Every finding on record at St Dominic Village Rehabilitation and Nursing Cent

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 3 of 4 residents (Residents #1, #2 and #5), 2 of 4 common areas (dining room and front TV room), 1 of 4 nurse's stations (Station 1) and vacant rooms in 1 of 4 halls (room [ROOM NUMBER], #102 and #103) in that: The facility failed to maintain the roof when ceiling tiles broke on 08/11/2026, causing flooding in Resident #2 and #5's bedrooms, the dining room, in the hallway near Station 1 and rooms #101, #102 and #103. The facility failed to ensure ceiling tiles in Resident #1's room and the front television room were maintained appropriately on 08/11/2026 when ceiling tiles in Resident #1's room were swollen and sagging and ceiling tiles in the front television room were stained. This failure could place residents, staff and the public at risk of unsanitary environment, injury or potential accidents due to unsafe conditions. Findings included: In an interview on 8/11/26 at 10:45am, Resident #4 said she was at the facility for therapy and admitted in July 2026. She said the facility appeared to have roof problems across the hall and said it rained on 08/08/2026 and there was water leaking in the hallway. In an observation on 8/11/26 at 11:15am, room [ROOM NUMBER] was vacant. The bathroom in room [ROOM NUMBER] had towels on the floor, two bucks filled with water and a peeling ceiling tile. The room had an odor that was damp and musty. Two ceiling tiles were broken and stained with brown lines where the tiles were broken. Six ceiling tiles were stained with large brown rings. One ceiling tile had ten areas of small circular black spots on the inside of the brown ring. In an observation on 8/11/26 at 11:20am, room [ROOM NUMBER] was vacant. A ceiling tile above the sink was broken and stained with a brown ring. Two ceiling tiles were missing. Half of a ceiling tile that measured 2 feet by 4 feet was swollen and stained with a brown ring. In an observation on 8/11/26 at 11:21am, room [ROOM NUMBER] was vacant. Seven ceiling tiles were missing. There was a stain on the floor beneath the missing ceiling tiles that was white in color and covered an area of about 2 feet. The bathroom in room [ROOM NUMBER] had one ceiling tile that had been replaced with a white tarp-like material with some black discoloration on the side and one ceiling tile that was replaced with plywood. There were towels and a bucket containing water on the floor. In an observation on 8/11/26 at 11:27am, in hallway of 100 hall next to the nurse's station the following was observed: There was a large brown ring on the ceiling tiles next to the biohazard room that measured about 1 foot by 1.5 feet. There were brown rings on the ceiling tiles near the spa. The brown rings were on two ceiling tiles there were slightly overlapping covering a 1 foot by 6-inch area. Another ceiling tile in the area had a brown ring that measured about 6 inches long and 4 inches wide.A ceiling tile that was holding the exit sign was bulging down and swollen. It was gray in color and there was a brown ring around the swollen gray area. A ceiling tile had a brown ring that measured about 1 foot by 5 inches. A ceiling tile had a brown ring that measured about 2 feet by 1 foot. There was a smaller ring in middle of the brown ring that was gray in color, and it was bulging down and swollen. A ceiling tile had a brown ring that was about 6 inches by 5 inches. A ceiling tile had a brown ring that was about 1 foot by 1.5 feet. In an observation on 8/11/26 at 11:35am revealed the ceiling tiles in the dining room were intact. In an observation on 8/11/26 at 11:39am, there were residents in the common area between the two courtyards watching television. The following was observed in the common area: A ceiling tile next to the double doors had a brown ring covering the whole tile about 2 feet by 4 feet and it was bulging down slightly. A ceiling tile in the middle of the common area next to the AC vent was bulging down and swollen. It was gray in color and there was a brown ring around the swollen gray area. A ceiling tile in the middle of the common area was bulging down and swollen covering an area of about 1.5 feet. Two ceiling tiles next to the courtyard were stained with a brown ring covering an area of about 2 feet by 1.5 feet. Two ceiling tiles next to the courtyard were stained with a brown ring covering an area of about 2 feet by 1 foot. In an observation on 8/11/26 at 11:46am, the ceiling tiles next to the air conditioning vent outside of room [ROOM NUMBER] were stained. There were brown rings on 2 ceiling tiles and the air conditioning vent had black spots dotted throughout the vent. In an observation on 8/11/26 at 1:22pm, Room A was vacant and had resident's personal belongings and pictures on the walls. There was a bucket on the floor and there was a steady stream of water dripping into the bucket from the ceiling. Two ceiling tiles were broken. In an interview on 8/11/26 at 1:26pm, Nurse R said Residents #2 and #5 were moved due to a leak in Room A. She said the residents did not have any injuries when the ceiling tiles were broken. Record review of Concern Form dated 7/28/26 regarding Resident #1 indicated Resident #1's family member reported that a ceiling tile needed to be replaced in her room. In an observation and interview on 8/11/26 at 1:30pm, Resident #1's family member stated they put new ceiling tiles in Resident #1's room because they had water stains. The family member said water was leaking into the new ceiling tiles. One ceiling tile had a circular gray stain that covered an area of about 6 inches. 3 ceiling tiles in the corner of the room had circular gray stains covering an area of about 1 foot. In an observation and interview on 8/11/26 at 1:45pm, Resident #5 said she had to move out of Room A due to a water leak. She said she moved to another room. She said when she was getting something out of her nightstand in the new room, a ceiling tile fell on to the nightstand and narrowly missed her head. She said if the ceiling tile hit her head she would own this place. She said the ceiling tile scratched her on the forearm. She showed me her arm and there was a one-inch scratch on her left forearm. She said she moved to a different room after that incident. In an observation on 8/11/26 at 2:00pm revealed it was raining outside. Record review of the website https://precip.ai/weather-station/zipcode/77021 on 8/12/26 at 3:46pm revealed the zip code where the facility was located received 0.38 inches of rain on 8/11/26 at 2:00pm. In an interview on 8/11/26 at 3:35pm, the Director of Maintenance said he started working at the facility in April 2026. He said he completed rounds twice a week to identify any issues. He said the roof was leaking and some ceiling tiles were stained and sagging. He said the facility had replaced about 500 ceiling tiles since he started in April 2026. He said they replace ceiling tiles daily. He said a company was going to start fixing the room on 8/17/26. He said ceiling tiles were important because they created a 20 minute smoke barrier. He said if a ceiling tile was missing and there was a fire then the smoke could spread. In an observation on 8/11/26 at 3:42pm, in hallway of 100 hall next to the nurse's station the ceiling tile that was holding an exit sign was broken and the exit sign was hanging down a couple of inches below the ceiling. The exit sign was almost parallel to the floor. There was a trash can under the ceiling that was filled with water. In an observation and interview on 8/11/26 at 3:45pm, two ceiling tiles in the dining room were missing and a trash can placed underneath the ceiling was filled with water. One ceiling tile that measured 2 foot by 4 foot was swollen and sagging. The maintenance director stated the leak in the dining room was new and stated anytime it rained the ceiling tiles were wet causing them to break. In an interview on 8/11/26 at 4:25pm, the Activity Director said they had to move the location of an planned activity if there was an environmental concern like the leaks. She said the maintenance staff replace ceiling tiles when they start to leak. She said she knew that residents could not be placed under a sagging ceiling tile or place them in harm's way. In an interview on 8/11/26 at 4:40pm, Resident #6 said she was the resident council president. She said the roof leaked when it rained. She said they put buckets in the hallways to catch the water. In an interview on 8/11/26 at 4:57pm, the Director of Nursing said the maintenance staff completed daily checks of the ceiling and fixed any problems. He said the roof had been leaking regularly. He said residents could be at risk of injury if they were seated in an affected area with sagging ceiling tiles. Record review of the facility's policy regarding Environment and Housekeeping dated July 2024 read, It is the policy of [facility] to provide daily housekeeping services to residents residing in the Skilled Nursing Facility. Purpose: To ensure all resident's personal and common areas are cleaned, sanitized, and maintained daily.Areas of the Skilled Nursing Facility shall be free of excessive dirt and debris.

Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services a complete and accurate direct care staffing information, including information for agency and contract staff, based on 1 of 4 quarters for payroll and other verifiable and auditable data in a uniform format according to specification established by Centers for Medicare and Medicaid Services. The facility failed to submit to Centers for Medicare and Medicaid Services the Payroll Base Journal data for the second quarter of 2026. The failure could put Residents at risk for inadequate staffing and not having their needs meets. Findings include: Record review of Centers for Medicare and Medicaid Services-Payroll Base Journal Staffing Data Report CASPER Report 1705D-Fiscial Year Quarter 2 -2026 (January 1-March 31) reveals the facility failed to submit data for the second quarter of 2026. In an interview on 6/25/2026 at 9:16 a.m. with the Administrator, he stated he has been at the facility since 2018. He stated the Payroll Base Journal for the second quarter of 2026 was not submitted due to transition of human resource personnel. He stated human resources was responsible for submitting Payroll Base Journal. He states the risk to the resident if the Payroll Base Journal are not able to be verified that the facility may not have adequate care for the Residents. In an interview on 6/25/22026 at 9:21 a.m. with the Human Resource Director, she states she has been working at the facility for three weeks. She states she has no idea why the Payroll Base Journal was not submitted for the second quarter of 2026. She stated human resources are responsible for ensuring it was completed. She states the risk to the Residents was the facility may not have adequate staffing levels to meet the needs of the Resident. Record review of the facility policy titled, Payroll Base Journal-Staffing revised in August 2023 revealed, Policy Statement: It is the policy of the facility that the Human Resource Director or Designee submit the Payroll Base Journal according to Centers for Medicare and Medicaid Services schedule below:

Based on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13% based on 4 errors out of 30 opportunities, which involved 3 of 4 residents (Resident #1, Resident #51, and Resident #75) and 1 of 1 staff (MA A) observed during medication administration reviewed for medication errors. The facility failed to ensure:1. Resident #1's Aspercreme lidocaine patch 4% was applied to the correct area of the body as ordered2. Resident #1 received the enteric coated extended release aspirin instead of chewable aspirin3. Resident #51 did not receive Vitamin D 25 mcg without a physician's order4. Resident #75 received the correct dosage of Cetirizine HCl Theses failures could place residents at risk of not receiving therapeutic dosages and/or effects of medications. Findings included:Resident #1Observation and interview on 6/24/26 at 8:47 a.m. revealed MA A administered chewable aspirin 81 mg tablet to Resident #1 orally and applied lidocaine patch 4% to Resident #1's right knee. MA A asked Resident #1 where she wanted the lidocaine patch and Resident #1 said she wanted the lidocaine patch on her right knee. Record review of Resident #1's Order Summary Report dated 6/24/26 revealed physician orders for aspirin EC oral tablet delayed release 81 mg with instructions to give 1 tablet my mouth one time a day, Aspercreme Lidocaine External Patch 4% (Lidocaine) with instructions to apply to across chest topically one time a day for pain and remove per schedule and Aspercreme Lidocaine External Patch 4% (Lidocaine) with instructions to apply to between shoulder blades topically one time a day for pain and remove per schedule. Record review of Resident #1's June 2026 MAR revealed administration on 6/24/26 at 9 a.m. both lidocaine administrations had a notation of 2 which per the MAR chart code meant Drug Refused. MAR revealed administration of aspirin EC oral tablet delayed release 81 mg with instructions to give 1 tablet by mouth one time a day on 6/24/26 at 9 a.m. Record review of Resident #1's progress notes revealed progress notes dated 6/24/26 at 11:21 a.m. of Note Text: Aspercreme Lidocaine External Patch 4% Apply to between shoulder blades topically one time a day for PAIN and remove per schedule want on right knee nurse notified. Record review of Resident #1's progress notes revealed progress notes dated 6/24/26 at 11:22 a.m. of Note Text: Aspercreme Lidocaine External Patch 4% Apply to across chest topically one time a day for PAIN and remove per schedule resident want on right knee charge nurse notified. Resident #51Observation on 6/24/26 at 8:31 a.m. revealed MA A administered Vitamin D 25 mcg orally to Resident #51. Record review of Resident #51's Order Summary Report dated 6/24/26 did not reveal a physician's order for Vitamin D 25 mcg. Record review of Resident #51's June 2026 MAR did not reveal Vitamin D 25 mcg. Resident #75Observation on 6/24/26 at 8:47 a.m. revealed MA A administered cetirizine hydrochloride 10 mg to Resident #75. Record review of Resident #75's Order Summary Report dated 6/24/26 revealed physician's order for Cetirizine HCl oral tablet 10 mg with instructions to give 0.5 tablet by mouth one time a day. Record review of Resident #75's June 2026 MAR revealed administration of Cetirizine HCl oral tablet 10 mg with instructions to give 0.5 tablet by mouth one time a day on 6/24/26 at 9 a.m. During interview on 6/24/2026 at 10:31 a.m., MA A said Resident #51 was on a vitamin and that she had just gotten back to work recently and maybe they had changed the order, but the order was supposed to be for vitamin B12. MA A said that the order was for Resident #75's Cetirizine was for 1/2 tablet. MA A said the cetirizine tablet did not have a score line so she would not be able to score the medication to administer a half tablet and she would notify the nurse to notify the doctor. MA A said Resident #1's aspirin should not have been chewable. MA A said she let Resident #1's nurse know that she was in pain somewhere different each time regarding the lidocaine patch. MA A said Resident #1 wanted the lidocaine patch on her leg rather than the shoulder. MA A said the possible effect it could have on a resident if they were given the wrong medication was that hopefully they were not allergic and she would let the nurse know that it was a medication error. MA A said they did in-services twice a month and as needed that include information regarding hand washing, blood pressure parameters and isolation. During interview on 6/24/2026 at 10:42 a.m., LVN B said she would speak to the doctor today when they come to the facility regarding the Cetirizine for Resident #75 because the medication could not be cut in half as ordered. On 6/25/2026 at 10:40 a.m., the surveyor attempted to contact the Consultant Pharmacist and left a message with the surveyor's contact information but did not receive a return phone call. During interview on 6/25/2026 at 1:51 p.m., RN A said she was the nurse for Resident #1. RN A said that the lidocaine patch order for Resident #1 was for across her chest and to her shoulders. RN A said the MA A came and told her that she put the patch on Resident #1's leg. RN A said she told Resident #1 that she had an order for the lidocaine patch that was to her chest and shoulder and if she was having pain somewhere else to let her know and she would take care of it. RN A said she checked Resident #1 this morning and this afternoon after therapy and she was doing fine. RN A said she told the MA A to let her know if there was another location that Resident #1 wanted to have the lidocaine patch somewhere else than was ordered. During interview on 6/25/26 at 9:43 a.m., the DON said if a medication was not administered per the order was that it could have an adverse effect on the resident. The DON said medication monitoring for MAs was done through the monitoring of the MAR and random observations. The DON said the pharmacy consult did observations. The DON said there was education and in-servicing done by the facility and pharmacy. The DON said the pharmacist did necessary education if there was a need. During interview on 6/25/26 at 10:14 a.m., the ADON said regarding medication administration oversight for the MAs that it was the Infection Control and Education Coordinator's responsibility, but she did education from time to time if there was a situation that they needed to address immediately. The ADON said she did cart audits and MAR to cart audits to make sure the medications were on the medication cart.During interview on 6/25/26 at 11:36 a.m., the Infection Control Nurse and Education Coordinator said she did education for the MAs that included mandatory in-services[TT4.1][CD4.2]. The Infection Control Nurse and Education Coordinator said she did medication administration observations [TT5.1][CD5.2]with each MAs a couple of times a year. The Infection Control Nurse and Education Coordinator said during these observations she looked at the entire process. The Infection Control Nurse and Education Coordinator said that she checked that when the MAs pulled the medication card that it matched what was in the computer. Record review of the facility's policy Medication Administration revised August 2025 revealed it was the policy to administer medications to residents verified with physician's orders.

Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #9) reviewed for adequate supervision.The facility failed to ensure Resident #9 had quarterly fall risk assessments completed. The failure could place residents at risk of possible injury and not having appropriate interventions in place. Findings included:Record review of Resident #9's face sheet dated 6/25/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a condition in which the brain's function is impaired due to underlying metabolic or systemic disturbances rather than structural brain damage), muscle wasting and atrophy (decrease in size), other lack of coordination, generalized muscle weakness, weakness, and unspecified abnormalities of gait (a person's manner of walking) and mobility.Record review of Resident #9's annual MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 9 that indicated moderate cognitive impairment. Section J (Health Conditions) revealed Resident #9 had not had any falls since admission/entry or reentry or the prior assessment whichever was most recent. Record review of Resident #9's care plan dated 6/25/26 revealed Resident #9 was care planned with a focus of being at risk for falls related to immobility and incontinence with intervention to follow the facility's fall protocol.Record review of Resident #9's assessments tab in the electronic medical record accessed by the surveyor of 6/25/26 at 12:51 p.m. revealed Resident #9's last quarterly Fall Risk Assessment was completed 11/10/2025. Review of Resident #9's Fall Risk Evaluation dated 11/10/2025 revealed Resident #9 had not had any falls in the past three months.During interview on 6/25/26 at 9:43 a.m., the DON said the last fall evaluation for Resident #9 that had been completed was dated 11/10/25. The DON said fall evaluations were typically completed on admission, after each fall and with the quarterly evaluation of the resident. The DON said if a fall risk assessment was not completed then it could lead to missing some intervention that could have been done. The DON said fall assessments were completed by the floor nurses and sometimes the manager depending on the circumstances. The DON said there was a falls meeting by the falls committee on Fridays where they went over the falls. The DON said the falls committee was the DON, ADON, Education Coordinator, activity coordinator and restorative. The DON said regarding the fall evaluation for Resident #9, that he was due for the second quarter and they were still in the second quarter so Resident #9 would have one completed. The DON said the quarter was for everybody and if it could align with their quarterly assessment, they make sure it was completed for things like falls. During interview on 6/25/26 at 10:14 a.m., the ADON said fall assessments were completed on admission, quarterly and at the time of a fall. The ADON said an effect if could have on the resident if a fall assessment was not completed when they should be was that they could miss an intervention that needed to be put in place for safety for the resident. The ADON said regarding Resident #9 he had a fall evaluation assessment dated [DATE] that was created 1/23/26. The ADON said evaluations should be completed within the quarter. During interview on 6/25/2026 at 1:49 p.m., Resident #9 denied having any falls since he had been at the facility. Resident #9 said he did not walk but used the wheelchair to move around which was observed in the room. Resident #9 said staff were available to assist him when needed to get into the wheelchair. During interview on 6/25/26 at 11:36 a.m., the Infection Control Nurse and Education Coordinator said she did education regarding fall assessments. The Infection Control Nurse and Education Coordinator said fall assessments should be completed each time there was a fall and was completed when the nurse completed the incident report. The Infection Control Nurse and Education Coordinator said fall assessments were completed upon admission and quarterly or four months later. The Infection Control Nurse and Education Coordinator said she did not do audits or monitoring of fall assessments as the educational coordinator. Record review of the facility's policy Falls and Injuries written June 2025 revealed reassessment of fall risk shall be conducted at least quarterly and after any fall incident.

Based on interview and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 2 of 5 residents reviewed for immunizations. (Resident #3 and Resident #65)The facility failed to document, in Resident #3's and Resident #65's medical records, having had received education, whether by self or with responsible party, of the benefits and potential side effects of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal.This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal, or being informed of the benefits/risk which could cause respiratory complications and potential adverse health outcomes.Findings included:Resident #3 Record review of Resident #3's face sheet dated 6/23/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including vascular dementia (a type of dementia caused by problems with blood flow to the brain, leading to cognitive decline).Record review of Resident #3's quarterly MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 10 that indicated moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) revealed Resident #3 did not receive the influenza vaccine in this facility and was not in the facility during this year's influenza vaccination season. Section O did not reveal any information regarding Resident #2's pneumococcal vaccination. Record review of Resident #3's admission MDS dated [DATE] revealed Resident #3 did not receive the influenza vaccine in this facility and was not in the facility during this year's influenza vaccination season. Section O did not reveal any information regarding Resident #3's pneumococcal or COVID-19 vaccinations. Record review of Resident #3's care plan dated 6/25/26 did not reveal any information related to immunizations.Record review of Resident #3's electronic medical record, accessed 6/25/26 at 1:37 p.m. did not reveal any information under the immunization's tab. Resident #65Record review of Resident #65's face sheet dated 6/25/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial infection of the skin and underlying tissues) of right lower limb. Record review of Resident #65's admission MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 3 that indicated severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) revealed Resident #65 did not receive the influenza vaccine in this facility and was not in the facility during this year's influenza vaccination season. Section O revealed Resident #65's pneumonia and COVID-19 vaccinations were not up to date. Record review of Resident #65's care plan dated 6/25/26 did not reveal any information related to immunizations.Record review of Resident #65's electronic medical record, accessed 6/25/26 at 1:37 p.m. did not reveal any information under the immunization's tab. During interview on 6/25/2026 at 1:54 p.m., the ADON said they did not have consent forms for vaccines for Resident #65. The ADON said she had gone through the medical record, and it did not have the immunization vaccine information. The ADON said Resident #65 was combative and not agreeable at times. The ADON said they would call Resident #65's family to see about getting consent for the vaccines or ask if he had the vaccines. The ADON said Resident #65 had been at the facility for about three weeks. The ADON said they tried to get the vaccine information as soon as the resident came in the facility. The ADON said they offered the vaccines and if the resident declined, they had the resident sign the form that they did not want the vaccines. The ADON said if the resident had vaccine information from the hospital records, then they put the information in the immunizations tab in the electronic medical record. The ADON said hopefully we would have been able to get in touch with the family and if they do not want the resident to get the vaccines then we would get verbal information over the phone. The ADON said she was over the 400 hallway where Resident #65 resided as unit manager. The ADON said if immunization information was not documented the resident could potentially develop an infection. The ADON said it was her and the manager's responsibility to make sure immunizations were being monitored. During interview on 6/25/2026 at 2:10 PM, the DON said immunization history should be completed as soon as they receive the record and sometimes, they had to rely on the family for the residents that could not speak for themselves. The DON said they typically document immunization information on admission but some families you could not reach right away but as soon as they give the information they could proceed. The DON said some local hospitals did not put the vaccine information in the clinicals while others local hospitals did but not all the hospitals. The DON said that immunization data was not part of the admission screening or any other assessment. The DON said if a resident came in and the vaccine data was not available then that information should be documented in the nurse's note. The DON said the unit manager and the ADON monitored that the immunizations were input. The DON said the unit manager for Resident #3 was Unit Manager A. The DON said if vaccine information was not documented and the resident did not receive the vaccine then an effect could be if they do not receive the vaccine and they were exposed to the disease was then they could develop the disease.During interview on 6/25/2026 at 2:20 p.m., Unit Manager A said he was the unit manager for Station #2 where Resident #3 resided. Unit Manager A said it was the nurse on duty who admitted the resident to screen them for vaccinations. Unit Manager A said if the nurse did not have the vaccine information they could call the responsible party, call the discharging facility or ask the resident if able. Unit Manager A said he monitored that immunization information was being updated in the electronic medical record by going into the electronic medical record and having checked the immunizations tab. Unit Manager A said he was not aware that Resident #3 did not have immunization information documented. Unit Manager A said he did not have an answer to why immunization information was not documented for Resident #3, but he did refuse care often. Unit Manager A said if Resident #3 had refused immunizations, then that should have been documented.During interview on 6/25/26 at 2:31 p.m., the Infection Control Nurse and Education Coordinator said she assisted with the administration of the flu vaccines for the residents. The Infection Control Nurse and Education Coordinator said the admitting nurse was responsible for screening residents for immunizations and would offer the vaccine. The Infection Control Nurse and Education Coordinator said she was not involved with the monitoring of the immunization screenings of the residents. Record review of the facility's policy Control of Communicable Disease Influenza revised December 2024 revealed Upon admission to the facility, the admissions staff will present the resident or family member or responsible party with an informed consent to obtain permission to give the vaccine at the appropriate time of the season. (If it is known by the family, resident or responsible party that the vaccine has been given prior to admission, proof of vaccination is requested).Record review of the facility's policy Pneumonia vaccine revised December 2023 revealed Upon admission, the resident medical record is reviewed to determine their pneumococcal vaccination history.

Based on interview and record review, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 5 residents who were reviewed for immunizations. (Resident #3 and Resident #65) The facility failed to document, in Resident #3's and Resident #65's medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal.This failure could place residents at risk of not being informed of complications and potential adverse health outcomes.Findings included:Resident #3 Record review of Resident #3's face sheet dated 6/23/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including vascular dementia (a type of dementia caused by problems with blood flow to the brain, leading to cognitive decline).Record review of Resident #3's quarterly MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 10 that indicated moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) did not reveal any information regarding COVID-19 vaccinations. Record review of Resident #3's admission MDS dated [DATE], section O (Special Treatments, Procedures, and Programs) did not reveal any information regarding Resident #3's pneumococcal or COVID-19 vaccinations. Record review of Resident #3's care plan dated 6/25/26 did not reveal any information related to immunizations.Record review of Resident #3's electronic medical record, accessed 6/25/26 at 1:37 p.m. did not reveal any information under the immunization's tab. Resident #65Record review of Resident #65's face sheet dated 6/25/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial infection of the skin and underlying tissues) of right lower limb. Record review of Resident #65's admission MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 3 that indicated severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) revealed Resident #65's pneumonia and COVID-19 vaccinations were not up to date. Record review of Resident #65's care plan dated 6/25/26 did not reveal any information related to immunizations.Record review of Resident #65's electronic medical record, accessed 6/25/26 at 1:37 p.m. did not reveal any information under the immunization's tab. During interview on 6/25/2026 at 1:54 p.m., the ADON said they did not have consent forms for vaccines for Resident #65. The ADON said she had gone through the medical record, and it did not have the immunization vaccine information. The ADON said Resident #65 was combative and not agreeable at times. The ADON said they would call Resident #65's family to see about getting consent for the vaccines or ask if he had the vaccines. The ADON said Resident #65 had been at the facility for about three weeks. The ADON said they tried to get the vaccine information as soon as the resident came in the facility. The ADON said they offered the vaccines and if the resident declined, they had the resident sign the form that they did not want the vaccines. The ADON said if the resident had vaccine information from the hospital records, then they put the information in the immunizations tab in the electronic medical record. The ADON said hopefully we would have been able to get in touch with the family and if they do not want the resident to get the vaccines then we would get verbal information over the phone. The ADON said she was over the 400 hallway where Resident #65 resided as unit manager. The ADON said if immunization information was not documented the resident could potentially develop an infection. The ADON said it was her and the manager's responsibility to make sure immunizations were being monitored. During interview on 6/25/2026 at 2:10 PM, the DON said immunization history should be completed as soon as they receive the record and sometimes, they had to rely on the family for the residents that could not speak for themselves. The DON said they typically document immunization information on admission but some families you could not reach right away but as soon as they give the information they could proceed. The DON said some local hospitals did not put the vaccine information in the clinicals while others local hospitals did but not all the hospitals. The DON said that immunization data was not part of the admission screening or any other assessment. The DON said if a resident came in and the vaccine data was not available then that information should be documented in the nurse's note. The DON said the unit manager and the ADON monitored that the immunizations were input. The DON said the unit manager for Resident #3 was Unit Manager A. The DON said if vaccine information was not documented and the resident did not receive the vaccine then an effect could be if they do not receive the vaccine and they were exposed to the disease was then they could develop the disease.During interview on 6/25/2026 at 2:20 p.m., Unit Manager A said he was the unit manager for Station #2 where Resident #3 resided. Unit Manager A said it was the nurse on duty who admitted the resident to screen them for vaccinations. Unit Manager A said if the nurse did not have the vaccine information they could call the responsible party, call the discharging facility or ask the resident if able. Unit Manager A said he monitored that immunization information was being updated in the electronic medical record by going into the electronic medical record and having checked the immunizations tab. Unit Manager A said he was not aware that Resident #3 did not have immunization information documented. Unit Manager A said he did not have an answer to why immunization information was not documented for Resident #3, but he did refuse care often. Unit Manager A said if Resident #3 had refused immunizations, then that should have been documented.During interview on 6/25/26 at 2:31 p.m., the Infection Control Nurse and Education Coordinator said she assisted with the administration of the flu vaccines for the residents. The Infection Control Nurse and Education Coordinator said the admitting nurse was responsible for screening residents for immunizations and would offer the vaccine. The Infection Control Nurse and Education Coordinator said she was not involved with the monitoring of the immunization screenings of the residents. Record review of the facility's undated Policy and Procedure COVID-19 revealed the facility was to ensure all residents were up to date with COVID-19 vaccinations, including booster doses as recommended and to provide education on the benefits and potential

Based on interviews and record reviews, the facility failed to ensure residents were free from misappropriation (Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.) for 1 of 5 residents (Resident #1) reviewed for misappropriation. The facility failed to protect Resident #1 from being exploited when LVN A deliberately used $800 from the resident's money without the resident's consent. This failure may cause residents to be left without sufficient funds to pay for their own care necessities, psychological distress, paranoia, and feelings of guilt and shame that could prevent them from reporting abuse, neglect, or exploitation. Findings include: Record Review of Resident #1's Face Sheet, dated 04/30/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included diabetic retinopathy with macular edema in left eye (an eye condition where high blood sugar damages blood vessels in the retina), lack of coordination, muscle weakness, post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event), and complete traumatic amputation (surgical removal) at level between knee and ankle left lower leg. Record review of Resident #1's Quarterly MDS (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status, used in nursing homes), dated 03/29/2026, reflected a BIMS score (a standardized, mandatory 0-15 point cognitive assessment tool used in long-term care settings to measure mental acuity in residents) of 15 indicating the resident was cognitively intact. During an interview on 04/30/2026 at 1:05 p.m., Resident #1 stated he trusted LVN A and provided her with his debit card and his PIN number to buy him food. Resident #1 stated he received a call from his bank when a payment was declined for $300. He stated the bank employee advised him there were some small amounts of money taken from his account in small increments for a total $800 that he never authorized to come out of his account. He stated that he knew of only his son and LVN A having access to his card. So, he stated he informed Navy Credit to stop the card and send him another card. He stated he had a talk with his son and LVN A about the money missing from his account. He stated LVN A admitted to using some of his money but also agreed to pay him back. He stated LVN A made installments for all the money she owed from her pay checks. He stated he did not report the incident to the facility because he decided not to. He stated that was the first on only time such incident happened to him During an interview on 04/30/2026 at 2:14 p.m., Resident #1's Banker stated the bank call center provided the banker with a report on 05/16/2025 for Resident #1's credit card of declined transactions of $300, $100, $50 and $200. The banker stated Resident #1 told him he did not authorize any of those transactions. During an interview on 04/30/2026 at 2:27 p.m., LVN A stated she was a former wound care nurse for the facility. She stated Resident #1 gave her his bank card to purchase items. She stated she was not a designated staff at the facility to purchase items for residents. She stated she helped Resident #1 out with items he wanted. She denies using the resident's card or his money without his knowledge. During an interview on 04/30/2026 at 2:48 p.m., the Activities Director, who worked at the facility for 42 years, stated if residents let her know they needed items purchased, she picked up items for them. She stated residents also asked their family members to purchase items for them as well. She stated she was unaware of any facility staff purchasing items for residents; including Resident #1. She stated no staff were allowed to purchase items for residents except her. She stated if the facility staff, who were not designated to purchase items for the residents, took residents' money or bank cards to buy items, residents' money could be misused. During an interview on 04/30/2026 at 3:02 p.m., the Administrator stated residents who could not purchase personal items, could ask the Activities Director to purchase items for them. He stated residents who had debit or credit cards in their possession always were cognitively intact and could make their own decisions for purchases. The Administrator stated he always insisted residents put money or cards in a safe inside the Administrator's office or trust funds. He stated he could not make them adhere to that if they chose not to. He stated he was unaware of facility staff purchasing items for residents; including Resident #1. The Administrator stated he was unaware Resident #1 had a credit card in his possession, otherwise, he would have offered to keep it in the safe. He stated he expected LVN A to direct Resident #1 to the Activities Director when the resident needed items purchased and let the Administrator know as well so he could keep track of those purchases and offer to keep resident #1's card in a safe. He stated he instructed the facility staff in the past not to take money or cards from residents. He stated if staff, who were not designated to purchase items to residents, took residents money or cards it could lead to misappropriation of money or allegations of how money was spent. Record review of the Abuse and Neglect Prohibition Policy and Procedure dated April 2025, reflected .Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Definitions: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This is stealing from the resident. Record review of the Residents Rights, Residents funds Policy dated August 2025, reflected .Policy Statement: 1. Right to Self-Management: Residents may manage their own finances; the facility cannot force usage of its management services.2. Voluntary Participation: With authorization, the facility will hold resident funds either in a safe or in a trust fund.III. Responsible Staff: Only designated staff must assist in the management of resident funds.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 out of 5 residents (Resident #2, Resident #3, Resident #4, and Resident #5), reviewed for care plans. - The facility failed to document Resident #2's fall from 8/29/25, and interventions put in place, which included a low bed, and a clutter free area.- The facility failed to document Resident #3's falls from 11/17/25 and 11/27/25, and interventions put in place, which included a low bed.- The facility failed to document Resident #4's falls from 10/22/25, 11/18/25, 11/27/25, and 12/3/25, and interventions put in place which included increased rounding, ordering labs, work up for tachycardia, a low bed, and a clutter free area.- The facility failed to document Resident #5's falls from 9/23/25 and 9/24/25, and interventions put in place which included increased toileting, HS snack, a low bed, and a clutter free area. These failures could place residents at risk for receiving delayed treatment and not obtaining/maintaining their highest practicable wellbeing. Findings included: 1. Record review of Resident #2's undated face sheet revealed he was a [AGE] year-old male, admitted on [DATE] with diagnoses of cerebral infarction (stroke), lack of coordination, dysarthria after stroke (slurred, slow, soft, or monotone speech), hemiplegia and hemiparesis affecting right side after stroke (paralysis and weakness), aphasia (trouble speaking), unsteadiness on feet, type 2 diabetes (body unable to produce insulin or resists it), muscle weakness, muscle wasting and atrophy, muscle weakness, and lack of coordination. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. The resident had an impairment on one side of his upper and lower extremities and used a wheelchair for mobility. Resident #2 was dependent (helper does all the effort and resident does none) for all ADLs and was always incontinent of bowel and bladder. The assessment indicated the resident had 1 fall since admission/entry or the prior assessment, but he did not have any injuries. He was not receiving therapy services. Record review of Resident #2's Care Plan dated 1/23/24 revealed the resident had an actual fall r/t impaired mobility on 3/27/25 with no injuries, and 8/29/25 with no injuries (Initiated 5/1/25 Revised 11/24/25. The goal was to resume usual activities without further incident through the review date (Initiated 5/1/25 Revised 12/4/25). Interventions included: continue interventions on the at-risk plan (Initiated 5/1/25), for no injuries determine/address causative factors of fall (Initiated 5/1/25), monitor/document/report PRN x 72hr to MD s/sx of pain, bruises, change in mental status, new onset confusion, sleepiness, or agitation (Initiated 5/1/25), neuro checks as ordered (Initiated 5/1/25), PT consult for strength and mobility (Initiated 5/1/25). The resident also had a low bed and a clutter free area that was not updated for the fall on 8/29/25. Record review of Resident #2's Progress Notes dated 8/29/25 at 9:13pm revealed the resident fell from his wheelchair to the floor after his shower. A CNA was in the room and witnessed it. The resident said he was trying to get his clothes that were on the sink, and he slid from his wheelchair to the floor. He did not hit his head. The charge nurse found the resident lying on his left side on the floor, facing the sink, with his gown on. Neuro checks were started, and no visible injuries were noted. Resident was assisted back to bed. Record review of Resident #2's Progress Notes dated 8/30/25 at 1:02pm revealed the resident was s/p fall day 2 and he was in his w/c propelling himself around the unit. Record review of Resident #2's Physician Orders reviewed on 12/16/25 from MD R revealed the following orders: - Falls monitoring: Keep bed low in locked position- Falls monitoring: Keep resident area clutter free In an observation on 12/16/25 at 1:58pm, Resident #2 had a low bed and a fall mat to the side of his bed. The resident was not in the room. 2. Record review of Resident #3's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease, type 2 diabetes, complete traumatic amputation at level between left hip and knee (missing left leg at thigh level), gastrostomy (tube into stomach for nutrition), muscle weakness, contracture of right ankle, muscle wasting and atrophy, lack of coordination, and atrial fibrillation (irregular heart beat). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. The resident was dependent for all ADLs and had an impairment on one side of her upper and lower extremities. The assessment revealed she was always incontinent of bowel and bladder. The assessment indicated the resident had had 1 fall since admission/entry or the prior assessment, with an injury that was not major (skin tears, abrasions [skin rubbed off], superficial bruises [bruises that are not deep], sprains). She was not receiving therapy services. Record review of Resident #3's Care Plan dated 12/18/23 revealed she had an actual fall r/t impaired balance on 8/9/24 with no injuries (Initiated 11/18/24). The goal was to resume usual activities without further incident through the review date (Initiated 11/18/24 Revised 12/4/25). Interventions included: 8/9/24-fall mats to side of bed (Initiated 8/9/24), continue interventions on the at-risk plan (Initiated 11/18/24), monitor/document/report PRN x 72hr to MD s/sx of pain, bruises, change in mental status, new onset confusion, sleepiness, or agitation (Initiated 11/18/24), Neuro checks as ordered (Initiated 11/18/24), and PT consult for strength and mobility (Initiated 11/18/24). The fall from 11/17/25 and 11/27/25 were not on the Care Plan, along with the interventions that were put in place which included a low bed. Record review of Resident #3's Progress Notes dated 11/17/25 at 4:14am revealed the resident was found on the floor during nursing rounds at 3:30am. The resident was near the bed on the right side with her bed sheets and blankets. Her head was upright. Neuros were started and there were no injuries or complaints of pain. Record review of Resident #3's Progress Note dated 11/27/25 at 4:44am revealed the resident was found lying on the floor. There were no visible signs of injuries, and an assessment was performed. Record review of Resident #3's Physician Orders reviewed on 12/16/25 by MD R revealed the following order: - Fall Precautions: Keep bed in low position and locked. In an observation on 12/16/25 at 1:54pm Resident #3 was lying in bed with a PEG tube (tube into stomach for nutrition). The bed was in a low position, and the bed was locked. The resident was not interviewable. Record review of the facility's Fall Committee binder reviewed on 12/17/25, revealed Resident #3's 11/17/25 fall was reviewed on 11/21/25. The new interventions was for PT to screen the resident. The fall from 11/27/25 was reviewed on 11/27/25 and the new intervention was to keep the bed in a low position. 3. Record review of Resident #4's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of traumatic subarachnoid hemorrhage (brain bleed), cerebral infarction, hemiplegia and hemiparesis, neuromuscular dysfunction of bladder (bladder will not empty), neurogenic bowel (bowel will not empty), hearing loss, lack of coordination, unsteadiness on feet, muscle wasting and atrophy, lack of coordination, dementia, muscle weakness, and abnormalities of gait and mobility. Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15, which indicated moderately impaired cognition. The resident had an impairment on one side of his upper and lower extremities. The assessment revealed the resident was supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with all ADLs and used a w/c for mobility. Resident #4 had 1 fall since admission/entry or the prior assessment and did not have an injury from it. According to the assessment he was receiving ST, OT, and PT. Record review of Resident #4's Care Plan dated 1/29/25 revealed he had an actual fall r/t muscle weakness 1/25/25 with no injury (Initiated 1/29/25). The goal was to resume usual activities without further incident through the review date (Initiated 1/29/25 Revised 11/13/25). Interventions included: 1/25/25-Encourage resident to use call light for assistance (Initiated 1/29/25), continue interventions on the at-risk plan (Initiated 1/29/25), for no acute injuries determine and address causative factors of fall (Initiated 1/29/25), PT consult for strength and mobility (Initiated 1/29/25). The falls from 10/22/25, 11/18/25, 11/27/25, and 12/3/25 were not on the Care Plan. Also, their interventions were not on the Care Plan which included: increased rounds, labs ordered, work up tachycardia, low/locked bed, and clutter free area. Record review of Resident #4's Progress Notes dated 10/22/25 at 10:24am revealed the Nurse went to administer medication to the resident, she found him sitting on the floor, near his w/c. The resident said he slid from his w/c. No injuries seen and resident denied any pain. Neuros started and resident helped back to bed. Record review of Resident #4s Progress Notes dated 11/18/25 at 7:03am revealed a Nurse found the resident lying on the floor with the bed linen and a pillow under him. He was facing the door. He did not remember what happened and thought he fell. No injuries were found, and no complaints of pain were noted. Record review of Resident #4's Progress Notes dated 11/19/25 at 6:12am revealed the resident was s/p fall day 1 of 3. The bed was at the lowest position, the fall mat was in place, and the call light was within reach. Record review of Resident #4's Progress Notes dated 11/27/25 at 7:06am revealed the incoming day shift Nurse found the resident lying on the floor in a fetal position. There were no visible injuries, but the resident seemed confused. The resident was sent to the ER for further examination. Record review of Resident #4's Progress Notes dated 11/27/25 at 1:23pm revealed the resident went to the ER at 8:15am and came back to the facility at 11:15am. CT scan performed at the ER was negative, along with the COVID and flu tests. Record review of Resident #4's Progress Notes dated 11/30/25 at 6:42am read, no c/o pain from fall 11/27. Resident got up about 2am. Took off his brief and urinated on the floor by his bed. Cna then cleaned up him and his bed. Put a pull up on him. Resident then took that off and put on his regular pants and put self back to bed. At some point earlier resident had urinated in front of the toilet. Resident reminded to use call light for assist. Staff reminded to use pullup instead of brief. Staff monitored resident frequently. Neuro vital wnl. Ll [call] light within reach. Bed in lowest position. ( resident normally wears briefs). Record review of Resident # 4's Progress Notes dated 12/1/25 at 2:27pm read, resident Lab result seen by resident [NP]. no new orders given. Record review of Resident #4's Progress Notes dated 12/3/25 at 6:38am read, Resident is in bed resting with eyes closed, on fall precaution, bed at the lower position, fall mat in place, no s/s of distress or discomfort at this time, call light within reach, willcontinue to monitor. Record review of Resident #4's Progress Notes dated 12/3/25 at 3:21pm revealed the resident was observed on the floor at 12:40pm. The resident was assessed, and no injuries were noted. The resident was put back in his w/c and neuros were initiated. Record review of Resident #4's Progress Notes dated 12/4/25 at 12:52pm read, Dr. ordered STAT EKG, for low heart rate of 44. Record review of Resident #4's Physician Orders reviewed on 12/16/25 revealed the following orders from MD R: - Falls monitoring: Keep bed low in locked position- Falls monitoring: Keep resident care area clutter free- CBC and BMP (labs) In an observation on 12/16/25 at 2:01pm, the resident was not in his room. The bed was in a low position, and he had a fall mat next to his bed. Record review of the facility's Fall Committee Binder on 12/17/25 revealed Resident #4's fall from 10/22/25 was reviewed on 10/24/25, and the new intervention was a therapy evaluation. The fall from 11/18/25 was reviewed on 11/21/25 with a new intervention to increase rounding. His fall from 11/27/25 was reviewed on 11/27/25 and labs were ordered as a new intervention. The fall from 12/3/25 was reviewed on 12/3/25 with a new intervention to work up the resident's tachycardia (it should be bradycardia, low heart rate). 4. Record review of Resident #5' undated face sheet revealed he was an [AGE] year-old male admitted on [DATE] with diagnoses of syncope and collapse (dizziness and fainting), type 2 diabetes, muscle weakness, muscle wasting and atrophy, lack of coordination, atrial fibrillation, and emphysema (lung disease making it hard to breathe). Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 out of 12, which indicated moderately impaired cognition. The resident was substantial/max assist (helper does more than half the effort) with all ADLs and used a wheelchair for mobility. He was always incontinent of bowel and bladder. The assessment indicated the resident had had 1 fall since admission/entry or the prior assessment with no injuries. He was not receiving therapy services. Record review of Resident #5's Care Plan dated 3/22/25 revealed he had an actual fall r/t impaired mobility. Actual fall 4/25/25 with no injuries. Actual fall 4/26/25 with no injuries. Actual fall 6/4/25 with no injuries. Actual fall 6/20/25 with a bruise to the left ear. Actual fall 10/1/25 with no injuries. (Initiated 4/30/25 Revised 10/25/25). The goal was to resume usual activities without further incident through the review date (Initiated 4/30/25 Revised 11/18/25). The interventions included: continue interventions on the at-risk plan (Initiated 4/30/25), fall mat to side of bed (Initiated 4/25/25), monitor/document/report PRN x 72hr to MD s/sx of pain, bruises, change in mental status, new onset confusion, sleepiness, or agitation (Initiated 4/30/25), PT consult for strength and mobility (Initiated 4/30/25), and send to ER for evaluation and treatment (Initiated 4/25/25). The falls from 9/23/25 and 9/24/25 along with the interventions, which included increased toileting and a snack at night, were not updated on the Care Plan. Record review of Resident #5's Progress Notes dated 9/23/25 at 11:01am revealed the nurse was informed the resident was on the floor. She saw the resident lying with both legs resting on the rails of the bed and his body on the floor. There were personal items scattered across the floor. The resident said he was trying to pick something up from the floor. The resident had an abrasion to his right cheek and left elbow which were cleaned and bandaged. The resident was educated to use the call light. Record review of Resident #5's Progress Notes dated 9/24/25 at 7:27am revealed the resident was found lying on the floor next to his bed. He said he was going to go eat. There were no visible injuries, was assisted back to bed, and neuros were started. Record review of Resident #5's Progress Notes dated 9/24/25 at 8:26am read, nurse writer interviewed resident about his fall this morning. Resident stated he was trying to get out of bed and added he was very hungry. nurse writer educated him on using the call light and re reciprocated information. After stating he was hungry, nurse writer provided breakfast sandwich to resident, assisted to sitting position while in bed and resident ate without issue. floor mat is placed to right side of bed for fall risk. Record review of Resident #5's Progress Notes dated 9/24/25 at 10:30 by MD E read, On 09/23/2025, had an unwitnessed fall while attempting to pick an item from the floor; no acute injury identified. Neuro checks initiated and ongoing; patient remains clinically stable with stable vital signs.Patient has been participating in physical therapy with some functional improvement noted, though he remains frail with generalized weakness.Patient requires minimum to moderate assistance with his Activities of Daily Living (ADLs), including meal set up and personal care. He is wheelchair to bed bound. He is totally dependent for toileting and is incontinent of bowel and bladder. Cognitively, the patient is alert and oriented to person and place but has periods of confusion and is a poor historian.The patient is at high risk for falls, with recent unwitnessed falls on 09/23/2025 and 09/24/2025. Fall prevention measures, including a floor mat by the bedside and call light education, have been implemented. Neurochecks are ongoing. He is participating in PT/OT for strength and function improvement. Record review of Resident #5's Progress Notes dated 12/10/25 at 10:45am by MD R read.No falls reported. Participating in restorative therapy for muscle strengthening. Record review of Resident #5's Physician Orders reviewed 12/16/25 revealed the following orders by MD R: - Falls Monitoring: Keep bed low in locked position- Falls Monitoring: Keep resident area clutter free- Floor mat at bedside- Provide a nighttime snack at bedtime In an observation on 12/16/25 at 2:01pm Resident #5 was not in his room. The bed was in a low position and there was a fall mat next to his bed. Record review of the facility's Fall Committee binder reviewed on 12/17/25 revealed Resident #5's fall on 9/23/25 was reviewed on 9/26/25 with a new intervention to toilet more frequently. His fall on 9/24/25 was reviewed on 9/26/25 and the new intervention was to give a snack at bedtime. In an interview on 12/16/25 at 3:10pm, the DON said after a fall happened, education was provided to the staff on the floor about new interventions to put in place to help prevent another fall. He said they had a Fall Committee that met every Friday and discussed the falls from that week, ensured new interventions were in place, and discussed the Care Plan updates. The DON said the Fall Committee consisted of therapy, restorative, activities, and nursing. He said they discussed the falls, came up with a plan of action, and ensured everything was done like neuros, and fall assessments. He said the Care Plan was updated by MDS and as needed by the Unit Managers. He said the MDS Coordinator would be the one who updated the falls on the Care Plan. The DON said the Care Plan should be updated after each fall with a new intervention to help mitigate another fall from happening. The DON said however, the interventions were already put in place by the nurse when the fall happened. So even though the Care Plan was not updated, the interventions were already in place. He agreed that the Care Plan should be updated with each fall and intervention, but they kept the information in other areas as well that the floor staff had access to. In an interview on 12/16/25 at 3:38pm, the MDS Coordinator said she had been working in MDS for 1.5yr. She said this (12/16/25) was her first day back in 6 weeks. She said the Fall Committee met every Friday, and MDS was not part of the Committee. She said the Fall Committee decided what interventions to update the Care Plan with and then the Unit Manager emailed her the date of the fall and what interventions to include. She said she did not go on her own and update the falls without being told first what to update. The MDS Coordinator said if the Fall Committee did not email her to let her know about a fall, she would not know how to update the Care Plans. In an interview on 12/17/25 at 11:12am, LVN M said the Care Plan was where someone would find the interventions for a fall risk resident, and that the floor staff did not update the Care Plans. She said the Care Plan was not the only place to find the interventions and that when staff gave report during shift change they told each other who was a fall risk and what interventions were in place. LVN M said some fall interventions included a low bed, increased rounds, and bringing the resident to the nurse's station. In an interview on 12/17/25 at 11:19am, RN B said interventions for a fall would be on the Care Plan, but staff also discussed them at shift change. She said after a fall happened, the staff discussed the new intervention also. She said fall interventions included increased rounds, a low bed, fall mats, and reminding the resident to use the call light. In an interview on 12/17/25 at 11:30am, CNA C said interventions for a fall could be found on a Care Plan. She said she also got updates about fall risk residents and interventions, in shift change. She said if she was not sure, she would ask her Unit Manager. CNA C said some of the fall interventions included keeping the bed and wheelchair locked, making rounds, and keeping the residents' items within reach. In an interview on 12/17/25 at 3:13pm with both the ADM and DON, the ADM said leadership met with the floor staff after the Fall Committee to inform them of the updated interventions. The DON said the Unit Managers were the ones who would go back to the nurses and inform them. Then the nurses would inform the CNAs. The DON said the Unit Managers met with the nurses daily and then at 2pm, and they had a shift change meeting and a meeting with the oncoming RN Manager. The DON said the evening Manager had a meeting with the nighttime Manager at shift change, and then the nighttime Manager had a meeting with the Unit Managers. The ADM said after the interventions were put in place, the Unit Managers, ADON, and the DON made rounds to ensure the interventions were there. The ADM said the MDS Coordinator was notified of the fall updates by other means and not just an email. The ADM said they had other safety meetings where falls were discussed, and the MDS were in attendance. The ADM and the DON both admitted that staff were implementing fall interventions, they were just not documented. They said they had an IDT meeting and were going to update every Care Plan. Record review of the facility's policy and procedure on Falls and Injuries (written June 2025) read in part: It is the policy of [NH] to minimize the risk of incidents or injuries to residents. The purpose of this policy is to establish a comprehensive, interdisciplinary program for. the standardized procedure for responding to a fall incident to protect residents from injury and promote their highest practicable physical well-being. Review and update the resident's fall risk assessment and care plan based on the findings of the investigation. The Falls committee will regularly review fall incidents, trends, and data to identify patterns (e.g., time of day, location, staff present). The program will be continuously evaluated for effectiveness, and adjustments to policies and procedures will be made as needed. Record review of the facility's policy and procedure on Health Care Plans (Revised March 2024) read in part: It is the policy of [NH] to involve all disciplines in the development of a resident health care plan that recognizes the resident's right to achieve his/her personal health goals. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition changes. Residents are re-assessed, and the care plan is updated at least every three (3) months or when a change in the resident condition occurs, such as weight loss or gain, decubitus ulcers development, dehydration, etc.

Based on observations, interviews, and record reviews the facility failed to ensure residents were free from sexual abuse and physical abuse for three of ten residents (Resident #61, #52 and #48) reviewed for abuse. -The facility failed to have a policy and procedure in place to address the determination of capacity to consent to sexual activity for residents who lacked the cognitive ability to consent. On 2/25/25 RA A witnessed inappropriate sexual behavior between two residents who had dementia. Resident #61 had his mouth on Resident #52's breast. -The facility failed to ensure Resident #48 was free of abuse when CNA A pushed Resident #48's face into his bed railings while providing incontinence care. This failure was identified as Non-Immediate Jeopardy. An Immediate Jeopardy situation was identified on 04/30/25. The IJ template was provided to the facility on [DATE] at 05:23 PM. While the IJ was removed on 05/03/25 at 1:00 PM the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of non-consensual sexual relations, physical pain, psychosocial distress and feeling uncomfortable. Findings include: Record review of the provider investigation report submitted to the state by the Administrator dated 3/04/2025 revealed in part: .Description of the Allegation: On 2/25/25 a staff member walked into the room of the listed female resident (Resident #52), observed the listed male resident (Resident #61) with his mouth on the breast of the female. The male was asked to leave the room without incident. The male resident was placed on one-to-one supervision until his transfer to a psychiatric/behavioral hospital for further evaluation/treatment. Both residents have a diagnosis of Dementia. Both residents have the capacity to be interviewed, however the female resident does not have the capacity to make informed decisions. The female resident was assessed for injuries. None were found or reported RP/Physician notified. RP reported that she did not want to send female resident to SANE-Sexual Assault Nurse Examiner. Resident is currently being followed by psychiatric services Incident reported to law enforcement .RPs, Physicians, Ombudsman notified. Staff in-serviced on Abuse. Other residents interviewed, no other incidents were reported or found. All residents are being monitored for both comfort and safety. Investigation Summary: Confirmed. Male resident placed on one to one supervision until transfer to psychiatric/behavioral hospital . Further review revealed police incident #0252699-25 and a witness statement from RA A confirming she witnessed Resident #61 in Resident #52's room with his mouth on her breast and was reported to the nurse on duty and the DON, he was asked to leave the room. The report included the facility's Abuse and Neglect policy as well as policy for Patient Care with Dignity, Respect and Safety. The report included staff in-service sign in sheet dated 2/25/25 and resident safe surveys conducted by the SW. Record review of Resident #61's face sheet dated 04/01/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia, cognitive communication deficit, muscle weakness and unsteady on his feet. Record review of Resident #61's admission MDS (a resident assessment tool) dated 8/13/2024 indicated he had a BIMS score of 11 out of 15 indicating moderately impaired cognition. He had no physical behavioral symptoms directed towards others. He used a walker for mobility. Record review of Resident #61's quarterly MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderate impaired cognition. Resident #61 had no physical behavioral symptoms directed towards others. Record review of Resident #61's undated care plan, downloaded from the electronic health records at entrance on 04/01/25, revealed the care plan did not address an inappropriate sexual incident on 2/25/2025 involving Resident #52 or sexual behaviors towards any other individuals. Record review of Resident #52's face sheet dated 04/01/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, depression, and cognitive communication deficit. Record review of Resident #52's admission MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating severe cognitive impairment. Further review of the admission MDS revealed she had no physical behavioral symptoms directed towards others. Record review of Resident #52 quarterly MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. Resident #52 sometimes felt lonely or isolated from others. Resident #52 had no physical behavioral symptoms directed towards others. Record review of Resident #52 undated care plan downloaded from the electronic health records at entrance on 04/01/25 revealed, Focus - Resident #52 received anti-anxiety medications daily for anxiety, date initiated 12/10/24. Interventions included: monitor/document/report PRN any adverse reactions to anti-anxiety therapy to include unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Further review revealed the care plan did not address an inappropriate sexual incident on 2/25/2025 involving Resident #61 or sexual behaviors towards any other individuals. Record review of Resident #61's progress note dated 2/25/25 at 3:16 PM and written by LVN C revealed when Resident #61 was observed with his mouth on Resident #1's chest, immediate intervention was provided to separate the residents and ensure safety. Resident #61 was redirected, and the resident was placed on one-on-one observations. Record review of the facility's one-on-one Behavior Monitoring Form dated 2/25/25 and 2/26/25 revealed Resident #61 was checked hourly after the incident starting on 2/25/25 at 3:00 PM and ending on 2/27/25 at 6:00 AM. CNA B and CNA C documented no behaviors were observed. The form was signed by the supervisor LVN C. Record review of Resident #61's Behavioral Health Diagnostic Assessment from the facility dated 03/14/2025 written by the Psychologist indicated the reason for referral was anxiety and the assessment indicated there was no sexual acting out. Record review of Resident #52's Behavioral Health Plan of Care from the facility dated 03/14/25 and written by the Psychologist indicated a primary diagnosis of adjustment disorder, anxiety, depression, and a secondary diagnosis of mild dementia with psychotic disturbance. The therapy focused on reducing symptoms of depression and anxiety. The resident was not a good historian and was occasionally confused. Further review revealed the sexual activity incident on 2/25/25 was not addressed. In an interview on 04/01/25 at 09:30 AM, RA A said back in February 2025 she walked into a resident room, and she witnessed Resident #52 and Resident #61 engaging in sexual activity. She said Resident #52 had her shirt up and Resident #61 was sucking on her breast. RA A said she tried to intervene and separate the residents but Resident #52 said she wanted Resident #61 to stay. RA A said she did not think Resident #52 was cognizant enough to give consent, so she immediately notified her nurse. In an interview on 04/01/25 at 11:45 AM, the DON stated the MDS nurse would normally be the one to update the care plan and he expected this after the incident with Residents #61 and #52. In an interview on 04/01/25 at 1:00 PM, the ADON stated the care plan should have been updated as soon as possible after the occurrence between Resident #61 and #52. The ADON stated she did not know why it was not updated but it should be as Resident #52 had behaviors and if there were specific approaches that were not reflected in the care plan, it would affect the care of the resident. The ADON stated Resident #61's care plan should also be updated for the same reason. In a telephone interview on 04/01/25 at 1:15 PM, the MDS Nurse stated she was one of the MDS nurses in charge of the long-term care residents and that the unit managers were responsible for updating care plans if behaviors for Residents #61 and #52 were involved since they were the ones who usually conduct the care conferences with the family and resident. The MDS nurse stated other responsible staff would be the SW and ADON. In an interview on 04/01/25 at 1:45 PM, the SW stated the care plan for Resident #61 and #52 should have been updated due to behavior issues and the purpose of the care plan was to reflect everything about the resident. The SW stated the incident could happen again if the care plan was not updated. Telephone interview on 4/1/2025 at 6:58 PM, Resident #61's RP stated he was unsure about whether he was ok with Resident #61 having sexual relations and he would wait until the next care conference to discuss it with the facility. The RP said Resident #61 had some degree of Alzheimer's but was not a predator. In an observation and interview on 04/02/25 at 8:45 AM, Resident #61 was in his room lying on his bed awake and alert. Resident #61 stated he was moved to room [ROOM NUMBER] a few days ago and did not know the reason for the move. In an observation and interview on 4/16/2025 at 2:14 PM, Resident #52 denied the incident about a male resident coming into her room and sucking on her breast. She said it was a fairytale and never happened. She stated she did not recognize Resident #61's name. The resident was not in any distress. Interview on 4/16/2025 at 4:20 PM, the DON stated according to the staff he was told Resident #52 was holding her shirt up and Resident #61 had his mouth on her breast. The DON stated there were no other incidents, that that was a situation they had never faced before. The DON stated there was no real reason for Resident #61 and #52 to be able to consent since they both have dementia. Resident #61 had never done anything like that before and had never been a trouble resident. The DON stated that capacity to consent forms for residents with dementia may be in the facility admission Packet, it may state the RP makes the decisions and that he would have to look and see what he could find as he was not sure. Interview on 4/16/2025 at 5:18 PM, Resident #61 stated he admitted he often went by Resident #52's room to make sure she ate. He would not say what he did and began using expletives and the interview ended. Telephone interview on 4/16/25 at 5:41 PM, Resident #61's RP stated that he was not sure about consenting for him to have sexual relations because he was only his nephew. He asked the surveyor if the elderly were still having sex in the nursing home. He did not provide an answer when asked if Resident #61 could consent to sexual relations. Telephone interview on 4/17/2025 at 9:14 AM, Resident #52's RP stated she would not prevent it if Resident #52 chose to have a male resident in her room, that she would let her live out her days the way she would like to and that if a sexual interaction happened again, she would not do anything. The RP stated something like that had never happened before. The RP stated the facility had never asked for consent to have sexual relations. The RP stated Resident #52 could not make decisions for herself and that she was like a [AGE] year-old. Interview on 4/17/2025 at 11:38 PM the Administrator stated Residents #61 and #11 had an established friendship that both families were aware of and were OK with. Resident #52 had not been deemed incompetent because she would tell him that she could make her own decisions. The Administrator stated the facility did not have consent forms for sexual activity. The Administrator stated there was no specific assessment for capacity to consent to sexual activity. The Administrator stated there was no specific policy when, how, who determined capacity to consent to sexual activity and where it would be documented. The Administrator stated we make it clear in resident rights and abuse policy we would be infringing on their rights. The Administrator stated at the time we assessed that neither resident was at risk. The Administrator stated, If it would happen again, they would be in the same situation, and he would not know how it would be addressed. The Administrator stated there were no policy revisions made after the investigation. The Administrator stated Resident #61 was moved from 400 hall to 200 hall due to the process of making a specialized are on Hall 400. On 04/17/2025 at 11:33 AM, an attempt was made to call Resident #61's physician. A voicemail and text message were sent to return Surveyor's call. No call back was received. Telephone interview on 4/17/2025 at 11:57 AM, Resident #52's Physician stated she had been notified about the incident. She stated Resident #52 did not have the capacity to consent to have sexual relations with other residents. She said at her stage of dementia, she would not understand fully what was happening. She said she was not a psychiatric doctor and not sure if she could have suffered any psycho-social harm but Resident #52 would possibly understand pain or injury. Telephone interview on 4/17/2025 at 12:27 PM, RA A stated she saw Resident #61 with Resident #52 at the entrance to Resident #52's room and noticed Resident #61 doing inappropriate things to Resident #52. RA A stated she tried to make Resident #61 leave but Resident #52 did not want him to leave. RA A called out for a nurse and nurse (unknown name) was able to get Resident #61 to leave. RA A stated she was instructed by the Administrator to sit with Resident #61. Telephone interview on 4/17/2025 at 3:00 PM, Resident #52's Psychologist stated she was not notified of the incident. Resident #52 would not have the capacity to consent to sexual relations due to her dementia worsening over the past 6 months. In a telephone interview on 04/18/25 at 1:30 PM, LVN C stated nursing staff were monitoring Resident #61 round the clock after the incident and remained by his side until he was transferred to the hospital on 2/27/25. LVN C stated Resident #61 had no behaviors and was always pleasant, friendly, and kept to himself. LVN C stated she worked quickly to get him to the behavioral hospital as soon as a bed was available. LVN C stated she had never seen sexual inappropriate behavior by Resident #61 or any resident before. LVN C confirmed she signed the one-on-one Behavior Monitoring Form dated 2/25/25 and 2/26/25. In a telephone interview on 04/18/25 at 3:50 PM, CNA C stated she observed Resident #61 every time he moved and followed him if he stepped out of the room. CNA C stated Resident #61 remained in his room and had no behaviors. CNA C stated she did sign the monitoring sheets dated 2/25/25 to 2/26/25 and confirmed her initials. Record review of the facility's Abuse and Neglect Prohibition Policy and Procedure, revised 02/24/2016 read in part Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriations of property .Definitions: .Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault .Investigation: 1. The facility will conduct an investigation on any alleged abuse/neglect, injuries of unknow origin, or misappropriation of resident property in accordance with state law . Further review of the policy did not address capacity to consent to sexual activity and how to assess capacity to consent to sexual activity. Record review of a copy of the facility's undated admission Packet revealed consent to sexual activity was not addressed. Record review of the facility's QAPI committee policy and procedure, written April 2024 revealed in part .It is the policy of the facility to establish a multi-disciplinary team whose responsibility is to monitor and evaluate systems of care, management practices, clinical care, residents' choice and quality of life to ensure our residents receive the highest quality of care possible .Our purpose entails identifying problems, initiating a plan of action to resolve problems, evaluate the results of actions taken to ensure effectiveness, review and revise action plans as necessary to obtain effectiveness and to review and revise facility policies, procedures and protocols when necessary . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 04/30/25. The Administrator was informed and provided the IJ template on 04/30/25 at 5:23 PM. A Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 05/02/25 at 03:13 PM. Plan of Removal: Item 1 was a revised Policy and Procedure for Sexual Abuse, which was completed on 5/1/25. The revision included an assessment and process to determine a resident's capacity to consent to sexual activity. This was completed on 5/2/25. Item 2 was placing Resident #61 on one-to-one supervision until a third mental health evaluation could be completed to determine if the resident was a threat to himself or other residents. Resident #61 was also evaluated to determine capacity to consent to sexual activity. This was completed on 5/2/25. Item 3 was Resident #52 being re-evaluated for her ability to consent to sexual activity, updating care plan, and ongoing psychosocial services. This was competed on 5/2/25. Item 4 was the process for enforcement of the new policy for residents that are found to have engaged in sexual activity. This was completed on 5/1/25. Item 5 was staff in-service on revised Policy and Procedure for Sexual Abuse. No staff was permitted to work until receiving the in-service. This was completed on 5/2/25. Monitoring of Plan of Removal: Record review of the facility policy titled Resident Sexual Activities dated April 2025 revealed the purpose of the policy was to establish policies and procedures for addressing both consensual /non-consensual sexual interactions involving residents, including investigation, and documentation. Procedures for the policy were: 1.Residents whose Brief Interview for Mental Status (BIMS) is 10 or below will be assessed for capacity to consent to sexual activity. 2. If the resident has demonstrated the ability to consent to sexual activity, the facility will provide adequate accommodation for space and privacy. Residents may be provided with basic education such as the use of condoms, sexually transmitted diseases etc. 3. If a resident has not demonstrated the ability to consent to a sexual activity, his/her responsible party will be notified of the sexual behavior (s) or desire to participate in one; in conjunction with the responsible party or medical power of attorney a plan to ensure the resident's safety from unwanted sexual acts(s) will be developed and implemented. 4. If a resident is a recipient of an unwanted sexual act by another resident the following steps will be taken: 1. Provide adequate monitoring for the resident until the person initiating the unwanted sexual act is either removed from the facility and or threat is neutralized. 2. If the person initiating the unwanted sexual act is a resident, this person will be placed on one-to-one monitoring until he/she is evaluated by a licensed mental health professional, discharged from the facility or deemed safe to remain in the facility, by a licensed professional. 5. When it has been determined that a sexual act between residents has occurred, all involved residents will be interviewed to determine if the act was consensual, and their response will be documented in the medical record. For residents which have been determined to not have the ability to consent to a sexual activity, the party responsible or power of attorney can record the response on behalf of the resident. 6. The facility's ombudsman will continue to be notified of reportable incidents of abuse and be utilized as a resource to advocate for resident rights. 7. The resident's care plan will be updated accordingly. Record review revealed the facility completed an assessment tool to determine a resident's capacity to consent to sexual related activities will be completed by any resident whose BIMS Score is 10 or below. The assessment tool submitted specifically addressed the residents understanding of what may be defined as a sexual activity and his/her ability to willingly consent without duress or coercion. The assessment would be administered and scored by a licensed mental health professional. A Licensed Mental Health Professional (LMHP) is a certified practitioner in the field of mental health, with the education, training, and licensure to provide a range of mental health services. Observation and record review from 5/1/25 to 5/5/25 throughout the survey revealed Resident #61 was placed on 1:1 supervision on 2-25-25 and remained on 1:1 supervision until he was sent to a behavioral health hospital on 2-27-25 for evaluation. He returned to the facility on 3-11-25 with no special instructions for supervision and returned with medications for hyper-sexual activity. Those medications were subsequently removed by his primary physician. There have been no sexual or other behaviors post interaction with Resident #52. Resident #61 was again placed on 1:1 supervision from 4/18/25 to 4/24/25 due to concerns from state surveyor. The resident was re-evaluated by a mental health professional on 4-24-25 and was subsequently able to consent to sexual related activities. His care plan was updated 4-24-25. In addition, the submitted assessment was administered to Resident #61, he had the capacity to consent to sexual activity. The resident was again placed on 1:1 supervision during the Plan of Removal and Monitoring and remained on until 5/2/25. The psychological re-assessment was completed by Psychiatric Nurse Practitioner on 5-2-25 and Resident #61 had not been found be a threat to himself, staff, or other residents. Record review revealed Resident #52 was evaluated on 5/2/25 by Psychiatric Nurse Practitioner and it was determined that she does have capacity to consent to sexual behavior. Review of staff in-service records regarding revised policy and procedure for sexual abuse was conducted on 5/3/25. Observed sign in sheets dated 5/1/25, 5/2/25, and 5/3/25 for education regarding new policy. Staff listed below were interviewed and were able to verbalize multiple types of abuse to include sexual abuse. They reported that they had received in- service specifically for resident with resident sexual activity. Staff were able to report that they are aware that upon admit that all residents will be assessed by the BIMS tool for mental status. Resident that receives 10 or less will then be given a more in-depth questionnaire concerning their ability to make consent regarding sexual activity and need to be assessed by a qualified mental health professional. Those residents who qualify and are able to give consent to sexual activity will be given privacy and education regarding condoms and sexual transmitted disease. Nurses were able to report if the resident was unable to consent to sexual activity she would notify the administrator, representative, POA. All staff reported in the event a resident was found to be involved in sexual activity and consent had not been received the resident would then be placed on one-on-one and assessed by a qualified medical professional. Staff will begin documenting sexual activity consent in the chart when it is consensual. In the event the sexual activity is not consensual the sexual activity, the residents would be separated and the event would be reported to the administrator. The care plan would be updated. 5.3.25 at 11:10 am LVN D 5.3.25 at 11:20 am CNA D 5.3.25 at 11:32 am LVN E 5.3.25 at 11:38 am LVN F 5.3.25 at 12:00 am CNA E 5.3.25 at 12:07 am RN B 5.3.25 at 12:16 pm RN C Interviews with the Administrator and DON from 5/1/25 to 5/5/25 throughout the survey revealed that residents that were found to have engaged in a sexual activity without another resident consent or with a resident that did not have the capacity to consent will be monitored one on one until a determination has been made by a licensed mental health professional regarding their ability to remain in the facility or until an alternate placement has been secured. The facility's nursing administration will be responsible for the scheduling and monitoring of residents placed on one-to one supervision. Daily oversight will be provided to ensure that the facility has the resources to do so, and that the supervision is carried out. The facility's Administrator will assist the nursing administration with the task. The facility was informed the immediacy was removed on 05/03/25 at 01:02 PM. The facility remained out of compliance at a scope of isolated at a severity level of no actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Failure identified outside of IJ Resident #48 Record review of Resident #48's face sheet, dated 04/02/25, revealed, a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #48 had diagnoses which included: type 2 diabetes, retention of urine, generalized muscle weakness, hemiplegia and hemiparesis (conditions causing weakness and paralysis on one side of the body) affecting right dominant side following a stroke ( brain tissue damage caused by blocked blood flow to the brain) and morbid obesity due to excessive calories. Record review of Resident #48's MDS, dated [DATE], revealed intact cognition as indicated by a BIMS score of 15 out of 15. Resident #48 had no verbal or physical behavioral symptoms directed towards others, no rejection of care, total dependence on staff for toileting hygiene and always incontinence of bowel. Record review of Resident #48's Care Plan, completed on 02/14/25 , revealed focus- ADL self-care deficit due to right hemiplegia, interventions- toileting: total assist with 1 staff, side rails- observe for injury or entrapment related to side rail use, reposition as necessary to avoid injury. An observation and interview on 04/01/25 at 08:37 AM revealed Resident #48 in bed with no pants with an incontinence brief visible. The resident had a blanket draped over his lower abdomen to mid-thigh. Resident #48 said in the previous month (February) when CNA A was providing incontinence care she rolled him on his side and his face was pushed into the bed railing. He said he screamed at CNA A to stop, she did not apologize, and he did not know if the CNA did it intentionally. He said CNA A was typically rough and rude during incontinence care and after the incident he requested she did not provide him care any longer. Resident #48 said the incident did not make him feel bad about himself or unsafe in the facility because CNA A was suspended and then terminated after the incident. He said he did not experience pain or sustain any injuries from the incident and the rest of the facility staff were fast and helpful even when he did not request for help. In an interview on 04/01/25 at 10:55 AM, LVN A said in February of 2025, Resident #48 reported he no longer wanted CNA A to provide care to him. She said the resident reported CNA A pushed his face into the bed rails when providing incontinence care and he had to yell at CNA A to stop. She said she notified the ADON and DON of the incident immediately following the incident. LVN A said other unidentified residents complained about CNA A's care in the past due to the staff being rough/rude. In an interview on 04/01/25 at 09:25 PM, CNA A said she was terminated from the facility following the incident with Resident #48. CNA A said when she provided incontinence care to Resident #48 with an unnamed student CNA, the resident did not have any complaints and there were no issues. She said when she turned Resident #48 on his side to clean, his peri area, she did not push the resident's face into the railing, he did not tell her to stop. CNA A said Resident #48 used a draw sheet, a piece of bedding used in healthcare settings to assist with repositioning patients to minimize friction and strain, since the resident was a large gentleman and his size made it impossible for her to push his face into the railing. In an interview on 04/01/25 at 11:13 AM, the DON said Resident #48 reported CNA A was rough when she turned him to wipe his backside during incontinence care, and the resident did not sustain any injuries or experience a change of condition following the incident. He said when he interviewed CNA A she apologized and claimed she did not push the resident into the railings. The DON said residents had previously complained about CNA A being assertive and some residents found her threatening. He said it was just CNA A's nature, and even with staff the way she talked could come off as combative so they had 1on1 conversations with her to see if she could change the way she talked. The DON said after the incident with Resident #48, management realized they tried everything, but she was not getting better and since she was not a good fit she was terminated. The DON said he did not think CNA A was a safety risk to residents emotionally or physically while she was employed at the facility. In an interview on 04/01/25 at 12:19 PM, the Administrator said the facility had no records of 1on1 conversations with CNA A regarding resident care . In an interview on 04/02/25 at 10:05 AM, the ADON said when performing incontinence care there needed to be 2 people who could assist with turning using the positioning sheet that way the other person not providing care could prevent the resident from hitting the railing. She said a pillow could also be used to prevent a resident from hitting the rails when turned to the side during incontinence care. The ADON said Resident #48 was alert, oriented and communicated his needs well. She said he did not have behaviors that would deem the resistant to care but he refused aspects of care in the past centered around catheter care. The ADON said sometime in February Resident #48 said when CNA A provided incontinence care she turned him over and his face touched the railing. She said all staff were trained and expected to be empathetic with residents, to be patient, kind, have a gentle touch and voice and honor the residents wishes. The ADON said CNA A was friendly and had a stern appearance which could be an issue for someone not knowing her. She said from everything she saw, CNA A had a gently voice

Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 7 Residents (Resident #61, Resident #52 and Resident #17) reviewed for care plans. The facility failed to ensure Resident #61's care plan with interventions for the inappropriate sexual interaction on 2/25/2025 was documented in a timely manner. The facility failed to ensure Resident #52's care plan with interventions for the inappropriate sexual interaction on 2/25/2025 was documented in a timely manner. The facility failed to ensure Resident #17's care plan accurately reflected the resident's behaviors which included yelling without stimulus, fighting the air . These deficient practices could place residents at risk of nonconsensual sexual relations and not receiving proper care and services. The findings include: Record review of Resident #61's face sheet, dated 04/01/2025, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia , heart failure, COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), diabetes, muscle weakness and cognitive communication deficit. Record review of Resident #61's quarterly MDS (resident assessment tool), dated 02/12/2025, revealed a BIMS score of 10 out of 15, which indicated moderate impaired cognition. Resident #61 had no potential indicators of psychosis, no presence of behavioral symptom, no rejection of care. Resident #61 had functional limitations and impairment to one side of the upper extremity. He used a walker for mobility. He required supervision or moderate assistance from staff for most ADLs. Record review of Resident #61's, undated, care plan revealed an inappropriate sexual incident on 2/25/2025 which involved Resident #52 was not addressed until 4/2/25. Further review revealed readmission from the hospital on 3/11/2025 was also not addressed until 4/2/25. Resident's care plan stated that the resident would not be allowed to be alone in any female resident's room. Record review of Resident #52 face sheet, dated 04/01/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia, age-related physical debility, muscle weakness, depression, and cognitive communication deficit. Record review of Resident #52 quarterly MDS, dated [DATE], revealed a BIMS score of 6 out of 15, which indicated severe cognitive impairment. Resident #52 sometimes felt lonely or isolated from others. Resident #52 had no potential indicators of psychosis, no presence of behavioral symptom, no rejection of care Resident #52 required moderate to maximal assistance from staff with most ADLs and used a wheelchair for mobility. Record review of Resident #52, undated, care plan revealed Focus - Resident #52 received anti-anxiety medications daily for anxiety, date initiated 12/10/24. Interventions included: monitor/document/report PRN any adverse reactions to anti-anxiety therapy to include unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Further review revealed a sexual activity incident on 2/25/2025 which involved Resident #61 was not addressed until 4/2/25. Resident #61 and Resident #52 are not to be alone together in either of their rooms. Residents will be allowed to visit in the common areas. Record review of the facility's incident report, dated 2/25/2025, read in part: .Description of the Allegation: On 2/25/25 a staff member walked into the room of the listed female resident (Resident #52), observed the listed male resident [Resident #61] with his mouth on the breast of the female. The male was asked to leave the room without incident .[Resident #52] was assessed head to toe and no injuries found or reported Record review of Resident #52's progress note, dated 2/26/2025 at 5:22 PM, written by SW revealed a telephone conversation between Resident #52's RP, the Administrator, and the SW. The progress note revealed the RP was asked if it were ok if Resident #52 and Resident #61 wanted to be in a consensual relationship, that it would be care planned accordingly. The progress note revealed RP planned to meet with the rest of the family within the week to discuss their thoughts on the matter. Further review of Resident #52's progress notes, dated 02/26/2025 to 04/01/2025, revealed no documentation of follow up with Resident #52's RP until 4/2/25. Record review of Resident #61's progress note, dated 2/25/2025 at 3:48 PM, written by the ADON revealed Resident #61's RP was notified via telephone that Resident #61 had an inappropriate interaction with another resident and would be sent to the hospital for a behavioral evaluation. Observation on 4/01/2025 at 10:55 AM, revealed Resident #52 was in a wheelchair, self-propelling down the hallway. Resident #52 was cleanly dressed and in no distress. In an interview on 04/01/25 at 09:30 AM, RA A said back in February she walked into a resident room, and she witnessed Resident #52 and Resident #61 engaging in sexual activity. She said Resident #52 had her shirt up and Resident #61 was sucking on her breast. RA A said she tried to intervene and separate the residents but Resident #52 said she wanted Resident #61 to stay. RA A said she did not think Resident #52 was cognizant enough to give consent, so she immediately notified her nurse . In an interview on 4/01/2025 at 11:45 AM, the DON stated on 2/25/2025 it was reported to him Resident #52 and Resident #61 were observed at the doorway of Resident #152's room. Resident #52 had her shirt up and Resident #61's mouth was on her breast. The DON stated the staff immediately intervened and separated the residents. The DON stated as far as he knew, the RP of Resident #52 did not have any problems with the friendship between Residents #52 and #61, even if it was sexual. The DON stated the MDS nurse was responsible to update care plans and expected the care plans for both Residents #61 and #52 to be updated after the incident. In a telephone interview on 4/01/2025 at 6:50 PM, Resident #61's RP stated the facility notified the RP regarding the incident on 2/25/25. In an observation and interview on 4/02/2025 at 8:45 AM, revealed Resident #61 was lying on his bed awake, alert and not in distress. He stated he just got moved to his current room from another room and did not know why he was moved. In an interview on 4/2/2025 at 1:00 PM, the ADON stated usually the MDS nurse would update care plans. The ADON stated the care plan was what drove the resident's care and would need to be updated to reflect the occurrence between Residents #61 and #52. The ADON stated Resident #52 had behaviors and it should be updated to include a new approach. The ADON stated she did not know why the care plans were not updated and would have to check to see if there was information needed before the update . The ADON stated if approaches were not listed in the care plan, this would affect the care of Resident #61 and Resident #52. In a telephone interview on 4/2/2025 at 1:15 PM, MDS A stated she was one of the MDS nurses in charge of the long-term care residents. MDS A stated the unit managers were the ones responsible to update any behaviors since they were the ones responsible to conduct care conferences with the family and resident. MDS A stated other responsible staff would be the SW and the ADON. In an interview on 4/2/2025 at 1:45 PM, the SW stated the care plans for Residents #61 and #52 should be updated because it was a behavior related incident. The SW stated the purpose of the care plan was to reflect everything about the resident and if not updated the incident could happen again. Resident # 17 Record review of Resident #17's face sheet, dated 04/02/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included: type 2 diabetes, high cholesterol, pain in left leg, unspecified altered mental status, and cognitive communication deficit. Record review of Resident #17's MDS, dated [DATE], revealed severe cognitive impairment as indicated by a BIMS score of 07 out of 15. She had no potential indicators of psychosis, no Hallucinations (experiences without real external input) or delusions (beliefs that are held contrary to reality), no physical behavioral symptoms towards others like hitting, kicking, pushing; no verbal behavioral symptoms towards others like threatening others, screaming and cursing at others and no other behavioral symptoms not directed towards other like verbal/vocal symptoms like screaming, and physical symptoms such as hitting or scratching self. Resident #17 had lower extremity impairment to both sides that limited her range of motion and was always incontinent of both bladder and bowel. Record review of Resident #17's Care Plan, completed on 02/13/25, revealed Focus: At times resident yells out due to cognitive deficit; intervention- 1:1 beside in-room visits and activities if unable to attend out of room events. Focus- resident has a behavior problem Yells at staff; interventions: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. An observation on 04/01/25 at 09:35 AM revealed, Resident #17 in bed in the fetal position under a blanket. The resident's bed was low to the ground and fall mats were located next to the bed. She appeared well dressed, well-groomed and in no immediate distress. The resident was confused and answered yes to all questions and her responses were sometimes unrelated to the questions being asked. In an interview on 04/01/25 at 11:13 AM, the DON said Resident #17 was constantly yelling and was receiving psych services. She was bed bound and her behaviors were typically late in the evening and early in the morning. The DON said the resident sometimes fought and yelled unprovoked and without any stimulus. In an interview on 04/02/25 at 12:20 PM, the ADON said Resident #17 was confused and had behaviors such as screaming out unprovoked, rolling out of bed but those behaviors had become less frequent. She said all Resident #17's behaviors should have been documented in the chart and MDS because documentation drives the care, accurate care. The ADON said the MDS when completed should accurately reflect the patient, painting a clear picture. She said an inaccurate MDS could place residents at risk of error. In an interview on 04/02/25 at 01:17 PM, MDS A said resident MDSs were completed through an interdisciplinary process, but she went over the document. She said the MDS should accurately reflect the residents', and she only knew Resident #17 screamed and yelled when she needed services like repositioning. MDS A said she was never notified or observed any documentation in Resident #17's chart that she had behaviors such as yelling unprovoked or fighting the air . In an interview on 04/02/25 at 01:30 PM, LVN B said she was Resident #17's nurse. She said Resident #17's usual behavior included yelling out unprovoked, but she had not noticed her fighting without stimulus . On 04/02/25 at 01:2 PM, a written request was made to the Administrator for the facility policy on accuracy of assessment. The policy was not provided prior to exit. Record review of the facility's policy and procedure for Health Care Plans, revised in March 2024, read in part: .It is the policy . to involve all disciplines in the development of a resident health care plan that recognizes the resident's right to achieve his/her personal health goals. Purpose: To ensure the development of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .1. An interdisciplinary team approach is used to develop a plan of care that meets the specific needs identified. 2. The process for meeting the goals includes providing supportive care, treating a disease or condition, rehabilitating physical or psychosocial impairment, and promoting health .6. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change .8. The interdisciplinary Team must review and update the care plan: c. When the resident has been readmitted to the facility from a hospital stay

Based on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 medication carts (Unit 2-B Nursing Cart) reviewed for medication storage . The facility failed to ensure Unit 2-B Nursing cart revealed was not unlocked and unattended with medication on top of the cart. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications. Findings include: An observation on 04/01/25 at 09:03 AM of the unlocked and unattended Unit 2-B Nursing cart revealed, a vial which contained Resident #16's Timolol eye drops, a medication used to treat glaucoma, on the top of the cart. The cart was in front of a patient room with the drawers easily accessible and facing the hall . In an observation and interview on 04/01/25 at 09:10 AM, inventory of the Unit 2-B Nursing Cart with LVN B revealed all drawers in the cart were unlocked and contained: Drawer 1 - More than 30 Lancets, a device with a small needle used to prick fingers to collect blood for blood sugar monitoring. - More than 10 pen needles, a short needle attached to pens used to inject medications under the skin. - Open and in use Basaglar and Novolog Insulin pens for Resident #16 - Open and in use Novolog Insulin and Insulin Glargine pens for Resident #2 - An open an in-use Humalog Insulin pen for Resident #8 - An open and in use Novolog 70-30 Insulin pen for Resident #1 - An open and in use Humalog Insulin pen - Alcohol prep Pads Drawer 2 - Topical medications including Nystatin 100,000, an anti-fungal, unit per gram for Resident #57. Drawer 3 - Multiple syringes which contained needles in sealed packets - 3 nail clippers - Hydrocortisone 1% cream - Syringe containing Saline for line flush Drawer 4 - Fluticasone Nasal Spray for Resident #51 - Inhaler for Resident #33 - Syringes which contained needles in sealed packets LVN B said all medications should be stored in nursing carts and carts must be locked when not under direct supervision of nursing staff. She said she left Resident #16's medication on top of the cart and forgot to lock the cart because another resident needed help. LVN B said unattended medications and unlocked medication carts could place residents at risk for medication errors or injuries if needles were accessed. In an interview on 04/01/25 at 11:13 AM, the DON said nursing carts were expected to be locked when not in use and under continuous supervision of staff to ensure the resident and medication safety. He said unlocked nursing carts and accessible medications placed residents at risk of unauthorized access to carts, medications errors or puncture injuries. Record review of the facility's policy titled Medication Administration revised 08/2024 revealed, 12- Never leave medication cart unlocked/ If the cart must be left due to an emergency, the cart is to be locked. All medications insured the cart and secured at all times, so they are inaccessible to resident. Do not leave medication on top of cart unattended.

Based on interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program to the maximum extent practicable for 1 of 5 residents (Resident #17) reviewed for PASARR. The facility failed to update the PASARR Level 1 forms for Resident #17 to indicate mental health illness. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings included: Record review of Resident #17's Admission Record, dated 12/28/2023, revealed an 84 -year-old male who admitted to the facility on [DATE]. Resident # 17 face sheet dated 02/08/2024 revealed that Resident # 17 had an active diagnosis of (PTSD) Post Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations.) with an onset documented as of 12/28/2023. Record review of Resident #17 clinical record, Resident #17 was diagnosed with Post Traumatic Stress Disorder (PTSD) with an onset documented as of 12/28/2024. PASRR Level 1 Screening for Resident #17 dated for 12/28/2023 indicated incorrect documentation of no mental health illness. As result of the incorrect documentation, it was determined that resident was not eligible for PASRR specialized services. Record review of Resident #17's care plan dated 12/28/2023 read in part Resident #17 uses psychotropic medications related to insomnia and anxiety but did not make mention of Post Traumatic Stress Disorder (PTSD). Interview on 02/06/24 at 10:43 am, Resident #17 stated that he often becomes anxious with staff as he felt that staff does not understand him. Resident #17 stated that he was abused as a child and as an adult he served in Navy. Resident #17 revealed that he often has trouble sleeping at night. He stated that he received his medications but did not know what medications he had been taking. Resident #17 denied receiving any services and support related to coping with PTSD and anxiety. Interview with MDS Coordinator on 02/06/24 at 11:56 AM revealed she had worked at the facility as an MDS Coordinator since December/2023. MDS Coordinator revealed that she was not aware why an updated PASRR Level I had not been completed for Resident #17 after identifying that Resident #17 was diagnosed with PTSD with an onset documented as of 12/28/2023. Interview with MDS Coordinator on 02/07/24 at 2:00 PM revealed that she was responsible for completing the PASRR. She stated that she completed a PASSR Level 1 referral update on 02/07/2024 after surveyors' interview on 02/06/2024. She confirmed that Resident #17's PASSR Level 1 on admission was negative and he was diagnosed with PTSD with an onset documented as of 12/28/2023. MDS Coordinator stated that she did not know that she had to submit an updated PASSR Level 1 indicating that Resident #17 had an active diagnosis of PTSD. The MDS Coordinator did not state whether she had received any training regarding PASSR . MDS Coordinator did not reveal how monitoring was conducted to ensure it was done timely and accurately. She did not know why the referral had not been completed on 12/28/23 and she said that it would be important for a resident to receive PASARR services if they qualified. The MDS Coordinator said that the potential risk to a resident for not having the corrected referral submitted to identify mental health illness, would be that the resident would not receive the necessary services qualified for. Record review of the facility's Resident Assessment-Coordination with PASARR Program policy dated implemented 6/2023 and Date Revised: 06/2023 revealed 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASARR.

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight for 1 of 5 residents (Residents #31) reviewed for nutrition. - The facility failed to ensure the implementation of the Registered Dietitian's recommendations that included Fortified meals for Resident #31. This failure could place residents at risk for weight loss and decline in health status. Findings include: Record review of Resident #31's Face Sheet dated 02/06/24 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: Alzheimer's Disease, and hypertension. Record review of Resident #31's MDS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15, no malnutrition, no specified therapeutic diet, and set-up and clean up assistance for eating. Record review of Resident #31's undated Care Plan revealed, no weight related care areas. Record review of Resident #31's weight dated 01/08/24 revealed, 89.8 lbs. Record review of Resident #31's Diet Requisition Form dated 01/08/24 revealed, the resident was on a regular diet. Record review of Resident #31's weight dated 01/17/24 revealed, 90.0 lbs. Record review of Resident #31's Nutrition/Dietary Note dated 01/22/24 at 11:16 AM revealed, Resident #31 was 90.5 lbs. with a BMI was 16.6 (underweight) and her ideal body weight was 136-147 lbs. Oral intake likely adequate to meet estimated nutritional needs; however resident BMI indicates she is underweight. Resident may benefit from fortified food plan to promote weight gain. Goals:1. Gradual weight gain with a BMI goal >20; 2. Maintain adequate oral intake and start fortified food plan, all meals, indefinitely. Record review of Resident #31's weight dated 01/23/24 revealed, 90.5 lbs. Record review of an email dated 01/25/24 at 08:00 AM revealed, an email from the dietician that read Attached are the recommendations from my last visit. I will be returning on Friday of this week. The email had Resident #31's dietary recommendation of start fortified food plan, all meals, indefinitely and it was addressed to the facility CEO, Administrator, DON, ADON and Unit Manager A. Record review of Resident #31's Order Summary Report dated 02/07/24 at 01:58 PM revealed, no entered orders for a fortified diet. Record review of Resident #31's Meal Tickets and Diet Requisition Form presented on 02/07/24 at 03:11 PM revealed, the resident was ordered and received a regular diet. She was not ordered or receiving fortified meals. An observation on 02/06/24 at 10:24 AM revealed, Resident #31 well dressed and in no immediate distress in her room. The resident appeared thin but not frail and confused. Resident #31 was unable to answer the surveyor's questions. In an interview on 02/07/24 at 02:50 PM, the ADON said after her weekly visit the dietician emails her recommendations and these recommendations are forwarded to the unit managers for order entry and implementation. She said if a resident had a dietary recommendation for fortified meals there should be a corresponding order entered. After reviewing Resident #31's EMR the ADON said there was no order for fortified meals entered for Resident #31. The ADON said the nurse managers are responsible for ensuring dietary orders are entered and implemented accurately. In an interview on 02/07/24 at 03:11 PM, Dietary Staff A said the dietician communicated her recommendations to the nursing team who then enter the orders into the system and sometime the nurse manager will deliver the orders to her for implementation. She said dietary recommendations are usually entered with 24 hours and then implemented on the next meal ticket. Dietary Staff A said Resident #31 did not have an order for fortified meals and the resident had the same ordered regular diet since admission on 01/08/24. In an observation and interview on 02/08/24 at 09:37 AM, Nurse Manager A said she was the nurse responsible for entering dietary orders for Resident #31's unit and residents are seen by the dietician weekly and new dietary orders are normally implemented within 24 hours. She said after the dietician sees a resident, she sends an email to nursing administration and the nurse manager is responsible for transcribing the new dietary orders into the system. Nurse Manager A said once the order is entered the nurse will print out the order and physically deliver it to the dietary department. She said she kept a binder of all new dietary orders that she signed off on once she implemented them. Observation of the binder revealed a print out on 01/24/24 with the dietician's orders. There were 5 resident names highlighted, including Resident #31, and all resident names had a check beside their orders except for Resident #31. Unit Manager A said she did not know why she failed to enter and implement Resident #31's new dietary orders and failure to implement dietary recommendations as orders could place residents at risk for untreated weight issues or weight loss. On 02/08/24 at 09:58 AM, an attempt was made to contact the dietician. A voicemail was left, but the dietician did not return the call prior to exit. Record review of the facility policy titled Dietary Services, Certified Dietician revised 09/2022 revealed, 1- the certified dietician must conduct assessments of residents to ensure proper intake; 3- the certified dietician must issues recommendations that will be reviewed by physician for approval then transcribed into the EMR and implemented by dietary services.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs for 1 of 4 medication Carts (Station 1 PRN Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure the Station 1 PRN nursing cart did not contain an expired bottle of Vitamin C 250 mg. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings Included: In an observation on 02/08/24 at 07:10 AM, inventory of the Station 1 PRN Nursing Cart with LVN A revealed: - An expired, open and in use stock bottle of Vitamin C 250 mg with a manufacturer's expiration date of 01/2024. LVN A said nursing staff are expected to check their medication carts daily for expired medications as they use the medications and then weekly. She said when supplements expire they might be less effective so they should be discarded because use could result in adverse reactions and under supplementation. In an interview on 02/08/24 at 07:40 AM, the DON said nursing staff are expected to check their carts daily as medication is used for inappropriately labeled and expired medications, while nursing management/unit managers also audit the carts once a week and randomly. He said expired medications must be removed and placed in the drug disposal bin in the medication room because it could result in adverse reactions. Record review of the facility policy titled Medication Administration revised 08/2022 revealed, 14. All multi-use containers must be labeled with opening date. If container is found to be opened and not labeled, it must be discarded. 15. All medication on the medication cart must be audited as needed, and any unlabeled, loose or expired medications must be removed and placed in medication destruction. 16. All expired and discontinued medications are reviewed and destroyed monthly by the pharmacy consultant.

Based upon observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and under proper temperature controls for 1 out of 8 Residents (Resident #43) and 1 of 4 medication carts ( Station 3 Medication Cart) reviewed for drug labeling and storage. - The facility failed to ensure the Station 3 Medication Cart did not contain an in-use insulin pen for Resident #43 with no open date. This failure could place residents at risk of adverse medication reactions and drug diversions. Findings included: Record review of Resident #43's Face Sheet dated 02/06/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of anxiety disorder, high cholesterol and type 2 diabetes. Record review of Resident #43's Quarterly MDS assessment dated [DATE] revealed, intact cognition as indicated by a BIMS of 14 out of 15, partial/moderate assistance with most ADLs and always continent of both bladder and bowel. Record review of Resident #43's undated Care Plan revealed, focus- resident has diabetes and requires insulin; intervention- diabetes medication as ordered by doctor. Record review of Resident #43's Order Summary Report dated 02/08/24 revealed, HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 69 = 0; 70 - 99 = 20; 100 - 150 = 30; 151 - 200 = 40; 201 - 250 = 50; 251 - 300 = 60; 301 - 350 = 70; 351 - 400 = 80 Above 400 call MD, subcutaneously three times a day for diabetes. In an observation on 02/08/24 at 07:27 AM, inventory of the Station 3 Medication Cart with LVN B revealed: - An open and in-use Insulin Lispro Pen for Resident #43 with no open date. LVN B said nursing staff are expected to check their carts daily as medications are used for inappropriately labeled medications. She said insulin pens must be labeled with the date opened in order to track the expiration date. LVN B said when insulin expires it can not be used and must be discarded in the drug disposal bin. She said since the insulin pen did not have an open date it should not be used because it could be expired and if used it could result in uncontrolled blood sugars. In an interview on 02/08/24 at 07:40 AM, the DON said nursing staff are expected to check their carts daily as medication is used for inappropriately labeled and expired medications, while nursing management/unit managers also audited the carts once a week and randomly. The DON said all multidose insulin pens/containers must be labeled with the date open/removed from the refrigerator in order to track the expiration. He said when insulin expired it could become unstable and less effective and use can result in uncontrolled/ineffective control of blood sugars. The DON said if an insulin pen did not have an open date it cannot be used and must be discarded in the drug disposal bins located in the medication room. Record review of the facility policy titled Medication Administration revised 08/2022 revealed, 14. All multi-use containers must be labeled with opening date. If container is found to be opened and not labeled, it must be discarded. 15.All medication on the medication cart must be audited as needed, and any unlabeled, loose or expired medications must be removed and placed in medication destruction. 16. All expired and discontinued medications are reviewed and destroyed monthly by the pharmacy consultant.

Based on interview, and record review, the facility failed to manage the personal funds of the resident deposited with the facility for 2 (Resident #29 and Resident #46) of 2 residents reviewed for with resident rights. The facility failed to ensure Resident #29 and Resident #46 trust fund accounts were spent down to avoid being over the amount allowed to have Medicaid Insurance benefits. This failure could place 2 residents, whose funds are managed by the facility, of losing their Medicaid insurance benefits Findings Included: Resident #29 An interview on 12/8/22 at 8:48 am with the CFO (Chief Financial Officer), he said he handled trust funds spending down trust fund balances and the remaining monies were from the Covid Relief money for Resident #29 and Resident #46, by sending out emails notifying Activities/ Management that the money is over or close to the 2,000-dollar limit. Residents #29 and Resident #46 that have over 2, 000 they investigated pre planned burial plans, but he thought they already had them, but their money will be spent down in the next couple of months. An interview on 12/8/22 at 10:41 am with the Administrator, she said that she was aware of the trust fund balances for Resident #29 and Resident #46 exceeding the amount limit requirements for trust funds with residents with Medicaid. She said that the money is from the Covid Relief funds and the facility have made and continue to make efforts to spend the money down. She said the facility has been in contact with the responsible parties and Medicaid regarding the trust fund accounts and spending. An interview on 12/8/222 at 10:46 am with the Activities Director, she said that the CFO will send emails to management when a trust fund account requires spending down. She said she would then purchase items for residents based on their likes and needs. An interview on 12/8/22 at 11:25 am with the former DON/Contract RN, he confirmed receiving emails from the CFO to spend down monies from the trust fund and would approve spending on items needed by the resident. Review of Resident #29's face sheet dated 12/8/22 revealed she was [AGE] years old year old, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included traumatic amputation and dysphagia (medical term for swallowing difficulties). Review of Resident #29''s Annual MDS assessment dated [DATE] revealed her BIMS (Brief Interview for Mental Status) score was 8 (minimaly impaired cognitively). Review of Resident #29's care plan dated 7/31/2019 revealed she was care planned for areas of care including confusion due to dementia and swallowing. Review of the facility patient fund balances report dated 11/30/22 revealed Resident #29 had a trust fund balance of $2,844.05. Resident #46 Review of Resident #46's face sheet dated 12/8/22 revealed she was [AGE] years old, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Dementia and muscle weakness. Review of Resident # 46's Annual MDS dated [DATE] under section C-Cognitive Patterns revealed she was severely impaired cognitively. Review of Resident #46's care plan dated 3/12/19 revealed a care plan in the area of Cognitive loss/Dementia. Review of the facility 's patient fund balances report dated 11/30/22 revealed Resident #46 had a trust fund balance of $3,538.9. Review of the facility's policy and procedure entitled Resident Trust Funds' dated revised July 2017 read in part . The CFO will monitor the trust funds and will work to spend down the resident's balance to keep the trust fund under the Medicaid approved asset limits.

Based on interview and record review, the facility failed to ensure assessments accurately reflected resident's status for 1 of 7 residents (CR #105) reviewed for their MDS. - The facility failed to prevent CR #105 from being inaccurately assessed for being hospitalized when she was instead discharged to community. These failures placed residents at risk for receiving unnecessary services or inadequate care. Findings included: Record review of CR #105's MDS, Section A, dated 10/25/2022, revealed the resident was discharged due to hospitalization . Record review of the CR #105's medical records revealed a medication list and discharge summary on file indicating resident was being discharged home with home health services. In an interview on 12/09/22 at 10:06AM, MDS Nurse A said he incorrectly selected hospitalization on the drop-down list for CR #105, instead of discharge to community due to human error. He said she was a skilled resident. So CR#105's discharge was planned as a scheduled discharge. Review of MDS for CR #105 revealed she had a Return Not Anticipated, dated 10/25/22, which in section A indicated she had been discharged to hospital instead of the community. He said that he did submit the admission and discharge assessments, both original and corrected, to CMS. He said that he used the RAI Manual to complete MDS assessments and for submission of MDS assessments. Record review of the facility's healthcare planning policy, dated September 2012, revealed the purpose of the policy is, . to develop and implement a comprehensive health care plan on each individual resident that summarizes the needs of the resident and the potential and actual problems the resident presents. The RAI Manual, dated October 2019, stated, . The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident ' s status .

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for 1 of 6 residents (Resident #12) reviewed for weight loss. 1. The facility failed to ensure Resident #12 had monthly weights documented, as care planned, for the month of July. 2. The facility failed to ensure Resident #12's meal intake records were not being documented as care planned. These failures placed residents with nutrition-related risks at risk of not having their nutritional needs addressed in a timely manner. Findings included: Record review of Resident #12's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with atrial fibrillation and Alzheimer's disease. Record review the physician orders revealed Resident #12 had an active order for pureed diet and fortified food plan starting 11/16/2022. Resident #12's care plan, dated 12/08/2022, revealed the resident was at risk for weight loss related to aging dementia, variable nutritional intake and limited mobility with a goal of maintaining a weight between 150lbs to 160lbs over the next 90 days. Listed interventions for her weight loss included, weekly weight after admission or until stable; monthly thereafter, monitoring and recording amount of meals consumed, and staff are to notify charge nurse if resident persistently leaves 25% or more on meal trays. Record review of Resident #12's vitals revealed resident's weights for the past 6 months were as follows: 6/13/22 - 164.2lbs 8/3/22 - 127.2lbs 9/6/22 - 132.6lbs 10/10/22 - 126.4lbs 11/3/22 - 123lbs Record review of Resident #12's meal intake for the month of December, revealed the resident's meal intake was not recorded on 12/1/2022 - 12/4/2022, 12/7/2022 for breakfast and lunch, and 12/8/2022 for breakfast. Observation on 12/08/2022 at 10:25AM revealed Resident #12 lying with breakfast tray at bedside her with 25-50% of her pureed breakfast meal consumed. In an interview with Charge Nurse D on 12/08/2022 at 10:30AM, he stated all residents were to have their meal intake documented and they were documented for Resident #12 as well. He stated Resident #12 was ordered nutritional shakes, fortified food plan, and supplements to help with her weight loss that has been an ongoing issue for the past few months. In an interview with CNA V on 12/08/2022 at 10:45AM, she stated she assisted Resident #12 with feeding and that day, she ate 50% of her breakfast meal. In an interview with RNA on 12/09/2022 at 10:24AM, she said she knew Resident #12 had not been eating well, received supplements, needed assistance with feedings, and experienced significant weight loss a couple of months ago. She said her process for documenting monthly weights included her printing reports listing all residents in need of monthly weights, weighing the residents, and documenting the weights. She stated she printed a report for weekly weights. She said she worked on the floor as an aide, while doing her best to complete her workload of monthly weights and asked for help when needed. However, if the monthly weight for Resident #12 were not completed in July, then it meant she dropped the ball. In an interview on 12/09/22 at 11:29AM, Unit Manager A ([NAME] RN) said RNA was responsible for obtaining resident weights in the weight loss program and she was the only restorative aide right now with a CNA assigned to assist her. She said that the DON was responsible for the oversight of the weight program at the facility. She said the DON kept a log of who was being weighed and tracked weights. She said the system for meal intake documentation involved the charge nurses reviewing the meal intake records after the CNAs documented thee meal intake percentage and if there was an issue with meal consumption, the charge nurses were to notify the unit managers. She said that she was familiar Resident #12's weight loss and eating habits. She said that she did not update care plans and would have to ask the MDS person about care plans. In an interview on 12/09/22 at 12:33PM, the former DON said RNA was responsible for taking the weight and reporting any discrepancies to the Unit Manager. He stated if Resident 12's care plan calls for the weights to be checked weekly or monthly, then it should be followed and all residents are to have the percent meal intake recorded for every meal per facility policy. In a phone interview on 12/09/22 at 01:04 PM, the Dietitian said she was familiar with Resident #12 and was aware of resident's decline in intake and said the resident often refused most food and supplements. She said that she always asked the restorative and nursing aides for more recent weights to use for her nutrition assessments on residents. In an interview on 12/09/2022 at 1:40 PM, CNA V stated meal intake percentage should have been documented for all residents per the facility's policy. She stated it was important to track how well the patient was eating. She stated the reason for missing documentation in the meal intake record was likely due to the reason of the staff on duty not having the time to fill in the intake records. When asked if she has ever missed the opportunity to document the resident's meal intake for that reason, she did not answer the question and stated she tried to take the meal intake sheet in the residents' rooms with her or sometimes wrote the percentage eaten down on the bottom of the meal ticket to document on the meal intake form later at the end of her shift. In an interview on 12/09/22 at 03:19 PM, Charge Nurse D who said that he reviewed documentation of meal intake records and said that he was not aware of any missing documentation for that week or the month of December. When asked if the CNAs did not complete the documentation as instructed, he did not answer the question but stated they should be reprimanded if they did not. He said negative outcomes or a decline in a resident could be missed if the documentation was not completed and that he would be the first person to reprimand the CNAs and then escalate it up to the unit manager and so on. He said that he did not hear regularly from his CNAs that residents were consuming less than 50% of their meals. Record review of the facility's weight policy, dated August 2021, stated, . all residents are weighed monthly and more often as order by a physician. Record review of the facility's meal intake policy, dated November 2008, stated . 1) The staff responsible for assisting the resident with meals, or the staff member picking up the resident's tray at the end of a meal shall record the meal intake of the resident after each meal. 2) all resident will have documentation daily. 3) Nurses are responsible for ensuring that the meal intake sheets are filled out each shift and are also responsible for having them filled out if is not done . Record review of the facility's healthcare planning policy, dated September 2012, revealed the purpose of the policy is, . to develop and implement a comprehensive health care plan on each individual resident that summarizes the needs of the resident and the potential and actual problems the resident presents.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable for 2 ( Hall 2-B and Hall 3 Medication Carts) out of 3 hall medication carts, reviewed for medication storage. - The facility failed to ensure the Hall 2-B and Hall 3 Medication Cart stored protein supplements had an open date. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: Hall 2-B Medication Cart In an observation and interview on 12/07/22 at 07:38 AM, inventory of the Hall 2-B Medication Cart with MA A revealed: - an open and in use bottle of Pro-Stat, a protein supplement, with no open date and manufacturer's instructions to discard 3 months after opening. MA A said that when a bottle of Pro-Stat was opened it must be labeled with the date in order to track the expiration date and nursing staff checked their carts daily for expired medications. She said she did not know that the protein supplement expired after 3 months and since there was no open date it should be treated as expired. MA A said the bottle of Pro-Stat must be discarded in the trash because its use could place residents at risk for side effects and GI upset. Hall 3 Medication Cart In an observation and interview on 12/07/22 at 07:56 AM, inventory of the Hall 3 Medication Cart with LVN A revealed: - an open and in use bottle of Pro-Stat, a protein supplement, with no open date and manufacturer's instructions to discard 3 months after opening. LVN A said when multidose bottles like Pro-Stat are opened they must be labeled with the date in order to track the expiration and nursing staff are expected to check their carts for expired and inappropriately labeled medications daily as used. She said since the bottle of protein supplement did not have an open date it could not be used and must be discarded. She said the use of expired protein supplement could no longer be used because it could place residents at risk for GI upset. In an interview on 12/07/22 at 11:43 AM, the DON said nursing staff were expected to check their carts daily as used for loose pills and expired or inappropriately labeled medications. He said multi-dose protein supplement bottles should be labeled with the date opened in order to track the expiration date. The DON said he didn't know the shelf life of Pro-Stat and if there is no open date, it should be treated as expired and could no longer be used. He said expired or inappropriately labeled medications should be discarded in the drug disposal bin located in the medication room because its use could place resident's at risk for intoxication or GI upset. Record review of the facility policy titled Medication Administration revised September 2018 revealed, General Statements: . 14- All multi-use containers must be labeled with opening date. If container is found to be opened and not labeled, it must be discarded.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals in accordance with State and Federal laws, stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 4 of 5 (Station 1-A Nursing Cart, Station 1-B Nursing Cart, Station 1-B Medication Aide Cart and Station 3 Mediation Aide Cart) medication carts reviewed for medication storage. The facility failed to ensure Station 1-A Nursing Cart, Station 1-B Nursing Cart, Station 1-B Medication Aide Cart and Station 3 Mediation Aide Cart medications were stored according to manufacturer specified temperatures. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings include: Station 1-A Nursing Cart In an observation and interview on 09/22/21 at 11:05 AM, inventory of the Station 1-A Nursing Cart with LVN B revealed an open bottle of Acidophilus, a [MEDICATION(S)], at room temperature in the drawer with manufacturer instructions of REFRIGERATE AFTER OPENING. LVN B said she did not know the bottle of acidophilus had to be refrigerated. She said all medications should be stored as recommended by the manufacturer, and since the [MEDICATION(S)] was not refrigerated it could not be used. LVN B said medications stored at the wrong temperature can have changes in their strength so they should be discarded in the drug disposal bin located in the medication storage room. Station 1-B Nursing Cart In an observation and interview on 09/22/21 at 11:11 AM, inventory of the Station 1-B Nursing Cart with LVN C revealed an open bottle of Acidophilus at room temperature in the drawer with manufacturer instructions of REFRIGERATE AFTER OPENING. LVN C said staff checked their carts for loose pills, expired medications and medications stored out of manufacturer specified temperature ranges every week. She said since the bottle of acidophilus was stored at room temperature and not in the fridge it had to discarded in the drug disposal bin located in the medication storage room . Station 1-B Medication Aide Cart In an observation on 09/22/21 at 11:14 AM, inventory of the Station 1-B Medication Aide Cart with MA A revealed an open bottle of Acidophilus at room temperature in the drawer with manufacturer instructions of REFRIGERATE AFTER OPENING. MA A said after review of the bottle, the acidophilus was supposed to be stored in the refrigerator not at room temperature. She said since it was stored at the wrong temperature the strength of the medication could not be guaranteed and it could not be used. MA A said the open bottle of acidophilus should be discarded in the drug disposal bin located in the mediation storage room. She said carts should be checked daily for loose pills expired medications and those stored outside of manufacturer specified temperature. Station 3 Medication Aide Cart In an observation and interview on 09/22/21 at 11:27 AM, inventory of the Station 3 Medication Aide Cart with MA B revealed an open bottle of Acidophilus at room temperature in the drawer with manufacturer instructions of REFRIGERATE AFTER OPENING. MA B said staff were supposed to check their carts daily for medication storage temperatures, expired medications and loose pills. She said she was not aware the bottle of acidophilus had to be refrigerated and since it was at the wrong temperature it could not be used. She said all expired medications and those stored at inappropriate temperatures should be discarded in the drug disposal bin located in the medication storage room. In an interview on 09/27/21 at 11:37 AM, the DON said staff were to check their carts every shift for loose pills, expired medications and those stored at the wrong temperature. He said the expectation was all medications were stored within their manufacturer specified ranges and if stored at the wrong temperature they should be discarded in the drug disposal bin located in the medication storage room. Record review of facility policy titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised 10/28/19, revealed 11- Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Record review of facility policy titled Disposal/Destruction of Expired and Discontinued Medication, revised 03/05/20, revealed 4- Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.

Based on interview and record review, the facility failed to notify and consult with the resident ' s physician when a resident had a change in condition for 1 closed record (CR #1) of 6 residents reviewed for physician notification in that: -- Resident #1 ' s abnormal lab results for four months, significant weight loss of 15.67% for months (November to February 2016) and the physician not being consulted resulted in Resident # 1 being admitted to the hospital [MEDICAL CONDITION] and G tube infection. This failure affected one closed record (CR #1) and placed an additional 46 residents on the 200 unit at risk of delayed treatment, complications which could result in unnecessary pain, delayed healing, harm and hospitalization . Intake # ' s 7, 4 and 9 Findings Include: Resident #1 Record review of CR #1's face sheet revealed she was a [AGE] years old who was admitted on to the facility on [DATE] and readmitted on [DATE]. CR #1 was discharged to the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Admission MDS dated [DATE] revealed she had a Brief interview for Mental Status (BIMS) score of 9 indicating that she was moderate cognitive impairment. Skin condition assessment revealed no pressure sore. She required the extensive assistance of two staff for bed mobility. She required total dependence with 1 to 2 staff support for all activities of daily living. She had impairment on both sides of upper and lower extremities with range of motion limitations. She was non-ambulatory and always incontinent of both bowel and bladder. Record review of CR #1's Care Plan revealed she was Care Planned for being at risk for impaired skin integrity related to anticoagulant therapy, advanced age and variable nutritional intake effective from [DATE] with the following interventions: Turn and reposition every ,[DATE] hours Encourage nutritional intake Monitor weight and record Monitor laboratory results and notify MD of all abnormal values promptly Monitor skin during ADL care of signs/symptoms of skin irritations and notify charge nurse. Pressure sore protocol is used to determine interventions to prevent pressure sores. Resident #1 was also Care Planned for being at risk for weight loss related to dysphagia and variable nutritional intake effective from [DATE] with the following interventions: Resident will be weighed weekly for the first 4 weeks after admission or until stable, monthly thereafter. Notify family, MD and Dietician of significant weight loss or persistent decline in appetite. Record review of CR #1's laboratory results revealed she had elevated white blood cells (WBC) for several months as follows: [DATE] 13.2 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.8 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.3 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.5 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 15.7 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 14.8 k/mm (Reference Range: 4XXX,[DATE].8) Clinical record did not show any documentation of Resident # 1's physician being notified of the abnormal labs. During an interview on [DATE] at 5:14 p.m. the DON said he would look for documentation that the physician was notified of CR #1's abnormal labs. He said abnormal labs should be reported to the physician . Record review of CR #1's Vital Sign history revealed no admission weight documented on [DATE]. Additionally, weekly weights were not performed on [DATE], [DATE], [DATE], and [DATE]. Record review of CR #1's Vital Sign history revealed the following weights: [DATE] 124lbs [DATE] 134lbs [DATE] 124lbs [DATE] 113.5lbs [DATE] 113.8lbs [DATE] 108.8lbs [DATE] 107.5lbs [DATE] 107.5lbs Record review of CR #1's Physician order [REDACTED]. Record review of CR #1's Nurses notes revealed no documentation that her MD was notified of her losing weight. CR #1 was not weighed the week of [DATE] and the week of [DATE]. Record review of the Physician ' s History and Physical (H and P) dated [DATE] and Progress notes from [DATE] to [DATE] revealed no documentation of CR #1's weight. On Physician ' s initial H & P dated [DATE] and her Progress note dated [DATE] she documented no weight record and on all other notes ([DATE], [DATE], [DATE] and [DATE]) weight was not addressed. During an interview on [DATE] at 12:15 p.m. the DON acknowledged that weekly weights were ordered for CR #1 effective [DATE]. He said the weekly weights on CR #1 were not performed. He said CR #1 was transferred to the hospital on [DATE]. During an interview on [DATE] at 12:25 p.m. the ADON said the facility had Dietician evaluation/assessments on [DATE] and [DATE] for CR #1. She said the facility did not have a Dietician for some time. She said the facility's Dietician started working at the facility in February 2016. Record review of CR #1's Dietician assessment dated [DATE] revealed Registered Dietician (RD) noted she had a significant weight loss (15.67%) in 3 months (November to February 2016) and recommended weekly weights for 4 weeks. No weights were documented for [DATE], [DATE] and from [DATE] to [DATE]. RD's recommendations included an increase in tube feedings. During an interview on [DATE] at 1:15 p.m. the Registered Dietician (RD) she said that she saw CR #1 for a dietary evaluation on [DATE] and again on [DATE]. She said CR #1 was scheduled to be seen again on [DATE]. and saw CR #1 on [DATE], [DATE] and the next assessment would be due on [DATE]. She said her recommendation to increase CR # 1's tube feeding was provided to the DON and the physician. Record review of hospital medical record for CR #1 revealed she was admitted to the Emergency Department on [DATE] with the following Diagnoses: [REDACTED]. [MEDICAL CONDITION]-significantly elevated WBC and elevated Lactic acid with multiple infections at multiple sites - PEG tube site, urinary tract Bacteremia - [MEDICAL CONDITION] - Susceptible Staphylococcus Aureus (MSSA) and bilateral heel (Left heel with [MEDICAL CONDITION]). Hypotensive likely secondary to underlying septic shock. Possible aspiration pneumonia. Multiple wounds - Deep Tissue Injury to both heels, sacral stage 2, left knee, elbow, Right inner foot, healing stage 2 on buttocks. CR #1 was discharged to a local Hospice on [DATE] with the following Diagnoses: [REDACTED]. CR #1 died on [DATE] at a local Hospice according to the family. Record review of the facility's policy and procedure dated [DATE] titled Notification of Abnormal Laboratory Results read in part it is the policy of St Dominic village to notify physicians of abnormal lab results as promptly as possible . any critical values called from the lab to the nurse must be called immediately to the physician, then faxed . Record review of the facility's policy and procedure titled Weights, Weighing of Residents revised [DATE] read in part all residents are weighed and measured for height on admission to the Nursing Home . all residents are weighed monthly and more often as ordered by a physician . weekly weights will be completed on all new admissions for a period of 4 weeks . Record review of the facility's policy and procedure titled Physician order [REDACTED]. The facility room roster listed 46 residents residing in the 200 unit.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect of residents for 1 closed record (CR # 1) of 6 residents reviewed for neglect in that: --CR #1 was discovered to have 6 facility acquired pressure sores, significant weight loss of 15.67 percent over 3 months, unreported abnormal labs and was transferred to a local hospital [MEDICAL CONDITION]. These failures affected 1 CR (closed record) resident and placed an additional 13 residents with Pressure Ulcers at risk for developing new ulcers, deterioration of existing Pressure Ulcers, Wound infection and a diminished quality of life. Intake # ' s 7, 4 and 9 Findings Include: Record review of CR #1's face sheet revealed she was a [AGE] years old who was admitted on to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Admission MDS dated [DATE] revealed she had a Brief interview for Mental Status (BIMS) score of 9 indicating that she was moderate cognitive impairment. Skin condition assessment revealed no pressure sore. She required the extensive assistance of two staff for bed mobility. She required total dependence with 1 to 2 staff support for all activities of daily living. She had impairment on both sides of upper and lower extremities with range of motion limitations. She was non-ambulatory and always incontinent of both bowel and bladder. Record review of CR #1's Care Plan revealed she was Care Planned for being at risk for impaired skin integrity related to anticoagulant therapy, advanced age and variable nutritional intake effective from [DATE] with the following interventions: Turn and reposition every ,[DATE] hours Encourage nutritional intake Monitor weight and record Monitor laboratory results and notify MD of all abnormal values promptly Monitor skin during ADL care of signs/symptoms of skin irritations and notify charge nurse. Pressure sore protocol is used to determine interventions to prevent pressure sores. Resident #1 was also Care Planned for being at risk for weight loss related to dysphagia and variable nutritional intake effective from [DATE] with the following interventions: Resident will be weighed weekly for the first 4 weeks after admission or until stable, monthly thereafter. Notify family, MD and Dietician of significant weight loss or persistent decline in appetite. Record review of CR #1's admissions nurse's note (CR) written by LVN A dated [DATE] revealed that CR #1 was admitted to the facility on [DATE] with one small pressure sore to her bottom that measured approximately 1 cm in diameter . Record review of initial Visit Report on [DATE] revealed CR # 1 had 2 documented wounds. Visit report dated [DATE] completed by the Wound Care Physician revealed CR # 1 had 7 wounds: #1 Right heel stage 4/Moist Black Eschar - Length 1cm; Width 1cm; Depth 0.6cm and Area 1 sq. cm #2 Left heel stage 4 with moderate serous exudate - Length 0.9cm; Width 1.7cm; Depth 0.6cm and Area 1.53 sq. cm. #3 Left Medial foot suspected Deep tissue Injury (DTI) - Length 3.5cm; Width 3.0cm; Depth 0 and Area 10.5 sq. cm. #4 Left Lateral Foot suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 1.2cm; Depth 0 and Area 1.8 sq. cm. #5 Left Fifth Toe suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 0.5cm; Depth 0 and Area 0.75 sq. cm. #6 Right Lateral Ankle suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 0.5cm; Depth 0 and Area 0.75 sq. cm. #7 Sacral stage 3 with moderate serous exudate - Length 3.0cm; Width 2.0cm; Depth 0.5cm and Area 6.0 sq. cm. During an interview on [DATE] at 4:40 p.m. the DON he said he did not know when CR # 1 developed 6 new pressure sores. He said CR # 1 was transferred to the hospital on [DATE] due to a change in condition. During an interview on [DATE] at 4:50 p.m. UM 2 said that CR #1 had pressure sores when she was transferred to her unit. During an interview on [DATE] at 5:00 p.m. the DON said the WCN just started in that position about 4 weeks ago. He said that the 2 unit managers and himself performed wound care treatment prior to the facility having a wound care nurse. During an interview on [DATE] at 5:10 p.m. the UM 1 said she did not know when Resident #1 developed the pressure wounds. During an interview on [DATE] at 11:30 a.m.with the ADON and DON, they said they could not find the admission skin assessment for CR # 1 and the weekly skin assessments for CR # 1. During an interview on [DATE] at 11:45 a.m. the DON said that his skin assessments were included in the progress notes. During an interview on [DATE] at 2:00 p.m. CR #1's Physician she said CR # 1 could develop pressure sores due to her many comorbidities. She said CR # 1 should have been on hospice. Record review of Resident #1 ' s Treatment Administration Record (TAR) from admission -[DATE] till she was transferred to the hospital on [DATE] revealed in part as follows: November No treatment was performed on coccyx from [DATE] to [DATE]. Also treatment was missed on [DATE] (Day shift); [DATE] (Evening and Night shifts); [DATE] (Evening Shift) and [DATE] (Evening Shift). Tube feeding Site Care was not done on [DATE] (Day and Evening shift); [DATE] (Day shift); [DATE] (Day shift); [DATE] (Evening and Night shifts); [DATE] (Day and Evening shift) and [DATE] (Evening Shift). Weekly weights were not done on [DATE]; [DATE] and [DATE]. December No treatment was performed on coccyx pressure sore [DATE] (Day shift) and [DATE] (Day shift). Peri and sacral area treatment not done on [DATE] (9.am; 1pm and 9pm); [DATE] (9am and 1pm) Peri and sacral area treatment not done on [DATE] (9pm); [DATE] (9 pm); [DATE] (9pm) and [DATE] (1pm). Coccyx pressure sore daily treatment not done on [DATE] and [DATE] Tube feeding Site Care was not done on[DATE] (Day shift); [DATE] (Day shift); [DATE] (Day shift) and [DATE]. January Coccyx pressure sore daily treatment not done on [DATE]; [DATE]; [DATE]; [DATE]; [DATE], [DATE]; [DATE] and [DATE]. Left Buttocks pressure sore daily treatment not done on [DATE]; [DATE] and [DATE]. February Coccyx pressure sore daily treatment not done on [DATE]; [DATE]; [DATE] and [DATE]. Left Buttocks pressure sore daily treatment not done on [DATE]; [DATE]; [DATE] and [DATE] March Weekly weights were not done on [DATE]; [DATE]; ,[DATE] and [DATE]. April Weekly weights were not done on [DATE]; [DATE]; [DATE] and [DATE]. During an interview on [DATE] at 5:30 p.m. the DON said he did not know why CR # 1's TAR (treatment administration record) indicated that treatments were not performed. He said maybe the staff forgot to click on the the submit button to sign them. He said CR #1's health was deteriorating. The DON said CR # 1 was ordered to be repositioned very 2 hours. The DON said CR # 1's ADL sheet should be documented with the times she was repositioned. The surveyor requested a copy of CR # 1's ADL sheet. CR # 1's ADL sheet was not provided to the surveyor at the time of exit. Record review of Resident #1 ' s Care Plan specified to turn and reposition resident every 2 to 3 hours. Record review of the Physician ' s History and Physical (H and P) plus Progress notes from [DATE] to [DATE] revealed no documentation of Resident #1 ' s weight. On Physician ' s initial H & P [DATE] and her Progress note dated [DATE] she documented no weight record and on all other notes ([DATE], [DATE], [DATE] and [DATE] weight was not addressed. Record review of CR # 1 ' s Vital Sign history revealed no admission weight documented on [DATE]. Additionally, weekly weights were not performed on [DATE], [DATE], [DATE], and [DATE]. Record review of CR # 1's Physician order [REDACTED]. Record review of CR #1 ' s Vital Sign history revealed the following weights: [DATE] 124lbs [DATE] 134lbs [DATE] 124lbs [DATE] 113.5lbs [DATE] 113.8lbs [DATE] 108.8lbs [DATE] 107.5lbs [DATE] 107.5lbs During an interview on [DATE] at 12:15 p.m. the DON acknowledged that weekly weights were ordered for CR # 1 effective [DATE] and that weights were not completed on [DATE] and [DATE]. Resident was sent to the hospital on [DATE]. During an interview on [DATE] at 12:25 p.m. the ADON said the facility had Dietician evaluation/assessments on [DATE] and [DATE] for Resident # 1. She said the facility did not have a Dietician for some time. She said the facility's Dietician started working at the facility in February 2016. Record review of Resident #1 ' s Dietician assessment dated [DATE] revealed Resident Dietician (RD) noted she had a significant weight loss (15.67%) in 3 months (November to February 2016) and recommended weekly weights for 4 weeks. No weights were documented for [DATE], [DATE] and from [DATE] to [DATE]. During an interview on [DATE] at 1:15 p.m. the Resident Dietician (RD) she said that she saw CR #1's for a dietary evaluation on [DATE] and again on [DATE]. She said CR #1 was scheduled to be seen again on [DATE]. and saw CR #1 on [DATE], [DATE] and the next assessment would be due on [DATE]. RD provided surveyor copies of her recommendations. Record review of CR #1's laboratory results revealed he had elevated white blood cells (WBC) for several months as follows: [DATE] 13.2 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.8 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.3 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.5 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 15.7 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 14.8 k/mm (Reference Range: 4XXX,[DATE].8) CR # 1's clinical record did not have documentation of CR # 1's physician being notified of her abnormal labs. During an interview on [DATE] at 5:14 p.m. the DON said he would look for documentation that the physician was notified of CR # 1's abnormal labs. He said abnormal labs should be reported to the physician . During an interview on [DATE] at 5:14 p.m. the DON said he was not able to locate CR # 1's admission and weekly skin assessments. He said he could not locate an admission weight on CR # 1 and that weekly weights had not been performed on CR # 1 as ordered on [DATE]. Record review of hospital medical record for Resident #1 revealed she was admitted to the Emergency Department on [DATE] with the following problems amongst others according to the Physician ' s documentation: [MEDICAL CONDITION]-significantly elevated WBC and elevated Lactic acid with multiple infections ant multiple sites - PEG tube site, urinary tract Bacteremia - [MEDICAL CONDITION] - Susceptible Staphylococcus Aureus (MSSA) and bilateral heel (Left heel with [MEDICAL CONDITION]). Hypotensive likely secondary to underlying septic shock. Possible aspiration pneumonia. Multiple wounds - Deep Tissue Injury to both heels, sacral stage 2, left knee, elbow, Right inner foot, healing stage 2 on buttocks. Resident #1 was discharged to Houston Hospice on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 died on [DATE] at Houston Hospice according to the family. Record review of the facility's policy and procedure titled Abuse and Neglect prohibition revised February 24, 2016 read in part Neglect means failure to provide goods and services necessary to avoid physical harm, mental or mental illness, injuries of unknown origin may occur as a result of neglect . facility supervisors will immediately correct and intervene in reported or identified situations in which neglect is at risk for occurring Record review of the facility's policy and procedure revised [DATE] titled Skin Integrity Assessment and Intervention of read in part it is the policy of St Dominic village to perform assessment on all residents upon admission and as needed to evaluate skin condition and to initiate protocols to ensure proper interventions . it is the policy of St Dominic village to have all pressure ulcers assessed immediately by all or part of the Wound Care Team within twenty -four (24) hours of discovery to evaluate for proper treatment initiation .the Admission assessment form is completed within * hours of admission . skin assessments are performed biweekly or more as needed for : resident who are bed bound, have a decrease in food or fluid intake, with ADL deficits(incontinence) and with observed abnormal findings related to skin integrity . Wound Care Consultant is available to evaluate treatments and make recommendations as necessary . treatments are administered as ordered by the physician .nutrition and hydration needs are evaluated by the Resident Dietician for residents with skin integrity impairments . and new admissions are assessed for risk factors (Pressure Sore Risk Assessment) on admission and weekly for four weeks and thereafter quarterly . FORMs: Admission Assessment Forms, Skin Integrity Pressure Ulcer Log, Pressure Sore Risk Assessment and Weekly Skin Sheet . Record review of the facility's policy and procedure dated [DATE] titled Notification of Abnormal Laboratory Results read in part it is the policy of St Dominic village to notify physicians of abnormal lab results as promptly as possible . any critical values called from the lab to the nurse must be called immediately to the physician, then faxed . Record review of the facility's policy and procedure titled Physician order [REDACTED]. Record review of the facility's policy and procedure titled Weights, Weighing of Residents revised [DATE] read in part all residents are weighed and measured for height on admission to the Nursing Home . all residents are weighed monthly and more often as ordered by a physician . weekly weights will be completed on all new admissions for a period of 4 weeks . Record review of the facility's policy and procedure titled Rounding revised [DATE] read in part Certified nursing assistants (CNAs) will round on their assigned residents every 2 hours and will turn and reposition . licensed nurses will round at different times throughout the shift to ensure CNAs are performing their duties as assigned . The CMS Form 672 listed 13 residents with Pressure Ulcers.

Based on interviews and record reviews the facility failed to ensure 1 of 6 residents (#1) reviewed received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: --CR #1 was discovered to have 6 facility acquired pressure sores, significant weight loss of 15.67 percent over 3 months, unreported abnormal labs and was transferred to a local hospital [MEDICAL CONDITION] These failures affected one CR resident (closed record) and placed an additional 13 residents with Pressure Ulcers at risk for developing new ulcers, deterioration of existing Pressure Ulcers, Wound infection and a diminished quality of life. Intake # ' s 7, 4 and 9 Findings Include: Record review of CR #1's face sheet (Closed Record - CR) revealed she was a [AGE] years old who was admitted on to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Admission MDS dated [DATE] revealed she had a Brief interview for Mental Status (BIMS) score of 9 indicating that she was moderate cognitive impairment. Skin condition assessment revealed no pressure sore. She required the extensive assistance of two staff for bed mobility. She required total dependence with 1 to 2 staff support for all activities of daily living. She had impairment on both sides of upper and lower extremities with range of motion limitations. She was non-ambulatory and always incontinent of both bowel and bladder. Record review of CR #1's Care Plan revealed she was Care Planned for being at risk for impaired skin integrity related to anticoagulant therapy, advanced age and variable nutritional intake effective from [DATE] with the following interventions: Turn and reposition every ,[DATE] hours Encourage nutritional intake Monitor weight and record Monitor laboratory results and notify MD of all abnormal values promptly Monitor skin during ADL care of signs/symptoms of skin irritations and notify charge nurse. Pressure sore protocol is used to determine interventions to prevent pressure sores. CR #1 was also Care Planned for being at risk for weight loss related to dysphagia and variable nutritional intake effective from [DATE] with the following interventions: Resident will be weighed weekly for the first 4 weeks after admission or until stable, monthly thereafter. Notify family, MD and Dietician of significant weight loss or persistent decline in appetite. Record review of CR #1's admissions nurse's note (CR) written by LVN A dated [DATE] revealed that CR #1 was admitted to the facility on [DATE] with one small pressure sore to her bottom that measured approximately 1 cm in diameter . Record review of initial Visit Report on [DATE] revealed CR # 1 had 2 documented wounds. Visit report dated [DATE] completed by the Wound Care Physician revealed CR # 1 had 7 wounds: #1 Right heel stage 4/Moist Black Eschar - Length 1cm; Width 1cm; Depth 0.6cm and Area 1 sq. cm #2 Left heel stage 4 with moderate serous exudate - Length 0.9cm; Width 1.7cm; Depth 0.6cm and Area 1.53 sq. cm. #3 Left Medial foot suspected Deep tissue Injury (DTI) - Length 3.5cm; Width 3.0cm; Depth 0 and Area 10.5 sq. cm. #4 Left Lateral Foot suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 1.2cm; Depth 0 and Area 1.8 sq. cm. #5 Left Fifth Toe suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 0.5cm; Depth 0 and Area 0.75 sq. cm. #6 Right Lateral Ankle suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 0.5cm; Depth 0 and Area 0.75 sq. cm. #7 Sacral stage 3 with moderate serous exudate - Length 3.0cm; Width 2.0cm; Depth 0.5cm and Area 6.0 sq. cm. During an interview on [DATE] at 4:40 p.m. the DON he said he did not know when CR # 1 developed 6 new pressure sores. He said CR # 1 was transferred to the hospital on [DATE] due to a change in condition. During an interview on [DATE] at 4:50 p.m. UM 2 said that CR #1 had pressure sores when she was transferred to her unit. During an interview on [DATE] at 5:00 p.m. the DON said the WCN just started in that position about 4 weeks ago. He said that the 2 unit managers and himself performed wound care treatment prior to the facility having a wound care nurse. During an interview on [DATE] at 5:10 p.m. the UM 1 said she did not know when Resident #1 developed the pressure wounds. During an interview on [DATE] at 11:30 a.m.with the ADON and DON, they said they could not find the admission skin assessment for CR # 1 and the weekly skin assessments for CR # 1. During an interview on [DATE] at 11:45 a.m. the DON said that his skin assessments were included in the progress notes. During an interview on [DATE] at 2:00 p.m. CR #1's Physician she said CR # 1 could develop pressure sores due to her many comorbidities. She said CR # 1 should have been on hospice. Record review of Resident #1 ' s Treatment Administration Record (TAR) from admission -[DATE] till she was transferred to the hospital on [DATE] revealed in part as follows: November No treatment was performed on coccyx from [DATE] to [DATE]. Also treatment was missed on [DATE] (Day shift); [DATE] (Evening and Night shifts); [DATE] (Evening Shift) and [DATE] (Evening Shift). Tube feeding Site Care was not done on [DATE] (Day and Evening shift); [DATE] (Day shift); [DATE] (Day shift); [DATE] (Evening and Night shifts); [DATE] (Day and Evening shift) and [DATE] (Evening Shift). Weekly weights were not done on [DATE]; [DATE] and [DATE]. December No treatment was performed on coccyx pressure sore [DATE] (Day shift) and [DATE] (Day shift). Peri and sacral area treatment not done on [DATE] (9.am; 1pm and 9pm); [DATE] (9am and 1pm) Peri and sacral area treatment not done on [DATE] (9pm); [DATE] (9 pm); [DATE] (9pm) and [DATE] (1pm). Coccyx pressure sore daily treatment not done on [DATE] and [DATE] Tube feeding Site Care was not done on[DATE] (Day shift); [DATE] (Day shift); [DATE] (Day shift) and [DATE]. January Coccyx pressure sore daily treatment not done on [DATE]; [DATE]; [DATE]; [DATE]; [DATE], [DATE]; [DATE] and [DATE]. Left Buttocks pressure sore daily treatment not done on [DATE]; [DATE] and [DATE]. February Coccyx pressure sore daily treatment not done on [DATE]; [DATE]; [DATE] and [DATE]. Left Buttocks pressure sore daily treatment not done on [DATE]; [DATE]; [DATE] and [DATE] March Weekly weights were not done on [DATE]; [DATE]; ,[DATE] and [DATE]. April Weekly weights were not done on [DATE]; [DATE]; [DATE] and [DATE]. During an interview on [DATE] at 5:30 p.m. the DON said he did not know why CR # 1's TAR (treatment administration record) indicated that treatments were not performed. He said maybe the staff forgot to click on the the submit button to sign them. He said CR #1's health was deteriorating. The DON said CR # 1 was ordered to be repositioned very 2 hours. The DON said CR # 1's ADL sheet should be documented with the times she was repositioned. The surveyor requested a copy of CR # 1's ADL sheet. CR # 1's ADL sheet was not provided to the surveyor at the time of exit. Record review of Resident #1 ' s Care Plan specified to turn and reposition resident every 2 to 3 hours. Record review of the Physician ' s History and Physical (H and P) plus Progress notes from [DATE] to [DATE] revealed no documentation of Resident #1 ' s weight. On Physician ' s initial H & P [DATE] and her Progress note dated [DATE] she documented no weight record and on all other notes ([DATE], [DATE], [DATE] and [DATE] weight was not addressed. Record review of CR # 1 ' s Vital Sign history revealed no admission weight documented on [DATE]. Additionally, weekly weights were not performed on [DATE], [DATE], [DATE], and [DATE]. Record review of CR # 1's Physician order [REDACTED]. Record review of CR #1 ' s Vital Sign history revealed the following weights: [DATE] 124lbs [DATE] 134lbs [DATE] 124lbs [DATE] 113.5lbs [DATE] 113.8lbs [DATE] 108.8lbs [DATE] 107.5lbs [DATE] 107.5lbs During an interview on [DATE] at 12:15 p.m. the DON acknowledged that weekly weights were ordered for CR # 1 effective [DATE] and that weights were not completed on [DATE] and [DATE]. Resident was sent to the hospital on [DATE]. During an interview on [DATE] at 12:25 p.m. the ADON said the facility had Dietician evaluation/assessments on [DATE] and [DATE] for Resident # 1. She said the facility did not have a Dietician for some time. She said the facility's Dietician started working at the facility in February 2016. Record review of Resident #1 ' s Dietician assessment dated [DATE] revealed Resident Dietician (RD) noted she had a significant weight loss (15.67%) in 3 months (November to February 2016) and recommended weekly weights for 4 weeks. No weights were documented for [DATE], [DATE] and from [DATE] to [DATE]. During an interview on [DATE] at 1:15 p.m. the Resident Dietician (RD) she said that she saw CR #1's for a dietary evaluation on [DATE] and again on [DATE]. She said CR #1 was scheduled to be seen again on [DATE]. and saw CR #1 on [DATE], [DATE] and the next assessment would be due on [DATE]. RD provided surveyor copies of her recommendations. Record review of CR #1's laboratory results revealed he had elevated white blood cells (WBC) for several months as follows: [DATE] 13.2 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.8 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.3 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.5 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 15.7 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 14.8 k/mm (Reference Range: 4XXX,[DATE].8) CR # 1's clinical record did not have documentation of CR # 1's physician being notified of her abnormal labs. During an interview on [DATE] at 5:14 p.m. the DON said he would look for documentation that the physician was notified of CR # 1's abnormal labs. He said abnormal labs should be reported to the physician . During an interview on [DATE] at 5:14 p.m. the DON said he was not able to locate CR # 1's admission and weekly skin assessments. He said he could not locate an admission weight on CR # 1 and that weekly weights had not been performed on CR # 1 as ordered on [DATE]. Record review of hospital medical record for Resident #1 revealed she was admitted to the Emergency Department on [DATE] with the following problems amongst others according to the Physician ' s documentation: [MEDICAL CONDITION]-significantly elevated WBC and elevated Lactic acid with multiple infections ant multiple sites - PEG tube site, urinary tract Bacteremia - [MEDICAL CONDITION] - Susceptible Staphylococcus Aureus (MSSA) and bilateral heel (Left heel with [MEDICAL CONDITION]). Hypotensive likely secondary to underlying septic shock. Possible aspiration pneumonia. Multiple wounds - Deep Tissue Injury to both heels, sacral stage 2, left knee, elbow, Right inner foot, healing stage 2 on buttocks. Resident #1 was discharged to Houston Hospice on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 died on [DATE] at Houston Hospice according to the family. Record review of the facility's policy and procedure titled Abuse and Neglect prohibition revised February 24, 2016 read in part Neglect means failure to provide goods and services necessary to avoid physical harm, mental or mental illness, injuries of unknown origin may occur as a result of neglect . facility supervisors will immediately correct and intervene in reported or identified situations in which neglect is at risk for occurring Record review of the facility's policy and procedure revised [DATE] titled Skin Integrity Assessment and Intervention of read in part it is the policy of St Dominic village to perform assessment on all residents upon admission and as needed to evaluate skin condition and to initiate protocols to ensure proper interventions . it is the policy of St Dominic village to have all pressure ulcers assessed immediately by all or part of the Wound Care Team within twenty -four (24) hours of discovery to evaluate for proper treatment initiation .the Admission assessment form is completed within * hours of admission . skin assessments are performed biweekly or more as needed for : resident who are bed bound, have a decrease in food or fluid intake, with ADL deficits(incontinence) and with observed abnormal findings related to skin integrity . Wound Care Consultant is available to evaluate treatments and make recommendations as necessary . treatments are administered as ordered by the physician .nutrition and hydration needs are evaluated by the Resident Dietician for residents with skin integrity impairments . and new admissions are assessed for risk factors (Pressure Sore Risk Assessment) on admission and weekly for four weeks and thereafter quarterly . FORMs: Admission Assessment Forms, Skin Integrity Pressure Ulcer Log, Pressure Sore Risk Assessment and Weekly Skin Sheet . Record review of the facility's policy and procedure dated [DATE] titled Notification of Abnormal Laboratory Results read in part it is the policy of St Dominic village to notify physicians of abnormal lab results as promptly as possible . any critical values called from the lab to the nurse must be called immediately to the physician, then faxed . Record review of the facility's policy and procedure titled Physician order [REDACTED]. Record review of the facility's policy and procedure titled Weights, Weighing of Residents revised [DATE] read in part all residents are weighed and measured for height on admission to the Nursing Home . all residents are weighed monthly and more often as ordered by a physician . weekly weights will be completed on all new admissions for a period of 4 weeks . Record review of the facility's policy and procedure titled Rounding revised [DATE] read in part Certified nursing assistants (CNAs) will round on their assigned residents every 2 hours and will turn and reposition . licensed nurses will round at different times throughout the shift to ensure CNAs are performing their duties as assigned . The CMS Form 672 listed 13 residents with Pressure Ulcers.

Based on observation, interview and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical contion demonstrates that they were unavoidable for 1 closed record (CR #1) of 6 residents who were reviewd for pressure sores in that: --CR #1 was discovered to have 6 facility acquired pressure sores, significant weight loss of 15.67 percent over 3 months, unreported abnormal labs and was transferred to a local hospital [MEDICAL CONDITION]. These failures affected one CR resident (closed record) and placed an additional 13 residents with Pressure Ulcers at risk for developing new ulcers, deterioration of existing Pressure Ulcers, Wound infection and a diminished quality of life. Intake # ' s 7, 4 and 9 Findings Include: CR # 1 Record review of CR #1's face sheet (Closed Record - CR) revealed she was a [AGE] years old who was admitted on to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's Admission MDS dated [DATE] revealed she had a Brief interview for Mental Status (BIMS) score of 9 indicating that she was moderate cognitive impairment. Skin condition assessment revealed no pressure sore. She required the extensive assistance of two staff for bed mobility. She required total dependence with 1 to 2 staff support for all activities of daily living. She had impairment on both sides of upper and lower extremities with range of motion limitations. She was non-ambulatory and always incontinent of both bowel and bladder. Record review of CR #1's Care Plan revealed she was Care Planned for being at risk for impaired skin integrity related to anticoagulant therapy, advanced age and variable nutritional intake effective from [DATE] with the following interventions: Turn and reposition every ,[DATE] hours Encourage nutritional intake Monitor weight and record Monitor laboratory results and notify MD of all abnormal values promptly Monitor skin during ADL care of signs/symptoms of skin irritations and notify charge nurse. Pressure sore protocol is used to determine interventions to prevent pressure sores. Resident #1 was also Care Planned for being at risk for weight loss related to dysphagia and variable nutritional intake effective from [DATE] with the following interventions: Resident will be weighed weekly for the first 4 weeks after admission or until stable, monthly thereafter. Notify family, MD and Dietician of significant weight loss or persistent decline in appetite. Record review of CR #1's admissions nurse's note (CR) written by LVN A dated [DATE] revealed that CR #1 was admitted to the facility on [DATE] with one small pressure sore to her bottom that measured approximately 1 cm in diameter . Record review of initial Visit Report on [DATE] revealed CR # 1 had 2 documented wounds. Visit report dated [DATE] completed by the Wound Care Physician revealed CR # 1 had 7 wounds: #1 Right heel stage 4/Moist Black Eschar - Length 1cm; Width 1cm; Depth 0.6cm and Area 1 sq. cm #2 Left heel stage 4 with moderate serous exudate - Length 0.9cm; Width 1.7cm; Depth 0.6cm and Area 1.53 sq. cm. #3 Left Medial foot suspected Deep tissue Injury (DTI) - Length 3.5cm; Width 3.0cm; Depth 0 and Area 10.5 sq. cm. #4 Left Lateral Foot suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 1.2cm; Depth 0 and Area 1.8 sq. cm. #5 Left Fifth Toe suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 0.5cm; Depth 0 and Area 0.75 sq. cm. #6 Right Lateral Ankle suspected Deep tissue Injury (DTI) - Length 1.5cm; Width 0.5cm; Depth 0 and Area 0.75 sq. cm. #7 Sacral stage 3 with moderate serous exudate - Length 3.0cm; Width 2.0cm; Depth 0.5cm and Area 6.0 sq. cm. During an interview on [DATE] at 4:40 p.m. the DON he said he did not know when CR # 1 developed 6 new pressure sores. He said CR # 1 was transferred to the hospital on [DATE] due to a change in condition. During an interview on [DATE] at 4:50 p.m. UM 2 said that CR #1 had pressure sores when she was transferred to her unit. During an interview on [DATE] at 5:00 p.m. the DON said the WCN just started in that position about 4 weeks ago. He said that the 2 unit managers and himself performed wound care treatment prior to the facility having a wound care nurse. During an interview on [DATE] at 5:10 p.m. the UM 1 said she did not know when Resident #1 developed the pressure wounds. During an interview on [DATE] at 11:30 a.m.with the ADON and DON, they said they could not find the admission skin assessment for CR # 1 and the weekly skin assessments for CR # 1. During an interview on [DATE] at 11:45 a.m. the DON said that his skin assessments were included in the progress notes. During an interview on [DATE] at 2:00 p.m. CR #1's Physician she said CR # 1 could develop pressure sores due to her many comorbidities. She said CR # 1 should have been on hospice. Record review of Resident #1 ' s Treatment Administration Record (TAR) from admission -[DATE] till she was transferred to the hospital on [DATE] revealed in part as follows: November No treatment was performed on coccyx from [DATE] to [DATE]. Also treatment was missed on [DATE] (Day shift); [DATE] (Evening and Night shifts); [DATE] (Evening Shift) and [DATE] (Evening Shift). Tube feeding Site Care was not done on [DATE] (Day and Evening shift); [DATE] (Day shift); [DATE] (Day shift); [DATE] (Evening and Night shifts); [DATE] (Day and Evening shift) and [DATE] (Evening Shift). Weekly weights were not done on [DATE]; [DATE] and [DATE]. December No treatment was performed on coccyx pressure sore [DATE] (Day shift) and [DATE] (Day shift). Peri and sacral area treatment not done on [DATE] (9.am; 1pm and 9pm); [DATE] (9am and 1pm) Peri and sacral area treatment not done on [DATE] (9pm); [DATE] (9 pm); [DATE] (9pm) and [DATE] (1pm). Coccyx pressure sore daily treatment not done on [DATE] and [DATE] Tube feeding Site Care was not done on[DATE] (Day shift); [DATE] (Day shift); [DATE] (Day shift) and [DATE]. January Coccyx pressure sore daily treatment not done on [DATE]; [DATE]; [DATE]; [DATE]; [DATE], [DATE]; [DATE] and [DATE]. Left Buttocks pressure sore daily treatment not done on [DATE]; [DATE] and [DATE]. February Coccyx pressure sore daily treatment not done on [DATE]; [DATE]; [DATE] and [DATE]. Left Buttocks pressure sore daily treatment not done on [DATE]; [DATE]; [DATE] and [DATE] March Weekly weights were not done on [DATE]; [DATE]; ,[DATE] and [DATE]. April Weekly weights were not done on [DATE]; [DATE]; [DATE] and [DATE]. During an interview on [DATE] at 5:30 p.m. the DON said he did not know why CR # 1's TAR (treatment administration record) indicated that treatments were not performed. He said maybe the staff forgot to click on the the submit button to sign them. He said CR #1's health was deteriorating. The DON said CR # 1 was ordered to be repositioned very 2 hours. The DON said CR # 1's ADL sheet should be documented with the times she was repositioned. The surveyor requested a copy of CR # 1's ADL sheet. CR # 1's ADL sheet was not provided to the surveyor at the time of exit. Record review of Resident #1 ' s Care Plan specified to turn and reposition resident every 2 to 3 hours. Record review of the Physician ' s History and Physical (H and P) plus Progress notes from [DATE] to [DATE] revealed no documentation of Resident #1 ' s weight. On Physician ' s initial H & P [DATE] and her Progress note dated [DATE] she documented no weight record and on all other notes ([DATE], [DATE], [DATE] and [DATE] weight was not addressed. Record review of CR # 1 ' s Vital Sign history revealed no admission weight documented on [DATE]. Additionally, weekly weights were not performed on [DATE], [DATE], [DATE], and [DATE]. Record review of CR # 1's Physician order [REDACTED]. Record review of CR #1 ' s Vital Sign history revealed the following weights: [DATE] 124lbs [DATE] 134lbs [DATE] 124lbs [DATE] 113.5lbs [DATE] 113.8lbs [DATE] 108.8lbs [DATE] 107.5lbs [DATE] 107.5lbs During an interview on [DATE] at 12:15 p.m. the DON acknowledged that weekly weights were ordered for CR # 1 effective [DATE] and that weights were not completed on [DATE] and [DATE]. Resident was sent to the hospital on [DATE]. During an interview on [DATE] at 12:25 p.m. the ADON said the facility had Dietician evaluation/assessments on [DATE] and [DATE] for Resident # 1. She said the facility did not have a Dietician for some time. She said the facility's Dietician started working at the facility in February 2016. Record review of Resident #1 ' s Dietician assessment dated [DATE] revealed Resident Dietician (RD) noted she had a significant weight loss (15.67%) in 3 months (November to February 2016) and recommended weekly weights for 4 weeks. No weights were documented for [DATE], [DATE] and from [DATE] to [DATE]. During an interview on [DATE] at 1:15 p.m. the Resident Dietician (RD) she said that she saw CR #1's for a dietary evaluation on [DATE] and again on [DATE]. She said CR #1 was scheduled to be seen again on [DATE]. and saw CR #1 on [DATE], [DATE] and the next assessment would be due on [DATE]. RD provided surveyor copies of her recommendations. Record review of CR #1's laboratory results revealed he had elevated white blood cells (WBC) for several months as follows: [DATE] 13.2 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.8 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.3 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 12.5 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 15.7 k/mm (Reference Range: 4XXX,[DATE].8) [DATE] 14.8 k/mm (Reference Range: 4XXX,[DATE].8) CR # 1's clinical record did not have documentation of CR # 1's physician being notified of her abnormal labs. During an interview on [DATE] at 5:14 p.m. the DON said he would look for documentation that the physician was notified of CR # 1's abnormal labs. He said abnormal labs should be reported to the physician . During an interview on [DATE] at 5:14 p.m. the DON said he was not able to locate CR # 1's admission and weekly skin assessments. He said he could not locate an admission weight on CR # 1 and that weekly weights had not been performed on CR # 1 as ordered on [DATE]. Record review of hospital medical record for Resident #1 revealed she was admitted to the Emergency Department on [DATE] with the following problems amongst others according to the Physician ' s documentation: [MEDICAL CONDITION]-significantly elevated WBC and elevated Lactic acid with multiple infections ant multiple sites - PEG tube site, urinary tract Bacteremia - [MEDICAL CONDITION] - Susceptible Staphylococcus Aureus (MSSA) and bilateral heel (Left heel with [MEDICAL CONDITION]). Hypotensive likely secondary to underlying septic shock. Possible aspiration pneumonia. Multiple wounds - Deep Tissue Injury to both heels, sacral stage 2, left knee, elbow, Right inner foot, healing stage 2 on buttocks. Resident #1 was discharged to Houston Hospice on [DATE] with the following Diagnoses: [REDACTED]. Resident #1 died on [DATE] at Houston Hospice according to the family. Record review of the facility's policy and procedure titled Abuse and Neglect prohibition revised February 24, 2016 read in part Neglect means failure to provide goods and services necessary to avoid physical harm, mental or mental illness, injuries of unknown origin may occur as a result of neglect . facility supervisors will immediately correct and intervene in reported or identified situations in which neglect is at risk for occurring Record review of the facility's policy and procedure revised [DATE] titled Skin Integrity Assessment and Intervention of read in part it is the policy of St Dominic village to perform assessment on all residents upon admission and as needed to evaluate skin condition and to initiate protocols to ensure proper interventions . it is the policy of St Dominic village to have all pressure ulcers assessed immediately by all or part of the Wound Care Team within twenty -four (24) hours of discovery to evaluate for proper treatment initiation .the Admission assessment form is completed within * hours of admission . skin assessments are performed biweekly or more as needed for : resident who are bed bound, have a decrease in food or fluid intake, with ADL deficits(incontinence) and with observed abnormal findings related to skin integrity . Wound Care Consultant is available to evaluate treatments and make recommendations as necessary . treatments are administered as ordered by the physician .nutrition and hydration needs are evaluated by the Resident Dietician for residents with skin integrity impairments . and new admissions are assessed for risk factors (Pressure Sore Risk Assessment) on admission and weekly for four weeks and thereafter quarterly . FORMs: Admission Assessment Forms, Skin Integrity Pressure Ulcer Log, Pressure Sore Risk Assessment and Weekly Skin Sheet . Record review of the facility's policy and procedure dated [DATE] titled Notification of Abnormal Laboratory Results read in part it is the policy of St Dominic village to notify physicians of abnormal lab results as promptly as possible . any critical values called from the lab to the nurse must be called immediately to the physician, then faxed . Record review of the facility's policy and procedure titled Physician order [REDACTED]. Record review of the facility's policy and procedure titled Weights, Weighing of Residents revised [DATE] read in part all residents are weighed and measured for height on admission to the Nursing Home . all residents are weighed monthly and more often as ordered by a physician . weekly weights will be completed on all new admissions for a period of 4 weeks . Record review of the facility's policy and procedure titled Rounding revised [DATE] read in part Certified nursing assistants (CNAs) will round on their assigned residents every 2 hours and will turn and reposition . licensed nurses will round at different times throughout the shift to ensure CNAs are performing their duties as assigned . The CMS Form 672 listed 13 residents with Pressure Ulcers.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving mistreatment, neglect or abuse are reported immediately to the administrator of the facility and to other officials in accordance with State law for 2 of 8 residents (Resident #2 and Resident #5) reviewed for abuse in that: -- Facility failed to report, protect, and investigate an allegation of abuse by Resident #2. --The facility failed to report, protect, and investigate an allegation of abuse on 12/10/2015 by Resident #5. An Immediate Jeopardy (IJ) was identified on 2/24/16. While the IJ was removed on 2/26/16, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. This failure affected 2 residents and placed the remaining 119 residents at risk of abuse, neglect, mistreatment, and misappropriation of property. Findings include: Resident #2 Review of his clinical record revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #2 ' s physician progress notes [REDACTED]. Review of Resident #2 ' s Quarterly MDS dated [DATE] revealed he had moderate hearing difficulty and moderately impaired vision. He had a BIMS score of 15, which indicated he was cognitively intact. Resident #2 required extensive assistance of one person for bed mobility, toilet use, bathing, and personal hygiene and was totally dependent on one to two people for transfers, locomotion, and dressing. During an observation and interview on 2/23/16 at 10:20 a.m., Resident #2 was lying in bed in his room. Resident # 2 said a female staff member had hit him on his leg on 02/22/16 at night. He said this was not the first time this had happened. He said he was also hit on 02/21/2016. He said both incidents happened before 10:00 pm. He said he was hit hard on the leg. He said it was the same person both times. Resident #2 said he wore a mask at night that covered his eyes. He said he could not see the person but said she spoke very bad English and had a strong accent. He said he thought the staff member started her shift at 7:00 p.m. Resident #2 said the incidents happened before 10:00 p.m. He said if I complain, they take longer to change me. Resident #2 said he did not tell any of the staff members about it. During an interview on 2/23/16 at 4:00 p.m. the ADON said she did not know why a resident would be afraid of retaliation. She said the facility did an inservice on 2/22/16 about retaliation due to an allegation made by Resident #8 concerning alleged retaliation. During an interview on 2/23/16 at 4:20 pm with Resident #2 and the ADON, Resident #2 told her he was hit on the leg by the same person who spoke bad English two nights in a row He said he could not understand what the person was saying. Resident #2 said the events happened before 10 pm. Resident #2 said he was afraid to report the incident as the staff might try to get revenge. Resident # 2 said the staff might make him wait and not change him. He said he felt bad that he was hit on the leg by a staff member and he did not feel safe in the facility. The ADON advised Resident # 2 in the future to tell the nurse or a housekeeper that he wanted to talk to the ADON. The ADON also told Resident #2 to call the front desk on his cell phone. The ADON told Resident #2 she would contact CNA J. Resident #2 said staff had retaliated before. Resident #2 said he had reported a similar incident to LVN G about two months ago. Resident #2 said he could not remember the name of the staff member that he had reported. The ADON left the room. Resident #2 said he did not trust anybody in the facility and he did not feel safe. During an interview on 2/24/16 at 8:50 a.m., LVN G said he did not remember Resident #2 making a complaint about a staff member to him. He said if Resident #2 told him he needed to be changed he would tell the CNAs. LVN G said if Resident #2 had told him the CNA ' s were not changing him quickly he would speak with the CNAs about this. LVN G said he would try to address a neglect allegation before reporting it. LVN G said in the military you try to settle things at the lowest level possible and get it corrected. LVN G said he had recently had abuse and neglect training and was able to name signs and symptoms of abuse. LVN G said he liked to do my own digging to find out the truth before I upset people. LVN G repeated several times that he watched Law & Order on television and liked to do his own investigations. LVN G said if a resident alleged that a staff member had hit him the staff member should not be allowed back in the resident's room until the investigation had been done. He also said he would notify the Unit Manager, ADON and Administrator. LVN G again said in the military you keep it at the lowest level. He said he reported the last allegation but he was sure it was an accident. LVN G said he was taught to report allegations of abuse versus trying to conduct his own investigations. During an interview on 2/24/16 at 9:30 am the Administrator was told about the allegation made by Resident #2. During an interview on 2/24/16 at 11:35 a.m. Resident #2 said he had gone out to the doctor that morning. He said the staff treated him good last night. He said the CNA who hit him came to apologize and she was scared. He was not able to identify the CNA by name. When asked when this happened he said, last night. He said the CNA he had made the allegation against worked with him last night and was good with him. He said nobody asked him any more questions. During an interview on 2/24/16 at 11:46 am the Administrator identified herself as the Abuse Prevention Coordinator. The Administrator said they interview Resident # 2 about the abuse allegation and reported it to the state. She said an assessment was performed and the resident ' s family and physician were notified. The Administrator said the CNA was identified and placed on leave. She said she was not aware that the CNA had spoken to Resident # 2 after the allegation of abuse became known. During an interview on 2/24/16 at 1:40 p.m. the Administrator said CNA J went into Resident #2's room when her shift started on 02/23/2016 at 07:00 pm. She said Resident #2 had asked for his eye covers and CNA J gave them to him. She said CNA J had been called not to return to work on 02/23/2016 but the facility was not able to speak with her. The Administrator said CNA J should not have been allowed back into Resident # 2 ' s room until the investigation had been completed. During an interview on 02/24/2016 with the ADON at 01:55 pm. she said she became aware of the allegation of abuse by Resident # 2 around 4:23 pm on 02/23/16. She said two staff members CNA J and CNA K had been identified as the possible abuser, but they decided it was CNA J. She said the facility tried to contact CNA J not to come to work on 02/23/2016 pending the results of the investigation. During an interview on 2/24/16 at 3:39 p.m. the Administrator said the facility had identified CNA J as the CNA who had gone into Resident # 2's room on 02/23/2016 in the evening. She said CNA J had clocked in to the facility at 6:47 p.m. The Administrator said she would find out what time staff went to get CNA J, but this information was not provided prior to exit on 2/26/16. The Administrator since CNA J could not be reached by phone prior to her shift; someone should have waited at the nurses ' station to get CNA J when she came in. During an interview on 2/25/16 at 9:55 a.m. Resident #2 said everything was okay and nothing was wrong. He said the Administrator talked to him yesterday. Resident #2 said staff were changing him quickly enough and often enough. During a telephone interview on 2/26/16 at 9:51 a.m. CNA J denied ever hitting Resident # 2 and she said she had not apologized to Resident # 2. She said she went into Resident #2 ' s room the evening of 2/23/16 and did what she always did for Resident #2; she put his eye mask on his face. She said she was sent home on 02/23/2016 by the ADON. CNA J said that if she witnessed a resident being abused she would report it to the nurse. Resident #5 Review of Resident #5 ' s clinical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5 ' s Significant Change MDS dated [DATE] revealed she had unclear speech and could sometimes make herself understood. Her BIMS score was 13, which indicated she was cognitively intact. Resident #5 required extensive assistance of at least one person for most activities of daily living except toileting, for which she was totally dependent on staff. Resident #5 was always incontinent of bowel and bladder. During an interview on 2/24/16 at 11:20 a.m. the Administrator was shown an Employee Counseling/Coaching Report dated 12/10/15 for CNA B which read in part Resident (#5) states employee did not provide care for her the entire shift. Solutions .CNA will no longer be assigned to specific resident. CNA also educated on check/change q 2h per facility protocol. The Administrator said an investigation of abuse should have been completed. In an interview on 2/24/16 at 1:40 p.m. The Administrator said there had been no investigation on the allegation made by Resident #5 against CNA B. The DON said CNA B was not on the schedule and had not worked at the facility for over a month. During an interview on 2/24/16 at 2:35 p.m. with RN O Unit Manager of Station One she said when she came to work on 12/10/15 LVN A told her Resident #5 had not been changed all night. She said LVN A wrote CNA B up for it. She said she along with LVN A signed the write up and it was placed in CNA B's human resource file. During an interview on 02/24/2016 at 02:45 pm the ADON said she spoke with Resident # 5 on a daily basis and that Resident #5 had never mentioned that a staff member had not provided care. She said she tries to support nurses who make allegations against the care staff. She said if there is an allegation of abuse or neglect the facility should do an investigation. She said she does not think Resident # 5 was spoken to concerning her allegation of not being changed during the night on 12/10/2015. The ADON said there is a breakdown in the facility's process of investigating complaints of abuse and neglect. She said this allegation of abuse should have been investigated and reported to the state. During an interview on 2/24/16 at 3:09 p.m. Resident #5 she said the staff sometimes treat her good and sometimes bad. She said she was often not changed enough. Resident #5 said sometimes the call button was out of her reach and she could not call for help. She said last time she could not reach her call button was approximately two weeks ago, at which time she said she was on the floor for 10 minutes before somebody came by and found her. She said she told LVN A that her call light was out of reach and LVN A told her she needed to wait for staff help. Resident #5 said she felt like LVN A scolded her. Resident #5 said that made her feel bad because I felt like that was not my fault. In continued interview on 2/24/16 at 3:09 p.m. Resident #5 said there was an aide who continued to shower her with water that was too hot after she was asked to stop. The aide told her she had to take a shower. Resident #5 said she could not remember what date that was, but thought it was when she first came to the facility. She said the aide told her to wash her face when Resident #5 kept complaining about how hot the water was. She said she told CNA N about the incident. She said CNA N told her the aide had been fired. Resident #5 said there was a date that nobody checked on her for a whole night. She said it might have been December. Resident #5 said she talked to the head nurse about it but she did not know the nurse ' s name, nor did she know the CNA ' s name. During an interview on 2/24/16 at 4:10 p.m. the Administrator said she had interviewed Resident # 5 about the incident with CNA B. She said Resident # 5 just said she wanted to go home. Record review of the facility ' s Abuse/Neglect, Investigation/Assessment, Reporting/Response Policy and Procedure revised August 2015 read in part, All reports of alleged abuse/neglect are reported to the proper authorities according to the guidelines set forth by the Texas Department on Ageing and Disability Services Department of Human Services.If an employee witnesses an abuse or hears a resident make an allegation of abuse, the employee immediately reports this to the supervisor on duty.Any employee accused of abuse/neglect is immediately suspended (with pay) until the incident has been investigated.Any employee has the right to ask someone to leave the building if they feel a residents (sic) is in danger. The Administrator makes the appropriate calls to the local and state authorities as o0utlined by the guidelines from the Texas Department of Human Services .(a) Notify Austin Special Investigation Section immediately and follow-up with a written report within five (5) working days. The administrator was notified on 2/24/16 at 5:30 pm that and immediate jeopardy had been identified based on the above failures. A plan of removal was submitted on 02/25/16. After revisions, it was accepted on 2/26/16 at 8:56 am. Plan of Removal · Abuse Prevention Coordinator in the facility was changed to the Administrator {name}, effective 2/24/2016. Signs and pictures will placed at each nurses station on 2/25/2016, to let staff, residents and families be aware of this change and who to report any allegations or known abuse. · Abuse and Prevention Policy and Procedure was updated on 2/24/2016, to include Procedures for Screening, Training, Prevention, Identification, Investigation, Protection and Reporting and Response (See Attached) · An in-service was started with all facility staff on 2/24/2016, to review the revised Abuse and Neglect Prohibition Policy. A test was also done with all staff to include 1. Who is the Abuse/Neglect Coordinator, 2. What are the 7 types of Abuse/Neglect, 3. What is the first thing to do if Abuse is suspected and known, 4. Who has the authority to ask someone to leave the facility, 5. What are signs to look for in residents to tell if they have possibly been abused, 6. What to do if an employee is in the building that should not be. This is concerning potential retaliation from an alleged abuser. The facility should never allow an employee that is the alleged abuser, to approach a resident and question a resident about the abuse in question. LVN ' s and Rn ' s had an additional question of what to immediately do if a resident makes as allegation of abuse against a staff member. (See Attached) · In-Service will continue until all facility staff have been in-serviced on the new policy. This will be completed by 2/26/16. · Nursing Administration (D.O.N., ADON, Unit Manager from stations 1,2,3&4) was in-serviced on Proper Investigation Procedures for Abuse and Neglect. This includes investigating all known and alleged abuse/neglect. This also includes making sure that alleged perpetrator of the abuse is immediately removed from the facility and is not allowed back in the facility for any reason until the conclusion of the investigation. · Nursing Administration (D.O.N., ADON, Unit Manager from stations 1,2,3&4) was also in-serviced on proper reporting of suspected or alleged abuse. If abuse and neglect is alleged it should be called into the state. Following new policy, the investigation is not done first, but rather it is called into the state and proper authorities then the investigation continues. · All residents who could answer, were asked questions about whether or not they feel safe here at St. Dominic Village. If they knew who to report abuse to and if they felt free to do so without retaliation. All responses are being evaluated and if the resident did not know their rights or who to report abuse to they were reminded and given a copy of their rights.(See Attached Form) · If anything is revealed in the random audits it will immediately be address by Abuse Prevention Coordinator. · Staff will not be allowed to work in the Rehabilitation and Nursing Center until the have received the Abuse and Neglect Training. Monitoring: Observation on 2/26/16 at 8:36 a.m. revealed a photograph and contact information showing the Administrator as Abuse Prevention Coordinator was posted near the front entrance on the inside of the facility. During an interview on 2/26/16 at 9:00 a.m. Resident #5 said staff had a meeting the day before and she was being treated well and with respect. Record review on 2/25/16 at 10:00 a.m. of the facility ' s Abuse and Neglect Policy and Procedure Revised February 24, 2016 revealed that all the seven components were present. Record review on 2/25/16 at 10:30 a.m. revealed the facility had begun training all staff on abuse and neglect and were continuing to do so. The administrator was informed on 2/26/16 at 9:20 am that the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. The facility ' s CMS 672 listed 121 residents.

Based on observation and record review and interview, the facility failed to develop and implement their written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 2 of 8 (Residents # 2 and #5) residents reviewed for abuse and neglect, in that: --The facility failed to have abuse and neglect policies for the areas of screening, training and prevention. An Immediate Jeopardy (IJ) was identified on 2/24/16. While the IJ was removed on 2/26/16, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. This failure affected 5 residents and placed the remaining 116 residents at risk of abuse, neglect, mistreatment, and misappropriation of property. Findings include: Abuse and Neglect Policy Record review of the facility ' s Abuse/Neglect, Investigation/Assessment, Reporting/Response Policy and Procedure revised August 2015 revealed the areas of Screening, Training, and Prevention were not covered in the policy. Record review on 2/25/16 at 10:00 a.m. of the facility ' s Abuse and Neglect Policy and Procedure Revised February 24, 2016 read in part, Prevention 1. Residents, families, and staff will be able to report concerns incidents, and concerns (sic) without fear of retribution or retaliation. All 7 required areas were covered. In an interview on 2/23/16 at 12:30 p.m. the ADON said she did not realize the facility's policies on abuse/neglect did not have all of the 7 necessary areas addressed. She said she did not realize the areas of screening, training, and prevention of abuse were not addressed in their policy. During an interview on 2/24/16 at 9:30 a.m. the Administrator said she did not realize that the areas of screening, training, and prevention were not part of the facility ' s Abuse and Neglect policy. He said other surveyors had not pointed this out to him. During an interview on 2/24/16 at 10:16 a.m. the Administrator said they were still looking in other facility policies to see if there was information regarding screening, training, and prevention. She said he would notify the surveyor if they were located. During an interview on 2/24/16 at 11:20 a.m. the Administrator said he realized that the facility's Abuse and Neglect policy needed to be updated to include the missing areas of screening, training and prevention. He said the facility was working to update its policy to include the seven areas required in the abuse and neglect policy. Resident #2 Review of his clinical record revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #2 ' s physician progress notes [REDACTED]. Review of Resident #2 ' s Quarterly MDS dated [DATE] revealed he had moderate hearing difficulty and moderately impaired vision. He had a BIMS score of 15, which indicated he was cognitively intact. Resident #2 required extensive assistance of one person for bed mobility, toilet use, bathing, and personal hygiene and was totally dependent on one to two people for transfers, locomotion, and dressing. He was always incontinent of bowel and bladder. During an observation and interview on 2/23/16 at 10:20 a.m., Resident #2 was lying in bed in his room. Resident # 2 said a female staff member had hit him on his leg on 02/22/16 at night. He said this was not the first time this had happened. He said he was also hit on 02/21/2016. He said both incidents happened before 10:00 pm. He said he was hit hard on the leg. He said it was the same person both times. Resident #2 said he wore a mask at night that covered his eyes. He said he could not see the person but said she spoke very bad English and had a strong accent. He said he thought the staff member started her shift at 7:00 p.m. Resident #2 said the incidents happened before 10:00 p.m. He said if I complain, they take longer to change me. Resident #2 said he did not tell any of the staff members about it. During an interview on 2/23/16 at 4:00 p.m. the ADON said she did not know why a resident would be afraid of retaliation. She said the facility did an inservice on 2/22/16 about retaliation due to an allegation made by Resident #8 concerning alleged retaliation. During an interview on 2/23/16 at 4:20 pm with Resident #2 and the ADON, Resident #2 told her he was hit on the leg by the same person who spoke bad English two nights in a row He said he could not understand what the person was saying. Resident #2 said the events happened before 10 pm. Resident #2 said he was afraid to report the incident as the staff might try to get revenge. Resident # 2 said the staff might make him wait and not change him. He said he felt bad that he was hit on the leg by a staff member and he did not feel safe in the facility. The ADON advised Resident # 2 in the future to tell the nurse or a housekeeper that he wanted to talk to the ADON. The ADON also told Resident #2 to call the front desk on his cell phone. The ADON told Resident #2 she would contact CNA J. Resident #2 said staff had retaliated before. Resident #2 said he had reported a similar incident to LVN G about two months ago. Resident #2 said he could not remember the name of the staff member that he had reported. The ADON left the room. Resident #2 said he did not trust anybody in the facility and he did not feel safe. During an interview on 2/24/16 at 8:50 a.m., LVN G said he did not remember Resident #2 making a complaint about a staff member to him. He said if Resident #2 told him he needed to be changed he would tell the CNAs. LVN G said if Resident #2 had told him the CNA ' s were not changing him quickly he would speak with the CNAs about this. LVN G said he would try to address a neglect allegation before reporting it. LVN G said in the military you try to settle things at the lowest level possible and get it corrected. LVN G said he had recently had abuse and neglect training and was able to name signs and symptoms of abuse. LVN G said he liked to do my own digging to find out the truth before I upset people. LVN G repeated several times that he watched Law & Order on television and liked to do his own investigations. LVN G said if a resident alleged that a staff member had hit him the staff member should not be allowed back in the resident's room until the investigation had been done. He also said he would notify the Unit Manager, ADON and Administrator. LVN G again said in the military you keep it at the lowest level. He said he reported the last allegation but he was sure it was an accident. LVN G said he was taught to report allegations of abuse versus trying to conduct his own investigations. During an interview on 2/24/16 at 9:30 am the Administrator was told about the allegation made by Resident #2. During an interview on 2/24/16 at 11:35 a.m. Resident #2 said he had gone out to the doctor that morning. He said the staff treated him good last night. He said the CNA who hit him came to apologize and she was scared. He was not able to identify the CNA by name. When asked when this happened he said, last night. He said the CNA he had made the allegation against worked with him last night and was good with him. He said nobody asked him any more questions. During an interview on 2/24/16 at 11:46 am the Administrator identified herself as the Abuse Prevention Coordinator. The Administrator said they interview Resident # 2 about the abuse allegation and reported it to the state. She said an assessment was performed and the resident ' s family and physician were notified. The Administrator said the CNA was identified and placed on leave. She said she was not aware that the CNA had spoken to Resident # 2 after the allegation of abuse became known. During an interview on 2/24/16 at 1:40 p.m. the Administrator said CNA J went into Resident #2's room when her shift started on 02/23/2016 at 07:00 pm. She said Resident #2 had asked for his eye covers and CNA J gave them to him. She said CNA J had been called not to return to work on 02/23/2016 but the facility was not able to speak with her. The Administrator said CNA J should not have been allowed back into Resident # 2 ' s room until the investigation had been completed. During an interview on 02/24/2016 with the ADON at 01:55 pm. she said she became aware of the allegation of abuse by Resident # 2 around 4:23 pm on 02/23/16. She said two staff members CNA J and CNA K had been identified as the possible abuser, but they decided it was CNA J. She said the facility tried to contact CNA J not to come to work on 02/23/2016 pending the results of the investigation. During an interview on 2/24/16 at 3:39 p.m. the Administrator said the facility had identified CNA J as the CNA who had gone into Resident # 2's room on 02/23/2016 in the evening. She said CNA J had clocked in to the facility at 6:47 p.m. The Administrator said she would find out what time staff went to get CNA J, but this information was not provided prior to exit on 2/26/16. The Administrator since CNA J could not be reached by phone prior to her shift; someone should have waited at the nurses ' station to get CNA J when she came in. During an interview on 2/25/16 at 9:55 a.m. Resident #2 said everything was okay and nothing was wrong. He said the Administrator talked to him yesterday. Resident #2 said staff were changing him quickly enough and often enough. During a telephone interview on 2/26/16 at 9:51 a.m. CNA J denied ever hitting Resident # 2 and she said she had not apologized to Resident # 2. She said she went into Resident #2 ' s room the evening of 2/23/16 and did what she always did for Resident #2; she put his eye mask on his face. She said she was sent home on 02/23/2016 by the ADON. CNA J said that if she witnessed a resident being abused she would report it to the nurse. Resident #5 Review of Resident #5 ' s clinical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5 ' s Significant Change MDS dated [DATE] revealed she had unclear speech and could sometimes make herself understood. Her BIMS score was 13, which indicated she was cognitively intact. Resident #5 required extensive assistance of at least one person for most activities of daily living except toileting, for which she was totally dependent on staff. Resident #5 was always incontinent of bowel and bladder. During an interview on 2/24/16 at 11:20 a.m. the Administrator was shown an Employee Counseling/Coaching Report dated 12/10/15 for CNA B which read in part Resident (#5) states employee did not provide care for her the entire shift. Solutions .CNA will no longer be assigned to specific resident. CNA also educated on check/change q 2h per facility protocol. The Administrator said an investigation of abuse should have been completed. In an interview on 2/24/16 at 1:40 p.m. The Administrator said there had been no investigation on the allegation made by Resident #5 against CNA B. The DON said CNA B was not on the schedule and had not worked at the facility for over a month. During an interview on 2/24/16 at 2:35 p.m. with RN O Unit Manager of Station One she said when she came to work on 12/10/15 LVN A told her Resident #5 had not been changed all night. She said LVN A wrote CNA B up for it. She said she along with LVN A signed the write up and it was placed in CNA B's human resource file. During an interview on 02/24/2016 at 02:45 pm the ADON said she spoke with Resident # 5 on a daily basis and that Resident #5 had never mentioned that a staff member had not provided care. She said she tries to support nurses who make allegations against the care staff. She said if there is an allegation of abuse or neglect the facility should do an investigation. She said she does not think Resident # 5 was spoken to concerning her allegation of not being changed during the night on 12/10/2015. The ADON said there is a breakdown in the facility's process of investigating complaints of abuse and neglect. She said this allegation of abuse should have been investigated and reported to the state. During an interview on 2/24/16 at 3:09 p.m. Resident #5 she said the staff sometimes treat her good and sometimes bad. She said she was often not changed enough. Resident #5 said sometimes the call button was out of her reach and she could not call for help. She said last time she could not reach her call button was approximately two weeks ago, at which time she said she was on the floor for 10 minutes before somebody came by and found her. She said she told LVN A that her call light was out of reach and LVN A told her she needed to wait for staff help. Resident #5 said she felt like LVN A scolded her. Resident #5 said that made her feel bad because I felt like that was not my fault. In continued interview on 2/24/16 at 3:09 p.m. Resident #5 said there was an aide who continued to shower her with water that was too hot after she was asked to stop. The aide told her she had to take a shower. Resident #5 said she could not remember what date that was, but thought it was when she first came to the facility. She said the aide told her to wash her face when Resident #5 kept complaining about how hot the water was. She said she told CNA N about the incident. She said CNA N told her the aide had been fired. Resident #5 said there was a date that nobody checked on her for a whole night. She said it might have been December. Resident #5 said she talked to the head nurse about it but she did not know the nurse ' s name, nor did she know the CNA ' s name. During an interview on 2/24/16 at 4:10 p.m. the Administrator said she had interviewed Resident # 5 about the incident with CNA B. She said Resident # 5 just said she wanted to go home. Record review of the facility ' s Abuse and Neglect Policy and Procedure Revised February 24, 2016 read in part, Prevention 1. Residents, families, and staff will be able to report concerns incidents, and concerns (sic) without fear of retribution or retaliation. Record review of the facility ' s Resident Rights, Organization of Ethics Policy revised July 2001 read in part, It is the policy of St. Dominic Village to acknowledge and respect each resident ' s fundamental right to consider care that safeguards his/her personal dignity and respects his/her cultural, psychosocial and spiritual values.2. Each resident has a right to a quality of life that supports independent expression, choice and decision making, consistent with applicable laws and regulations. Record review of the facility ' s Abuse/Neglect, Investigation/Assessment, Reporting/Response Policy and Procedure revised August 2015 read in part, All reports of alleged abuse/neglect are reported to the proper authorities according to the guidelines set forth by the Texas Department on Ageing and Disability Services Department of Human Services.If an employee witnesses an abuse or hears a resident make an allegation of abuse, the employee immediately reports this to the supervisor on duty.Any employee accused of abuse/neglect is immediately suspended (with pay) until the incident has been investigated.Any employee has the right to ask someone to leave the building if they feel a residents (sic) is in danger. The Administrator makes the appropriate calls to the local and state authorities as outlined by the guidelines from the Texas Department of Human Services .(a) Notify Austin Special Investigation Section immediately and follow-up with a written report within five (5) working days. Record review of the facility ' s Abuse and Neglect Policy and Procedure Revised February 24, 2016 read in part, Prevention 1. Residents, families, and staff will be able to report concerns incidents, and concerns (sic) without fear of retribution or retaliation. The administrator was notified on 2/24/16 at 5:30 pm that and immediate jeopardy had been identified based on the above failures. A plan of removal was submitted on 02/25/16. After revisions, it was accepted on 2/26/16 at 8:56 am. Plan of Removal · Abuse Prevention Coordinator in the facility was changed to the Administrator {name}, effective 2/24/2016. Signs and pictures will placed at each nurses station on 2/25/2016, to let staff, residents and families be aware of this change and who to report any allegations or known abuse. · Abuse and Prevention Policy and Procedure was updated on 2/24/2016, to include Procedures for Screening, Training, Prevention, Identification, Investigation, Protection and Reporting and Response (See Attached) · An in-service was started with all facility staff on 2/24/2016, to review the revised Abuse and Neglect Prohibition Policy. A test was also done with all staff to include 1. Who is the Abuse/Neglect Coordinator, 2. What are the 7 types of Abuse/Neglect, 3. What is the first thing to do if Abuse is suspected and known, 4. Who has the authority to ask someone to leave the facility, 5. What are signs to look for in residents to tell if they have possibly been abused, 6. What to do if an employee is in the building that should not be. This is concerning potential retaliation from an alleged abuser. The facility should never allow an employee that is the alleged abuser, to approach a resident and question a resident about the abuse in question. LVN ' s and Rn ' s had an additional question of what to immediately do if a resident makes as allegation of abuse against a staff member. (See Attached) · In-Service will continue until all facility staff have been in-serviced on the new policy. This will be completed by 2/26/16. · Nursing Administration (D.O.N., ADON, Unit Manager from stations 1,2,3&4) was in-serviced on Proper Investigation Procedures for Abuse and Neglect. This includes investigating all known and alleged abuse/neglect. This also includes making sure that alleged perpetrator of the abuse is immediately removed from the facility and is not allowed back in the facility for any reason until the conclusion of the investigation. · Nursing Administration (D.O.N., ADON, Unit Manager from stations 1,2,3&4) was also in-serviced on proper reporting of suspected or alleged abuse. If abuse and neglect is alleged it should be called into the state. Following new policy, the investigation is not done first, but rather it is called into the state and proper authorities then the investigation continues. · All residents who could answer, were asked questions about whether or not they feel safe here at St. Dominic Village. If they knew who to report abuse to and if they felt free to do so without retaliation. All responses are being evaluated and if the resident did not know their rights or who to report abuse to they were reminded and given a copy of their rights.(See Attached Form) · If anything is revealed in the random audits it will immediately be address by Abuse Prevention Coordinator. · Staff will not be allowed to work in the Rehabilitation and Nursing Center until the have received the Abuse and Neglect Training. Monitoring: Observation on 2/26/16 at 8:36 a.m. revealed a photograph and contact information showing the Administrator as Abuse Prevention Coordinator was posted near the front entrance on the inside of the facility. During an interview on 2/26/16 at 9:00 a.m. Resident #5 said staff had a meeting the day before and she was being treated well and with respect. Record review on 2/25/16 at 10:00 a.m. of the facility ' s Abuse and Neglect Policy and Procedure Revised February 24, 2016 revealed that all the seven components were present. Record review on 2/25/16 at 10:30 a.m. revealed the facility had begun training all staff on abuse and neglect and were continuing to do so. The administrator was informed on 2/26/16 at 9:20 am that the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for its effectiveness. The facility ' s CMS 672 listed 121 residents.

Based on interview and record review, the facility failed to follow their abuse/neglect policy to prohibit abuse or mistreatment of [REDACTED].#1) reviewed for abuse, as evidenced by: -CR #1 was sexually assaulted by her visitor/boyfriend -CR #1's visitor was verbally abusive An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. This failure affected 1 CR and could place 121 current residents at risk of being abused. Finding include: Intake # 5 and 6 Record review of CR #1's file revealed CR #1 was admitted to the facility on [DATE], on hospice, and was [AGE] years old. CR #1's [DIAGNOSES REDACTED]. CR #1 was re-admitted to the facility on [DATE] and expired on [DATE]. Record review of CR #1's hospital emergency room report, dated [DATE] read in part: .Chief complaint: Reported sexual assault. This occurred today. Occurred at a nursing home .she was reportedly sexually assaulted vaginally and anally .physical exam: .shows apparent trauma .Progress and Procedures: .bruising along her buttocks and peri-anal region . Record review of law enforcement form revealed incident # ,[DATE]. Title: Investigation-Sexual Assault. Record review of CR #1's quarterly MDS, assessment date [DATE], revealed CR #1 had unclear speech; was sometimes understood; sometimes understands; she required extensive assistance to total dependence for ADL care; had an indwelling catheter and was always incontinent of bowel. In an interview on [DATE] at 11:15 am the law enforcement officer stated another officer took the initial report of sexual assault when the incident occurred on Sunday, [DATE]. The officer stated CR #1 was transferred to an area hospital for a rape kit; he also stated CR #1 died this morning, [DATE], at 7:15 am. In an interview with the Administrator on [DATE] at 11:30 am she stated CR #1 had been at the facility since [DATE]. She stated the BF visited often and they had no reason to question his visitation. She stated he always appeared dis-shelved, but on the day of the incident he was irritated/agitated. She stated the staff had stated they could always tell he had been drinking. She stated the police informed them the family had indicated he had hit CR #1 in the past. She stated staff reported they observed CR #1's arms and legs were off the side of the bed; CR #1 was crying and he told her to shut up. The BF reported to staff that CR #1 had a headache. The CNA reported the residents headache to the nurse who gave her medications. When the medication was administered, the resident was crying and couldn't say where the pain was. CR #1 was Spanish speaking only; the BF spoke English. In continued interview, the Administrator stated, after the BF left, the CNA went in to provide peri care and noticed CR #1 had on a different color brief than what she normally wore and her injuries were apparent. CNA stated resident said in Spanish I'm scared, he did it, he did it . After that point the resident only cried, she was not verbally responsive. CR #1 was sent to the hospital on Sunday at 8:10 pm and a rape kit was performed. When she returned she had orders for antibiotics. When she returned she was moved into a private room and placed on crisis care and someone was assigned to her all the times. She was not responsive at all once she returned from the hospital. In an interview on [DATE] at 12:15 pm CNA A stated CR #1's BF visits all the time, usually arrives around lunch and leaves after their shift, which ends at 7:00 pm. She stated he usually was using the call light every ,[DATE] minutes for CR #1 to be changed. She stated on the day of the incident he kept saying she had a headache. CNA A stated CNA C reported that she saw the BF with CR #1 out of bed with her legs open and he told her to be quiet. CNA C came out and asked CNA A to go in and ask CR #1 what happened. When they entered the room CR #1 appeared afraid and was observed crying at which time the BF told her to be quiet. When CNA A asked CR #1 what happened she just cried. She stated they left and did not return until after the BF left the building. After he left, CR #1 cried a lot and would stop breathing for small periods of time. CNA A stated the nurse (LVN D) stated it was probably the medications. CNA A stated when they changed CR #1 they saw fresh red bruise around her vagina and CR #1 said he did it. CNA A stated she asked CR #1 did he do this to you and she said yes he did it, he did it. She stated CR #1 was observed with her roommates yellow brief on. In an interview on [DATE] at 12:45 pm CNA B stated on [DATE] the BF came between 11:00 am and 12 noon as they were getting ready for lunch. She stated as she was passing out CR #1's tray the BF kept saying CR #1 had a headache and told her to shut up. CNA B stated she told the medication aide (not identified) about the residents headache. She stated as she was still passing trays CNA C came out of the room and stated he (the BF) had CR #1 out of bed. When they went back into the room, CR #1 was back in bed and he kept pushing her down saying headache ; at that time LVN D came in and gave CR #1 [MEDICATION NAME]. CNA B stated she knew he would call when CR #1 needed to be changed so she didn't go back into the room. She stated he left about 6:15 pm. She stated she went in to change CR #1 ' s roommate and CR #1 had her arms above her head, eyes were rolling and she would stop breathing. She stated CR #1 kept crying and saying I'm scared. She stated she went and told LVN D who said it was the [MEDICATION NAME]. She stated she returned to the room and after providing care to the roommate, she started to provide care to CR #1 when she saw the brief that CR #1 had on was bloodshot red and had some type of discharge. She stated she went and got the nurse. She stated at that time she thought about the BF's behavior and said something was wrong. She stated at that time she also noticed that CR #1 had on the wrong brief. She stated residents are assigned to wear certain briefs/colors and CR #1 had on a brief/color that was assigned to her roommate. In an interview on [DATE] at 1:30 pm CNA C stated on [DATE] she walked in CR #1 ' s room and saw the BF with the resident off the bed. CNA C stated CR #1 did not have on any clothes and the curtain was pulled all the way. She stated she asked him what was he trying to do to her and told him to wait right there. She stated she then went and got CNA A to come and ask CR #1 what was he trying to do to her. She stated the BF kept saying CR #1 had a headache. CNA C stated the BF left quickly after CR #1 was given her medication. In an interview on [DATE] at 1:50 pm the ADON stated she was not here on the day of the incident. She stated staff should have been making rounds every 2 hours; patient safety is first. She stated visitors who exhibit that type of behavior should be asked to leave. Record review of CNA B's written statement read in part: On [DATE] her (CR #1's) BF came in around lunchtime maybe 11:30 am or 12:00 pm. Around 1:30 pm or 2:00 pm her BF comes out of the room and starts saying that CR #1 has a headache I told the nurse .he put her call light on so I went inside and he told me about her headache again. At that time I noticed that CR #1 was crying hysterically. He then got mad and told her to shut up and started cursing .Then around 1:45 pm CNA C .tells us she had just caught him wit her half way off the bed with her legs open. CNA C asked CNA A to asked CR #1 what he was doing but CR #1 didn ' t say anything. CNA C told him he could not have her out of bed .Around 6:15 pm we went back to change her .around 6:30 pm we noticed .the entire top of her vagina looked bruised and red .some type of discharge or body fluid on her vagina as well .When we turned her over .she had a big bruise on her left butt cheek. When I changed CR #1 earlier .she didn ' t have anything wrong with her. He always appears to be drunk or on drugs .when I went to change her I noticed someone had tried to change her and clean her because she had on her roommates yellow diaper instead of the blue one I had put on her. Record review of facility policy titled, Abuse/Neglect, Investigation/Assessment, Reporting/Response, revised [DATE], read in part: . It is the policy .to provide a safe environment for residents free from abuse and/or neglect .Purpose: to ensure the well-being, safety and positive care for all residents .sexual abuse includes .sexual assault .in the event an abuse or allegation of abuse should occur, the following steps are taken to maintain and pursue the goal of quality resident care: always remove the resident from danger. Keep resident out of harm ' s way. Never leave the resident with the person . The facility administrator was notified on [DATE] at 3:35 pm that an IJ situation had been identified. In an interview on [DATE] at 1:00 pm LVN D stated on [DATE] at around 1:30 pm she was called to CR #1's room because CR #1 had a headache. She stated CR #1's BF was in the room and he stated he had brought her some food. She stated she gave the resident PRN (as needed) [MEDICATION NAME] and told the BF to let he medicine work before he fed her. She stated she returned in 30 minutes and at no time was the resident crying. She stated at 6:40 pm she was called back to the residents room by the aides and at that time assessed the resident and found that she was bleeding, had bruised buttocks and her front was red and swollen. The final plan of removal was submitted on [DATE] at 4:32 pm after several revision. The IJ was removed on [DATE]. Called a mandatory in-service Friday ([DATE]) evening beginning at 5:00 pm and ending at 11:00 pm on the following: Revised Abuse and Neglect Prohibition Policy Senate Bill #9 Rounding (for nursing staff) Abuse validation test given What an employee is to do if they believe a visitor is impaired or intoxicated. Continued mandatory in-service for all employees coming on duty on Saturday ([DATE]) morning prior to the staff going on floor to care for residents. All employees, in all departments that have not been in-serviced have been identified. In-servicing will continue until all employees are in-serviced. No staff will be allowed to work on the floor without the in-service. Currently have in-serviced 196 of 198 total employees All employees re-signed the Senate Bill #9 acknowledgement and took a quiz on Abuse and Neglect All employees reminded of who the Abuse Coordinators are for St. Dominic Village. Abuse Coordinators are: Administrator Assistant Director of Nurses New administrative policy developed that all visitors must sign in when entering the facility. All receptionists have been in-serviced on mandatory sign-in policy. Addressed employees involved in the incident and educated and completed disciplinary action [DATE] Updated Abuse and Neglect policy to include asking family members or visitors to leave if they are witnessed being abusive to residents and/or appear to be intoxicated or impaired in any way. Staff will perform questionnaires with residents today ([DATE]) to ensure they feel safe, and know who to report abuse/neglect to, were given copies of the resident rights. 25 residents were interviewed. The Surveyor confirmed the plan had been implemented sufficiently to remove the IJ by: Interviews were conducted with 3 LVN ' s; 2 CNA ' s; 2 Receptionist; 1 Dietary staff and 1 maintenance staff on abuse policy, sign in policy, facility abuse coordinators and rounding schedule. Review of in-services conducted between [DATE] - [DATE] on topics including: types of abuse, identification of abuse coordinators, Senate Bill #9 and sign in registration; abuse/neglect reporting and investigation. Review of resident questionnaires. 5 residents were interviewed regarding satisfaction and feeling safe. In an interview on [DATE] at 3:54 pm the Administrator was asked how did she think this IJ came about and she stated she thought staff were used to the visitors presence and did not pay as much attention as they should have. She stated the facility had put procedures in place, updated their abuse policy, in-services staff and empowered staff to tell visitors to leave if a resident was in danger. She stated they also had a strict sign in policy as well as a new rounding policy, every 2 hours and nurses now fill out rounding sheets and turn them in. In an interview on [DATE] at 4:06 pm, the DON when asked how did he think this IJ came about, he stated possibly the CNA was not aware of what was going on and if the visitor was impaired or not. He stated the staff have been told they can ask visitors to leave. He stated they have in-serviced all of the staff on abuse/neglect and talked about the importance of rounding every 2 hours and being aware of who is in the building, resident safety, inappropriate behavior and asking visitors to leave. The Administrator was informed on [DATE] at 2:50 pm that the IJ was removed; however the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. According to the CMS 2567, the facility census was 121.

Based on interview and record review, the facility failed to implement their written abuse/neglect policy to prohibit abuse or mistreatment of [REDACTED].#1) reviewed for abuse, as evidenced by: -CR #1 was sexually assaulted by her visitor/boyfriend -CR #1's visitor was verbally abusive An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was re moved on [DATE], the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. This failure affected 1 CR and could place 121 current residents at risk of being abused. Finding include: Intake # 5 and 6 Record review of facility policy titled, Abuse/Neglect, Investigation/Assessment, Reporting/Response , revised [DATE], read in part: . It is the policy .to provide a safe environment for residents free from abuse and/or neglect .Purpose: to ensure the well-being, safety and positive care for all residents .sexual abuse includes .sexual assault .in the event an abuse or allegation of abuse should occur, the following steps are taken to maintain and pursue the goal of quality resident care: always remove the resident from danger. Keep resident out of harm ' s way. Never leave the resident with the person . Record review of CR #1's file revealed CR #1 was admitted to the facility on [DATE], on hospice, and was [AGE] years old. CR #1's [DIAGNOSES REDACTED]. CR #1 was re-admitted to the facility on [DATE] and expired on [DATE]. Record review of CR #1's hospital emergency room report, dated [DATE] read in part: .Chief complaint: Reported sexual assault. This occurred today. Occurred at a nursing home .she was reportedly sexually assaulted vaginally and anally .physical exam: .shows apparent trauma .Progress and Procedures: .bruising along her buttocks and peri-anal region . Record review of law enforcement form revealed incident # ,[DATE]. Title: Investigation-Sexual Assault. Record review of CR #1 ' s quarterly MDS, assessment date [DATE], revealed CR #1 had unclear speech; was sometimes understood; sometimes understands; she required extensive assistance to total dependence for ADL care; had an indwelling catheter and was always incontinent of bowel. In an interview on [DATE] at 11:15 am the law enforcement officer stated another officer took the initial report of sexual assault when the incident occurred on Sunday, [DATE]. The officer stated CR #1 was transferred to an area hospital for a rape kit; he also stated CR #1 died this morning, [DATE], at 7:15 am. In an interview with the Administrator on [DATE] at 11:30 am she stated CR #1 had been at the facility since [DATE]. She stated the BF visited often and they had no reason to question his visitation. She stated he always appeared dis-shelved, but on the day of the incident he was irritated/agitated. She stated the staff had stated they could always tell he had been drinking. She stated the police informed them the family had indicated he had hit CR #1 in the past. She stated staff reported they observed CR #1's arms and legs were off the side of the bed; CR #1 was crying and he told her to shut up. The BF reported to staff that CR #1 had a headache. The CNA reported the residents headache to the nurse who gave her medications. When the medication was administered, the resident was crying and couldn ' t say where the pain was. CR #1 was Spanish speaking only; the BF spoke English. In continued interview, the Administrator stated, after the BF left, the CNA went in to provide peri care and noticed CR #1 had on a different color brief than what she normally wore and her injuries were apparent. CNA stated resident said in Spanish I ' m scared, he did it, he did it . After that point the resident only cried, she was not verbally responsive. CR #1 was sent to the hospital on Sunday at 8:10 pm and a rape kit was performed. When she returned she had orders for antibiotics. When she returned she was moved into a private room and placed on crisis care and someone was assigned to her all the times. She was not responsive at all once she returned from the hospital. In an interview on [DATE] at 12:15 pm CNA A stated CR #1's BF visits all the time, usually arrives around lunch and leaves after their shift, which ends at 7:00 pm. She stated he usually was using the call light every ,[DATE] minutes for CR #1 to be changed. She stated on the day of the incident he kept saying she had a headache. CNA A stated CNA C reported that she saw the BF with CR #1 out of bed with her legs open and he told her to be quiet. CNA C came out and asked CNA A to go in and ask CR #1 what happened. When they entered the room CR #1 appeared afraid and was observed crying at which time the BF told her to be quiet. When CNA A asked CR #1 what happened she just cried. She stated they left and did not return until after the BF left the building. After he left, CR #1 cried a lot and would stop breathing for small periods of time. CNA A stated the nurse (LVN D) stated it was probably the medications. CNA A stated when they changed CR #1 they saw fresh red bruise around her vagina and CR #1 said he did it. CNA A stated she asked CR #1 did he do this to you and she said yes he did it, he did it . She stated CR #1 was observed with her roommates yellow brief on. In an interview on [DATE] at 12:45 pm CNA B stated on [DATE] the BF came between 11:00 am and 12 noon as they were getting ready for lunch. She stated as she was passing out CR #1 ' s tray the BF kept saying CR #1 had a headache and told her to shut up . CNA B stated she told the medication aide (not identified) about the residents headache. She stated as she was still passing trays CNA C came out of the room and stated he (the BF) had CR #1 out of bed. When they went back into the room, CR #1 was back in bed and he kept pushing her down saying headache; at that time LVN D came in and gave CR #1 [MEDICATION NAME]. CNA B stated she knew he would call when CR #1 needed to be changed so she didn't go back into the room. She stated he left about 6:15 pm. She stated she went in to change CR #1's roommate and CR #1 had her arms above her head, eyes were rolling and she would stop breathing. She stated CR #1 kept crying and saying I'm scared. She stated she went and told LVN D who said it was the [MEDICATION NAME]. She stated she returned to the room and after providing care to the roommate, she started to provide care to CR #1 when she saw the brief that CR #1 had on was bloodshot red and had some type of discharge. She stated she went and got the nurse. She stated at that time she thought about the BF's behavior and said something was wrong. She stated at that time she also noticed that CR #1 had on the wrong brief. She stated residents are assigned to wear certain briefs/colors and CR #1 had on a brief/color that was assigned to her roommate. In an interview on [DATE] at 1:30 pm CNA C stated on [DATE] she walked in CR #1's room and saw the BF with the resident off the bed. CNA C stated CR #1 did not have on any clothes and the curtain was pulled all the way. She stated she asked him what was he trying to do to her and told him to wait right there. She stated she then went and got CNA A to come and ask CR #1 what was he trying to do to her. She stated the BF kept saying CR #1 had a headache. CNA C stated the BF left quickly after CR #1 was given her medication. In an interview on [DATE] at 1:50 pm the ADON stated she was not here on the day of the incident. She stated staff should have been making rounds every 2 hours; patient safety is first. She stated visitors who exhibit that type of behavior should be asked to leave. Record review of CNA B's written statement read in part: On [DATE] her (CR #1's) BF came in around lunchtime maybe 11:30 am or 12:00 pm. Around 1:30 pm or 2:00 pm her BF comes out of the room and starts saying that CR #1 has a headache I told the nurse .he put her call light on so I went inside and he told me about her headache again. At that time I noticed that CR #1 was crying hysterically. He then got mad and told her to shut up and started cursing .Then around 1:45 pm CNA C .tells us she had just caught him wit her half way off the bed with her legs open. CNA C asked CNA A to asked CR #1 what he was doing but CR #1 didn ' t say anything. CNA C told him he could not have her out of bed .Around 6:15 pm we went back to change her .around 6:30 pm we noticed .the entire top of her vagina looked bruised and red .some type of discharge or body fluid on her vagina as well .When we turned her over .she had a big bruise on her left butt cheek. When I changed CR #1 earlier .she didn ' t have anything wrong with her. He always appears to be drunk or on drugs .when I went to change her I noticed someone had tried to change her and clean her because she had on her roommates yellow diaper instead of the blue on I had put on her. The facility administrator was notified on [DATE] at 3:35 pm that an IJ situation had been identified. In an interview on [DATE] at 1:00 pm LVN D stated on [DATE] at around 1:30 pm she was called to CR #1's room because CR #1 had a headache. She stated CR #1's BF was in the room and he stated he had brought her some food. She stated she gave the resident PRN (as needed) [MEDICATION NAME] and told the BF to let he medicine work before he fed her. She stated she returned in 30 minutes and at no time was the resident crying. She stated at 6:40 pm she was called back to the residents room by the aides and at that time assessed the resident and found that she was bleeding, had bruised buttocks and her front was red and swollen. The final plan of removal was submitted on [DATE] at 4:32 pm after several revision. The IJ was removed on [DATE]. Called a mandatory in-service Friday ([DATE]) evening beginning at 5:00 pm and ending at 11:00 pm on the following: Revised Abuse and Neglect Prohibition Policy Senate Bill #9 Rounding (for nursing staff) Abuse validation test given What an employee is to do if they believe a visitor is impaired or intoxicated. Continued mandatory in-service for all employees coming on duty on Saturday ([DATE]) morning prior to the staff going on floor to care for residents. All employees, in all departments that have not been in-serviced have been identified. In-servicing will continue until all employees are in-serviced. No staff will be allowed to work on the floor without the in-service. Currently have in-serviced 196 of 198 total employees. All employees re-signed the Senate Bill #9 acknowledgement and took a quiz on Abuse and Neglect. All employees reminded of who the Abuse Coordinators are for St. Dominic Village. Abuse Coordinators are: Administrator Assistant Director of Nurses New administrative policy developed that all visitors must sign in when entering the facility. All receptionists have been in-serviced on mandatory sign-in policy. Addressed employees involved in the incident and educated and completed disciplinary action. [DATE] Updated Abuse and Neglect policy to include asking family members or visitors to leave if they are witnessed being abusive to residents and/or appear to be intoxicated or impaired in any way. Staff will perform questionnaires with residents today ([DATE]) to ensure they feel safe, and know who to report abuse/neglect to, were given copies of the resident rights. 25 residents were interviewed. The Surveyor confirmed the plan had been implemented sufficiently to remove the IJ by: Interviews were conducted with 3 LVN ' s; 2 CNA ' s; 2 Receptionist; 1 Dietary staff and 1 maintenance staff on abuse policy, sign in policy, facility abuse coordinators and rounding schedule. Review of in-services conducted between [DATE] - [DATE] on topics including: types of abuse, identification of abuse coordinators, Senate Bill #9 and sign in registration; abuse/neglect reporting and investigation. Review of resident questionnaires. 5 interviews with residents regarding satisfaction and feeling safe. In an interview on [DATE] at 3:54 pm the Administrator was asked how did she think this IJ came about and she stated she thought staff were used to the visitors presence and did not pay as much attention as they should have. She stated the facility had put procedures in place, updated their abuse policy, in-services staff and empowered staff to tell visitors to leave if a resident was in danger. She stated they also had a strict sign in policy as well as a new rounding policy, every 2 hours and nurses now fill out rounding sheets and turn them in. In an interview on [DATE] at 4:06 pm, the DON when asked how did he think this IJ came about, he stated possibly the CNA was not aware of what was going no and if the visitor was impaired or not. He stated the staff have been told they can ask visitors to leave. He stated they have in-serviced all of the staff on abuse/neglect and talked about the importance of rounding every 2 hours and being aware of who is in the building, resident safety, inappropriate behavior and asking visitors to leave. The Administrator was informed on [DATE] at 2:50 pm that the IJ was removed; however the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. According to the CMS 2567, the facility census was 121.

Based on interview and record review, the facility administration failed to administer the facility in a manner that effectively maintained the highest practicable physical, mental and psycho-social well-being for 1 of 9 residents (CR #1) reviewed for effective facility administration. The Administrator failed to: - identify resident safety issues; -failed to implement the facility policy abuse/neglect policy; -failed to train the faciilty management staff on the recognition and reporting of abuse/neglect; -failed to evaluate/re-evaluate facility policy on abuse/neglect and visitation after a sexual assault incident occurred; -failed to provide a safe living environmnet for residents. The DON failed to: -train nursing staff on sign/symptoms/types of abuse -train staff on ensuring residents are free from abuse/neglect -train staff on reporting abuse/neglect An Immediate Jeopardy (IJ) was identified on 8-14-15. While the IJ was re moved on 8/19/15, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. This failure affected 1 CR and could place 121 current residents at risk of not receiving the care and supervision needed to safety and a high quality of life. Intake # 5 and 6 Findings include: In an interview on 8/19/15 at 3:54 pm the Administrator was asked how did she think this IJ came about and she stated she thought staff were used to the visitors presence and did not pay as much attention as they should have. She stated the facility had put procedures in place, updated their abuse policy, in-services staff and empowered staff to tell visitors to leave if a resident was in danger. She stated they also had a strict sign in policy as well as a new rounding policy, every 2 hours and nurses now fill out rounding sheets and turn them in. In an interview on 8/19/15 at 4:06 pm, the DON when asked how did he think this IJ came about, he stated possibly the CNA was not aware of what was going no and if the visitor was impaired or not. He stated the staff have been told they can ask visitors to leave. He stated they have in-serviced all of the staff on abuse/neglect and talked about the importance of rounding every 2 hours and being aware of who is in the building, resident safety, inappropriate behavior and asking visitors to leave. In an interview with the Administrator on 8/4/15 at 11:30 am she stated CR #1 had been at the facility since 4/7/15. She stated the BF visited often and they had no reason to question his visitation. She stated he always appeared dis-shelved, but on the day of the incident he was irritated/agitated. She stated they could always tell he had been drinking. She stated the police informed them the family had indicated there he had hit CR #1 in the past. She stated staff reported they observed CR #1 ' s arms and legs were off the side of the bed; CR #1 was crying and he told her to shut up. The BF reported to staff that CR #1 had a headache. The CNA reported the residents headache to the nurse who gave her medications. When the medication was administered, the resident was crying and couldn ' t say where the pain was. CR #1 was Spanish speaking only; the BF spoke English. In continued interview, the Administrator stated, after the BF left, the CNA went in to provide peri care and noticed she had on a different color brief than what she normally wore and injuries were apparent. CNA stated resident said in Spanish I ' m scared, he did it, he did it . After that point the resident only cried, she was not verbally responsive. CR #1 was sent to the hospital on Sunday at 8:10 pm and a rape kit was performed. In an interview on 8/14/15 at 12:15 pm CNA A stated CR #1 ' s BF visits all the time, usually arrives around lunch and leaves after their shift, which ends at 7:00 pm. She stated he usually was using the call light every 15-20 minutes for CR #1 to be changed. She stated on the day of the incident he kept saying she had a headache. CNA A stated CNA C reported that she saw him with CR #1 out of bed with her legs open and he told her to be quiet. CNA C came out and asked CNA A to go in and ask CR #1 what happened. When they entered the room CR #1 appeared afraid and was observed crying at which time the BF told her to be quiet. When CNA A asked CR #1 what happened she just cried. She stated they left and did not return until after he had left. After he left, CR #1 cried a lot and would stop breathing for small periods of time. She stated the nurse (LVN D) stated it was probably the medications. CNA A stated when they changed CR #1 they saw fresh red bruise around her vagina and CR #1 said he did it. CNA A states she asked CR #1 did he do this to you and she said yes he did it, he did it. She stated CR #1 was observed with her roommates yellow brief on. In an interview on 8/14/15 at 12:45 pm CNA B stated on 8/2/14 the BF came between 11:00 am and 12 noon as they were getting ready for lunch. She stated as she was passing out CR #1 ' s tray the BF kept saying CR #1 had a headache and told her to shut up. CNA B stated she told the medication aide (not identified) about the residents headache. She stated as she was still passing trays CNA C came out of the room and stated he (the BF) had CR #1 out of bed. When they went back into the room, CR #1 was back in bed and he kept pushing her down saying headache; at that time LVN D came in and gave CR #1 [MEDICATION NAME]. CNA B stated she knew he would call when CR #1 needed to be changed so she didn't go back into the room. She stated he left about 6:15 pm. She stated she went in to change CR #1's roommate and CR #1 had her arms above her head, eyes were rolling and she would stop breathing. She stated CR #1 kept crying and saying I ' m scared. She stated she went and told LVN D who said it was the [MEDICATION NAME]. She stated she returned to the room and after providing care to the roommate, she started to provide care to CR #1 when she saw the brief was bloodshot red and had some type of discharge. She stated she went and got the nurse. She stated at that time she thought about the BF's behavior and said something was wrong. She stated at that time she also noticed that CR #1 had on the wrong brief. In an interview on 8/14/15 at 1:30 pm CNA C stated on 8/2/14 she walked in CR #1's room and saw the BF with the resident off the bed. CNA C stated CR #1 did not have on any clothes and the curtain was pulled all the way. She stated she asked him what was he trying to do to her and told him to wait right there. She stated she then went and got CNA A to come and ask CR #1 what was he trying to do to her. She stated the BF kept saying she had a headache. CNA C stated the BF left quickly after CR #1 was given her medication. In an interview on 8/14/15 at 1:50 pm the ADON stated she was not there on the day of the incident, 8/2/15. She stated staff should have been making rounds every 2 hours; patient safety is first. She stated visitors who exhibit that type of behavior should be asked to leave. The facility administrator was notified on 8/14/15 at 3:35 pm that an IJ situation had been identified. Record Review of the POS [REDACTED].Responsible for the .development and implementation of policies and procedures .develop and implement abuse and neglect policies .ensure resident rights are honored by all staff . Record Review of the POS [REDACTED]. Maintains adequate staffing to ensure high quality resident care .Be an advocate for the residents .Participate in staff development and training . The IJ was removed on 8/19/15 IJ plan was as follow: Called a mandatory in-service Friday (8-14-15) evening beginning at 5:00 pm and ending at 11:00 pm on the following: Revised Abuse and Neglect Prohibition Policy Senate Bill #9 Rounding (for nursing staff) Abuse validation test given What an employee is to do if they believe a visitor is impaired or intoxicated. Continued mandatory in-service for all employees coming on duty on Saturday (8-15-15) morning prior to the staff going on floor to care for residents. All employees, in all departments that have not been in-serviced have been identified. In-servicing will continue until all employees are in-serviced. No staff will be allowed to work on the floor without the in-service. Currently have in-serviced 196 of 198 total employees All employees re-signed the Senate Bill #9 acknowledgement and took a quiz on Abuse and Neglect. All employees reminded of who the Abuse Coordinators are for St. Dominic Village. Abuse Coordinators are: Administrator Assistant Director of Nurses New administrative policy developed that all visitors must sign in when entering the facility. All receptionists have been in-serviced on mandatory sign-in policy. Addressed employees involved in the incident and educated and completed disciplinary action. 8-15-15 Updated Abuse and Neglect policy to include asking family members or visitors to leave if they are witnessed being abusive to residents and/or appear to be intoxicated or impaired in any way. Staff will perform questionnaires with residents today (8-15-15) to ensure they feel safe, and know who to report abuse/neglect to, were given copies of the resident rights. 25 residents were interviewed. The Surveyor confirmed the plan had been implemented sufficiently to remove the IJ by: Interviews were conducted with 3 LVN ' s; 2 CNA ' s; 2 Receptionist; 1 Dietary staff and 1 maintenance staff on abuse policy, sign in policy, facility abuse coordinators and rounding schedule. Review of in-services conducted between 8/14/15 - 8/17/15 on topics including: types of abuse, identification of abuse coordinators, Senate Bill #9 and sign in registration; abuse/neglect reporting and investigation. Review of resident questionnaires 5 interviews with residents regarding satisfaction and feeling safe. The Administrator was informed on 8/19/15 at 2:50 pm that the IJ was removed; however the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. According to the CMS 2567, the facility census was 121.

Based on interview and record review the facility failed to prevent implement their policy and procedure for the prevention of neglect for 1 of 22 residents (Closed Record (CR) #15) reviewed for abuse and neglect. Facility failed to: Prevent CR #15 when she was unresponsive from falling out of her wheelchair. Assess CR #15 prior to moving her after she fell from her wheelchair in the hall. Assess CR #15 prior to moving her after she was taken from the floor in the hall to her bed and moved from her bed to the floor. CR #15 sustained a fractured neck, hip, subdural hematoma and died days later. This failure affected 1 resident and place 117 residents at risk for neglect. # 0 Findings include: CR #15 Record review of CR #15's face sheet revealed she was a [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of facility's incident/accident report dated [DATE] at 2:00 p.m. revealed CR #15 was found unresponsive. The report further documented that while being transported to her room, CR #15's feet got caught under her wheelchair, she fell on to the floor and hit her head. Record review of CR #15's Nurses note, dated [DATE] at 1:58 p.m. revealed CR #15 slumped unresponsive in her wheel chair. While being transported to her room by staff, CR #15 fell to the floor, hit her head on the floor and received a gash to her forehead. There was no documentation of assessment or vital signs when CR #15 was found unresponsive in her wheelchair. There was no documentation that facility applied cervical, spinal or femoral immobilization after she fell on the floor and before or after she was moved to her room. Record review of Facility report dated [DATE] at 2:00 p.m. revealed LVN G, when returning to the unit, noticed CR #15 sitting in a wheelchair, unresponsive. LVN G began to apply sternum rub but CR #15 remained unresponsive. LVN G then turned CR #15's wheelchair while calling for assistance to get CR #15 to her room. LVN G noticed CR #15 feet were criss-crossed underneath the wheelchair. LVN G stopped to ask the code status of CR #15 and to untangle her feet. At that time, MA L arrived to assist in taking CR #15 to her room, as the wheelchair began to move forward, CR #15 tumbled forward out of the wheelchair and hit her head. MA L, then picked up CR #15 and carried her to her room. In an interview on [DATE] at 9:40 a.m., LVN G stated that after MA L started to wheel CR #15 to her room. When he had rolled her about 2 feet, LVN G noticed CR #15's feet were caught under the wheelchair. Before she could let MA L know about the condition of CR #15's feet, CR #15 fell forward face first to the floor. At that time, MA L picked up CR #15, cradled her in his arms and carried CR #15 back to her room, 6 doors down the hallway (approximately 45 feet). He placed CR #15 on her bed. LVN G stated that when CR #15 was on the bed, she started assessing the resident. When LVN G was questioned regarding proper procedure following a resident's fall, LVN G replied that Certified Nursing Aides and Certified Medication Aides were supposed to call nurses so they could assess if it was safe to pick up a resident from the floor. LVN G was asked if she assessed CR #15 before the Resident was picked up from the floor. LVN G replied "No". In an interview with MA L on [DATE] at 10:30 a.m., he stated that as CR #15 slid half way out of her wheelchair he tried to reach CR #15 with his left arm and with his right arm he tried to control the chair. He said CR #15 ended up falling head first hitting the floor. According to MA L, once CR #15 was on the floor she was facing down "like in a praying position, with her head on the floor". He said LVN G told him "we need to get her to the room". At that time, MA L, positioned arms around CR #15 hips and back of the head and neck and carried CR #15 back to her room on his arms. MA L placed CR #15 on her bed with the Resident's head towards the foot of the bed. MA L said then he washed blood off his hands at the room's sink. MA L said he heard LVN G saying "I need her on the floor". So he and LVN G picked up CR #15 and laid her on the floor. In an interview on [DATE] at 1:00 p.m., family member of CR #15 said that the family member received a phone call from the facility at 3:00 p.m. on [DATE]. LVN G notified family member that CR #15 had a bump on the head but was sent to hospital to see why she was not responsive. (sic) LVN G said further that CR #15 was going to be fine. The Family member said that around 7:30 p.m. she received a phone call from Emergency Department (ER) Doctor revealing the seriousness of CR #15's condition. According to CR #15's family member, she was told by Emergency Department Doctor that CR #15 had sustained a fall at the nursing facility. The ER doctor told her CR #15 had a fractured neck front and back at cervical vertebra C1 and C2. He said the injury was life threatening. The ER doctor also told Family Member that CR #15 had 15 to 20 stitches in the head and a left [MEDICAL CONDITION]. During this interview, CR #15's family member stated that she was not made aware of the seriousness of the situation when LVN G called her earlier. When the Family Member saw CR #15 at the hospital, the Resident's whole head was black and blue and required a sitter to stay with her at all times to keep her from moving. Family Member was told if Resident moved, she could stop breathing. According to CR #15's family member, she met with facility staff day after the fall and requested answers about the incident. Family Member asked why she was not made aware of seriousness of CR #15's injuries. CR #15's Family member said CR #15 died few days after the fall and that the doctors told the family member that there was nothing that they could do to save CR #15's life. In an interview on [DATE] at 2:50 p.m., LVN G stated that if she went to a room and a resident was on the floor, she would check if the resident was OK, and call for help. LVN G said she would not pick up the resident from the floor unless resident was checked for any broken bones. LVN G said, "If you have not assessed the patient you do not pick him up." In an interview with Unit Manager D on [DATE] at 3:22 p.m., she stated that on the day that CR #15 fell , MA L called for help. When Unit Manager D went into CR #15's room, she found CR #15 on the floor with LVN G kneeling towards CR #15. LVN G's back was to Unit Manager D. According to Unit Manager D, LVN G was doing sternum rubs to CR #15's chest. Unit Manager D stated that she was able to see the laceration on CR #15's head; "it was pretty big size, like a smiling face". Manager D asked CR #15 if she was in pain. CR #15 answered questions but not appropriately. Unit Manager D further revealed she applied head neck immobilization. During this interview, Unit Manager D verified that the facility's Policy that if a resident was found unresponsive that staff would not pick up a resident without being assessed first by a nurse. If a resident fell , nobody would touch him until a nurse completed an assessment. Record review of facility's undated witness statement of LVN G revealed that after CR #15 feet got caught under wheelchair, CR #15 fell on to floor, hitting head and received a gash to the top of forehead. MA L, at that point, picked up CR #15 and carried her to her room. MA L laid CR #15 on the bed. LVN G then saw small chunks of food coming out of CR #15's mouth and proceeded to sweep the food from her mouth. After sweeping CR #15's mouth, additional staff assisted LVN G in repositioning CR #15 as LVN G continued with sternum rub and talked to her. Record review of undated facility's witness Statements, MA L revealed that after CR #15 fell to the floor, and hit head very hard, LVN G and MA L walked over to CR #15, who was breathing and with blood coming from her head. MA L asked LVN G if she wanted him to take CR #15 to the room and LVN G replied "OK". After MA L placed CR #15 in bed, LVN G requested to have CR #15 placed on the floor. MA L then placed CR #15 on the floor. Then LVN G started chest compressions and mouth to mouth breathing. LVN G at that time asked MA L to go out and get help. There were no statements in the investigation that facility assessed for a pulse, breathing or checked vital signs while CR #15 was in her wheel chair or after she fell on the floor Record review of undated Witness Statement of LVN H, verified that as CR #15's feet got caught under wheelchair, CR #15 fell forwards, hitting head on the floor. LVN H heard a loud thud of impact. Then MA L picked CR #15 up and carried her to her room. Record review of Witness Statement written on [DATE] at 12:40 p.m., LVN H stated he went to room [ROOM NUMBER], saw CR #15 lying on the floor on her back beside bed. CR 15's feet were towards the head of the bed. CR #15 was verbally responsive with her eyes closed. LVN H saw ice pack to top of her head and blood at her hairline. LVN H stated that, when Emergency Medical Services arrived, an EMT questioned LVN H (sic) CR #15's legs were usually like this? "It looks like one leg is shorter than the other", "From where I am standing, it looks like one leg is a lot shorter than the other. She might have a broken hip". Record review of Facility's Abuse/Neglect policy and procedure, revised ,[DATE], revealed the Definition of Neglect -Read in part ... " An impaired quality of life for the resident due to the absence of minimal services or resources to meet basic needs, including ... Placing residents in an unsafe or unsupervised condition. " Record review of facility policy and procedure on falls, revised ,[DATE] stated: "It is the policy of Facility to evaluate all residents before moving when a fall has occurred. 1. When a resident falls, the resident is not to be moved until assessed by licensed nurse. 2. The licensed nurse assesses for the following: ... d. Injury - bumps, bruises, unnatural position of limbs 3. If there is no need for first aid, and if the resident is not injured, get help and return resident to bed. 4. If resident has stopped breathing or is bleeding or has fainted, give proper first aid. 5. If resident has painful area, bumps, or limbs in unnatural position, permit resident to stay on floor. Do not move or leave an injured person. Summon help to call physician and then carry out orders. 6. Notify responsible party and complete incident report." The facility's 672 form listed a census of 118.

Based on interview and record review the facility failed to implement their written policies and procedures that prohibit neglect for 1 of 22 residents (Closed Record (CR) #15 ) reviewed for abuse and neglect. Facility failed to: - Properly assess unresponsive resident (CR #15) found in her wheelchair. - Prevent an unresponsive resident from falling out of her wheelchair - CR #15. - Assess CR #15 prior to moving her after she fell from her wheelchair in the hall. - Assess CR #15 prior to moving her after she was taken from the floor in the hall to her bed and moved from her bed to the floor. - CR #15 sustained a fractured neck, hip, subdural hematoma and died . This failure affected 1 resident and place 117 residents at risk for neglect. # 0 Findings include: Record review of Facility's Abuse/Neglect policy and procedure, revised ,[DATE], revealed the Definition of Neglect -Read in part ... " An impaired quality of life for the resident due to the absence of minimal services or resources to meet basic needs, including ... Placing residents in an unsafe or unsupervised condition. " CR #15 Record review of CR #15's face sheet revealed a [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of facility incident/accident report dated [DATE] at 2:00 p.m. revealed CR #15 was found unresponsive. The report further documented that while being transported to her room, CR #15's feet got caught under her wheelchair, she fell on to the floor and hit her head. Record review of CR #15's Nurses note, dated [DATE] at 1:58 p.m. revealed CR #15 slumped unresponsive in her wheel chair. While being transported to her room by staff, CR #15 fell to the floor, hit her head on the floor and received a gash to her forehead. Sternal rub was continued and ice and pressure dressing were applied to forehead. Vital signs were obtained twice. There was no documentation of assessment or vital signs when CR #15 was found unresponsive in her wheelchair. There was no documentation that facility applied cervical, spinal or femoral immobilization after she fell on the floor and before or after she was moved to her room. Record review of Facility report dated [DATE] at 2:00 p.m. revealed LVN G, when returning to the unit, noticed CR #15 sitting in a wheelchair, unresponsive. LVN G began to apply sternum rub but CR #15 remained unresponsive. LVN G then turned CR #15's wheelchair while calling for assistance to get CR #15 to her room. LVN G noticed CR #15 feet were criss-crossed underneath the wheelchair. LVN G stopped to ask the code status of CR #15 and to untangle her feet. At that time, MA L arrived to assist in taking CR #15 to her room, as the wheelchair began to move forward, CR #15 tumbled forward out of the wheelchair and hit her head. MA L, then picked up CR #15 and carried her to her room. In an interview on [DATE] at 9:40 a.m., LVN G stated that after MA L started to wheel CR #15 to her room. When he had rolled her about 2 feet, LVN G noticed CR #15's feet were caught under the wheelchair. Before she could let MA L know about condition of her feet, CR #15 fell forward face first to the floor. At that time, MA L picked up CR #15, cradled her in his arms and carried CR #15 back to her room, 6 doors down the hallway (approximately 45 feet). He placed CR #15 on her bed. LVN G stated that when CR #15 was on the bed, she started assessing the resident. When LVN G was questioned regarding proper procedure following a resident's fall, LVN G replied that Certified Nursing Aides and Certified Medication Aides were supposed to call nurses so they could assess if it was safe to pick up a resident from the floor. LVN G was asked if she assessed CR #15 before the resident was picked up from the floor. LVN G replied "No". In an interview with MA L on [DATE] at 10:30 a.m., stated that as CR #15 slid half way out of her wheelchair as MA L tried to reach back of the resident's wheelchair. CR#15 and her wheelchair started moving forwards. MA L said he tried to reach to CR #15 with his left arm and with his right arm he tried to control the chair. He said CR #15 ended up falling head first hitting the floor. According to MA L, once CR #15 was on the floor she was facing down "like in a praying position, with her head on the floor". He said LVN G told him "we need to get her to the room". At that time, MA L, positioned arms around CR #15 hips and back of the head and neck and carried CR #15 back to her room on his arms. MA L placed CR #15 on her bed with the resident's head towards the foot of the bed. MA L said then he washed blood off his hands at the room's sink. MA L said he heard LVN G saying "I need her on the floor". So he and LVN G picked up CR #15 and laid her on the floor. In an interview on [DATE] at 2:50 p.m., LVN G stated that if she went to a room and a resident was on the floor, she would check if the resident was OK, and call for help. LVN G said she would not pick up the resident from the floor unless the resident was checked for any broken bones...assessed by a nurse. In an interview with Unit Manager D on [DATE] at 3:22 p.m., she stated that on the day that CR #15 fell , MA L called for help. When Unit Manager D went into CR #15's room, she found CR #15 on the floor with LVN G kneeling towards CR #15. LVN G's back was to Unit Manager D. According to Unit Manager D, LVN G was doing sternum rubs to CR #15's chest. Unit Manager D stated that she was able to see CR #15's laceration "it was pretty big size, like a smiling face" on top of CR#15's head. Manager D asked CR #15 if she was in pain. CR #15 answered questions but not appropriately. Unit Manager D further revealed she applied head neck immobilization. Unit Manager D verified that the facility's Policy and Procedure was that if a resident was found unresponsive a nurse would assess; and that staff would not pick up a resident. If a resident fell , nobody would touch him until a nurse completed an assessment. Record review of facility's undated witness statement of LVN G revealed that after CR #15 feet got caught under wheelchair, CR #15 fell on to floor, hitting head and received a gash to the top of forehead. MA L, at that point, proceeded in picking CR #15 up off of floor and carried CR #15 to the room and laid CR #15 on the bed. LVN G then saw small chunks of food coming out of CR #15's mouth and proceeded to sweep mouth. After sweeping CR #15's mouth, additional staff assisted LVN G in repositioning CR #15 as LVN G continued with sternum rub and talked to her. Further Record review of undated facility's witness Statements, MA L revealed that after CR #15 fell to the floor, and hit head very hard, LVN G and MA L walked over to CR #15, who was breathing and with blood coming from her head. MA L asked LVN G if she wanted him to take CR #15 to the room and LVN G replied "OK". After MA L placed CR #15 in bed, LVN G requested to have CR #15 placed on the floor. MA L then placed CR #15 on the floor. Then LVN G started chest compressions and mouth to mouth breathing. LVN G at that time asked MA L to go out and get help. There were no statements in the investigation that facility obtained assessed for a pulse, breathing or checked vital signs while CR #15 was in her wheel chair or after she fell on the floor Record review of undated Witness Statement of LVN H, verified that as CR #15's feet got caught under wheelchair, CR #15 fell forwards, hitting head on the floor. LVN H heard a loud thud of impact. Then MA L picked up CR #15 and carried her to her room. Record review of Witness Statement written on [DATE] at 12:40 p.m., LVN H stated he went to room [ROOM NUMBER], saw CR #15 laying on the floor on her back beside bed. CR #5's feet were towards the head of the bed. CR #15 was verbally responsive with her eyes closed. LVN H saw ice pack to top of her head and blood at her hairline. LVN H stated that, when Emergency Medical Services arrived, an EMT questioned LVN H (sic) CR #15's legs were usually like this? "It looks like one leg is shorter than the other", "from where I am standing, it looks like one leg is a lot shorter than the other, she might have a broken hip". Record review of facility policy and procedure on falls, dated November/2011 read in part.... "1. When a resident falls, the resident is not to be moved until assessed by licensed nurse. 2. The licensed nurse assesses for the following: d. Injury - bumps, bruises, unnatural position of limbs 3. If there is no need for first aid, and if the resident is not injured, get help and return resident to bed. 4. If resident has stopped breathing or is bleeding or has fainted, give proper first aid. 5. If resident has painful area, bumps, or limbs in unnatural position, permit resident to stay on floor. Do not move or leave an injured person. Summon help to call physician and then carry out orders. 6. Notify responsible party and complete incident report." Record review of Policies and Procedures dated [DATE], stated: "It is the policy of St. Dominic Village to evaluate all residents before moving when a fall has occurred." The facility's 672 form listed a census of 118.

Based on interview and record review the facility failed to ensure the environment remained free of accidents and hazards for 1 of 22 residents (Closed Record (CR) #15 ) reviewed for adequate supervision and assistance to prevent accidents. Facility failed to: Prevent CR #15 when she was unresponsive from falling out of her wheelchair. Assess CR #15 prior to moving her after she fell from her wheelchair in the hall. Assess CR #15 prior to moving her after she was taken from the floor in the hall to her bed and moved from her bed to the floor. CR #15 sustained a fractured neck, hip, subdural hematoma and died days later. This failure affected 1 resident and placed 117 residents at risk for harm from accidents and hazards. # 0 Findings include: CR #15 Record review of CR #15's face sheet revealed she was a [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of facility's incident/accident report dated [DATE] at 2:00 p.m. revealed CR #15 was found unresponsive. The report further documented that while being transported to her room, CR #15's feet got caught under her wheelchair, she fell on to the floor and hit her head. Record review of CR #15's Nurses note, dated [DATE] at 1:58 p.m. revealed CR #15 slumped unresponsive in her wheel chair. While being transported to her room by staff, CR #15 fell to the floor, hit her head on the floor and received a gash to her forehead. There was no documentation of assessment or vital signs when CR #15 was found unresponsive in her wheelchair. There was no documentation that facility applied cervical, spinal or femoral immobilization after she fell on the floor and before or after she was moved to her room. Record review of Facility report dated [DATE] at 2:00 p.m. revealed LVN G, when returning to the unit, noticed CR #15 sitting in a wheelchair, unresponsive. LVN G began to apply sternum rub but CR #15 remained unresponsive. LVN G then turned CR #15's wheelchair while calling for assistance to get CR #15 to her room. LVN G noticed CR #15 feet were criss-crossed underneath the wheelchair. LVN G stopped to ask the code status of CR #15 and to untangle her feet. At that time, MA L arrived to assist in taking CR #15 to her room, as the wheelchair began to move forward, CR #15 tumbled forward out of the wheelchair and hit her head. MA L, then picked up CR #15 and carried her to her room. In an interview on [DATE] at 9:40 a.m., LVN G stated that after MA L started to wheel CR #15 to her room. When he had rolled her about 2 feet, LVN G noticed CR #15's feet were caught under the wheelchair. Before she could let MA L know about the condition of CR #15's feet, CR #15 fell forward face first to the floor. At that time, MA L picked up CR #15, cradled her in his arms and carried CR #15 back to her room, 6 doors down the hallway (approximately 45 feet). He placed CR #15 on her bed. LVN G stated that when CR #15 was on the bed, she started assessing the resident. When LVN G was questioned regarding proper procedure following a resident's fall, LVN G replied that Certified Nursing Aides and Certified Medication Aides were supposed to call nurses so they could assess if it was safe to pick up a resident from the floor. LVN G was asked if she assessed CR #15 before the Resident was picked up from the floor. LVN G replied "No". In an interview with MA L on [DATE] at 10:30 a.m., he stated that as CR #15 slid half way out of her wheelchair he tried to reach CR #15 with his left arm and with his right arm he tried to control the chair. He said CR #15 ended up falling head first hitting the floor. According to MA L, once CR #15 was on the floor she was facing down "like in a praying position, with her head on the floor". He said LVN G told him "we need to get her to the room". At that time, MA L, positioned arms around CR #15 hips and back of the head and neck and carried CR #15 back to her room on his arms. MA L placed CR #15 on her bed with the Resident's head towards the foot of the bed. MA L said then he washed blood off his hands at the room's sink. MA L said he heard LVN G saying "I need her on the floor". So he and LVN G picked up CR #15 and laid her on the floor. In an interview on [DATE] at 1:00 p.m., family member of CR #15 said that the family member received a phone call from the facility at 3:00 p.m. on [DATE]. LVN G notified family member that CR #15 had a bump on the head but was sent to hospital to see why she was not responsive. (sic) LVN G said further that CR #15 was going to be fine. The Family member said that around 7:30 p.m. she received a phone call from Emergency Department (ER) Doctor revealing the seriousness of CR #15's condition. According to CR #15's family member, she was told by Emergency Department Doctor that CR #15 had sustained a fall at the nursing facility. The ER doctor told her CR #15 had a fractured neck front and back at cervical vertebra C1 and C2. He said the injury was life threatening. The ER doctor also told Family Member that CR #15 had 15 to 20 stitches in the head and a left hip fracture. During this interview, CR #15's family member stated that she was not made aware of the seriousness of the situation when LVN G called her earlier. When the Family Member saw CR #15 at the hospital, the Resident's whole head was black and blue and required a sitter to stay with her at all times to keep her from moving. Family Member was told if Resident moved, she could stop breathing. According to CR #15's family member, she met with facility staff day after the fall and requested answers about the incident. Family Member asked why she was not made aware of seriousness of CR #15's injuries. CR #15's Family member said CR #15 died few days after the fall and that the doctors told the family member that there was nothing that they could do to save CR #15's life. In an interview on [DATE] at 2:50 p.m., LVN G stated that if she went to a room and a resident was on the floor, she would check if the resident was OK, and call for help. LVN G said she would not pick up the resident from the floor unless resident was checked for any broken bones. LVN G said, "If you have not assessed the patient you do not pick him up." In an interview with Unit Manager D on [DATE] at 3:22 p.m., she stated that on the day that CR #15 fell , MA L called for help. When Unit Manager D went into CR #15's room, she found CR #15 on the floor with LVN G kneeling towards CR #15. LVN G's back was to Unit Manager D. According to Unit Manager D, LVN G was doing sternum rubs to CR #15's chest. Unit Manager D stated that she was able to see the laceration on CR #15's head; "it was pretty big size, like a smiling face". Manager D asked CR #15 if she was in pain. CR #15 answered questions but not appropriately. Unit Manager D further revealed she applied head neck immobilization. During this interview, Unit Manager D verified that the facility's Policy that if a resident was found unresponsive that staff would not pick up a resident without being assessed first by a nurse. If a resident fell , nobody would touch him until a nurse completed an assessment. Record review of facility's undated witness statement of LVN G revealed that after CR #15 feet got caught under wheelchair, CR #15 fell on to floor, hitting head and received a gash to the top of forehead. MA L, at that point, picked up CR #15 and carried her to her room. MA L laid CR #15 on the bed. LVN G then saw small chunks of food coming out of CR #15's mouth and proceeded to sweep the food from her mouth. After sweeping CR #15's mouth, additional staff assisted LVN G in repositioning CR #15 as LVN G continued with sternum rub and talked to her. Record review of undated facility's witness Statements, MA L revealed that after CR #15 fell to the floor, and hit head very hard, LVN G and MA L walked over to CR #15, who was breathing and with blood coming from her head. MA L asked LVN G if she wanted him to take CR #15 to the room and LVN G replied "OK". After MA L placed CR #15 in bed, LVN G requested to have CR #15 placed on the floor. MA L then placed CR #15 on the floor. Then LVN G started chest compressions and mouth to mouth breathing. LVN G at that time asked MA L to go out and get help. There were no statements in the investigation that facility assessed for a pulse, breathing or checked vital signs while CR #15 was in her wheel chair or after she fell on the floor Record review of undated Witness Statement of LVN H, verified that as CR #15's feet got caught under wheelchair, CR #15 fell forwards, hitting head on the floor. LVN H heard a loud thud of impact. Then MA L picked CR #15 up and carried her to her room. Record review of Witness Statement written on [DATE] at 12:40 p.m., LVN H stated he went to room 232, saw CR #15 lying on the floor on her back beside bed. CR 15's feet were towards the head of the bed. CR #15 was verbally responsive with her eyes closed. LVN H saw ice pack to top of her head and blood at her hairline. LVN H stated that, when Emergency Medical Services arrived, an EMT questioned LVN H (sic) CR #15's legs were usually like this? "It looks like one leg is shorter than the other", "From where I am standing, it looks like one leg is a lot shorter than the other. She might have a broken hip". Record review of Facility's Abuse/Neglect policy and procedure, revised ,[DATE], revealed the Definition of Neglect -Read in part ... " An impaired quality of life for the resident due to the absence of minimal services or resources to meet basic needs, including ... Placing residents in an unsafe or unsupervised condition. " Record review of facility policy and procedure on falls, revised ,[DATE] stated: "It is the policy of Facility to evaluate all residents before moving when a fall has occurred. 1. When a resident falls, the resident is not to be moved until assessed by licensed nurse. 2. The licensed nurse assesses for the following: ... d. Injury - bumps, bruises, unnatural position of limbs 3. If there is no need for first aid, and if the resident is not injured, get help and return resident to bed. 4. If resident has stopped breathing or is bleeding or has fainted, give proper first aid. 5. If resident has painful area, bumps, or limbs in unnatural position, permit resident to stay on floor. Do not move or leave an injured person. Summon help to call physician and then carry out orders. 6. Notify responsible party and complete incident report." The facility's 672 form listed a census of 118.

Based on observation, interview and record review the facility failed to ensure that one of six sampled residents (#3) received adequate supervision and assistance devices during transfers to prevent an avoidable accident resulting in an injury. - On 9/25/10, CNA A transferred Resident #3 from the bed to a Geri chair without the assistance of another CNA as required by the plan of care. After the transfer, Resident #3 complaint that her leg was hurting. She sustained a fracture of her right tibia and fibula that resulted in hospitalization from ,[DATE] to 9/29/10. This failure caused pain and injury to Resident #3 and could place 23 other residents requiring total assistance with transfers at risk for injury and unnecessary pain. Findings include: Review of the face sheet for Resident #3 revealed that she was a [AGE] year old female admitted on 10/15/09 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set assessment dated [DATE] revealed that she was alert with memory problems and impaired decision making skills. She required total assistance of two staff members for bed mobility and transfers. Balance while standing was coded as not able to attempt and the accidents section was coded for falls in the last 31-180 days. Review of Resident #3's care plans dated 6/3/2010 and updated on 9/2/2010 revealed: "Resident requires total assistance with bathing, transfers, toileting, bed mobility, locomotion on/off unit via Geri-chair...related to Alz./Dementia, physical limitations...Approaches/Interventions: Resident requires 2-3 person asst. with transfers using the EZ lift..." The resident had history of a fractured femur in 2009. Observation on 10/13/10 at 9:35 am revealed that Resident #3 was in bed laying on her back with the head of the bed elevated and her legs positioned towards her left side. The resident stated at the time that she was not feeling well and was going to stay in bed for a while. Review of the facility Incident and Accident reports for the month of September 2010 revealed a report dated 9/25/2010 for Resident #3. Further review of the report revealed: "While transferring Res. to (Geri chair), from bed, Res. suffered a swollen R knee (and) R tibia swelling transferred by 1 CNA x ray/Doppler ordered. Observation on 10/13/2010 at 2:50 pm revealed that Resident #3 was inside her room sitting in a Geri-chair. Further observation revealed she had an immobilizer on her right leg. When questioned about it she said" "Oh honey, they broke my leg." When asked who, she said: " I do not know, one girl here, she didn't mean to, I think." Resident #3 was unable to remember any other details. Review of the nurses' notes for Resident #3 revealed: -" 9/25/2010 5:50 am Res. complained to this nurse that her R lower leg "was broken". This writer noted that RLE from knee to(sic) double in size, esp. knee cap swelling... 9:34 am- transported to Methodist hospital. -9/29/2010 3?:25 pm Resident returned via (ambulance)...head to toe assessment...Braced on right leg intact, loosed and checked RT leg, swollen also RT ankle and foot, lg. dark bruise complete leg...Bruise Rt (upper) inner arm and L (upper) outer arm..." (sic) Review of a facility form titled Investigation Follow-up and dated 9/25/2010 revealed: "...Summary of the investigation-CNA transferred Resident without asst. of other staff. Policy of facility is any who use a geri-chair is required the asst of 2 person to asst...Recommendations: Counseled (cna) and staff- Inserviced staff, written citation to (cna)..."(sic) Form was marked as no follow up needed, abuse not suspected and it was signed by the Director of Nurses. Review of the statement completed by CNA A and dated 9/25/2010 revealed:"...usually I transferr her from chair to bed or bed to chair by myself without a problem or no complaints, This particular morning I let her bedrails down, had the (gerichair) lock and close to her bed, I did the proper procedure for transferring from bed to chair...she claim I hurt her leg, I checked her out and observe her leg, rolled her in the hall and immediately report and showed it to (nurse)..."(sic) In an interview on 10/13/10 at 2:55 pm, CNA B said that Resident #3 required 2 people to be transferred to the Geri-chair and " now with the fracture we use three or four people to transfer her. I was not here when it happen and it was before we got here in the morning. We just received an in-service from the nurses regarding transfers and who needs two staff members." In an interview on 10/13/10 at 3:05 pm, LVN C said: " I can only tell you what I heard, that her (Resident #3) leg was broken." When questioned she said that the resident always needed two people for transfers to the Geri-chair. She said that the facility just finished an in-service with the staff about safe transfers. In an interview on 10/13/2010 at 3:20 pm with CNA D she said: " The Resident needed two people before, now we need three or four because of the fracture. We just received training on transfers." In an interview on 10/13/2010 at 4:00 pm the ADON said that CNA A was counseled because she failed to follow the proper procedure and to transfer Resident #3 with two people instead of one. She said that after the incident the facility re in-serviced all the staff on safe transfers and placed a list of all the residents that require two people for transfers at the nurses' stations. A sign was also posted on Resident #3's room to let staff know about her needs. Review of the form titled Inservice Education Program Record and dated 9/29/2010 revealed: "...outline of material: The Standard of Practice for transfers and Repositioning was discussed ans staff informed how to handle resident for transfers to Geri-chair with use of properly positioned lift sheets. (Q+A) Acknowledgement form explained and return, signature requested. Review of the knowledge form signed by the staff revealed: "Two Person Transfers To and From the Bed and/or Chair. ...It is the standard of practice of this facility that any resident that requires total care, requires 2 person assistance for transfers and repositioning at all times. In addition, any resident that is unsteady in stance or conditions warrant 2 person assistance to transfer or repositioning due to physical weakness or limitations, will be transferred with 2 staff members at all times. There are no exceptions. I understand the above directiveand acknowledge that I will follow it or be subject to disciplinary action...as it related to violation of safety to a resident..." Review of the form placed at each nurses' station (no date) revealed: " Attention Nurses and Certified Nurse Assistants: The following residents must have 2-person assist to get up. No exceptions, no excuses. The residents that are on the list must be gotten up with the use of a lift sheet that is positioned from the top of the shoulder to the mid thigh of that resident, if they are gotten up to a Geri-chair, No exceptions, no excuses..." The list had a total of 23 residents to include Resident #3 that had an dditional note: "Move her to get-up list day shift only." Review of the Personnel file for CNA A revealed an orientation inventory sheet dated 8/18/10 that included safety, personnel policies and abuse/neglect. The list provided by the facility revealed a total of 23 residents that required 2 person assist for transfers.