Every finding on record at The Heights on Huebner

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 4 (Resident #4, Resident #103, Resident #26, and Resident #144) of 22 residents reviewed for accidents and hazards.1. The facility failed to ensure Resident #144 and Resident #103 did not have a disposable razor in his room.2. The facility failed to ensure Resident #4 did not have prohibited chemical and topical products stored in her room.3. The facility failed to ensure Resident #26 did not have prohibited medications and flammable products stored in his room.These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.The findings included: 1. Record review of Resident #144's face sheet date 1/13/26 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included lack of coordination, syncope and collapse (sudden, brief loss of consciousness with loss of postural tone followed by spontaneous complete recovery, fainting), and muscle weakness. Record review of Resident #144's baseline care plan dated 1/7/26 reflected that the resident was at risk for falls and had a self-care deficit with interventions that included to provide ADL care as indicated. Resident #144's baseline care plan reflected that the resident required dressing and grooming assistance with 1 person assist related to recent hospitalization that resulted in weakness and debility. Record review of Resident #103's face sheet dated 1/13/26 reflected a 79- year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a chronic progressive syndrome characterized by a decline in memory, thinking, reasoning, language, and the ability to perform daily activities severe enough to interfere with independent functioning), Parkinson's disease (chronic, progressive neurodegenerative disorder characterized primarily by motor dysfunction), diabetes (a chronic metabolic disorder characterized by persistent elevated blood glucose levels cause by defects in insulin secretion, insulin action, or both), unsteadiness on feet, and abnormalities of gait and mobility. Record review of Resident #103's most recent quarterly MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills and required setup or clean-up assistance with personal hygiene including shaving. Record review of Resident #103's comprehensive care plan with revision date 1/13/26 reflected the resident had a self-care deficit weakness and debility, cognitive impairment, and limited physical functioning related to stiff or limited joint range of motion, and had Parkinson's with interventions that included 1 person assist with hygiene. During an observation on 1/13/26 at 9:20 a.m., a light blue handle disposable razor was observed on Resident #144's dresser at the foot of the bed. During an observation and interview on 1/13/26 at 11:55 a.m., Resident #144 stated he was newly admitted to the facility and admitted on Thursday (1/8/26) related to a bad attack and was on the floor for over a day before somebody found him. Resident #144 was observed with a light blue handle disposable razor on the resident's dresser at the foot of the bed. Resident #144 stated the disposable razor observed was provided to him by his family member two days ago. Resident #144 stated he last used the disposable razor that morning during his shower. Resident #144 stated he was not assisted with his showers and was able to go into the shower room without staff assistance. During an observation on 1/13/26 at 11:58 a.m., Resident #103 was observed with a cup at the bedside that had 5 pink handle disposable razor blades. During an observation and interview on 1/13/26 at 1:41 p.m., Resident #103 summoned CNA F into his room and stated someone had come into his room and took his personal items that included cologne and his disposable razors. Resident #103 stated the disposable razor blades were his personal property, and he last used them to shave himself the previous evening during his shower. During an observation and interview on 1/13/26 at 1:44 p.m., with CNA F revealed Resident #144 in his room with family visiting at the bedside. Resident #144 stated, somebody came into his room and took the disposable razor that was on top of the dresser. Resident #144's family member stated he had brought the disposable razors to the resident and a second family member stated there were more disposable razors on the bottom drawer of the dresser. CNA F opened the bottom drawer of Resident #144's dresser and pulled out a disposable razor. CNA F stated that disposable razors were not allowed in the resident's room because it was considered a safety hazard and other residents could wander into the room and have access to it and could accidentally cut themselves. CNA F stated, for a resident to be able to keep a disposable razor in their room it had to be care planned. CNA F stated there was no particular staff assigned to look for or monitor for items that could potentially be a safety hazard as it was everybody's responsibility. During a follow up interview on 1/13/26 at 1:45 p.m., CNA F stated there was only one resident he knew of who was allowed to shave himself and that resident used an electric shaver. CNA F stated Resident #103 and Resident #144 were not supposed to have disposable razors in their rooms because the razors were considered an accident hazard and the residents could cut themselves. CNA F stated, in addition, the facility had residents who wandered and that person could have access to the disposable razors and potentially cut themselves. CNA F stated that residents who were capable of shaving themselves still had to have staff on standby in case there was an accident. During an interview on 1/14/26 at 9:19 a.m., the DON stated she was not aware or could not think of residents who wandered into other resident's rooms. The DON stated she was not aware of any residents who could independently shower. The DON stated, if a resident's care plan reflects the resident had a 1-person assistant, then that meant there was standby assistance by staff. The DON stated residents were allowed to have disposable razor blades in their rooms as long as it was care planned. The DON stated that residents needed to be assessed to safely use the disposable razor and it was for safety reasons. 2. Record review of Resident #4's admission record revealed a female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included spinal stenosis of the cervical region (narrowing of the spinal canal in the neck that can compress the spinal cord and nerves causing pain, weakness, or numbness), heart failure (a chronic condition in which the heart is unable to pump blood effectively), hypertension (persistently elevated blood pressure), and diabetes mellitus (a chronic metabolic disorder characterized by elevated blood glucose levels). Record review of Resident #4's admission MDS, dated [DATE], revealed the resident's BIMS score was 15. Section GG of the MDS revealed the Resident #4 was dependent on staff for personal hygiene; indicating the helper did all of the effort for the activity or that two or more helpers were required. Record review of Resident #4's care plan, created on 11/20/25 and last revised on 1/1/26, revealed a self-care deficit related to spinal stenosis, dysphagia, cardiac disease, diabetes mellitus, weakness and debility, and immobility. The care plan revealed the resident required dressing and grooming with two-person assistance. Record review of Resident #4's physician orders dated 1/13/26 revealed no orders for the resident to self-administer medications or topical agents. During an observation on 1/13/26 at 11:34 a.m., a bottle of medical adhesive remover (a chemical solvent used to remove medical tape and dressings, labeled as flammable) and a bottle of pain relief cream containing lidocaine hydrochloride 4% (a topical anesthetic used to numb pain, labeled keep out of reach of children) were observed on Resident #4's bedside dresser. During an interview on 1/13/26 at 11:35 a.m. Resident #4 stated she was unsure where the adhesive remover spray came from, but she thought her family possible brought in the lidocaine ointment for her to use but she had not used it because the facility was placing lidocaine patches on her. During an interview on 1/13/26 at 11:14 a.m., LVN G stated Resident #4 was not supposed to have those items and she had not noticed them prior. LVN G removed the items and stated she would place them on the medication cart. 3. Record review of Resident #26's admission Record/Face Sheet, dated 4/29/24, revealed a [AGE] year-old male admitted with diagnoses including effusion of the left knee (abnormal accumulation of fluid within the knee joint causing swelling and pain), acute diastolic (congestive) heart failure (a condition in which the heart is unable to relax and fill properly, resulting in fluid buildup and decreased blood flow), and vascular dementia (a decline in cognitive function caused by reduced blood flow to the brain). Record review of Resident #26's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15. Section GG revealed the Resident #26 required setup or clean-up assistance for personal hygiene. Record review of Resident #26's admission/readmission care plan initiated 4/29/24 revealed the resident was at risk for self-care deficit, falls, skin concerns, pain, infection, nutritional and hydration concerns, and emotional distress related to weakness and debility. Interventions included administering medication and treatments as ordered, providing ADL care as indicated, monitoring health status, and referring concerns to nursing staff. Record review of Resident #26's physician orders, dated 1/13/26, revealed no orders for the resident to self-administer medications or topical agents. During an observation and interview on 1/12/26 at 10:44 a.m., a bottle of rubbing alcohol (a flammable antiseptic chemical) and a bottle of aerosol lidocaine spray (a topical anesthetic delivered in aerosol form) were observed on top of the dresser in plain sight. Resident #26 stated he used the lidocaine for his hand, and he could have whatever items he wanted because he had been there for some time. During an interview on 1/13/26 at 11:47 a.m. ADON G stated medications, and topical products should not be kept at the bedside unless care planned. ADON G stated staff should remove those items because other confused residents could get ahold of those items. ADON G stated he was assigned that hallway to monitor residents' rooms for prohibited items but had not noticed the items in either resident's room prior. During an interview on 1/14/26 at 8:59 a.m., the DON stated residents were not allowed to have medications at the bedside unless assessed and care planned. The DON stated the items may have been from the hospital and mixed with personal belongings and staff were not aware the residents had them. The DON stated staff would need to more closely monitor what items residents return with when they went to the store. The DON stated if they had a confused resident they could possibly get ahold of the items. Record review of the facility document titled Items Not Allowed in Resident Rooms, undated, revealed in part, .The following articles are not permitted because they are controlled by codes, regulations, standards, or because the presence and/or use of such articles have been interpreted by the Texas Health and Human services (THHS) to have an adverse effect on the health and safety of the residents.Any medications, over the counter or prescription.Ointments, over the counter or prescription.Any substance bearing a warning statement 'keep out of reach of children'.Straight razors.Chemical products.Flammable products.Alcohol.Scissors or any sharp object.Aerosol sprays of any type.

Based on observation, interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 8 residents (Residents #4) reviewed for medical records. 1. The facility failed to ensure Resident #4's medication consent form was missing the nurse signature required to witness on the original medication consent for her antidepressant medication venlafaxine and the replacement consent form did not include the medication name. 2. The facility failed to ensure Resident #4's medication orders and Medication Administration Record (MAR) accurately reflected the correct route of administration, medications were documented as administered by mouth when the resident received all medications via gastrostomy tube (G-tube) (a tube surgically placed through the abdominal wall into the stomach to provide nutrition, fluids, and medications when a person cannot safely swallow). 3. The facility failed to ensure Resident #4's out-of-hospital Do Not Resuscitate (OOH DNR) document was clear and accurately completed, the physician's signature was not placed in the designated signature area. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.The findings include:1. Record review of Resident #4's admission record revealed a female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included spinal stenosis of the cervical region (narrowing of the spinal canal in the neck that can compress the spinal cord and nerves causing pain, weakness, or numbness), heart failure (a chronic condition in which the heart is unable to pump blood effectively), hypertension (persistently elevated blood pressure), encounter for surgical aftercare following surgery on the digestive system (a follow-up medical encounter for care, monitoring, and recovery after a surgical procedure involving the gastrointestinal tract). and diabetes mellitus (a chronic metabolic disorder characterized by elevated blood glucose levels). Record review of Resident #4's admission MDS, dated [DATE], revealed the resident's BIMS score was 15 (fully intact cognition). Section K revealed the resident had a feeding tube. Record review of Resident #4's care plan, created on 11/20/25 and last revised on 01/01/26, revealed the resident required a feeding tube related to dysphagia and was NPO (nothing by mouth). The care plan revealed the resident received enteral nutrition and was on EBH precautions related to the PEG tube, required the head of bed to be elevated and to avoid lying flat while feedings were running, and required staff to cue and assist with positioning. The care plan further revealed staff were to provide local care to the G-tube site as ordered, monitor for signs and symptoms of infection, and refer any feeding pump or care concerns to nursing. During a record review on 1/14/26 at 9:24 a.m. Resident #4 had a consent in the EHR for medication venlafaxine (an antidepressant medication used to treat depression, anxiety, and panic disorders by increasing levels of serotonin and norepinephrine in the brain). The consent was signed and dated by Resident #4 but was blank under the section for the person obtaining permission. During an observation, interview, and record review on 1/14/26 at 11:13 a.m. ADON C provided a different copy of Resident #4's Medication consent, dated 1/8/26. The document was blank in the section for Psychotropic Medication Prescribed, stated it was for depression, the area for the Residents information indicated she gave verbal consent, and was signed by a person obtaining the permission. ADON C stated the form should list the medication you are getting consent for so the resident was aware of what the medication was, what drug category it was in, and what they are consenting to. 2. Record review of Resident #4's active physician orders, dated 1/13/26, revealed two active orders for Venlafaxine HCl 37.5 mg for depression. One order directed to give one tablet by mouth one time a day, and a second order directed to give one tablet via PEG-tube one time a day. The orders reflect ADON C entered the orders for this medication. Record review of Resident #4's January 2026 Medication Administration Record (MAR) reflected:-Duloxetine HCl 30 mg (an antidepressant used to treat depression and anxiety) ordered give 1 capsule by mouth one time a day for depression (01/09/26-01/11/26) and also give 1 capsule via PEG-tube one time a day for depression (beginning 01/12/26). The MAR showed the Duloxetine was administered by mouth on 1/10/26 and 1/11/26.-Lokelma 10 g oral packet (a potassium-binding medication used to treat high potassium levels) ordered give by mouth one time a day (01/09/26-01/11/26) and also give via G-tube one time a day (beginning 01/11/26). The MAR showed the lokelma was administered by mouth on 1/10/26.-Amoxicillin 500 mg (a broad-spectrum antibiotic used to treat bacterial infections) ordered give by mouth two times a day (01/10/26-01/11/26) and also give via G-tube two times a day (beginning 01/11/26). The MAR showed the amoxicillin was administered by mouth twice on 1/12/26 and once on 1/11/26.-Hydroxyzine HCl 10 mg (an antihistamine used to treat anxiety and agitation) ordered give 1 tablet by mouth every 8 hours as needed for anxiety/agitation (01/05/26-01/11/26) and also ordered give 1 tablet via G-tube every 8 hours as needed (beginning 01/11/26). The MAR showed hydroxyzine was administered on 1/5/26 and 1/9/26 by mouth.-Loperamide HCl 2 mg (an antidiarrheal medication used to treat loose stools) ordered give 1 tablet by mouth every 12 hours as needed (12/24/25-01/05/26) and also ordered give 1 tablet via PEG-tube every 12 hours as needed (beginning 01/05/26).-Venlafaxine HCl 37.5 mg (an antidepressant used to treat depression) ordered give 1 tablet by mouth one time a day (01/13/26) and also ordered give 1 tablet via PEG-tube one time a day (beginning 01/14/26). The MAR reflected Venlafaxine was never administered. During an interview on 1/14/26 at 10:37 a.m. RN I stated Resident #4 always received her medication via g tube and not by mouth. RN I stated she had contacted the provider to correct the orders from by mouth to via peg tube. RN I stated although the resident never took any of the medications by mouth the orders should reflect via peg tube because the resident could aspirate if taken orally. During an interview on 1/14/26 at 11:13 a.m. ADON C stated the resident's antidepressant medication was changed from duloxetine to venlafaxine because it was easier to crush and administer via her peg tube. ADON C stated Resident #4 never received any medication orally despite what the orders showed and what was check off as administered on the MAR. ADON C stated after they deactivated the orders, they would continue to show active for that day but would be discontinued the following day. 3. Record review of Resident #4's out-of-hospital Do Not Resuscitate (OOH DNR), dated 11/21/25, revealed the resident's signature was present in Section A. The form contained a handwritten signature in the section labeled Attending Physician in the middle portion of the document. The section at the bottom of the form labeled All persons who have signed above must sign below, acknowledging that this document has been properly completed contained the resident's signature written across the line for the attending physician, and the physician signature line in that section was blank. A handwritten arrow was present in the same section for the attending physician signature to a blank line below. During an interview on 1/13/26 at 4:58 p.m. the SW stated the physicians' signature appeared to be present on the DNR in both sections required on the DNR. When this surveyor again reviewed the physician signature line remained blank. The SW stated it could be redone to look better but the DNR was still valid. During an interview on 1/14/26 at 1:42 p.m. the DON stated they did not have a policy for medical record documentation or nursing documentation. The DON stated she did not think they had a policy for consent but would check. No policies were provided.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 5 of 6 residents (Resident #7, Residents #97, Resident#34. Resident #144 and Resident #4) reviewed for infection control.1. The facility failed to ensure CNA D sanitized the pulse oximeter used between Resident #7 and Resident #97.2. The facility failed to ensure MA E sanitized the blood pressure cuff used between Resident #34 and Resident #144.3. The facility failed to ensure Resident #4's wound bed did not come in contact with a used bed sheet after it was cleaned while RN L was performing wound care. 4. The facility failed to ensure CNA J and CNA K did not hold Resident #4's catheter above bladder level.These failures could place residents at risk for cross contamination and infection.The findings included: 1. Record review of Resident #7's face sheet dated 1/13/26 reflected an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included respiratory bronchiolitis interstitial lung disease, heart failure, and respiratory failure. Record review of Resident #7's comprehensive care plan with revision date 1/2/26 reflected Resident #7 was at risk of experiencing shortness of breath and required oxygen therapy related to ineffective gas exchange with interventions that included monitoring for signs and symptoms of respiratory distress and report to the physician as needed respirations and pulse oximetry. Record review of Resident #97's face sheet dated 1/13/26 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included morbid obesity due to excess calories, hyperlipidemia, and respiratory disorders. Record review of Resident #97's comprehensive care plan with revision date 12/16/25 reflected the resident was at risk for significant infections and/or current infections related to compromised medical condition with interventions that included to monitor vital signs as indicated. Resident #97's comprehensive care plan reflected the resident was at risk of experiencing shortness of breath. During an observation on 1/13/26 at 8:19 a.m., CNA D entered Resident #7's room and obtained an oxygen saturation reading with the pulse oximeter. CNA D exited the room, documented his finding on a sheet of paper and re-entered the same room and obtained Resident #97's oxygen saturation with the same pulse oximeter used on Resident #7. CNA D documented his finding on the sheet of paper and walked down the hall to deliver the sheet of paper to an unidentified male nurse. 2. Observation on 1/13/26 at 8:29 a.m. during the medication pass, revealed MA E placed the wrist blood pressure cuff around her left wrist and prepared medications for Resident #34. MA E removed the wrist blood pressure cuff from her left arm and placed it on Resident #34's right wrist. MA E did not sanitize the wrist blood pressure cuff prior to placing it on Resident #34's right wrist. MA E, after obtaining Resident #34's blood pressure, removed the wrist blood pressure cuff and placed it on the medication cart counter. MA E then prepared Resident #144's medications and took the wrist blood pressure cuff and placed it on Resident #144's left wrist. MA E did not sanitize the wrist blood pressure cuff after using it on Resident #34 or before using it on Resident #144. During an interview on 1/13/26 at 9:20 a.m., MA E stated, the wrist blood pressure cuff she used was her own personal equipment and used it throughout the shift. MA E stated she never thought about sanitizing the wrist blood pressure cuff between residents and was not sure how to do it. MA E stated, I guess it (blood pressure cuff) would be cleaned between residents because of cross contamination. MA E stated, if there was cross contamination, the resident could get an infection or pass on an infection to somebody else. During an interview on 1/13/26 at 9:26 a.m., CNA D stated he had obtained oxygen saturations on Resident #7 and Resident #97. CNA D stated that the pulse oximeter used was his personal equipment that he used throughout the shift. CNA D stated he used a sanitizing wipe to disinfect the pulse oximeter after he used it on Resident #7 and before he used it on Resident #97. CNA D obtained the package of wipes he stated he used to sanitize the pulse oximeter from Resident #7 and Resident #97's room and presented a package of wet wipes use for incontinence care. CNA D stated the wipes were used for incontinence care and he should have been using the micro kill disinfectant wipes to clean the pulse oximeter instead. CNA D exited the resident room and went down the hall and presented a container marked, Germicidal Alcohol Wipes. CNA D stated, the germicidal wipes were supposed to be used to properly disinfect the pulse oximeter, otherwise there was a risk of cross contamination, and an infection could occur between the residents. CNA D stated he had received infection control in-service training approximately 2 to 3 weeks ago. During an interview on 1/14/26 at 9:14 a.m., the DON stated it was her expectation that medical equipment, such as pulse oximeters and blood pressure cuffs, should be disinfected prior to use and between residents to prevent cross contamination and to prevent an infection. The DON stated that incontinent wipes should not be used to clean medical equipment. Record review of the facility document titled Cleaning and Disinfecting Non-Critical Resident-Care Items with revision date June 2011 revealed in part, .The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items.Non-critical items are those that come in contact with intact skin but not mucous membranes.Non-critical resident-care items include.blood pressure cuffs.Reusable items are cleaned and disinfected or sterilized between residents.low-level disinfectants for non-critical items include.ethyl or isopropyl alcohol.phenolic germicidal detergents. 3. Record review of Resident #4's admission record revealed a female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included spinal stenosis of the cervical region (narrowing of the spinal canal in the neck that can compress the spinal cord and nerves causing pain, weakness, or numbness), heart failure (a chronic condition in which the heart is unable to pump blood effectively), hypertension (persistently elevated blood pressure), encounter for surgical aftercare following surgery on the digestive system (a follow-up medical encounter for care, monitoring, and recovery after a surgical procedure involving the gastrointestinal tract). and diabetes mellitus (a chronic metabolic disorder characterized by elevated blood glucose levels). Record review of Resident #4's admission MDS, dated [DATE], revealed the resident's BIMS score was 15 (fully intact cognition). Section H revealed the resident had a indwelling catheter. Record review of Resident #4's care plan, created on 11/20/25 and last revised on 01/01/26, revealed the resident had actual or at risk for skin impairment with a pressure injury to the sacrum and a surgical wound to the right shoulder. The care plan revealed the resident was to receive skin treatments as ordered, use pressure relieving devices and a therapeutic pressure reducing mattress, and remain free from complications related to skin injury. The care plan further revealed the resident was at risk for infection related to a compromised medical condition and was to be monitored for signs and symptoms of infection. The care plan revealed the resident required a urinary catheter and was at risk for catheter related injury and infection, and staff were to provide catheter care each shift and as indicated, check tubing for kinks, and maintain catheter safety. Record review of Resident #4's active physician orders, dated 12/22/25, revealed orders for an 18 French Foley catheter with a 10 cc balloon to be changed monthly and as needed, an order for the Foley catheter to be changed every night shift starting on the 15th and ending on the 15th of each month, and an order for Foley catheter care with perineal wipes and/or soap and water every shift. Record review of Resident #4's active wound care orders, dated 01/06/26, revealed an order to cleanse the sacral wound with wound cleanser or normal saline, pat dry, apply Medihoney (a medical-grade honey product used to promote wound healing and prevent bacterial growth), cover with calcium alginate (an absorbent dressing derived from seaweed used to manage wound drainage and support healing), and secure with a dry dressing every day shift for the sacrum (the triangular bone at the base of the spine, located between the hip bones, that forms the back part of the pelvis) and buttocks. During an observation on 1/13/26 at 9:58 a.m., RN L, wearing clean gloves, was observed cleansing Resident #4's sacral wound bed from the center outward. RN L removed her gloves, performed hand hygiene, donned new gloves, and blotted the wound bed with dry gauze when slight bleeding was noted. RN L then removed her gloves, performed hand hygiene, and donned new gloves again. While RN L was performing wound care, CNA J was observed assisting to hold the resident in a side-lying position. CNA J began to allow the resident to roll backward, and the resident's wound bed came into contact with the bed sheet. RN L then asked CNA J if there was a clean sheet available. CNA J pointed to the bedside table and stated a clean sheet was available to change out. The resident's wound bed remained in contact with the bed sheet at that time. RN L then instructed CNA J to reposition the resident to allow full access to the wound bed. RN L applied Medihoney to the wound bed and secured the dressing. The wound bed was not cleansed again after it had come into contact with the bed sheet. During an interview on 1/13/26 at 10:15 a.m., RN L stated she did not notice the wound bed had come into contact with the bed sheet during wound care. RN L then stated she cleaned the wound bed after it touched the sheet. When asked what should occur if a wound bed touches a bed sheet, RN L stated the sheet would be considered contaminated and the wound bed should be cleansed again because it places the resident at risk for infection. During an interview on 1/14/26 at 9:05 a.m., the DON stated RN L had informed her that the surveyor questioned the wound bed touching the bed sheet during wound care. The DON stated RN L reported she was not aware the wound bed had touched the sheet and stated she had cleaned the wound bed. The DON stated if a wound bed comes into contact with a bed sheet, staff were expected to cleanse the wound bed again because it places the resident at risk for infection if not. Record review of the facility document titled Charge Nurse Proficiency Check Offs for RN L, dated 01/15/2025, revealed she was evaluated and signed off as competent in wound care, G-tube medication administration, hand hygiene, PPE donning and doffing, and infection control related skills. Record review of the Wound Care Competency checklist for RN L, dated 01/15/2025, revealed required steps included: maintaining a clean field, cleansing the wound from inner to outer, removing soiled dressings, applying topical medications as ordered, applying dressings, and restarting the procedure if any area became contaminated. The checklist further required staff to maintain a clean field and to start over if any area was contaminated 4. During an observation on 1/13/26 at 10:05 a.m., CNA J and CNA K were observed providing incontinent care and catheter care to Resident #4. After care was completed, the aides repositioned the resident in bed and moved the catheter bag and drainage tubing from the right side of the bed back to the left side where it had been prior to care. CNA K was observed holding the catheter tubing arm's length in the air while standing at the bedside to hand it to CNA J. The resident was lying flat in bed at that time. During an interview on 1/13/26 at 11:47 a.m., CNA J and CNA K stated they did not notice they had held the catheter bag and tubing above the resident's bladder during care. CNA J stated the catheter bag and tubing should not be raised above the bladder because it can become contaminated. CNA K stated she was not aware of the reason the catheter bag and tubing should not be raised above bladder level. Both CNAs stated they had received training on catheter care. Record review of the facility catheter care skills checklist for CNA J, dated 10/21/2025, revealed she was evaluated and signed off as competent in female catheter care. The checklist specifically required staff to keep the drainage bag below the level of the bladder during care and repositioning to avoid contamination and backflow. Record review of the facility catheter care skills checklist for CNA K, dated 10/22/2025, revealed she was evaluated and signed off as competent in female catheter care. The checklist specifically required staff to keep the drainage bag below the level of the bladder during care and repositioning to avoid contamination and backflow. During an interview on 1/14/26 at 8:59 a.m. the DON stated staff should not hold a catheter bag above the level of the resident's bladder because it could put urine back into someone's bladder, potentially place the resident at risk of infection. Record review of the facility policy titled Skin and Wound Prevention and Management, dated 3/14/19 and revised January 2023, revealed, the community will ensure that a resident admitting into the community will [be] evaluated and identify the associated risks that may result in skin breakdown. The policy further stated staff were to apply treatments as ordered and prevent exposure of wounds to contaminated surfaces. Record review of the facility policy titled Infection Prevention and Control, dated 3/13/19 and revised April 2024, revealed staff were to follow standard precautions.perform hand hygiene between tasks. The policy stated staff were to prevent cross contamination during resident care and to follow standard precautions, contact precautions, isolation precautions and enhanced barrier precautions.standard precautions apply to all residents.hand hygiene shall be performed before and after resident contact. Record review of the facility policy titled Incontinence and Catheterization Assessment and Evaluation, implemented 2017 and revised January 2023, revealed, the community employs standard infection control practices in managing catheters and associated drainage system. The policy further stated, the community strives to keep the resident catheter clean to minimize bacterial migration into the urethra and bladder.the community takes measures to maintain free urine flow through any indwelling catheter.

Based on observation, interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 5 of 11 residents (Resident #6, Resident #9, Resident #46, Resident #68, and Resident #125) who were reviewed for resident assessments. 1.The facility failed to document Resident #6's use of scheduled pain medication and lack of use of anticonvulsant medication on the quarterly MDS assessment. 2.The facility failed to document Resident #9's use of anticonvulsant medication on the quarterly MDS assessment. 3.The facility failed to document Resident #46's use of antiplatelet medication on the quarterly MDS assessment. 4.The facility failed to document Resident #68's use of antiplatelet medication and hypoglycemic medication on the quarterly MDS assessment. 5.The facility failed to document the correct number of skin issues Resident #125 had upon admission on the admission MDS assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.The findings included: 1.Record review of Resident #6's admission sheet dated 8/31/2025 with an initial admission date of 5/25/2022 documented a [AGE] year-old female resident with diagnoses including cerebral infarction (stroke), heart disease, epilepsy (seizure disorder), depression, anxiety, joint pain, and peripheral vascular disease (a progressive disorder that affects blood flow to the limbs, primarily caused by narrowing or blockage of blood vessels). Record review of Resident #6's MDS assessment dated [DATE] documented a BIMS score of 15 indicating intact cognition and recorded the use of antianxiety, antidepressant, anticoagulant, opioid, and anticonvulsant medications. Further review of the MDS revealed the document did not include the resident's use of scheduled pain medication in the last five days of the assessment in Section J – Health Conditions J0100. Pain Management At any time in the last 5 days, has the resident: A. Received scheduled pain medication regimen? Record review of Resident #6's order summary documented an active order for the opioid analgesic Tramadol with an order date of 9/03/2025. Further review of the order summary revealed there was no active order for an anticonvulsant medication. Record review of Resident #6's January 2026 MAR documented the resident had been receiving Tramadol as prescribed. Further review of the January MAR revealed Tramadol was ordered as Tramadol 50mg, Give 2 tablet by mouth two times a day for Pain. Record review of Resident #6's care plan with an initiation date of 4/14/2024 documented the resident is at risk for experiencing discomfort or pain r/t: Hx of fractures, Immobility, Co-morbid medical conditions, Joint discomfort/Stiff joints/Decreased joint movement. The care plan further documented interventions including Therapy referral as indicated. 2.Record review of Resident #9's admission sheet dated 10/11/2024 with an initial date of 4/26/2024 documented a [AGE] year-old female resident with diagnoses including dementia, cerebral palsy (a condition affecting a person's ability to control their muscles and movements), epilepsy, anxiety, schizoaffective disorder (a disorder that includes symptoms of both schizophrenia [such as hallucinations and delusions] and mood disorders [such as depression or mania]), bipolar disorder (a disorder of severe mood swings, including manic highs and depressive lows), and hypertension (high blood pressure). Record review of Resident #9's MDS dated [DATE] documented a BIMS score of 12 indicating moderate cognitive impairment and recorded the use of antipsychotic, antianxiety, antidepressant, diuretic, and opioid medication. Further review of the MDS revealed the assessment did not include the resident's use of anticonvulsant medication. Record review of Resident #9's order summary documented an active order for the anticonvulsant medication Depakote with an order date of 10/11/2024. Record review of Resident #9's December 2025 MAR documented the resident had been receiving Depakote as prescribed. Further review of the December MAR recorded Depakote was ordered as Depakote 125mg, Give 3 tablet by mouth three times a day for Seizures 3 tabs to equal 375mg. Record review of Resident #9's care plan with an initiation date of 5/29/2024 documented the resident requires psychotropic medications and I am at potential risk for side effects r/t my medication regimen., with a goal the resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension (low blood pressure), gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. 3. Record review of Resident #46's admission sheet dated 4/09/2025 with an original admission date of 12/21/2023 documented a [AGE] year-old male resident with diagnoses including cerebral infarction, heart disease, peripheral vascular disease, type 2 diabetes, depression, hypertension, and post-traumatic stress disorder. Record review of Resident #46's MDS assessment dated [DATE] documented a BIMS score of 15 indicating intact cognition. Further review of Resident #46's MDS revealed the assessment did not document the resident's use of antiplatelet medication. Record review of Resident #46's order summary included an active order for the antiplatelet medication Clopidogrel with an order date of 5/13/2025. Record review of Resident #46's December 2025 MAR documented the resident had been receiving Clopidogrel as prescribed. Clopidogrel was ordered as Clopidogrel 75mg, Give 75 mg by mouth one time a day. Record review of Resident #46's care plan with an initiation date of 7/29/2024 documented the resident was prescribed medication/medications that lens me to a risk for abnormal bleeding, easily bruised and/or skin issues/injury. Anti-platelet., with interventions including Inspect my skin during care and report all skin injuries as indicated. 4.Record review of Resident #68's admission sheet dated 6/12/2025 documented a [AGE] year-old female resident with diagnoses including dementia, kidney failure, type 2 diabetes mellitus, heart disease, hyperlipidemia (high cholesterol), and depression Record review of Resident #68's MDS assessment dated [DATE] documented a BIMS score of 12 indicating moderate cognitive impairment. Further review of MDS revealed the assessment did not include the resident's use of antiplatelet and hypoglycemic medication. Record review of Resident #68's order summary included an active order for the antiplatelet medication Aspirin with an order date of 6/12/2025 and active orders for the hypoglycemic medications Insulin Glargine with an order date of 6/19/2025 and Insulin Lispro with an order date of 6/13/2025. Record review of Resident #68's December 2025 MAR documented the resident was receiving Aspirin, Insulin Glargine, and Insulin Lispro as prescribed. Aspirin was ordered as Aspirin 81mg, Give 1 tablet by mouth one time a day. Insulin Glargine was ordered as Insulin Glargine 100 unit/mL, Inject 10 unit subcutaneously one time a day for Diabetes HOLD for BS less than 100. Insulin Lispro was ordered as Insulin Lispro 100 unit/mL, Inject as per sliding scale: If 150-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units Greater than 400 administer 12 units and notify MD, subcutaneously before meals and at bedtime for Diabetes. Record review of Resident #68's care plan with an initiation date of 6/12/2025 documented the resident was prescribed medication/medications that lends me to a risk for abnormal bleeding, easily bruised and/or skin issues/injury., with interventions including to monitor the resident for abnormal bleeding and monitor my skin for excess bruising as indicated. Further review of the care plan documented the resident has diabetes and I am at risk for: Complications associated with diabetes: Frequent Infections, Diabetic wounds, Vision Impairment, Hyper/Hypo-Glycemia, Renal Failure, Cognitive/Physical Impairment., with interventions including Administer my medications as recommended by my doctor, monitor labs as indicated. Promptly report abnormal labs results and significant clinical findings to my doctor as indicated. During an interview with the MDS LVN on 1/13/2026 at 3:28 PM, the MDS LVN stated, she gathered data for the MDS from interviews with the residents and family and information received from staff including nurses, social services, and rehab. The MDS LVN stated she made sure the MDS was complete and presented it to the MDS RN. The MDS LVN stated it was important for the assessment to be accurate, because it gave a picture of a resident and helps with care planning. The MDS LVN stated the MDS was part of a resident's care, and an accurate assessment helps with the coordination of care with other entities. During an interview with the DON on 1/14/26 at 9:10 AM, the DON stated her expectation for the MDS assessments was for them to be updated when there were changes. The DON stated medications could change all the time, and she expected them to be accurate because that was how they bill. During an interview with the MDS RN on 1/14/26 at 1:12 PM, the MDS RN stated she is the one ultimately responsible for the accuracy of the MDS. The MDS RN stated she expected her staff to enter information for the MDS correctly before they submit it to her. The MDS RN stated it was important for the MDS to be accurate, because it reflects a resident's care, what a resident receives at the facility, and how they bill. 5. Record review of the admission Record for Resident #125 documented an [AGE] year-old male admitted [DATE]. His diagnoses included cerebral infarction (stroke), Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema (a form of diabetes where there are signs of eye damage and don't involve swelling in the macula), legal blindness, and peripheral vascular disease (slow progressive disorder of the blood vessels). Record review of Resident #125's MDS dated [DATE] revealed a BIMS score of 14 indicating the resident's cognition was intact. Under Section M, Skin Conditions, the following entries were made: -M0210 Unhealed Pressure Ulcers/Injuries was marked Yes - M0300 Current number of Unhealed Pressure Ulcers/Injuries at Each Stage, answers for the number of pressure ulcers was marked 0. - Section F #1 – Unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar – the number entered was 2. - Section F #2 – Number of these unstageable pressure ulcers that were present upon admission/entry or reentry – the number entered was 2. -M1040 – Other Ulcers, Wounds and Skin Problems Item B – Diabetic foot ulcer(s) was checked. Record review of Resident #125's Care Plan dated 12/02/25 revealed a focus for actual or at risk for skin impairment and noted actual sites: left heel and left 2nd toe. Record review of Resident #125's Initial Skin Issues report prepared by Treatment Nurse, RN L, with effective date of 12/2/25 and a created date of 12/9/26, revealed 6 areas of skin issues including pressure ulcer of left heel, diabetic foot ulcer on 2nd digit (toe), other skin issue on right dorsum 1st digit (great toe), pressure ulcer on right heel, pressure ulcer on sacrum (lower back), and pressure ulcer of right medial malleolus (inner ankle). During an interview with RN L on 01/12/26 at 1:00 pm, RN L stated that Resident #125 had been admitted with 6 wounds which were treated and all except 2 had been resolved. RN L stated she would provide her written skin report. During an interview with the MDS LVN on 1/13/2026 at 3:28 PM, the MDS LVN stated, she gathered data for the MDS from interviews with the residents and family and information received from staff including nurses, social services, and rehab. The MDS LVN stated she made sure the MDS was complete and presented it to the MDS RN. The MDS LVN stated it was important for the assessment to be accurate, because it gave a picture of a resident and helped with care planning. The MDS LVN stated the MDS was part of a resident's care, and an accurate assessment helps with the coordination of care with other entities. During an interview on 01/13/26 at 4:00 pm with MDS LVN, the MDS LVN stated that all but 2 of the skin conditions had been resolved by the time the last MDS assessment was completed on 12/11/25. The MDS LVN also stated that the look back period to consider answers for this area of the MDS was 7 days which would include 12/4/25 through 12/11/25. Since all 6 wounds identified in the initial skin report were still present during this time period, the MDS LVN acknowledged they should have been included on the MDS. Review of the facility policy titled Comprehensive Assessments with a revision date of March 2023 noted The community uses the Resident Assessment Instrument (RAI) to develop the comprehensive resident assessment. It identifies the care, services, and treatments that each resident needs to attain or maintain his or her highest practicable mental and physical functional status., and .The RAI is the primary assessment tool used in the comprehensive assessment process., and .Each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each resident's status, needs, strengths, and areas of decline., and .A registered nurse conducts or coordinates the assessment. The coordinator ensures that appropriate and qualified professionals contribute to the assessment. Regardless of whether the registered nurse conducts or coordinates, he or she is responsible for certifying that the assessment has been completed. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 revealed in section J0100: Pain Management scheduled pain medication regimen was defined as Pain medication order that defines dose and specific time interval for pain medication administration. In the section Coding Instructions for J0100A, Been on a Scheduled Pain Medication Regimen, the user's manual noted Code 1, yes: if the medical record contains documentation that a scheduled pain medication was received. Section N0415: High-Risk Drug Classes: Use and Indication noted Medications are an integral part of the care provided to residents of nursing homes., and Residents taking medications in these medication categories and pharmacologic classes are at risk of side effects that can adversely affect health, safety, and quality of life., and Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look back period. and Code all high-risk drug class medications according to their pharmacological classification, not how they are being used.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 emergency care cart reviewed for storage of drugs.The facility failed to ensure the emergency cart did not have expired tracheostomy kits.This deficient practice could place residents at risk of adverse reactions.The findings included:During an observation and interview on [DATE] beginning at 10:40 a.m. with RN B revealed inspection of the emergency cart was observed with two packages of Tracheostomy Clean and Care Kits. One kit had an expiration date of [DATE] and the other had an expiration date of 12/2024. RN B stated he was responsible for ensuring the emergency cart was stocked and was checked by him every day. RN B stated there should not be any expired items in the emergency cart. The DON approached the Surveyor and RN B during the inspection at 10:50 a.m. and stated if items were to be taken from the emergency cart during an emergency, the nurse would be checking the expiration date of the item prior to use. RN B stated, if a nurse needed to take supplies from the emergency cart during an emergency, they would be checking for expiration dates.During a follow up interview requested by RN B on [DATE] at 2:50 p.m., he stated, the emergency cart that was inspected did not have any medications in it and the facility did not have any residents in the facility with tracheostomies currently. Record review of the AED and Crash Cart Inspection Log for [DATE] reflected in part, Daily Inspection: Nurse to validate supplies are available on crash cart and Nurse to initial that the Crash Cart has been inspected and is ready for emergency use. Review of the Crash Cart Inspection Log reflected the daily inspection and nurse initials were documented daily from [DATE], to [DATE], which indicated the cart had been checked as indicated.Record review of the facility document titled Pharmacy Services: Provision of Medications and Biologicals with revision date [DATE] reflected in part, .The community provides routine and emergency medications and biologicals to its residents or obtains them under an agreement.The community maintains an emergency medication kit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. A bag of celery stalks was opened and undated in the refrigerator 2. A bag of sliced ham was opened in the refrigerator. 3. A bag of cereal was opened in the pantry. These failures could place residents who consume meals and snacks from the kitchen at risk for food borne illness.The findings included: During an observation of the facility kitchen on 01/11/2026 at 9:20 AM, a bag of celery was discovered opened and undated in the refrigerator, a bag of sliced ham was discovered opened in the refrigerator, and a bag of cereal was discovered opened in the pantry. During an interview with the Dietary Manager on 01/11/2026 at 10:45 AM, the Dietary Manager stated she would have staff remove undated and unsealed items from the refrigerator and pantry. The Dietary Manager further stated if items were undated or unsealed, they could be expired, and freshness could not be guaranteed. During an interview with the Dietitian on 01/11/2026 at 12:15 PM, the Dietitian stated it was important for food items to be dated and sealed to keep things from expiring. Record review of the facility policy titled Food Storage, dated 2018 noted To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines., and 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated., and 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.

Based on record review and interview, the facility failed to ensure the resident had the right to formulate an advance directive and determine the choice to receive or not receive cardiopulmonary resuscitation (CPR) for 1 (Resident #26) of 8 residents reviewed for resident rights. The facility failed to ensure Resident #26's out-of-hospital Do Not Resuscitate (OOH DNR) was complete and valid for use in an emergency. This failure could result in failure to honor the resident's wishes during a medical emergency. Findings included: Record review of Resident #26's admission Record/Face Sheet, dated [DATE], revealed a [AGE] year-old male admitted with diagnoses including effusion of the left knee (abnormal accumulation of fluid within the knee joint causing swelling and pain), acute diastolic (congestive) heart failure (a condition in which the heart is unable to relax and fill properly, resulting in fluid buildup and decreased blood flow), and vascular dementia (a decline in cognitive function caused by reduced blood flow to the brain). The admission record revealed the resident's advance directive was DNR. Record review of Resident #26's Quarterly MDS assessment, dated [DATE], revealed the resident's BIMS score was 15, indicating the resident's cognition was intact for daily decision making. Record review of Resident #26's comprehensive care plan, initiated [DATE], revealed a focus area for advance directives. The care plan stated, Code status DNR - Do Not Resuscitate. Honor my advance directives, care wishes, and code status will be respected and honored as indicated. Record review of Resident #26's physician order summary, dated [DATE], revealed an order for DNR with an order date of [DATE] and no end date. Record review of Resident #26's OOH DNR, dated [DATE], revealed the document was signed by the resident and notarized. The document did not contain a physician's signature. During an interview on [DATE] at 4:40 p.m., the DON stated all resident DNRs were located in the electronic health record under the miscellaneous tab unless they were pending signatures and waiting to be scanned. The DON stated the Social Worker (SW) was in charge of DNR paperwork. The DON stated the facility would honor a DNR pending the physician's signature, as long as the form was filled out. The DON stated emergency medical services honored a DNR in the past without a physician's signature. During an interview on [DATE] at 4:58 p.m., the SW stated Resident #26's DNR was in the electronic health record. After reviewing the OOH DNR, the SW stated the DNR appeared to be pending the physician's signature. The SW stated she would check the physician's folder to see if the form was waiting for signature. The SW stated she may have attempted to have the medical director sign the form and placed it back in the physician's folder. The SW stated she would have to verify if she emailed the physician, requesting signature. The SW stated there was a verbal order from the physician for Resident #26 to be a DNR. The SW stated she was unsure if emergency medical services would honor a DNR without a physician's signature. She stated nursing staff were the ones who responded to codes. Record review of the facility's policy titled Advanced Directives, dated February 2017 and revised [DATE], revealed, Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission.Prior to or upon admission, the community will provide the resident with information about the resident's right to formulate an advance directive .A copy of the advance directive and subsequent revisions will be included in the resident's medical record. The nurse should then obtain a physician's order for appropriate care decision in order to initiate and implement the preferred treatment wishes expressed. The IDT should honor the care decision expressed and initiate the advance directive by initiating the Out of Hospital Do Not Resuscitate (OOH DNR) form and should obtain the medical provider/physician's signature as per the OOH DNR form instructions. The medical record and resident plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described.

Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #148) reviewed for dialysis:The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #148.This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included:Record review of Resident #148's face sheet dated 1/14/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included end stage renal disease (permanent stage or chronic kidney disease in which the kidneys have lost nearly all their ability to function), diabetes (chronic metabolic disorder characterized by elevated blood glucose due to insufficient insulin production), chronic viral hepatitis C (long-term infection of the liver cause by the hepatitis C virus leading to ongoing liver inflammation and damage), heart failure, and dependence on renal dialysis (medical treatment that replaces some functions of the kidneys).Record review of Resident #148's Order Summary Report dated 1/14/26 reflected the following:- Dialysis to be done at dialysis clinic Monday, Wednesday, and Friday at 10:15 a.m., with order date 1/11/26 and no end date.Record review of Resident #148's initial/baseline care plan dated 1/12/26 reflected the resident had end stage kidney disease and required dialysis treatments with interventions that included to coordinate transportation to and from dialysis treatments, monitor/document/report to the physician any signs or symptoms of infection to access site, such as redness, swelling, warmth, or drainage and remove post dialysis bandage if indicated and monitor for signs and symptoms of bleeding.Record review of the Pre-Dialysis Assessment document presented to the Surveyor by Resident #148, dated 1/12/26 revealed the following:- Patient's Infection Control Status: No know (sic) exposure & asymptomatic was noted- Exposed to: N/A was noted- Does the patient have one or more of the following conditions that would warrant precaution or isolation: N/A was noted- Current Vitals: B/P 177/89, P 78, T 98, R 18, O2 95- Pain Level 0- Fistula Location: Left Arm- Post Dialysis Assessment: Wet Weight Kg 64.7, Dry Weight 55.2 Kg- Post Dialysis Vitals: B/P 161/83, Pulse 79, Temp. 97.5, Resp. 17, O2 Sats. N/A- DIALYSIS NURSE: signed by Dialysis Clinic RNRecord review of the Pre-Dialysis Assessment document presented to the Surveyor by RN B, dated 1/12/26 revealed the following:- Patient's Infection Control Status: No know (sic) exposure & asymptomatic was noted-Exposed to section and Does the patient have one or more of the following conditions that would warrant precaution or isolation had a diagonal line over it- Current Vitals: B/P 156/80, P 84, T 98.4, R 20, O2 94 Room air- Fistula Location: Left arm- Post Dialysis Assessment was blank- Post Dialysis Vitals: B/P 142/76, Pulse 78, Temp. 98.1, Resp. 18, O2 Sats. 95 RA- DIALYSIS NURSE section was blankDuring an observation and interview on 1/13/26 at 4:45 p.m., Resident #148 stated he had recently admitted to the facility on Saturday (1/10/26) but had been receiving dialysis treatments for the past 2 1/2 years. Resident #148 revealed and was observed with the dialysis port located on the left upper arm. Resident #148 stated he had scheduled dialysis treatments every Monday, Wednesday, and Friday. Resident #148 stated he last went to dialysis on Monday, 1/12/26. Resident #148 stated he was provided with a sack lunch and in the sack lunch he found a folded-up piece of paper. Resident #148 stated he did not know what the document in the sack lunch was and believed he had either lost it or thrown it away. Resident #148 stated he was not told what to do with the folded-up piece of paper, but if I had been asked to give it to somebody I would have done that. Resident #148 reached into the small trash bin observed at the bedside and pulled out a folded-up piece of paper and handed it to the Surveyor. Resident #148 presented the Surveyor with a document titled, Pre-Dialysis Assessment which included the resident's name, dated 1/12/26, a set of current vital signs, and a set of post-dialysis vital signs with the wet weight (64.7 Kg) and dry weight (55.2 Kg), signed by the dialysis clinic RN. Resident #148 took back the Pre-Dialysis Assessment document, folded it back up, and placed it on the nightstand.During an interview on 1/13/26 at 4:58 p.m., RN A stated she worked the day shift on 1/12/26 and prepared the Pre-Dialysis Assessment document for Resident #148, and because it was the first time the resident was sent to dialysis from their facility, the resident did not have a dialysis binder, so RN A stated she placed the Pre-Dialysis Assessment document in Resident #148's sack lunch. RN A stated she was responsible for inputting the current vitals on the form, and then the resident was supposed to give the document to the dialysis clinic staff, and then the dialysis clinic staff filled out their portion and then the document was sent back to the facility with the resident. RN A stated she was not on duty when Resident #148 returned from dialysis and could not recall who was on duty after her. RN A stated the post dialysis assessment vital signs section of the Pre-Dialysis Assessment document was supposed to be filled in by the facility nurse when the resident returned. RN A stated, once the document was completed, it was placed in a basket at the nurse's station for the medical records staff to pick up and scan into the resident's electronic record.During an interview on 1/13/26 at 5:04 p.m., the DON stated the Pre-Dialysis Assessment document should be completed by the facility nurse before the resident was sent to dialysis. The DON stated the Pre-Dialysis Assessment document was sent with the resident and the dialysis clinic was supposed to fill in their portion of the document. The DON stated the document was supposed to be returned to the facility with the resident, and the document either stayed in the resident's binder, or it gets picked up by medical records and was scanned into the resident's electronic record. The DON stated, the purpose of the Pre-Dialysis Assessment document was to obtain pre-dialysis and post-dialysis weights and to record information regarding any issues with the treatment, to see how well the resident tolerated the treatment, and if the resident received medications while at the dialysis clinic. The DON stated the Pre-Dialysis Assessment document for Resident #148 could not be located but RN B, who was responsible for medical records, was trying to locate the document and would provide to the Surveyor when found. During an observation and interview on 1/13/26 at 5:14 p.m., RN B presented the Surveyor with Resident #148's Pre-Dialysis Assessment document dated 1/12/26. RN B stated the document was missing information that was supposed to be provided by the dialysis clinic staff. The Pre-Dialysis Assessment document presented by RN B and the document provided to the Surveyor by Resident #148 did not match. RN B was asked if the Pre-Dialysis Assessment document he presented to the Surveyor was the original document from 1/12/26, and RN B stated, yes. RN B stated the information provided on the Pre-Dialysis Assessment form was crucial because it showed any issues encountered during the dialysis treatment which included a drop in blood pressure. RN B stated he was responsible for checking the Pre-Dialysis Assessment document for completeness and accuracy before it was scanned into the electronic record and should be checked usually the following day.During an interview on 1/13/26 at 5:27 p.m., ADON C stated she placed a call to the dialysis clinic and was able to obtain the dry weight for Resident #148. ADON C stated the Pre-Dialysis Assessment document was important because information provided on the document determined if the resident was stable when he left the facility prior to treatment and the dialysis clinic was supposed to provide the resident's weights and any issues seen during treatment or any additional orders or restrictions, such as fluid restriction. ADON C stated, once the document was brought back to the facility, it was placed in a box at the nurse's station, and then RN B would pick up the document and scan it into the electronic record. ADON C stated, RN B was responsible for ensuring the document was completed, and if there was any missing information, RN B would either make a call to the dialysis clinic or inform the floor nurse to obtain the information before scanning the document into the record. ADON C stated, we can't scan it (Pre-Dialysis Assessment document) until it's filled out.During a follow-up interview on 1/14/26 at 8:53 a.m., the DON stated the facility did not have a policy regarding documenting post dialysis vitals on the Pre-Dialysis Assessment document, but stated vitals obtained by the nurse were documented in the electronic record. Record review of the facility document titled, Hemodialysis - Care of Residents with revision date January 2023 reflected in part, .Compliance Guidelines.The community provided residents with safe, accurate, and appropriate care, assessments, and interventions to maintain or improve resident outcomes.Overview.Hemodialysis is a process of cleansing the blood of accumulated waste products, it is used for residents with end-stage renal failure.Pre-Treatment.Coordinate with the dialysis treatment center.

Based on interviews, observation, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 6 residents (Residents #1 and #2) reviewed for care plans, in that: Resident #1 and Resident #2's care plan was not updated to reflect their need of being fed at mealtimes. This failure could affect residents who have care areas not addressed by the care plans by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: Record review of Resident #1's admission record, dated 11/04/25, reflected an [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), Parkinson's disease (movement disorder of the nervous system) with dyskinesia (involuntary muscle movements), and Protein calorie malnutrition. Record review of Resident #1's quarterly MDS assessment, dated 10/20/25, reflected Resident #1 had a BIMS of 4 out of 15, indicating severely impaired cognition. It revealed Resident #1 needed supervision or touching assistance when eating. Record review of Resident #1's care plan, undated, reflected .Eating & Drinking: I am able to feed my self and drink without physical assistance. May need to prepare my tray/foods and drinks.:, initiated 10/04/22. Record review of Resident #1's SLP Evaluation and Plan of Treatment, dated 10/06/25-11/04/25, reflected Resident #1 required supervision/assistance at mealtime 76-90% of the time. Record review of Resident #2's admission record, dated 11/05/25, reflected a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include muscle wasting and atrophy, protein-calorie malnutrition, cognitive communication deficit, muscle weakness, lack of coordination, and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #2's MDS assessment (no type selected), dated 10/20/25, reflected Resident #2 had a BIMS of 4 out of 15, indicating severely impaired cognition. It further reflected Resident #2 needed partial/moderate assistance with eating. Record review of Resident #2's care plan, undated, reflected .Eating & Drinking: I am able to feed my self and drink without physical assistance. May need to prepare my tray/foods and drinks.:, initiated 02/13/25. Record review of Resident #2's OT Discharge summary, dated [DATE]-[DATE], reflected Resident #2 needed partial/moderate assistance when performing eating tasks. Interview and observation on 11/04/25 at 12:38 PM, LVN B was sitting at the table with Resident #1 and Resident #2. She was currently helping Resident #1 eat. She revealed both of these residents needed help getting fed. Interview on 11/05/25 at 02:25 PM, CNA A revealed some days Resident #1 will feed herself and staff will help at the end of the meal. She revealed sometimes staff needed to help Resident #1 with her meal the whole mealtime. She revealed the staff knew what resident needed assistance by keeping an eye on the residents in the dining room, but CNAs also used the Kardex (a section in residents' medical record that told the CNAs what to do for resident care) to find out about resident care. Interview on 11/05/25 at 02:53 PM, LVN B revealed both Resident #1 and Resident #2 needed help getting fed at mealtimes. She revealed she knew a resident needed help with eating based on observations at mealtimes and did not need a care plan to know this. Interview on 11/06/25 at 11:52 AM, SLP revealed he worked with Resident #1 and not Resident #2. He revealed Resident #1 needed help with eating at mealtimes. He revealed it was important for Resident #1 to receive help at mealtimes so she could receive proper nutrition, and it would be a safety issue if she did not receive help. Interviews on 11/06/25 at 01:01 PM, MDS nurse C and MDS nurse D revealed multiple staff were able to update resident care plans because it could be challenging for MDS nurses to be able to document everything necessary for resident care in their respective care plans. They revealed they oversaw that the care plans were up to date but might miss some updates. MDS nurse C revealed Resident #1 would sometimes feed herself, but other days Resident #1 needed help with eating. MDS nurse C further revealed Resident #2 also needed help eating and their care plans needed to be updated. MDS nurse D revealed updating care plans were important because it was the residents' plan of care and a blueprint. Interview on 11/06/2025 at 01:27 PM, the ADON revealed Resident #1 and Resident #2 needed help when being fed and the nursing staff looked at care plans to know this about resident care. Interview on 11/06/25 at 04:35 PM, the DON and ADM revealed it was challenging to keep care plans up to date; however, they were important for resident care. They revealed the updated care plan updated the Kardex which told CNAs what to do. They revealed they ensured their CNAs and nurses were up to date with knowing what to do for resident care. Record review of facility's policy, Care Plan, dated February 2017, reflected, .The care plan should serve as a guide, which should direct care needs, care choices and care preferences.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 of 3 residents (Residents #1) reviewed for infection control. The facility failed to ensure LVN-A and CNA-B wore gowns while providing catheter care to Resident #1 who was on EBP. This failure could affect residents who required assistance with catheter care and could place residents at risk for cross contamination and infections. The finding included: Record review of Resident #1's admission Record, dated 04/29/2025 revealed a [AGE] year-old man initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included: Cerebral Palsy (a congenital disorder of movement and muscle tone) and Obstructive and Reflux Uropathy (condition where urine cannot drain through urinary tract and urine can back up into the kidneys). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating normal cognitive function. He was assessed as having an in-dwelling catheter. Record review of Resident #1's Care Plan, initiated 10/01/2016, revealed the resident required a Supra-pubic catheter (a small flexible tube inserted directly into the bladder through a small incision in the lower abdomen to drain urine), related to diagnosis of urinary retention. Record review of Resident #1's Order Summary dated 04/29/2025 revealed an order for enhanced barrier precautions related to suprapubic catheter. Observation on 05/01/2025 at 10:10 a.m. revealed LVN-A and CNA-B were performing catheter care to Resident #1, wearing gloves but no gowns. There was an EBP sign posted outside Resident #1's door. During an interview with LVN-A on 05/01/2025 at 10:20 a.m., LVN-A stated he knew he should have put on a gown in addition to the gloves to perform catheter care for Resident #1, because any residents with indwelling catheters should be on enhanced barrier precautions. LVN-A stated he knew what enhanced barrier precautions were and had received training in infection control, but just forgot to put on the gown. He stated that not wearing a gown while providing direct care to a resident with a catheter could result in spread of infection. Interview on 05/01/2025 at 10:38 a.m. with CNA-B revealed he knew what the EBP sign outside Resident#1's door meant and that he should have worn a gown when he was cleaning Resident #1. He stated he had been trained about EBP, but just forgot. He stated that by not wearing a gown while working directly with Resident #1, it could result in the spread of germs. During an interview with the DNS on 05/01/2025 at 12:11 p.m., the DNS stated that the staff should have worn both gown and gloves when providing direct care, such as catheter care to Resident #1, and that not following EBP precautions would increase the risk of spreading infection. Record Review of the facility's policy titled Infection Prevention and Control revised April 2024, revealed EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing . and Residents/patients with the following clinical indication should be under EBP: Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status.

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 of each resident for 1 of 5 medication carts (treatment cart) reviewed for pharmacy services. There was one medication (Anasept Gel - antimicrobial skin and wound gel) expired on 09/14/2023 found inside the treatment cart on 10/31/2024. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Observation on 10/31/2024 at 4:21 p.m. revealed one gel (Anasept Gel) of antimicrobial skin and wound was found inside the treatment cart, and it expired 09/14/2023. Interview on 10/31/2024 at 4:22 p.m. treatment nurse LVN-C acknowledged one gel (Anasept Gel) of antimicrobial skin and wound was found inside the treatment cart, and it expired 09/14/2023. Treatment nurse LVN-C said she did not know what reason the expired medication was inside the treatment cart, and nurses should discard all expired medications from the medication carts as per the facility policy. Potential harm was nurses might use the expired medication, and the expired medication might not have therapeutic effects. Interview on 11/01/2024 at 12:25 p.m., with the DON said there was no specific policy regarding expired medication, but facility nurses should discard all expired medications from the medication carts. Record review of the facility policy, titled Medication Cart Use and Storage, dated 03/15/2019, revealed The following equipment may be generally found in/on the medication cart: appropriate liquid, labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions. (Resident #152) The facility failed to develop Resident #152's baseline care plan regarding the resident's BiPap (Bilevel Positive Airway Pressure - device that helps breathing) care for within 48 hours of admission on 10/23/2024. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #152's face sheet, dated 11/01/2024, reflected the resident was a [AGE] year old female and admitted to the facility on [DATE] with diagnoses of vertebral fracture (backbone fracture), chronic obstructive pulmonary disease (damaged to the lung), pleural effusion (buildup of fluid in the lung), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), and muscle wasting and atrophy (decrease in size and wasting of muscle). Record review of Resident #152's Brief Interview of Mental Status (BIMS), dated 10/26/2024, reflected the resident's BIMS score was 14 out of 15, which indicated the resident had intact cognitive function. Record review of Resident #152's baseline care plan, dated initiated 10/23/2024, reflected there was no baseline care plan regarding Resident #152's BiPap care. Record review of Resident #152's physician's orders, dated 10/23/2024, reflected there was no physician's order regarding Resident #152's BiPap care. Observed on 10/29/2024 at 10:29 a.m. revealed there was a BiPap machine and mask on the nightstand beside the bed of Resident #152's room. Interview on 11/01/2024 at 11:46 a.m. Resident #152 stated she was using the BiPap every day when she was sleeping, and she brought it from her home. Interview on 11/01/2024 at 10:00 a.m. with CNA-A said Resident #152 used the BiPap every night since the resident was admitted to the facility. Interview on 11/01/2024 at 10:05 a.m. the MDS nurse (RN-B) acknowledged Resident #152 was using a BiPap when the resident was sleeping every night since the resident was admitted to the facility on [DATE]. The MDS nurse RN-B stated she should have developed Resident #152's baseline care plan within 48 hours regarding the resident's BiPap care because the resident was admitted with the BiPap. The MDS nurse RN-B said she missed the resident's BiPap when developing baseline care plan. Interview on 11/01/2024 at 12:25 p.m. the DON stated the MDS nurse should have developed Resident #152's baseline care plan within 48 hours regarding the resident's BiPap care because the resident was admitted with the BiPap, and baseline care plans affected actual care through which nurses knew how to provide care appropriately to Resident #152; therefore, no baseline care plan might affect inappropriate care to the resident. Record review of the facility policy, titled Care Planning, revised 01/2023, reflected the care plan should be initiated upon admission, continued to be developed during the initial 48 to 72 hours. The care plan should serve as a guide, which should direct care needs, care choices, and care preferences.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 2 (Resident #152) reviewed for respiratory care. Resident #152 did not have physician's orders regarding the resident's BiPap (Bilevel Positive Airway Pressure - device that helps breathing) care when the resident was using the BiPap every night since admission on 10/23/2024. This failure could affect residents with a BiPap and could lead to lack of care as ordered by the physician. The findings included: Record review of Resident #152's face sheet, dated 11/01/2024, reflected the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnoses of vertebral fracture (backbone fracture), chronic obstructive pulmonary disease (damaged to the lung), pleural effusion (buildup of fluid in the lung), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), and muscle wasting and atrophy (decrease in size and wasting of muscle). Record review of Resident #152's Brief Interview of Mental Status (BIMS), dated 10/26/2024, reflected the resident's BIMS score was 14 out of 15, which indicated the resident had intact cognitive function. Record review of Resident #152's baseline care plan, dated initiated 10/23/2024, reflected there was no baseline care plan regarding Resident #152's BiPap care. Record review of Resident #152's physician's orders, dated 10/23/2024, reflected there was no physicians order regarding Resident #152's BiPap care, such as set-up the machine and how to care the tubing. Observed on 10/29/2024 at 10:29 a.m. revealed there was a BiPap machine and mask on the nightstand beside the bed of Resident #152's room. Interview on 11/01/2024 at 11:46 a.m. Resident #152 stated she was using the BiPap every day when she was sleeping, and she brought it from her home. Further interview with Resident #152 said she knew how to use it and did not see facility nurses took care of Resident #152's BiPap. Interview on 11/01/2024 at 10:00 a.m. CNA-A said Resident #152 used the BiPap every night since the resident was admitted to the facility. Interview on 11/01/2024 at 10:05 a.m. the MDS nurse (RN-B) acknowledged Resident #152 was using a BiPap when the resident was sleeping every night since the resident was admitted to the facility on [DATE]. The MDS nurse RN-B stated there was no physician's orders regarding Resident #152's BiPap care, such as machine set up and how to care for the tubing. The facility nurses should have obtained the physician's orders for Resident #152's BiPap care because the resident was using it every night, and the physician's orders affected actual care through which nurses knew how to provide care appropriately to Resident #152; therefore, no physician's orders might affect lack of care to the resident. Interview on 11/01/2024 at 12:25 p.m. the DON stated the facility nurses should have obtained physician's orders for Resident #152's BiPap care because the resident was admitted with the BiPap and said the facility did not have specific policy regarding Bipap.

Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (100 hall medication cart) reviewed for drug security. 100 Hall nurse's medication cart was left unattended, unlocked with the keys hanging from the lock outside the nurses' station with the drawers facing the outward and could be opened by anyone who passed by. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: Observations on 08/17/2024 from 5:04 p.m. to 5:10 p.m. during in interview with RN A on 100 hall out of site of the nurses station, RN A stated she was doing wound care on 08/17/24. As the surveyor and RN A walked over to the nurses' station the 100 Hall medication cart was parked outside the nurse's station towards the 100 hall with the keys hanging from the lock that was in the unlocked position, the drawers were facing outward and could be opened by anyone who walked by, and the nurse responsible for the 100 Hall medication cart was not within site of the cart. As RN A walked by the 100 Hall medication cart with the keys in the lock that was in the unlocked position, she removed the keys from the lock, put them in her scrub top pocket, but did not lock the medication cart. RN A and the surveyor walked into the nurses' station where the unlocked drawers to the 100 Hall medication cart were out of their line of site. While the surveyor was interviewing RN A, an unidentified male visitor walked by the unlocked 100 Hall medication cart with the drawers faced outward. RN B, who was working on 100 hall, walked from the direction of the front offices, past the 100 Hall medication cart, reached over to the unlocked cart and the surveyor heard a clicking sound like the lock had been pushed into the cart and RN B walked into the nurses' station and sat down. When the surveyor stepped out of the nurses' station and passed by the 100 Hall medication cart it was locked. In an interview on 08/17/24 at 6:06 p.m. RN B, who was responsible for the 100 Hall medication cart, stated she always would push on the locks on the medications carts when she walks by them to make sure they were locked. RN B said she could not remember if the 100 Hall medication cart had been unlocked when she walked by it when the surveyor was talking to RN A at the nurses' station. In an interview on 08/23/24 at 5:23 p.m., RN A stated she did not remember what she removed from the medication cart that she and the surveyor passed by on 08/17/24, even after the surveyor asked her if she remembered pulling the keys out from the lock. RN A stated the cart that was parked outside the nurses' station facing the 100 hall on 08/17/24 would have been the 100 Hall nurses' medication cart. In an interview on 08/24/24 from 11:04 a.m. to 11:24 a.m., the DON stated medications were kept secured in a locked medication cart, and the medication cart keys should be always kept on the nurse or medication aide responsible for the cart. The DON stated the harm of having an unlocked medication cart with the drawers accessible to anyone who walked by would be they could take the medications from the cart and ingest the medications. In an interview on 08/24/24 at 11:38 a.m., the Administrator stated medications were kept secured in the locked medication cart and the nurse would keep the medication cart keys with them, not on top of the cart, hanging from the cart. The administrator said if the nurse was out of site of the medication cart the medication cart needs to be locked. The administrator stated the harm that could happen if the medication cart keys were left in an unlocked medication cart with the drawers facing outward could result in a resident could get into the cart, have access to the medications, and take the medications or someone could steal the medications from the cart. Record review of the Medication Cart Use & Storage Policy, dated 03/15/2019, revealed The medication cart and its storage bins are kept locked until the specified time of medication administration. If an emergency occurs during the medication pass, the nurse/medication aide securely locks the medication cart before attending to the emergency situation .Medication cart keys shall be kept in the nurse's/medication aide's possession until turned over to the next shift nurse.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for that described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (#5, #6 and #7) reviewed for care plans. 1. Resident #5's care plan did not indicate that she had a colostomy (a surgical opening for the colon in the abdomen). 2. Resident #6's care plan did not indicate that she had a foley catheter (a flexible tube that was inserted through the urethra and into the bladder to drain urine). 3. Resident #7's care plan did not indicate that he had a suprapubic catheter (a tube that was inserted through the lower abdomen and directly into the bladder in order to drain urine). The deficient practice could place residents at risk of not having needs identified and interventions established. The findings were: 1. Review of Resident #5's face sheet revealed she was an [AGE] year-old female who had an initial admitted [DATE] and a readmitted [DATE]. She had diagnoses which included surgical aftercare following surgery on the digestive system, hypertensive heart disease (heart problems caused by high blood pressure), and dementia (general term for impaired ability to remember, think, or make decisions). Review of Resident #5's MDS, dated [DATE], revealed a BIMS score of 13 indicating no cognitive impairment. Review, on 05/14/2024, of facility list of residents with indwelling devices revealed Resident #5 had a colostomy. Review of Resident #5's May 2024 physician orders revealed orders with a start date of 2/29/2024, that stated to empty colostomy bag every shift for hygiene, check stoma for edema/bleeding Q shift for hygiene and to prevent infection, and clean area around stoma with soap and H20, pat dry, apply skin prep/stoma adhesive QD every shift for hygiene. Review of Resident #5's care plan revealed a care plan for a colostomy with a date initiated and created on date of 05/14/2024 (after state surveyor intervention). During an interview with Resident #5 on 05/15/2024 at 11:30am, she stated she had surgery to insert the colostomy approximately three to four months ago and the facility staff provided assistance with emptying and changing the colostomy. 2. Review of Resident #6's face sheet revealed he was a [AGE] year-old male who had an admitted [DATE] and readmitted [DATE]. He had diagnoses which included benign prostatic hyperplasia (noncancerous enlargement of the prostate gland). Review of Resident #6's Admission MDS, dated [DATE], revealed Resident #6 had a BIMS score of 3 indicating severe cognitive impairment. Review on 05/14/2024, of facility list of residents with indwelling devices revealed Resident #6 had a foley catheter. Review of Resident #6's May 2024 physician orders revealed an order for a foley catheter with a start date of 04/15/2024. Review of Resident #6's care plan revealed a care plan for an indwelling foley catheter with a date initiated and created on date of 05/14/2024 (after state surveyor intervention). 3. Review of Resident #7's face sheet revealed he was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included urine retention (difficulty urinating and emptying of the bladder). Review of resident's MDS dated [DATE] revealed no BIMS score completed on the MDS. Review, on 05/14/2024, of facility list of residents with indwelling devices revealed Resident #7 had a suprapubic catheter. Review of Resident #7's May 2024 physician orders revealed an order for a suprapubic catheter with a start date of 05/08/2024. Review of Resident #7's care plan revealed a care plan for an indwelling suprapubic catheter with an date initiated and created on date of 05/14/2024 (after state surveyor intervention). During an interview with the MDS Coordinator on 05/16/2024, she stated the purpose of the care plan was to plan the residents care and personalize the care to the resident so that the facility is following the resident's wishes and preferences. She stated the care plan was fluid and should reflect the resident's current care. She stated the care plan should be updated upon admission and when something changes with the resident's care. She furthermore stated, she updated several resident's care plans to include indwelling devices on 05/14/2024 after this state investigator's arrival to the facility and stated these devices should have been care planned upon admission or when the devices were implanted. She stated it was important to care plan these devices because they were part of the resident's plan of care. During an interview with the DON on 05/16/2024 at 1:12pm, she stated her expectation was for a resident's care plan to be updated upon admission and within twenty-four hours of any changes. She also stated it was important for the care plan to be accurate because it was a reflection of the resident's individualized care and needs. Review of the facility policy titled Care Plans, dated February 2017 and revised January 2023, stated the community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. It also stated, the care plan should be initiated upon admission, continued to be developed during the initial 48-72 hours, throughout the completion of the admission comprehensive assessment.

Based on interview and record review, the facility failed to complete a comprehensive assessment of 1 of 24 residents (Resident # 78) reviewed for comprehensive person-centered care plans in that The facility failed to do a comprehensive assessment for Resident #78 that included a preference to receive medications in the dining room. This deficient practice could place residents at risk of receiving inadequate assessments not individualized to their care needs. The findings included: Record review of Resident # 78's face sheet dated 9/28/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: [Dementia] is a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life. [Conductive Hearing Loss] Hearing loss is caused by something that stops sounds from getting through the outer or middle ear. [Unspecified Pain] Physical suffering or discomfort caused by illness or injury Record review of Resident # 78's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating intact cognition. Record review of Resident # 78's care plans dated 9/28/23 did not reveal any care plan regarding the resident's preference to receive medications in the dining room. Record review of Resident # 78's Physician orders, dated 9/28/23, did not reveal any physician orders to administer medication with food. Observation and interview on 9/28/23 at 8:45 a.m., Medication aide F administered morning medication to Resident # 78 in the dining room. Medication aide F stated Resident # 78 preferred her medication in the dining room along with her meals. Medication aide F stated she did not have a doctor's order to give medications with a meal but would inform the DON. Medication aide F stated by giving medications to Resident # 78 in the dining room along with food, Resident # 78 risked possibly less absorption of a medication. Interview with Resident # 78 on 9/28/23 at 9:00 a.m. stated she preferred all her medication in the dining room along with her meal, because if she takes medication on an empty stomach, she gets nauseous. Interview on 9/28/23 at 9:15 a.m., MDS Nurse A stated she was assigned care plans for long-term care residents to include Resident # 78. MDS Nurse A stated she was unaware that Resident # 78 preferred her medication in the dining room. MDS Nurse A stated she reviewed all long-term residents' care plans quarterly following an interdisciplinary team approach. She stated she does not know why Resident # 78's preference to have received medications in the dining room was not reflected in the care plan, but she would update it. MDS Nurse A stated if the care plan does not indicate Resident # 78's preference to receive medication in the dining room, the nursing staff risked not being on the same page regarding Resident # 78's preferences. In an interview on 8/28/23 at 10:35 a.m., the DON stated the care plan had not been revised to include the preference for Resident # 78 to receive medications in the dining room. The DON revealed the interdisciplinary team updated care plans quarterly. She further revealed the entire nursing leadership team was responsible for updating care plans; she was unsure how the update to the care plan was missed. The DON stated by not revising care plans, staff risked not being on the same page regarding resident care. Record review of the facility policy, Care Plans: February 2017, revealed The care plan will describe the services to be furnished to attain or maintain the highest practicable physical, mental, and psychological well-being.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (Resident #61) reviewed for abuse and neglect. The facility did not thoroughly investigate when Resident #61 was bitten by a visitors dog. This failure could place residents at risk for allegations of abuse or neglect not being thoroughly investigated by the facility and reported as required. Findings include: A face sheet dated 09/23/2023 indicated Resident #61 was [AGE] years old admitted on [DATE] with diagnosis that included but not limited to the following: Anxiety, type 2 diabetes (high blood sugar levels), muscle wasting and atrophy to multiple sites, hypertension (high blood pressure), insomnia and depression. A MDS dated [DATE] indicated Resident #61 had moderate cognitive impairment. A care plan dated 08/20/23 revealed Resident #61 was at risk for skin injury, new or worsening skin condition; thin, fragile, loose skin-09/11/2023: dog bite top of right hand. During an interview on 09/28/2023 at 1:31 p.m. the Resident said, my hand hurts and it is messy. Resident #61 went on to say she was bitten on the hand by a dog someone brought into the facility. Resident #61 further stated she asked the owner of the dog if the dog bit and if she could pet him. Resident #61 reported the dog owner told her the dog did not bite and she could pet him. Resident #61 said, I don't think anyone that has a dog that bites should ever bring one into a facility like this, they just should not. Resident #61 stated if a dog came up to her now, she would shy away and get away. During an interview on 09/28/2023 at 3:25 p.m. the DON stated the dog bite was not reported to the State of Texas through TULIP because the facility did not believe it should be reported and considered it an incident. The DON stated Resident #61's incident was not investigated. The DON said the incident did not need to be investigated, it was not abuse or neglect, it was an incident. During an interview on 09/29/2023 at 1:58 p.m. the Administrator stated the dog bite was not reported to the State of Texas through TULIP because the facility considered the event an incident and the incident was not investigated and explained the facility did not consider the dog bite abuse or neglect. A policy regarding pets being brought into by the facility was requested. The Administrator stated the facility did not have a facility policy regarding animals being brought into the facility by visitors. The Administrator explained the facility had a practice of asking for vaccination records prior to allowing any animals into the facility resident care area. She was not at the facility the day of the incident and did not who allowed the dog into the resident care area or did not know why the dog's vaccinations records were not requested prior to entry. She further stated, she did not investigate the incident, as it did not meet the reporting guidelines of the Long Term Care Regulatory Provider Letter Number: PL 19-17, Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission and provided a copy. Review of Provider Letter 19-17, dated 7/10/2019, revealed neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury should be reported immediately, but not later than two hours after the incident occurs or is suspected.

Based on interview and record review the facility failed to implement their written policies and procedures for reporting all allegations involving abuse, neglect and injuries of an unknown source in accordance with the state law for 1 of 8 residents (Resident #61) reviewed for abuse and neglect. The facility did not provide the state agency with a provider investigation report within 5 working days. This failure could place residents at risk of injury abuse and neglect. Findings included: A face sheet dated 09/23/2023 indicated Resident #61 was [AGE] years old admitted on [DATE] with diagnosis that included but not limited to the following: Anxiety, type 2 diabetes (high blood sugar levels), muscle wasting and atrophy to multiple sites, hypertension (high blood pressure), insomnia and depression. A MDS dated [DATE] indicated Resident #61 had moderate cognitive impairment. A care plan dated 08/20/23 revealed Resident #61 was at risk for skin injury, new or worsening skin condition; thin, fragile, loose skin-09/11/2023: dog bite top of right hand. A Progress note with an effective date of 09/11/2023 revealed Resident #61, was walking down 100 hallway. A dog bit her rt hand, skin tear size of a quarter. Minimal bleeding cleaned with antiseptic and dressed in Antibiotic ointment. Dog owner is emailing shot records. Said he had all his shots. Contacted Doctor, new order for antibiotic. See new orders. Will monitor for infection, dressing change daily. A subsequent progress note, in Resident #61's electronic health record, with an effective date of 09/11/2023 revealed the patient complained of pain in right hand, the Doctor was contacted and T3 1-2 tabs Q6hours PRN for pain not to exceed 4g in 24-hour period. During an interview on 09/28/2023 at 1:31 p.m. Resident #61 said, my hand hurts and it is messy. Resident #61 went on to say she was bitten on the hand by a dog someone brought into the facility. Resident #61 further stated she asked the owner of the dog if the dog bit and if she could pet him. Resident #61 reported the dog owner told her the dog did not bite and she could pet him. Resident #61 said, I don't think anyone that has a dog that bites should ever bring one into a facility like this, they just should not. She stated if a dog came up to her now, she would shy away and get away. During an interview on 09/28/2023 at 3:25 p.m. the DON stated the dog bite was not reported to the State of Texas through TULIP because the facility did not believe it should be reported and considered it an incident. During an interview on 09/29/2023 at 1:58 p.m. the Administrator stated the dog bite was not reported to the State of Texas through TULIP because the facility considered the event an incident. A policy regarding pets being brought into the facility by visitors was requested. The Administrator stated the facility did not have a facility policy regarding animals being brought into the facility by visitors. The Administrator explained the facility had practice of asking for vaccination records prior to allowing any animals into the facility resident care area. She was not at the facility the day of the incident and did not know who allowed the dog into the resident care area or why the dog's vaccinations records were not requested prior to entry. She reported vaccination records indicated the dog was a mixed breed dog that weighed 80 to 85 pounds.

Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 2 residents (Resident #22) reviewed for injuries of unknown origin. Resident #22 was discovered with a bruise to the head without a report to the state agency. This failure could place residents at risk for harm by not reporting and investigating allegations of abuse, neglect, or injuries of unknown origins. The findings included: A record review of Resident #22's admission record, dated 7/22/2022, revealed an [AGE] year old admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #22's significant change MDS dated [DATE], revealed a Brief Mental Interview Status score of 03, indicating severe cognitive impairment. Further review revealed Resident #22 required full assistance with activities of daily life. A record review of Resident #22's care plan dated 7/22/2022, revealed, I am at risk for falls related to jerky random and uncontrollable movements of body .Intervention's helmet on went up to avoid head injury. A record review of Resident #22's nurse progress notes revealed a note dated 4/7/2022 at 5:30 AM, authored by LVN A, CNA was doing rounds and reported Resident having palm sized purple discoloration to the right side of forehead. DON, Dr., and RP notified. Initiated neuro checks. During an interview on 7/19/2022 at 2:30 PM Resident #22's representative stated the facility nurse called him the early morning of 4/7/2022 and reported Resident #22 was discovered with a raised dark bruise to her right forehead. Resident #22's representative stated he inquired of the DON how Resident #22 came to have the injury and the DON stated the origin of the injury was unknown. During an interview on 7/22/2022 at 2:21 PM, the DON stated Resident #22 was discovered with a raised dark bruise to her right forehead in the early morning of 4/8/2022 by the CNA attending to care. The DON stated Resident #22 was diagnosed with [CONDITION(S)] chorea disease and thus Resident #22 experienced sudden unintentional uncontrolled spastic muscle movements. The DON stated on 4/7/2022 the facility celebrated fiesta and invited residents and their families to the party. The DON stated Resident #22 wore a soft helmet to protect her from any injuries however, on that day Resident #22 was not wearing her helmet possibly due to her representative removed her helmet during the event. The DON stated she interviewed the CNA who assisted Resident #22 with the evening meal and then assisted her to bed. The CNA stated the evening went well without any unusual events, Resident #22 was assisted to bed and was checked on throughout the evening. The DON stated at 4:00 AM the CNA providing incontinent care utilized the overhead bed light and saw the raised dark bruise to Resident#22's right forehead. Resident #22 was assessed by the nurse, Resident #22's physician received a report with orders for x-rays which revealed no fractures or internal injuries, and Resident #22's representative received a report of the discovered bruise. The DON stated she initiated an investigation for the unwitnessed injury and could not definitively identify the origin of the injury and deduced the injury probably resulted from spastic involuntary movement of her head and possibly struck something during the time she did not wear her helmet during the facility's fiesta party. The DON stated the injury of unknown origin was not reported to the state agency. The DON stated, at the time I did not consider the discovery a reportable event .I understand I should have reported the bruise to the Administrator or the TULIP website. The DON stated injuries of unknown origin require reporting to the abuse, neglect, and exploitation prevention coordinator to rule out potential abuse and failure to report, investigate could potentially leave residents in jeopardy for harm. A record review of the Texas Unified Licensed Information Portal on 7/22/2022, did not reveal any report of an allegation of injury of unknown injury for Resident #22. A record review of the facility's Reporting Abuse to Community Management policy dated July 2018, revealed, policy statement: it is the responsibility of our team members, community consultants, attending physicians, family members, visitors, etc., to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of president property to community management. And .Team members, community consultants, and attending physicians shall report any suspected abuse or incidents of abuse to the community designated abuse coordinator promptly. In the absence of the community abuse coordinator such reports may be made to the director of nursing services and if not available then to the nurse supervisor on duty. In accordance with SB-9 failure to report abuse is a misdemeanor. The administrator and director of nurses shall be properly notified of the suspected abuse or incident of abuse. If such incidents occur or are discovered after hours the administrator and director of nursing services shall be called at home or shall be paged and informed of such incident. When an alleged or suspected case of exploitation, mistreatment, neglect, injuries of an unknown source, or abuse is reported, the community administrator or his her designee will notify the following persons or agencies per the current state federal reporting requirements of such incident, if appropriate the state licensing certification agency responsible for surveying licensing the community .

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team, after each assessment, which included both the comprehensive and baseline, for 1 of 2 (Resident #290) residents reviewed for care plans. The facility did not provide a care plan meeting or revise Resident #290's care plan after he was admitted with wound care needs. This failure could place residents at risk for not having their needs met for their healthcare maintenance. The findings included: A record review of Resident #290's admission record revealed a [AGE] year old admitted on [DATE] and a discharge date of [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #290's Discharge MDS dated [DATE] revealed a brief Mental Status Interview score of 15 indicating no mental cognition impairment. A record review of Resident #290's May 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack with wet to dry one inch plain packing strip and cover with dry dressing, twice a day. Left thigh (surgical) cleanse with normal saline or wound cleanser, apply Eucerin to the graph site and leave open to air. Right thigh (surgical) graft site, cut back xeroform gauze as lifts away from graph site, apply Eucerin to site, leave open to air. A record review Resident #290's nursing progress notes revealed a note dated 4/15/2022, authored by RN D, Resident is a new admission, admitted from hospital. Family or resident representative present at time of admission? No. Resident condition on admission, stable. All orders confirmed acknowledged and approved by physician. A record review of Resident #290's electronic medical records revealed an e-mail from the hospital's social worker, dated 4/15/2022, patient is a [AGE] year-old male admitted with a Necrotizing Soft Tissue Injury to the left hip knee area. Patient had been at (skilled nursing facility) prior to (hospital) admission and was readmitted for nausea and vomiting. Two wound vacs now discontinued but wound care needs remain along with therapy needs. Wound care instructions per provider: Apply [MEDICATION(S)] (medication is used to prevent minor skin infections) to xeroform (wound dressing bandage) then xeroform to graft site. Do not directly apply [MEDICATION(S)] to graft site. Failure to adhere to this could result in shearing of the graft. A record review of Resident #290's care plan dated 3/29/2022 did not reveal any care support plans for wound care or [CONDITION(S)] or any revisions for Resident's new needs after his re-admission on 4/15/2022 after an extended hospitalization . During an interview on 7/21/2022 at 9:14 AM Resident #290's Power of Attorney stated Resident #290 was admitted to the facility for a skin injury to his legs. Resident #290's POA stated she was concerned for his care and potential discharge to a possible unsafe home environment when she called the facility's social Worker and received a care plan date. Resident #290's POA stated she arrived for the care plan meeting and discovered there was no meeting planned and referred to the Physical Therapy director. Resident #290's POA could not definitively recall the alleged date of the meeting. During an interview on 7/21/2022 at 9:32 AM Resident #290 stated he was admitted to the facility on [DATE] with needs for a skin infection and wound care. Resident #290 stated he was sent to the hospital when he experienced nausea and vomiting and spent a month at the hospital for a hernia repair and returned to the facility with new needs for wound care and therapy. Resident #290 stated he wanted to go home as soon as possible but the facility did not provide a care plan meeting to discuss his needs. During an interview on 7/22/2022 at 3:15 PM the MDS Nurse stated she had no evidence of an interdisciplinary team care plan meeting for Resident #290, other than records revealing the social worker and the physical therapist spoke with both the Resident #290 and Resident #290's POA about discharge plans. During an interview on 7/22/2022 at 3:00 PM the DON stated the facility's policy is each Resident will receive an interdisciplinary team care plan meeting after the resident's comprehensive assessment, admission, or change of condition. The DON stated the facility process was for the resident's admission to be recorded on a printed calendar and then shared with the social worker who along with the MDS nurses schedule the IDT care plan meeting. The DON stated the meeting would be recorded in the resident's electronic medical record and the care plan would reflect the meeting changes if any. The DON confirmed Resident #290 had needs for wound care and were not reflected in the care plan. The DON stated the lack of care plan to support Resident #290's needs for wound care could have negatively affected his health however, Resident #290 was receiving wound care per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the facility's Care Plans policy, dated February 2017, revealed, Comprehensive care plans: the community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs, that are identified in the comprehensive assessment. Their care plan will describe the services to be furnished to attain or maintain the residents highest practical physical, mental, and psychosocial well-being, any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment. The comprehensive care plan is developed within seven days of the completion of the comprehensive assessment; is prepared by an interdisciplinary team including the attending physician, a registered nurse with responsibility for the Resident, and other appropriate team members and disciplines as determined by the resident's needs, involves participation of the resident and his or her family or legal representative interdisciplinary care planning.

Based on observation, interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for 3 of 14 residents (Residents #23, 7, and 13) reviewed for neglect, in that: 1. Resident #23 required 2 staff to transfer her. Resident #23 sustained left tibia fractures twice during transfers where CNAs (an unknown CNA and CNA K) twisted her leg. 2. Resident #7 was assessed as needing two-person assistance using the mechanical lift for transfers. CNA P transferred Resident #7 using the mechanical lift by herself. Resident #7 was found to have a fractured right tibia. 3. Resident #13 needed one-person assistance with a gait belt for transfers. RA E transferred Resident #13 using a gait belt fastened above her breasts, instead of around her waist per facility policy and professional standards. Resident #13 sustained multiple bruises above her breasts. An Immediate Jeopardy situation was identified on 10/21/14. The Immediate Jeopardy was removed on 10/22/14 but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices led to improper transfers for residents #23, #7, and #13 and could affect 20 residents who needed a mechanical lift for transfers, 69 residents who needed a gait belt for transfers, and 14 residents who needed two person assistance with transfers and place them at risk of injury. The findings were: 1A. Review of Resident #23's face sheet dated 10/8/14 revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's physician progress notes [REDACTED].#23 was readmitted after an open reduction, internal fixation surgery to her left ankle after a non-healing displaced fracture. Review of Resident #23's MDS assessment dated [DATE] revealed she had moderate cognitive impairment and required extensive assistance of two people for transfers. Review of Resident #23's comprehensive care plan dated 7/9/14 revealed the resident had a fractured lower left extremity, and staff were to follow the physician's orders [REDACTED]. The care plan did not specify the amount of staff needed for transfers. The care plan indicated for staff to check the "POC" for transfer needs. In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the POC, the computer kiosk, for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old worksheets were not kept, and could not provide any previous worksheets with Resident #23's transfer status. Review of Resident #23's physician progress notes [REDACTED].#23 had anxiety about bearing weight on her left leg. The physician, MD W, noted Resident #23 required maximum assistance for transfers. In an interview on 10/21/14 at 11:00 a.m., MD W said Resident #23 was very anxious and had to go slow with transfers, because she had trouble putting her feet in the right place for a transfer. The physician said maximum assistance could be done by 1 or 2 people, but for Resident #23, 2 people were required. The physician said the CNAs reported to her that they were using 2 people for transfers of Resident #23. Review of the facility Grievance log revealed a grievance dated 9/4/14 from Resident #23's family member. In the grievance, the family member noted on 8/23/14 in the evening Resident #23, during a transfer from the wheelchair to the bed, her left booted foot got tangled up in the CNAs feet, resulting in the rod and screw becoming dislodged and a crack in the tibia. The family member noted some of the CNAs did not know how to transfer patients. The family member noted she showed one CNA how to remove the side from the wheelchair, and noted the CNAs did not lower the bed when they were transferring the resident into bed. Review of Resident #23's physician orders [REDACTED].#23's left ankle due to pain. Review of Resident #23's radiology report dated 8/24/14 revealed Resident #23 had "a recent undisplaced fracture distal shaft of the left tibia just above the tibial rodding. " Review of Resident #23's nursing notes did not reveal any information about an incident involving Resident #23 on 8/23/14 or 8/24/14. Review of the facility Incident and Accident Reports from August 2014 did not reveal an incident report related to Resident #23. Review of ADL records for August 2014 revealed CNA B documented Resident #23 received assistance of one person for transfers on 8/23/14 in the evening shift. Review of Resident #23's physician progress notes [REDACTED].#23 went to the orthopedist and received a new cast on her left leg. The MD noted Resident #23 said she twisted her leg during a transfer with a CNA. The MD noted Resident #23's roommate confirmed the improper transfer. MD W noted that Resident #23 now was unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/18/14 at 11:22 a.m., Resident #23 said her roommate had discharged earlier that week. She said she did not remember hurting her leg in August. Review of Resident #23's physician progress notes [REDACTED].#23's attending physician noted the resident was now unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/17/14 at 2:45 p.m., Resident #23's family member said Resident #23 broke her leg twice in the facility due to transfers by CNAs. She said the resident had become more depressed and confused since the injury. The resident's family member said the resident did not tell her which CNA transferred her that evening. Further review of the grievance dated 9/4/14 revealed the DON had written that all MAs, CNAs, and RAs were receiving training in transfers and gait belt training from the director of rehabilitation. Review of In-Service training dated 8/27/14-9/2/14 revealed there was nothing specific mentioned about Resident #23. The transfer training specified staff should not twist the legs of residents. In an interview on 10/21/14 at 12:18 p.m., ADON T said she was told by the nurse on 8/24/14 that Resident #23 said she broke her leg during a transfer. She said after looking at the schedule, she believed CNA B performed the transfer. She said she did not talk to Resident #23 or CNA B about the incident. She said all she did was to tell the CNAs, all the CNAs, to make sure they attended the transfer training being performed that week. She said there was no follow up or monitoring of the CNAs after the in-services were done to ensure they were doing transfers appropriately. She said there were no new interventions put into place for Resident #23 to prevent another fracture. Review of the staffing sign-in sheet dated 8/23/14 revealed CNA K and CNA B were the CNAs on Resident #23's hall. In an interview on 10/21/14 at 11:22 a.m., CNA K said she did not help Resident #23 on 8/23/14. In an interview on 10/21/14 at 2:19 p.m., CNA B said she believed Resident #23 required one person to help transfer her, but said she always asked another person to help because she did not feel comfortable transferring the resident by herself. She said the other staff member would actually do the transfers, CNA B did not. CNA B said she would do other duties of ADL care, but the other person did the transfers and she would just stand by. She said she did not transfer Resident #23 when she broke her leg in August. 1B. Review of Resident #23's attending physician progress notes [REDACTED].#23 remained non-weight bearing on her left leg. In interviews on 10/21/14 at 11:22 a.m. with CNA K and on 10/21/14 at 2:19 p.m. with CNA B, the CNAs said they were told by either the PT or the charge nurse how much help a resident needed for transfers and if a resident was non-weight bearing. Review of Resident #23's physician progress notes [REDACTED].#23 was very anxious when CNAs transfer her from the wheelchair to the bed because she feels her last tibia fracture happened during a CNA transfer. MD W noted Resident #23 thought the CNAs transferred her too fast as well and it was too hard for Resident #23 to coordinate her left leg during transfers. MD W noted Resident #23 needed maximum assistance to transfer and was a high fall risk. MD W noted she spoke with CNAs regarding safe transfers in and out of bed and also discussed to please slow down when transferring Resident #23 due to her high anxiety from the previous fracture. The note indicated MD W spoke with the nurse after speaking with the family. Review of Resident #23's physical therapy progress notes dated 9/19/14 revealed Resident #23's progress was limited due to exacerbated pain with movement of the lower left leg. The note indicated Resident #23 had self-limiting behaviors and fears of putting weight on her lower left leg. Review of an Incident Report dated 9/24/14 revealed Resident #23's family member went to ADON T and said "the facility broke" Resident #23's leg that day. ADON T noted Resident #23 called her family member crying and saying that during a transfer to the bed from the wheelchair she heard her leg crack. The incident report noted there were no witnesses. ADON T noted on the incident report that the team member who assisted her said she did hear a noise when she assisted the resident but that the noise came from the resident's shoe. No other statements were included with the incident report. In an observation and interview on 10/18/14 at 11:22 a.m., Resident #23 was sitting in her wheelchair in her room. A large cast covered her left leg. She said she obtained the fracture in her leg when a CNA transferred her and twisted her leg. She said the CNA "was new and didn't know what she was doing." Review of ADL records for September 2014 revealed CNA K documented Resident #23 received assistance of one person for transfers on 9/24/14 in the evening shift. Review of Resident #23's radiology report dated 9/24/14 revealed the resident had a slightly angulated distal fibular fracture. The ADL sheets indicated Resident #23 refused to be transferred on 9/25/14. Review of Resident #23's orthopedist progress note dated 9/29/14 revealed the doctor noted "She had another incident late last week, where she was being helped to move, again appears accidental, but in the process of being helped feet got tangled with her helper, got tangled in the sheets and had twisting injury, heard a snap ...X-ray studies show that the fracture above the TTC nail has displaced through the healing callus that we had ...This is the second time this has happened ... I do not know if she will be able to tolerate a long leg cast very well ...We talked to her family about trying to emphasize with the facility (they are) to make sure they have at least two people to help her every time she moves, just to help prevent this from happening any more, solely because we need to fix this, this would be a very difficult thing to fix with her other fixation in place. " In an interview on 10/17/14 at 5:48 p.m., ADON T said she spoke with the resident and the aide that transferred her, but did not do any further investigation. She said she did not speak with any other staff or residents during the investigation and did not have any written witness statements. In an interview on 10/17/14 at 5:52 p.m., the administrator and DON said they were aware of the incident at the time and there was no further investigation done other than the one done by the ADON. They said the incident was not reported to the state survey agency because they knew how the incident occurred, during a transfer. They said it was not investigated as potential abuse or neglect. In an interview on 10/21/14 at 11:22 a.m., CNA K said Resident #23 required 2 people to transfer her. She said Resident #23 did not try to get up without assistance and was very anxious with transfers. She said when Resident #23 broke her leg in September, she was assisting her with the transfer. She said she stood Resident #23 up, transferred her and sat her down. She said the resident said "Ooh" She said she thought it was the resident's shoe making noise. She said she told ADON T what happened the next day, but did not report it to anyone that day. In a further interview with CNA K on 10/21/14 at 2:13 p.m., she said she was aware Resident #23 required 2 people to transfer her. She said she transferred the resident by herself, which she knew she shouldn't do. She said there was only 2 staff on that hall and "a lot of residents" to put back into bed after lunch. She said she knew Resident #23 required 2 people for a transfer, but she said she was not aware the resident should not bear weight on her left foot. 2. Review of Resident #7's face sheet dated 12/6/12 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #7's MDS dated [DATE] revealed she had [DIAGNOSES REDACTED]. Review of Resident #7's comprehensive care plan revised 7/15/13 and updated quarterly indicated she required two- person physical assistance with a mechanical lift for transfers. Review of Resident #7's incident and accident report dated 9/1/14 revealed while staff was assisting the resident with a mechanical lift transfer, the resident leaned forward in her wheelchair and she twisted her ankle. The incident report did not note any evidence that the staff member was interviewed about the incident. In an interview on 10/15/14 at 3:50 p.m., Resident #7 said she broke her leg when staff transferred her without using the mechanical lift. She said she lied to the facility staff when they asked her how she broke her leg because she wanted to protect the staff member. Review of Resident #7's physician orders [REDACTED]. Review of Resident #7's chart revealed an orthopedic physician progress notes [REDACTED].#7 had a fracture to the right fibula. Observation on 10/15/14 at 11:25 a.m. revealed Resident #7 sitting in her wheelchair. A cast was on her right foot. In an interview on 10/15/14 at 4:38 p.m., ADON T said she did not have any other investigation other than what was on the incident report. She said she just went with what the resident said. During an interview on 10/17/14 8:19 a.m., the administrator said a full investigation into the incident was not done due to Resident #7 stating that she hurt her foot by herself. During an interview on 10/17/14 at 9:45 a.m. with CNA P, she confirmed that she transferred Resident #7 at approximately 6:45 a.m. on 9/1/14 with the mechanical lift by herself. CNA P further confirmed that she knew she should not transfer Resident #7 alone with the mechanical lift but that everyone else was busy at that time and she was just trying to get everyone up for breakfast. During an interview on 10/21/14 at 3:10 p.m., the administrator said she was not aware CNA P had transferred Resident #7 alone with the mechanical lift. She said she had not asked CNA P how she did the mechanical lift transfer during her interview. She said the staff member involved in the incident should have been interviewed at the time of the incident. She said the mechanical lift should be used by two staff members not by only one. Review of the mechanical lift manufacturer's recommendations dated 2011 revealed "Although (the manufacturer) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. " In an interview on 10/21/14 at 11:41 a.m. and 10/22/14 at 5:20 p.m., the DON said there were no skills competency checks of staff related to transfers. 3. Review of Resident #13's face sheet dated 10/13/14 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's MDS assessment dated [DATE] revealed she had severly impaired cognition and was assessed as needing one -person assistance with transfers. Review of Resident #13's comprehensive care plan revised 2/5/13 and updated quarterly revealed the resident had an ADL self-care deficit related to dementia, fatigue, and limited mobility. The staff intervention was to provide assistance for ADLs. The care plan specified "See POC documentation for assistance required." In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Observation of Resident #13 in the hospital room on 10/15 /14 at 9:22 a.m. revealed there were three dime size bruises to the right bicep. The bruises were purple in color. Observation of Resident #13's chest revealed a discolored bruise the size of a quarter to the upper left chest several inches from the resident's collar bone. She had an immobilizer on her leg due to having a fractured tibia and fibula of unknown origin at the facility. Interview with Restorative Aide E on 10/17/14 at 11:00 a.m. revealed he wrapped the gait belt above Resident #13's breasts prior to transferring her into the wheel chair on 10/11/14. In an interview on 10/23/14 at 4:00 p.m., the DON said RA E was interviewed about the transfer, and he said he was using a gait belt. The DON said she did not ask him how the gait belt was positioned on the resident and therefore did not realize he used it incorrectly. She said she just wanted to ensure he was using a gait belt. She said the gait belt should be positioned around the waist. Review of the facility Gait Belt Transfer Orientation/Training dated January 2009 revealed staff were trained to "apply gait belt securely around waist, and insure gait belt is not restricting circulation or breathing, or injurious to skin integrity ...Put the belt around the waist over the clothing with the buckle in front. If the person wearing the belt is female, be sure the belt is not over her breasts. " Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities dated 2013 revealed "D. Assisting Resident to Transfer to Chair or Wheelchair using Transfer Belt ...3. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting your fingers under it. " In an interview on 10/21/14 at 12:18 p.m., ADON T said there was no facility investigation policy that she was aware of. She said there was nothing that spelled out how to do an investigation on the incidents. She said she just reviewed the incident reports and made sure all the blanks were completed in the computer. She said the computer did not have any prompts as far as who to interview. In an interview on 10/21/14 at 12:49 p.m., the DON said that ADON T handled all of the investigation into the incidents. She said that because ADON T believed the transfers were done appropriately, there was no follow up. In an interview on 10/22/14 at 5:20 p.m., the DON said incident reports were reviewed during morning meeting to ensure they were completed. She said ADON T would identify staff and interview the residents for the incident reports and notate on the bottom of the report her findings. The DON said she and the administrator would review the notes to ensure an investigation was done. Then the DON would take the incident report, review it to determine whether it needed to be reported to the state survey agency, and close it out if it did not need to be reported. She said Resident #23 and Resident #7's incidents were not investigated further and were closed. She said incidents were also reviewed at the weekly Quality of Life meetings. The incidents would be reviewed to see if there were staffing patterns. She said a "Vigor" report would be generated for residents with falls, fractures, falls with serious injuries. She said there were no trends identified for Residents #23, #7 or #13 because they were on different hallways. In an interview on 10/22/14 at 6:30 p.m., the administrator said she reviewed the incident reports, and if she had questions she would ask ADON T or the DON. She said for Resident #23's incidents, she verbally asked ADON T what kind of transfer was care planned, but did not verify or have anyone verify what the assessment specified. She confirmed she was the Abuse Prohibition Coordinator. Review of the facility Resident Abuse Policy revised May 2011 revealed "Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ...Recognizing Signs and Symptoms of Abuse/Neglect ...Signs of Actual Physical Abuse - Fractures, dislocations or sprains of questionable origin; ...Signs of Actual Physical Neglect - Inadequate provision of care; ...Investigating Unexplained Injuries ...Should a resident be observed with unexplained injuries (including bruises, operations and injuries of an unknown source), the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record ...The investigation will follow the protocols set forth in our Community's established abuse investigation guidelines ...The management-appointed individual conducting the investigation will, at a minimum: ...Interview the person(s) reporting the incident, Interview any witnesses to the incident, Interview the resident (as medically appropriate), Interview the resident's attending physician to determine the resident's current mental status, Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, Interview the resident's roommate, family members, and visitors, Interview other residents to whom the accused team member provides care or services, and review all events leading up to the alleged incident ...Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports ...Preventing Resident Abuse ...Our abuse prevention/intervention program includes, but it's not necessarily limited to, the following: ...Monitoring staff on all shifts to identify inappropriate behaviors for residents ...assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict ...striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met." The facility Administrator was notified on 10/21/14 at 3:10 p.m. that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 10/21/14 at 9:25 p.m.. The Plan of Removal was accepted by the surveyors on 10/21/14 at 10:04 p.m.. The facility developed and implemented an action plan on October 21, 2014. The facility took the following actions to remove the IJ: Transfers 1. In-service on appropriate transfer techniques to include but not limited to use of gait belt, 1X, 2X and mechanical Lift, to include non-weight bearing residents and hip precautions (nursing team members to include nurse aides, medication aides, Restorative Aides, LVN's, RN's); return demonstration. Will develop a communication system between nursing and therapy to ensure that appropriate transfer techniques are communicated to nurse aides. 2. RN to re-assess residents requiring assistance with transfers and assess for appropriate transfer technique. 3. Review nurse aide assignment sheets and care plans for residents requiring assistance with transfers and update as needed as we become aware of change in conditions/transfers during Quality of Life meetings, management meetings and nursing communication reports. After assessment of residents, a communication form will be distributed to the rehab department, DON & MDS/Care Plan Coordinator. Nurse aides will receive an updated assignment sheet. Monitoring 1. DON/Licensed Nurses/designee will observe transfers that coincide with the quarterly review and review care plans x 90 days to include all shifts. 2.Findings will be brought to QAPI for at least the next 90 days. Reporting Abuse/Neglect 1. In-service team members on abuse/neglect and reporting of abuse/neglect in relation to incidents & accidents. 2.Incident & accident reports (risk management) and written/verbal grievances will be reviewed at stand-up meeting by administrator/designee, DON/designee, Therapy/designee, MDS Coordinator/designee, and SW/designee. Based on findings, such as fractures, bruises, hematomas and injuries of unknown origin, thorough investigation will be conducted. 3. Licensed nurse overseeing the incident & accident reporting system will receive in-service training on determining which incidents & accidents require thorough investigation. Monitoring 1. On a weekly basis, team members across all departments will be asked to verbalize what constitutes abuse/neglect and reporting of abuse/neglect. 2. Findings will be brought to QAPI for at least the next 60 days. 3. Review the last 30 days of incidents to evaluate if any are reportable or require further investigation. Investigating Abuse & Neglect 1. Administrator and Clinical Management team will receive training on investigating allegations of abuse/neglect and reporting to DADS. 2. A regional (corporate) support team member will be notified at the time the facility identifies or receives a potential abuse/neglect allegation in order to facilitate the thorough investigation process. Monitoring 1. A regional (corporate) support team member will review investigation findings prior to final submission to DADS within the mandatory time frame of 24 hours with the report to follow within 5 days. 2. Findings will be brought to the QAPI for at least the next 60 days. Interviews with facility staff from all shifts on 10/22/14 from 2:45 p.m. to 5:50 p.m. revealed they had received training on transfers for residents who required assistance by one and two staff, mechanical lifts, non-weight bearing, hip precautions with return demonstration, abuse and neglect and reporting incidents. Observations on 10/22/14 at 4:07 p.m. revealed training was being provided to staff on transfers. On 10/22/14 at 5:50 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff in-services and revise policies and procedures. Review of the facility Resident Abuse Policy revised May 2011 revealed "Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ...Recognizing Signs and Symptoms of Abuse/Neglect ...Signs of Actual Physical Abuse - Fractures, dislocations or sprains of questionable origin; ...Signs of Actual Physical Neglect - Inadequate provision of care; ...Investigating Unexplained Injuries ...Should a resident be observed with unexplained injuries (including bruises, operations and injuries of an unknown source), the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record ...The investigation will follow the protocols set forth in our Community's established abuse investigation guidelines ...The management-appointed individual conducting the investigation will, at a minimum: ...Interview the person(s) reporting the incident, Interview any witnesses to the incident, Interview the resident (as medically appropriate), Interview the resident's attending physician to determine the resident's current mental status, Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, Interview the resident's roommate, family members, and visitors, Interview other residents to whom the accused team member provides care or services, and review all events leading up to the alleged incident ...Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports ...Preventing Resident Abuse ...Our abuse prevention/intervention program includes, but it's not necessarily limited to, the following: ...Monitoring staff on all shifts to identify inappropriate behaviors for residents ...assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict ...striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met." Information provided by the facility on 10/23/14 indicated 20 residents needed a mechanical lift for transfers, 69 residents needed a gait belt for transfers, and 14 residents needed two person assistance with transfers.

Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance for 1 of 7 residents (Resident #7) reviewed for transfers in that: CNA A did not use a gait belt per facility procedure or lock the wheelchair when Resident #7 was transferred from the wheelchair to the bed. These deficient practices could affect 65 residents who used a gait belt to transfer and place them at risk for injury. The findings were: Review of Resident #7's face sheet dated 12/2/14 revealed Resident #7 was admitted on [DATE]. Further review of this same document revealed Resident #7 [DIAGNOSES REDACTED]. Review of Resident #7's Significant Change Minimum Data Set with an Assessment Reference Date of 11/28/14 revealed Resident #7 required extensive assistance one person assist for transfers. Review of Resident #7's Care Plan with a last review date of 12/1/14 revealed Resident #7 required assistance of 1 with transferring. Observation on 12/2/14 at 8:54 a.m. revealed Resident #7 was in her room with CNA A. Further observation revealed CNA A was transferring Resident #7 from the wheelchair to the bed. Observation revealed CNA A did not use a gait belt for the transfer but wrapped her arms around Resident #7's waist to transfer her. Further observation revealed Resident #7's wheelchair brakes were not in the locked position throughout the process of transferring the resident. During interviews on 12/2/14 at 10:45 a.m. and at 11:12 a.m. with CNA A, she indicated she did not use a gait belt to transfer Resident #7 because Resident #7 was able to stand up with support. CNA A further confirmed she did not lock Resident #7's wheelchair brakes because she forgot. During an interview on 12/2/14 at 2:48 p.m. with the DON, she indicated when transferring Resident #7 a gait belt should have been used and further indicated the brakes on the wheelchair should have been locked when transferring a resident. Review of the facility Policy and Procedures for Gait Belts dated January 2009 revealed "As one means to promote our safety policy, you are being issued a gait belt to be used for all transfers of residents". During an interview on 12/2/14 at 3:15 p.m. with the DON, she indicated there were 65 residents who used a gait belt when transferring.

Based on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receive assistance devices to prevent accidents for 5 of 19 residents (Residents #23, #7, #13, #5 & #8) reviewed for accidents and a safe environment in that: IJ Findings: 1. Resident #23 was assessed as requiring 2 staff to transfer her. Resident #23 sustained left tibia fractures twice during transfers where CNAs (an unknown CNA and CNA K) twisted her leg. 2. Resident #7 was assessed as needing two-person assistance using the mechanical lift for transfers. CNA P, who knew Resident #7 needed two staff members to transfer her with the mechanical lift, transferred Resident #7 using the mechanical lift by herself. Later that day, Resident #7 was found to have a fractured right tibia. 3. Resident #13 needed one-person assistance with a gait belt for transfers. RA E transferred Resident #13 using a gait belt fastened above her breasts, instead of around her waist per facility policy and professional standards. Resident #13 sustained multiple bruises above her breasts. An Immediate Jeopardy situation was identified on 10/21/14. The Immediate Jeopardy was removed on 10/22/14 but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-IJ: 4. Resident #5 had a [DIAGNOSES REDACTED]. 5. GVN D and RA E did not spread the base of the mechanical lift device before they transferred Resident # 8 to the wheelchair. These deficient practices could affect 6 residents who had a [DIAGNOSES REDACTED]. and could result in falls, and injury. The findings were: IJ Findings: 1A. Review of Resident #23's face sheet dated 10/8/14 revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's physician progress notes [REDACTED].#23 was readmitted after an open reduction, internal fixation surgery to her left ankle after a non-healing displaced fracture. Review of Resident #23's MDS assessment dated [DATE] revealed she had moderate cognitive impairment and required extensive assistance of two people for transfers. Review of Resident #23's comprehensive care plan dated 7/9/14 revealed the resident had a fractured lower left extremity, and staff were to follow the physician's orders for weight bearing status. The care plan did not specify the amount of staff needed for transfers. The care plan indicated for staff to check the "POC" for transfer needs. In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the POC, a computer kiosk, for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old worksheets were not kept, and could not provide any previous worksheets with Resident #23's status. Review of Resident #23's physician progress notes [REDACTED].#23 had anxiety about bearing weight on her left leg. The physician, MD W, noted Resident #23 required maximum assistance for transfers. In an interview on 10/21/14 at 11:00 a.m., MD W said Resident #23 was very anxious and had to go slow with transfers, because she had trouble putting her feet in the right place for a transfer. The physician said maximum assistance could be done by 1 or 2 people, but for Resident #23, 2 people were required. The physician said the CNAs reported to her that they were using 2 people for transfers of Resident #23. Review of Resident #23's physician orders dated 8/24/14 revealed an order to x-ray Resident #23's left ankle due to pain. Review of Resident #23's radiology report dated 8/24/14 revealed Resident #23 had "a recent undisplaced fracture distal shaft of the left tibia just above the tibial rodding. " Review of ADL records for August 2014 revealed CNA B documented Resident #23 received assistance of one person for transfers on 8/23/14 in the evening shift. Review of Resident #23's physician progress notes [REDACTED].#23 went to the orthopedist and received a new cast on her left leg. The MD noted Resident #23 said she twisted her leg during a transfer with a CNA. The MD noted Resident #23's roommate confirmed the improper transfer. MD W noted that Resident #23 now was unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/18/14 at 11:22 a.m., Resident #23 said her roommate had discharged earlier that week. She said she did not remember hurting her leg in August. Review of Resident #23's physician progress notes [REDACTED].#23's attending physician noted the resident was now unable to bear weight (non-weight bearing) on her left leg. Review of the facility Grievance log revealed a grievance dated 9/4/14 from Resident #23's family member. In the grievance, the family member noted on 8/23/14 in the evening Resident #23, during a transfer from the wheelchair to the bed, her left booted foot got tangled up in the CNAs feet, resulting in the rod and screw becoming dislodged and a crack in the tibia. The family member noted some of the CNAs did not know how to transfer patients. The family member noted she showed one CNA how to remove the side from the wheelchair, and noted the CNAs did not lower the bed when they were transferring the resident into bed. In an interview on 10/17/14 at 2:45 p.m., Resident #23's family member said Resident #23 broke her leg twice in the facility due to transfers by CNAs. She said the resident had become more depressed and confused since the injury. The resident's family member said the resident did not tell her which CNA transferred her that evening. Further review of the grievance dated 9/4/14 revealed the DON had written that all MAs, CNAs, and RAs were receiving training in transfers and gait belt training from the director of rehabilitation. Review of In-Service training dated 8/27/14-9/2/14 revealed there was nothing specific mentioned about Resident #23. The transfer training specified staff should not twist the legs of residents. In an interview on 10/21/14 at 12:18 p.m., ADON T said she was told by the nurse on 8/24/14 that Resident #23 said she broke her leg during a transfer. She said after looking at the schedule, she believed CNA B performed the transfer. She said all she did was to tell the CNAs, all the CNAs, to make sure they attended the transfer training being performed that week. She said there was no follow up or monitoring of the CNAs after the in-services were done to ensure they were doing transfers appropriately. She said there were no new interventions put into place for Resident #23. Review of the staffing sign-in sheet dated 8/23/14 revealed CNA K and CNA B were the CNAs on Resident #23's hall. In an interview on 10/21/14 at 11:22 a.m., CNA K said she did not help Resident #23 on 8/23/14. In an interview on 10/21/14 at 2:19 p.m., CNA B said she believed Resident #23 required one person to help transfer her, but said she always asked another person to help because she did not feel comfortable transferring the resident by herself. She said the other staff member would actually do the transfers, CNA B did not. CNA B said she would do other duties of ADL care, but the other person did the transfers and she would just stand by. She said she did not transfer Resident #23 when she broke her leg in August. 1B. Review of Resident #23's attending physician progress notes [REDACTED].#23 remained non-weight bearing on her left leg. In interviews on 10/21/14 at 11:22 a.m. with CNA K and on 10/21/14 at 2:19 p.m. with CNA B, the CNAs said they were told by either the PT or the charge nurse how much help a resident needed for transfers and if a resident was non-weight bearing. Review of Resident #23's physician progress notes [REDACTED].#23 was very anxious when CNAs transfer her from the wheelchair to the bed because she feels her last tibia fracture happened during a CNA transfer. MD W noted Resident #23 thought the CNAs transferred her too fast as well and it was too hard for Resident #23 to coordinate her left leg during transfers. MD W noted Resident #23 needed maximum assistance to transfer and was a high fall risk. MD W noted she spoke with CNAs regarding safe transfers in and out of bed and also discussed to please slow down when transferring Resident #23 due to her high anxiety from the previous fracture. The note indicated MD W spoke with the nurse after speaking with the family. Review of Resident #23's physical therapy progress notes dated 9/19/14 revealed Resident #23's progress was limited due to exacerbated pain with movement of the lower left leg. The note indicated Resident #23 had self-limiting behaviors and fears of putting weight on her lower left leg. Review of an Incident Report dated 9/24/14 revealed Resident #23's family member went to ADON T and said "the facility broke" Resident #23's leg that day. ADON T noted Resident #23 called her family member crying and saying that during a transfer to the bed from the wheelchair she heard her leg crack. The incident report noted there were no witnesses. ADON T noted on the incident report that the team member who assisted her said she did hear a noise when she assisted the resident but that the noise came from the resident's shoe. No other statements were included with the incident report. In an observation and interview on 10/18/14 at 11:22 a.m., Resident #23 was sitting in her wheelchair in her room. A large cast covered her left leg. She said she obtained the fracture in her leg when a CNA transferred her and twisted her leg. She said the CNA "was new and didn't know what she was doing." Review of ADL records for September 2014 revealed CNA K documented Resident #23 received assistance of one person for transfers on 9/24/14 in the evening shift. Review of Resident #23's radiology report dated 9/24/14 revealed the resident had a slightly angulated distal fibular fracture. The ADL sheets indicated Resident #23 refused to be transferred on 9/25/14. Review of Resident #23's orthopedist progress note dated 9/29/14 revealed the doctor noted "She had another incident late last week, where she was being helped to move, again appears accidental, but in the process of being helped feet got tangled with her helper, got tangled in the sheets and had twisting injury, heard a snap ...X-ray studies show that the fracture above the TTC nail has displaced through the healing callus that we had ...This is the second time this has happened ... I do not know if she will be able to tolerate a long leg cast very well ...We talked to her family about trying to emphasize with the facility (they are) to make sure they have at least two people to help her every time she moves, just to help prevent this from happening any more, solely because we need to fix this, this would be a very difficult thing to fix with her other fixation in place. " In an interview on 10/17/14 at 5:52 p.m., the administrator and DON said they were aware of the incident at the time and they knew how the incident occurred, during a transfer. In an interview on 10/21/14 at 11:22 a.m., CNA K said Resident #23 required 2 people to transfer her. She said Resident #23 did not try to get up without assistance and was very anxious with transfers. She said when Resident #23 broke her leg in September, she was assisting her with the transfer. She said she stood Resident #23 up, transferred her and sat her down. She said the resident said "Ooh." She said she thought it was the resident's shoe making noise. She said she told ADON T what happened the next day, but did not report it to anyone that day. In a further interview with CNA K on 10/21/14 at 2:13 p.m., she said she was aware Resident #23 required 2 people to transfer her. She said she transferred the resident by herself, which she knew she shouldn't do. She said there was only 2 staff on that hall and "a lot of residents" to put back into bed after lunch. She said she knew Resident #23 required 2 people for a transfer, but she said she was not aware the resident should not bear weight on her left foot. 2. Review of Resident #7's face sheet dated 12/6/12 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #7's MDS dated [DATE] revealed she had [DIAGNOSES REDACTED]. Review of Resident #7's comprehensive care plan revised 7/15/13 and updated quarterly indicated she required two- person physical assistance with a mechanical lift for transfers. Review of Resident #7's incident and accident report dated 9/1/14 revealed while staff was assisting the resident with a mechanical lift transfer, the resident leaned forward in her wheelchair and she twisted her ankle. In an interview on 10/15/14 at 3:50 p.m., Resident #7 said she broke her leg when staff transferred her without using the mechanical lift. She said she lied to the facility staff when they asked her how she broke her leg because she wanted to protect the staff member. Review of Resident #7's physician orders revealed an order on 9/1/14 for an x-ray to the right ankle for pain. Review of Resident #7's chart revealed an orthopedic physician progress notes [REDACTED].#7 had a fracture to the right fibula. Observation on 10/15/14 at 11:25 a.m. revealed Resident #7 sitting in her wheelchair. A cast was on her right foot. During an interview on 10/17/14 at 9:45 a.m. with CNA P, she confirmed that she transferred Resident #7 at approximately 6:45 a.m. on 9/1/14 with the mechanical lift by herself. CNA P further confirmed that she knew she should not transfer Resident #7 alone with the mechanical lift but that everyone else was busy at that time and she was just trying to get everyone up for breakfast. During an interview on 10/21/14 at 3:10 p.m., the administrator said she was not aware CNA P had transferred Resident #7 alone with the mechanical lift. She said she had not asked CNA P how she did the mechanical lift transfer during her interview. She said the staff member involved in the incident should have been interviewed at the time of the incident. She said the mechanical lift should be used by two staff members not by only one. Review of the mechanical lift manufacturer's recommendations dated 2011 revealed "Although (the manufacturer) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. " In an interview on 10/21/14 at 11:41 a.m. and 10/22/14 at 5:20 p.m., the DON said there were no skills competency checks of staff related to transfers. 3. Review of Resident #13's face sheet dated 10/13/14 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's MDS assessment dated [DATE] revealed she had severly impaired cognition and was assessed as needing one -person assistance with transfers. Review of Resident #13's comprehensive care plan revised 2/5/13 and updated quarterly revealed the resident had an ADL self-care deficit related to dementia, fatigue, and limited mobility. The staff intervention was to provide assistance for ADLs. The care plan specified "See POC documentation for assistance required." In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Observation of Resident #13 in the hospital room on 10/15 /14 at 9:22 a.m. revealed there were three dime size bruises to the right bicep. The bruises were purple in color. Observation of Resident #13's chest revealed a discolored bruise the size of a quarter to the upper left chest several inches from the resident's collar bone. She had an immobilizer on her leg due to having a fractured tibia and fibula of unknown origin at the facility. Interview with Restorative Aide E on 10/17/14 at 11:00 a.m. revealed he wrapped the gait belt above Resident #13's breasts prior to transferring her into the wheel chair on 10/11/14. In an interview on 10/23/14 at 4:00 p.m., the DON said RA E was interviewed about the transfer, and he said he was using a gait belt. The DON said she did not ask him how the gait belt was positioned on the resident and therefore did not realize he used it incorrectly. She said she just wanted to ensure he was using a gait belt. She said the gait belt should be positioned around the waist. Review of the facility Gait Belt Transfer Orientation/Training dated January 2009 revealed staff were trained to "apply gait belt securely around waist, and insure gait belt is not restricting circulation or breathing, or injurious to skin integrity ...Put the belt around the waist over the clothing with the buckle in front. If the person wearing the belt is female, be sure the belt is not over her breasts. " Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities dated 2013 revealed "D. Assisting Resident to Transfer to Chair or Wheelchair using Transfer Belt ...3. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting your fingers under it. " In an interview on 10/22/14 at 5:20 p.m., the DON said there was no competency about transfers done to determine how much training the CNAs had with transfers. She said that since Resident #23 was admitted , there had only been the transfer training performed by the rehabilitation director on 8/27/14-9/3/14, but staff had not been monitored after the training that she knew of. In an interview on 10/22/14 at 6:30 p.m., the administrator said she reviewed the incident reports, and if she had questions she would ask ADON T or the DON. She said for Resident #23's incidents, she verbally asked ADON T what kind of transfer was care planned, but did not verify or have anyone verify what the assessment specified. She said there had been a lack of transfer training, and she was not sure if staff had been monitored after the transfer training on 8/27/14-9/3/14, and said the nurse managers may have monitored staff. She said she should have asked more questions from staff during the investigation to determine if interventions were implemented appropriately. The facility Administrator was notified on 10/21/14 at 3:10 p.m. that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 10/21/14 at 9:25 p.m.. The Plan of Removal was accepted by the surveyors on 10/21/14 at 10:04 p.m.. The facility developed and implemented an action plan on October 21, 2014. The facility took the following actions to remove the IJ: Transfers 1. In-service on appropriate transfer techniques to include but not limited to use of gait belt, 1X, 2X and mechanical Lift, to include non-weight bearing residents and hip precautions (nursing team members to include nurse aides, medication aides, Restorative Aides, LVN's, RN's); return demonstration. Will develop a communication system between nursing and therapy to ensure that appropriate transfer techniques are communicated to nurse aides. 2. RN to re-assess residents requiring assistance with transfers and assess for appropriate transfer technique. 3. Review nurse aide assignment sheets and care plans for residents requiring assistance with transfers and update as needed as we become aware of change in conditions/transfers during Quality of Life meetings, management meetings and nursing communication reports. After assessment of residents, a communication form will be distributed to the rehab department, DON & MDS/Care Plan Coordinator. Nurse aides will receive an updated assignment sheet. Monitoring 1. DON/Licensed Nurses/designee will observe transfers that coincide with the quarterly review and review care plans x 90 days to include all shifts. 2.Findings will be brought to QAPI for at least the next 90 days. Reporting Abuse/Neglect 1. In-service team members on abuse/neglect and reporting of abuse/neglect in relation to incidents & accidents. 2.Incident & accident reports (risk management) and written/verbal grievances will be reviewed at stand-up meeting by administrator/designee, DON/designee, Therapy/designee, MDS Coordinator/designee, and SW/designee. Based on findings, such as fractures, bruises, hematomas and injuries of unknown origin, thorough investigation will be conducted. 3. Licensed nurse overseeing the incident & accident reporting system will receive in-service training on determining which incidents & accidents require thorough investigation. Monitoring 1. On a weekly basis, team members across all departments will be asked to verbalize what constitutes abuse/neglect and reporting of abuse/neglect. 2. Findings will be brought to QAPI for at least the next 60 days. 3. Review the last 30 days of incidents to evaluate if any are reportable or require further investigation. Investigating Abuse & Neglect 1. Administrator and Clinical Management team will receive training on investigating allegations of abuse/neglect and reporting to DADS. 2. A regional (corporate) support team member will be notified at the time the facility identifies or receives a potential abuse/neglect allegation in order to facilitate the thorough investigation process. Monitoring 1. A regional (corporate) support team member will review investigation findings prior to final submission to DADS within the mandatory time frame of 24 hours with the report to follow within 5 days. 2. Findings will be brought to the QAPI for at least the next 60 days. Interviews with facility staff from all shifts on 10/22/14 from 2:45 p.m. to 5:50 p.m. revealed they had received training on transfers for residents who required assistance by one and two staff, mechanical lifts, non-weight bearing, hip precautions with return demonstration, abuse and neglect and reporting incidents. Observations on 10/22/14 at 4:07 p.m. revealed training was being provided to staff on transfers. On 10/22/14 at 5:50 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff in-services and revise policies and procedures. Non-IJ Findings: 4. Review of Resident #5's Consolidated Physician Orders dated 10/15/14 revealed Resident #5 was admitted on [DATE]. Further review of this same form revealed Resident #5's [DIAGNOSES REDACTED]. Review of Resident #5's care plan with a creation date of 8/12/14 revealed "I have Seizure Disorder". Further review under this same document revealed "Seizure Precautions: Do not leave me alone during a seizure, Protect from injury". Observation on 10/15/14 at 8:15 a.m. revealed Resident #5 was in bed. There were no fall mats on the floor, and the bed was not in the lowest position. Observation on 10/15/14 at 6:35 p.m. revealed Resident #5 was lying in bed and the bed was not in the lowest position. During an interview on 10/16/14 at 3:15 p.m. with the DON, she indicated she was unaware of when Resident #5's seizures were or what type of seizures he had. The DON further indicated Resident #5 has not had any signs or symptoms of seizures. During an observation on Resident #5's room with the DON on 10/16/14 at 3:15 p.m. resident #5 was sitting in his wheelchair by the bed. Further observation of the room revealed there were no fall mats and Resident #5's bed had an air mattress. During an interview on 10/16/14 at 3:15 p.m. with the DON, she indicated Resident #5 needed fall mats and his bed should be in the lowest position. 5. Record review of Resident #8's order summary dated 10/2014 revealed she was admitted on [DATE] with Hypertension, Non-Alzheimer's Dementia, and cognitive communication deficit. Record review of the quarterly MDS dated [DATE] revealed she was totally dependent on staff, and required two staff for transfers. Record review of the Care Plan dated 9/17/14 revealed she had a stroke and had hemi[DIAGNOSES REDACTED] (tightness and stiffness) of her arms. Resident #8 had an ADL self-care performance deficit, and required total assist of two staff using a hoyer lift (mechanical lift device) for all transfers. Record review of the facility policy and procedure titled "Hoyer Lift", dated 3/1/13 revealed to place hands on the steering handle, pump hydraulic pump handle, and be sure legs of the lift are spread apart to prevent tip over). Observation on 10/16/14 at 9:50 a.m. revealed Resident #8 was in bed. GVN D and RA E placed the resident on top of the mesh sling. GVN D brought the mechanical lift device to the bed. GVN D and RA E hooked Resident #8 onto the mechanical lift device. GVN D did not spread apart the legs of the device before she lifted the resident off the bed. During an interview on 10/16/14 at 10:00 a.m. with GVN D she confirmed she did not spread apart the legs of the mechanical lift device because it usually got caught onto the wires of the bed. During an interview on 10/21/14 at 9:45 a.m. with the DHR she said the staff was trained on how to transfer with a mechanical lift device on orientation. During an interview on 10/21/14 at 2:10 p.m. with the DRS she said the legs should be spread apart of the mechanical lift device before the resident was moved from the bed. Review of the information provided by the facility on 10/23/14 revealed there were 6 residents who had a [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to implement written policies and procedures to prohibit neglect to protect residents at risk injuries from transfers for 3 of 14 residents (Residents #23, 7, and 13) reviewed for neglect, in that: 1. Resident #23 required 2 staff to transfer her. Resident #23 sustained left tibia fractures twice during transfers where CNAs (an unknown CNA and CNA K) twisted her leg. The facility was aware of the incidents but did not complete an incident report for the first fracture, did not thoroughly investigate the incidents, and did not report the incidents to the state survey agency. 2. Resident #7 needed two-person assistance using the mechanical lift for transfers. CNA P, who knew Resident #7 needed two staff members to transfer her with the mechanical lift, transferred Resident #7 using the mechanical lift by herself. Resident #7 was found to have a fractured right tibia. The facility knew about the incident but did not thoroughly investigate the incident until after surveyor intervention. 3. Resident #13 needed one-person assistance with a gait belt for transfers. RA E transferred Resident #13 using a gait belt fastened above her breasts, instead of around her waist per facility policy and professional standards. Resident #13 sustained multiple bruises above her breasts. The incident was not thoroughly investigated until after surveyor intervention. An Immediate Jeopardy situation was identified on 10/21/14. The Immediate Jeopardy was removed on 10/22/14 but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices led to improper transfers for residents #23, #7, and #13 and could affect 20 residents who needed a mechanical lift for transfers, 69 residents who needed a gait belt for transfers, and 14 residents who needed two person assistance with transfers and place them at risk of injury. The findings were: Review of the facility Resident Abuse Policy revised May 2011 revealed "Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ...Recognizing Signs and Symptoms of Abuse/Neglect ...Signs of Actual Physical Abuse - Fractures, dislocations or sprains of questionable origin; ...Signs of Actual Physical Neglect - Inadequate provision of care; ...Investigating Unexplained Injuries ...Should a resident be observed with unexplained injuries (including bruises, operations and injuries of an unknown source), the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record ...The investigation will follow the protocols set forth in our Community's established abuse investigation guidelines ...The management-appointed individual conducting the investigation will, at a minimum: ...Interview the person(s) reporting the incident, Interview any witnesses to the incident, Interview the resident (as medically appropriate), Interview the resident's attending physician to determine the resident's current mental status, Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, Interview the resident's roommate, family members, and visitors, Interview other residents to whom the accused team member provides care or services, and review all events leading up to the alleged incident ...Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports ...Preventing Resident Abuse ...Our abuse prevention/intervention program includes, but it's not necessarily limited to, the following: ...Monitoring staff on all shifts to identify inappropriate behaviors for residents ...assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict ...striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met." 1A. Review of Resident #23's face sheet dated 10/8/14 revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's physician progress notes [REDACTED].#23 was readmitted after an open reduction, internal fixation surgery to her left ankle after a non-healing displaced fracture. Review of Resident #23's MDS assessment dated [DATE] revealed she had moderate cognitive impairment and required extensive assistance of two people for transfers. Review of Resident #23's comprehensive care plan dated 7/9/14 revealed the resident had a fractured lower left extremity, and staff were to follow the physician's orders [REDACTED]. The care plan did not specify the amount of staff needed for transfers. The care plan indicated for staff to check the "POC" for transfer needs. In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Review of Resident #23's physician progress notes [REDACTED].#23 had anxiety about bearing weight on her left leg. The physician, MD W, noted Resident #23 required maximum assistance for transfers. In an interview on 10/21/14 at 11:00 a.m., MD W said Resident #23 was very anxious and had to go slow with transfers, because she had trouble putting her feet in the right place for a transfer. The physician said maximum assistance could be done by 1 or 2 people, but for Resident #23, 2 people were required. The physician said the CNAs reported to her that they were using 2 people for transfers of Resident #23. Review of the facility Grievance log revealed a grievance dated 9/4/14 from Resident #23's family member. In the grievance, the family member noted on 8/23/14 in the evening Resident #23, during a transfer from the wheelchair to the bed, her left booted foot got tangled up in the CNAs feet, resulting in the rod and screw becoming dislodged and a crack in the tibia. The family member noted some of the CNAs did not know how to transfer patients. The family member noted she showed one CNA how to remove the side from the wheelchair, and noted the CNAs did not lower the bed when they were transferring the resident into bed. Review of Resident #23's physician orders [REDACTED].#23's left ankle due to pain. Review of Resident #23's radiology report dated 8/24/14 revealed Resident #23 had "a recent undisplaced fracture distal shaft of the left tibia just above the tibial rodding. " Review of Resident #23's nursing notes did not reveal any information about an incident involving Resident #23 on 8/23/14 or 8/24/14. Review of the facility Incident and Accident Reports from August 2014 did not reveal an incident report related to Resident #23. Review of ADL records for August 2014 revealed CNA B documented Resident #23 received assistance of one person for transfers on 8/23/14 in the evening shift. Review of Resident #23's physician progress notes [REDACTED].#23 went to the orthopedist and received a new cast on her left leg. The MD noted Resident #23 said she twisted her leg during a transfer with a CNA. The MD noted Resident #23's roommate confirmed the improper transfer. MD W noted that Resident #23 now was unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/18/14 at 11:22 a.m., Resident #23 said her roommate had discharged earlier that week. She said she did not remember hurting her leg in August. Review of Resident #23's physician progress notes [REDACTED].#23's attending physician noted the resident was now unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/17/14 at 2:45 p.m., Resident #23's family member said Resident #23 broke her leg twice in the facility due to transfers by CNAs. She said the resident had become more depressed and confused since the injury. The resident's family member said the resident did not tell her which CNA transferred her that evening. Further review of the grievance dated 9/4/14 revealed the DON had written that all MAs, CNAs, and RAs were receiving training in transfers and gait belt training from the director of rehabilitation. There was no evidence the incident on 8/23/14 was investigated. Review of In-Service training dated 8/27/14-9/2/14 revealed there was nothing specific mentioned about Resident #23. The transfer training specified staff should not twist the legs of residents. In an interview on 10/21/14 at 12:18 p.m., ADON T said she was told by the nurse on 8/24/14 that Resident #23 said she broke her leg during a transfer. She said after looking at the schedule, she believed CNA B performed the transfer. She said she did not complete an incident report and was not aware an incident report was not done. She said normally an incident report would be done. She said she didn't think of it. She said she did not talk to Resident #23 or CNA B about the incident. She said all she did was to tell the CNAs, all the CNAs, to make sure they attended the transfer training being performed that week. She said there was no follow up or monitoring of the CNAs after the in-services were done to ensure they were doing transfers appropriately. She said there were no new interventions put into place for Resident #23. She said she did not interview other residents about transfers or interview staff about the incident. Review of the staffing sign-in sheet dated 8/23/14 revealed CNA K and CNA B were the CNAs on Resident #23's hall. In an interview on 10/21/14 at 11:22 a.m., CNA K said she did not help Resident #23 on 8/23/14. In an interview on 10/21/14 at 2:19 p.m., CNA B said she believed Resident #23 required one person to help transfer her, but said she always asked another person to help because she did not feel comfortable transferring the resident by herself. She said the other staff member would actually do the transfers, CNA B did not. CNA B said she would do other duties of ADL care, but the other person did the transfers and she would just stand by. She said she did not transfer Resident #23 when she broke her leg in August. 1B. Review of Resident #23's attending physician progress notes [REDACTED].#23 remained non-weight bearing on her left leg. In interviews on 10/21/14 at 11:22 a.m. with CNA K and on 10/21/14 at 2:19 p.m. with CNA B, the CNAs said they were told by either the PT or the charge nurse how much help a resident needed for transfers and if a resident was non-weight bearing. Review of Resident #23's physician progress notes [REDACTED].#23 was very anxious when CNAs transfer her from the wheelchair to the bed because she feels her last tibia fracture happened during a CNA transfer. MD W noted Resident #23 thought the CNAs transferred her too fast as well and it was too hard for Resident #23 to coordinate her left leg during transfers. MD W noted Resident #23 needed maximum assistance to transfer and was a high fall risk. MD W noted she spoke with CNAs regarding safe transfers in and out of bed and also discussed to please slow down when transferring Resident #23 due to her high anxiety from the previous fracture. The note indicated MD W spoke with the nurse after speaking with the family. Review of Resident #23's physical therapy progress notes dated 9/19/14 revealed Resident #23's progress was limited due to exacerbated pain with movement of the lower left leg. The note indicated Resident #23 had self-limiting behaviors and fears of putting weight on her lower left leg. Review of an Incident Report dated 9/24/14 revealed Resident #23's family member went to ADON T and said "the facility broke" Resident #23's leg that day. ADON T noted Resident #23 called her family member crying and saying that during a transfer to the bed from the wheelchair she heard her leg crack. The incident report noted there were no witnesses. ADON T noted on the incident report that the team member who assisted her said she did hear a noise when she assisted the resident but that the noise came from the resident's shoe. No other statements were included with the incident report. In an observation and interview on 10/18/14 at 11:22 a.m., Resident #23 was sitting in her wheelchair in her room. A large cast covered her left leg. She said she obtained the fracture in her leg when a CNA transferred her and twisted her leg. She said the CNA "was new and didn't know what she was doing." Review of ADL records for September 2014 revealed CNA K documented Resident #23 received assistance of one person for transfers on 9/24/14 in the evening shift. Review of Resident #23's radiology report dated 9/24/14 revealed the resident had a slightly angulated distal fibular fracture. The ADL sheets indicated Resident #23 refused to be transferred on 9/25/14. Review of Resident #23's orthopedist progress note dated 9/29/14 revealed the doctor noted "She had another incident late last week, where she was being helped to move, again appears accidental, but in the process of being helped feet got tangled with her helper, got tangled in the sheets and had twisting injury, heard a snap ...X-ray studies show that the fracture above the TTC nail has displaced through the healing callus that we had ...This is the second time this has happened ... I do not know if she will be able to tolerate a long leg cast very well ...We talked to her family about trying to emphasize with the facility (they are) to make sure they have at least two people to help her every time she moves, just to help prevent this from happening any more, solely because we need to fix this, this would be a very difficult thing to fix with her other fixation in place. " In an interview on 10/17/14 at 5:48 p.m., ADON T said she spoke with the resident and the aide that transferred her, but did not do any further investigation. She said she did not speak with any other staff or residents during the investigation and did not have any written witness statements. In an interview on 10/17/14 at 5:52 p.m., the administrator and DON said they were aware of the incident at the time and there was no further investigation done other than the one done by the ADON. They said the incident was not reported to the state survey agency because they knew how the incident occurred, during a transfer. They said it was not investigated as potential abuse or neglect. In an interview on 10/21/14 at 11:22 a.m., CNA K said Resident #23 required 2 people to transfer her. She said Resident #23 did not try to get up without assistance and was very anxious with transfers. She said when Resident #23 broke her leg in September, she was assisting her with the transfer. She said she stood Resident #23 up, transferred her and sat her down. She said the resident said "Ooh" She said she thought it was the resident's shoe making noise. She said she told ADON T what happened the next day, but did not report it to anyone that day. In a further interview with CNA K on 10/21/14 at 2:13 p.m., she said she was aware Resident #23 required 2 people to transfer her. She said she transferred the resident by herself, which she knew she shouldn't do. She said there was only 2 staff on that hall and "a lot of residents" to put back into bed after lunch. She said she knew Resident #23 required 2 people for a transfer, but she said she was not aware the resident should not bear weight on her left foot. 2. Review of Resident #7's face sheet dated 12/6/12 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #7's MDS dated [DATE] revealed she had [DIAGNOSES REDACTED]. Review of Resident #7's comprehensive care plan revised 7/15/13 and updated quarterly indicated she required two- person physical assistance with a mechanical lift for transfers. Review of Resident #7's incident and accident report dated 9/1/14 revealed while staff was assisting the resident with a mechanical lift transfer, the resident leaned forward in her wheelchair and she twisted her ankle. The incident report did not note any evidence that the staff member was interviewed about the incident. In an interview on 10/15/14 at 3:50 p.m., Resident #7 said she broke her leg when staff transferred her without using the mechanical lift. She said she lied to the facility staff when they asked her how she broke her leg because she wanted to protect the staff member. Review of Resident #7's physician orders [REDACTED]. Review of Resident #7's chart revealed an orthopedic physician progress notes [REDACTED].#7 had a fracture to the right fibula. Observation on 10/15/14 at 11:25 a.m. revealed Resident #7 sitting in her wheelchair. A cast was on her right foot. In an interview on 10/15/14 at 4:38 p.m., ADON T said she did not have any other investigation other than what was on the incident report. She said she just went with what the resident said. During an interview on 10/17/14 8:19 a.m., the administrator said a full investigation into the incident was not done due to Resident #7 stating that she hurt her foot by herself. During an interview on 10/17/14 at 9:45 a.m. with CNA P, she confirmed that she transferred Resident #7 at approximately 6:45 a.m. on 9/1/14 with the mechanical lift by herself. CNA P further confirmed that she knew she should not transfer Resident #7 alone with the mechanical lift but that everyone else was busy at that time and she was just trying to get everyone up for breakfast. During an interview on 10/21/14 at 3:10 p.m., the administrator said she was not aware CNA P had transferred Resident #7 alone with the mechanical lift. She said she had not asked CNA P how she did the mechanical lift transfer during her investigation interview. She said the staff member involved in the incident should have been interviewed at the time of the incident. She said the mechanical lift should be used by two staff members not by only one. Review of the mechanical lift manufacturer's recommendations dated 2011 revealed "Although (the manufacturer) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. " In an interview on 10/21/14 at 11:41 a.m. and 10/22/14 at 5:20 p.m., the DON said there were no skills competency checks of staff related to transfers. 3. Review of Resident #13's face sheet dated 10/13/14 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's MDS assessment dated [DATE] revealed she had severely impaired cognition and was assessed as needing one -person assistance with transfers. Review of Resident #13's comprehensive care plan revised 2/5/13 and updated quarterly revealed the resident had an ADL self-care deficit related to dementia, fatigue, and limited mobility. The staff intervention was to provide assistance for ADLs. The care plan specified "See POC documentation for assistance required." In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Observation of Resident #13 in the hospital room on 10/15 /14 at 9:22 a.m. revealed there were three dime size bruises to the right bicep. The bruises were purple in color. Observation of Resident #13's chest revealed a discolored bruise the size of a quarter to the upper left chest several inches from the resident's collar bone. She had an immobilizer on her leg due to having a fractured tibia and fibula of unknown origin at the facility. Interview with Restorative Aide E on 10/17/14 at 11:00 a.m. revealed he wrapped the gait belt above Resident #13's breasts prior to transferring her into the wheel chair on 10/11/14. In an interview on 10/23/14 at 4:00 p.m., the DON said RA E was interviewed about the transfer, and he said he was using a gait belt. The DON said she did not ask him how the gait belt was positioned on the resident and therefore did not realize he used it incorrectly. She said she just wanted to ensure he was using a gait belt. She said the gait belt should be positioned around the waist. Review of the facility Gait Belt Transfer Orientation/Training dated January 2009 revealed staff were trained to "apply gait belt securely around waist, and insure gait belt is not restricting circulation or breathing, or injurious to skin integrity ...Put the belt around the waist over the clothing with the buckle in front. If the person wearing the belt is female, be sure the belt is not over her breasts. " Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities dated 2013 revealed "D. Assisting Resident to Transfer to Chair or Wheelchair using Transfer Belt ...3. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting your fingers under it. " In an interview on 10/21/14 at 12:18 p.m., ADON T said there was no facility investigation policy that she was aware of. She said there was nothing that spelled out how to do an investigation on the incidents. She said she just reviewed the incident reports and made sure all the blanks were completed in the computer. She said the computer did not have any prompts as far as who to interview. In an interview on 10/21/14 at 12:49 p.m., the DON said that ADON T handled all of the investigation into the incidents. She said that because ADON T believed the transfers were done appropriately, there was no follow up. In an interview on 10/22/14 at 5:20 p.m., the DON said incident reports were reviewed during morning meeting to ensure they were completed. She said ADON T would identify staff and interview the residents for the incident reports and notate on the bottom of the report her findings. The DON said she and the administrator would review the notes to ensure an investigation was done. Then the DON would take the incident report, review it to determine whether it needed to be reported to the state survey agency, and close it out if it did not need to be reported. She said Resident #23 and Resident #7's incidents were not investigated further and were closed. She said incidents were also reviewed at the weekly Quality of Life meetings. The incidents would be reviewed to see if there were staffing patterns. She said a "Vigor" report would be generated for residents with falls, fractures, falls with serious injuries. She said there were no trends identified for Residents #23, #7 or #13 because they were on different hallways. In an interview on 10/22/14 at 6:30 p.m., the administrator said she reviewed the incident reports, and if she had questions she would ask ADON T or the DON. She said for Resident #23's incidents, she verbally asked ADON T what kind of transfer was care planned, but did not verify or have anyone verify what the assessment specified. She confirmed she was the Abuse Prohibition Coordinator. The facility Administrator was notified on 10/21/14 at 3:10 p.m. that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 10/21/14 at 9:25 p.m.. The Plan of Removal was accepted by the surveyors on 10/21/14 at 10:04 p.m.. The facility developed and implemented an action plan on October 21, 2014. The facility took the following actions to remove the IJ: Transfers 1. In-service on appropriate transfer techniques to include but not limited to use of gait belt, 1X, 2X and mechanical Lift, to include non-weight bearing residents and hip precautions (nursing team members to include nurse aides, medication aides, Restorative Aides, LVN's, RN's); return demonstration. Will develop a communication system between nursing and therapy to ensure that appropriate transfer techniques are communicated to nurse aides. 2. RN to re-assess residents requiring assistance with transfers and assess for appropriate transfer technique. 3. Review nurse aide assignment sheets and care plans for residents requiring assistance with transfers and update as needed as we become aware of change in conditions/transfers during Quality of Life meetings, management meetings and nursing communication reports. After assessment of residents, a communication form will be distributed to the rehab department, DON & MDS/Care Plan Coordinator. Nurse aides will receive an updated assignment sheet. Monitoring 1. DON/Licensed Nurses/designee will observe transfers that coincide with the quarterly review and review care plans x 90 days to include all shifts. 2.Findings will be brought to QAPI for at least the next 90 days. Reporting Abuse/Neglect 1. In-service team members on abuse/neglect and reporting of abuse/neglect in relation to incidents & accidents. 2.Incident & accident reports (risk management) and written/verbal grievances will be reviewed at stand-up meeting by administrator/designee, DON/designee, Therapy/designee, MDS Coordinator/designee, and SW/designee. Based on findings, such as fractures, bruises, hematomas and injuries of unknown origin, thorough investigation will be conducted. 3. Licensed nurse overseeing the incident & accident reporting system will receive in-service training on determining which incidents & accidents require thorough investigation. Monitoring 1. On a weekly basis, team members across all departments will be asked to verbalize what constitutes abuse/neglect and reporting of abuse/neglect. 2. Findings will be brought to QAPI for at least the next 60 days. 3. Review the last 30 days of incidents to evaluate if any are reportable or require further investigation. Investigating Abuse & Neglect 1. Administrator and Clinical Management team will receive training on investigating allegations of abuse/neglect and reporting to DADS. 2. A regional (corporate) support team member will be notified at the time the facility identifies or receives a potential abuse/neglect allegation in order to facilitate the thorough investigation process. Monitoring 1. A regional (corporate) support team member will review investigation findings prior to final submission to DADS within the mandatory time frame of 24 hours with the report to follow within 5 days. 2. Findings will be brought to the QAPI for at least the next 60 days. Interviews with facility staff from all shifts on 10/22/14 from 2:45 p.m. to 5:50 p.m. revealed they had received training on transfers for residents who required assistance by one and two staff, mechanical lifts, non-weight bearing, hip precautions with return demonstration, abuse and neglect and reporting incidents. Observations on 10/22/14 at 4:07 p.m. revealed training was being provided to staff on transfers. On 10/22/14 at 5:50 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff in-services and revise policies and procedures. Information provided by the facility on 10/23/14 indicated 20 residents needed a mechanical lift for transfers, 69 residents needed a gait belt for transfers, and 14 residents needed two person assistance with transfers.

Based on interview and record review, the facility failed to ensure the QA Committee identified issues with respect to which quality assessment and assurance activities were necessary and to develop and implement appropriate plans of action to correct identified quality deficiencies for 3 of 14 residents (Residents #23, 7, and 13) reviewed for neglect, in that: The Administrator and the DON failed to modify interventions and action plans identified in the Quality Assurance committee related to the ADON not thoroughly investigating incidents, and did not implement action plans when Residents #23 and Resident #7 sustained fractures related to transfers. An Immediate Jeopardy situation was identified on 10/21/14. The Immediate Jeopardy was removed on 10/22/14, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices led to improper transfers for residents #23, #7, and #13 and could affect 20 residents who needed a mechanical lift for transfers, 69 residents who needed a gait belt for transfers, and 14 residents who needed two person assistance with transfers and place them at risk of injury. Findings included: Review of the CMS-2567 dated 10/31/13 revealed the facility was cited for failing to thoroughly investigate an incident. ADON T did not thoroughly investigate an incident of verbal abuse. The facility plan of correction included oversight by the QA Commitee. In an interview on 10/21/14 at 12:18 p.m., ADON T said there was no facility investigation policy that she was aware of. She said there was nothing that spelled out how to do an investigation on the incidents. She said she just reviewed the incident reports and made sure all the blanks were completed in the computer. She said the computer did not have any prompts as far as who to interview. In an interview on 10/21/14 at 12:49 p.m., the DON said that ADON T handled all of the investigation into the incidents. She said that because ADON T believed the incidents were not due to neglect, there was no follow up. In an interview on 10/22/14 at 5:20 p.m., the DON said incident reports were reviewed during morning meeting to ensure they were completed. She said ADON T would identify staff and interview the residents for the incident reports and notate on the bottom of the report her findings. The DON said she and the administrator would review the notes to ensure an investigation was done. Then the DON would take the incident report, review it to determine whether it needed to be reported to the state survey agency, and close it out if it did not need to be reported. She said incidents were also reviewed at the weekly Quality of Life meetings. The incidents would be reviewed to see if there were staffing patterns. She said a "Vigor" report would be generated for residents with falls, fractures, falls with serious injuries. She said there was no monitoring of ADON T in the QA Committee, and no new interventions were put into place. In an interview on 10/22/14 at 6:30 p.m., the administrator said she reviewed the incident reports, and if she had questions she would ask ADON T or the DON. She said ADON T had not been monitored in relation to investigating incidents and no new interventions or action plans were put into place. 1. Review of Resident #23's face sheet dated 10/8/14 revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's physician progress notes [REDACTED].#23 was readmitted after an open reduction, internal fixation surgery to her left ankle after a non-healing displaced fracture. Review of Resident #23's MDS assessment dated [DATE] revealed she had moderate cognitive impairment and required extensive assistance of two people for transfers. Review of Resident #23's comprehensive care plan dated 7/9/14 revealed the resident had a fractured lower left extremity, and staff were to follow the physician's orders [REDACTED]. The care plan did not specify the amount of staff needed for transfers. The care plan indicated for staff to check the "POC" for transfer needs. In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Review of Resident #23's physician progress notes [REDACTED].#23 had anxiety about bearing weight on her left leg. The physician, MD W, noted Resident #23 required maximum assistance for transfers. In an interview on 10/21/14 at 11:00 a.m., MD W said Resident #23 was very anxious and had to go slow with transfers, because she had trouble putting her feet in the right place for a transfer. The physician said maximum assistance could be done by 1 or 2 people, but for Resident #23, 2 people were required. The physician said the CNAs reported to her that they were using 2 people for transfers of Resident #23. Review of Resident #23's physician orders [REDACTED].#23's left ankle due to pain. Review of Resident #23's radiology report dated 8/24/14 revealed Resident #23 had "a recent undisplaced fracture distal shaft of the left tibia just above the tibial rodding. " Review of Resident #23's nursing notes did not reveal any information about an incident involving Resident #23 on 8/23/14 or 8/24/14. Review of the facility Incident and Accident Reports from August 2014 did not reveal an incident report related to Resident #23. Review of ADL records for August 2014 revealed CNA B documented Resident #23 received assistance of one person for transfers on 8/23/14 in the evening shift. Review of Resident #23's physician progress notes [REDACTED].#23 went to the orthopedist and received a new cast on her left leg. The MD noted Resident #23 said she twisted her leg during a transfer with a CNA. The MD noted Resident #23's roommate confirmed the improper transfer. MD W noted that Resident #23 now was unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/18/14 at 11:22 a.m., Resident #23 said her roommate had discharged earlier that week. She said she did not remember hurting her leg in August. Review of Resident #23's physician progress notes [REDACTED].#23's attending physician noted the resident was now unable to bear weight (non-weight bearing) on her left leg. Review of the facility Grievance log revealed a grievance dated 9/4/14 from Resident #23's family member. In the grievance, the family member noted on 8/23/14 in the evening Resident #23, during a transfer from the wheelchair to the bed, her left booted foot got tangled up in the CNAs feet, resulting in the rod and screw becoming dislodged and a crack in the tibia. The family member noted some of the CNAs did not know how to transfer patients. The family member noted she showed one CNA how to remove the side from the wheelchair, and noted the CNAs did not lower the bed when they were transferring the resident into bed. In an interview on 10/17/14 at 2:45 p.m., Resident #23's family member said Resident #23 broke her leg twice in the facility due to transfers by CNAs. She said the resident had become more depressed and confused since the injury. The resident's family member said the resident did not tell her which CNA transferred her that evening. Further review of the grievance dated 9/4/14 revealed the DON had written that all MAs, CNAs, and RAs were receiving training in transfers and gait belt training from the director of rehabilitation. There was no evidence the incident on 8/23/14 was investigated. Review of In-Service training dated 8/27/14-9/2/14 revealed there was nothing specific mentioned about Resident #23. The transfer training specified staff should not twist the legs of residents. In an interview on 10/21/14 at 12:18 p.m., ADON T said she was told by the nurse on 8/24/14 that Resident #23 said she broke her leg during a transfer. She said after looking at the schedule, she believed CNA B performed the transfer. She said she did not complete an incident report and was not aware an incident report was not done. She said normally an incident report would be done. She said she didn't think of it. She said she did not talk to Resident #23 or CNA B about the incident. She said all she did was to tell the CNAs, all the CNAs, to make sure they attended the transfer training being performed that week. She said there was no follow up or monitoring of the CNAs after the in-services were done to ensure they were doing transfers appropriately. She said there were no new interventions put into place for Resident #23. She said she did not interview other residents about transfers or interview staff about the incident. Review of the staffing sign-in sheet dated 8/23/14 revealed CNA K and CNA B were the CNAs on Resident #23's hall. In an interview on 10/21/14 at 11:22 a.m., CNA K said she did not help Resident #23 on 8/23/14. In an interview on 10/21/14 at 2:19 p.m., CNA B said she believed Resident #23 required one person to help transfer her, but said she always asked another person to help because she did not feel comfortable transferring the resident by herself. She said the other staff member would actually do the transfers, CNA B did not. CNA B said she would do other duties of ADL care, but the other person did the transfers and she would just stand by. She said she did not transfer Resident #23 when she broke her leg in August. Review of Resident #23's attending physician progress notes [REDACTED].#23 remained non-weight bearing on her left leg. In interviews on 10/21/14 at 11:22 a.m. with CNA K and on 10/21/14 at 2:19 p.m. with CNA B, the CNAs said they were told by either the PT or the charge nurse how much help a resident needed for transfers and if a resident was non-weight bearing. Review of Resident #23's physician progress notes [REDACTED].#23 was very anxious when CNAs transfer her from the wheelchair to the bed because she feels her last tibia fracture happened during a CNA transfer. MD W noted Resident #23 thought the CNAs transferred her too fast as well and it was too hard for Resident #23 to coordinate her left leg during transfers. MD W noted Resident #23 needed maximum assistance to transfer and was a high fall risk. MD W noted she spoke with CNAs regarding safe transfers in and out of bed and also discussed to please slow down when transferring Resident #23 due to her high anxiety from the previous fracture. The note indicated MD W spoke with the nurse after speaking with the family. Review of Resident #23's physical therapy progress notes dated 9/19/14 revealed Resident #23's progress was limited due to exacerbated pain with movement of the lower left leg. The note indicated Resident #23 had self-limiting behaviors and fears of putting weight on her lower left leg. Review of an Incident Report dated 9/24/14 revealed Resident #23's family member went to ADON T and said "the facility broke" Resident #23's leg that day. ADON T noted Resident #23 called her family member crying and saying that during a transfer to the bed from the wheelchair she heard her leg crack. The incident report noted there were no witnesses. ADON T noted on the incident report that the team member who assisted her said she did hear a noise when she assisted the resident but that the noise came from the resident's shoe. No other statements were included with the incident report. In an observation and interview on 10/18/14 at 11:22 a.m., Resident #23 was sitting in her wheelchair in her room. A large cast covered her left leg. She said she obtained the fracture in her leg when a CNA transferred her and twisted her leg. She said the CNA "was new and didn't know what she was doing." Review of ADL records for September 2014 revealed CNA K documented Resident #23 received assistance of one person for transfers on 9/24/14 in the evening shift. Review of Resident #23's radiology report dated 9/24/14 revealed the resident had a slightly angulated distal fibular fracture. The ADL sheets indicated Resident #23 refused to be transferred on 9/25/14. Review of Resident #23's orthopedist progress note dated 9/29/14 revealed the doctor noted "She had another incident late last week, where she was being helped to move, again appears accidental, but in the process of being helped feet got tangled with her helper, got tangled in the sheets and had twisting injury, heard a snap ...X-ray studies show that the fracture above the TTC nail has displaced through the healing callus that we had ...This is the second time this has happened ... I do not know if she will be able to tolerate a long leg cast very well ...We talked to her family about trying to emphasize with the facility (they are) to make sure they have at least two people to help her every time she moves, just to help prevent this from happening any more, solely because we need to fix this, this would be a very difficult thing to fix with her other fixation in place. " In an interview on 10/17/14 at 5:48 p.m., ADON T said she spoke with the resident and the aide that transferred her, but did not do any further investigation. She said she did not speak with any other staff or residents during the investigation and did not have any written witness statements. In an interview on 10/17/14 at 5:52 p.m., the administrator and DON said they were aware of the incident at the time and there was no further investigation done other than the one done by the ADON. They said the incident was not reported to the state survey agency because they knew how the incident occurred, during a transfer. They said it was not investigated as potential abuse or neglect. In an interview on 10/21/14 at 11:22 a.m., CNA K said Resident #23 required 2 people to transfer her. She said Resident #23 did not try to get up without assistance and was very anxious with transfers. She said when Resident #23 broke her leg in September, she was assisting her with the transfer. She said she stood Resident #23 up, transferred her and sat her down. She said the resident said "Ooh" She said she thought it was the resident's shoe making noise. She said she told ADON T what happened the next day, but did not report it to anyone that day. In a further interview with CNA K on 10/21/14 at 2:13 p.m., she said she was aware Resident #23 required 2 people to transfer her. She said she transferred the resident by herself, which she knew she shouldn't do. She said there was only 2 staff on that hall and "a lot of residents" to put back into bed after lunch. She said she knew Resident #23 required 2 people for a transfer, but she said she was not aware the resident should not bear weight on her left foot. 2. Review of Resident #7's face sheet dated 12/6/12 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #7's MDS dated [DATE] revealed she had [DIAGNOSES REDACTED]. Review of Resident #7's comprehensive care plan revised 7/15/13 and updated quarterly indicated she required two- person physical assistance with a mechanical lift for transfers. Review of Resident #7's incident and accident report dated 9/1/14 revealed while staff was assisting the resident with a mechanical lift transfer, the resident leaned forward in her wheelchair and she twisted her ankle. The incident report did not note any evidence that the staff member was interviewed about the incident. In an interview on 10/15/14 at 3:50 p.m., Resident #7 said she broke her leg when staff transferred her without using the mechanical lift. She said she lied to the facility staff when they asked her how she broke her leg because she wanted to protect the staff member. Review of Resident #7's physician orders [REDACTED]. Review of Resident #7's chart revealed an orthopedic physician progress notes [REDACTED].#7 had a fracture to the right fibula. Observation on 10/15/14 at 11:25 a.m. revealed Resident #7 sitting in her wheelchair. A cast was on her right foot. In an interview on 10/15/14 at 4:38 p.m., ADON T said she did not have any other investigation other than what was on the incident report. She said she just went with what the resident said. During an interview on 10/17/14 8:19 a.m., the administrator said a full investigation into the incident was not done due to Resident #7 stating that she hurt her foot by herself. During an interview on 10/17/14 at 9:45 a.m. with CNA P, she confirmed that she transferred Resident #7 at approximately 6:45 a.m. on 9/1/14 with the mechanical lift by herself. CNA P further confirmed that she knew she should not transfer Resident #7 alone with the mechanical lift but that everyone else was busy at that time and she was just trying to get everyone up for breakfast. During an interview on 10/21/14 at 3:10 p.m., the administrator said she was not aware CNA P had transferred Resident #7 alone with the mechanical lift. She said she had not asked CNA P how she did the mechanical lift transfer during her interview. She said the staff member involved in the incident should have been interviewed at the time of the incident. She said the mechanical lift should be used by two staff members not by only one. Review of the mechanical lift manufacturer's recommendations dated 2011 revealed "Although (the manufacturer) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. " In an interview on 10/21/14 at 11:41 a.m. and 10/22/14 at 5:20 p.m., the DON said there were no skills competency checks of staff related to transfers. 3. Review of Resident #13's face sheet dated 10/13/14 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's MDS assessment dated [DATE] revealed she had severly impaired cognition and was assessed as needing one -person assistance with transfers. Review of Resident #13's comprehensive care plan revised 2/5/13 and updated quarterly revealed the resident had an ADL self-care deficit related to dementia, fatigue, and limited mobility. The staff intervention was to provide assistance for ADLs. The care plan specified "See POC documentation for assistance required." In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Observation of Resident #13 in the hospital room on 10/15 /14 at 9:22 a.m. revealed there were three dime size bruises to the right bicep. The bruises were purple in color. Observation of Resident #13's chest revealed a discolored bruise the size of a quarter to the upper left chest several inches from the resident's collar bone. She had an immobilizer on her leg due to having a fractured tibia and fibula of unknown origin at the facility. Interview with Restorative Aide E on 10/17/14 at 11:00 a.m. revealed he wrapped the gait belt above Resident #13's breasts prior to transferring her into the wheel chair on 10/11/14. In an interview on 10/23/14 at 4:00 p.m., the DON said RA E was interviewed about the transfer, and he said he was using a gait belt. The DON said she did not ask him how the gait belt was positioned on the resident and therefore did not realize he used it incorrectly. She said she just wanted to ensure he was using a gait belt. She said the gait belt should be positioned around the waist. Review of the facility Gait Belt Transfer Orientation/Training dated January 2009 revealed staff were trained to "apply gait belt securely around waist, and insure gait belt is not restricting circulation or breathing, or injurious to skin integrity ...Put the belt around the waist over the clothing with the buckle in front. If the person wearing the belt is female, be sure the belt is not over her breasts. " Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities dated 2013 revealed "D. Assisting Resident to Transfer to Chair or Wheelchair using Transfer Belt ...3. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting your fingers under it. " In an interview on 10/22/14 at 5:20 p.m., the DON said Resident #23 and Resident #7's incidents were not investigated further and were closed. She said there were no trends identified for Residents #23, #7 or #13 because they were on different hallways. She said there were no action plans put into place for Resident #23 or #7 after their injuries. She said there was no competency about transfers done to determine how much training the CNAs had with transfers. She said that since Resident #23 was admitted , there had only been the transfer training performed by the rehabilitation director on 8/27/14-9/3/14, but staff had not been monitored after the training that she knew of. In an interview on 10/22/14 at 6:30 p.m., the administrator said for Resident #23's incidents, she verbally asked ADON T what kind of transfer was care planned, but did not verify or have anyone verify what the assessment specified. She said she was not sure if staff had been monitored after the transfer training on 8/27/14-9/3/14, and said the nurse managers may have monitored staff. The facility Administrator was notified on 10/21/14 at 3:10 p.m. that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 10/21/14 at 9:25 p.m.. The Plan of Removal was accepted by the surveyors on 10/21/14 at 10:04 p.m.. The facility developed and implemented an action plan on October 21, 2014. The facility took the following actions to remove the IJ: Transfers 1. In-service on appropriate transfer techniques to include but not limited to use of gait belt, 1X, 2X and mechanical Lift, to include non-weight bearing residents and hip precautions (nursing team members to include nurse aides, medication aides, Restorative Aides, LVN's, RN's); return demonstration. Will develop a communication system between nursing and therapy to ensure that appropriate transfer techniques are communicated to nurse aides. 2. RN to re-assess residents requiring assistance with transfers and assess for appropriate transfer technique. 3. Review nurse aide assignment sheets and care plans for residents requiring assistance with transfers and update as needed as we become aware of change in conditions/transfers during Quality of Life meetings, management meetings and nursing communication reports. After assessment of residents, a communication form will be distributed to the rehab department, DON & MDS/Care Plan Coordinator. Nurse aides will receive an updated assignment sheet. Monitoring 1. DON/Licensed Nurses/designee will observe transfers that coincide with the quarterly review and review care plans x 90 days to include all shifts. 2.Findings will be brought to QAPI for at least the next 90 days. Reporting Abuse/Neglect 1. In-service team members on abuse/neglect and reporting of abuse/neglect in relation to incidents & accidents. 2.Incident & accident reports (risk management) and written/verbal grievances will be reviewed at stand-up meeting by administrator/designee, DON/designee, Therapy/designee, MDS Coordinator/designee, and SW/designee. Based on findings, such as fractures, bruises, hematomas and injuries of unknown origin, thorough investigation will be conducted. 3. Licensed nurse overseeing the incident & accident reporting system will receive in-service training on determining which incidents & accidents require thorough investigation. Monitoring 1. On a weekly basis, team members across all departments will be asked to verbalize what constitutes abuse/neglect and reporting of abuse/neglect. 2. Findings will be brought to QAPI for at least the next 60 days. 3. Review the last 30 days of incidents to evaluate if any are reportable or require further investigation. Investigating Abuse & Neglect 1. Administrator and Clinical Management team will receive training on investigating allegations of abuse/neglect and reporting to DADS. 2. A regional (corporate) support team member will be notified at the time the facility identifies or receives a potential abuse/neglect allegation in order to facilitate the thorough investigation process. Monitoring 1. A regional (corporate) support team member will review investigation findings prior to final submission to DADS within the mandatory time frame of 24 hours with the report to follow within 5 days. 2. Findings will be brought to the QAPI for at least the next 60 days. Interviews with facility staff from all shifts on 10/22/14 from 2:45 p.m. to 5:50 p.m. revealed they had received training on transfers for residents who required assistance by one and two staff, mechanical lifts, non-weight bearing, hip precautions with return demonstration, abuse and neglect and reporting incidents. Observations on 10/22/14 at 4:07 p.m. revealed training was being provided to staff on transfers. On 10/22/14 at 5:50 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff in-services and revise policies and procedures. Information provided by the facility on 10/23/14 indicated 20 residents needed a mechanical lift for transfers, 69 residents needed a gait belt for transfers, and 14 residents needed two person assistance with transfers. kx6r11

Based on observation, interview and record review, the facility failed to thoroughly investigate incidents of neglect for 3 of 14 residents (Residents #23, 7, and 13) and failed to report allegations of neglect for 2 of 14 residents (Resident #23 and #7) reviewed for neglect, in that: 1. Resident #23 required 2 staff to transfer her. Resident #23 sustained left tibia fractures twice during transfers where CNAs (an unknown CNA and CNA K) twisted her leg. The facility was aware of the incidents but did not complete an incident report for the first fracture, did not thoroughly investigate the incidents, and did not report the incidents to the state survey agency. 2. Resident #7 needed two-person assistance using the mechanical lift for transfers. CNA P, who knew Resident #7 needed two staff members to transfer her with the mechanical lift, transferred Resident #7 using the mechanical lift by herself. Resident #7 was found to have a fractured right tibia. The facility knew about the incident but did not thoroughly investigate the incident until after surveyor intervention. 3. Resident #13 needed one-person assistance with a gait belt for transfers. RA E transferred Resident #13 using a gait belt fastened above her breasts, instead of around her waist per facility policy and professional standards. Resident #13 sustained multiple bruises above her breasts. The incident was not thoroughly investigated until after surveyor intervention. An Immediate Jeopardy situation was identified on 10/21/14. The Immediate Jeopardy was removed on 10/22/14 but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices led to improper transfers for residents #23, #7, and #13 and could affect 20 residents who needed a mechanical lift for transfers, 69 residents who needed a gait belt for transfers, and 14 residents who needed two person assistance with transfers and place them at risk of injury. The findings were: 1A. Review of Resident #23's face sheet dated 10/8/14 revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's physician progress notes [REDACTED].#23 was readmitted after an open reduction, internal fixation surgery to her left ankle after a non-healing displaced fracture. Review of Resident #23's MDS assessment dated [DATE] revealed she had moderate cognitive impairment and required extensive assistance of two people for transfers. Review of Resident #23's comprehensive care plan dated 7/9/14 revealed the resident had a fractured lower left extremity, and staff were to follow the physician's orders [REDACTED]. The care plan did not specify the amount of staff needed for transfers. The care plan indicated for staff to check the "POC" for transfer needs. In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Review of Resident #23's physician progress notes [REDACTED].#23 had anxiety about bearing weight on her left leg. The physician, MD W, noted Resident #23 required maximum assistance for transfers. In an interview on 10/21/14 at 11:00 a.m., MD W said Resident #23 was very anxious and had to go slow with transfers, because she had trouble putting her feet in the right place for a transfer. The physician said maximum assistance could be done by 1 or 2 people, but for Resident #23, 2 people were required. The physician said the CNAs reported to her that they were using 2 people for transfers of Resident #23. Review of the facility Grievance log revealed a grievance dated 9/4/14 from Resident #23's family member. In the grievance, the family member noted on 8/23/14 in the evening Resident #23, during a transfer from the wheelchair to the bed, her left booted foot got tangled up in the CNAs feet, resulting in the rod and screw becoming dislodged and a crack in the tibia. The family member noted some of the CNAs did not know how to transfer patients. The family member noted she showed one CNA how to remove the side from the wheelchair, and noted the CNAs did not lower the bed when they were transferring the resident into bed. Review of Resident #23's physician orders [REDACTED].#23's left ankle due to pain. Review of Resident #23's radiology report dated 8/24/14 revealed Resident #23 had "a recent undisplaced fracture distal shaft of the left tibia just above the tibial rodding. " Review of Resident #23's nursing notes did not reveal any information about an incident involving Resident #23 on 8/23/14 or 8/24/14. Review of the facility Incident and Accident Reports from August 2014 did not reveal an incident report related to Resident #23. Review of ADL records for August 2014 revealed CNA B documented Resident #23 received assistance of one person for transfers on 8/23/14 in the evening shift. Review of Resident #23's physician progress notes [REDACTED].#23 went to the orthopedist and received a new cast on her left leg. The MD noted Resident #23 said she twisted her leg during a transfer with a CNA. The MD noted Resident #23's roommate confirmed the improper transfer. MD W noted that Resident #23 now was unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/18/14 at 11:22 a.m., Resident #23 said her roommate had discharged earlier that week. She said she did not remember hurting her leg in August. Review of Resident #23's physician progress notes [REDACTED].#23's attending physician noted the resident was now unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/17/14 at 2:45 p.m., Resident #23's family member said Resident #23 broke her leg twice in the facility due to transfers by CNAs. She said the resident had become more depressed and confused since the injury. The resident's family member said the resident did not tell her which CNA transferred her that evening. Further review of the grievance dated 9/4/14 revealed the DON had written that all MAs, CNAs, and RAs were receiving training in transfers and gait belt training from the director of rehabilitation. There was no evidence the incident on 8/23/14 was investigated. Review of In-Service training dated 8/27/14-9/2/14 revealed there was nothing specific mentioned about Resident #23. The transfer training specified staff should not twist the legs of residents. In an interview on 10/21/14 at 12:18 p.m., ADON T said she was told by the nurse on 8/24/14 that Resident #23 said she broke her leg during a transfer. She said after looking at the schedule, she believed CNA B performed the transfer. She said she did not complete an incident report and was not aware an incident report was not done. She said normally an incident report would be done. She said she didn't think of it. She said she did not talk to Resident #23 or CNA B about the incident. She said all she did was to tell the CNAs, all the CNAs, to make sure they attended the transfer training being performed that week. She said there was no follow up or monitoring of the CNAs after the in-services were done to ensure they were doing transfers appropriately. She said there were no new interventions put into place for Resident #23. She said she did not interview other residents about transfers or interview staff about the incident. Review of the staffing sign-in sheet dated 8/23/14 revealed CNA K and CNA B were the CNAs on Resident #23's hall. In an interview on 10/21/14 at 11:22 a.m., CNA K said she did not help Resident #23 on 8/23/14. In an interview on 10/21/14 at 2:19 p.m., CNA B said she believed Resident #23 required one person to help transfer her, but said she always asked another person to help because she did not feel comfortable transferring the resident by herself. She said the other staff member would actually do the transfers, CNA B did not. CNA B said she would do other duties of ADL care, but the other person did the transfers and she would just stand by. She said she did not transfer Resident #23 when she broke her leg in August. 1B. Review of Resident #23's attending physician progress notes [REDACTED].#23 remained non-weight bearing on her left leg. In interviews on 10/21/14 at 11:22 a.m. with CNA K and on 10/21/14 at 2:19 p.m. with CNA B, the CNAs said they were told by either the PT or the charge nurse how much help a resident needed for transfers and if a resident was non-weight bearing. Review of Resident #23's physician progress notes [REDACTED].#23 was very anxious when CNAs transfer her from the wheelchair to the bed because she feels her last tibia fracture happened during a CNA transfer. MD W noted Resident #23 thought the CNAs transferred her too fast as well and it was too hard for Resident #23 to coordinate her left leg during transfers. MD W noted Resident #23 needed maximum assistance to transfer and was a high fall risk. MD W noted she spoke with CNAs regarding safe transfers in and out of bed and also discussed to please slow down when transferring Resident #23 due to her high anxiety from the previous fracture. The note indicated MD W spoke with the nurse after speaking with the family. Review of Resident #23's physical therapy progress notes dated 9/19/14 revealed Resident #23's progress was limited due to exacerbated pain with movement of the lower left leg. The note indicated Resident #23 had self-limiting behaviors and fears of putting weight on her lower left leg. Review of an Incident Report dated 9/24/14 revealed Resident #23's family member went to ADON T and said "the facility broke" Resident #23's leg that day. ADON T noted Resident #23 called her family member crying and saying that during a transfer to the bed from the wheelchair she heard her leg crack. The incident report noted there were no witnesses. ADON T noted on the incident report that the team member who assisted her said she did hear a noise when she assisted the resident but that the noise came from the resident's shoe. No other statements were included with the incident report. In an observation and interview on 10/18/14 at 11:22 a.m., Resident #23 was sitting in her wheelchair in her room. A large cast covered her left leg. She said she obtained the fracture in her leg when a CNA transferred her and twisted her leg. She said the CNA "was new and didn't know what she was doing." Review of ADL records for September 2014 revealed CNA K documented Resident #23 received assistance of one person for transfers on 9/24/14 in the evening shift. Review of Resident #23's radiology report dated 9/24/14 revealed the resident had a slightly angulated distal fibular fracture. The ADL sheets indicated Resident #23 refused to be transferred on 9/25/14. Review of Resident #23's orthopedist progress note dated 9/29/14 revealed the doctor noted "She had another incident late last week, where she was being helped to move, again appears accidental, but in the process of being helped feet got tangled with her helper, got tangled in the sheets and had twisting injury, heard a snap ...X-ray studies show that the fracture above the TTC nail has displaced through the healing callus that we had ...This is the second time this has happened ... I do not know if she will be able to tolerate a long leg cast very well ...We talked to her family about trying to emphasize with the facility (they are) to make sure they have at least two people to help her every time she moves, just to help prevent this from happening any more, solely because we need to fix this, this would be a very difficult thing to fix with her other fixation in place. " In an interview on 10/17/14 at 5:48 p.m., ADON T said she spoke with the resident and the aide that transferred her, but did not do any further investigation. She said she did not speak with any other staff or residents during the investigation and did not have any written witness statements. In an interview on 10/17/14 at 5:52 p.m., the administrator and DON said they were aware of the incident at the time and there was no further investigation done other than the one done by the ADON. They said the incident was not reported to the state survey agency because they knew how the incident occurred, during a transfer. They said it was not investigated as potential abuse or neglect. In an interview on 10/21/14 at 11:22 a.m., CNA K said Resident #23 required 2 people to transfer her. She said Resident #23 did not try to get up without assistance and was very anxious with transfers. She said when Resident #23 broke her leg in September, she was assisting her with the transfer. She said she stood Resident #23 up, transferred her and sat her down. She said the resident said "Ooh" She said she thought it was the resident's shoe making noise. She said she told ADON T what happened the next day, but did not report it to anyone that day. In a further interview with CNA K on 10/21/14 at 2:13 p.m., she said she was aware Resident #23 required 2 people to transfer her. She said she transferred the resident by herself, which she knew she shouldn't do. She said there was only 2 staff on that hall and "a lot of residents" to put back into bed after lunch. She said she knew Resident #23 required 2 people for a transfer, but she said she was not aware the resident should not bear weight on her left foot. 2. Review of Resident #7's face sheet dated 12/6/12 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #7's MDS dated [DATE] revealed she had [DIAGNOSES REDACTED]. Review of Resident #7's comprehensive care plan revised 7/15/13 and updated quarterly indicated she required two- person physical assistance with a mechanical lift for transfers. Review of Resident #7's incident and accident report dated 9/1/14 revealed while staff was assisting the resident with a mechanical lift transfer, the resident leaned forward in her wheelchair and she twisted her ankle. The incident report did not note any evidence that the staff member was interviewed about the incident. In an interview on 10/15/14 at 3:50 p.m., Resident #7 said she broke her leg when staff transferred her without using the mechanical lift. She said she lied to the facility staff when they asked her how she broke her leg because she wanted to protect the staff member. Review of Resident #7's physician orders [REDACTED]. Review of Resident #7's chart revealed an orthopedic physician progress notes [REDACTED].#7 had a fracture to the right fibula. Observation on 10/15/14 at 11:25 a.m. revealed Resident #7 sitting in her wheelchair. A cast was on her right foot. In an interview on 10/15/14 at 4:38 p.m., ADON T said she did not have any other investigation other than what was on the incident report. She said she just went with what the resident said. During an interview on 10/17/14 8:19 a.m., the administrator said a full investigation into the incident was not done due to Resident #7 stating that she hurt her foot by herself. During an interview on 10/17/14 at 9:45 a.m. with CNA P, she confirmed that she transferred Resident #7 at approximately 6:45 a.m. on 9/1/14 with the mechanical lift by herself. CNA P further confirmed that she knew she should not transfer Resident #7 alone with the mechanical lift but that everyone else was busy at that time and she was just trying to get everyone up for breakfast. During an interview on 10/21/14 at 3:10 p.m., the administrator said she was not aware CNA P had transferred Resident #7 alone with the mechanical lift. She said she had not asked CNA P how she did the mechanical lift transfer during her investigation interview. She said the staff member involved in the incident should have been interviewed at the time of the incident. She said the mechanical lift should be used by two staff members not by only one. Review of the mechanical lift manufacturer's recommendations dated 2011 revealed "Although (the manufacturer) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. " In an interview on 10/21/14 at 11:41 a.m. and 10/22/14 at 5:20 p.m., the DON said there were no skills competency checks of staff related to transfers. 3. Review of Resident #13's face sheet dated 10/13/14 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's MDS assessment dated [DATE] revealed she had severly impaired cognition and was assessed as needing one -person assistance with transfers. Review of Resident #13's comprehensive care plan revised 2/5/13 and updated quarterly revealed the resident had an ADL self-care deficit related to dementia, fatigue, and limited mobility. The staff intervention was to provide assistance for ADLs. The care plan specified "See POC documentation for assistance required." In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Observation of Resident #13 in the hospital room on 10/15 /14 at 9:22 a.m. revealed there were three dime size bruises to the right bicep. The bruises were purple in color. Observation of Resident #13's chest revealed a discolored bruise the size of a quarter to the upper left chest several inches from the resident's collar bone. She had an immobilizer on her leg due to having a fractured tibia and fibula of unknown origin at the facility. Interview with Restorative Aide E on 10/17/14 at 11:00 a.m. revealed he wrapped the gait belt above Resident #13's breasts prior to transferring her into the wheel chair on 10/11/14. In an interview on 10/23/14 at 4:00 p.m., the DON said RA E was interviewed about the transfer, and he said he was using a gait belt. The DON said she did not ask him how the gait belt was positioned on the resident and therefore did not realize he used it incorrectly. She said she just wanted to ensure he was using a gait belt. She said the gait belt should be positioned around the waist. Review of the facility Gait Belt Transfer Orientation/Training dated January 2009 revealed staff were trained to "apply gait belt securely around waist, and insure gait belt is not restricting circulation or breathing, or injurious to skin integrity ...Put the belt around the waist over the clothing with the buckle in front. If the person wearing the belt is female, be sure the belt is not over her breasts. " Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities dated 2013 revealed "D. Assisting Resident to Transfer to Chair or Wheelchair using Transfer Belt ...3. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting your fingers under it. " In an interview on 10/21/14 at 12:18 p.m., ADON T said there was no facility investigation policy that she was aware of. She said there was nothing that spelled out how to do an investigation on the incidents. She said she just reviewed the incident reports and made sure all the blanks were completed in the computer. She said the computer did not have any prompts as far as who to interview. In an interview on 10/21/14 at 12:49 p.m., the DON said that ADON T handled all of the investigation into the incidents. She said that because ADON T believed the transfers were done appropriately, there was no follow up. In an interview on 10/22/14 at 5:20 p.m., the DON said incident reports were reviewed during morning meeting to ensure they were completed. She said ADON T would identify staff and interview the residents for the incident reports and notate on the bottom of the report her findings. The DON said she and the administrator would review the notes to ensure an investigation was done. Then the DON would take the incident report, review it to determine whether it needed to be reported to the state survey agency, and close it out if it did not need to be reported. She said Resident #23 and Resident #7's incidents were not investigated further and were closed. She said incidents were also reviewed at the weekly Quality of Life meetings. The incidents would be reviewed to see if there were staffing patterns. She said a "Vigor" report would be generated for residents with falls, fractures, falls with serious injuries. She said there were no trends identified for Residents #23, #7 or #13 because they were on different hallways. In an interview on 10/22/14 at 6:30 p.m., the administrator said she reviewed the incident reports, and if she had questions she would ask ADON T or the DON. She said for Resident #23's incidents, she verbally asked ADON T what kind of transfer was care planned, but did not verify or have anyone verify what the assessment specified. She confirmed she was the Abuse Prohibition Coordinator. Review of the facility Resident Abuse Policy revised May 2011 revealed "Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ...Recognizing Signs and Symptoms of Abuse/Neglect ...Signs of Actual Physical Abuse - Fractures, dislocations or sprains of questionable origin; ...Signs of Actual Physical Neglect - Inadequate provision of care; ...Investigating Unexplained Injuries ...Should a resident be observed with unexplained injuries (including bruises, operations and injuries of an unknown source), the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record ...The investigation will follow the protocols set forth in our Community's established abuse investigation guidelines ...The management-appointed individual conducting the investigation will, at a minimum: ...Interview the person(s) reporting the incident, Interview any witnesses to the incident, Interview the resident (as medically appropriate), Interview the resident's attending physician to determine the resident's current mental status, Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, Interview the resident's roommate, family members, and visitors, Interview other residents to whom the accused team member provides care or services, and review all events leading up to the alleged incident ...Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports ...Preventing Resident Abuse ...Our abuse prevention/intervention program includes, but it's not necessarily limited to, the following: ...Monitoring staff on all shifts to identify inappropriate behaviors for residents ...assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict ...striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met." The facility Administrator was notified on 10/21/14 at 3:10 p.m. that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 10/21/14 at 9:25 p.m.. The Plan of Removal was accepted by the surveyors on 10/21/14 at 10:04 p.m.. The facility developed and implemented an action plan on October 21, 2014. The facility took the following actions to remove the IJ: Transfers 1. In-service on appropriate transfer techniques to include but not limited to use of gait belt, 1X, 2X and mechanical Lift, to include non-weight bearing residents and hip precautions (nursing team members to include nurse aides, medication aides, Restorative Aides, LVN's, RN's); return demonstration. Will develop a communication system between nursing and therapy to ensure that appropriate transfer techniques are communicated to nurse aides. 2. RN to re-assess residents requiring assistance with transfers and assess for appropriate transfer technique. 3. Review nurse aide assignment sheets and care plans for residents requiring assistance with transfers and update as needed as we become aware of change in conditions/transfers during Quality of Life meetings, management meetings and nursing communication reports. After assessment of residents, a communication form will be distributed to the rehab department, DON & MDS/Care Plan Coordinator. Nurse aides will receive an updated assignment sheet. Monitoring 1. DON/Licensed Nurses/designee will observe transfers that coincide with the quarterly review and review care plans x 90 days to include all shifts. 2.Findings will be brought to QAPI for at least the next 90 days. Reporting Abuse/Neglect 1. In-service team members on abuse/neglect and reporting of abuse/neglect in relation to incidents & accidents. 2.Incident & accident reports (risk management) and written/verbal grievances will be reviewed at stand-up meeting by administrator/designee, DON/designee, Therapy/designee, MDS Coordinator/designee, and SW/designee. Based on findings, such as fractures, bruises, hematomas and injuries of unknown origin, thorough investigation will be conducted. 3. Licensed nurse overseeing the incident & accident reporting system will receive in-service training on determining which incidents & accidents require thorough investigation. Monitoring 1. On a weekly basis, team members across all departments will be asked to verbalize what constitutes abuse/neglect and reporting of abuse/neglect. 2. Findings will be brought to QAPI for at least the next 60 days. 3. Review the last 30 days of incidents to evaluate if any are reportable or require further investigation. Investigating Abuse & Neglect 1. Administrator and Clinical Management team will receive training on investigating allegations of abuse/neglect and reporting to DADS. 2. A regional (corporate) support team member will be notified at the time the facility identifies or receives a potential abuse/neglect allegation in order to facilitate the thorough investigation process. Monitoring 1. A regional (corporate) support team member will review investigation findings prior to final submission to DADS within the mandatory time frame of 24 hours with the report to follow within 5 days. 2. Findings will be brought to the QAPI for at least the next 60 days. Interviews with facility staff from all shifts on 10/22/14 from 2:45 p.m. to 5:50 p.m. revealed they had received training on transfers for residents who required assistance by one and two staff, mechanical lifts, non-weight bearing, hip precautions with return demonstration, abuse and neglect and reporting incidents. Observations on 10/22/14 at 4:07 p.m. revealed training was being provided to staff on transfers. On 10/22/14 at 5:50 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff in-services and revise policies and procedures. Information provided by the facility on 10/23/14 indicated 20 residents needed a mechanical lift for transfers, 69 residents needed a gait belt for transfers, and 14 residents needed two person assistance with transfers.

Based on interview and record review, the administrator and the DON failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 3 of 14 residents (Residents #23, 7, and 13) reviewed for neglect, in that: The Administrator failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect when Residents #23, #7 and #13 had injuries of unknown origin. The Administrator and the DON failed to supervise the ADON to ensure incidents involving injuries of unknown origin were thoroughly investigated. The Administrator and the DON failed to utilize outside resources available to them to ensure incidents were investigated and reported to the state survey agency as required. The DON failed to effectively train and monitor staff to ensure transfers were performed appropriately, even after 2 residents sustained fractures of unknown origin related to transfers in a short period of time. The Administrator and the DON failed to modify interventions and action plans identified in the Quality Assurance committee related to the ADON not thoroughly investigating incidents, and did not implement actions plans related to the incidents with Resident #23. The Administrator and DON failed to thoroughly investigate incidents with Residents #23, #7 and #13 to ascertain if interventions were in place during the incidents. These deficient practices resulted in Resident #23 sustaining a broken leg twice during transfers, experiencing a decrease in ADLs and increased fear during transfers. An Immediate Jeopardy situation was identified on 10/21/14. The Immediate Jeopardy was removed on 10/22/14, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices led to improper transfers for residents #23, #7, and #13 and could affect 20 residents who needed a mechanical lift for transfers, 69 residents who needed a gait belt for transfers, and 14 residents who needed two person assistance with transfers and place them at risk of injury. Findings included: 1. Review of Resident #23's face sheet dated 10/8/14 revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's physician progress notes [REDACTED].#23 was readmitted after an open reduction, internal fixation surgery to her left ankle after a non-healing displaced fracture. Review of Resident #23's MDS assessment dated [DATE] revealed she had moderate cognitive impairment and required extensive assistance of two people for transfers. Review of Resident #23's comprehensive care plan dated 7/9/14 revealed the resident had a fractured lower left extremity, and staff were to follow the physician's orders [REDACTED]. The care plan did not specify the amount of staff needed for transfers. The care plan indicated for staff to check the "POC" for transfer needs. In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Review of Resident #23's physician progress notes [REDACTED].#23 had anxiety about bearing weight on her left leg. The physician, MD W, noted Resident #23 required maximum assistance for transfers. In an interview on 10/21/14 at 11:00 a.m., MD W said Resident #23 was very anxious and had to go slow with transfers, because she had trouble putting her feet in the right place for a transfer. The physician said maximum assistance could be done by 1 or 2 people, but for Resident #23, 2 people were required. The physician said the CNAs reported to her that they were using 2 people for transfers of Resident #23. Review of Resident #23's physician orders [REDACTED].#23's left ankle due to pain. Review of Resident #23's radiology report dated 8/24/14 revealed Resident #23 had "a recent undisplaced fracture distal shaft of the left tibia just above the tibial rodding. " Review of Resident #23's nursing notes did not reveal any information about an incident involving Resident #23 on 8/23/14 or 8/24/14. Review of the facility Incident and Accident Reports from August 2014 did not reveal an incident report related to Resident #23. Review of ADL records for August 2014 revealed CNA B documented Resident #23 received assistance of one person for transfers on 8/23/14 in the evening shift. Review of Resident #23's physician progress notes [REDACTED].#23 went to the orthopedist and received a new cast on her left leg. The MD noted Resident #23 said she twisted her leg during a transfer with a CNA. The MD noted Resident #23's roommate confirmed the improper transfer. MD W noted that Resident #23 now was unable to bear weight (non-weight bearing) on her left leg. In an interview on 10/18/14 at 11:22 a.m., Resident #23 said her roommate had discharged earlier that week. She said she did not remember hurting her leg in August. Review of Resident #23's physician progress notes [REDACTED].#23's attending physician noted the resident was now unable to bear weight (non-weight bearing) on her left leg. Review of the facility Grievance log revealed a grievance dated 9/4/14 from Resident #23's family member. In the grievance, the family member noted on 8/23/14 in the evening Resident #23, during a transfer from the wheelchair to the bed, her left booted foot got tangled up in the CNAs feet, resulting in the rod and screw becoming dislodged and a crack in the tibia. The family member noted some of the CNAs did not know how to transfer patients. The family member noted she showed one CNA how to remove the side from the wheelchair, and noted the CNAs did not lower the bed when they were transferring the resident into bed. In an interview on 10/17/14 at 2:45 p.m., Resident #23's family member said Resident #23 broke her leg twice in the facility due to transfers by CNAs. She said the resident had become more depressed and confused since the injury. The resident's family member said the resident did not tell her which CNA transferred her that evening. Further review of the grievance dated 9/4/14 revealed the DON had written that all MAs, CNAs, and RAs were receiving training in transfers and gait belt training from the director of rehabilitation. There was no evidence the incident on 8/23/14 was investigated. Review of In-Service training dated 8/27/14-9/2/14 revealed there was nothing specific mentioned about Resident #23. The transfer training specified staff should not twist the legs of residents. In an interview on 10/21/14 at 12:18 p.m., ADON T said she was told by the nurse on 8/24/14 that Resident #23 said she broke her leg during a transfer. She said after looking at the schedule, she believed CNA B performed the transfer. She said she did not complete an incident report and was not aware an incident report was not done. She said normally an incident report would be done. She said she didn't think of it. She said she did not talk to Resident #23 or CNA B about the incident. She said all she did was to tell the CNAs, all the CNAs, to make sure they attended the transfer training being performed that week. She said there was no follow up or monitoring of the CNAs after the in-services were done to ensure they were doing transfers appropriately. She said there were no new interventions put into place for Resident #23. She said she did not interview other residents about transfers or interview staff about the incident. Review of the staffing sign-in sheet dated 8/23/14 revealed CNA K and CNA B were the CNAs on Resident #23's hall. In an interview on 10/21/14 at 11:22 a.m., CNA K said she did not help Resident #23 on 8/23/14. In an interview on 10/21/14 at 2:19 p.m., CNA B said she believed Resident #23 required one person to help transfer her, but said she always asked another person to help because she did not feel comfortable transferring the resident by herself. She said the other staff member would actually do the transfers, CNA B did not. CNA B said she would do other duties of ADL care, but the other person did the transfers and she would just stand by. She said she did not transfer Resident #23 when she broke her leg in August. Review of Resident #23's attending physician progress notes [REDACTED].#23 remained non-weight bearing on her left leg. In interviews on 10/21/14 at 11:22 a.m. with CNA K and on 10/21/14 at 2:19 p.m. with CNA B, the CNAs said they were told by either the PT or the charge nurse how much help a resident needed for transfers and if a resident was non-weight bearing. Review of Resident #23's physician progress notes [REDACTED].#23 was very anxious when CNAs transfer her from the wheelchair to the bed because she feels her last tibia fracture happened during a CNA transfer. MD W noted Resident #23 thought the CNAs transferred her too fast as well and it was too hard for Resident #23 to coordinate her left leg during transfers. MD W noted Resident #23 needed maximum assistance to transfer and was a high fall risk. MD W noted she spoke with CNAs regarding safe transfers in and out of bed and also discussed to please slow down when transferring Resident #23 due to her high anxiety from the previous fracture. The note indicated MD W spoke with the nurse after speaking with the family. Review of Resident #23's physical therapy progress notes dated 9/19/14 revealed Resident #23's progress was limited due to exacerbated pain with movement of the lower left leg. The note indicated Resident #23 had self-limiting behaviors and fears of putting weight on her lower left leg. Review of an Incident Report dated 9/24/14 revealed Resident #23's family member went to ADON T and said "the facility broke" Resident #23's leg that day. ADON T noted Resident #23 called her family member crying and saying that during a transfer to the bed from the wheelchair she heard her leg crack. The incident report noted there were no witnesses. ADON T noted on the incident report that the team member who assisted her said she did hear a noise when she assisted the resident but that the noise came from the resident's shoe. No other statements were included with the incident report. In an observation and interview on 10/18/14 at 11:22 a.m., Resident #23 was sitting in her wheelchair in her room. A large cast covered her left leg. She said she obtained the fracture in her leg when a CNA transferred her and twisted her leg. She said the CNA "was new and didn't know what she was doing." Review of ADL records for September 2014 revealed CNA K documented Resident #23 received assistance of one person for transfers on 9/24/14 in the evening shift. Review of Resident #23's radiology report dated 9/24/14 revealed the resident had a slightly angulated distal fibular fracture. The ADL sheets indicated Resident #23 refused to be transferred on 9/25/14. Review of Resident #23's orthopedist progress note dated 9/29/14 revealed the doctor noted "She had another incident late last week, where she was being helped to move, again appears accidental, but in the process of being helped feet got tangled with her helper, got tangled in the sheets and had twisting injury, heard a snap ...X-ray studies show that the fracture above the TTC nail has displaced through the healing callus that we had ...This is the second time this has happened ... I do not know if she will be able to tolerate a long leg cast very well ...We talked to her family about trying to emphasize with the facility (they are) to make sure they have at least two people to help her every time she moves, just to help prevent this from happening any more, solely because we need to fix this, this would be a very difficult thing to fix with her other fixation in place. " In an interview on 10/17/14 at 5:48 p.m., ADON T said she spoke with the resident and the aide that transferred her, but did not do any further investigation. She said she did not speak with any other staff or residents during the investigation and did not have any written witness statements. In an interview on 10/17/14 at 5:52 p.m., the administrator and DON said they were aware of the incident at the time and there was no further investigation done other than the one done by the ADON. They said the incident was not reported to the state survey agency because they knew how the incident occurred, during a transfer. They said it was not investigated as potential abuse or neglect. In an interview on 10/21/14 at 11:22 a.m., CNA K said Resident #23 required 2 people to transfer her. She said Resident #23 did not try to get up without assistance and was very anxious with transfers. She said when Resident #23 broke her leg in September, she was assisting her with the transfer. She said she stood Resident #23 up, transferred her and sat her down. She said the resident said "Ooh" She said she thought it was the resident's shoe making noise. She said she told ADON T what happened the next day, but did not report it to anyone that day. In a further interview with CNA K on 10/21/14 at 2:13 p.m., she said she was aware Resident #23 required 2 people to transfer her. She said she transferred the resident by herself, which she knew she shouldn't do. She said there was only 2 staff on that hall and "a lot of residents" to put back into bed after lunch. She said she knew Resident #23 required 2 people for a transfer, but she said she was not aware the resident should not bear weight on her left foot. 2. Review of Resident #7's face sheet dated 12/6/12 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #7's MDS dated [DATE] revealed she had [DIAGNOSES REDACTED]. Review of Resident #7's comprehensive care plan revised 7/15/13 and updated quarterly indicated she required two- person physical assistance with a mechanical lift for transfers. Review of Resident #7's incident and accident report dated 9/1/14 revealed while staff was assisting the resident with a mechanical lift transfer, the resident leaned forward in her wheelchair and she twisted her ankle. The incident report did not note any evidence that the staff member was interviewed about the incident. In an interview on 10/15/14 at 3:50 p.m., Resident #7 said she broke her leg when staff transferred her without using the mechanical lift. She said she lied to the facility staff when they asked her how she broke her leg because she wanted to protect the staff member. Review of Resident #7's physician orders [REDACTED]. Review of Resident #7's chart revealed an orthopedic physician progress notes [REDACTED].#7 had a fracture to the right fibula. Observation on 10/15/14 at 11:25 a.m. revealed Resident #7 sitting in her wheelchair. A cast was on her right foot. In an interview on 10/15/14 at 4:38 p.m., ADON T said she did not have any other investigation other than what was on the incident report. She said she just went with what the resident said. During an interview on 10/17/14 8:19 a.m., the administrator said a full investigation into the incident was not done due to Resident #7 stating that she hurt her foot by herself. During an interview on 10/17/14 at 9:45 a.m. with CNA P, she confirmed that she transferred Resident #7 at approximately 6:45 a.m. on 9/1/14 with the mechanical lift by herself. CNA P further confirmed that she knew she should not transfer Resident #7 alone with the mechanical lift but that everyone else was busy at that time and she was just trying to get everyone up for breakfast. During an interview on 10/21/14 at 3:10 p.m., the administrator said she was not aware CNA P had transferred Resident #7 alone with the mechanical lift. She said she had not asked CNA P how she did the mechanical lift transfer during her interview. She said the staff member involved in the incident should have been interviewed at the time of the incident. She said the mechanical lift should be used by two staff members not by only one. Review of the mechanical lift manufacturer's recommendations dated 2011 revealed "Although (the manufacturer) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. " In an interview on 10/21/14 at 11:41 a.m. and 10/22/14 at 5:20 p.m., the DON said there were no skills competency checks of staff related to transfers. 3. Review of Resident #13's face sheet dated 10/13/14 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's MDS assessment dated [DATE] revealed she had severly impaired cognition and was assessed as needing one -person assistance with transfers. Review of Resident #13's comprehensive care plan revised 2/5/13 and updated quarterly revealed the resident had an ADL self-care deficit related to dementia, fatigue, and limited mobility. The staff intervention was to provide assistance for ADLs. The care plan specified "See POC documentation for assistance required." In an interview on 10/17/14 at 6:00 p.m., MDS Coordinator LVN Q said she did not put the transfer status into the care plan because it changed so much. She said staff were to check the computer kiosk for a resident's transfer needs. She said the CNAs also had a resident worksheet that listed the transfer and weight-bearing status of residents. She said the old ones were not kept, and could not provide any previous sheets with Resident #23's status. Observation of Resident #13 in the hospital room on 10/15 /14 at 9:22 a.m. revealed there were three dime size bruises to the right bicep. The bruises were purple in color. Observation of Resident #13's chest revealed a discolored bruise the size of a quarter to the upper left chest several inches from the resident's collar bone. She had an immobilizer on her leg due to having a fractured tibia and fibula of unknown origin at the facility. Interview with Restorative Aide E on 10/17/14 at 11:00 a.m. revealed he wrapped the gait belt above Resident #13's breasts prior to transferring her into the wheel chair on 10/11/14. In an interview on 10/23/14 at 4:00 p.m., the DON said RA E was interviewed about the transfer, and he said he was using a gait belt. The DON said she did not ask him how the gait belt was positioned on the resident and therefore did not realize he used it incorrectly. She said she just wanted to ensure he was using a gait belt. She said the gait belt should be positioned around the waist. Review of the facility Gait Belt Transfer Orientation/Training dated January 2009 revealed staff were trained to "apply gait belt securely around waist, and insure gait belt is not restricting circulation or breathing, or injurious to skin integrity ...Put the belt around the waist over the clothing with the buckle in front. If the person wearing the belt is female, be sure the belt is not over her breasts. " Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities dated 2013 revealed "D. Assisting Resident to Transfer to Chair or Wheelchair using Transfer Belt ...3. Apply the transfer belt over the resident's clothing around the waist and check the fit by inserting your fingers under it. " In an interview on 10/21/14 at 12:18 p.m., ADON T said there was no facility investigation policy that she was aware of. She said there was nothing that spelled out how to do an investigation on the incidents. She said she just reviewed the incident reports and made sure all the blanks were completed in the computer. She said the computer did not have any prompts as far as who to interview. In an interview on 10/21/14 at 12:49 p.m., the DON said that ADON T handled all of the investigation into the incidents. She said that because ADON T believed the transfers were done appropriately, there was no follow up. In an interview on 10/22/14 at 5:20 p.m., the DON said incident reports were reviewed during morning meeting to ensure they were completed. She said ADON T would identify staff and interview the residents for the incident reports and notate on the bottom of the report her findings. The DON said she and the administrator would review the notes to ensure an investigation was done. Then the DON would take the incident report, review it to determine whether it needed to be reported to the state survey agency, and close it out if it did not need to be reported. She said Resident #23 and Resident #7's incidents were not investigated further and were closed. She said incidents were also reviewed at the weekly Quality of Life meetings. The incidents would be reviewed to see if there were staffing patterns. She said a "Vigor" report would be generated for residents with falls, fractures, falls with serious injuries. She said there were no trends identified for Residents #23, #7 or #13 because they were on different hallways. She said there were no action plans put into place for Resident #23 or #7 after their injuries. She said there was no competency about transfers done to determine how much training the CNAs had with transfers. She said that since Resident #23 was admitted , there had only been the transfer training performed by the rehabilitation director on 8/27/14-9/3/14, but staff had not been monitored after the training that she knew of. She said she had resources available to her to help her with injuries of unknown origin or incident investigations, including her corporate nurse, the standard operating procedures from corporate, sister facilities, other DONs, and the Medical Director. She said she did not consult with or utilize these resources regarding the incidents with Resident #23, #7 or #13. In an interview on 10/22/14 at 6:30 p.m., the administrator said she reviewed the incident reports, and if she had questions she would ask ADON T or the DON. She said for Resident #23's incidents, she verbally asked ADON T what kind of transfer was care planned, but did not verify or have anyone verify what the assessment specified. She confirmed she was the Abuse Prohibition Coordinator. She said the nurse managers were all assigned a hallway and were supposed to observe care. She said there had been a lack of transfer training, and she was not sure if staff had been monitored after the transfer training on 8/27/14-9/3/14, and said the nurse managers may have monitored staff. She said she should have asked more questions from staff during the investigation to determine if interventions were implemented appropriately. She said she had resources available to her to help ensure investigations were thorough and that incidents were reported as necessary, including her corporation, the corporate nurse, sister facilities, the state survey agency program manager, administrator colleagues, the Medical Director and the facility policy and procedures. She said she did not consult with or utilize these resources regarding the incidents with Resident #23, #7 or #13. Review of the facility Resident Abuse Policy revised May 2011 revealed "Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ...Recognizing Signs and Symptoms of Abuse/Neglect ...Signs of Actual Physical Abuse - Fractures, dislocations or sprains of questionable origin; ...Signs of Actual Physical Neglect - Inadequate provision of care; ...Investigating Unexplained Injuries ...Should a resident be observed with unexplained injuries (including bruises, operations and injuries of an unknown source), the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record ...The investigation will follow the protocols set forth in our Community's established abuse investigation guidelines ...The management-appointed individual conducting the investigation will, at a minimum: ...Interview the person(s) reporting the incident, Interview any witnesses to the incident, Interview the resident (as medically appropriate), Interview the resident's attending physician to determine the resident's current mental status, Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, Interview the resident's roommate, family members, and visitors, Interview other residents to whom the accused team member provides care or services, and review all events leading up to the alleged incident ...Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports ...Preventing Resident Abuse ...Our abuse prevention/intervention program includes, but it's not necessarily limited to, the following: ...Monitoring staff on all shifts to identify inappropriate behaviors for residents ...assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict ...striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met." The facility Administrator was notified on 10/21/14 at 3:10 p.m. that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on 10/21/14 at 9:25 p.m.. The Plan of Removal was accepted by the surveyors on 10/21/14 at 10:04 p.m.. The facility developed and implemented an action plan on October 21, 2014. The facility took the following actions to remove the IJ: Transfers 1. In-service on appropriate transfer techniques to include but not limited to use of gait belt, 1X, 2X and mechanical Lift, to include non-weight bearing residents and hip precautions (nursing team members to include nurse aides, medication aides, Restorative Aides, LVN's, RN's); return demonstration. Will develop a communication system between nursing and therapy to ensure that appropriate transfer techniques are communicated to nurse aides. 2. RN to re-assess residents requiring assistance with transfers and assess for appropriate transfer technique. 3. Review nurse aide assignment sheets and care plans for residents requiring assistance with transfers and update as needed as we become aware of change in conditions/transfers during Quality of Life meetings, management meetings and nursing communication reports. After assessment of residents, a communication form will be distributed to the rehab department, DON & MDS/Care Plan Coordinator. Nurse aides will receive an updated assignment sheet. Monitoring 1. DON/Licensed Nurses/designee will observe transfers that coincide with the quarterly review and review care plans x 90 days to include all shifts. 2.Findings will be brought to QAPI for at least the next 90 days. Reporting Abuse/Neglect 1. In-service team members on abuse/neglect and reporting of abuse/neglect in relation to incidents & accidents. 2.Incident & accident reports (risk management) and written/verbal grievances will be reviewed at stand-up meeting by administrator/designee, DON/designee, Therapy/designee, MDS Coordinator/designee, and SW/designee. Based on findings, such as fractures, bruises, hematomas and injuries of unknown origin, thorough investigation will be conducted. 3. Licensed nurse overseeing the incident & accident reporting system will receive in-service training on determining which incidents & accidents require thorough investigation. Monitoring 1. On a weekly basis, team members across all departments will be asked to verbalize what constitutes abuse/neglect and reporting of abuse/neglect. 2. Findings will be brought to QAPI for at least the next 60 days. 3. Review the last 30 days of incidents to evaluate if any are reportable or require further investigation. Investigating Abuse & Neglect 1. Administrator and Clinical Management team will receive training on investigating allegations of abuse/neglect and reporting to DADS. 2. A regional (corporate) support team member will be notified at the time the facility identifies or receives a potential abuse/neglect allegation in order to facilitate the thorough investigation process. Monitoring 1. A regional (corporate) support team member will review investigation findings prior to final submission to DADS within the mandatory time frame of 24 hours with the report to follow within 5 days. 2. Findings will be brought to the QAPI for at least the next 60 days. Interviews with facility staff from all shifts on 10/22/14 from 2:45 p.m. to 5:50 p.m. revealed they had received training on transfers for residents who required assistance by one and two staff, mechanical lifts, non-weight bearing, hip precautions with return demonstration, abuse and neglect and reporting incidents. Observations on 10/22/14 at 4:07 p.m. revealed training was being provided to staff on transfers. On 10/22/14 at 5:50 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff in-services and revise policies and procedures. Information provided by the facility on 10/23/14 indicated 20 residents needed a mechanical lift for transfers, 69 residents needed a gait belt for transfers, and 14 residents needed two person assistance with transfers.

Based on observation, interview, and record review,the facility failed to ensure each resident's drug regimen was free from the administration of unnecessary drugs for 1 of 13 residents (Resident #13) whose medications were reviewed, in that: Resident #13 was not monitored and accurately assessed for side effects and adverse reactions of antipsychotic medication resulting in continued abnormal involuntary movements for the resident. This deficient practice could affect 20 residents who received psychoactive medications and place them at risk for adverse drug reactions. The findings were: Review of Resident #13's face sheet dated 10/13/14 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the Medication Review Report dated 10/13/2014 and signed by the DON and Physician revealed Resident # 13 had medication administrations that included 0.25 mg of [MEDICATION NAME] by mouth two times a day for Tardive Dyskinesia/[MEDICAL CONDITION] (Tardive Dyskensia is purposeless movements of arms, legs, fingers and toes. In some severe cases, TD can include swaying movements of the trunk or hips or affect the muscles associated with breathing) with a note to call the physician for increased sedation, and a 125 mg capsule of [MEDICATION NAME] Sprinkles by mouth twice daily for Anxiety. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed severe impairment to cognitive skills (never/rarely made decisions), unclear speech, could sometimes make herself understood, and could sometimes understand others. The Quarterly Minimum Data Set ((MDS) dated [DATE] under Section D. Mood: Staff Assessment of Resident Mood for Resident #13 item H. read " Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual." Staff assessed Resident #13 as "Yes" to the symptom presence and a symptom frequency of nearly every day. Review of Resident #13's comprehensive care plan initiated 9/9/11 and last updated 10/9/14 revealed Resident #13 took antipsychotic medication, the goal was to remain free of drug related complications, incuding movement disorder. Interventions included monitoring and documenting side effects and adverse reactions such as tardive dyskinesia. Review of the Abnormal Involuntary Movement Scale (AIMS) Assessment administered by facility staff on Resident #13 and dated 4/22/14 revealed no facial or oral movements. The assessment noted Mild movement (a "2") to upper extremities (arms, wrists, hands, fingers), and no movement to lower extremities (legs, knees, ankles, toes). There was no movement to neck, shoulders, and hips such as rocking, twisting, or squirming. The severity of the abnormal movements was mild (a "2") and incapacitation due to abnormal movements was minimal. Review of the Abnormal Involuntary Movement Scale (AIMS) Assessment administered by facility staff on Resident #13 and dated 2/7/14 revealed no facial or oral movements. The assessment noted Mild movement (a "2") to upper extremities (arms, wrists, hands, fingers), and no movement to lower extremities (legs, knees, ankles, toes). There was no movement to neck, shoulders, and hips such as rocking, twisting, or squirming. The severity of the abnormal movements was mild (a "2") and incapacitation due to abnormal movements was minimal. Review of the Abnormal Involuntary Movement Scale (AIMS) Assessment administered by facility staff on Resident #13 and dated 5/3/14 revealed no facial or oral movements. The assessment noted Mild movement (a "2") to upper extremities (arms, wrists, hands, fingers), and no movement to lower extremities (legs, knees, ankles, toes). There was no movement to neck, shoulders, and hips such as rocking, twisting, or squirming. The severity of the abnormal movements was mild (a "2") and incapacitation due to abnormal movements was minimal. Review of the Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] revealed Resident #13 had no facial or oral movements. The assessment noted Mild (a "2")movement to upper extremities (arms, wrists, hands, fingers), and no movement to lower extremities (legs, knees, ankles, toes). There was no movement to neck, shoulders, and hips such as rocking, twisting, or squirming. The severity of the abnormal movements was mild and incapacitation due to abnormal movements was minimal. The assessment indicated if there was moderate (a "3") to severe (a "4") movements in any body area, the resident should have a complete evaluation by a neurologist and if there were only mild movements (a "2") in one area, the resident was to be monitored. The AIMS overall score for Resident #13 was assessed as Mild (a "2"). Review of the Abnormal Involuntary Movement Scale (AIMS) Assessment administered by facility staff on Resident #13 and dated 8/18/14 revealed no facial or oral movements. The assessment noted Mild movement (a "2") to upper extremities (arms, wrists, hands, fingers), and no movement to lower extremities (legs, knees, ankles, toes). There was no movement to neck, shoulders, and hips such as rocking, twisting, or squirming. The severity of the abnormal movements was mild (a "2") and incapacitation due to abnormal movements was minimal. Review of the Psychiatric Consultant notes dated 9/18/14 revealed no observation of [MEDICAL CONDITION]. A problem list of [MEDICAL CONDITION]/Dementia with behavioral disturbance, Impulse control disorder, Anxiety state, [MEDICAL CONDITION], and under Medical Decision Making: "Pt with an increase in repetitive movement/TD: Will start [MEDICATION NAME] 0.5 mg bid, and will decrease [MEDICATION NAME] 0.25mg bid." Observation of Resident #13 in her hospital room on 10/15/14 from 9:00 a.m. to 9:33 a.m. revealed she occasionally puckered her lips, blinked and grimaced. She continuously moved her left arm up toward her face and then down hitting her bed from the downward motion. Resident #13's right arm started to move up and down at the elbow and did not reach the side of her face. Resident # 13 moved sideways from left to right and rubbed her back against the bed cover. During this observation, Resident #13 would bend her left leg at the knee and fan her left lower leg in and out (motion) under the covers. The constant up and down movement to her right hand pulled out the intravenous needle from her hand. Interview with .Resident #13's family member on 10/15/14 at 10:08 a.m revealed Resident #13 had developed the repetitive movement to her hands, arms and legs in the nursing facility and was at one time pulling out her hair from the repetitive motion. She said the movements had been severe this year. Interview with CNA E on 10/15/14 at 7:10 p.m. revealed Resident #13 rocked herself back and forth when seated. She could not be unsupervised during meals in the dining room because she could jerk and slide down from her chair. Resident #13's knees would often hit underneath the table from the constant movement of her lower extremities. She could push her knees up when seated and rest her feet on the floor. Interview with RN S on 10/15/14 at 7:55 p.m. revealed Resident #13 had constant movement to her arms and hands. She frequently scratched herself from the constant movement. Resident #13 had contractures to both legs but still had movement. She had a good appetite but was unable to feed herself and when seated she would rock back and forth. Resident #13 required assistance from staff with her meals. Interview with CNA B on 10/15/14 at 8:15 p.m. revealed Resident #13 had constant upper extremity movement and would move back and forth when seated in her wheel chair. The rails to her bed were padded to keep her from injuring herself from the constant movement of her hands and legs. Interview with the MDS Coordinator on 10/22/14 at 3: 45 p.m. revealed she completed the Abnormal Involuntary Movement Assessment and did do a visual of the resident while completing it. She said the resident would exhibit mild (a "2") to moderate (a "3") movements of her upper extremity, but she did not see any movements in her lower extremity because when she assessed the resident, the resident was in bed. She said she did not rely on the nursing staff to inform her of the severity of the resident's movements. Interview with the Director of Nursing on 10/22/14 at 4:58 p.m. revealed Resident #13's movements were closer to moderate (a "3") or severe (a "4") in her upper extremity and her trunk (abdomen area). She said Resident #13 had been that way for awhile, longer than just this summer. The DON reviewed the AIMS assessment and read out loud that scoring a 3 or 4 in one body area would prompt a referral for a complete neurological exam. The Director of Nursing said Resident #13 had not been referred to a neurologist. Review of the National Alliance of Mental Illness fact sheet "Tardive Dyskinesia" revealed "The most effective treatment for [REDACTED]. Because usually months to years of antipsychotic treatment pass before the onset of TD, a person taking medications should see their psychiatrist for regular evaluations to ensure that any signs of TD are recognized before they become severe. Most psychiatrists will use a standardized rating scale called "The Abnormal Involuntary Movement Scale"-AIMS for short-to screen for TD at least once each year." The facility's CMS 672 form dated 10/14/13 listed 20 residents on antipsychotic medications.