routine bed checks and provision of necessary care. Staff failed to confirm R1's well-being and provide necessary care for a period of approximately 10 hours. It was determined by the coroner that R1 had been deceased approximately 8- 12 hours prior to being found by facility staff. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 10:30PM when R1 was last assisted by staff. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:30 AM. The surveyor confirmed by interview and record review that the immediacy was removed on [DATE] at 10:00 AM. Findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R1's facility assessment dated [DATE] showed he requires limited assistance of 1 staff member for bed mobility and extensive assistance of 1 staff member for toileting, dressing, and personal hygiene. The same facility assessment showed R1's cognitive skills for daily decision making were severely impaired. The facility's undated policy Routine Resident Checks showed, Staff shall make routine resident checks to help maintain resident safety and wellbeing . 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8 hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge nurse any changes in the resident's condition and medical needs . R1's [DATE] skilled charting nursing assessment showed he required assistance with bed mobility and is incontinent of urine The facility's undated policy and procedure Perineal Care showed, . Nursing staff will provide perineal care to residents twice a day, after each incontinence, or more often as needed. R1's [DATE] 8:30AM nursing progress note entered by V3 (Registered Nurse/RN) showed, This nurse was informed that resident was not breathing. Resident dressed without shoes, laying prone face down on a pillow. Small amount of sanguineous drainage assessed on pillow. Right arm cold. On [DATE] at 3:15 PM, V3 (RN Manager) said she was on call on Saturday, [DATE]. V3 said she arrived at the facility at 7:30 AM. V3 said at roughly 8:30AM, V7 (Certified Nursing Assistant/CNA) came into her office and said R1 was gone. V3 said she went to the room and R1 was lying face down in his pillow with his face directly on the pillow. V3 said she could tell his right cheek was purplish blue and there was blood visible on the pillow. V3 said R1's face was not off to the side. V3 said it was just before the EMS arrived that R1 was rolled over to get him presentable. V3 said R1's face was a dark purple color except for his chin was white. V3 said R1 had blood around mouth, on his teeth, and in his mustache area. V3 said R1's arm was up and at a 90-degree angle because rigor mortis had set in. V3 said V4 (Licensed Practical Nurse/LPN) told her she had not gone into R1's room and there was a discussion about just leaving him sleep. V3 said V5 (LPN) reported to her that she had not yet gone into R1's room. V3 said she spoke with V10 (1:1 CNA) and V10 told her she looked in the room from outside the door but had not gone into R1's room since her shift started at 6:00 AM. V3 said through her investigation she found that the last time anyone was in R1's room was on [DATE] before 11:00PM. V3 said there was no staff in R1's room between 11:00 PM and 8:15 AM. On [DATE] at 9:09 AM, V11 (County Coroner) said he responded to the call from the police department and when he arrived at the facility, he went straight to R1's room. He said when he went into the room R1 had been rolled over on the bed from what appeared to be his sleeping position (one arm down and one arm up). V11 said R1's skin on his anterior body was a deep purple color. V11 said there was obvious lividity which gives experts an idea of the length of time he had been deceased . V11 said from his experience in being a coroner, his experience from his previous position in law enforcement, and his current research it had likely been ,d+[DATE] hours since R1 had expired. On [DATE] at 9:15 AM, V15 (Police Chief) said he was dispatched to the facility on [DATE]. V15 said R1 had been moved prior to him arriving at the facility. V15 said rigor mortis had set in and he was concerned when V10 (CNA) said she had checked on R1 every 15 minutes since she arrived for her shift at 6:00 AM. V15 said there was blood on the resident's face around his nose and blood on a pillow that had been moved to the floor. V15 said lividity (bluish-purple discoloration of skin after death which is a sign of livor mortis and occurs when blood pools at the lowest point of the body due to gravity and loss of blood circulation) had clearly set in which he feels would be the cause of the blood on the pillow. V15 said based on his investigation as of [DATE] he is concerned that no staff entered R1's room between approximately 10:20 PM on [DATE] and 8:30 AM on [DATE]. On [DATE] at 9:32 AM, V14 (Paramedic) said they responded to a call to the facility for a DOA (Dead on Arrival). V14 said when they entered R1's room there was many staff members in the room and R1 was laying on his back. V14 said because R1 was found lying face down in his pillow he had full lividity from his face to his toes and appeared to have been dead greater than 12 hours. V14 said he determined how long R1 had been deceased based on the full lividity to R1's body. The Immediate Jeopardy that began on [DATE] at 10:30 PM was removed on [DATE] at 10:00 AM when the facility took the following actions to remove the immediacy. The facility [Administrator/Director of Nursing/Assistant Director of Nursing/Clinical Staff] will take immediate action to ensure residents are provided nursing care and assistance based off their individual needs. The facility [Administrator/Director of Nursing/Assistant Director of Nursing/Clinical Staff] will in-service all nursing staff on facility policy [Resident - Monitoring and Rounds Policy]. The facility [Administrator/Director of Nursing/Assistant Director of Nursing/Clinical Staff] will establish polices and train staff on bed check procedures and frequency as covered in the facility [Resident - Monitoring and Rounds Policy]. A bed check procedure is defined as assuring resident is not in distress by entering room and assessing if the resident is awake and/or voicing needs or signs of distress. Frequency of monitoring will be based upon resident's needs. The facility [Administrator/Director of Nursing/Assistant Director of Nursing/Clinical Staff] will in-service staff on assisting residents with ADL's and ensure staff understand the frequency of checks based off of individual needs determined by an on-going assessment and audit of the resident's care plans. In-services are being conducted beginning [DATE] and no employee will be allowed to work until they have been in-serviced. In-services to include: [Resident - Monitoring and Rounds]. The Medical Director was notified about the Immediate Jeopardy on [DATE]. During his next visit, the Medical Director will be meeting with the Interdisciplinary Team to discuss the Immediate Jeopardy and ways to address the alleged deficient practice. A Quality Assurance and Performance Improvement (QAPI) meeting will be held with the Medical Director, facility Administrator, Director of Nursing, and Social Services Director to review plan. The Director of Nursing/designee and Administrator will be responsible for implementation of process. The in-service(s) will be started on [DATE] and be completed [DATE]. No employee will be able to return to work until they complete the in-service.

Facility failures resulted in two deficient practice statements. I. Based on observation, interview, and record review the facility failed to provide necessary care and services by not repositioning, toileting, or providing incontinence care for a resident dependent upon staff for all activities of daily living and who was severely cognitively impaired. This failure resulted in R1 receiving no personal care or well-being check for a period of approximately ,d+[DATE] hours prior to R1 being found deceased . The facility failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 10:30PM when R1 was last assisted by staff. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:30 AM. The surveyor confirmed by interview and record review that the immediacy was removed on [DATE] at 10:00 AM. Findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility assessment dated [DATE] showed he required limited assistance of 1 staff member for bed mobility and extensive assistance of 1 staff member for toileting, dressing, and personal hygiene. The same facility assessment showed R1's cognitive skills for daily decision making were severely impaired. R1's care plan initiated on [DATE] showed, I have an ADL (Activities of Daily Living) self-care performance deficit related to [CONDITION(S)] . I require extensive assist of 1 with turning and repositioning in bed . The same care plan showed another intervention with the same date of [DATE], Bed Mobility: I require extensive assist x 2 staff and as necessary . R1's care plan showed a care plan initiated on [DATE], I had an actual fall with no injury related to [CONDITION(S)], dementia, impulsive behavior and a history of falls . intervention: Maintain regular toileting at set intervals and PRN (as needed). R1's care plan for impaired cognitive function related to dementia showed, . ask yes/no questions in order to determine my needs . Cue, reorient, and supervise as needed . R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . needs close monitoring due to his frequent falls/poor ambulation . R1's [DATE] skilled charting nursing assessment showed he required assistance with bed mobility and is incontinent of urine. The facility's fall log printed on [DATE] showed R1 had 6 witnessed falls and 3 unwitnessed falls in the previous 6 months. R1's last fall occurred on [DATE] at 5:55AM when he was found sitting on the edge of his bed with blood on the right side of his neck. R1 was sent to the acute care hospital and received 2 staples to the back of his head. R1's [DATE] 8:30AM nursing progress note entered by V3 (Registered Nurse/RN) showed, This nurse was informed that resident was not breathing. Resident dressed without shoes, laying prone face down on a pillow. Small amount of sanguineous drainage assessed on pillow. Right arm cold. Administrator notified. On [DATE] at 9:09 AM, V11 (County Coroner) said he responded to the call from the police department and when he arrived at the facility he went straight to R1's room. He said when he went into the room R1 had been rolled over on the bed from what appeared to be his sleeping position (one arm down and one arm up). V11 said R1's skin on his anterior body was a deep purple color. V11 said there was obvious lividity which gives experts an idea of the length of time he had been deceased . V11 said from his experience in being a coroner, his experience from his previous position in law enforcement, and his current research it had likely been ,d+[DATE] hours since R1 had expired. V11 said through his collection of statements from staff at the facility he believes the resident was not looked in on from approximately ,d+[DATE]:30 PM until the next morning when it was discovered that he was deceased . The facility daily staffing schedule showed from 10:00 PM on [DATE] through 8:30 AM on [DATE] the following CNAs (Certified Nursing Assistants) were scheduled on R1's hall. V7 was scheduled from 2 PM - 1030 PM on [DATE]. V8 was scheduled 10:30 PM - 1 AM to cover another hall but was told she would need to keep an eye on the residents on R1's hall as well. V6 was scheduled from 2 AM - 6:30 AM. No one appeared on the daily nursing schedule for [DATE] as the 1:1 aide for R1. V6 and V7 both reported V10 was assigned to be 1:1 with R1 on [DATE]. The nurse assigned to R1's hall on the night of [DATE] through the morning of [DATE] was V4 (Licensed Practical Nurse/LPN). The nurse assigned to R1's hall on [DATE] starting at 6:00 AM was V5 (LPN). On [DATE] at 12:24 PM, V7 (CNA) said on [DATE] she helped R1 to bed about 9:30 PM because they were trying to get him on a schedule since he sometimes gets up in the middle of the night. V7 said the last time she saw R1 was approximately 10:15 PM and R1 was sleeping. V7 said R1 was fine when she checked on him at 10:15 PM. V7 said her shift ended at 10:30 PM and there was no one specifically assigned to cover R1's hall at that time so she reported off to V16 (CNA Supervisor) when she left. V7 said there would usually be someone coming on that hall to report off to, but staffing is short quite a bit. V7 said when she came back in at 6:00 AM she was back on R1's hall. V7 said she did not check on R1 because R1 was supposed to be with a 1:1 aide. V7 said she was the only aide scheduled on that hall for the day shift. On [DATE] at 3:28 PM, V8 (CNA) said she was scheduled to work another hall on [DATE] and she arrived late to work that day because she overslept. V8 said when she got to work she was told she was going have to keep an eye on R1's hall as well. V8 said she went into R1's room between 10:30 PM and 10:50 PM and took an oxygen saturation reading and a temperature for their typical monitoring of residents and R1 did not wake up. V8 said the last time she checked on R1 was approximately 1:00 AM and she did not enter his room. V8 said she peeked into R1's room from the door and he was still sleeping. On [DATE] at 1:30 PM, V6 (CNA) said she was the only aide who worked R1's hall from 2:00 AM until 6:00 AM on [DATE]. V6 said they check on residents every hour to two hours whether they are sleeping or not. V6 said they check on incontinent residents every 2 hours throughout the night to make sure they are not wet. V6 said they are told usually not to wake up R1 if he is sleeping and just do a visual check, if he isn't stirring then just leave him. V6 said she sometimes does the visual checks from outside the room. V6 said R1 was incontinent at times. V6 said when she saw R1, he was lying flat on his stomach but his head appeared to be facing the wall. V6 said the lights were not on. V6 said she left at 6 AM and reported to V7 (CNA) that R1 was sleeping. V6 said V10 was also there at 6:00 AM and V10 was assigned to be 1:1 with R1 that day. V6 said R1 did not wake up at all between 2 AM and 6 AM. V6 said before she arrived at the facility at 2 AM there were only 2 CNAs in the entire building, and this does happen on some nights. V6 said she did not go in R1's room and check on him from 2 AM - 6 AM. On [DATE] at 2:36 PM, V4 (LPN) said she worked R1's hall from 6:30 PM on [DATE] until 7:00 AM on [DATE]. V4 said R1 had a 1:1 CNA with him on 1st and 2nd shift but not on 3rd shift. V4 said R1 gets up in the night at times and he would have to have someone with him. V4 said she walked past his room during her shift but never went into the room. V4 said when she left at 7:00 AM, R1 was in his bed. V4 said R1 is scheduled to receive some medications at 6:00 AM but since he was still in bed she put the medications in the top drawer of the medication cart and reported to V4 (LPN) that R1 would need his medications when he gets up. V4 said the last time she gave medications to and interacted with R1 was between 9:00 PM and 9:30 PM on [DATE]. V4 said she documented that she gave R1 his morning medications, but she should have struck out that administration record because she did not give him his medications. V5 said she did not go in the room after 9:30 PM on [DATE]. On [DATE] at 3:15 PM, V3 (Registered Nurse Manager) said she was on call on Saturday, [DATE]. V3 said she arrived at the facility at 7:30 AM. V3 said, At roughly 8:30AM, V7 (CNA) came into my office and said R1 was gone. V3 said V10 (1:1 aide for R1) went to get V5 (LPN). V3 said R1 was a 1 person assist for all cares. V3 said she went to the room and R1 was lying face down in his pillow with his face directly on the pillow. V3 said she could tell his right cheek was purplish blue and there was blood visible on the pillow. V3 said R1's face was not off to the side. V3 said it was just before the EMS arrived that R1 was rolled over to get him presentable. V3 said R1's face was a dark purple color except for his chin was white. V3 said R1 had blood around mouth, on his teeth, and in his mustache area. V3 said R1's arm was up and at a 90-degree angle because rigor mortis had set in. V3 said she notified the administrator right away at 8:34 AM. V3 said, It was a scene like no other, nothing I had ever seen. V3 said V4 (LPN) told her she had not gone into R1's room and there was a discussion about just leaving him sleep. V3 said V5 (LPN) reported to her that she had not yet gone into R1's room. V3 said she spoke with V10 (1:1 CNA) and V10 told her she looked in the room from outside the door but had not gone into R1's room since her shift started at 6:00 AM. V3 said through her investigation she found that the last time anyone was in R1's room was on [DATE] before 11:00 PM. V3 said there was no staff in R1's room between 11:00 PM and 8:15 AM. On [DATE] at 9:15 AM, V15 (Police Chief) said he was dispatched to the facility on [DATE]. V15 said R1 had been moved prior to him arriving at the facility. V15 said rigor mortis had set in and he was concerned when V10 (CNA) said she had checked on R1 every 15 minutes since she arrived for her shift at 6:00 AM. V15 said there was blood on the resident's face around his nose and blood on a pillow that had been moved to the floor. V15 said lividity (bluish-purple discoloration of skin after death which is a sign of livor mortis and occurs when blood pools at the lowest point of the body due to gravity and loss of blood circulation) had clearly set in which he feels would be the cause of the blood on the pillow. V15 said based on his investigation as of [DATE] he is concerned that no staff entered R1's room between approximately 10:20 PM on [DATE] and 8:30 AM on [DATE]. On [DATE] at 9:32 AM, V14 (Paramedic) said they responded to a call to the facility for a DOA (Dead on Arrival). V14 said when they entered R1's room there was many staff members in the room and R1 was laying on his back. V14 said because R1 was found lying face down in his pillow he had full lividity from his face to his toes and appeared to have been dead greater than 12 hours. V14 said he works for the ambulance service and also for a funeral home. V14 said he determined how long R1 had been deceased based on the full lividity to R1's body. V14 said when a person dies, their body starts to deteriorate. V14 said at about ,d+[DATE] hours gravity starts pushing blood down out of the vascular spaces and causes the part of the person's body at the lowest point to become a deep purple. V14 said if you apply pressure to an area of recent lividity the area will turn white and that is an indicator of the time frame of death. V14 said if you apply pressure to an area of lividity and there is no change it means the tissue has now been stained by the components of the blood and indicates a longer time frame of death. V14 said based on the pattern of lividity he observed, R1 was laying directly face down. V14 said facility staff told him they do 20-minute bed checks and he is concerned why staff would not have repositioned him if they had done the bed checks. On [DATE] at 10:43 AM, V2 (Assistant Director of Nursing) said R1 was pretty much 1:1 since he got to the facility due to his poor safety awareness. V2 said she is unsure of what the CNAs do during rounding or how often they do rounds. V2 said she knows they don't go in some of the resident's rooms and they don't shake them or anything, but they do open the door and look in. V2 said if a resident is incontinent they are checked on throughout the night and the staff physically put their hands on the resident. V2 said R1 was both continent and incontinent; there were a lot of times he would say he had to go to the bathroom. V2 said if someone is continent and incontinent she would think they would be checked on throughout the night just like those who are always incontinent. V2 said residents that require assistance with bed mobility would be repositioned every 2 hours. On [DATE] at 12:43 PM, V9 (CNA) said residents are checked on every ,d+[DATE] hours sometimes more frequently. V9 said if residents are sleeping they are still checked on every 2 hours. V9 said she would gently wake them up. The facility's undated policy Routine Resident Checks showed, Staff shall make routine resident checks to help maintain resident safety and wellbeing . 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8 hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any chance in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge nurse any changes in the resident's condition and medical needs . The facility's undated policy and procedure Position - Side Lying showed, . Nursing staff will reposition residents every 2 hours or more often as needed . The facility's undated policy and procedure Perineal Care showed, . Nursing staff will provide perineal care to residents twice a day, after each incontinence episode, or more often as needed . The Immediate Jeopardy that began on [DATE] at 10:30 PM was removed on [DATE] at 10:00 AM when the facility took the following actions to remove the immediacy. The facility [Administrator/Director of Nursing/Assistant Director of Nursing/Clinical Staff] will take immediate action to ensure residents are provided nursing care and assistance based off their individual needs. The facility [Administrator/Director of Nursing/Assistant Director of Nursing/Clinical Staff] will in-service all nursing staff on facility policy [Resident - Monitoring and Rounds Policy]. The facility [Administrator/Director of Nursing/Assistant Director of Nursing/Clinical Staff] will establish polices and train staff on bed check procedures and frequency as covered in the facility [Resident - Monitoring and Rounds Policy]. A bed check procedure is defined as assuring resident is not in distress by entering room and assessing if the resident is awake and/or voicing needs or signs of distress. Frequency of monitoring will be based upon resident's needs. The facility [Administrator/Director of Nursing/Assistant Director of Nursing/Clinical Staff] will in-service staff on assisting residents with ADL's and ensure staff understand the frequency of checks based off of individual needs determined by an on-going assessment and audit of the resident's care plans. In-services are being conducted beginning [DATE] and no employee will be allowed to work until they have been in-serviced. In-services to include: [Resident - Monitoring and Rounds]. The Medical Director was notified about the Immediate Jeopardy on [DATE]. During his next visit, the Medical Director will be meeting with the Interdisciplinary Team to discuss the Immediate Jeopardy and ways to address the alleged deficient practice. A Quality Assurance and Performance Improvement (QAPI) meeting will be held with the Medical Director, facility Administrator, Director of Nursing, and Social Services Director to review plan. The Director of Nursing/designee and Administrator will be responsible for implementation of process. The in-service(s) will be started on [DATE] and be completed [DATE]. No employee will be able to return to work until they complete the Inservice. II. Based on interview and record review the facility failed to provide the necessary care and services for a newly admitted resident by not providing care for a resident's peritoneal drainage system for a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R3's death with cause of death as bilateral pleural effusion and [CONDITION(S)] resulting from pulmonary congestion. Findings include: R3's nursing progress note dated [DATE] at 4:22 PM showed, went into resident's room for noon medications. Resident reported continued nausea. Resident requested to go to the bathroom. Writer assisted into wheelchair, reported nausea and requested to sit for a moment before moving further. Writer gave resident the emesis basin and stepped out of the room for a short time. Upon returning writer asked if he was ready to try to use the bathroom. Resident stated yes, d/t (due to) weakness writer asked CNA to assist also, two CNA's entered to assist to bathroom when resident became limp and began agonal breathing. CNA's called writer into room. Writer called residents name, resident looked at writer for split second and then became unresponsive . R3's nursing progress note dated [DATE] at 7:57 PM showed, Fax sent to [physician] office to notify of resident's passing. R3's death certificate showed under cause of death, a. bilateral pleural effusion, b. [CONDITION(S)] resulting from pulmonary congestion . R3's face sheet showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's [DATE] admission summary showed R3 arrived to the facility at 6:00 PM and was alert and oriented x 3. R3's [DATE] Nursing Progress Note showed, Resident admission completed by off going nurse. Resident reported arrival was at 6 PM . Resident was observed on portable oxygen . Resident noted to be alert and able to verbally make needs known to staff. Endorsing nurse was completing orders as resident requested to have {Brand name} Pneumothorax drainage system drained. Resident noted to have output of 400ml after three hours plus draining duration . R3's [DATE] Nursing Progress Note showed, Pneumo tube disconnected from the wound vac for the night . R3's [DATE] Nursing Progress Note showed, Pneumo tubing dressing removed. Stated it wasn't put on right. States needs a sterile field, washed hands and put on alcohol around skin where tube is coming out, clamp was on and dressing applied. Was not happy with nurse. Told resident I can't tape with gloves on. Stated he would wait until morning to see someone that knows how he wants the procedure done. R3's [DATE] Skilled Evaluation showed, . Lungs, Left and Right crackles throughout . diminished, absent . Resident request to have {Brand name} Pneumothorax drainage system drained. Resident noted to have output of 425 ml after three hours plus draining duration . R3's electronic medical record showed no evidence of R3's Pneumothorax drainage system being drained on [DATE], [DATE], [DATE], [DATE], or [DATE]. R3 was in the facility for 12 days and his drainage system was not drained 5 times. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:05PM, V17 (R3's Pulmonologist) said R3 had a recurrent history of pulmonary effusion and ascites (collection of fluid) in his abdomen. V17 said the placement of the {Brand name} catheter was a joint decision between himself and R3's gastrointestinal specialist because R3 was collecting so much fluid he was requiring thoracentesis and paracentesis approximately every 5 weeks. V17 said the gastrointestinal physician was draining up to 6 liters of fluid out of R3's abdomen and he [the pulmonologist] was draining up to 2 liters of fluid out of R3's lungs. V17 said the {Brand name} catheter was placed to give R3 a way to drain fluid without having to come in to the office and have repeated invasive procedures like the paracentesis and thoracentesis and gives the patient or family member a way to drain some of the fluid off so the patient does not have to be in distress. V17 said he would assume if a patient was admitted to a facility with orders for this type of catheter they would contact someone to get more information. V17 said he would assume the nurses at the facility would ask some questions if they weren't familiar with a patient's catheter. R3's [DATE] Skin/Wound note showed, Admission skin assessment (6 days after admission) - Pneumo drainage to right lower quadrant - tube intact with clamp and cap in place. One stitch intact above site. Area covered with gauze and duoderm. Coccyx has a 0.2 cm OA (open area), area cleansed and duoderm placed . R3's nursing progress note dated [DATE] showed, .OA (open area) to buttock . R3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's medical record included no wound measurements or treatments for a wound to the coccyx or buttocks. R3's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] an order was entered to change the oxygen tubing every Wednesday. R3's POS did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:36 PM, V4 (Licensed Practical Nurse/LPN) said admission assessments are done as soon as possible but within 24 hours of admission to the facility for sure. On [DATE] at 10:43 AM, V3 (Assistant Director of Nursing) reviewed R3's chart with the surveyor and said she is not sure why there were no orders for oxygen, wound care, or the peritoneal drain. V3 said the nurse on the floor does the admission and the night nurse checks it for accuracy. V3 said she is not sure why an order that came through on [DATE] to hold R3's anticoagulant was not processed until [DATE]. V3 said orders should be processed on the same day they are received. The facility's undated policy titled Admission Process showed, . 4. The charge nurse will complete the following: A. A complete head to toe assessment will be performed and documented in the nurse's notes. B. Complete the nurse's admission assessment. C. Verify all transfer orders with the MD (physician). D. Transcribe all orders to the POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . E. Complete the admission checklist and turn into the DON. 5. The DON will audit the admission chart within 24 hours to ensure completeness .

Based on observation, interview and record review, the facility failed to implement their Coronavirus Emergency Pandemic Policy by not isolating new admissions and not using full Personal Protective Equipment (PPE) while providing care to new admissions. The facility failed to follow contact precautions for residents with C. Dif. The facility failed to identify residents on transmission based precautions. These failures resulted in residents being unprotected from communicable disease transmission after an exposure to COVID-19 and C. Dif. This applies to all 58 facility residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on October 15, 2020 when the facility became aware a COVID positive employee had worked in the facility on October 13, 2020 and was not wearing PPE correctly. The Immediate Jeopardy was identified on October 22, 2020 when it was determined contact tracing of potentially exposed residents had not been initiated, potentially exposed residents were not placed on recommended transmission based precautions, proper PPE was not used for care of residents on isolation or new admissions, residents on isolation were not identified by the facility, and new admissions were not quarantined on precautions. V1 (Administrator) was notified of the Immediate Jeopardy on October 28, 2020 at 2:15 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on October 30, 2020, however noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The October 22, 2020 Facility Data Sheet showed 58 residents in the facility. 1. On October 22, 2020 at 8:05 AM, this surveyor was allowed to walk into the building to the doorway of the Administrative offices (at least 18 feet) before a temperature was taken. At 1:00 PM, V2 (Assistant Administrator) was at his desk talking with an employee within six feet of him. V2's mask was improperly placed under his nose and mouth. V2 pulled his face mask over his mouth and nose when this surveyor came to the doorway. 2. R1's face sheet showed admittance to the facility on [DATE] from an acute care hospital. R1's hospital record showed a history of [MEDICAL CONDITION] fibrosis of the lung, stage 5 [MEDICAL CONDITION], recurrent renal cell [MEDICAL CONDITION] of the right kidney, metastatic bone tumor, stroke, left nephrectomy, Type II diabetes, and high blood pressure. R1's nursing progress note dated October 21, 2020 showed R1 had a [MEDICAL TREATMENT] graft to his right forearm and a central line to the right chest. On October 22, 2020 at 8:54 AM, R1's room door was open and R1 was in bed not wearing a mask. There was no COVID or contact isolation precaution signage outside of the room entrance and no isolation cart or supplies outside R1's room. There was no isolation trash receptacle in R1's room. At 9:20 AM, two ambulance personnel entered the facility wearing a face mask and gloves. They entered R1's room (new admission) accompanied by V11 (Certified Nursing Assistant/CNA). V11 wore a surgical mask and no gloves. The ambulance staff and V11 assisted R1 to a standing position and transferred R1 to the ambulance cart. R1 was not wearing a mask. R1 had an indwelling urinary catheter, a central line to the right chest, and a hinged brace to the right leg. V11 told the ambulance staff that R1 had a broken right leg and left arm. V11 did not tell the ambulance staff that R1 was on COVID precautions or that R1 was on contact precautions for C. Dif. R1 was taken out of the facility for a scheduled [MEDICAL TREATMENT] appointment. On October 22, 2020 at 8:05 AM, V2 stated the facility had an adequate supply of PPE and received three new admissions on October 21, 2020 (identified as R1-R3). V2 said V1 (Administrator) monitors the PPE supply. At 8:58 AM, V10 (CNA) said she knows who is on isolation if there is an isolation cart outside the resident's room and if there's a sign that says please see nurse on the door. V10 walked down E hall with this surveyor and said R1 was not on isolation. R1's physician order [REDACTED]. R1's hospital record showed R1 was admitted on [DATE], had surgery on the right distal femur on October 7 and 11 days later developed an elevated white blood cell count, abdominal pain, nausea, diarrhea and a fever of 101.1. R1's hospital discharge summary dated October 21, 2020 showed to continue with contact precautions. 3. R2's face sheet showed admittance to the facility on [DATE]. R2's hospital record showed [DIAGNOSES REDACTED]. On October 22, 2020 at 8:58 AM, V10 (CNA) walked down E hall with this surveyor and identified R2 (new admission) as having isolation for C. Dif. R2's room door was open and R2 was in the room without a mask on. There was no isolation signage outside of R2's room for COVID or C Dif. precautions. On October 22, 2020 at 2:15 PM, V13 (Housekeeper) told V12 (Housekeeping Supervisor), The therapist told me I need a gown on when I'm in R2's room. V12 told V13, You do not need a gown on. You're not touching the toilet; the brush is touching the toilet. R2's physician order [REDACTED]. R2's hospital discharge instructions showed for R2 to remain on contact precautions while he has C-Dif. ([MEDICAL CONDITION]) infection (infection transmitted through feces). 4. R3's face sheet showed admittance to the facility on [DATE] from an acute care hospital. R3's hospital records showed a history of oxygen dependent [MEDICAL CONDITION], chronic [MEDICAL CONDITION], obstructive sleep apnea, obesity, heart failure, hypertension, stage 4 [MEDICAL CONDITION], Type 2 diabetes, and inability to ambulate due to knee pain. On October 22, 2020 at 8:58 AM, V10 walked down E hall with this surveyor. R3's room door was ajar and R3 was in the room without a mask on. There was no COVID precaution signage or isolation supplies outside of R3's room. There was no isolation trash receptacle in the room. On October 22, 2020 at 9:00 AM, V10 said she didn't know why R3 (new admission) was on isolation. R3's physician order [REDACTED]. 5. On October 22, 2020 at 8:58 AM, V10 walked down E hall with this surveyor and identified R5 as on isolation for a wound infection. There was no contact precaution isolation signage outside R5's door. On October 22, 2020 at 9:05 AM, V11 (CNA) said R5 is on isolation for C. Dif. At 9:10 AM, V6 (Registered Nurse/RN) could not identify why R5 was on isolation. V6 stated, I only work Wednesday and Thursdays. R5 goes in and out of the facility frequently, so we restart 14-day isolation each time. V6 asked V3 (Director of Nursing/DON) why R5 is on isolation. V3 stated that R5 had [DIAGNOSES REDACTED]. V3 and V6 began looking in the computer to identify why R5 is on isolation. V3 stated, I don't want to tell you the wrong thing. At 1:00 PM, V1 (Administrator) stated, Residents get their vital signs checked three times a day. If they're new admissions on COVID-19 precautions, this includes checking for additional symptoms every shift and a pulse oximetry is checked every shift. COVID precautions include wearing a mask and gloves only, not full PPE (gowns, eye protection and N95) because they've had a negative COVID test. At 1:15 PM, V5 (Infection Control Nurse) stated, I just started reviewing infection control policies. V1 is in charge of the COVID policies. COVID Precautions include a surgical mask and gloves. I suggested staff wear full PPE, but V1 was concerned about our supply. COVID isolation should include shoe protectors, gowns, masks, face shield and gloves. COVID isolation should be a combination of contact and droplet isolation. I haven't seen a policy on quarantine for new admissions. The facility prefers to put a sign on the door directing staff to 'see the nurse before entering' (as opposed to signage indicating type of isolation and type of PPE required). There isn't a need for isolation carts outside a resident room because PPE is readily available. I'm not sure if our policy requires isolation specific signage. Residents on COVID isolation should have an isolation cart outside their room for additional PPE, such as gowns, goggles, and face shields. The facility-provided supply list of Personal Protective Equipment (PPE) showed the following stock: face masks - 3,750; N95 masks - 1,643; gowns - 1,770; safety glasses - 124; face shields - 186; gloves - 65,000. At 6:00PM, V15 (Local Health Department Director of Public Health Services) stated V16 (Infection Control Consultant/IDPH) and herself visited the facility on October 16, 2020. V15 stated that V2 was verbally aggressive toward them and difficult to approach with the assistance they were there to provide. V1 kept interrupting V16 and asking if there was anything else. V1 was not receptive to the hands-on guidance they were there to provide and would not allow a tour of the facility. V15 said she emailed V1 Long Term Care Guidance as far back as March and sent guidance updates as they became available throughout the pandemic. V15 provided copies of the emails that were sent to V1. V16 sent an email to V1 on October 20, 2020 with seven additional links to important facility guidance. A copy of this email was provided to this surveyor. Residents who are new admissions need to be cared for in full PPE even if they had a negative COVID test prior to admission and that is what I told V1. Symptoms can be delayed up to 14 days later so the residents need to be quarantined for 14 days. On October 23, 2020 at 9:16 AM, V1 (Administrator) stated, COVID Precautions are recognized by the Illinois Department of Public Health (IDPH) and the Centers for Disease Control and Prevention (CDC). We follow the guidelines. We don't make up our own. V1 was asked if wearing only a mask and gloves was effective against the transmission of COVID-19. V1 stated, It will decrease transmission. We don't have any positive cases in the building, and we don't admit COVID positive residents. The Centers for Disease Control and Prevention (CDC) current guidance showed if a health care provider (HCP) is diagnosed with [REDACTED]. The facility provided two lists of residents currently on isolation. List #1 showed R1 (new admission) on COVID precautions, R2 (new admission) on contact precautions, R5 on contact precautions and R6 on COVID precautions. R3 (new admission) and R4 (refused COVID testing) were not listed. List #2 showed R2 on contact precautions, R3 on COVID precautions, R5 on contact precautions, and R6 on COVID Isolation. R1 (new admission) was not on the list. The CNA report sheet printed October 22, 2020 by V8 (CNA) showed R2 was on isolation for C, Dif. This report sheet did not show any isolation precautions for R1, R2, R3, R4 or R5. This sheet did not identify R1, R3, R4, and R5 had precautions in place for COVID. IDPH's Personal Protective Equipment (PPE) Guidance for COVID-19 in Long Term Care Settings showed observation units for new admissions/readmission require the following PPE: surgical masks, unless N95 is warranted, eye protection (face shield or goggles) for the care of all patients/residents, gloves for each patient/resident interaction and prioritization of gowns. The World Health Organization (WHO) brief dated July 9, 2020 showed COVID-19 is spread through contact and droplets with an infected person. The incubation period of COVID-19, which is the time between exposure to [MEDICAL CONDITION] and symptom onset, is on average 5-6 days, but can be as long as 14 days. The Centers for Disease Control and Prevention (CDC) recommendations dated April 30, 2020 showed new admissions whose COVID status is unknown and are being observed should be cared for using all recommended COVID-19 PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, (i.e., goggles or a disposable face shield that covers the front and sides of the face, gloves, and gowns. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). The facility's undated Transmission Based Precautions policy showed the facility will take appropriate precautions to prevent transmission of infectious agents. This policy showed healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. This policy showed for Severe Acute Respiratory Syndrome ([DIAGNOSES REDACTED]) (an infectious disease with symptoms including fever and cough and in some cases progressing to pneumonia and [MEDICAL CONDITION]. It is caused by a coronavirus.) to wear eye protection. The facility's Infection Control Policy dated October 15, 2020 showed when it is determined that a resident requires isolation to prevent the spread of infections, the facility must isolate the resident in order to ensure that infection is not spread. The facility's September 17, 2020 Coronavirus Emergency Pandemic Policy Addendum showed the center's Coronavirus program includes transmission-based precautions. The program incorporates Administrative procedures and infection control methods to prevent and reduce the generation of infectious droplet nuclei. Symptoms may appear anywhere from 2 to 14 days after exposure. Section 14. Admission of this policy showed new admissions will be quarantined for 14 days in the designated area of the center. Section 15. Admission/Readmission Quarantine Hall showed staff should wear full PPE (gowns, gloves, mask, N95 (if possible)/KN95 and eye protection). Residents to wear cloth mask or cover nose and mouth with tissue when staff enter the resident's room. Section 19. Prevention showed ensure all healthcare personnel wear a facemask or cloth covering for source control while in the facility. The facility's nursing in service documentation showed no employee in-services for the months of September and October 2020. An undated facility posting showed residents that have been newly admitted /returned will be under COVID-19 Precautions. This is an order in Point Click Care called COVID monitoring and should be a duration for 14 days. It is important that you use a surgical mask, cloth masks are not acceptable, and gloves with the care of these residents. Additionally, it is recommended that ALL residents wear masks outside of their room and in their rooms with staff care, as tolerated. The Immediate Jeopardy that began on October 15, 2020 was removed on October 30, 2020 when the facility took the following actions to remove the immediacy: All staff and residents will be baseline tested [DATE] Residents who refuse testing will be placed into quarantine for 14 days and monitored for signs and symptoms of COVID-19. Staff who refuse testing will be removed from the working schedule. New admission/readmission(s) will be quarantine for 14 days in the designated area of the center. Staff will be required PPE: isolation gown, gloves, eye protection and N-95 respirator. The center will readmit their residents after hospitalization and quarantine resident for 14 days. Should private room be unavailable on the quarantine area, residents may cohort. This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. Residents will be asked to wear face mask or cloth covering while in room. (Contact local health authority and regional for guidance). When precautions are implemented, the charge nurse in the section where precautions are instituted shall: Maintain an adequate array of isolation supplies (i.e., gloves, gowns, masks, etc. as needed) near the isolation room so that appropriate protective clothing can be easily put on before entering the isolation room; Make sure that a laundry hamper and waste containers are placed in/near the isolation room and that each is lined with a red plastic liner if indicated; Place necessary equipment and supplies in the room that will be needed during precautions; Make sure that an adequate supply of antiseptic soap and paper towels are maintained in the room during the isolation period; Explain to the resident the reason(s) for the precautions. When isolation precautions are implemented, a sign advising visitors to report to the Nurses Station prior to entering the room must be placed at the entrance/doorway of the resident's room. Categories of isolation are outlined in a separate policy in this manual entitled Infection Control Precautions; Categories of. A supply of isolation notices and stickers is maintained at each nurses' station. In-service training will be provided upon employment and at least annually for all employees on the use of isolation notices. All agency employee must come to the building to be tested 24 hours prior to working a shift (Contact local health authority and regional for guidance). When precautions are implemented, the charge nurse in the section where precautions are instituted shall: Maintain an adequate array of isolation supplies (i.e., gloves, gowns, masks, etc. as needed) near the isolation room so that appropriate protective clothing can be easily put on before entering the isolation room; Make sure that a laundry hamper and waste containers are placed in/near the isolation room and that each is lined with a red plastic liner if indicated; Place necessary equipment and supplies in the room that will be needed during precautions; Make sure that an adequate supply of antiseptic soap and paper towels are maintained in the room during the isolation period; Explain to the resident the reason(s) for the precautions. When isolation precautions are implemented, a sign advising visitors to report to the Nurses Station prior to entering the room must be placed at the entrance/doorway of the resident's room. Categories of isolation are outlined in a separate policy in this manual entitled Infection Control Precautions; Categories of. A supply of isolation notices and stickers is maintained at each nurses' station. In-service training will be provided upon employment and at least annually for all employees on the use of isolation notices. All contact tracing will be initiated after exposure by Infection control and DON All agency employee must come to the building to be tested 24 hours prior to working a shift All staff including agency staff will be in-serviced on the facility COVID - 19 policy. This policy is attached. All staff including agency staff are being in-serviced on wearing required PPE gown, N95, eye protection and gloves, and what precautions the facility residents required prior to caring for them. No new staff member in any department will be allowed to work until they have received training on the COVID - 19 policy. In-Service conducted: In-services are being conducted by the Administrator and Director of Nursing beginning 10/28/20 and no employee will be allowed to work until they have been in-serviced on the facility COVID - 19, Infection Control policies which encompasses the following: Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that test negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive. The center will follow CDC guidance for Testing Guidelines for Nursing Homes section Non-diagnostic testing of asymptomatic residents without known or suspected exposure to an individual infected with [DIAGNOSES REDACTED]- CoV-2 and center's policy for COVID-19. CDC website:https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html. Routine testing of staff should be based on the extent of [MEDICAL CONDITION] in the community. The center will use their county positivity rate in the prior week as the trigger for staff testing frequency. The center should monitor their county positive rate every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing accordingly per the below table: CMS has clarified that due to the frequency of testing, facility should use the color coding to determine their county rate, even if the numerical value doesn't seem to match the color code. Community COVID-19 Activity/County Positivity Rate in the past week/Minimum Testing Frequency LOW GREEN (<5%) Once a month MEDIUM YELLOW (5%-10%) Once a week* HIGH RED (>10%) Twice a week* The Director of Nursing as the responsible person to complete the task to ensure all COVID - 19 regulations from both the CDC, County Health Department, and IDPH are reviewed and incorporated into the facility's policies and followed. The Infection Preventionist, DON, and/or designee will review updated CDC, County Health and IDPH recommendations and implement/update policy and procedure as appropriate. Staff training to include COVID - 19 regulations, testing requirements for COVID -19 for residents and staff. Administrative procedures and infection control methods to prevent and reduce the generation of infectious droplet nuclei (i.e., staff training on airborne, droplet and standard precautions and cough hygiene) Employees are to follow the center's procedure for PPE and eye protection. Staff who refuse testing will be removed from the working schedule. Residents who refuse testing will be quarantine. PCR tests results will be obtained by the Infection Control Preventionist, DON, ADON and/or Administrator. The Infection Preventionist, DON, and/or designee will review updated CDC, County Health and IDPH recommendations and implement/update policy and procedure as appropriate. The center may use the crisis capacity from the CDC guidance for optimization of isolation gowns states: Consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same HCP when interacting with more than one patient known to be infected with the same infectious disease when these patients housed in the same location (i.e., COVID-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. If the gown becomes visibly soiled, it must be removed and discarded. PPE requirements for Covid-19 positive; isolation gown, gloves, eye protection and N95 or higher-level respirator. Involvement of Medical Director The Medical Director was notified about the Immediate Jeopardy on 10/28/2020. The Medical Director will be meeting with the Interdisciplinary team on 11/3/2020 to discuss more about the immediate Jeopardy and ways to address the alleged deficient practice. Involvement of QA A QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Who is responsible for implementation of process? The Director of Nursing/designee, and Administrator will be responsible for implementation of process. The in-service/s will be started on 10/28/2020 and completed 10/29/2020. No employee will be able to return to work until they complete the In-service.

Based on interview and record review, the facility failed to perform facility wide baseline testing for COVID-19.The facility failed to perform facility wide COVID-19 testing of residents and staff immediately after an employee tested positive for COVID-19. The facility failed to identify the residents cared for by the COVID-19 positive staff member and place those residents on transmission based precautions. The facility failed to obtain test results after conducting COVID testing. The facility failed to have a policy in place to address refusal of COVID testing by residents. These failures resulted in the potential exposure of residents and staff to COVID-19. This applies to all 58 facility residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on October 15, 2020 when the facility became aware a COVID positive employee had worked in the facility on October 13, 2020 and was not wearing Personal Protective Equipment (PPE) correctly. The Immediate Jeopardy was identified on October 22, 2020 when it was determined the facility had not completed facility wide baseline testing, the facility did not perform COVID-19 testing of residents and staff after a potential exposure on October 13, 2020, the facility did not identify the residents who were potentially exposed and cared for by the COVID positive employee, did not have a procedure in place to obtain COVID test results and address resident refusal of COVID-19 testing. V1 (Administrator) was notified of the Immediate Jeopardy on October 28, 2020 at 2:15 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on October 30, 2020 , but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The October 22, 2020 Facility Data Sheet showed 58 residents in the facility. 1. On October 22, 2020 at 8:05 AM, V2 (Assistant Administrator) stated all facility residents and staff had been tested for COVID-19. The first round of baseline testing was completed last week and the second round was being done today. The facility's testing consent forms were dated October 12-14, 2020 (10-12 days ago). On October 22, 2020 at 12:00 PM, V1 stated he is trying to get access to obtain COVID test results from last week. V1 stated V18 (Medical Director) has access to the results, but he (V1) does not. V1 said he reached out to V18 but was unable to reach him. At 12:11 PM, V18 stated, I'm not sure I know how to access the COVID test results from last week and was not aware of any test results yet. On October 22, 2020 at 6:00 PM, V15 (Local Health Department/LHD/Director of Public Health Services) stated, The facility probably only tested half of their staff, as they ran out of testing supplies. I told them I would disqualify the testing as they didn't test all residents and staff within 24 hours of each other and so they needed to retest. They did not complete their facility baseline testing because all staff and residents were not tested within 24 hours of each other. As of October 22, 2020 the facility did not complete facility wide baseline testing of all staff, or testing of all staff after a possible exposure to a COVID-19 positive staff member. 2. At 12:25 PM, V3 (Director of Nursing/DON) stated, V17, an agency CNA, tested positive for COVID-19 and has been in isolation. V3 stated, V17 has not been in the facility for two weeks. On October 26, 2020 at 10:47 AM, V17 stated she usually works at the facility 3-4 days a week. She began to experience fever, chills, body aches, nausea and diarrhea on October 13, 2020. V17 stated she tested positive for COVID-19 on October 15, 2020 and had pneumonia. V17 stated she notified the agency she is employed by of her test results. V17 stated most of the staff at the facility were not compliant with wearing their masks. V17 stated she was never tested for COVID-19 by the facility or her staffing agency. V17 stated, You'd think the facility would test the people working in their building. V17 stated she filled out a screening questionnaire at the beginning of her shift and took her temperature. V17 stated she was not required to rescreen halfway through her shift. The facility's staff assignment sheet dated October 13, 2020 (the day the employee began having symptoms) showed V17 worked day shift (6:00 AM-2:30 PM) on the E hall with two other CNAs. An undated facility-provided document identifies V17 as having worked in the facility and having a COVID-19 positive diagnosis. An email dated October 27, 2020 from V17's agency showed they were notified the early morning of October 15, 2020 that V17 was getting tested for COVID-19. After verifying V17's positive COVID test result the agency notified the facility. Documentation from the staffing agency dated October 15, 2020 at 3:04 PM, showed V5 (Infection Control Nurse) contacted the agency to voice concerns of V17 not wearing her PPE properly (after facility became aware of V17's positive COVID test). The document showed V17 often wore her face mask around her chin and not over her nose and mouth. The agency advised V5 that there should be a concern for the residents and coworkers to be direct exposures. 3. On October 22, 2020 at 12:25 PM, V3 (DON) stated R4 has dementia and is set in her ways.4 refused COVID-19 testing last week. R4's room is not on the quarantine hallway. The facility provided list of residents on isolation does not include R4. There is no isolation signage or isolation bin outside of R4's room. At 12:45 PM, V1 stated all the resident and staff test results were negative. At 1:00 PM, V1 was asked why a resident COVID testing refusal plan was not in place. V1 stated the facility didn't plan for that, when asked about what should be done if a resident refuses COVID testing as R4 did. At 1:50 PM, V1 stated he was waiting on the Local Health Department (LHD) to get back to him on the resident refusal piece for the policy. V1 stated, It's not currently in our policy. On October 22, 2020 at 6:00 PM, V15 stated, I never discussed resident or staff refusal of testing or to preserve the supply of PPE with V1. On October 23, 2020 at 11:30 AM, V16 (Illinois Department of Public Health/IDPH/Infection Control Consultant) stated the facility had not completed baseline testing per guidance. V16 stated she had serious concerns about the facility not paying attention to current guidance and they may only respond to regulatory intervention. The facility's county COVID positivity rate as of October 21, 2020 was 9.2% which dictates weekly testing of staff. The facility-provided employee list compared to the staff that had baseline testing for COVID-19 the week of October 12 showed 52 employees were not tested . Ten employees (V13 and V19-27) tested were not on the facility-provided list of employees. The Centers for Disease Control and Prevention (CDC) current guidance showed the facility should determine which residents received direct care from and which health care provider (HCP) had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. The residents cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED]. The facility's September 24, 2020 COVID-19 Testing and Response Plan showed it shall be the policy of the facility to guard against the introduction and spread of [DIAGNOSES REDACTED]-CoV-2 (COVID-19) within its community of residents and staff. The facility uses available and current guidance from the Centers for Disease Control and Prevention (CDC), Center for Medicare and Medicaid Services (CMS), the Illinois Department of Public Health (IDPH), and Local Health Department (LHD) officials to instruct the development and implementation of policies and procedures that comprise its strategy to prevent, respond to, and mitigate the presence of [DIAGNOSES REDACTED]-CoV-2. Under this plan, Section III. B 2 Testing Capacity and Protocol, the facility failed to identify how they will protect residents from an exposure if a resident refuses testing. Under the plan's III. F Test Kit Supply, it showed the facility calculates the total number of test kits necessary to have in inventory and on order to complete testing. Under the plan's III. G Baseline Testing, it showed the facility will complete baseline testing of all residents and staff by October 20, 2020. A list of facility staff who were not tested for COVID-19 during the initial testing was requested from V1 on October 23, 2020, again by email on October 25, 2020, again by voicemail on October 26, 2020 and lastly on October 27, 2020 from V2. A list was received on October 27, 2020 at 11:25 AM and included 33 employees. This list was inconsistent with the named staff whose testing consents were reviewed and neither list includes V1 or V2. An email received from V1 on October 27, 2020 acknowledges all staff were not tested for COVID-19 during the initial baseline testing. Illinois Department of Public Health (IDPH) Guidance effective August 14, 2020 and revised October 21, 2020 showed a written COVID-19 testing plan and response strategy is in place and includes initial testing of all residents and staff and a policy is in place for addressing residents and staff that refuse testing in each of the following: (a) symptomatic, or (b) asymptomatic. A facility produced letter showed as of October 22, 2020, none of the facility staff had tested positive for COVID-19 but adds an agency staff person who had been in the facility tested positive. The Immediate Jeopardy that began on October 15, 2020 was removed on October 30, 2020 when the facility took the following actions to remove the immediacy: All staff and residents will be baseline tested [DATE]. Residents who refuse testing will be placed into quarantine for 14 days and monitored for signs and symptoms of COVID-19. Staff who refuse testing will be removed from the working schedule. New admission/readmission(s) will be quarantine for 14 days in the designated area of the center. Staff will be required PPE: isolation gown, gloves, eye protection and N-95 respirator. The center will readmit their residents after hospitalization and quarantine resident for 14 days. Should private room be unavailable on the quarantine area, residents may cohort. This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. The facility failed to obtain test results after doing COVID testing. The facility failed to have a policy in place to address refusal of COVID testing by residents. All contact tracing will be initiated after exposure by Infection control and DON. All agency employees must come to the building to be tested 24 hours prior to working a shift (Local health authority and regional for guidance). All staff including agency staff will be in-serviced on the facility COVID - 19 policy. This policy is attached. All staff including agency staff are being in-serviced on wearing required PPE gown, N95, eye protection and gloves, and what precautions the facility residents required prior to caring for them. No new staff member in any department will be allowed to work until they have received training on the COVID - 19 policy. In-Service conducted In-services are being conducted by the Administrator and Director of Nursing beginning 10/28/20 and no employee will be allowed to work until they have been in-serviced on the facility COVID - 19, Infection Control policies which encompasses the following: Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that test negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive. The center will follow CDC guidance for Testing Guidelines for Nursing Homes section Non-diagnostic testing of asymptomatic residents without known or suspected exposure to an individual infected with [DIAGNOSES REDACTED]- CoV-2 and center's policy for COVID-19. CDC website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html. Routine testing of staff should be based on the extent of [MEDICAL CONDITION] in the community. The center will use their county positivity rate in the prior week as the trigger for staff testing frequency. The center should monitor their county positive rate every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing accordingly per the below table: CMS has clarified that due to the frequency of testing, facility should use the color coding to determine their county rate, even if the numerical value doesn't seem to match the color code. Community COVID-19 Activity/County Positivity Rate in the past week/Minimum Testing Frequency LOW - GREEN (<5%) - Once a month MEDIUM - YELLOW (5%-10%) - Once a week* HIGH - RED (>10%) - Twice a week* The Director of Nursing as the responsible person to complete the task to ensure all COVID - 19 regulations from both the CDC, County Health Department, and IDPH are reviewed and incorporated into the facility's policies and followed. The Infection Preventionist, DON, and/or designee will review updated CDC, County Health and IDPH recommendations and implement/update policy and procedure as appropriate. Staff training to include COVID - 19 regulations, testing requirements for COVID -19 for residents and staff. Administrative procedures and infection control methods to prevent and reduce the generation of infectious droplet nuclei (i.e., staff training on airborne, droplet and standard precautions and cough hygiene) Employees are to follow the center's procedure for PPE and eye protection. Staff who refuse testing will be removed from the working schedule. Residents who refuse testing will be quarantine. PCR tests results will be obtained by the Infection Control Preventionist, DON, ADON and/or Administrator. The Infection Preventionist, DON, and/or designee will review updated CDC, County Health and IDPH recommendations and implement/update policy and procedure as appropriate. The center may use the crisis capacity from the CDC guidance for optimization of isolation gowns states: Consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same HCP when interacting with more than one patient known to be infected with the same infectious disease when these patients housed in the same location (i.e., COVID-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. If the gown becomes visibly soiled, it must be removed and discarded. PPE requirements for Covid-19 positive; isolation gown, gloves, eye protection and N95 or higher-level respirator. Involvement of Medical Director The Medical Director, was notified about the immediate Jeopardy on 10.28.2020. The Medical Director will be meeting with the Interdisciplinary team on 11/3/2020 to discuss more about the immediate Jeopardy and ways to address the alleged deficient practice. Involvement of QA A QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Who is responsible for implementation of process? The Director of Nursing/designee, and Administrator will be responsible for implementation of process. The in-service/s will be started on 10/28/2020 and completed 10/29/2020. No employee will be able to return to work until they complete the In-service.

Based on observation, interview, and record review the facility failed to safely position a resident in bed and failed to raise the side rail for a resident in bed. These facility failures resulted in the resident falling from the bed onto the floor, having uncontrolled bleeding and fracturing R4's ethmoid sinus. This applies to 1 of 3 residents (R4) reviewed for falls in the sample of 4. The findings include: The facility's electronic [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS) for R4 dated (MONTH) 2, (YEAR) shows R4 to have severe cognitive impairment and requires extensive assist of two staff for transfers and one person physical assist for bed mobility. On (MONTH) 12, (YEAR), at 9:32 AM R4 was sitting in her wheel chair at an activity. R4 had faded bruising under her nose and up the left side of her face. On (MONTH) 12, (YEAR), at 9:45 AM, V6 Certified Nursing Assistant (CNA) said she transferred R4 into bed with the mechanical lift by herself on (MONTH) 4, (YEAR). V6 said she lowered R4 down onto the raised bed, positioning her close to the edge of the bed and slightly turned on her side so V6 could complete incontinence care. V6 said the side rail was down and covered by the bedspread so she did not realize it was not up. V6 said she turned away from the resident's bed to take the mechanical lift out of the room and when she turned back around R4 was falling out of the bed onto the floor. V6 said she never should have put R4 so close to the edge of the bed and should have made sure the side rail was up before walking away. V6 said she will wait for help next time. On (MONTH) 12 (YEAR) at 3:40 PM, V9 (Resident Assistant) said she was passing water to the resident across the hallway from R4 and saw V6 headed out of R4's room with the mecahnical lift and saw R4 on the floor next to her bed. On (MONTH) 12, (YEAR), at 12:59 PM, V3 Licensed Practical Nurse (LPN) said R4 at times will wiggle around in the bed and can lift her head up off the bed. V3 said the resident should be safely positioned in the center of the bed and the side rail should be up when staff walk away from the resident while in bed. On (MONTH) 12, (YEAR), at 1:10 PM, V7 CNA said the side rails should be up and the resident positioned in the center of the bed if walking away from them while in bed. On (MONTH) 12, (YEAR) at 2:00 PM, V2 Director of Nurses (DON) said when caring for a resident in bed, the resident should be positioned in the center of the bed and the side rails should be up. On (MONTH) 12 (YEAR), at 2:10 PM, V1 Administrator said she expects the staff to position residents on their backs in the center of the bed and make sure the side rails are up before walking away from the bed. The nursing progress note dated (MONTH) 4, (YEAR) shows R4 was observed laying on the floor beside her bed with her left arm behind her back. Several skin tears were seen on both of R4's arms. R4's nose was bleeding large amounts of blood and an abrasion was seen on her nose. The note also shows staff were unable to move the resident due to nose bleeding. An ambulance was called and R4 was taken to the local hospital. The physician's Primary Care Progress Note dated (MONTH) 5, (YEAR) shows R4 had a fall at the nursing home and was transferred to local hospital and was found to have a fracture of her ethmoid sinus. (The ethmoid is a square bone at the root of the nose, forming part of the cranium). The facility's fall investigation record dated (MONTH) 4, (YEAR) shows R4 was placed near the edge of her bed, slightly on her side, the side rail was not raised and the bed was in the high position. The report also shows as a result of R4 being left in that position and the side rail not being up contributed to R4 rolling out of bed onto the floor. The care plan for R4 with a revision date of (MONTH) 1, (YEAR) shows a second CNA to be present to assure proper positioning is completed, when in bed, have resident roll to their side using side rail, assist as needed and handle resident gently when moving or positioning and maintain body alignment. The facility's undated fall prevention policy shows each resident receives adequate supervision and assistance devices to prevent accidents. 2a. care planning and implementation of preventative measures.

Based on interview and record review the facility failed to immediately report an allegation of abuse to the Administrator, the facility failed to thoroughly investigate allegations of abuse, and the facility failed to protect residents from an employee with an allegation of abuse. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy situation began on January 29, 2017 at 2:30PM, when E22 was witnessed verbally abusing R45, and it was not immediately reported to the Administrator. On May 3, 2017 at 11:30 AM, the administrator was informed of the Immediate Jeopardy related to not immediately reporting allegations of abuse, thoroughly investigating allegations of abuse, and protecting residents. While the immediacy was removed on January 30, 2017, the facility remains out of compliance at a severity level two as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication regarding allegations of abuse. This applies to 3 of 15 residents (R45, R48, R53) reviewed for abuse in the sample of 15 and 1 resident (R28) in the supplemental sample. The findings include: 1. A facility investigation report for February 1, 2017 shows a final report of an allegation of verbal abuse toward R45. The report shows R45 has [MEDICAL CONDITION] affecting his left side and has impaired cognition. On April 25, 2017 at 10:00 AM, R45 was observed lying in bed, his left hand contracted, and appears to have minimal use of his left arm. R45 was alert and had periods of confusion and was unable to answer questions appropriately. The report shows on January 29, 2017, Z2 (Occupational Therapist) heard E22 (CNA - Certified Nursing Assistant) speak to R45 in a rude tone when asking what do you want? Z2 reported R45 requested to get out of his wheelchair into bed and E22 responded by telling him I just got here, you will have to wait. And you will get up when I get you up! On April 27, 2017, at 8:50 AM, Z2 stated this incident occurred at shift change for second shift, at approximately 2:30 PM. According to the incident report, this incident was not immediately reported to the administrator, and E22 continued to work until the end of her shift at 10:30 PM. The facility incident report shows Z1 (R8's sister) called the facility on January 30, 2017 at 1:00 PM, and reported that on January 29, 2017 at approximately 7:00PM (4 hours after first incident, and same resident) she overheard a CNA yell at a resident and speak very unprofessionally. It was reported the CNA said something to the effect of 'you are on your light too fu**ing much and I am not going to answer it anymore.' Z1 had reported the tone was horrendous and the F word was used a couple of times. The report shows R45 was residing in the room across the hall from Z1's sister. On April 27, 2017 at 10:20 AM, Z1 said the tone used by the staff was harsh, and included swearing at another resident. Z1 said it was loud enough to hear through a closed door and over the television, yet no staff on duty (January 29, 2017) reported any incident of verbal abuse. Z1 said it really bothered her, and requested that CNA not care for her sister. On April 26, 2017 at 12:00 PM, E1 said using the shift assignment sheets, she determined E22 to be the staff member responsible for the second incident on January 29th as well. On April 26, 2017 at 2:25 PM, E1 said Z2 notified her of the incident from January 29, 2017 between R45 and E22, on the morning of January 30, 2017. E1 said she did not consider the first allegation as verbal abuse. E1 said she planned on re-educating E22 about how to speak to residents and place her on 90 day probation. E1 said she then received a call from R8's sister reporting of a staff member using foul language and yelling at a resident. E1 said she began an investigation, but did not immediately call E22 to suspend her, and allowed her to return to the facility on [DATE] at 1:45 PM. On April 27, 2017 at 10: 45AM, E1 said when E22 arrived at the facility on January 30, 2017 at 1:45, reporting for her shift, she was escorted into the Director of Nursing (DON) office on B wing. E1 said E22 was questioned about the allegation and provided a written statement. E1 said E22 was notified of her suspension at that time, and the DON escorted E22 toward the exit on E wing. E1 said while E22 was walking in the hallway she began yelling and swearing and referred to R45 by his room number, blaming him for her suspension. E1 said she was in her office and did not witness the incident. On April 27, 2017 at 11:00 AM, E23 and E7 (CNA) each said residents and families were sitting near the E wing nurses station when E22 was swearing and yelling. E23 said she was sure the families heard all of it. E7 reported E22 was down E wing, very angrily standing at the desk and said These little [***] es want to suspend me over fu**ing (room number for R45). E7 reports E22 was asked to leave by staff and she replied I don't like you anyways. On April 26, 2017 at 12:00 PM, E1 said allegations of abuse should be immediately reported, and an investigation will be initiated immediately. E1 said during her investigations she interviews residents, employees, families and anyone that may be involved with any alleged abuse. The facility investigation file shows the abuse investigation was not initiated until January 30, 2017 at 1:10 PM, after the second allegation of verbal abuse was reported. The investigation does not include witness statements from any CNA's or nurses working the second shift on January 29, 2017. 2. An incident report faxed to IDPH shows on October 3, 2016 at 4:00 PM, R28 reported a CNA was rough while providing care. The facility abuse investigation does not include the name of the alleged CNA named in the allegation, and therefore it is unknown if a witness statement was obtained. There is no evidence of a CNA being immediately suspended pending the outcome of the investigation. The investigation does not show any statements from residents regarding their care. Based on staff statements the allegation was determined to be unfounded, without a complete investigation. On April 26, 2017 at 11:30 AM, E1 said R28's daughter reported the allegation, and stated it was the CNA who was caring for her about 4:00 PM on October 3, 2016. E1 stated she believes the CNA was E7, but was not sure and would have to pull a schedule to make sure that was correct. E1 said she thought there were resident interviews, but not sure where they would be if they are not in the file. 3. A facility incident report for December 12, 2016 at 4:45 PM, R48 reported an allegation of verbal abuse to staff. The resident said the alleged abuse occurred on December 9, 2016 at approximately 1:30 PM. The incident report shows statements were taken from the CNA (unnamed in all of the reports), staff and residents. The investigation contains only one CNA and one LPN (Licensed Practical Nurse) statements. No staff interviews were obtained for the date of the event and only 4 residents were asked about the CNA's meeting their needs, not about verbal interactions. There is no evidence in the investigation of any CNA being suspended during the investigation. On April 26, 2017 at 11:30 AM, E1 said R48 did not mention a CNA by name but did describe her, and with schedules and daily assignments it was determined to be E36. E1 said all CNA's should have been interviewed. 4. A facility incident report for March 4, 2017 shows R53 reported an allegation of physical abuse regarding her care on the evening of March 3, 2017. The initial and final reports do not list a CNA for the evening of March 3, 2017. The investigation file contains only 2 CNA statements and 1 LPN statement. No further staff were interviewed and it is unknown who is the alleged perpetrator of the abuse and if they were interviewed. There is no evidence of the CNA accused of abuse being suspended during the investigation. The facility February monthly staff meeting minutes shows an agenda to include types of abuse and when/who to report any allegations. The sign in sheets for the meeting show only 35 employees signed as attended. The facility employee roster shows there are 88 employees who should have attended/received the training. The education hand out provided is a list of definitions for abuse and lists each type of abuse. The back side of the hand out is an abuse prevention training program post- test with 10 true/false questions, with the answers already provided. On April 27, 2017 at 11:35 AM, E1 was interviewed regarding facility Quality Assurance projects and she stated during the last annual survey the facility was cited for abuse, but could not explain a process or action plan to address abuse concerns. The provider history file Casper report run on March 15, 2017 shows the facility was cited in 2014, 2015 and 2016 for failure to immediately report and investigate allegations of abuse. On May 3, 2017 the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: 1. E22 was terminated on January 30, 2017. 2. All staff will be inserviced on the Abuse Policy and procedure and on the need to follow those policies. The inservice included abuse prevention, the differences between grievances and reportable abuse allegations, reporting immediately all allegations of abuse, and review of the abuse policy and procedure. 3. The facility contacted all contract staff in writing notifying them any employee providing services inside the facility will be required to complete the education for the facility Abuse Prevention Program prior to delivering services. 4. All staff inlcuding new-hire employees will be inserviced prior to reporting to work. 5. Actions completed by Administrator and DON on April 26, 2017: (a) 100% in-service education with facility staff on abuse policy and procedure. (b) 100% education given to new hires during orientation for all departments on the abuse policy and procedure including reporting. (C)Staff on vacation, leave of absence, and new hires will receive educatin prior to reporting to their area for work. 6. The QAPI Committee will meet monthly o review any infraction in following the facility abuse policy and procedure. 7. Interviews were conducted with staff members from all departments within the facility on May 3, 2017 to verify education/training was given as identified by the facility. 8. Schedules were monitored by the Administratror and all Department Heads to ensure employees received education and training prior to working.

Based on observation, interview, and record review the facility failed to ensure residents were free from verbal abuse. The facility failed to immediately report an allegation of abuse to the administrator, and failed to immediately suspend a Certified Nurse Assistant (CNA) after an allegation of abuse. This failure resulted in an immediate jeopardy. The Immediate Jeopardy began on January 29, 2017 at 2:30 PM when E22 began verbally abusing R45, and E22 continued to verbally abuse R45 throughout her shift. On May 3, 2017 at 11:30 AM, the administrator was informed of the Immediate Jeopardy related to E22's behavior towards R45. The immediacy was removed on January 30, 2017 when E22 was terminated. The facility remains out of compliance at a severity level two as the facility needs to complete training of all staff on abuse procedures. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. These failures apply to 1 of 5 residents (R45) reviewed for abuse in the sample of 15. The findings include: A facility investigation report for February 1, 2017 shows a final report of an allegation of verbal abuse toward R45. The report shows R45 has [MEDICAL CONDITION] affecting his left side and has impaired cognition. On April 25, 2017 at 10:00 AM, R45 was observed lying in bed, his left hand contracted, and appears to have minimal use of his left arm. R45 was alert and had periods of confusion and was unable to answer questions appropriately. The report shows on January 29, 2017, Z2 (Occupational Therapist) heard E22 (CNA - Certified Nursing Assistant) speak to R45 in a rude tone when asking what do you want? Z2 reported R45 requested to get out of his wheelchair into bed and E22 responded by telling him I just got here, you will have to wait. And you will get up when I get you up! On April 27, 2017, at 8:50 AM, Z2 stated this incident occurred at shift change for second shift, at approximately 2:30 PM. According to the incident report, this incident was not immediately reported to the administrator, and E22 continued to work through the end of her shift at 10:30 PM. The facility incident report shows Z1 (R8's sister) called the facility on January 30, 2017 at 1:00 PM, and reported that on January 29, 2017 at approximately 7:00PM (4 hours after first incident and same resident) she overheard a CNA yell at a resident and speak very unprofessionally. It was reported the CNA said something to the effect of 'you are on your light too fu**ing much and I am not going to answer it anymore.' Z1 had reported the tone was horrendous and the F word was used a couple of times. The report shows R45 was residing in the room across the hall from Z1's sister. On April 27, 2017 at 10:20 AM, Z1 said the tone used by the staff was harsh, and included swearing at another resident. Z1 said it was loud enough to hear through a closed door and over the television, yet no staff on duty January 29, 2017 reported any incident of verbal abuse. Z1 said it really bothered her, and requested that CNA not care for her sister. On April 26, 2017 at 12:00 PM, E1 said using the shift assignment sheets, she determined E22 to be the staff member responsible for the second incident on January 29th as well. On April 25, 2017 at 1:30 PM, Z3 (R49's daughter) said she is in the facility every afternoon. Z3 said she has watched the CNA's that are assigned to one hallway, float all over the building because some residents require 2 CNA's to transfer using a mechanical lift. Z3 said sometimes the CNA's have 2 wings of residents to care for. On April 26, 2017 at 2:25 PM, E1 said Z2 notified her of the incident from January 29, 2017 between R45 and E22, on January 30, 2017. E1 said she did not consider the first allegation as verbal abuse. E1 said she planned on re-educating E22 about how to speak to residents and place her on 90 day probation. E1 said she then received a call from R8's sister reporting of a staff member using foul language and yelling at a resident. E1 said she began an investigation, but did not call E22 to suspend her, and allowed her to return to the facility on [DATE] at 1:45 PM. On April 27, 2017 at 10: 45AM, E1 said when E22 arrived at the facility on January 30, 2017 at 1:45, reporting for her shift, she was escorted into the Director of Nursing (DON) office on B wing. E1 said E22 was questioned about the allegation and provided a written statement. E1 said E22 was notified of her suspension at that time, and the DON escorted E22 toward the exit on E wing. E1 said while E22 was walking in the hallway she began yelling and swearing and referred to R45 by his room number, blaming him for her suspension. E1 said she was in her office and did not witness the incident. On April 27, 2017 at 11:00 AM, E23 and E7 (CNA) each said residents and families were sitting near the E wing nurses station when E22 was swearing and yelling. E23 said she was sure the families heard all of it. E7 reported E22 was down E wing, very angrily standing at the desk and said These little [***] es want to suspend me over fu**ing (room number). E7 reports E22 was asked to leave by staff and she replied I don't like you anyways. The facility's December 2013 policy for abuse prevention defines verbal abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. The facility February monthly staff meeting minutes show an agenda to include types of abuse and when/who to report any allegations. The sign in sheets for the meeting show only 35 employees in attendance. The education hand out provided is a list of definitions for abuse and lists each type of abuse. The back side of the hand out is an abuse prevention training program post- test with 10 true/false questions, with the answers already provided. On April 27, 2017 at 11:35 AM, E1 was interviewed regarding facility Quality Assurance projects and she stated during the last annual survey the facility was cited for abuse, but could not explain a process or action plan to address abuse concerns. On May 3, 2017 the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: 1. E22 was terminated on January 30, 2017. 2. All staff will be inserviced on the Abuse Policy and procedure and on the need to follow those policies. The inservice included abuse prevention, the differences between grievances and reportable abuse allegations, reporting immediately all allegations of abuse, and review of the abuse policy and procedure. 3. The facility contacted all contract staff in writing notifying them any employee providing services inside the facility will be required to complete the education for the facility Abuse Prevention Program prior to delivering services. 4. All staff inlcuding new-hire employees will be inserviced prior to reporting to work. 5. Actions completed by Administrator and DON on April 2017: (a) 100% in-service education with facility staff on abuse policy and procedure. (b) 100% education given to new hires during orientation for all departments on the abuse policy and procedure including reporting. (C)Staff on vacation, leave of absence, and new hires will receive educatin prior to reporting to their area for work. 6. The QAPI Committee will meet monthly to review any infraction in following the facility abuse policy and procedure. 7. Interviews were conducted with staff members from all departments within the facility on May 3, 2017 to verify education/training was given as identified by the facility. 8. Schedules were monitored by the Administratror and all Department Heads to ensure employees received education and training prior to working.

Based on observation, interview, and record review the facility failed to assess and prevent the development of a left and a right heel ulcer. These failures resulted in R1 developing bilateral deep tissue injuries to the left and right heels. The facility also failed to implement treatments to promote healing for R2. This applies to 2 of 4 residents (R1 & R2) reviewed for pressure ulcers in the sample of 15. The findings include: 1. On 3/5/2015 at 9:25am, E15 (Licensed Practical Nurse) was changing R1's left and right heel dressings. E2 (Director of Nursing - DON) pointed to the yellow colored areas on R1's left and right heel wounds and stated, "this is slough." R1's right heel (lateral posterior area) and left heel (posterior area) both had slough covered deep tissue injury to of foot. On 3/4/2015 at 8:40am, R1 was lying in the bed on her left side. R1's heel protectors were on the floor next to the bed. On 3/4/2015 at 8:41am, E5 (certified nursing assistant - CNA) pulled back the blanket to expose R1's feet. R1 was wearing socks and her heels were resting on the mattress. E5 stated, "Heel protectors are used when the resident is up in the chair. We never put them on in the bed." On 3/4/2015 at 8:43am, E3 (Assistant Director of Nursing-ADON) said, "R1 needs heel protectors on when in bed." The MDS (Minimum Data Set) dated 8/21/14 shows R1 needs extensive assistance of 2 persons to move to and from a laying position, turning side to side, and for positioning her body while in bed. A blank Braden Scale for predicting pressure sore risk for R1 was presented by the facility on 3/5/2015. No Pressure Sore risk had been done by the facility. R1's Full Body assessment dated [DATE] shows there were no wounds present on the heels on admission. R1's Physician Telephone Orders dated 8/18/14 show, "Float heels while in bed." The Care Plan for R1 initiated 8/28/14 directs the certified nursing assistants to begin the use of "pressure reducing boots to bilateral feet when in bed and as needed to prevent pressure to heels." On 9/9/14 an intervention to float the heels off the bed was added. R1's nurse's notes dated 9/4/14 shows, " left heel has fluid filled blister 4.5cm x 3cm and (a) right heel blister, no fluid, 4.3cm x 4cm." R1's Wound Assessment Flow Sheet dated 9/6/14 shows a 4cm L (length) by 3cm W (width) by 0.3cm D (depth) wound, with a black wound base to the right heel. The Wound Assessment Flow Sheet dated 9/6/14 shows a 4cm L (length) by 3cm W (width) by 0.3cm D (depth) wound, with a black wound base to the right heel. The Wound Assessment Flow Sheet dated 9/14/14, shows a 9 L(length) 8 W(width) DTI (deep tissue injury), with an eschar (thick dark colored dead tissue) wound base to R1's left heel. R1's nurse's notes dated 9/5/14 show, "Per Z1 (Primary Physician) skin prep to bilateral heels every shift, float heels while in bed." The facility's Comprehensive Wound Program policy (undated) shows, "Any high risk resident or a resident with a wound will receive the appropriate pressure relieving devices as deemed appropriate by the facility, designated wound nurse and Director of nursing." On 03/05/15 at 1210pm, Z1 (Primary Physician) stated, "Heel protection should be used at all times. Heel protectors stop localized pressure." 2. The Minimum Data Set (MDS) of 7/17/14 shows R2 was admitted on [DATE] with the following Diagnoses: [REDACTED]. On 3/4/15 at 10:05 AM, E11 (Licensed Practical Nurse-LPN) applied skin prep and a foam dressing to the stage II pressure ulcer on R2's right buttocks. The open area measured 0.4 x 0.4 cm with light pink tissue. There was an area of reddened tissue around the open area that measured 4 x 5 cm. No drainage was present. On 3/3/15 at 10:05 AM, E11 stated she believes the open area "was due to shearing." The facility's Wound Documentation Sheet of 2/24/15 shows a skin shear to R2's right buttocks. The facility's Wound Assessment Flow Sheet dated 2/24/15 shows a stage II pressure ulcer to R2's upper right buttocks measuring 0.5 x 0.7 x 0.1 cm with no drainage present. The facility's Braden Scale Sheet (tool used for determining a resident's risk of pressure ulcer development) of 11/27/14 shows R2 had a Braden score of 12 (high risk). R2's Pressure Ulcer Care Plan of 2/24/15 shows R2 had a stage II pressure ulcer on his right coccyx area. Interventions included administering medications and treatments as ordered and monitoring for effectiveness, monitoring nutritional status, serving diet as ordered, and monitoring and recording intakes. The Dietary Recommendations for Physician Approval Sheet of 12/2/14 shows R2's Body Mass Index (BMI) was 16.3 and he had lost 16 pounds in 5 months. The sheet shows R2 had an [MEDICATION NAME] level of 3.0 (low) and had open wounds to the coccyx and heel areas. The Dietitian recommended adding Pro Stat (liquid protein) 30 ml twice daily, and an 8 ounce fortified shake (whole milk, ice cream and other nourishing ingredients) once daily. The Dietary Recommendation Sheet was agreed to by R2's Physician on 12/8/14. The Nutritional Assessment Consultant Sheet of 12/2/14 shows R2's was "considered a high nutrition risk and may benefit from additional high protein supplement to meet increased nutrient needs for wound healing." R2's Potential for Alteration in Skin Integrity Care Plan of 1/29/15 lists encouraging good nutrition and hydration in order to promote healthier skin as an intervention. The Physicians Order Sheets of 12/1/14 - 3/31/15 show Pro Stat 30 ml twice daily and an 8 ounce fortified shake daily was never initiated. On 3/5/15 at 10:55 AM, E11 (Licensed Practical Nurse-LPN) stated "I don't see the Dietitian recommendations written on the January and February Medication Administration Records (MARs). " The facility's February Meal Intake Sheet for R2 has 9 of 28 days filled out for the breakfast meal, 7 of 28 days filled out for the lunch meals and 3 of 28 days filled out for the supper meal. On 3/5/15 at 3:00 PM, E2 (DON) stated " The CNAs have not been filling out the intake sheets like they are supposed to. " The Minimum Data Set of 1/13/15 shows R2 is always incontinent of bowel and bladder.

A. Based on interview and record review, the facility neglected to follow their policy and procedure for Accident/Incident Occurrence and their policy on Resident Change in Condition for a resident after a fall. This neglect contributed to a 4 day delay in the identification and treatment of [REDACTED]. This applies to 1 of 6 residents, (R1), reviewed for falls in the sample of 34. The findings include: The facility's policy for Change in Condition, dated 3/5/12, states the licensed nursing staff will: "assess any changes noted through direct observation or through assigned staff...Chart in the nurses notes, assessment data, observations...physician should be updated at least daily, (for a minimum of 48 hours), of the resident's status, including any deterioration or improvement. The facility's policy Accident/Incident Occurrence, (Undated), shows "all accidents or incidents where there is injury or the potential to result in injury," should have interventions initiated. The policy shows all residents that having sustained an injury, or were involved in a fall, should be observed "closely for any change from normal habits that could be an indication that there is an injury not noticed or diagnosed during the initial assessment." R1's Minimum Data Set ((MDS) dated [DATE] identified R1 as being able to transfer and/or ambulate with one person limited physical assist. The MDS showed R1's balance as not steady but was able to stabilize without assist. An incident investigation dated 8/8/14 at 6:15 PM, shows R1 was "observed (on the floor), laying on her left side...with complaints of left knee pain." The nursing note of 8/8/14 at 6:30 PM, shows R1 was non-weight bearing which was not "her usual." The 8/9/14 nursing notes shows R1 was complaining of pain in her left hip when moved and exhibited a decrease in appetite by only eating "a few bites of meal." No nursing entries were made again until 8/11/14 at 12:00 PM which reads, "resident (R1) grabs at left leg when moved. The nursing note dated 8/11/14 at 4:00 PM, shows an order was obtained for an X-Ray of R1's left hip. The nursing note written on 8/11/14 at 5:50 PM documents an order was received to send R1 to the local hospital emergency department for evaluation and treatment. The nursing notes show R1 left the facility at 6:45 PM and was admitted to the local hospital with a [DIAGNOSES REDACTED]. The defination of a [MEDICAL CONDITION] is a "break in the upper quarter of the femur (thigh) bone. The Radiology report dated 8/11/14 at 5:26 PM, show R1 with an "acute left intertrochanteric fracture with a near 90 degree angualtion of the fracture fragments." R1 required surgical intervention on 8/12/14. On 9/5/14 between 10:35 AM and 2:20 PM, E3, E7, E9, and E11 Certified Nursing Assistant's (CNA's), stated they were aware of R1's fall. All stated they worked with R1 during the 4 days following the fall and noticed her decreased ability to bear weight and an onset of complaints of pain to her left hip area. All stated they reported these findings to the on duty nurses on a daily and every shift basis. On 9/11/14, E16 (RN) stated R1 "stayed in bed" and "complained of her (R1's) left leg hurting" on 8/9/14. E16 said, "E11 kept telling us, (nurses), (R1) was hurting badly." E16 said "E11 kept insisting R1 was complaining of left hip pain." E16 said, "we, (nurses), need to listen to the CNA's." E16 stated she did not document an assessment/re-assessment on R1 on 8/9/14 when E11 reported the complaints to her. E16 said she really didn't notice anything different because R1 has behaviors and sometimes just stays in bed. E16 stated assessments are to be completed and documented in the nursing notes every shift for 3 days following a fall. E16 said "I don't know why, I just didn't document it." E16 stated no new interventions were implemented for R1. E16 said R1 "gets anxious" and "refuses cares," so "I use the topical [MEDICATION NAME] ordered to decrease her (R1's) behaviors. It makes her more cooperative." The nursing notes between 8/8/14 and 8/11/14 show no treatment or interventions were implemented for R1. There was no additional pain medication ordered or given. There was no documentation of re-assessment of R1 despite her noted changes in condition (inability to bear weight, deformity of left leg, decreased in appetite and continual complaints of left hip/leg pain.) On 9/5/14 between 9:45 AM and 2:45 PM, E5, E7, E8, E9, and E11, (CNA's) were interviewed. All stated they do not feel the nursing staff takes their observations and concerns seriously when presented. All stated they feel there are many times when there are significant, (several days), delays in getting residents sent out for evaluations. On 9/11/14 at 11:50 AM, E19 (LPN) stated she was the nurse on duty when R1 fell on [DATE]. R1 was found on the floor on her left side. E19 stated she helped staff "roll R1 to her back and R1 complained of "pain to her left knee and began grabbing at it." E19 stated she didn't notice any shortening or rotation. E19 said R1 was uncooperative with a (mechanical lift) transfer which is the standard for lifting people following a fall. For this reason, E19 stated the staff used a 3 person assist to get her up into her wheelchair because she would not bear weight. E19 said she had the CNA's take R1 to her room and transfer her to the bed so "I could re-assess her." E19 said "She (R1) kept rubbing her left leg" but "I didn't see anything different, (besides not bearing weight)." E19 said she was off for the next 3 days but when she returned on Monday, 8/11/14, R1 was still "acting like something was hurting." E19 said because R1 was still hurting, "I called the doctor to get an order for [REDACTED]. B. Based on observation, interview and record review, the facility neglected to follow their policy and procedure for Accident/Incident Occurrences after an allegation of theft was reported. This neglect resulted in a cash loss of greater than $200.00 for R3, and the loss of personal property for R8, R9. This applies to 3 of 14 residents (R3, R8, R9 ) reviewed for neglect/theft in the sample of 25. The findings include: The facility's policy Accident/Incident Occurrence, (undated), states, interventions are to be initiated for "Allegations of mistreatment, neglect, or misappropriation of resident property registered by residents, visitors, or others." Incidents that "involve mistreatment, neglect, or abuse, injuries including injuries of unknown origin and misappropriation of resident funds . . . b) the facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the Investigation is in progress, c) the facility must ensure that any incident, related investigations, and corrective actions taken are reported immediately to the Administrator of the facility; and to other State Survey/licensing/certification officials in accordance with State Law, within 5 working days of the incident, utilizing established procedures." On 9/5/14 at 8:25 AM, R3 stated he has had money stolen from him on several occasions. R3 likes to have about $200.00 cash on hand to take family and/or friends out on the weekends. R3 said the facility provides the use of a locked dresser drawer in his room. R3 used to put his cash in his billfold and place it in the locked drawer in his room until he had the money stolen from his drawer. R3 stated he placed his billfold in his locked drawer and placed the drawer key in his trouser pocket. At bedtime, R3's trousers were hung in his closet with the key in the pocket. The next morning, the key was gone and so was the billfold and cash. R3 said he reported the theft of the theft of over $200.00 to the administrative personnel. R3 was not aware of any investigation or any efforts made to locate the missing money. R3 was told that he could place his money in the front office to be locked up. R3 expressed concerns that if he were to use the front office lock up, he would not be able to have access to his money from Friday evening until Monday. R3 added, "the missing key" to his locked drawer "mysteriously returned" to his room several days later. R3 said, with no other options, he began placing his cash in a "waterproof" envelope and taping it to his abdomen. R3 said this method seemed to be working until recently, (7/18/14). R3 shared that while he was in the shower, (on 7/18/14), "the envelope had at least $200.00" and it "disappeared" from the seat of his walker. R3 stated when he undressed, he placed the envelope on the seat of his walker and covered the envelope with paper napkins. R3 was able to give details of the events that occurred during the shower and verbalized his belief that it was taken by E4 (CNA). R3 reported the money missing. R3 said "this time they must have called the local sheriff's department because they showed up." On 9/12/14 at 10:25 AM, R3 stated he has money stolen at 3-4 month intervals. R3 said, "I keep telling them and reporting it but it keeps happening. Will you be able to keep this from happening to others here?" On 9/5/14 at 12:35 PM, E8 (CNA) stated, on 7/18/14, after lunch, R3 was to be given a shower. E8 asked E4 to sit with R3 while she obtained some clean clothes from his room. Upon returning to the shower room, E8 said E4 had already showered R3 and was drying him off. E8 said E4 "left the shower room when I returned." E8 said 30-45 minutes later, R3 returned to the shower room stating his money/envelope was missing. R3 lost more than $200.00 with the event of 7/18/14. Grievance logs for the past 3 months showed R8, R9 and R25 all reported personal items missing with no investigation initiated/completed and no alternatives for protection of personal property provided. The investigation file for the allegation of theft dated 7/18/14 showed no resident interviews were conducted. No report was submitted to the Public Health Department and no further interventions were implemented/offered to ensure the safety of R3's money in the future. On 9/5/14 at 1:30 PM, E1 (Administrator) stated a summary of the investigation for 7/18/14 was not completed until today, (9/5/14), by E12 (Human Resources). This report was written 7 weeks after the allegation was initially reported. All investigations completed and submitted to the Department of Public Health from February 2014 to the present, (7 months) were reviewed. There were no allegations of theft investigated by the facility or reported to the Public Health Department. Between 9/5/14 and 9/12/14, interviews were conducted with E1, E2 (Acting Director of Nursing), E3, E6, E7, E8, E9, E11 (CNA's), and E27 Licensed Practical Nurse (LPN). All stated they were aware R3 had issues with money stolen/missing over the course of his stay. All stated there had been allegations of theft in the past. All were aware that R3 was taping the money to his abdomen in an effort to prevent future loss/theft.

Based on interview and record review, the facility failed to provide the necessary care and services by not re-assessing and providing treatment for [REDACTED]. The facility also failed to assess a residents need for pain management. These failures contributed to R1 not obtaining pain medication or evaluation and treatment for [REDACTED]. This applies to 1 of 6 residents (R1) reviewed for falls in the sample of 34. The findings include: R1 has [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identifies R1 as being able to transfer and/or ambulate with one person limited physical assist. The MDS showed R1's balance as not steady but able to stabilize without assist. On 9/5/14 at 2:00 PM, E9, Certified Nursing Assistant (CNA), stated she (E9) "heard" R1 fall on 8/8/14, on the second shift. E9 said R1 was sitting on the floor in front of her wheelchair. E9 said "I could tell something was wrong because she, (R1) didn't bear any weight when I picked her up and she usually walks." E9 said R1 was complaining of pain while E9 was rolling her in the wheelchair down the hall to her room. E9 said R1 can be difficult to understand because R1 speaks several languages, but R1 was "clearly" complaining of pain. (R1's care plan of 7/14/14 showed R1 does speak multiple languages.) On 9/5/14 at 10:35 AM, E3 (CNA) stated she and E7 (CNA) worked with R1 on 8/11/14. E3 stated R1 was non-weight bearing at that time which is not "her usual." E3 stated E7 had told her she was aware of R1's decline in condition and had been reporting those changes to the nursing staff for the past two days. E3 stated she went with E7 to report it again on 8/11/14. On 9/5/14 at 11:00 AM, E7 stated she was aware of R1's fall. E7 said it took the facility (nurses) "about a week" to send her out to get checked. E7 said she is unaware of why it took so long but that the "nurses just don't listen to the CNA's." E7 said "I told them I thought she, (R1) had a fracture because she would not bear weight and was walking prior to her fall." E7 said she reported it daily until R1 was sent out. On 9/5/14 at 12:35 PM, E8 (CNA) stated she worked the day after R1 fell , (8/9/14). E8 stated she reported to the nurse on duty that R1 was not "acting right." E8 said R1 refused to get out of bed and her left leg was "bowed out." E8 stated she was unaware of when R1 was sent to the hospital for evaluation and treatment but is aware it was longer than two days because she reported R1's change in condition for two days. On 9/5/14 at 2:20 PM, E11 (CNA) stated she worked 4 evenings in a row starting the night R1 fell . E11 stated she began her routine bed checks when she noticed "a large bump on (R1's) left leg, it was rotated out and when I went to touch it she yelled out in pain." E11 stated she had E26 (Wound Nurse) come to R1's room to assess it. E11 said E26 looked at it, stated "It's not broken." and left the room. E11 said the CNA's were "pad rolling" R1 because she was in "excruciating pain" when moved. E11 stated she also reported her concerns related to R1's change in condition to E16 Registered Nurse, (RN), and E27 LPN. E11 said it was 4 days after R1's fall before she (R1) was given an X-Ray and sent out for treatment. On 9/11/14, E16 (RN) stated R1, "stayed in bed" and "complained of her (R1's) left leg hurting" on 8/9/14 and 8/10/14. E16 said, "E11 kept telling us, (nurses), (R1) was hurting badly." E16 said "E11 kept insisting R1 was complaining of left hip pain." E16 said, "we, (nurses), need to listen to the CNA's." E16 stated she did not document an assessment/re-assessment on R1 when E11 reported the complaints to her. E16 said she "really didn't notice anything different" because R1 "has behaviors and sometimes just stays in bed." E16 stated assessments are to be completed and documented in the nursing notes every shift for 3 days following a fall. E16 said she "I don't know why, I just didn't document it." E16 stated no new interventions were implemented for R1 after her fall. E16 said R1 "gets anxious" and "refuses cares," so "I use the topical [MEDICATION NAME] ordered to decrease her (R1's) behaviors. It makes her more cooperative." The nursing notes between 8/8/14 and 8/11/14 verify no treatment nor interventions were implemented for R1. There was no additional pain medication ordered or given. There was no documentation of re-assessment of R1 despite her noted changes in condition (inability to bear weight, deformity of left leg, decreased in appetite and continual complaints of left hip/leg pain.) On 9/5/14 between 9:45 AM and 2:45 PM, E5, E7, E8, E9, and E11, (CNA's) were interviewed. All stated they do not feel the nursing staff takes their observations and concerns seriously when presented. All stated they feel there are many times when there are significant, (several days), delays in getting residents sent out for evaluations. On 9/11/14 at 11:50 AM, E19 (LPN) stated she was the nurse on duty when R1 fell on [DATE]. E19 said R1 was "found on the floor on her left side." E19 stated she helped staff "roll R1 to her back." E19 said R1 complained of "pain to her left knee and began grabbing at it." E19 stated she didn't notice any shortening or rotation. E19 said R1 was "uncooperative with a (mechanical lift) transfer" which is the facility practice for lifting people following a fall. E19 stated the staff used a "3 person assist" to get her, (R1) up into her wheelchair because she, (R1) would not bear weight. E16 said she told the CNA's to take R1 to her room and transfer her to the bed so "I could re-assess her." E16 said "She (R1) kept rubbing her left leg" but "I didn't see anything different, (besides not bearing weight)." E16 said she was off for the next 3 days but when she returned on Monday, 8/11/14, R1 was still "acting like something was hurting." E16 said because R1 was still hurting, "I called the doctor to get an order for [REDACTED]. An incident investigation dated 8/8/14 at 6:15 PM, documented R1 was "observed (on the floor), laying on her left side...with complaints of left knee pain." The nursing note of 8/8/14 at 6:30 PM, described R1 as currently non-weight bearing, (a change in resident's condition.) The 8/9/14 nursing note showed R1 was complaining of "pain in her left hip when moved" and exhibited a decrease in appetite by only eating "a few bites of meal." There were no other entries made until 8/11/14 at 12:00 PM which read, "resident (R1) grabs at left leg when moved." The nursing note dated 8/11/14 at 4:00 PM, shows an order for [REDACTED]. The nursing notes show R1 left the facility at 6:45 PM and was admitted to the local hospital with a [DIAGNOSES REDACTED]. The defination of a [MEDICAL CONDITION] is a break in the upper quarter of the femur (thigh) bone. The Radiology report dated 8/11/14 at 5:26 PM, showed R1 with an "acute left intertrochanteric fracture with a near 90 degree angulation of the fracture fragments." R1 required surgical intervention on 8/12/14. The facility's policy for Change in Condition, dated 3/5/12, states the licensed nursing staff will: "assess any changes noted through direct observation or through assigned staff...Chart in the nurses notes, assessment data, observations...physician should be updated at least daily, (for a minimum of 48 hours), of the resident's status, including any deterioration or improvement. The facility's policy Accident/Incident Occurrence, (Undated), shows "all accidents or incidents where there is injury or the potential to result in injury," should have interventions initiated. The policy shows all residents that having sustained an injury, or were involved in a fall, should be observed "closely for any change from normal habits that could be an indication that there is an injury not noticed or diagnosed during the initial assessment."

Based on observation, interview and record review the facility failed to supervise a confused resident at risk for elopement. The facility also failed to ensure that her personal alarm device was functional. These failures resulted in R1 exiting the facility on 10/5/13, walking approximately 4 miles, falling and sustaining a fractured right hand. This applies to 1 of 3 residents (R1) reviewed for wandering/elopement in a sample of 3. The findings include: The Minimum Data Set of 5/2/13 shows that R1 has [DIAGNOSES REDACTED]. This same document shows that R1 has a Brief Interview for Mental Status score of 7 (Severe cognitive impairment). R1's Elopement Risk assessment dated [DATE] shows that R1 scored a 6 (at risk). The Nurse's Notes (NN) dated 7/26/13 state, "North door safety alarm sounding- upon investigation found (R1) outside assisted one to one staff brought (R1) back in facility. Cooperative stated she needed to go to bed wanting to go home..." The NN dated 8/29/13 states, "Went out C wing door with CNA behind her in the rain." The NN dated 9/20/13 states, "Resident found in wrong room after supper." The NN dated 9/23/13 states, "Resident found walking out the door..." The NN dated 10/5/13 states ,"Noted to scratches to leg bilaterally, CNA states (R1) went out the door early before shift change and was in the garden, leg scratches from brush...." The NN dated 10/5/13 states, "(DON) and (Administrator) at ER. Resident alert and oriented to name only. Resident stated, 'I was headed home.' " The Physician's Progress note dated 5/25/13 states, "Episodes of trying to leave facility and anger. Doesn't understand complexity of her health issues." The Physician's Progress note dated 8/10/13 states, "Pleasantly confused. Wants to go home. Doesn't know month or year." The facility Preliminary 24-hour Incident Investigation Report states, "On 10/5/13 at approximately 8:40 AM, (R1's) nurse was unable to locate resident. Code Violet (missing person) called. At approximately 9:30 AM entire facility and grounds searched and unable to locate (R1) 911 notified of missing resident. POA notified. At 9:45 AM facility notified (R1) was located and enroute to (local hospital) ER. X-ray positive for right hand fracture. (R1) admitted to (local hospital)." This same document also states, "Swelling to nose, lip and right hand." On 10/8/13 at 1:30 PM, E1 (Administrator) stated, "On 10/5/13 I got a call about 9:30 AM to say that (R1) was missing. She was found on Stagecoach Trail close to Main St and 5 Points- about 2 miles from the facility. A person in the community had seen her walking on the road and called the police. The police called the ambulance and she was taken to (local hospital). She was last seen between 8:15 and 8:30 AM. (R1) is extremely mobile. She does not use any assistive devices. We found out later that (Z3-visitor) said that she followed him out the door when he left the faciity on Saturday. He didn't tell anyone." On 10/8/13 at 3:30 PM, E3(RN) stated, "(R1) is always up and ready for breakfast. When I saw her she was sitting at the nurse's station, then she went into the dining room. I went to the dining room to pass medication. I passed medications to 2 or 3 other residents then I poured her medication but I put it aside because she had already left the dining room. I passed a few more then I got called away because another resident fell down the hall. I spent about 20 minutes down there. As I was walking out someone asked me if I had seen (R1). I asked (E7-LPN) if she had seen (R1). I told the CNA to go look for her. I called a Code Violet, I called the DON, and called 911, we looked everywhere. A CNA even got in her car and went up to the dollar store. About 10 minutes later the Policemen came in and said, 'I think we know where (R1) is.' I called the ER to make sure it was her. I have no idea how she got out." On 10/8/13 at 3:10 PM, E5(LPN) stated, "R1's (monitoring bracelet)) is attached to her ankle. The alarm should go off if she is within so many feet of the door. (To turn it off) the code must be entered. Most staff know the code. If it is entered wrong then the alarm gets louder. No alarms were heard on Saturday. I heard she went out the front door by the office. We tested all the other (monitoring bracelets) that afternoon. The door worked for some but not for others." On 10/8/13 at 1:45 PM, E7(LPN) stated, "(R1) wants to get out the front door all the time. At least a few times a week tries to get out." On 10/8/13 at 1:55 PM, E9(CNA) stated, "(R1) is very confused. Everyday she is packing her stuff. She tries to get out a couple times a week." On 10/9/13 at 10:00 AM, E13(CNA) stated, "They said the (monitoring) system wasn't working because it didn't go off. (R1) always wants to go home. She goes to any door. It takes a lot of convincing to get her back in. She is so headstrong." On 10/9/13 at 10:45 AM, Z3 (Visitor) stated, "I walked out to my truck. When I looked back , she had walked out behind me. She stopped at the bench and sat down. Then I saw her walking down the highway. No alarms went off when I went out the door. I call her the "uptown girl" because she is always walking around here with all her stuff. This was the first time I had seen her outside. I knew she had an alarm on but it just didn't dawn on me. The light didn't go on (in my head) to say she shouldn't be outside." On 10/8/13 at 3:10 PM, when asked how she hurt her arm, R1 stated, "I fell off the back-end of Albert M.'s trailer. He was coming out around the other side of the Catholic Cemetery and he took the turn too sharp and I went flying. " On 10/9/13 at 9:00 AM, Z1(Police Chief) stated, "A passerby found her, saw her fall and called 911. About 1 mile out of town. It is a County Highway so the speed limit is 55 mph. The Officer went and the ambulance came right after. I was on vacation and the Officer that responded is on vacation this week so I can't talk to him. The (local) ambulance transported her so they would know more." The Police Report dated 10/5/13 states, "Officer was dispatched to the area of Main Street Rd and 5 Corners Rd for a female subject walking that had fallen. Upon arrival I met (R1). (R1) had blood on her face and hands that she had stated was from falling. I requested that (local) Ambulance respond to the scene. As I spoke with (R1) some of her answers didn't make sense. I saw what appeared to be a medical alert bracelet on her ankle. (R1) advised that she had gotten that from the (local) fair, and they gave everyone a bracelet on her ankle. (R1) was also not able to remember the year she was born. (Local) ambulance arrived on scene and transported (R1) to (Local ) hospital. I gave dispatch the family contact information that (R1) had given me and requested dispatch to notify them of the situation. Approximately 20 minutes later I was dispatched to (facility) for a resident that had wandered off. Upon arrival I discovered that (R1) was the resident that had wandered off. I advised staff where I had found her and that she had been sent to (local) hospital. The staff at the nursing home advised that they would call her family and the hospital to notify them." On 10/9/13 at 9:15AM, Z2 (Paramedic) stated, "She told me her name. She knew her birth date but not the year. She wasn't sure how old she was. I didn't think she was from the nursing home. She looked like anyone else out for a walk. She said she walks everyday between (2 local towns). She knew her address in (neighboring town). She convinced me that she knew where she was. She had blood on her nose and an abrasion. Had been bleeding from the mouth but it had stopped. I could tell she had fallen. I was thankful she didn't wander into a cornfield- we would still be looking for her. She knew her brother and sister-in-law but she told me she was [AGE] years old. She even had the nurses at the hospital convinced that she knew what she was talking about." The Pre-hospital Care Report Sheet (Paramedic Run Sheet) dated 10/5/13 states, "Called for reported unknown problem/man down at W. Main St at Crossroads in the city of (--). On arrival, found a [AGE] year old female patient weighing 45 kg. Chief complaint of facial injuries..... Upon arrival we found a [AGE] year old woman who was walking and fell in the wet grass. At 9:08 AM, the patient was found sitting in the back of the squad car. Initial assessment revealed the patient had a GCS of 15 (Eye=4, Verbal=5, Motor=6) with VS of 127/909,, P-100 and R-18. Other significant physical exam findings: Pt had a small laceration on her nose and bleeding from her mouth which had stopped.... We discovered that woman had escaped the (facility) and was walking home to (neighboring town)." The hospital Progress Note/ Chief Complaint/ History of Present Illness dated 10/5/13 states, "The patient "escaped" from the nursing home. While walking on the road, she fell into the ditch after a truck went by her and she states she sustained some bruises and abrasions." The hospital History and Physical dated 10/5/13 states, "(R1) reports that she was walking down the road and she was enjoying herself because she really loves walking. She was walking along the road side. She noticed that there were 2 cars coming. There was a truck trying to get in ahead of those 2 cars. It swerved rapidly in front of them and in the process she thought that she was brushed and knocked into the ditch." The hospital X-Ray Report dated 10/5/13 states, "Mildly displaced comminuted fracture of the fifth metacarpal." R1's Treatment Flow Sheets dated 7/2013, 8/2013, 9/2013 do not show any monitoring for functionality or positioning of R1's alert system bracelet. The 10/2013 Treatment Sheet states, "Check (Alert System) for placement." On 10/9/13 at 11:05 AM, E2 (DON) stated, "Before this month there were some people that only had 'check placement' and not 'check function' on the treatment records. I audited and now they all have both. The nurses should check the function (of the Alert System) every night." The undated facility policy entitled Code Alert Policy/Procedure states, "Nurse will write the order on the physician's orders [REDACTED]."

Based on observation, interview, and record review the facility failed to supervise and have fall prevention interventions for 2 residents (R4 and R1) at high risk for falls. This failure resulted in R4 sustaining a fractured left hip on 8/4/13 and a fractured right hip on 8/27/2013. Both fractures required surgical repair. This applies to 2 of 4 residents (R1 & R4) reviewed for accidents and supervision in the sample of 4. The findings include: 1. R4 was initially admitted to the facility on [DATE], from the hospital (face sheet). She was admitted with a fractured left femur and subsequent status [REDACTED]. R4 ' s Minimum Data Set of 6/27/13, documents R4 has cognitive impairment. She requires extensive assistance with transferring, dressing, and bathing/hygiene. R4 doesn ' t ambulate. Her [DIAGNOSES REDACTED]. The careplan does not have interventions showing how the facility will supervise R4, or protect her from falls. A facility incident report dated 8/4/2013 at 5:05 AM, shows R4 was found on the floor of her room, with the personal alarm sounding. A hospital history and physical report documents R4 was admitted , from the facility, to the hospital with a fractured left hip on 8/4/2013. An undated surgical report documents, R4 underwent a left hip pinning. E4 was readmitted to the facility on [DATE] with non-weight bearing orders for the left lower extremity, according to the POS (same date). The facility Incident Investigation documents R4 was found on the floor of the living room, in front of the television, on 8/27/2013, at 8:30 PM. The investigation states R4's pressure alarm was sounding. The report shows one of R4' s fall interventions was to be placed in a high visual area. On 8/29/2013 at 8:45 AM, E2 (Director of Nursing) stated the fall was not witnessed by staff. E2 said R4 was watching television in the living room. She said R4 was to be in a highly visual area when out of bed. The area of R4 ' s fall could not be visualized from the nursing desk. There is a wall blocking the living room from the nurse ' s desk. E2 said R4 told the 2 Certified Nursing Assistants (E5 & E7) on 8/27/13, " I am sick of television. I just want to go home. " E2 said the resident was sent to the hospital and was diagnosed with [REDACTED]. E2 said the resident is scheduled for repair of the right hip today (8/29/2013). 2. R1 ' s [DIAGNOSES REDACTED]. The fall Risk Assessment of 5/23/13 shows R1 is at high risk for falls. She has intermittent confusion, several falls in the past 3 months, poor balance, requires use of an assistive device, and takes narcotics and diuretics. A facsimile of 12/4/2012 (sent to Z4) documents R1 had 2 falls on 12/3/2012. The reason stated for the falls is R1 gets up without using the call light. Hospital physician discharge orders document R1 was in the hospital from 8/8 to 8/12/2013. The Emergency Department physician documentation of 8/4/2013, states, " Apparently fell at nursing home yesterday, and today complains of pain upper mid back and right hip ...very poor historian ...status [REDACTED]. " A Nursing Note of 8/23/2013 at 1:20 AM, states, " Resident fell on bathroom floor. Two nodules noted on both temporals. Complained of left shoulder pain. Range of motion performed and within normal limits. All Neuro within normal limits. Power of Attorney called and doctor faxed. " On 8/23/2013 at 6:30 AM, nurses notes show R1 ' s POA was called regarding her increasingly swollen left eye and extensive facial bruising. Nursing Notes from 8/23 to 8/25/2013 shows R1 complained of a headache. The resident ' s injuries were described as bruising to both eyes and forehead. A large hematoma is above her left eye. There is no documentation showing Z4 was notified of R1 ' s complaints of a headache and the extensive bruising. A hospital Emergency Department Record of 8/25/2013 documents, " Evaluation in the emergency room revealed a pleasant and generally alert [AGE] year old white female who had already developed raccoon eyes. She had without exaggeration a golf ball size hematoma over her left eye. Both eyes were virtually swollen shut due to edema and ecchymosis. The ecchymosis was extending down onto her cheeks and into the neck. Workup revealed she had and INR of 10 (high clotting time) ... " The documentation shows R1 was admitted to the hospital for treatment of [REDACTED]. A 6/6/2013 Negotiated Risk Contract documents R1 needs a bed/chair alarm because she won ' t use the call light when she needs assistance. A care plan initiated on 6/11/2012 states R1 is at risk for injury due to her medications, falls and pain. On 12/4/2012, the care plan states, " Chooses not to use call light to get assistance, often refuses to participate in restorative programs. " The care plan has not been updated with new interventions after each fall, in an attempt to prevent R1 from falling. The care plan shows R1 is on the high risk fall program. The interventions include request urinalysis and speech therapy, frequent checks, encourage participation in restorative programs, administer medications as ordered, involve in groups and activities of interest for diversion and added supervision, observe safety practices - offer reasonable solutions and/or redirection, encourage to do as much as possible for self on a daily basis, and remind resident to ask for assistance if feeling poorly or unsteady. There is nothing on the care plan regarding the resident requiring a personal alarm. On 8/27/2013 at 2:30 PM, E7 (Certified Nursing Assistant) said she has never seen an alarm on R1. On 8/27/2013 at 1:30 PM, R1 returned to the facility. She was in bed. The resident had extensive bruising on her entire face spreading down her neck. She had a very large hematoma on the left side of her forehead. The bruises were of varying color, from deep purple to yellow. R1 states, " I don ' t feel very good. " The facility ' s Qualified High Risk Program (undated) states the purpose of the policy and procedure (P & P) is to keep residents as safe as possible. The P & P states, " ... Each fall will be reviewed by the IDT (Interdisciplinary Team) at the daily QA meeting. An investigation will be conducted to ascertain what may have caused the fall ...From this investigation - resident specific interventions will be put into place ...Each time a resident has an additional fall - further documentation including new interventions will be implemented / modified if the root cause cannot be determined ... "

Based on interview and record review the facility neglected to have a policy and procedure related to staff interventions when a resident expresses suicidal ideation or threats of self harm. The facility also neglected to have a policy and procedure in place for the storage/use of disposable razors. These failures contributed to R1 lacerating his wrists with a modified disposable razor on 8/17/11. An Immediate Jeopardy was identified on 8/31/11. The Immediate Jeopardy began on 7/25/11 at 7:30 PM when R1 scratched his hand causing a skin tear and expressed a desire to die. While the immediacy was removed on 8/31/11 the facility remains out of compliance at a severity level two. Additional time is needed to monitor and evaluate the effectiveness of the training and education of the staff and the policy and procedure implementation. This applies to 1 of 35 residents (R1) reviewed for depression and self harm in a sample of 35. The findings include: R1's Nurse's Notes dated 7/25/11 at 7:30 PM state, "Nurse entered room found skin tear on resident's left hand. Asked resident what happened. Resident stated, "I have nothing to live for, I want to die. I scratched myself." resident very depressed and tearful. Cleansed skin tear and applied steri strips. 1.5 cm long. No complaints of discomfort. Sat with resident for a bit to cheer up. Medication given without difficulty. Requested Tylenol to help relax. POA (Power of Attorney) aware. Attempted to call on-call doctor, left message x 3. No return call. Fax written for Z3." On 8/29/11 at 10:30 AM, E3 (Life Enrichment Coordinator) stated, "I talked to him the next day and he didn't remember a thing. He denied saying anything. So I put him on 72 hour monitoring " E3 described 72 hour monitoring as resident interviews at random times throughout the 72 hour period. E3 was asked if the 72 hour monitoring was part of the facility policy related to residents with suicidal ideation. E3 stated, "It is just what I do. There may be a policy, I don't know. I just take it as it comes. I've only been here about 1 year." E3 was asked to describe R1's cognitive status on admission. E3 stated, "He had the start of dementia. His cognitive status varied. He would say, 'That is what happens when you get old.' He knew his dementia was setting in but seemed okay with it." E3 was asked what her qualifications were for her position. E3 stated, "I have a high school diploma and some college. I have a consultant that comes 1 x a month." R1's medical record shows that R1 was seen by Z2 (Social Work Consultant) on 8/12/11. E3 stated, "If I have any concerns I can call her. I don't believe I called her after (the incident) on 7/25/11." The Nurse's Notes dated 8/17/11 state, "Found resident in bathroom sitting in wheelchair with multiple cut marks to bilateral wrists. Floor covered with blood. Made statement, "Just let me go." Immediately got another nurse to assist with bleeding. Received order to transfer resident to (Hospital) for psych eval and possible admission. Wife and POA notified." On 8/29/11 at 1:00 PM, the facility was asked if they had a policy regarding residents that elicit [MEDICAL CONDITION] and a policy regarding the storage/use of disposable razors. E1 (Administrator) replied, "Common Sense." The facility provided a copy of an undated policy entitled : Protocol for Handling Behavioral Emergencies. This policy does not address procedures for residents who inflict self harm or who express [MEDICAL CONDITION]. On 8/29/11 at 3:00 PM, E1 confirmed that the facility does not have a policy regarding the storage/use of disposable razors. On 8/31/11 at 9:30 AM, E1, the facility Administrator was notified of the Immediate Jeopardy related to R1's self- injurious behaviors and lack of facility intervention. Through observation, interview and record review the surveyor confirmed that the facility took the following actions to remove the Immediacy: 1. On 8/17/11 at 5:00 PM all nursing staff completed an in house audit to remove any resident personal items that could be a safety concern to residents. 2. From 8/18/11 through present, QA audits are being completed daily to ensure the safety of the residents. 3. No safety razors are allowed in the facility effective 8/18/11. All families were notified of the change. 4. On 8/18/11 Inservicing was done as follows: -(A new) Policy and Procedure for Handling Self Harm Behavior was initiated and inserviced to staff by (Z2) Consultant on 8/18/11. - Policy and Procedure for Safety of Residents when Shaving was initiated and inserviced on 8/18/11. - [MEDICAL CONDITION] Meds/Hot Rack - Mood Changes/ MD Notification 5. On admission each resident will be assessed for negative behaviors and [MEDICAL CONDITION]. MDS Data collection tool will be completed in the first 72 hours. New residents will have safety alarm and checked on every 15 minutes during the first 72 hour period. If there are any negative statements/[MEDICAL CONDITION] staff will per policy immediately place resident on 1:1's and notify Director of Nursing, Administrator and physician for referral for psych eval. 6. Each day in morning meeting, behaviors will be discussed to ensure that appropriate interventions are implemented, care planning has been completed. The resident with the behavior will be placed on hot rack charting for 72 hours to ensure proper documentation/monitoring of the behavior. All residents with behaviors will be referred to the in house psychologist who visits weekly. 7. All behavior interventions will be added to the staff communication book for staff to review and sign off on. Based on interview and record review the facility neglected to have a policy and procedure related to staff interventions when a resident expresses suicidal ideation or threats of self harm. The facility also neglected to have a policy and procedure in place for the storage/use of disposable razors. This failure resulted in an Immediate Jeopardy which began on 7/25/11 at 7:30 PM when R1 scratched his hand causing a skin tear and expressed a desire to die. The Immediate Jeopardy was identified on 8/31/11. While the immediacy was removed on 8/31/11 the facility remains out of compliance at a severity level two. Additional time is needed to monitor and evaluate the effectiveness of the training and education of the staff and the policy and procedure implementation. This applies to 1 of 35 residents (R1) reviewed for depression and self harm in a sample of 35. R1's Nurse's Notes dated 7/25/11 at 7:30 PM state, "Nurse entered room found skin tear on resident's left hand. Asked resident what happened. Resident stated, "I have nothing to live for, I want to die. I scratched myself." resident very depressed and tearful. Cleansed skin tear and applied steri strips. 1.5 cm long. No complaints of discomfort. Sat with resident for a bit to cheer up. Medication given without difficulty. Requested Tylenol to help relax. POA (Power of Attorney) aware. Attempted to call on-call doctor, left message x 3. No return call. Fax written for Z3." On 8/29/11 at 10:30 AM, E3 (Life Enrichment Coordinator) stated, "I talked to him the next day and he didn't remember a thing. He denied saying anything. So I put him on 72 hour monitoring " E3 described 72 hour monitoring as resident interviews at random times throughout the 72 hour period. E3 was asked if the 72 hour monitoring was part of the facility policy related to residents with suicidal ideation. E3 stated, "It is just what I do. There may be a policy, I don't know. I just take it as it comes. I've only been here about 1 year." The Nurse's Notes dated 8/17/11 state, "Found resident in bathroom sitting in wheelchair with multiple cut marks to bilateral wrists. Floor covered with blood. Made statement, "Just let me go." Immediately got another nurse to assist with bleeding. Received order to transfer resident to (Hospital) for psych eval and possible admission. Wife and POA notified." On 8/29/11 at 1:00 PM, the facility was asked if they had a policy regarding residents that elicit [MEDICAL CONDITION] and a policy regarding the storage/use of disposable razors. E1 (Administrator) replied, "Common Sense." The facility provided a copy of an undated policy entitled : Protocol for Handling Behavioral Emergencies. This policy does not address procedures for residents who inflict self harm or who express [MEDICAL CONDITION]. On 8/29/11 at 3:00 PM, E1 confirmed that the facility does not have a policy regarding the storage/use of disposable razors. On 8/31/11 at 9:30 AM, E1, the facility Administrator was notified of the Immediate Jeopardy related to R1's self- injurious behaviors and lack of facility intervention. Through observation, interview and record review the surveyor confirmed that the facility took the following actions to remove the Immediacy: 1. On 8/17/11 at 5:00 PM all nursing staff completed an in house audit to remove any resident personal items that could be a safety concern to residents. 2. From 8/18/11 through present, QA audits are being completed daily to ensure the safety of the residents. 3. No safety razors are allowed in the facility effective 8/18/11. All families were notified of the change. 4. On 8/18/11 Inservicing was done as follows: - Policy and Procedure for Handling Self Harm Behavior was initiated and inserviced to staff by (Z2) Consultant on 8/18/11. - Policy and Procedure for Safety of Residents when Shaving was initiated and inserviced on 8/18/11. - [MEDICAL CONDITION] Meds/Hot Rack - Mood Changes/ MD Notification 5. On admission each resident will be assessed for negative behaviors and [MEDICAL CONDITION]. MDS Data collection tool will be completed in the first 72 hours. New residents will have safety alarm and checked on every 15 minutes during the first 72 hour period. If there are any negative statements/[MEDICAL CONDITION] staff will per policy immediately place resident on 1:1's and notify Director of Nursing, Administrator and physician for referral for psych eval. 6. Each day in morning meeting, behaviors will be discussed to ensure that appropriate interventions are implemented, care planning has been completed. The resident with the behavior will be placed on hot rack charting for 72 hours to ensure proper documentation/monitoring of the behavior. All residents with behaviors will be referred to the in house psychologist who visits weekly. 7. All behavior interventions will be added to the staff communication book for staff to review and sign off on.

Based on interview and record review the facility failed to ensure that a newly admitted resident who expressed a lack of interest in life and a desire to die received psychosocial interventions to assist with his adjustment to a change in his life circumstances. This failure resulted in R1 lacerating his wrists with a disposable razor on 8/17/11. An Immediate Jeopardy was identified on 8/31/11. The Immediate Jeopardy began on 7/25/11 at 7:30 PM when R1 scratched his hand causing a skin tear, expressed a desire to die and stated that he had nothing to live for. While the immediacy was removed on 8/31/11 the facility remains out of compliance at a severity level two. Additional time is needed to monitor and evaluate the effectiveness of the training and education of the staff and the policy and procedure implementation. This applies to 1 of 35 residents (R1) reviewed for depression and suicidal ideation in a sample of 35. The findings include: The physician's orders [REDACTED]. The POS also shows that R1 is ordered to take [MEDICATION NAME] (Antidepressant) 30 mg Every Night. The Minimum Data Set of 7/29/11 shows that R1 has a Cognitive Score of 10 (Moderate Impairment.) The Nurse's Notes dated 7/25/11 at 7:30 PM state, "Nurse entered room found skin tear on resident's left hand. Asked resident what happened. Resident stated, 'I have nothing to live for, I want to die. I scratched myself.'. Resident very depressed and tearful. Cleansed skin tear and applied steri strips. 1.5 cm long. No complaints of discomfort. Sat with resident for a bit to cheer up. Medication given without difficulty. Requested Tylenol to help relax. POA (Power of Attorney) aware. Attempted to call on-call doctor, left message x 3. No return call. Fax written for Z3." On 8/29/11 at 10:30 AM, E3 (Life Enrichment Coordinator) stated, "I talked to him the next day and he didn't remember a thing. He denied saying anything. So I put him on 72 hour monitoring " E3 described 72 hour monitoring as resident interviews at random times throughout the 72 hour period. E3 was asked if the 72 hour monitoring was part of the facility policy related to residents with suicidal ideation. E3 stated, "It is just what I do. There may be a policy, I don't know. I just take it as it comes. I've only been here about 1 year." E3 was asked to describe R1's cognitive status on admission. E3 stated, "He had the start of dementia. His cognitive status varied. He would say, 'That is what happens when you get old.' He knew his dementia was setting in but seemed okay with it." E3 was asked what her qualifications were for her position. E3 stated, "I have a high school diploma and some college. I have a consultant that comes 1 x a month." R1's medical record shows that R1 was seen by Z2 (Social Work Consultant) on 8/12/11. E3 stated, "If I have any concerns I can call her. I don't believe I called her after (the incident) on 7/25/11." E3's Interdisciplinary Progress Note dated 7/26/11 at 11:00 AM states, "Spoke with resident. No concerns/complaints at this time. Writer addressed resident regarding incident that occurred last night and in which resident stated, "I have nothing to live for, I want to die. I scratched myself." Resident denied making statements. Resident has [DIAGNOSES REDACTED]." The Social Service Progress Notes dated 7/29/11 state, "(R1) was admitted from (hospital) for therapies following a fall and a [MEDICAL CONDITION]. He is alert and oriented x 1-2 with some confusion and forgetfulness. He has good memory recall of past events and a poor memory recall of present events. He is able to make his wants and needs known and can understand and respond to others, although not generally appropriately. He has not exhibited any mood or behavior problems to contend with and takes his meal in the dining room." On 8/29/11 at 12:00 PM, Z1 stated, "He was very depressed- he couldn't remember things. He was really bothered by that. He watched 2 brothers and a sister with Dementia. He was really frustrated by the disease. He is in the hospital now and he is getting counseling there. It has really helped a lot." On 8/30/11 at 2:45 PM, Z2 stated, "My role is to audit charts, assist with dealing with issues and provide inservice and education for the staff." Z2 was asked what her expectation would be if a resident expressed a desire to die. Z2 stated, "My expectation is that the resident would be sent out. If there is a major issue I am available if they need me. I've made them aware of that and they have called me before. I think what happened is that is was an oversight on the facility's part. I don't know what the nurse was thinking." R1's Depression Scale dated 7/26/11 shows that R1 scored a 0 (no signs of depression). This same document states, "Resident made negative statements on 7/26/11. Reassessed for signs and symptoms of depression. Resident assessed with [REDACTED]. States he doesn't remember making any statements. Will monitor." R1's careplan dated 7/26/11 states, "The resident has a history of self-harmful ideation (thoughts) and/or behavior. This appears to be related to: Poor impulse control, Feelings of helplessness, hopelessness; little hope that life will improve." The approaches/ interventions include: "If negative statements made or self harm threats made resident will be monitored by social services for 72 hours., (Physician) notified of changes in behavior. and If self harm occurs resident will be sent to the hospital for evaluation." On 8/31/11 at 9:30 AM, E1, the facility Administrator was notified of the Immediate Jeopardy related to R1's self- injurious behaviors and lack of facility intervention. Through observation, interview and record review the surveyor confirmed that the facility took the following actions to remove the Immediacy: 1. On 8/17/11 at 5:00 PM all nursing staff completed an in house audit to remove any resident personal items that could be a safety concern to residents. 2. From 8/18/11 through present, QA audits are being completed daily to ensure the safety of the residents. 3. No safety razors are allowed in the facility effective 8/18/11. All families were notified of the change. 4. On 8/18/11 Inservicing was done as follows: -(A new) Policy and Procedure for Handling Self Harm Behavior was initiated and inserviced to staff by (Z2) Consultant on 8/18/11. - Policy and Procedure for Safety of Residents when Shaving was initiated and inserviced on 8/18/11. - [MEDICAL CONDITION] Meds/Hot Rack - Mood Changes/ MD Notification 5. On admission each resident will be assessed for negative behaviors and [MEDICAL CONDITION]. MDS Data collection tool will be completed in the first 72 hours. New residents will have safety alarm and checked on every 15 minutes during the first 72 hour period. If there are any negative statements/[MEDICAL CONDITION] staff will per policy immediately place resident on 1:1's and notify Director of Nursing, Administrator and physician for referral for psych eval. 6. Each day in morning meeting, behaviors will be discussed to ensure that appropriate interventions are implemented, care planning has been completed. The resident with the behavior will be placed on hot rack charting for 72 hours to ensure proper documentation/monitoring of the behavior. All residents with behaviors will be referred to the in house psychologist who visits weekly. 7. All behavior interventions will be added to the staff communication book for staff to review and sign off on.

Based on interview and record review the facility failed to supervise a resident with a history of depression, self-injurious behavior and statements indicating a desire to die to prevent the resident from attempting to commit suicide The facility failed to ensure that the resident did not have access to sharp objects capable of causing injury. On 8/17/11 R1 was found in his bathroom with lacerations to both wrists, blood pooled on the floor and a self modified disposable razor. These failures resulted in an Immediate Jeopardy which began on 7/25/11 at 7:30 PM when R1 scratched his hand causing a skin tear and expressed a desire to die. The Immediate Jeopardy was identified on 8/31/11. While the immediacy was removed on 8/31/11 the facility remains out of compliance at a severity level two. Additional time is needed to monitor and evaluate the effectiveness of the training and education of the staff and the policy and procedure implementation. This applies to 1 of 35 residents (R1) reviewed for depression in a sample of 35. The findings include: The physician's orders [REDACTED]. The POS also shows that R1 is ordered to take Remeron (Antidepressant) 30 mg Every Night. The Minimum Data Set of 7/29/11 shows that R1 has a Cognitive Score of 10 (Moderate Impairment.) The Nurse's Notes dated 7/25/11 at 7:30 PM state, "Nurse entered room found skin tear on resident's left hand. Asked resident what happened. Resident stated, "I have nothing to live for, I want to die. I scratched myself." resident very depressed and tearful. Cleansed skin tear and applied steri strips. 1.5 cm long. No complaints of discomfort. Sat with resident for a bit to cheer up. Medication given without difficulty. Requested Tylenol to help relax. POA (Power of Attorney) aware. Attempted to call on-call doctor, left message x 3. No return call. Fax written for Z3." The Behavior Tracking Sheet dated 7/25/11 states, "Resident stated, "I want to die, I have nothing to live with." Resident very depressed and tearful. Skin tear noted to left hand- resident scratched self. Sat with resident for a bit to cheer up." On 8/29/11 at 10:40 AM, E4(LPN) stated, "(On 7/25/11) I asked him what happened. He said, "I cut myself." I looked through his room and didn't see anything in his drawers that he could have cut himself with. Then I noticed his fingernails were long so I cut them. He is normally a little confused and depressed. I comforted him- told him it was okay. I told him he was just here for therapy and then he was going to go home." E4 was asked if she put any special precautions or monitoring in place for R1 after this incident. E4 stated, "No, we didn't do 15 minute checks, I guess we should have." E4 was asked what the facility policy was if a resident expressed a desire to die. E4 stated, "They like us to do 15 minute checks or sit in there with the resident." The (Facility) Interdisciplinary Progress Notes dated 7/26/11 shows the following note written by E3 (life enrichment coordinator), "Spoke with resident, No concerns/complaints at this time. Writer addressed resident regarding incident that occurred last night and in which resident stated,, "I have nothing to live for, I want to die. I scratched myself." Resident denied making statements, resident has a [DIAGNOSES REDACTED]. Doctor was notified, medication change was made (Remeron increased from 15 mg to 30 mg), writer will monitor resident for next 72 hours and reassess for depression and self harm." The same document shows that E3 checked on R1 on 7/27 (untimed), 7/28 at 10:30 AM and 7/29 at 10:30 AM. R1's careplan dated 7/26/11 states, "The resident has a history of self-harmful ideation (thoughts) and/or behavior. This appears to be related to: Poor impulse control, Feelings of helplessness, hopelessness; little hope that life will improve." The approaches/ interventions include: "As warranted conduct a room check/search and remove: Any sharp objects or similar contraband (razor blades, razors, knives, scissors, hammer, nails, screwdriver, screws, needles"and "If self harm occurs resident will be sent to the hospital for evaluation." On 8/29/11 at 12:15 PM, E9 (LPN) stated, "He had what I call "Sundowners" and he got more confused at night." The Nurse's Notes dated 8/17/11 state, "Found resident in bathroom sitting in wheelchair with multiple cut marks to bilateral wrists. Floor covered with blood. Made statement, "Just let me go." Immediately got another nurse to assist with bleeding. Received order to transfer resident to (Hospital) for psych eval and possible admission. Wife and POA notified." On 8/29/11 at 11:30 AM, E8 (RN) stated, "I was going my medication pass and the door to R1's room was shut. (E8 confirmed that R's room was the last room at the end of the hall just as it was during the incident on 7/25/11 ) I opened the door but I couldn't get it open all the way because the bathroom door was against it. I got in and R1 was in the wheelchair (in the bathroom) with his back to me. I saw blood on the floor. I asked R1 where he was bleeding from and he showed me his wrists. I put cold compresses of them and I went down the hall and brought (E9) back with me. (R1) seemed fine earlier in the day. He would get depressed in the evening." On 8/29/11 at 12:15 PM, E9 (LPN) stated, "When I got to the room, E8 had placed wet cloths on his wrists. He was sitting in the wheelchair and there were puddles of blood all over the floor- about softball size. There were splatters of blood too. I told E8 to get E1 (Administrator) and I told the CNA to get housekeeping. By this time I was applying pressure and he was not bleeding anymore. R1 had taken pieces of toilet paper and kind of tented them over the puddles of blood on the floor. I saw a long blue thing on the floor. I kicked it with my foot and then picked it up and saw that it was a razor blade- like a (disposable razor) without the handle, just the blade. R1 had snapped the handle off and the bottom of the blue plastic shield to expose the blade. R1 said, "You weren't supposed to find me." He had superficial cuts on his right wrist and then a bigger gash on the right wrist. The left wrist had a gash on it too and less superficial cuts. Thank God he didn't cut himself deeper. It could have been a lot worse." E9 was asked where R1 could have gotten the razor from. E9 stated, "He told us his wife brought them in the day before. There were maybe 3 or 4 of them in a ziplock bag. He said he did it because he couldn't get a hold of her. He kept apologizing. Sorry he put us through this." E9 was asked if she was aware of the incident from 7/25/11. E9 stated, "I don't know anything about that." E9 was asked what the facility policy was regarding someone expressing a desire to die. E9 stated, "Nothing like this has ever happened before. I would notify the Administrator. If someone says they are going to hurt themselves we need to tell the person in charge and go through the room to remove anything that might be dangerous." On 8/29/11 starting at 11:00 AM, E5, E6 and E7 (CNAs) were asked if they were aware of R1's incident on 7/25/11, if they did any additional monitoring of R1 and what the facility policy is regarding the use/ storage of disposable razors. E5 stated, "They (razors) are stored in the nursing closet. Supposed to be locked. Then we put in sharps container in the shower room." E6 stated, "Razors are to be kept away from residents, put in the sharps container in the shower room. I don't know anything about the incident on 7/25/11. We were never told to do any extra monitoring of (R1)" E7 stated, "(R1) always had razors in his room and shaving cream. He would shave himself. I would set him up at the sink and check on him. He did okay, he never cut himself. About 1 week before this happened (incident on 8/17/11) there were 2 or 3 razors in the wash basin on the sink in his bathroom. You had to dig for them because they were on the bottom. I was never told of the incident on 7/25/11. We never did any increased monitoring of (R1). If there is anything we need to know about the residents then the nurse tells us when we come in." On 8/29/11 at 12:55 PM, Z1 stated, "They brought the razors in- one of the CNAs. He kept saying, I need to shave, I need to shave so they brought in razors, shaving cream and after lotion. I did not bring them in. The man in the bed next to him had some too." On 8/30/11 at 2:45 PM, Z2 stated, "It is the facility policy that alert residents can have razors. Someone told me that R1's wife brought them in and didn't tell anyone." The emergency room Summary Report dated 8/17/11 states, "Patient reports knee pain and right hip pain. States that it was too much for him to handle so he took a razor blade to his bilateral wrists." The facility document entitled Emergency Department Visit dated 8/17/11 and dictated by the Physician's Assistant states, "(R1) states what he did was "really stupid." he states that he just got frustrated, had an altercation, everything kind of balled up together and got him frustrated, so he cut his wrists." This same document states, "The patient has multiple superficial lacerations with a few of them deeper than others requiring closure." The Addendum to Emergency Department Visit dated 8/17/11 and dictated by the ER physician states, "(R1) had multiple stories which might have been secondary to his dementia but he had these horizontal lacerations across both wrists that either might have been frustration with his chronic pain or frustration with his wife. He was evaluated by Crisis and deemed appropriate for admission." The Hospital Psychosocial assessment dated [DATE] states, "The patient is not quite sure why he cut his wrists. He stated first to the nurse upon arrival to the emergency room that he was tired of dealing with the pain in his legs. By the time I spoke to the patient, the patient stated he did it to seek attention. the patient does have a mild case of dementia. Administrator stated that the patient when found in the bathroom, stated he was not meant to be caught. He stated to me hours later that he knew deep down inside someone was going to find him. He has been tearful all night about what he did." This same document states, "(R1's )memory recall for remote is good, recent is poor and immediate is fair." and " Treatment goals are to get a hold of his depression, get some coping skills so that he will feel better." The Psychiatric Admission Note dated 8/17/11 states, "(R1) reports depression, anhedonia (lack of pleasure in things that should bring pleasure), decreased energy, decreased appetite and insomnia." On 8/31/11 at 9:30 AM, E1, the facility Administrator was notified of the Immediate Jeopardy related to R1's self- injurious behaviors and lack of facility intervention. Through observation, interview and record review the surveyor confirmed that the facility took the following actions to remove the Immediacy: 1. On 8/17/11 at 5:00 PM all nursing staff completed an in house audit to remove any resident personal items that could be a safety concern to residents. 2. From 8/18/11 through present, QA audits are being completed daily to ensure the safety of the residents. 3. No safety razors are allowed in the facility effective 8/18/11. All families were notified of the change. 4. On 8/18/11 Inservicing was done as follows: - Policy and Procedure for Handling Self Harm Behavior was initiated and inserviced to staff by (Z2) Consultant on 8/18/11. - Policy and Procedure for Safety of Residents when Shaving was initiated and inserviced on 8/18/11. - Psychotropic Meds/Hot Rack - Mood Changes/ MD Notification 5. On admission each resident will be assessed for negative behaviors and suicidal ideations. MDS Data collection tool will be completed in the first 72 hours. New residents will have safety alarm and checked on every 15 minutes during the first 72 hour period. If there are any negative statements/suicidal ideations staff will per policy immediately place resident on 1:1's and notify Director of Nursing, Administrator and physician for referral for psych eval. 6. Each day in morning meeting, behaviors will be discussed to ensure that appropriate interventions are implemented, care planning has been completed. The resident with the behavior will be placed on hot rack charting for 72 hours to ensure proper documentation/monitoring of the behavior. All residents with behaviors will be referred to the in house psychologist who visits weekly. 7. All behavior interventions will be added to the staff communication book for staff to review and sign off on.

Based on Interview and Record Review the facility neglected to follow their Discharge policy and procedure and neglected to have a complete policy and procedure in place to assure the safety and welfare of a resident (R1) when discharged from the facility. On 8/2/11 at 11:00am, R1 was discharged home. When R1 returned to the home environment there was no working phone, inadequate cooling due to hot weather, problems with water, no food available/accessible for R1 and no help for ADL care. These failures resulted in R1 being found on 8/4/11 at 12:15pm, (49 hours later) alone, incontinent of feces, dehydrated in a home temperature of 94 degrees Farenheit after sitting for 2 days in a chair, unable to care for herself. R1 was admitted to the hospital on [DATE] with Dehydration, Weakness, Urinary Tract Infection and Inability to care for herself. This is for 1 of 3 residents (R1) reviewed for neglect in a sample of 3. The findings include: The facility's Discharge Procedure (no date) showed, "Purpose: To prepare resident for discharge. To assure for instructions for family and resident.; Policy: Licensed nursing staff will assist the resident with discharge procedures.; Procedure - To Home: 1. Physician order [REDACTED]. Complete facility specific discharge form, Resident Care Instruction Sheet and/or Discharge Planning instructions (one copy remains on the chart).; 4. A discharge conference will be held with resident/family participation: a. Other agencies/referrals in attendance, if applicable.; b. On-going plan of care reviewed.; c. Other disciplines present.; d. Equipment identified, ordered and instructions given, if applicable.; 5. Complete the Personal Inventory Record with signature of resident or family/responsible party and nurse.; 6. Document in the nurses notes all meds with the prescription number, name of medication and number being sent home. The resident or family signs the nurses' notes for receipt of medications, followed by the nurses' co-signature may be documented on a facility specific form. (No controlled medications sent with resident.); 7. Licensed staff will document how the resident left the facility, with whom, if meds were sent and personal items sent. i.e. "Discharge per wheelchair with wife, medication and personal items sent with resident."; 8. The face sheet is completed with the statement "resident and all personal belongings and medications discharge to______. Responsible party signature________. Resident's home address_______. Signature of the nurse_________. Date______. Time______.; 9. Document in the nurses' notes at least: a. Resident status at discharge.; b. Resident/family impression of stay.; c. Disposition of personal belongings and/or medications.; d. Persons accompanying resident.; e. Any other pertinent information.; f. Where discharged to.; 10. Complete the medication/treatment sheets, the activities of daily living sheet, etc. and file in the appropriate section of the chart." This procedure does not address visiting the home environment to assure it can meet the needs of the resident. The Interdisciplinary Discharge Plan of Care and Summary dated 8/2/11 for R1 showed, "admitted - 4/26/11; Age - 60; discharge date - 8/2/11; Time - 11:00am; Discharge To: Home with Son; Social Services: Community Resources Needed Post Discharge.; Name - Z5 (Home Health Care).; Services: Nursing - Yes. Skilled nursing, Physical Therapy and Occupational Therapy.; Personal Care: No.; Meals: No.; Housekeeping: No.; Wounds - No skin issues.; Summary: R1 was admitted for fractured left tibia/fibula. She participated well in therapy. Towards the end of her stay she wanted physical therapy and occupational therapy at bedside, which couldn't be done. R1 refused therapy x 3 and was discontinued. Then decided she was ready to go home. (Signed by Social Services (E4) on 8/3/11).; Physical Therapy: Assistive devices needed - slide board, walker and grab bars. Goals - R1 moderate assist with slide board transfers.; Occupational therapy: Assistive devices needed - Grab bars, walker, reacher and shoe horn.; Home evaluation date: not applicable. Goals - R1 is moderate assist x 1 -2 people with all activities of daily living.; Nursing: Narrative discharge instructions - Discharge instructions given. Discharge medication list went over with R1 with good understanding. Home health to follow. Questions asked and answered. discharged to son's home via wheelchair van service." The Prehospital Care Report for R1 dated 8/4/11 showed, "Subjective: Called for a reported medical transport at.... On arrival, found R1. Chief complaint of dehydration. Secondary complaint(s) of unable to ambulate. A home health nurse handled the case, as this was her first visit with R1. The nurse identified that R1 had not been up since Tuesday and was most likely unable to care for herself at this time. She and a family member called R1's primary care provider and arranged for direct admission.; Objective: At 12:45pm, R1 was found sitting in a chair, Alert and oriented..., unable to get out of the chair since assisted to it by her son Tuesday night. When transferred to the cot, there was a strong odor of old urine and possibly feces. A pad was underneath R1 and was stained with dark brown and red coloring. Initial assessment revealed R1 had...with vital sign of 107/68, pulse 103, respiratory rate 18, blood sugar 219. R1 stated, I was discharged from the nursing home and the wheelchair van dropped me off at my house Tuesday and just pushed me into my house and left. My son came home and helped me to my chair. I haven't been up since."; Assessment: The field impression of R1 was general malaise and other central nervous system problem. R1 has a history of MS and broke her leg on 4/23/11 and was admitted to the hospital and subsequently to the nursing home and rehab. R1 complains of left leg pain from this injury and is unable to ambulate, needing 2-3 man lift assistance." The Hospital History and Physical dated 8/4/11 for R1 showed, "Admission Diagnoses: [REDACTED].; R1 has End Stage MS, sustained left tibia fracture in the spring of 2011. R1 has had follow up xrays where it showed that it was healing. R1 still has pain when she is standing and has been unable to really complete much physical therapy. R1 was unhappy at the nursing home and wanted to try living at home again. However, after being discharged home, family was unable to care for her, and her functional capacity had changed dramatically. R1 is now faced with permanent nursing home placement and is quite upset about about that. While R1 was home for 2 days, she was unable to move out of the chair to get up and drink anything. R1 became dehydrated and weak.; Assessment/Plan: Dehydration with [MEDICAL CONDITION] patient who is unable to care for self. After sitting at home for 2 days without air-conditioning, the patient was brought in. She is quite weak and dehydrated. We will gently rehydrate with fluids, let her have a general diet. She does not have any eating restrictions and will have physical therapy/occupational therapy evaluation. Benign essential hypertension. Continue her medication. Type 2 Diabetes. Continue on current medications. History of frequent urinary tract infections. We will check for infection as the cause of her myalgia. End stage [MEDICAL CONDITION] requiring nursing home placement, have put in social service consult." On 8/10/11 at 9:20am, E4 (Social Services) stated, "Discharge planning starts as soon as a resident walks in the door. I look for home health, what equipment is needed and talk with the family. I will call and set up a referral for home health. If a resident needs equipment I will set up for delivery. If the resident needs any help they can call here. R1 was discharged a week or two ago. R1 refused therapy 3 times so she was discharged from therapy and said okay and that she would go home. We spoke with R1's doctor and he said R1 needed assistance and if we set up home health for R1 he would give the order for R1's discharge. R1 needed assistance with activities of daily living and personal care. R1 has MS and pain. R1 did not walk in therapy. R1 used a wheelchair. R1 brought the wheelchair with her and it was sent back with her. R1 said she could transfer with a slide board and someone to guide her. I set up home heath (Z5) for R1. All I had to do is call them (Z5). Home health can't see a resident on the day they go home, it has something to do with medicare. I set up transport home for R1. I met Z6 (R1's son) once. He did not have a big role in her care. Z6 is the power of attorney for health care. I could never get a hold of Z6. I never talked to Z6 about R1's discharge. R1 said her name was on the lease for the house. I never saw the lease. I never talked to R1's son. R1 was sent home to her address that was a previous address listed." R1's Occupational Therapy Daily Treatment Note showed, "6/2/11 - R1 needed to take bed bath with certified nursing assistants, treatment cut short today.; 6/9/11 - R1 unable to come to therapy due to orthopedic appointment.; 6/10/11 - R1 refused during time of treatment due to bingo.; 6/27/11 - R1 exhibiting complete cooperation with therapy program, reporting she is anxious to make up for the two days she missed last week when she was ill.; 6/28/11 - R1 became nauseated while in therapy and needed to go back to her room. R1 later experienced a migraine therefore thearapy was performed in her room today.; 7/18/11 - R1 is sick, vomiting. Check with pt times three. Does not want to work in therapy today.; 7/19/11 - R1 is vomiting. Not able to hold food down after meals. Refusing therapy in gym and bedside. R1's Occupational Therapy Daily Treatment Note showed, "7/21/11 - Completed care plan with R1 and other staff. R1 not feeling well today due to her migraine. Requesting to stay in room with lights off due to symptoms. R1's discharge plans is to discharge home or to apartment. needing to get a hold of son to determine if 24 hour care is required. If son continues to live with R1 or is moving out." On 8/10/11 at 3:00pm, R1 stated, "E4 (Social Services) and E5 (Licensed Practical Nurse - LPN/MDS Care Plan Coordinator) came to my room one day and said because I wasn't going to the dining room and refused rehab three times I would have to leave. They had me sign a paper that said I wasn't going to rehab anymore. I told them, "Why am I here if I can't get therapy anymore? I might as well go home." So they decided to discharge me. My son didn't know I was coming home. I thought they were supposed to arrange everything for me for at home? The phone didn't work, the air didn't work, there wasn't any food or water. I just sat in my chair. I don't know what would have happened if Z4 had not found me. Z4 didn't know I was going home. Z4 is on my records as a close friend." E1 stated she felt neglected at the facility because, "They lied about me. I distrusted them." On 8/11/11 at 1:12pm, E2 (Director of Nursing - DON) stated R1 was "realistic to a certain degree" about her disease process but was not realistic about her ability to care for herself. E2 stated, "R1 stayed in her room because it was dark and cool. The lights gave her a headache. R1 did do some therapy in her room." The facility's Abuse Prevention Program Facility Policy, dated 1/26/00, showed, "Handout C - Causes of angry or agitated Resident Behaviors: Causes related to physical or medical conditions - Fatigue.... Physical discomfort such as pain, fever, illness, constipation, fecal impaction or urinary tract infection. Stress.; Causes related to the living environment: too many people in the environment. Too hot or too cold.; Other causes: Feelings of abandonment, insecurity or fear. Inability to perform what was once a simple task. Information overload, too much happening at one time. May be responding to others who are hostile.... Response to impatience, stress, irritability. Resident is scolded, confronted, contradicted." The facility's Abuse Prevention Program Facility Policy, dated 1/26/00, showed Handout F - Physical Symptoms of excessive stress: Recurrent headaches, Feeling tired throughout the day. Becoming sick more often.; Emotional symptoms of excessive stress: Radical mood swings. Cynicism about the motives and values of others. Changes in personality." The facility's Abuse Prevention Program Facility Policy, dated 1/26/00, showed, "The nursing home affirms the right of our residents to be free from abuse, neglect, missapropriation or resident property, corporal punishment, and involuntary seclusion. The nursing home therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the nursing home is doing all that is within its control to prevent occurences of mistreatment, neglect or abuse of our residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment.; Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or in the deterioration of a resident's physical or mental condition." .

Based on Interview and Record Review the facility failed to maintain contact with a family member (Z6), close friend (Z4) or legal representative about plans for R1's proposed discharge from the facility. Social services interventions failed to address residents' needs and link social supports, physical care, and physical environment with residents' needs. These failures resulted in R1 being found at home on 8/4/11 at 12:15pm, alone, incontinent of feces, dehydrated in a air temperature of 94 degrees Farenheit after sitting for 2 days in a chair, unable to care for herself. R1 was admitted to the hospital on [DATE] with Dehydration, Weakness, Urinary Tract Infection and Inability to care for herself. This is for 1 of 3 residents (R1) reviewed for discharge notification in a sample of 3. The findings include: On 8/10/11 at 3:00pm, R1 stated, "E4 (Social Services) and E5 (Licensed Practical Nurse - LPN/MDS Care Plan Coordinator) came to my room one day and said because I wasn't going to the dining room and refused rehab three times I would have to leave. They had me sign a paper that said I wasn't going to rehab anymore. I told them, "Why am I here if I can't get therapy anymore? I might as well go home." So they decided to discharge me. My son didn't know I was coming home. I thought they were supposed to arrange everything for me for at home? The phone didn't work, the air didn't work, there wasn't any food or water. I just sat in my chair. I don't know what would have happened if Z4 had not found me. Z4 didn't know I was going home. Z4 is on my records as a close friend. Why didn't E4 help me with applications for housing like she was supposed to? E4 put applications in my dresser drawer at the nursing home where I couldn't get to them. I had to keep asking E4 for help. E4 finally helped me fill out some papers the week before I left." A form, "Medicare Non-Coverage Letter for Current Resident Whose Coverage is Ceasing" dated 7/27/11 for R1 is the "paper" R1 was told to sign per E2 (Director of Nursing - DON) on 8/11/11 at 2:20pm. The (written) Social Service notes for R1 showed, "7/27/11 at 7:30am - Spoke with R1 this morning about why she doesn't come down for meals. R1 said she doesn't come down because of the lights and because it is too hot." On 8/11/11 at 2:10pm, E4 (Social Services - SS) confirmed this was the last written Social Service note for R1. On 8/10/11 at 9:20am, E4 (Social Services) stated, "Discharge planning starts as soon as a resident walks in the door. I look for home health, what equipment is needed and talk with the family. I will call and set up a referral for home health. If a resident needs equipment I will set up for delivery. If the resident needs any help they can call here. R1 was discharged a week or two ago. R1 refused therapy 3 times so she was discharged from therapy and said okay and that she would go home. We spoke with R1's doctor and he said R1 needed assistance and if we set up home health for R1 he would give the order for R1's discharge. R1 needed assistance with activities of daily living and personal care. R1 has multiple sclerosis (MS) and pain. R1 did not walk in therapy. R1 used a wheelchair. R1 brought the wheelchair with her and it was sent back with her. R1 said she could transfer with a slide board and someone to guide her. I set up home heath (Z5) for R1. All I had to do is call them (Z5). Home health can't see a resident on the day they go home, it has something to do with medicare. I set up transport home for R1. I met Z6 (R1's son) once. He did not have a big role in her care. Z6 is the power of attorney for health care. I could never get a hold of Z6. I never talked to Z6 about R1's discharge. R1 said her name was on the lease for the house. I never saw the lease. I never talked to R1's son. R1 was sent home to her address that was a previous address listed." R1's (typed) Social Service Notes showed, "5/9/11 - R1's goal is to return home after therapy. R1 is her own responsible party and she is a full code. Her family remains supportive, her son visiting frequently.; 5/25/11 - R1's goal is to return home, I am currently helping her look for a low income apartment. R1 is her own responsible party but her son is her power of attorney for healthcare and she remains a do not resuscitate. Her family remains supportive, her son visiting when possible.; 6/24/11 - R1 remains alert and oriented to person, time and place with a good memory recall of past and present events. R1 is able to make her wants and needs known and can understand and respond appropriately to to hers. R1 has not exhibited any mood or behavior problems to contend with and continues to take her meals in her room. Her family remains supportive, visiting when possible, she is her own responsible party and she is a full code. Long term care placement will continue at this time due to her physical and medical needs.; 7/20/11 - R1 remains alert and oriented to person, time and place with a good memory recall of past and present events. R1 is able to make her wants and needs known and can understand and respond appropriately to others. R1 has not exhibited any mood or behavior problems to contend with and continues to take her meals in her room. Her family remains supportive, visiting when possible, she is her own responsible party and she remains a full code. her goal is to return home, I am currently helping her look for an affordable apartment." On 8/11/11 at 2:10pm E4 confirmed these Social Service Notes for R1 were made by E4 and the last typed social service note for R1 is dated 7/20/11. On 8/11/11 at 2:10pm, E4 (Social Services) stated, "R1 said Z4 (R1's friend) was going to help her fill out applications for housing. Then R1's friend (Z4) went on vacation. I would periodically stop in and ask R1 if she needed some help and she would say, "No." The Interdisciplinary Discharge Plan of Care and Summary dated 8/2/11 for R1 showed, "admitted - 4/26/11; Age - 60; discharge date - 8/2/11; Time - 11:00am; Discharge To: Home with Son; Social Services: Community Resources Needed Post Discharge.; Name - Z5 (Home Health Care).; Services: Nursing - Yes. Skilled nursing, Physical Therapy and Occupational Therapy.; Personal Care: No.; Meals: No.; Housekeeping: No.; Wounds - No skin issues.; Summary: R1 was admitted for fractured left tibia/fibula. She participated well in therapy. Towards the end of her stay she wanted physical therapy and occupational therapy at bedside, which couldn't be done. R1 refused therapy x 3 and was discontinued. Then decided she was ready to go home. (Signed by Social Services (E4) on 8/3/11).; Physical Therapy: Assistive devices needed - slide board, walker and grab bars. Goals - R1 moderate assist with slide board transfers.; Occupational therapy: Assistive devices needed - Grab bars, walker, reacher and shoe horn.; Home evaluation date: not applicable. Goals - R1 is moderate assist x 1 -2 people with all activities of daily living.; Nursing: Narrative discharge instructions - Discharge instructions given. Discharge medication list went over with R1 with good understanding. Home health to follow. Questions asked and answered. discharged to son's home via wheelchair van service." R1's Death and Discharge Record showed, "Resident: R1.; Date of Admission: 4/26/11.; Primary Physician: Z7.; Primary Admission Diagnosis: [REDACTED].; Date/Time of Discharge: 8/2/11.; Length of stay: (No written response).; Name of facility receiving resident: (No written response.); Reason for discharge: Home.; Doctor approved: Yes.; How transferred: Via wheelchair van.; Release to: Z6 (R1's son).; Signature: (No signature)." The Resident Discharge Plan dated 7/28/11 for R1 showed, "Previous living arrangements: with family.; Primary Admission Diagnosis - Fractured left tibia/fibula.; Other current Diagnoses: [REDACTED].; What plan does the resident/family have in regard to discharge of the resident? R1's goal is to return home after therapy.; Any special problem related to discharge planning? (No response written/typed).; Special Services required in discharge planning: (No responses written, typed or checked).; Plans for discharge: (No response written, typed or checked).; Comments: Home health care. Transportation set up." On 8/10/11 at 8:25am, Z4 (R1's friend) stated, "R1 and Z6 have a poor relationship. It is a love hate relationship, it is strange. It is totally dysfunctional. Z6 doesn't really care. Z6 doesn't care what happens to R1. Z6 has stuff at the house but lives most of the time with his girlfriend in Savanna. R1 pays half of the rent and the electric and heat. It is a very poor environment. It is sad. The landlord wants Z6 out and has the house up for sale. personally I would bulldoze it, it is that bad. R1 is truly a good lady. R1 was discharged on Tuesday (8/2/11) and I didn't know. On Wednesday (8/3/11) I went to a play and did not get home until 11:00pm. The home health nurse called me and said she wanted to schedule a time to see R1 but could not get a hold of R1. The home health nurse did not say it was an emergency. The next morning (8/4/11) I called and the phone did not work. I decided to go to R1's house at noon. I walked in and I thought R1 was dead. R1 was sitting in her recliner, hanging over the side of it with her mouth open. The house was hot, hot, hot! I shook R1 over and over and she came too. R1 complained of being hungry and thirsty. I went over to the air conditioner and when I turned it on, the temperature read 94 degrees. The air conditioner ran for about 10 minutes and shut off. There was something wrong with it. So I opened some windows. R1 told me that her son told her she couldn't drink the water in the house because there was something wrong with it. I went to the pantry and there was some bottled water in there that I had brought R1 before she went into the hospital. I gave that to R1. I went and found a can of beef stew and gave that to R1. There was nothing to eat in the refrigerator, just condiments. I called the home health nurse and told her to come out. She said she would be there within an hour. R1 can't stand or walk. R1 was left in a chair from Tuesday around noon until Thursday at noon. R1's cathter bag had dark colored urine. It looked awful and had a red tinge to it. R1 was incontinent in her diaper, full of two days worth of stuff. I called R1's doctor and he was told R1 wanted out of the nursing home, was not cooperative with care and said she could be dismissed because she was ready. Z7 said he would call the hospital and arrange for R1 to be admitted and to call the ambulance. The home health nurse came and saw the situation, emptied R1's cathter bag and helped transfer R1 to the ambulance cart. I was horrified R1 had been left there. There was no telephone, no air conditioning and no food. I left a message for Z6 and told him R1 was on the way to the hospital. I told Z6 he is not responsible for taking care of R1 but he is responsible for making sure R1 is taken care of. I told E4 (Social Services) not to send R1 home when it is time for her to go home because it was not a good situation at home. E4 said she would help R1 find a place but did not really seem interested in helping R1 out." On 8/10/11 at 9:55am, Z2 (Home Health Registered Nurse) stated, "R1 was a new patient for me. Another nurse had R1 before she went to the nursing home. We see every patient usually in 24 hours, maximum of 48 hours. The first time I saw R1 was on 8/4/11 at 12:15pm. I went to R1's house and she was completely soiled. R1's catheter was full. I couldn't get a hold of R1 there was no phone, it had been disconnected. I tried calling Z6 (R1's son) and left a message. Z6 never called back. I called Z4 (R1's friend). Z4 called me and said she got a hold of R1 and that R1 needed a nurse immediately. The air conditioning was not on. No windows were open. The place was filthy. There was no water because the landlord had not fixed the well. R1 had been sitting in a chair for the last 2 days unable to move or walk. R1 said she had not taken her medications in 2 days. Z4 called R1's doctor and arranged for R1 to go to the hospital. By the time I got there Z4 had opened the windows, turned the air on, contacted R1's physician and got R1 something to drink from somewhere. All i did was empty R1's catheter and help get her transferred to the ambulance. I called the hospital social services because I could not let R1 go back knowing what I saw. I don't know if this is how she always has lived or if the son agreed to take care of R1 and then didn't." The Hospital History and Physical dated 8/4/11 for R1 showed, "Admission Diagnoses: [REDACTED].; R1 has End Stage MS, sustained left tibia fracture in the spring of 2011. R1 has had follow up xrays where it showed that it was healing. R1 still has pain when she is standing and has been unable to really complete much physical therapy. R1 was unhappy at the nursing home and wanted to try living at home again. However, after being discharged home, family was unable to care for her, and her functional capacity had changed dramatically. R1 is now faced with permanent nursing home placement and is quite upset about about that. While R1 was home for 2 days, she was unable to move out of the chair to get up and drink anything. R1 became dehydrated and weak.; Assessment/Plan: Dehydration with multiple sclerosis patient who is unable to care for self. After sitting at home for 2 days without air-conditioning, the patient was brought in. She is quite weak and dehydrated..." On 8/10/11 at 10:25am, E1 (Administrator) stated, "I know R1 decided she wanted to be off therapy and wanted to go home. E4 (Social Services) worked with R1 through her discharge plan. R1 couldn't go home without 24 hour care." E1 was told that R1 went home to the conditions described by Z2 in her interview on 8/10/11 at 9:55am. E1 stated, "I would have ensured there was someone available to take care of R1 before she was sent home. This is awful. They should have made sure R1's son was contacted or a family friend to take care of R1 until home health was there." R1's Care Plan dated 4/26/11 showed, "Problem: New admission to our facility following a brief hospitalization . Plans to return home when physical therapy and occupational therapy completed.; Goal: Will verbalize any concerns regarding placement to staff during routine contacts through next review.; Approaches/Interventions: Encourage her to verbalize any concerns regarding placement/care issues. Allow her time and privacy to verbalize concerns. Inform of resident's rights including the right to participate in care/treatment decisions. Encourage frequent visits from family and friends. Refer to appropriate agencies prior to discharging to home and assist as needed with arrangements for services. Involve in physical therapy and occupational therapy as ordered by her physician and assess her home environment prior to her discharge." This care plan was reviewed and continued for R1 on 7/26/11. R1's Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 7/20/11 showed limited assistance of 1 person for bed mobility and dressing.; Extensive assistance of one person for locomotion on the unit, locomotion off the unit, toilet use, personal hygiene and bathing.; Total dependence with assistance of 2 staff for transfers.; Functional range of motion: lower extremity - impairment on both sides.; Urinary incontinence - catheter.; Bowel continence - always incontinent.; Height - 65 inches.; Weight - 160 pounds." R1's Nursing assessment dated [DATE] showed, "Diabetic.; Oriented to person, place, day, date, time, alert.; Speech - clear.; Behavior - cooperative.; Mood - pleasant.; Safety - uses call light appropriately.; Method of elimination - assisted.; Locomotion - wheelchair, assisted.; Transfer - 2 assist and slideboard.; Bed mobility - assist x 2.; Activities of daily living - Assist." The Weekly Medicare Meeting form dated 7/25/11 for R1 showed, "Occupational therapy: Sitting - independent with set up. Upper body dressing - independent with set up. Lower body dressing - moderate assistance of 1 person. Toilet transfer - minimal assistance to moderate assistance. Eating - independent with set up. Recommendation - 24 hour care."

Based on interview and record review the facility failed to have a discharge plan for a resident that involved the resident's son and close friend to assist the resident with the new living environment. The facility failed to assess the resident's care needs at home and failed to develop a plan designed to ensure the individual's needs will be met after discharge from the facility. As a result of these failures R1 was found at home 2 days after discharge, alone, incontinent of feces, having little to eat or drink, sitting in a chair for 2 days in 94 degree temperature with ineffective cooling and unable to care for herself. R1 was admitted to a local hospital on [DATE] with Dehydration, Weakness and a Urinary Tract Infection. This applies to 1 of 3 residents reviewed for discharge planning in the sample of 3. The Findings include: On 8/10/11 at 9:20am, E4 (Social Services) stated, "Discharge planning starts as soon as a resident walks in the door. I look for home health, what equipment is needed and talk with the family. I will call and set up a referral for home health. If a resident needs equipment I will set up for delivery. If the resident needs any help they can call here. R1 was discharged a week or two ago. R1 refused therapy 3 times so she was discharged from therapy and said okay and that she would go home. We spoke with R1's doctor and he said R1 needed assistance and if we set up home health for R1 he would give the order for R1's discharge. R1 needed assistance with activities of daily living and personal care. R1 has MS and pain. R1 did not walk in therapy. R1 used a wheelchair. R1 brought the wheelchair with her and it was sent back with her. R1 said she could transfer with a slide board and someone to guide her. I set up home heath (Z5) for R1. All I had to do is call them (Z5). Home health can't see a resident on the day they go home, it has something to do with medicare. I set up transport home for R1. I met Z6 (R1's son) once. He did not have a big role in her care. Z6 is the power of attorney for health care. I could never get a hold of Z6. I never talked to Z6 about R1's discharge. R1 said her name was on the lease for the house. I never saw the lease. I never talked to R1's son. R1 was sent home to her address that was a previous address listed." The Interdisciplinary Discharge Plan of Care and Summary dated 8/2/11 for R1 showed, "admitted - 4/26/11;Age - 60; discharge date - 8/2/11; Time - 11:00am; Discharge To: Home with Son; Social Services: Community Resources Needed Post Discharge.; Name - Z5 (Home Health Care).; Services: Nursing - Yes. Skilled nursing, Physical Therapy and Occupational Therapy.; Personal Care: No.; Meals: No.; Housekeeping: No.; Wounds - No skin issues.; Summary: R1 was admitted for fractured left tibia/fibula. She participated well in therapy. Towards the end of her stay she wanted physical therapy and occupational therapy at bedside, which couldn't be done. R1 refused therapy x 3 and was discontinued. Then decided she was ready to go home. (Signed by Social Services (E4) on 8/3/11).; Physical Therapy: Assistive devices needed - slide board, walker and grab bars. Goals - R1 moderate assist with slide board transfers.; Occupational therapy: Assistive devices needed - Grab bars, walker, reacher and shoe horn.; Home evaluation date: not applicable. Goals - R1 is moderate assist x 1 -2 people with all activities of daily living.; Nursing: Narrative discharge instructions - Discharge instructions given. Discharge medication list went over with R1 with good understanding. Home health to follow. Questions asked and answered. discharged to son's home via wheelchair van service." The Resident Discharge Plan dated 7/28/11 for R1 showed, "Previous living arrangements: with family.; Primary Admission Diagnosis - Fractured left tibia/fibula.; Other current Diagnoses: [REDACTED].; What plan does the resident/family have in regard to discharge of the resident? R1's goal is to return home after therapy.; Any special problem related to discharge planning? (No response written/typed).; Special Services required in discharge planning: (No responses written, typed or checked).; Plans for discharge: (No response written, typed or checked).; Comments: Home health care. Transportation set up." R1's Nurses Notes showed, "8/2/11 - discharged home via wheelchair van. All medications given to R1. All belongings sent home." The facility's Discharge Procedure (no date) showed, "Purpose: To prepare resident for discharge. To assure for instructions for family and resident.; Policy: Licensed nursing staff will assist the resident with discharge procedures.; Procedure - To Home: 1. Physician order [REDACTED]. Complete facility specific discharge form, Resident Care Instruction Sheet and/or Discharge Planning instructions (one copy remains on the chart).; 4. A discharge conference will be held with resident/family participation: a. Other agencies/referrals in attendance, if applicable.; b. On-going plan of care reviewed.; c. Other disciplines present.; d. Equipment identified, ordered and instructions given, if applicable.; 5. Complete the Personal Inventory Record with signature of resident or family/responsible party and nurse.; 6. Document in the nurses notes all meds with the prescription number, name of medication and number being sent home. The resident or family signs the nurses' notes for receipt of medications, followed by the nurses' co-signature may be documented on a facility specific form. (No controlled medications sent with resident.); 7. Licensed staff will document how the resident left the facility, with whom, if meds were sent and personal items sent. i.e. "Discharge per wheelchair with wife, medication and personal items sent with resident."; 8. The face sheet is completed with the statement "resident and all personal belongings and medications discharge to______. Responsible party signature________. Resident's home address_______. Signature of the nurse_________. Date______. Time______.; 9. Document in the nurses' notes at least: a. Resident status at discharge.; b. Resident/family impression of stay.; c. Disposition of personal belongings and/or medications.; d. Persons accompanying resident.; e. Any other pertinent information.; f. Where discharged to.; 10. Complete the medication/treatment sheets, the activities of daily living sheet, etc. and file in the appropriate section of the chart." On 8/10/11 at 8:25am, Z4 stated, "R1 and Z6 have a poor relationship. It is a love hate relationship, it is strange. It is totally dysfunctional. Z6 doesn't really care. Z6 doesn't care what happens to R1. Z6 has stuff at the house but lives most of the time with his girlfriend in Savanna. R1 pays half of the rent and the electric and heat. It is a very poor environment. It is sad. The landlord wants Z6 out and has the house up for sale. personally I would bulldoze it, it is that bad. R1 is truly a good lady. R1 was discharged on Tuesday (8/2/11) and I didn't know. On Wednesday (8/3/11) I went to a play and did not get home until 11:00pm. The home health nurse called me and said she wanted to schedule a time to see R1 but could not get a hold of R1. The home health nurse did not say it was an emergency. The next morning (8/4/11) I called and the phone did not work. I decided to go to R1's house at noon. i walked in and I thought R1 was dead. R1 was sitting in her recliner, hanging over the side of it with her mouth open. The house was hot, hot, hot! I shook R1 over and over and she came too. R1 complained of being hungry and thirsty. I went over to the air conditioner and when I turned it on, the temperature read 94 degrees. The air conditioner ran for about 10 minutes and shut off. There was something wrong with it. So I opened some windows. R1 told me that her son told her she couldn't drink the water in the house because there was something wrong with it. I went to the pantry and there was some bottled water in there that I had brought R1 before she went into the hospital. I gave that to R1. I went and found a can of beef stew and gave that to R1. There was nothing to eat in the refrigerator, just condiments. I called the home health nurse and told her to come out. She said she would be there within an hour. R1 can't stand or walk. R1 was left in a chair from Tuesday around noon until Thursday at noon. R1's cathter bag had dark colored urine. It looked awful and had a red tinge to it. R1 was incontinent in her diaper, full of two days worth of stuff. I called R1's doctor and he was told R1 wanted out of the nursing home, was not cooperative with care and said she could be dismissed because she was ready. Z7 said he would call the hospital and arrange for R1 to be admitted and to call the ambulance. The home health nurse came and saw the situation, emptied R1's cathter bag and helped transfer R1 to the ambulance cart. I was horrified R1 had been left there. There was no telephone, no air conditioning and no food. I left a message for Z6 and told him R1 was on the way to the hospital. I told Z6 he is not responsible for taking care of R1 but he is responsible for making sure R1 is taken care of. I told E4 (Social Services) not to send R1 home when it is time for her to go home because it was not a good situation at home. E4 said she would help R1 find a place but did not really seem interested in helping R1 out." The Hospital History and Physical dated 8/4/11 for R1 showed, "Admission Diagnoses: [REDACTED].; R1 has End Stage MS, sustained left tibia fracture in the spring of 2011. R1 has had follow up xrays where it showed that it was healing. R1 still has pain when she is standing and has been unable to really complete much physical therapy. R1 was unhappy at the nursing home and wanted to try living at home again. However, after being discharged home, family was unable to care for her, and her functional capacity had changed dramatically. R1 is now faced with permanent nursing home placement and is quite upset about about that. While R1 was home for 2 days, she was unable to move out of the chair to get up and drink anything. R1 became dehydrated and weak.; Assessment/Plan: Dehydration with [MEDICAL CONDITION] patient who is unable to care for self. After sitting at home for 2 days without air-conditioning, the patient was brought in. She is quite weak and dehydrated. We will gently rehydrate with fluids, let her have a general diet. She does not have any eating restrictions and will have physical therapy/occupational therapy evaluation. Benign essential hypertension. Continue her medication. Type 2 Diabetes. Continue on current medications. History of frequent urinary tract infections. We will check for infection as the cause of her myalgia. End stage [MEDICAL CONDITION] requiring nursing home placement, have put in social service consult." On 8/10/11 at 3:00pm, R1 stated, "E4 (Social Services) and E5 (Licensed Practical Nurse - LPN/MDS Care Plan Coordinator) came to my room one day and said because I wasn't going to the dining room and refused rehab three times I would have to leave. They had me sign a paper that said I wasn't going to rehab anymore. I told them, "Why am I here if I can't get therapy anymore? I might as well go home." So they decided to discharge me. My son didn't know I was coming home. I thought they were supposed to arrange everything for me for at home? The phone didn't work, the air didn't work, there wasn't any food or water. I just sat in my chair. I don't know what would have happened if Z4 had not found me. Z4 didn't know I was going home. Z4 is on my records as a close friend. Why didn't E4 help me with applications for housing like she was supposed to? E4 put applications in my dresser drawer at the nursing home where I couldn't get to them. I had to keep asking E4 for help. E4 finally helped me fill out some papers the week before I left." R1's (typed) Social Service Notes showed, "5/9/11 - R1's goal is to return home after therapy. R1 is her own responsible party and she is a full code. Her family remains supportive, her son visiting frequently.; 5/25/11 - R1's goal is to return home, I am currently helping her look for a low income apartment. R1 is her own responsible party but her son is her power of attorney for healthcare and she remains a do not resuscitate. Her family remains supportive, her son visiting when possible.; 6/24/11 - R1 remains alert and oriented to person, time and place with a good memory recall of past and present events. R1 is able to make her wants and needs known and can understand and respond appropriately to others. R1 has not exhibited any mood or behavior problems to contend with and continues to take her meals in her room. Her family remains supportive, visiting when possible, she is her own responsible party and she is a full code. Long term care placement will continue at this time due to her physical and medical needs.; 7/20/11 - R1 remains alert and oriented to person, time and place with a good memory recall of past and present events. R1 is able to make her wants and needs known and can understand and respond appropriately to others. R1 has not exhibited any mood or behavior problems to contend with and continues to take her meals in her room. Her family remains supportive, visiting when possible, she is her own responsible party and she remains a full code. her goal is to return home, I am currently helping her look for an affordable apartment." On 8/11/11 at 2:10pm E4 confirmed these Social Service Notes for R1 were made by E4 and the last typed social service note for R1 is dated 7/20/11. On 8/11/11 at 2:10pm, E4 stated, "R1 said Z4 (R1's friend) was going to help her fill out applications for housing. Then R1's friend (Z4) went on vacation. I would periodically stop in and ask R1 if she needed some help and she would say, "No." On 8/10/11 at 10:25am, E1 (Administrator) stated, "I know R1 decided she wanted to be off therapy and wanted to go home. E4 (Social Services) worked with R1 through her discharge plan. R1 couldn't go home without 24 hour care." E1 was told that R1 went home to the conditions described by Z2 in her interview on 8/10/11 at 9:55am. E1 stated, "I would have ensured there was someone available to take care of R1 before she was sent home. This is awful. They should have made sure R1's son was contacted or a family friend to take care of R1 until home health was there." On 8/10/11 at 9:55am, Z2 (Home Health Registered Nurse) stated, "R1 was a new patient for me. Another nurse had R1 before she went to the nursing home. We see every patient usually in 24 hours, maximum of 48 hours. The first time I saw R1 was on 8/4/11 at 12:15pm. I went to R1's house and she was completely soiled. R1's catheter was full. I couldn't get a hold of R1 there was no phone, it had been disconnected. I tried calling Z6 (R1's son) and left a message. Z6 never called back. I called Z4 (R1's friend). Z4 called me and said she got a hold of R1 and that R1 needed a nurse immediately. The air conditioning was not on. No windows were open. The place was filthy. There was no water because the landlord had not fixed the well. R1 had been sitting in a chair for the last 2 days unable to move or walk. R1 said she had not taken her medications in 2 days. Z4 called R1's doctor and arranged for R1 to go to the hospital. By the time I got there Z4 had opened the windows, turned the air on, contacted R1's physician and got R1 something to drink from somewhere. All I did was empty R1's catheter and help get her transferred to the ambulance. I called the hospital social services because I could not let R1 go back knowing what I saw. I don't know if this is how she always has lived or if the son agreed to take care of R1 and then didn't." R1's Care Plan dated 4/26/11 showed, "Problem: New admission to our facility following a brief hospitalization . Plans to return home when physical therapy and occupational therapy completed.; Goal: Will verbalize any concerns regarding placement to staff during routine contacts through next review.; Approaches/Interventions: Encourage her to verbalize any concerns regarding placement/care issues. Allow her time and privacy to verbalize concerns. Inform of resident's rights including the right to participate in care/treatment decisions. Encourage frequent visits from family and friends. Refer to appropriate agencies prior to discharging to home and assist as needed with arrangements for services. Involve in physical therapy and occupational therapy as ordered by her physician and assess her home environment prior to her discharge." This care plan was reviewed and continued for R1 on 7/26/11. R1's Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 7/20/11 showed limited assistance of 1 person for bed mobility and dressing.; Extensive assistance of one person for locomotion on the unit, locomotion off the unit, toilet use, personal hygiene and bathing.; Total dependence with assistance of 2 staff for transfers.; Functional range of motion: lower extremity - impairment on both sides.; Urinary incontinence - catheter.; Bowel continence - always incontinent.; Height - 65 inches.; Weight - 160 pounds." R1's Occupational Therapy Daily Treatment Note showed, "7/21/11 - Completed care plan with R1 and other staff. R1 not feeling well today due to her migraine. Requesting to stay in room with lights off due to symptoms. R1's discharge plans is to discharge home or to apartment. needing to get a hold of son to determine if 24 hour care is required. If son continues to live with R1 or is moving out." R1's Care Plan Conference Summary showed, "5/26/11 - Discharge Potential: Discharge? needs toilet next to sink, bars for toilet. Needs application for apartments. Does use Department of Rehabilitation Services - personal assistant cooks the meals. Possible meal delivery.; 7/21/11 - Discharge potential - (no response written). Special requests/Choices/Conditions - No family and resident refused 7/21/11 care plan." E4 (Social Services), E5 (Licensed Practical Nurse/MDS Care Plan Coordinator), E6 (Certified Occupational Therapy Assistant), E7 (Food Service Supervisor) and E8 (Licensed Practical Nurse) were listed as in attendance for R1's care plan conference on 7/21/11. The Weekly Medicare Meeting form dated 7/25/11 for R1 showed, "Occupational therapy: Sitting - independent with set up. Upper body dressing - independent with set up. Lower body dressing - moderate assistance of 1 person. Toilet transfer - minimal assistance to moderate assistance. Eating - independent with set up. Recommendation - 24 hour care." R1's Nursing assessment dated [DATE] showed, "Diabetic.; Oriented to person, place, day, date, time, alert.; Speech - clear.; Behavior - cooperative.; Mood - pleasant.; Safety - uses call light appropriately.; Method of elimination - assisted.; Locomotion - wheelchair, assisted.; Transfer - 2 assist and slideboard.; Bed mobility - assist x 2.; Activities of daily living - Assist."

Based on interview, and record review the facility failed to ensure staff used a gait belt with a resident transfer. The facility failed to review and revise approaches to prevent repeated falls and reduce the risk of injury. These failures contributed to R1 falling and sustaining a shoulder fracture and finger laceration. This applies to 2 of 3 residents (R1 & R2) reviewed for falls in the sample of 3. The findings include: 1. The Minimum data set (MDS) of 06/03/11 shows R1 was admitted on [DATE] and required extensive assistance of two or more staff with transfers. R1's fall risk assessment dated [DATE] shows her to be at "HIGH RISK" for falls. The plan of care updated 07/21/11 states, "Problem: Potential for fall/injury...Approaches/Interventions: Transfer with 2 assist with wheeled walker to wheel chair." The facility Incident Investigation Report sent 07/22/11 states, "Resident was lowered to the ground during a transfer. Resident struck third digit right hand and right hip on bed frame. No LOC or head injury. Laceration requiring 5 sutures to the third digit right hand...Resident returned to facility, sling intact to right arm and splint to right third digit. denies pain or discomfort." The 07/27/11 physician progress notes [REDACTED]." On 08/04/11 at 10:30 AM, E1 (Administrator) said, E4, Certified Nursing Assistant (CNA) received corrective action because she was the CNA who transferred R1 and she failed to use the gait belt. R1's injury possibly could have been prevented, if a gait belt had been used. The facility corrective action notification dated 07/26/11 states, "On 07/21/11 it was noted that you did not follow policy by utilizing a gait belt when transferring (R1). The resident became dizzy, you lowered her to the floor and she sustained a fracture to her right shoulder and a laceration to her right finger. By not following policy and procedures you had the potential to cause harm to a resident as well as violate resident rights, quality of care..." On 08/04/11 at 12:20 PM, R1 stated, "I got light headed and fell . (E4) didn't have a gait belt on." On 08/04/11 at 2:15 PM,E4 stated, "We should use a gait belt with stand pivot transfers...I helped (R1) up by pushing her from behind her wheelchair. I transferred her by myself, the student was in the room getting supplies for me. I didn't use a gait belt when I transferred R1...I think (R1) should be a two person assist." The facility Transfer Training & Body Mechanics Inservice (dated 06/17/11) states, "6. MUST ALWAYS USE A SAFETY BELT unless otherwise specified- it is considered elderly neglect when not using a safety belt." (p. 2) The non-dated facility Employee Dress Code states, "Dress Code will be as follows: All CNA's will be required to keep with their person a gait belt at all times." The non-dated facility Gait Belt Policy states, "It shall be the policy that all residents will utilize a gait belt for ambulation and/or transfers." 2. The MDS of 03/03/11 shows R2 requires limited assistance of one staff member with transfers. The fall risk assessment dated [DATE] shows R2 to be at "HIGH RISK" for falls. The plan of care updated 07/21/11 states, "Problem: Fall Risk... fell : 6/5/10, 6,9,10, 8/15/10, 9/13/10, 12/6/10, 12/26/10, 3/6/11, 5/15/11, 6/19/11, and 7/23/11. The same plan of care gives the same intervention "therapy screen" after his falls on 3/6/11, 5/15/11 and 7/25/11. R2's falls were not assessed and no approaches were identified to reduce the risk of injury from falls after 5/15/11, 6/19/11 or 7/23/11. The Rehabilitation Screen dated 6/20/11 states, "No functional decline noticed causing fall. Patient is recommended to continue to ambulate with rolling walker with supervision of one person. Continue to use bed/chair alarm." The Rehabilitation Screen dated 7/25/11 states, "Recommending walker to be keep on right side of bed - stronger transfer side."