Every finding on record at The Shoal

Based on observation, interviewed and record review the facility failed to ensure that 1 of (Resident #67) 7 residents reviewed for abuse and neglect was free from neglect in that--Resident #67 was left outside at a dialysis center overnight without medications, incontinence care or food.-The facility failed to ensure that Resident #67 was transported from dialysis center.-The facility failed to follow up with Resident #67 when he did not return back to the facility.The noncompliance was identified as PNC IJ began on 07/03/26 and ended on 07/04/26. The facility had corrected the noncompliance before the investigation began on 07/09/26. These failures place residents that leave the facility for appointments at risk of abuse, neglect, accidents and danger of being harmed. Findings include Record review of Resident # 67's clinical record revealed a 77- year-old male, admitted to the facility initially on 05/12/26 and re admitted on [DATE]. His diagnoses included unspecified fracture of right pubis, fracture of fifth lumbar vertebra, routine healing, type 2 diabetes Mellitus with neuropathy (nerve damage caused by prolonged high blood sugar), end Stage Renal Disease (irreversible stage of chronic kidney disease, where kidneys function at 15% or less), foot ulcer, and difficulty in walking. Record review of Resident # 67's physician's orders, start date 7/2/2026, revealed dialysis-check site for bleeding and sign or symptoms of infection every shift. May transport resident to appointment via ambulance as indicated. Record review of Resident #67's MDS, dated [DATE], revealed BIMS 12 (intact cognition) and was independent with mobility. Resident # 1 was frequently incontinent for urinary and always incontinent for bladder. Resident # 1 ambulate with a walker or wheelchair. Resident # 1's did not indicate any behaviors. Record review of Resident #67's care plan dated 07/04/26 with a target date of 07/28/26 revealed -Resident #67 requires assistance for meeting his physical needs. Goals: The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. -Resident #67 has an ADL self-care performance deficit r/t recent fracture of pubis/spine and Late Effects of CVA. Goal: The resident will improve current level of function through the review date. Date Initiated: 07/10/2026 -Resident #67 has impaired cognitive function or impaired thought processes r/t Late Effects of CVA Date Initiated: 07/10/2026 Revision on: 07/10/2026 -Resident #67 has a communication problem r/t impaired ability to understand. Date Initiated: 07/09/2026 Goal The resident will be able to make basic needs known on a daily basis through the review date. Date Initiated: 07/09/2026, target date 07/21/26 -Resident #67-has Diabetes Mellitus Date Initiated: 07/09/2026 Goals: Resident #67 will be free from any s/sx of hyperglycemia through the review date.07/21/26. Resident #67 will be free from any s/sx of hypoglycemia through the target date on 07/21/26 -Resident #67 is at risk for falls r/t history of falls prior to admission w/ major injuries and impaired cognition. Goal: Resident #67 will be free of falls through the target date: 07/21/2026 -Resident #67 is on pain medication therapy (hydrocodone, lidocaine patch) r/t disease process right hip pain, neuropathy Goal: The resident will be free of any discomfort or adverse side effects from pain medication through the target date of 07/21/26 -Resident #67 has an alteration in musculoskeletal status r/t Fractures of Right Pubis and 5th Lumbar Vertebra Goal: Resident #67 will remain free of complications related to fractures, such as contracture formation, embolism and immobility through target date of 07/21/26. -Resident #67 needs dialysis (HD) r/t renal failure. Goal: Resident #67 will have immediate intervention should any s/sx of complications from dialysis occur through the review Target Date: 07/21/2026 Goals: Resident #67 will have no s/sx of complications from dialysis, through the target Date: 07/21/26. Intervention: Check and change dressing daily at access site. Document. Date Initiated: 7/09/26 Check Left IJ sight daily for s/s of infection, bleeding. Dressing is changed at HD. Change dressing PRN if coming off or soiled. Date Initiated: 07/09/2026, Revision on: 08/01/26 Encourage resident to go for the scheduled dialysis appointments. Resident receives Date Initiated: 07/09/26 Revision on: 08/01/26 Monitor labs and report to doctor as needed. Date Initiated: 07/09/2026 Monitor VITAL SIGNS (every shift and PRN). Notify MD of significant abnormalities. Revision on: 08/01/26 Record review of the facility's Personnel Disciplinary Record for RN B, dated 7/4/2026, revealed RN B was fired on 7/4/2026. Reason for action: it was identified that appropriate follow-up communication was not completed for a resident (Resident # 67) that was to return from dialysis. RN B failed to conduct a thorough follow-up when a resident (Resident #67) did not return from dialysis to include informing the DON and Administrator. Record review of the facility's Employee Inservice/Training Abuse, Neglect and Exploitation, dated 7/4/2026, revealed in part Please review attached ANE policy and procedures; report all suspected abuse and neglect immediately to the Abuse Coordinator (Administrator) and if you cannot get in contact with the Abuse Coordinator report to the DON. Record review of the facility's Employee Inservice/Training Immediate notification when resident do not return from dialysis or appointments, dated 7/4/2026, revealed in part To ensure residents safety, timely follow up when a resident does not return to the facility as expected from dialysis, medical appointments, hospital visits, or outside appointments is mandatory. Staff must immediately notify DON, ADON'S, or Administrator when a resident does not return as expected. Record review of the facility's Employee Inservice/Training Progress Notes for Leaving and Returning to Facility, dated 7/6/2026, revealed A progress note must be placed in the EHR each time a resident leaves the facility stating time, place, where the are going and who transported them. An additional note is required when the residents return along with the resident's status upon return. Observation and interview on 7/9/2026 at 12:10 pm, revealed Resident #67 was present at the facility he was alert and oriented. During an interview, Resident #67 said he was admitted to this facility on July 2, 2026 and he was transported to dialysis on 7/3/2026 by ambulance in the afternoon after lunch. He said he completed his dialysis treatment in the evening, and he waited outside for transportation to take him back to the nursing facility, but no one showed up. He said he went outside to find his way back to the facility but attempting to cross the road, he was almost hit by a moving car, He said at that time he decided to go back to the dialysis center. He said when he got back to the dialysis center, he could not get inside the building. He said he wheeled around the building knocking on every window, but no one answered the door. He said he did not want to go back to the street because he was afraid for his life and decided to remain in front of the dialysis till the following morning when the door was open. He said during the night, a dog attacked him before the owner took the dog away. He said he was afraid as he had no phone to contact his family. He said his experience was very fearful. He said he did not remember anything else. During an interview on 7/9/2026 at 12:20 pm, Resident #64's RP said, Resident #67 was admitted to this facility on 7/2/2026. He said the facility was responsible for transporting Resident # 67 to and from dialysis on Monday, Wednesday, and Friday at 2:00 pm. Resident #67's RP said on 7/3/2026 Resident # 67 was transported to dialysis around 2:00PM but the facility did not arrange for transportation to transport Resident #67 back to the facility. He said he received a call from the dialysis center on 7/4/2026 around 6:00AM, that Resident # 67 was at the dialysis center and resident # 67 was not scheduled for dialysis. Resident #67's RP said he asked Resident # 67 what happened and Resident # 67 told him that no one picked him up from dialysis. He stated that Resident #67 told him that he was trying to get back to the nursing facility but was almost struck by a vehicle so Resident # 67 returned to the dialysis center, however, when he returned to this center, the center was closed so he stayed outside the center overnight. Resident #67's RP said Resident # 67 was sitting in dirty wheelchair and he was unkept. He stated that prior to leaving the dialysis center staff checked Resident # 67 vitals. He stated that Resident # 67 was stable and had no injuries. During a telephone interview with CNA A on 7/10/2026 at 3:33 pm, she stated that she provided care to Resident # 67 on 7/3/2026. She stated that Resident # 67 had dialysis on 7/3/2026 and he was transported to dialysis via ambulance. She stated that she did not remember the time, but it was after lunch. She stated that she round on 7/3/2026 approximately 7:00 pm and she noticed Resident # 67 was not in his room. She stated that told the nurse that Resident # 67 was not in his room. She stated that she did not remember the nurse's name. During a telephone interview with RN A on 7/10/2026 at 4:30 pm, she stated that she provided care to Resident # 67 on 7/3/2026 she stated that she checked Resident # 67's vitals prior to him going to dialysis. She stated that he was transported to dialysis at 1:45 pm on 7/3/2026. She stated that Resident # 67 returned to the nursing facility on 7/4/2026 between 8:00 am and 9:00 am. She stated that Resident # 67 was accompanied by Family Member # 1. She stated that Family Member #1 told her that Resident # 67 was out night. She stated that she asked Resident # 67 if he was out with his friend and she stated that Resident # 67 told her he did not have any friend. He told her that no one picked him up from dialysis. She stated that Resident # 67 looked like he was unkept and he was not in distress. She stated that she completed a full body assessment on Resident # 67 and she checked his vitals. She stated she wanted to get him cleaned up and fed. She stated that she contacted the DON. She stated that she discharged Resident # 67 on 7/4/2026 because she was told by RN B that Resident # 67 left ama. She stated that RN B told her that she attempted to discharge Resident # 67 out of the system but was not successful. She stated that RN B told her that Resident # 67 told her that he left the dialysis center with a friend and he would disclose the friend's name when he returned. She stated Resident # 67 was prescribed Lasix and if he missed this medication, he could retain more fluid, and this could cause fluid overload. She stated that Resident # 67 is prescribed blood pressure medication and if he missed this medication his blood pressure could go up. During a telephone interview with RN B on 7/10/2026 at 5:14 pm she stated that she did not provide care to Resident # 67 on 7/3/2026. She stated that Resident #67 was assigned to her on 7/3/2026. She stated that a CNA reported that Resident # 67 had not returned from dialysis. She stated that she contacted dialysis on 7/3/2026 between 7:45 pm and 8:00 pm and she did not receive an answer. She stated that she reached out to another nurse who works for this facility, and she was told by this nurse that sometimes residents are sent to the hospital from dialysis. She stated that she denied contacting the local hospital. She denied contacting the NP and/or MD, RP, DON, or Administrator. She stated that on 7/4/2026 at 5:30 am she received a call from the dialysis center, and she was informed that Resident # 67 was the center. She stated that she asked to speak to Resident # 67, and he told her that he left dialysis on 7/3/2026 and he was with a friend. She stated that she contacted the DON. She stated that due toe Resident #67 not receiving proper care his site could have leaked, he had dialysis, therefore, he could have had hypotension and weakness. During an interview with the DON on 7/10/2026 at 6:00 pm, she stated that she expects staff to round every 2 hours. She stated that residents return from dialysis around the same time. She stated that she expects nurses to contact the dialysis center within 30 minutes of the resident not returning from dialysis. She stated that she was not aware that Resident 67 did not return from dialysis. She stated that on 7/4/2026 between 5:30 am and 6:00 am she received a call from RN B. She stated that RN B informed her that she received a call from dialysis and was told that Resident # 67 was at the dialysis center. She stated that RN B informed her that she spoke with Resident # 67 who stated that he left the dialysis center on 7/3/2026 with a friend. She stated that RN B told her that she contacted the dialysis center on 7/3/2026 and she did not receive an answer. She stated that RN B should have contacted her, the NP/MD and the RP. She stated that RN B denied contacting the DON, NP/MD, and the RP. She stated that she arrived at the nursing facility on 7/4/2026 and she spoke with Family Member # 1 who stated informed her that Resident # 67 stated the nursing facility did not pick Resident# 67 up from dialysis as a result Resident # 67 slept outside of the dialysis center. During an interview with the DON on 7/22/2026 at 2:20 pm she stated that Resident # 67 has dialysis on Monday, Wednesday and Friday. She stated that on 7/3/2026 Resident # 67 was transported to the dialysis center by a third-party transportation service. She stated that stated that on 7/4/2026 she attempted to interview Resident # 67, however, he was asleep. She stated that Resident # 67 was assessed by RN A. She stated that Resident # 67 did not have any marks or bruise and Resident # 67 was not in distress. She stated that Resident was not on insulin and he had an order for glucose monitoring only. She stated that the risk of Resident #67 staying outside all night could have been dehydrated and/or hungry. The DON stated this incident was not investigated or reported to state due to Resident # 67's initial report that he left the dialysis center with a friend. During an interview with RN A on 7/22/2026 at 2:44 pm she reiterated that she assessed Resident # 67 on July 4, 2026. She stated that Resident # 67 was not in distress when he returned to the facility on July 4, 2026. She stated that Resident # 67's vitals were stable. She stated that Resident # 67 was a diabetic, but he did not take insulin for blood sugar. She stated that there is an order to monitor Resident # 67's blood sugar. She stated that the risk of Resident # 67 could have encountered as result of not returning to the facility were Resident # 67 could have had a hypertensive crisis. She stated that the risk Resident # 67 could have encountered as a result of staying outside all night he could have wandered off to an unfamiliar location. During an interview with NP A on 7/22/2026 at 3:00 pm she stated that Resident # 67 was alert times 3 with forgetfulness. She stated that Resident # 67 had end stage renal dialysis. She stated that he had dialysis three times a week. She stated that Resident # 67 has Type II Diabetes and he was not insulin dependent. She stated that on 7/4/2026 the facility notified her that Resident # 67 did not return from dialysis on 7/3/2026. She stated that on 7/4/2026 RN A assessed Resident # 67 and reported that his vitals were stable and there were no s/sx of distress. NP A stated that Resident # 67 was at risk of being dehydrated as he stayed outside the entire night. She stated that she ordered lab work CMP and urinalysis. She stated Resident #67's CMP results were normal. She stated that Resident # 67 refused the urinalysis. NP A stated that she assessed Resident # 67 on 7/6/2026 and there were no concerns as his vitals were stable. She stated that Resident # 67 did not want to discuss the incident that occurred on 7/3/2026. During an interview with the Dialysis Group Administrator on 7/22/2026 at 4:00 pm she stated on 7/3/2026 Resident # 67 received dialysis. She stated that Resident # 67 ended dialysis on 7/22/2026 at 6:22 pm. She stated that Dialysis Nurse A contacted the nursing facility on 7/3/2026 around 5: 22 pm to notify the facility that Resident # 67 would be ready for at 6:30 pm. She stated that Dialysis Nurse A informed her that he checked the inside of the building and there were no patients inside the building. She stated that Dialysis Nurse A stated that he looked outside the front door and there were no patients outside and he locked the front door. She stated that IT retrieved the video footage and provided the following information: 7/3/2026 at 6:28 pm Resident # 67 went into the lobby. 7/3/2026 at 6:47 pm Resident # 67 wheeled himself outside. 7/3/2026 at 7:28 pm staff checked the lobby, restrooms outside view of the building where the waiting area is outside by the bench and the locked the front door. 7/3/2026 at 7:31 pm staff left the building. She stated that around 8:00 pm was Resident # 67 was observed rolling around in his wheelchair. She stated that Resident # 67 never left premises. She stated that apparently Resident # 67 was on the side of the building in a blind spot (out of view of the camera). She stated that IT and the attorney reviewed the video footage in its entirety. She stated that throughout the night Resident # 67 was observed propelling in his wheelchair. She stated that around 3:00 am Resident #67 was observed pulling on the back door. She stated that staff arrived at 4:09 am. She stated that Resident # 67 remained outside the entire night. She stated that Resident # 67 did not go towards the street. Besides staff arriving on 7/4/2026 at 4:09 am there were no other cars on the premises. The Dialysis Group Administrator stated that when a dialysis patient is cognitive, they go and come as they please. She stated that when a dialysis patient is not cognitive the patient will remain in the chair until transportation arrives. During an interview with Dialysis RN A on 7/22/2026 at 4:15 pm he stated that Resident # 67 has been receiving dialysis at this center for a few months. He stated that Resident # 67 is cognitive. He stated that Resident # 67 had dialysis on Monday, Wednesday and Friday's and Resident # 67's chair time was 2:00 pm. He stated on 7/3/2026 Resident # 67's dialysis began around 2:00 pm. He stated that prior to dialysis Resident # 67 was given a protein bar. He stated that Resident # 67 also had a jacket and a snack bag. He stated that on 7/3/2026 around 5:15 pm he contacted Family Member A and informed him that Resident # 67 would be ready to pick up in one hour. He stated that Family Member A informed him that Resident # 67 was staying at a local nursing facility and contacted the facility. Dialysis RN A stated that he contacted the nursing facility, and he informed them that Resident # 67 would be ready for pick up in one hour. He stated that he does not know who he spoke with, but he was told that transportation would be at the dialysis to pick Resident # 67 up. He stated that on 7/3/2026 Resident # 67 finished dialysis a little early. He stated that Resident # 67 went to the lobby to wait for transportation. He stated that on 7/3/2026 around 7:20 pm he completed rounds which consisted of checking the lobby and the lobby restrooms. He stated that there were no residents in the building. He stated that he looked out the front door and made sure no resident was sitting on the bench. He stated that he proceeded to lock the front door. The Dialysis RN A stated that he and the technician exited the facility at 7:30 pm. He stated that they exited the back door and there were residents observed on the premises. During an interview with Receptionist A on 7/22/2026 at 4:40 pm she stated that on 7/3/2026 approximately 9:00 am she contacted the transportation company to scheduled transportation for Resident # 67 to and from dialysis. She stated that Resident # 67 was a new resident who was admitted [DATE]. She stated that Resident # 67 was scheduled to be transported to dialysis on 7/3/2025 at 1:45 pm as his chair time was 2:00pm. She stated that the reservation was confirmed by Transportation Receptionist A. She stated that she and Transportation Receptionist A discussed the return trip from dialysis to the nursing facility. She stated that Transportation Receptionist A informed her that she would use the same time as before; she stated that Resident # 67 was a resident at this facility last month. She stated that Resident # 67 has dialysis Monday, Wednesday and Friday and he had to be a dialysis by 2:00 pm and the return trip was supposed to be at 6:30 pm. During a telephone interview with Dialysis RNB on 7/23/2026 at 7:40 am she stated that she arrived at the dialysis center on 7/4/2026 at 4:00 am. She stated that she unlocked the lobby door at 5:00 am. She stated that she went to the lobby to get a patient who was scheduled for dialysis at 5:30 am. She stated that she noticed Resident # 67 in the lobby. She stated that she had never seen Resident # 67, and she asked him if he was at the dialysis center for dialysis. She stated that Resident # 67 told her he had dialysis on 7/3/2026 and he stayed outside the night before. She stated that Resident # 67 told her he was a resident at the local nursing facility. She stated that she contacted the nursing facility and informed them that Resident # 67 was at the dialysis center and he was not scheduled for dialysis. She stated that she spoke with the nurse at the nursing facility who was assigned to Resident # 67. She stated that Resident # 67 spoke with RN B and she overheard Resident # 67 say he was with a friend. She stated that as asked Resident # 67 what happened and he did not answer her. She stated that she did not know what happened. She stated that she contacted Family Member A who picked Resident # 67 up and transported him to the nursing facility. She stated that Resident # 67 was alert and oriented. She stated that resident # 67 was clean. She stated that she assessed Resident # 67 and he did not have any s/sx of dizziness, distress or injuries. S During a telephone interview with Transportation Receptionist A on 7/23/2026 at 9:10 am she stated that on 7/3/2026 she scheduled transportation for Resident #67. She stated that she did not know the name of the staff who scheduled the transportation. She stated that Resident # 67 was scheduled for transportation to the dialysis center on Monday, Wednesday and Friday with a pickup time at 1:45 pm. She stated that staff did not schedule a return ride. She stated that she only schedules what the staff or family member request. Transportation Receptionist A confirmed that Resident # 67 transportation scheduled had been adjusted and it currently reflected transportation to the dialysis center on Monday, Wednesday and Friday with a pickup time of 1:45 pm and transportation from the dialysis center nursing facility with a return time of 6:30 pm. During an interview with the Administrator on 7/23/2026@ 3:24 pm she stated that this incident was not reportable as Resident # 67 stated that he left the dialysis center with a friend. She stated that they got two different storied from Resident # 67 and they could not determine what happened. She started that a root cause analysis was conducted and it was determined the facility did not ensure timely escalation when Resident # 67 did not return from a dialysis. She stated that staff were educated on abuse, neglect and exploitation. Record review of nursing note dated 07/04/26 revealed 7/4/2026 08:45 - Nurse Note Late Entry: Patient showed up to facility with brother. Head to toe completed and vitals assessed and WNL. NP notified. STAT CBC/CMP UA/CS ordered. Attempted to collect UA/CS but resident refused. will continue to monitor During an interview with facility DON and the Administrator on 08/07/26 at 1:00PM, The DON said she learnt of the incident after the fact on 07/04/26 when the night nurse informed her that Resident #67 did not come back from dialysis on 07/03/25. She said she immediately came to the facility and assessed Resident 64 for any signs of injury. The Administrator said she learnt of the incident the morning of 07/04/26. She said she immediately started an investigation to find out what happened. The DON said all staff were immediately in serviced on elopement risk assessment, following up on residents that are out on appointment and transportation confirmation. DON said the facility had implemented a multi-check program to ensure that all residents that leave the facility for any appointments are being accounted for on every shift. The DON said all staff are to give reports by walking round to ensure that all residents are accounted for and if out of the facility, staff are to note the whereabout and means of contact. The DON said destination place and expected time of arrival will be documented. During an interview with CNA E on 08/07/26 at 1:30PM, she said she would find out the whereabout of the residents if not seen on 2 rounds. She said if his\her food was present after meal, she would take it to the kitchen after checking with the nurse. She said she had an in-service in July 2026 about checking on residents and letting the charge nurse know that the resident had not been seen. During an interview with CNA F on 08/07/26 at 1:40PM, she said most of the time, she knows where her residents are. They are either in their room, sitting out at the lobby watching television or out on medical appointments. She said she would find out from the nurse's if expected back during mealtime or not so that she can save their food. If resident does not return as expected, she would tell the nurse to check. She said she had in-service on elopement and checking on residents about three weeks ago but does not remember the date. During an interview with Receptionist D on 08/07/26 at 1:50PM, she said she had the facility's daily census, and a sign in and out sheet at the front desk. She said she checks out all residents leaving the facility and when they come in they are checked in. She said Some residents do go out to sit outside and she knows who they are and do check on them from time to time. Interview with LVN K on 08/07/26 at 2:00PM, she said she worked from 6AM to 6PM. She said if a resident goes out to any appointment during her shift, she will document the time he/ she leaves and expected time of arrival. She said if the resident does not come back at the expected time, she would check with the office or wherever the resident is and find out the whereabout of the resident and document in the resident's chart. She said if unable to locate the residents she would immediately put the information on the chart box (a communication system within the facility alerting all staff that a resident is missing. She said that goes to the DON and the Administrator as well. She said she would personally call the DON and the Administrator. In an interview with MA I on 08/07/26 at 4:00PM, she said if she did not see a resident during her medication pass, she would find out from the nurse the whereabout of the resident and document in the resident's medication that the resident was out. She said she would come back again it the resident was back or not. She said she works 2-10pm but would alert the nurse. During an interview with LVN K on 08/07/26 at 4:30PM, He said he worked 6AM to 6PM. HE said if he sent any resident out for any type of appointment, he would document the time he/she leaves the facility and estimated time of arrival. He said he would give and take about an hour; he would follow up with provided destination. He said if no answer, he would follow up with transportation, the DON and the Administrator. He would check with family members\RP on resident's clinical record. He said He would send out information on the chart box. During an interview with Receptionist G on 08/08/26 at 10:00AM, she said she scheduled resident's appointment or sometimes the nurses. She said she works on weekends. She said all residents going in and out of the facility must sign in and out leaving and coming in. She said if a resident is not back at the expected time she would call the charge nurse to let him/her know that resident was out and had not returned at the expected time so that the nurse can check. She said at the end of her shift, she gives report to the charge nurse on duty, and the charge nurse would follow up if any resident was out. She said she was not on duty during the time of the incident. She said she had an in-service following up to ensure that residents sent out by the facility had transportation to bring them back. During an interview with CNA L on 08/08/26 at1:45PM, she said the last in-service she had was monitoring call lights and customer services last week. She said last month she had an in-service on monitoring residents and ensuring that all assigned residents are accounted for at the end of their shift. She said she would find out about any resident that she did not see and report to the charge nurse as soon as possible. During an interview with the DON and the Administrator on 08/08/26 at 3:00PM, the Administrator said the checking system was not in place prior to the incident. She said the multi-check point was implemented on 07/04/26. The DON said all staff were in-service on notifying all staffing personnel if a resident could not be located. She said the chart-box is a system of notification that sends information to all staff. The Administrator said both staff no longer worked at the facility. Attempt was made to call both staff at different times on 08/08/26 but no answer. Record review of sign dated 07/04/26 titled Resident sign in revealed the receptionist signed out residents when they left the facility and when they came back. The Sheets detailed time when they leave the facility and expected time of arrival that include telephone # and contact person. Record review of the facility's Elopement Policy, revised December 2007, revealed in part 4) If an employee discovers that a resident is missing from the facility he/she shall: a)Determine if the resident is out on an authorized leave or pass; b) If the resident was not authorized to leave initiate a search of the building (s) and premises; c) If the resident is not located, notify the Administrator and the Director of Nursing Se

Based on interview and record review, the facility failed to consult with the resident's physician and representative of one (Resident # 67) of 5 residents reviewed for resident rights. -The facility failed to notify Resident # 67's physician and representative when the resident did not return from a scheduled dialysis treatment on 7/3/2026 that resulted in the resident being left outside of dialysis center overnight without medications, incontinence care or food.This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Record review of Resident # 1's face sheet, dated July 10,2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of right pubis, subsequent encounter for fracture with routine healing (encounters after the patient has received active treatment for the injury/condition and is receiving routine care during the healing or recovery phase), Diabetes Mellitus with neuropathy (nerve damage caused by prolonged high blood sugar) End Stage Renal Disease (irreversible stage of chronic kidney disease, where kidneys function at 15% or less), difficulty in walking. Record review of Resident #1's MDS, dated [DATE], revealed BIMS 12 (intact cognition) and was independent with mobility. Resident # 1 was frequently incontinent for urinary and always incontinent for bladder. Resident # 1 ambulate with a walker or wheelchair. Resident # 1's did not indicate any behaviors. Record review of Resident #1's baseline Care Plan, not dated, revealed Resident # 1 has impaired cognitive function or impaired thought process; goal: Resident # 1 will improve current level of cognitive function; Interventions: administer medication as ordered. Monitor/document for side effects and effectiveness, communicate with the resident /family caregivers regarding residents capabilities and needs; Resident # 1 has diabetes mellitus; goal-Resident # 1 will be free from any signs and symptoms of hyperglycemia ( high blood sugar) , free from any signs and symptoms of hypoglycemia ( low blood sugar) and Resident # 1 will have no complications related to diabetes; intervention-diabetes medication as ordered by doctor. Record review of admission/discharge report dated 7/9/2026, revealed in part: 7/2/2026 Resident # 67 was admitted from an Acute care hospital; 7/3/2026 Resident #67 was discharged home/apartment with no home health services and 7/4/2026 Resident # 67 admission type was Home/Apartment with no home health service.During an interview on 7/9/2026 at 12:10 pm, Resident #67 stated that he was admitted to this facility on July 2, 2026. He stated that he was transported to dialysis on 7/3/2026 by ambulance; he stated he did not remember the time. He stated that it was after lunch. He stated that he completed the dialysis treatment and he waited outside for transportation back to the nursing facility. He stated that he did not remember the time, and he did not remember how long he waited. He stated that he left the dialysis center in wheelchair. He stated that he was trying to return to the nursing facility. He stated that he did not know where he was going. He stated that he decided to return to the dialysis center. He stated that this is when he was almost struck by a car. He stated that when he returned to the dialysis center the center was closed. He stated that he remained at the dialysis center until the next morning. He stated that he was afraid as he had no way to contact his family. During an interview on 7/9/2026 at 12:20 pm, Family Member # 1 stated that Resident # 1 was admitted to this facility on 7/2/2026. He stated that facility was responsible for transporting Resident # 67 to and from dialysis. He stated that Resident # 67 has dialysis on Monday, Wednesday, and Friday at 2:00 pm. He stated that on 7/3/2026 Resident # 67 was transported to dialysis around 2:00 pm. He stated that the nursing facility did not send transportation to pick Resident # 67 up. He stated that 7/4/2026 around 6:00 am he received a call from staff at dialysis center, and he was informed that Resident # 67 was at the dialysis center and Resident # 67 was not scheduled for dialysis. Family Member # 1 stated that at this point he did not know what happened. He stated that he was informed by unknown staff at the dialysis center that Resident # 67 apparently spent the night outside of the dialysis center. He stated that he asked Resident # 67 what happened and Resident # 67 told him that no one picked him up from dialysis, so he left the center. He stated that Resident #67 told him that he was trying to get back to the nursing facility. He stated that Resident # 67 told him he was almost struck by a vehicle so Resident # 67 returned to the dialysis center, however, when he returned to this center it was closed. He stated that Resident # 67 said he waited around the dialysis center. Family Member # 1 stated that Resident # 67 was sitting in a wheelchair and he was dirty and unkept. He stated that prior to leaving the dialysis center staff checked Resident # 67 vitals. He stated that Resident # 67 did not have any injuries and he was stable. He stated that he was upset because when he returned Resident # 67 to the nursing facility staff did not know he was missing. He stated that Resident # 67's dinner from the day before was in the room and his breakfast was outside the door. He stated that the nurse at the nursing facility assessed Resident # 67. He stated that DON came and spoke with him. He stated that nursing facility did not provide transportation for Resident # 67 to return from dialysis. He stated that DON acted like nothing happened. He stated that he was informed by the DON that there was transportation scheduled for Resident #67 to return to the nursing facility. He stated that no one from the nursing facility contacted him or the dialysis center. During a telephone interview with RN B on 7/10/2026 at 5:14 pm she stated that she did not provide care to Resident # 67 on 7/3/2026. She stated that Resident #67 was assigned to her on 7/3/2026. She stated that a CNA reported that Resident # 67 had not returned from dialysis. She stated that she contacted dialysis on 7/3/2026 between 7:45 pm and 8:00 pm and she did not receive an answer. She stated that she reached out to another nurse who works for this facility, and she was told by this nurse that sometimes residents are sent to the hospital from dialysis. She stated that she denied contacting the local hospital. She denied contacting the NP and/or MD, RP, DON, or Administrator. She stated that on 7/4/2026 at 5:30 am she received a call from the dialysis center, and she was informed that Resident # 67 was the center. She stated that she asked to speak to Resident # 67, and he told her that he left dialysis on 7/3/2026 and he was with a friend. She stated that she contacted the DON. She stated that due to Resident #67 not receiving proper care his site could have leaked, he had dialysis, therefore, he could have had hypotension and weakness. During an interview with the DON on 7/10/2026 at 6:00 pm, she stated that staff are expected to be round every 2 hours. She stated that residents return from dialysis around the same time. She stated that she expects nurses to contact the dialysis center within 30 minutes of the resident not returning from dialysis. She stated that she was not aware that Resident 67 did not return from dialysis. She stated that on 7/4/2026 between 5:30 am and 6:00 am she received a call from RN B. She stated that RN B informed her that she received a call from dialysis and was told that Resident # 67 was at the dialysis center. She stated that RN B informed her that she spoke with Resident # 67 who stated that he left the dialysis center on 7/3/2026 with a friend. She stated that RN B told her that she contacted the dialysis center on 7/3/2026 and she did not receive an answer. She stated that RN B should have contacted her, the NP/MD and the RP. She stated that RN B denied contacting the DON, NP/MD, and the RP. She stated that she arrived at the nursing facility on 7/4/2026 and she spoke with Family Member # 1 who stated informed her that Resident # 67 stated the nursing facility did not pick Resident# 67 up from dialysis as a result Resident # 67 slept outside of the dialysis center. The DON stated Resident # 67 was scheduled to be picked up and returned to this nursing facility on 7/3/2026. She stated that because of Resident # 67 not returning to the nursing facility he could have resulted in Resident # 67 having hypotension and low blood sugar levels. She stated that this incident was not reported to the State Survey Agency because Resident # 67 reported that a friend picked him up from the dialysis center. Record review of the facility's Elopement Policy, revised December 2007, revealed in part 4) If an employee discovers that a resident is missing from the facility he/she shall: a)Determine if the resident is out on an authorized leave or pass; b) If the resident was not authorized to leave initiate a search of the building (s) and premises; c) If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor) , the Attending Physician, and law enforcement official and ( as necessary, volunteer agencies;).

Based on observation interview and record review the facility failed to ensure that allegations involving abuse, neglect, and exploitation were reported immediately, but no later than 2 hours after allegation was made to the State Survey Agency of 1 of 5 resident (Resident #67) reviewed for abuse and neglect. The facility failed to report to the State Surve Agency (HHSC) an incident in which Resident #67 did not return to facility from a scheduled dialysis treatment on 7/3/2026 that resulted in the resident being left outside of dialysis center overnight without medications, incontinence care, or food without reliable means of contacting the facility or representative. This failure placed residents at risk of abuse/neglect and could lead to a diminished quality of life. Findings Include: Record review of Resident # 67's clinical record revealed a 77- year-old male, admitted to the facility initially on 05/12/26 and re admitted on [DATE]. His diagnoses included unspecified fracture of right pubis, fracture of fifth lumbar vertebra, routine healing, type 2 diabetes Mellitus with neuropathy (nerve damage caused by prolonged high blood sugar), end Stage Renal Disease (irreversible stage of chronic kidney disease, where kidneys function at 15% or less), foot ulcer, and difficulty in walking. Record review of Resident #67's admission MDS, dated [DATE] revealed a BIMS score of 8 (Moderate impairment on cognition). On functioning ability, he was assessed as needing assistance in the following areas- -Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed -Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). -Toilet transfer: The ability to get on and off a toilet or commode. - Tub/shower transfer: The ability to get in and out of a tub/shower. - Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. Was coded as Dependent - Helper does all the effort. Residents do none of the effort to complete the activity. or the assistance of 2 or more helpers is required for the residents to complete the activity. Record review of Resident #67's care plan dated 07/04/26 with a target date of 07/28/26 revealed -Resident #67 requires assistance for meeting his physical needs. Goals: The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Resident #67 has an ADL self-care performance deficit r/t recent fracture of pubis/spine and Late Effects of CVA. Goal: The resident will improve current level of function through the review date. Date Initiated: 07/10/2026 The resident has impaired cognitive function or impaired thought processes r/t Late Effects of CVA Date Initiated: 07/10/2026 Revision on: 07/10/2026 Resident #67 has a communication problem r/t impaired ability to understand. Date Initiated: 07/09/2026 Goal The resident will be able to make basic needs known daily through the review date. Date Initiated: 07/09/2026, target date 07/21/26 The resident has Diabetes Mellitus Date Initiated: 07/09/2026 Goals: Resident #67 will be free from any s/sx of hyperglycemia through the review date.07/21/26. Resident #67 will be free from any s/sx of hypoglycemia through the target date on 07/21/26 Resident #67 is at risk for falls r/t history of falls prior to admission w/ major injuries and impaired cognition. Goal: Resident #67 will be free of falls through the target date: 07/21/2026 During an interview on 7/9/2026 at 12:20 pm, Resident #67's RP said, Resident #67 was admitted to this facility on 7/2/2026. He said the facility was responsible for transporting Resident # 67 to and from dialysis on Monday, Wednesday, and Friday at 2:00 pm. Resident #67's RP said on 7/3/2026 Resident # 67 was transported to dialysis around 2:00PM but the facility did not arrange for transportation to transport Resident #67 back to the facility. He said he received a call from the dialysis center on 7/4/2026 around 6:00AM, that Resident # 67 was at the dialysis center and resident # 67 was not scheduled for dialysis. Resident #67's RP said he asked Resident # 67 what happened and Resident # 67 told him that no one picked him up from dialysis. He stated that Resident #67 told him that he was trying to get back to the nursing facility but was almost struck by a vehicle so Resident # 67 returned to the dialysis center, however, when he returned to this center, the center was closed so he stayed outside the center overnight. Resident #67's RP said Resident # 67 was sitting in dirty wheelchair and he was unkept. He stated that prior to leaving the dialysis center staff checked Resident # 67 vitals. He stated that Resident # 67 was stable and had no injuries. During an interview with the DON on 7/10/2026 at 6:00 pm, she stated that staff are expected to be round every 2 hours. She stated that residents return from dialysis around the same time. She stated that she expects nurses to contact the dialysis center within 30 minutes of the resident not returning from dialysis. She stated that she was not aware that Resident 67 did not return from dialysis. She stated that on 7/4/2026 between 5:30 am and 6:00 am she received a call from RN B. She stated that RN B informed her that she received a call from dialysis and was told that Resident # 67 was at the dialysis center. During an interview with facility Administrator and the DON on 08/07/26 at 2:00PM, she said she did not report the incident because she learnt of the incident after the fact. She said the resident was already present at the facility, assessed and there was no injury noted on the resident. The administrator said she followed the state guidelines for reporting abuse, neglect and exploitation. The DON said Resident #67 was provided care and made comfortable. Record review of the facility's Elopement Policy, revised December 2007, revealed in part 4) If an employee discovers that a resident is missing from the facility he/she shall: a)Determine if the resident is out on an authorized leave or pass; b) If the resident was not authorized to leave initiate a search of the building (s) and premises; c) If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor) , the Attending Physician, and law enforcement official and ( as necessary, volunteer agencies;). Record review of Resident # 1's face sheet, dated July 10,2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of right pubis, subsequent encounter for fracture with routine healing (encounters after the patient has received active treatment for the injury/condition and is receiving routine care during the healing or recovery phase), Diabetes Mellitus with neuropathy (nerve damage caused by prolonged high blood sugar) End Stage Renal Disease (irreversible stage of chronic kidney disease, where kidneys function at 15% or less), difficulty in walking. Record review of Resident #1's MDS, dated [DATE], revealed BIMS 12 (intact cognition) and was independent with mobility. Resident # 1 was frequently incontinent for urinary and always incontinent for bladder. Resident # 1 ambulate with a walker or wheelchair. Resident # 1's did not indicate any behaviors. Record review of Resident #1's baseline Care Plan, not dated, revealed Resident # 1 has impaired cognitive function or impaired thought process; goal: Resident # 1 will improve current level of cognitive function; Interventions: administer medication as ordered. Monitor/document for side effects and effectiveness, communicate with the resident /family caregivers regarding residents capabilities and needs; Resident # 1 has diabetes mellitus; goal-Resident # 1 will be free from any signs and symptoms of hyperglycemia ( high blood sugar) , free from any signs and symptoms of hypoglycemia ( low blood sugar) and Resident # 1 will have no complications related to diabetes; intervention-diabetes medication as ordered by doctor. During an interview on 7/9/2026 at 12:10 pm, Resident #67 stated that he was admitted to this facility on July 2, 2026. He stated that he was transported to dialysis on 7/3/2026 by ambulance; he stated he did not remember the time. He stated that it was after lunch. He stated that he completed the dialysis treatment and he waited outside for transportation back to the nursing facility. He stated that he did not remember the time, and he did not remember how long he waited. He stated that he left the dialysis center in wheelchair. He stated that he was trying to return to the nursing facility. He stated that he did not know where he was going. He stated that he decided to return to the dialysis center. He stated that this is when he was almost struck by a car. He stated that when he returned to the dialysis center the center was closed. He stated that he remained at the dialysis center until the next morning. He stated that he was afraid as he had no way to contact his family. During a telephone interview with RN B on 7/10/2026 at 5:14 pm she stated that she did not provide care to Resident # 67 on 7/3/2026. She stated that Resident #67 was assigned to her on 7/3/2026. She stated that a CNA reported that Resident # 67 had not returned from dialysis. She stated that she contacted dialysis on 7/3/2026 between 7:45 pm and 8:00 pm and she did not receive an answer. She stated that she reached out to another nurse who works for this facility, and she was told by this nurse that sometimes residents are sent to the hospital from dialysis. She stated that she denied contacting the local hospital. She denied contacting the NP and/or MD, RP, DON, or Administrator. She stated that on 7/4/2026 at 5:30 am she received a call from the dialysis center, and she was informed that Resident # 67 was the center. She stated that she asked to speak to Resident # 67, and he told her that he left dialysis on 7/3/2026 and he was with a friend. She stated that she contacted the DON. She stated that due to Resident #67 not receiving proper care his site could have leaked, he had dialysis, therefore, he could have had hypotension and weakness. During an interview with the DON on 7/10/2026 at 6:00 pm, she stated that staff are expected to be round every 2 hours. She stated that residents return from dialysis around the same time. She stated that she expects nurses to contact the dialysis center within 30 minutes of the resident not returning from dialysis. She stated that she was not aware that Resident 67 did not return from dialysis. She stated that on 7/4/2026 between 5:30 am and 6:00 am she received a call from RN B. She stated that RN B informed her that she received a call from dialysis and was told that Resident # 67 was at the dialysis center. She stated that RN B informed her that she spoke with Resident # 67 who stated that he left the dialysis center on 7/3/2026 with a friend. She stated that RN B told her that she contacted the dialysis center on 7/3/2026 and she did not receive an answer. She stated that RN B should have contacted her, the NP/MD and the RP. She stated that RN B denied contacting the DON, NP/MD, and the RP. She stated that she arrived at the nursing facility on 7/4/2026 and she spoke with Family Member # 1 who stated informed her that Resident # 67 stated the nursing facility did not pick Resident# 67 up from dialysis as a result Resident # 67 slept outside of the dialysis center. The DON stated Resident # 67 was scheduled to be picked up and returned to this nursing facility on 7/3/2026. She stated that because of Resident # 67 not returning to the nursing facility he could have resulted in Resident # 67 having hypotension and low blood sugar levels. She stated that this incident was not reported to the State Survey Agency because Resident # 67 reported that a friend picked him up from the dialysis center. During an interview with the Administrator on 7/23/2026@ 3:24 pm she stated that this incident was not reportable as Resident # 67 stated that he left the dialysis center with a friend. She stated that they got two different storied from Resident # 67 and they could not determine what happened. She started that a root cause analysis was conducted and it was determined the facility did not ensure timely escalation when Resident # 67 did not return from a dialysis. She stated that staff were educated on abuse, neglect and exploitation. Review of the facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised 8/2024, revealed in part 8) Identify and investigate all possible incidents of abuse, neglect , mistreatment, or misappropriation of resident property; 9) Investigate and report any allegations within timeframe required by federal requirements.

Based on observation, interview, and record review the facility failed to ensure residents have the right to dignified existence, self-determination for 1 of 6 residents (Resident #20) reviewed for dignity.RN V failed to knock, identify themselves before entering Resident #20's room.This failure could cause loss of privacy, decreased sense of safety for residents, and potential psychosocial harm.Findings included: Record review of Resident #20's admission record revealed a [AGE] year-old female who admitted into the facility on [DATE]. Her diagnoses included anxiety disorder, pneumonia, need for assistance with personal care, muscle weakness and pain.Record review of Resident #20's Care Plan initiated on 06/01/2026 read. requires assistance with her physical needs. She enjoys independent leisure activities, word puzzles, movies/tv, groups, exercise class, and 1:1 social visits. We will provide materials for individualized activities as desired and accommodate wants/needs accordingly. The interventions/tasks read. All staff to converse with Resident #20 while providing care.Record review of Resident #20's Initial MDS assessment dated [DATE] revealed a BIMS score of 14 out 15 which indicated she was oriented and able to recall information appropriately with no significant memory or thinking impairment detected based off testing. Resident #20 required substantial/maximal assistance with lower body dressing.During an interview and observation on 06/09/2026 at 10:06 a.m., Resident #20 stated, I hate it here and she felt staff do not treat her with respect or dignity. Resident #20 stated when she asked for assistance, staff respond with an attitude, often saying what do you want in a tone that was rude and dismissive. She stated staff do not knock before entering her room, which made her feel disrespected and as if her privacy was not valued. She stated staff made her feel like she was a bother when she requested help. Resident #20 stated the interactions made her feel unwelcome, uncomfortable, and unhappy living in the facility. Resident #20 asked if she could be assisted with the room temperature and was asked to use the call light button. It was observed RN V to walk into Resident #20's room without knocking or identifying herself before asking Resident #20 what she needed.During an interview on 06/09/2026 at 10:12 a.m., RN V stated the expectation for answering call lights was for staff to enter the resident's room, ask what the resident needs, and then turn the call light off. She stated that, for dignity, staff are expected to knock before entering any resident room, regardless of whether the door was open or closed. RN V stated the risk of not knocking and identifying oneself was that the residents may not know who entered the room, which could affect their sense of safety and dignity. RN V stated she did not realize that she did not knock before entering the room or identifying herself, she was just focused on answering the call light.During an interview on 06/10/2026 at 1:12 p.m., the DON stated the expectation for dignity was for staff to introduce themselves, explain what they were going to do, and respect the resident preferences, including the right to refuse care. She stated staff were expected to knock and identify themselves before entering a resident's room. She stated the risk of not doing so as the resident not knowing who entered the room, which could cause the resident to feel scared, startled, or unsure of the situation.Record review of the facility's policy for 'Resident Rights' revised 08/2024 read.Policy Statement1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;

Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 (Resident #4) of 2 resident reviewed for gastrostomy tubes (a surgically implanted tube into the stomach to provide delivery of nutrition).RN A failed to check for placement of gastrostomy tube (g-tube) prior to administering medication.This failure could place residents with g-tubes at risk of complications such as aspiration, abdominal injury, tube dislodgement and hospitalization. Findings included:Record review of Resident #4's face sheet dated 06/11/26 revealed a [AGE] year-old first admitted to the facility on [DATE] and initially admitted on [DATE]. Diagnoses included cerebral infarction (death of brain tissue), gastrostomy status (a surgically implanted tube to allow provision of nutritional support), Dysphagia (swallowing disorder), malnutrition, Aphasia (language disorder caused by damage in a specific area of the brain) Hemiplegia (one sided paralysis or severe loss of strength on one side), Dementia (a decline in cognitive function), and Diabetes (a chronic condition that occurs when the body cannot properly use blood sugars).Record review of Resident #4's quarterly MDS dated [DATE] revealed she had short term and long-term memory problems. She had severely impaired cognitive skills for daily decision making. She had lower extremity limitations in range of motion. She was dependent on staff assistance for oral hygiene, toileting needs, bathing, dressing, personal hygiene and mobility. She required a feeding tube for delivery of nutritional support.Record review of Resident #4's undated care plan revealed: Focus - Resident #4 was NPO, on tube feeding for inadequate oral intake r/t decreased appetite AEB need for Gastrostomy-tube. Goal - Resident #4 will remain free of side effects or complications r/t to tube feeding through review date, target date 07/25/26. Interventions included - check for tube placement and gastric contents/residual volume per facility protocol and record. Monitor/document/report PRN any s/sx of Aspiration: fever, SOB, tube dislodged, self-estuation, tube dysfunction or malfunction.Record review of Resident #4's active physician orders as of 6/10/26 revealed the following:*enteral feed order every shift: check tube placement before initiation of formula, medication administration and flushing tube or at least every 8 hours, start date was 11/13/25. *Aspiration precaution: monitor for choking, teary eyes, nasal drip, coughing-notify MD with change in condition every shift, start date 11/3/25. *Buspirone HCL oral tablet 5mg: give 2 tablets twice a day for restlessness and anxiety.During an observation on 6/10/26 at 8:00 AM, Resident #4 was alert, on her back in bed with the HOB raised, the tube feeding was turned on and delivering formula to the resident through the gastrostomy tube. RN A had crushed and prepared the medication Buspirone 5mg tablets x 2 tablets. RN A added 20 ml of water to the crushed medication. RN A performed hand washing, put on a disposable gown and clean gloves. RN A paused the TF pump, disconnected the tubing from the G-tube, attached the barrel of the 60 ml syringe to the G-tube and poured 30 ml of water into the barrel. The water was not infusing by gravity. RN A attached the plunger to the barrel and pushed until the water infused into the resident. RN A did not check for placement of the G-tube. RN A poured the medication that dissolved in 20 ml of water into the barrel of the syringe as it infused into the resident. RN A poured 30 ml of water into the barrel of the syringe as it infused into the resident then attached the tubing to the pump. RN A then turned the pump on. Resident #4 remained alert and in no distress.In an interview on 6/10/26 at 8:15 AM, RN A stated he did check for placement of Resident #4's G-tube by attaching the barrel of the syringe and observing backup of formula into the syringe, when he was satisfied then he poured the water into the barrel of the syringe. RN A stated the risk when pushing too hard with the syringe would be injury to the abdomen, but he pushed only gently. RN A stated another risk could be the internal balloon could pop and dislodge the G-tube. RN A stated he did receive training on G-tube medication administration during orientation 7 months ago.In an interview on 6/10/26 at 4:27 PM, the DON stated when administering medication via G-tube she would make sure the tube was patent (open and free of obstruction) by attaching a syringe to the G-tube and pulling back to check for residual. The DON stated she would then check for placement by injecting some air using the syringe and listening to the air using a stethoscope placed over the abdomen. The DON stated checking for placement was done to make sure medications do not go into the wrong space and the risk to the resident would be aspiration. The DON stated if fluid was not infusing her expectation would be that the nurse milk the tubing to break up any formula that was stuck in the tubing. The DON stated pushing fluid into the G-tube either forcibly or gently should not be done because it may cause discomfort for the resident. The DON stated checking for placement and residual should be done every single time prior to medication administration or prior to starting tube feeding or administration of a bolus of feeding.Record review of the facility policy and procedure for Administering Medications through an Enteral Tube (feeding tube), revised on 08/2024 read in part: .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube.General Guidelines.3. Administer each medication separately and flush between medications.The following equipment and supplies will be necessary when performing this procedure.12. Stethoscope.6. Verify placement of feeding tube: a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. 7. Stop feeding and flush tubing with at least 15ml warm purified water (or prescribed amount).9. Dilute medication:.b. Dilute crushed (powdered) medication with at least 30 ml purified water (or prescribed amount).11. Reattach syringe (without the plunger) to the end of the tubing. 12. Administer medication by gravity flow: a. Pout diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. B. open the clamp and deliver medication slowly. c. Begin flush before the tubing drains completely.14. When the last of the medication begins to drain from the tubing, flush the tubing with 15ml of warm purified water(or prescribed amount). 15. Quickly clamp the tubing when the flush is complete. Remove syringe.

Based on observation, interview and record review, the facility failed to ensure that residents had the right to be free from abuse for 1 (Resident #84) of 5 residents reviewed for abuse. The facility failed to ensure that Resident #84 from was free from mental abuse, verbal abuse, and deprivation of services by staff when CNA K verbally abused Resident #84 on 4/23/25 and placed his call light out of his reach. The failure could place residents at risk of mental abuse, verbal abuse, and deprivation of services by staff. Findings included: Record review of Resident #84's face sheet dated 4/24/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Epilepsy (seizure disorder) and Cognitive Communication Deficit (difficulty communicating). Record review of Resident #84's quarterly MDS dated [DATE] revealed a BIMS score of 10 that suggested moderate cognitive impairment and a functional abilities code of 01 for toileting hygiene indicating he was dependent for others to complete. Record review of care plan follow up for Resident #84 dated 4/22/25 revealed in-service to be conducted due to concern related to staff putting call light on the floor. Record review of facility's Sign In Sheet for 4/22/25 revealed CNA K and CNA L worked 10 p.m. to 6 a.m. and LPN B worked 6 p.m. to 6 a.m. on the #100 Hallway where Resident #84 resided. Record review of Resident #84's Care Plan Report printed 4/24/25 revealed Resident #84 was dependent on staff for meeting physical needs. Interventions included staff will approach Resident #84 in a calm, non-threating manner when interacting with him, encourage to use bell to call for assistance, and caregivers to provide opportunity for positive interactions. Record review of Employee Inservice/Training for Abuse/Neglect revealed training was completed on 4/23/25. Record review of Suspected Verbal Abuse Questionnaire revealed trainings completed on 4/23-5/5/25. Record review of Employee Inservice/Training for Abuse, Neglect & Exploitation, Resident Rights, and Ensuring call [NAME] in reach of Residents revealed trainings were completed on 4/26/25. Observation of video recorded on 4/23/25 at 2:32 a.m. revealed CNA K entered Resident #84's room. At 2:33 a.m. CNA K said, Shame on you [Resident #84] and Shame on you for trying to make everybody else's night awful. At 2:34 a.m. CNA K said I bet you won't get it back while she was holding the call light and leaves the call light on the floor. At 2:34 a.m. CNA K also said that ain't got nothing to do with why you are acting a fool. CNA K provided incontinence care to Resident #84 at 2:36 a.m. and exited the room [ROOM NUMBER]:38 a.m. At 2:38 a.m. the call light could be seen on the floor near the curtain in the middle of the room. During interview on 4/23/25 at 10:07 a.m., Resident #84's family member said there was an incident around 2 a.m. on 4/23/25 and they had a video of the incident. Surveyor viewed the video with time stamp that started on 4/23/25 at 2:25 a.m. on Resident #84's family member's phone. Resident #84's family member said CNA K member was saying you are not going to mess up our night and you are messing everybody else's night up and the surveyor was shown sections of the video where Resident #84's family member said this was occurring. At the time the surveyor viewed in the video CNA K was also seen placing the call light near the curtain in the middle of the room and saying, I bet you won't get that back. Observation on 4/23/25 at 10:07 a.m., Resident #84 was tearing up while his family member was showing the surveyor the video of the incident on 4/23/25 at 2:25 a.m. During interview on 4/23/25 at 10:58 a.m., when Resident #84 was asked how he felt last night when CNA K came into the room he said, they don't care. When asked if staff does not speak to him nicely, Resident #84 shook his head yes. When asked if he was afraid last night, Resident #84 shook his head yes. During interview on 4/23/25 at 10:58 a.m., Resident #84's family member said they did not know the names of the staff members in the video that started on 4/23/25 at 2:25 a.m. Surveyor requested Resident #84's family member to provide a copy of the video as soon as possible. Resident #84's family member said that they were not going to show the video to anyone at the facility before leaving and they would send a copy to the administration this afternoon when they send the other videos. On 4/23/25 at 12:33 p.m., surveyor attempted to contact CNA K via phone but received message that wireless customer was not available. On 4/23/25 at 12:44 p.m., surveyor called CNA L via phone and a male voice answered but was disconnected. Surveyor called CNA L back immediately and left a message with request to call surveyor, but no call back received prior to survey exit. On 4/23/25 at 12:47 p.m., surveyor called LPN B via phone and left a message with request to call surveyor, but no call back received prior to survey exit. On 4/23/25 at 1:24 p.m., surveyor notified Administrator and DON regarding Resident #84's family member showing video to surveyor with concerns of female staff member telling Resident #84 you are not going to mess up our night, you are messing everybody else's night up and I bet you won't get this back in regarding to the resident's call light. During interviews on 4/23/25 at 1:24 p.m., the Administrator and DON said they were unaware of any reports of abuse regarding Resident #84. The Administrator and DON said the allegations in the video from Resident #84's family member was not acceptable practices for the CNA to act and they would be upset with these actions. The Administrator said she considered these actions to be abuse and would be reportable. The Administrator said she would suspend the staff right away and start an investigation. During interview on 4/23/25 at 3:46 p.m., the Administrator and DON denied any concerns told to them regarding staff from the overnight shift. The Administrator said she had completed the self-report and was starting the investigation. The Administrator said she had not received any videos from Resident #84's family member. During interview on 4/23/25 at 5:18 p.m., the Administrator said that both CNAs from the video were suspended pending the investigation and CNA L had provided a statement. The Administrator said she had tried to call Resident #84's family member and they did not answer but she would attempt to reach out again this evening. Record review of Personnel Disciplinary Record dated 4/23/25 for CNA K revealed suspension with reason on suspension pending investigation. During interview on 4/24/25 at 11:19 a.m., the DON said they had already started in-servicing staff regarding call lights. Record review of written statement from LPN B dated 4/23/25 revealed they had made sure the call light was within easy reach of Resident #84. LPN B said they had never had any negative reports from residents regarding CNAs and had not received any messages from Resident #84's family with any concerns from the night of 4/22/25. Record review of email dated 4/24/25 at 3:10 p.m. revealed Resident #84's family member had provided a copy of the video regarding the incident that occurred on 4/23/25 to the surveyor. During interview on 4/24/25 at 11:19 a.m., the DON said they have abuse training quite often and have abuse in-services when they did a self-report and annually through their online in-service system. The DON said she monitored for abuse by talking to the residents and that the residents were open. The DON said she also watched interactions between residents and staff and stood outside the rooms to listen to conversations. The DON said she also looked at resident's skin assessments and looked for bruises. Record review of Personnel Disciplinary Record dated 4/24/25 for CNA K revealed dismissal with reason termination due to abuse allegation. The Personnel Disciplinary Record was not signed by CNA K with note staff member not returning call. During interview on 4/25/24 at 8:21 a.m., ADON A said staff had in-services monthly for abuse and neglect or when something happened. ADON A denied seeing any abuse or neglect at the facility or residents/family members reporting abuse to her. On 4/25/25 at 10:33 a.m., the Administrator said an adverse effect of verbal abuse was the resident could be scared to ask for help, become isolated, their health could decline, or the resident could be afraid the same person could come back in and speak to them in the same manner. The Administrator said if a resident could not reach their call light, then their care would be affected or the staff's ability to meet the resident's needs. The administrator said she sat in on resident council meetings and reviewed resident rights and talked about abuse. The Administrator said they monitored for signs of abuse or neglect and did life satisfaction rounds randomly. The Administrator said they did abuse trainings at least quarterly. The Administrator said she would do more monitoring of the facility including life satisfaction surveys and town halls and that everyone would be responsible. The Administrator said CNA K had been dismissed. On 4/25/25 at 10:33 a.m., the DON said an adverse effect of verbal abuse was the resident could be scared to ask for help, be afraid that the same person could come back in and speak to them in the same manner, the resident's health could decline, or the resident could become isolated. The DON said if a resident cannot reach their call light, then the resident could have a delay in care. Record review of CNA K's personnel file on 4/25/25 at 12:16 p.m. revealed New Hire Application Checklist dated 4/30/24 and current nurse aide license to expire 4/9/2026. CNA K was not listed on the Employee Misconduct Registry dated 4/30/24. No disciplinary actions noted in CNA K's personnel file. During Interview on 4/25/25 at 2:05 p.m., the Administrator said she did not think CNA K had any prior disciplinary actions. The Administrator said she believed disciplinary actions would be in the employee's file, but human resources was on vacation this week and she was unsure if they kept the disciplinary actions in another place. Record review of CNA K's User Learning dated 4/25/25 revealed she had completed Communicating Effectively on 3/4/25, Abuse, Neglect, and Exploitation on 12/8/24 and Elder Abuse: The Elder Justice Act on 12/7/24. Record review of facility's policy Perineal Care revised 8/2024 revealed that after providing incontinence care staff should place the call light within easy reach of the resident. Record review of facility's policy Abuse Prevention Program revised December 2016 revealed residents have the right to be free from abuse that includes but was not limited to verbal and mental abuse.

Based on observation, interview and record review, the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 (Resident #84) of 5 residents reviewed for respect and dignity . The facility failed to provide Resident #84 privacy when providing incontinence care on 4/23/25 as the door to the room was open and the privacy curtains were not pulled. The failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem. Findings included: Record review of Resident #84's face sheet dated 4/24/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Epilepsy (seizure disorder) and Cognitive Communication Deficit (difficulty communicating). Record review of Resident #84's quarterly MDS dated [DATE] revealed a BIMS score of 10 that suggested moderate cognitive impairment. Record review of facility's Sign In Sheet for 4/22/25 revealed CNA K and CNA L worked 10 p.m. to 6 a.m. and LPN B worked 6 p.m. to 6 a.m. on the #100 Hallway where Resident #84 resided. Record review of Employee Inservice/Training for Ensuring Privacy during Residents Care was completed on 4/26/25. Observation of video on 4/23/25 at 2:35 a.m. revealed CNA K provided incontinence care to Resident #84 and left the door to the hallway open and privacy curtains were left open. On 4/23/25 at 12:33 p.m., surveyor attempted to contact CNA K via phone but received message that wireless customer was not available. On 4/23/25 at 12:47 p.m., surveyor called LPN B via phone and left a message with request to call surveyor, but no call back received prior to survey exit. On 4/25/25 at 10:33 a.m., the Administrator said the curtains and door should be closed when providing care. The Administrator said training regarding privacy was through online training and in-services that was completed upon hire, annually and as needed if issues. The Administrator said to monitor for resident privacy that they did daily rounds. The Administrator said if a resident did not have privacy, then a negative effect on the resident would be due to resident dignity. The Administrator said CNA K had been dismissed. On 4/25/25 at 10:33 a.m., the DON said residents' curtains and door should be closed when providing care. The DON said training regarding privacy was through online training and in-services that was completed upon hire, annually and as needed if there were issues. The DON said if a resident did not have privacy, it could have a negative effect on the resident due to resident dignity. On 4/25/25 at 11:26 a.m., ADON A said the expectation regarding resident privacy was that the door will be closed. and curtain pulled when providing care. ADON A said she monitored for privacy when she was out on the unit. ADON A said that failing to provide privacy for a resident was a dignity issue and the resident could feel like no care if privacy was not provided. Record review of Personnel Disciplinary Record dated 4/24/25 for CNA K revealed dismissal with reason termination due to abuse allegation. The Personnel Disciplinary Record was not signed by CNA K with note staff member not returning call. Record review of facility's policy Perineal Care revised 8/2024 revealed Avoid unnecessary exposure of the resident's body. Record review of facility's policy Confidentiality of Information and Personal Privacy revised October 2017 revealed the facility will strive to protect the resident's privacy regarding personal care.

Based on observation, interviews, and record reviews, the facility failed to ensure the MDS assessment accurately reflected resident's status for 1 (Resident #22) of the 6 residents reviewed for accuracy of assessments. Resident # 22's assessment did reflect her hearing loss on section B0200 hearing inadequate on, quarterly, and annual assessment since admitted [DATE] and readmitted [DATE] This deficient practice could affect residents at the facility by contributing to inadequate care based on inaccurate assessments. The findings included: Record review of Resident # 22 face sheet revealed resident is an [AGE] year-old female and was admitted [DATE] with a diagnosis of upper respiratory tract, depression disorder, pain, hyperkalemia (high potassium), dementia, bipolar disorder, and diabetes type II. Record review of Residents #22 5-day admitted d 9/27/2017 section B category B0200. Hearing ability to hear was code 0 Adequate - no difficulty in normal conversation, social interaction, listening to TV. Section B0300 of Resident's #22 MDS dated [DATE] revealed the following: Hearing Aid Enter Code, 0 Hearing aid or other hearing appliance used in completing B0200. Record review of Resident #22's Quarterly MDS revealed Resident #22 had a BIMS of 14 which indicates moderate cognitive impairment. Record review of Resident #22 physicians' orders and care plan revealed no documentation pertaining to hearing aids. Interview and observation with Resident #22 on 4/22/25 at 9:45AM, Resident expressed she was unable to hear the questions being asked of her and that surveyor would have to speak up and to speak loudly, close to her ear. Even speaking up Resident #22 had difficulty understanding the surveyor. Resident #22 said I cannot hear good I am hard of hearing, and I don't know where my hearing aides are. Resident #22 said I told the nurse, and the people up front I cannot hear and wanted to see a doctor. Resident #22 said I had hearing aid when I came here a while back, I guess they are lost. Observation of Resident #22 on 4/22/25 at 10:00AM revealed no hearing aid present, resident was moving close to roommate to see if she would be able to tell her what was being said. Interview with CNA #2 on 4/22/2025 at 10:00AM, she reported that she had never seen hearing aids for Resident #22. I just speak loudly when I assisted her so she can hear and understand me. I do know she needs them because we have to yell in her ear, and she is able to respond to us that way. CNA #2 reported it is our responsibility to make sure we report to nurse or the upper management that a resident is having trouble hearing. CNA #2 reported if a resident cannot hear us talking to them than they may not understand what is going on and they may not be able to tell us what is going on or answer the questions right. Interview on 4/22/2025 at 10:15AM, CNA #5 stated I remember Resident #22 having hearing aids. I just speak loudly when I am talking to her. Interview with LVN #1 on 4/22/2025 at 10:25AM, she reported that she was unaware of Resident #22 having an issue with hearing, I notice her roommate would answer the questions for her, but I thought it was because they have been roommates for so long and they just knew each other like that. LVN #1 stated if she (Resident #22) had a hearing problem I would let the social worker know and she will take it from there. I would also tell the doctor and family. If Resident #22 lost her hearing that will affect her overall care as well. Interview with SW on 4/22/2025 at 11:00AM, SW stated I send residents out to UTMB for hearing, and she was not one of them. I do sections CDE of MDS and the MDS nurse does the coding for hearing, vison. I was not told Resident #22 had issues with hearing. I do know I had to talk loudly to her sometimes. I believe she had some hearing aids when she was admitted . I will get her on the list for UTMB to be seen today. Interview on 4/22/2025 at 11:30AM, the MDS nurse said I do sections B, sometimes I do all the sections of the MDS. Yes, I coded Resident #22 MDS quarterly and annual that she had no issues with hearing and no hearing aid was present. I did interview her. MDS nurse confirmed that Resident #22 MDS all of them were inaccurate and that could lead to her not getting or receiving the proper care she needed. MDS section B should have reflected she had hearing aids and inadequate hearing. Review of facility policy, Resident Assessment reviewed on 4/22/2025, read in part it is the policy of this facility to ensure that the assessment accurately reflect the resident's status.

Based on observation, interviews, and record reviews, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities, for 1 (Resident #22) of the 6 residents reviewed for the use of assistive device in that- Resident #22 was not assessed and did not receive care for her hearing deficit. This failure could place residents at risk of not receiving appropriate care and services needed to maintain their health and quality of life. The findings included: Record review of Resident # 22 face sheet revealed resident is an [AGE] year-old female and was admitted [DATE] with a diagnosis of upper respiratory tract, depression disorder, pain, hyperkalemia (a condition characterized by abnormally high levels of potassium in the blood), dementia, bipolar disorder, and diabetes type II. Record review of Residents #22 5-day admitted d 9/27/2017 section B category B0200. Hearing ability to hear was code 0 Adequate - no difficulty in normal conversation, social interaction, listening to TV. Section B0300 of Resident's #22 MDS dated [DATE] revealed the following: Hearing Aid Enter Code, 0 Hearing aid or other hearing appliance used in completing B0200. Record review of Resident #22's Quarterly MDS revealed Resident #22 had a BIMS of 14 which indicates moderate cognitive impairment. Record review of Resident #22 physicians' orders and care plan revealed no documentation pertaining to hearing aids. Interview and observation with Resident #22 on 4/22/25 at 9:45AM, Resident expressed she was unable to hear the questions being asked of her and that surveyor would have to speak up and to speak loudly, close to her ear. Even speaking up Resident #22 had difficulty understanding the surveyor. Resident #22 said I cannot hear good I am hard of hearing, and I don't know where my hearing aides are. Resident #22 said I told the nurse, and the people up front I cannot hear and wanted to see a doctor. Resident #22 said I had hearing aid when I came here a while back, I guess they are lost. Observation of Resident #22 on 4/22/25 at 10:00AM revealed no hearing aid present, resident was moving close to roommate to see if she would be able to tell her what was being said. Interview with CNA #2 on 4/22/2025 at 10:00AM, she reported that she had never seen hearing aids for Resident #22. I just speak loudly when I assisted her so she can hear and understand me. I do know she needs them because we have to yell in her ear and she is able to respond to us that way. CNA #2 reported it is our responsibility to make sure we report to nurse or the upper management that a resident is having trouble hearing. CNA #2 reported if a resident cannot hear us talking to them than they may not understand what is going on and they may not be able to tell us what is going on or answer the questions right. Interview on 4/22/2025 at 10:15AM, CNA #5 stated I remember Resident #22 having hearing aids. I just speak loudly when I am talking to her. Interview with LVN #1 on 4/22/2025 at 10:25AM, she reported that she was unaware of Resident #22 having an issue with hearing, I notice her roommate would answer the questions for her, but I thought it was because they have been roommates for so long and they just knew each other like that. LVN #1 stated if she (Resident #22) had a hearing problem I would let the social worker know and she will take it from there. I would also tell the doctor and family. If Resident #22 lost her hearing that will affect her overall care as well. Interview with SW on 4/22/2025 at 11:00AM, SW stated I send residents out to University of Texas Medical Branch (UTMB) for hearing, and she was not one of them. I do sections CDE of MDS and the MDS nurse does the coding for hearing, vison. I was not told Resident #22 had issues with hearing. I do know I had to talk loudly to her sometimes. I believe she had some hearing aids when she was admitted . I will get her on the list for UTMB to be seen today. Interview on 4/22/2025 at 11:30AM, the MDS nurse said I do sections B, sometimes I do all the sections of the MDS. Yes, I coded Resident #22 MDS quarterly and annual that she had no issues with hearing and no hearing aid was present. I did interview her. MDS nurse confirmed that Resident #22 MDS all of them were inaccurate and that could lead to her not getting or receiving the proper care she needed. MDS section B should have reflected she had hearing aids and inadequate hearing. Review of facility policy, Resident Assessment reviewed on 4/22/2025, read in part it is the policy of this facility to ensure that the assessment accurately reflect the resident's status.

Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the facility must include the expiration date when applicable for one (#100 Hallway medication aide medication cart) out of four medications carts reviewed for labeling of drugs. The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma (eye condition that damages the optic nerve) and other causes of high pressure inside the eye) were labeled with expiration date on all medication carts. This failure could place residents at risk of not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications. Findings included: Record review of Resident #42's face sheet dated 4/24/2025, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (high blood sugar) without Complications and unspecified Open-Angle Glaucoma (eye condition that damages the optic nerve). Record review of Resident #42's quarterly MDS dated [DATE] revealed a BIMS score of 13 that suggested cognition was intact (13-15). Record review of Resident #42's Order Summary Report dated 4/24/25 revealed Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes at bedtime for Open Angle Glaucoma with order date of 8/2/2024. Record review of Resident #42's April MAR printed 4/24/25 revealed Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes at bedtime with administration dates from 4/1-4/23/25. Record review of Resident #42's Care Plan Report printed 4/24/25 revealed Resident #42 had impaired visual function related to Glaucoma (eye condition that damages the optic nerve) with Latanoprost drops daily. Observation on 4/23/25 at 9:15 a.m. revealed Latanoprost 0.005% eye drops for Resident #42 with no open date documented found on the #100 Hallway medication aide medication cart. During interview on 4/23/25 at 9:20 a.m., MA G said eye drops should be dated when they were opened. MA G said if a resident is given eye drops past the use by date the resident could get an eye infection and if the eye drops were not dated when they were opened then they would not be able to know when to dispose of the eye drops. During interview on 4/24/25 at 11:19 a.m., the DON said the medication aides and nurses were responsible for checking their medication carts. The DON said the DON and ADON audited the medication carts weekly, and the pharmacist also checked medication carts monthly. The DON said if a medication was given past the use by date, then there could be decreased effectiveness of the medication or adverse reactions depending on the medication. During interview on 4/25/24 at 8:21 a.m., ADON A said the medication aides were responsible for checking the medication carts. ADON A said the DON and ADONs spot checked the medication carts weekly. The ADON A said that the Pharmacist comes to the facility monthly and checked the medication carts. The ADON A said if a medication had a use by recommendation and no open date is documented then the resident could get an eye infection. The ADON A said if a medication that had a used by recommendation and no open date was documented then staff would not know when to dispose of the medication and they would need to get a new medication. ADON A said staff had in-services or trainings at least monthly related to medications. During interview on 4/25/24 at 8:40 a.m., the Pharmacist said they tell staff to date everything when opened to be on the safe side. The Pharmacist said Latanoprost 0.005% needs to be disposed of after six weeks from opening. The Pharmacist said they come to the facility monthly and performed spot checks of medication carts. The Pharmacist said if they saw a problem then they will do one on one training of the staff. The Pharmacist said an adverse reaction that a resident could experience if it unknown how long a medication had been opened for and used past the recommendations was the medication could be less effective. Record review of facility's policy Medication Storage dated 1/25 revealed outdated, contaminated, discontinued, or deteriorated medications are immediately removed from stock. Record review also revealed medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 (Resident #84) of 5 residents that were reviewed for infection control practices. The facility failed to ensure that CNA K followed proper infection control while providing care to Resident #84 on 4/23/25. The failure could place residents at risk of infection, decline in health, or cross contamination. Findings included: Record review of Resident #84's face sheet dated 4/24/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Epilepsy (seizure disorder) and Cognitive Communication Deficit (difficulty communicating). Record review of Resident #84's annual/quarterly MDS dated [DATE] revealed a BIMS score of 10 that suggested moderate cognitive impairment. Record review of Resident #84's Care Plan Report printed 4/24/25 revealed focus of bladder incontinence with intervention to clean peri-area with each incontinence episode. Record review of facility's Sign In Sheet for 4/22/25 revealed CNA K and CNA L worked 10 p.m. to 6 a.m. and LPN B worked 6 p.m. to 6 a.m. on the #100 Hallway where Resident #84 resided. Observation of video on 4/23/25 at 2:32 a.m. revealed CNA K entered Resident #84's room. At 2:33 a.m. CNA K reached into her right scrub pocket with her right hand and pulled a bag out and ate from the bag using her right hand to place food in her mouth. CNA K picked up a pillow from the floor using her right hand and placed it on the bed. At 2:34 a.m. CNA K put food in her mouth twice using her hands, touched the curtain and picked up the call light from the right side of the bed while holding a bag of food in her left hand. At 2:34 a.m. CNA K put food in her mouth using her right hand. CNA K then touched Resident #84's right arm, pulled down his sheet and touched his diaper with her right hand. At 2:35 a.m. CNA K poured food in her left hand and ate the food putting her hand to her mouth. At 2:35 a.m. CNA K picked up a box of gloves with her left hand, a brief with her right hand and put on a pair of gloves. At 2:36 a.m. CNA K wiped Resident #84's bottom using the dirty diaper and did not use wipes during incontinence care. At 2:36 a.m. CNA K threw the dirty diaper on the floor knocking the clean diaper on the floor which she picked up and placed on Resident #84. At 2:37 a.m. CNA K placed Resident #84's blankets over him while wearing the gloves she used to change his dirty diaper and then picked up the dirty diaper off the floor and placed in the trash. Then CNA K removed her gloves and placed them in the trashcan. At 2:38 a.m., CNA K exited the room and shut the door. CNA K was not observed entering or exiting restroom or using hand sanitizer during the time she was in Resident 84's room during the video . During interview on 4/23/25 at 10:07 a.m., Resident #84's family member showed surveyor the video from 4/23/25 that started at 2:25 a.m. At 10:58 a.m. Resident #84's family member said they were not going to speak to anyone at the facility regarding the video prior to leaving the facility. Resident #84's family member said they would send the video from 4/23/25 to the administrator when she sends other videos that she was sending to the administrator. Surveyor received copy of the video on 4/24/25 at 3:10 p.m. from Resident #84's family member. On 4/23/25 at 12:33 p.m., surveyor attempted to contact CNA K via phone but received message that wireless customer was not available. On 4/23/25 at 12:47 p.m., surveyor called LPN B from via phone and left a message with request to call surveyor, but no call back received prior to survey exit . During interview on 4/25/25 at 8:21 a.m., ADON A said the Infection Control Preventionist was who monitored for infection control . ADON A said staff should wash their hands if they touch anything soiled, before and after providing resident care. ADON A said staff should use hand sanitizer between each resident interaction. ADON A said staff should wear gloves when staff had direct contact. ADON A said staff had in-services when something new comes out regarding infection control of if they see high infection rates. On 4/25/25 at 10:33 a.m., the Administrator said it was an expectation for staff to follow the regulations regarding infection control and nursing was who monitored for infection control. The Administrator said if staff did not use proper infection control practices like washing hands and using hand sanitizer then the resident could get a possible infection. The Administrator said she monitored for infection control when making daily rounds. The Administrator said CNA K had been dismissed. On 4/25/25 at 10:33 a.m., the DON said she did daily rounds and throughout the day multiple times a day to monitor for infection control. The DON said staff should use gloves when providing care especially for incontinence care, wound care, touching food on the trays and showers. The DON said staff should wash their hands before and after applying gloves. The DON said staff had annual training and training as needed regarding infection control. The DON said if Infection Control saw any trends, then she would do trainings as needed. The DON said if staff did not use proper infection control practices like washing hand and using hand sanitizer then the resident could get a possible infection. On 4/25/25 at 11:32 a.m., Infection Control said expectations was staff was following standard precautions and washing hands before and after using gloves. Infection Control said they did in-services and trainings regarding infection control and that online trainings were monthly and was unsure how often infection control trainings were completed but probably quarterly. Infection Control said she did pop up inspections about 3-4 times a week to make sure staff were following infection control. Infection Control said a staff member should not be eating in a resident's room and had not seen any staff eating in resident rooms. Infection Control said if staff did not use proper infection control, then an infection could pass from one resident to another. Record review of facility's Employee Inservice/Training form dated 4/25/25 revealed training for staff to remove gloves after being soiled, no eating in resident rooms and to wash hands with hand sanitizer or soap and water after removing globes. Record review of CNA K's User Learning dated 4/25/25 revealed she completed About Infection Control and Prevention on 12/8/24, Bloodborne Pathogens and the Use of Standard Precautions on 3/6/25, Hand Hygiene Basics on 11/24/24 and Infection Control: Basic Concepts on 11/24/24. Record review of Personnel Disciplinary Record dated 4/24/25 for CNA K revealed dismissal with reason termination due to abuse allegation. The Personnel Disciplinary Record was not signed by CNA K with note staff member not returning call. Record review of facility's policy Perineal Care revised 8/2024 revealed staff should wash and dry hands thoroughly prior to starting and after providing care. Record review also revealed that perineal and rectal/buttocks area should be washed using wet washcloth and soap or skin cleansing agent. Record review of facility's policy Infection Control - Standard Precautions revised October 2018 revealed that hands are washed with soap and water after removing gloves and before eating. Record review also revealed that hand hygiene (handwashing with soap or use of alcohol-based rub) was to be performed before and after contact with the resident, after contact with items in the resident's room and after removing personal protective equipment. Record review also revealed gloves are removed promptly after use and before touching non-contaminated items and environmental surfaces. Record review also revealed that hands are to be washed immediately after gloves are removed to avoid the transfer of microorganisms to other residents or environments.

Based on Observation, interview and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment for 3 (Resident #11, #29, & #50) of 18 residents reviewed for comprehensive assessment. 1 The facility failed to accuretly assess Resident #11's lack of teeth and no dentures. 2 The facility failed to accurately assess Resident # 29 for her hearing deficit. 3 The facility failed to accurately assess Resident #50 for his oral cavity. These failures could place the residents at risk of not having all medical needs assessed and met. Findings included: 1.Record review of Resident # 11's electronic face sheet on 02/13/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, hypertension, muscle wasting, abnormal weight loss, diabetes, schizophrenia, anxiety, and depression. Review of Resident #11's Annual MDS dated [DATE] revealed a BIMS score of 7, indicating she was severely impaired on cognition. Her Functional Status indicated she required limited assistance with her ADLs. Her Dental Status did not note any broken or loosely fitting dentures. Section L (B) no natural teeth or tooth fragment(s) (edentulous) was left blank. L (Z) was coded as no problem. Observation on 02/12/23 at 11:00AM revealed Resident #11 was on her wheelchair alert and oriented. She was observed snaking on chips. Observation on 02/13/24 at 12:20PM revealed Resident #11 had lunch in the dining room she was served mechanical altered diet. She had hard time with the meat and requested for soup which was provided. Observation of her oral cavity revealed she had no teeth in her oral cavity. 2.Record review of Resident # 29's electronic face sheet on 02/13/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Peripheral neuropathy (nerve damage caused by several different conditions) hypertension, muscle wasting, hearing loss ear, and heart failure. Review of Resident #29's Annual MDS assessment dated [DATE] revealed she had a BIMS score of 12 that indicated she was cognitively intact. Her Functional Status indicated she required limited assistance with her ADLs. Record review of section B of the MDS hearing, speech, and vision, were all coded as adequate. Record review of Resident 29's care plan initiated on 10/14/22 updated 10/27/23 read in part the resident has a communication problem related to hearing deficit. . Intervention The resident will be able to make basic needs known daily basis through the review target date of 12/27/23. . communication: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off television\radio to reduce environmental noise, Ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. . Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. . Monitor/document frustration level. Wait 30 seconds before providing resident with . Monitor/document residents' ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. Observation and interview on 02/12/24 at 9:40AM revealed Resident #26 was on wheelchair in front of her room. During an interview, Resident #29 said come closer and speak louder I can't hear you. 3.Record review of Resident # 50's electronic face sheet on 02/13/24 revealed a [AGE] year-old male admitted to the facility on initially on 12/13/2017 and readmitted on [DATE]. His diagnoses included muscle weakness, hypertension, type 2 diabetes mellitus with diabetic neuropathy, adult failure to thrive, depressive episodes, vitamin deficiency, heart disease, chronic kidney disease, and liver cirrhosis. Review of Resident #50's Annual MDS dated [DATE] revealed a BIMS score of 12 indicated he was cognitively intact. Record review section L (A) Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) was left blank section L(Z) was coded 0 no oral dental problem. Observation and interview on02/13/24 at 1:0PM revealed Resident #50 was up on his bed eating his lunch which was mechanical diet. During an interview he open his mouth and said his lower teeth are grounded to his gum and he had three on his upper cavity. He said he had no dentures and had not seen any dentist. He continued with his meal. During an interview on 02/14/23 at 1:30PM, MDS coordinator A said she started at the facility sometimes in June of 2023 and there was back flow of MDS that needed to be done. She said would look at Resident # 11, #29 and 50 to see what was wrong. During an interview on 02/14/24 at 2:00PM, MDS coordinator A stated Resident #11 had no teeth in her oral cavity, Resident #29 had hearing loss and Resident #50 had few teeth on his upper cavity and all his lower teeth are grounded down to his gum. She said she would reassess all residents and update their MDS as pointed out. She said an inaccurate assessment would result in needed services not being provided to residents. Policy on accuracy of MDS assessment was requested from the MDS coordinator A on 02/14/24 at 2:15PM. No policy was provided prior to exit on 02/14/24 at 5:00pm

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that expired food products was not used in food preparation and served to resident. The facility failed to ensure that dented cans of food were stored separately. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings included: Observation and interview of the facility kitchen on [DATE] at 8:40 AM revealed the dietary Manager opened a 4 oz carton of milk to use in food preparation. Observation of the carton revealed a used by date of [DATE]. Further observation revealed two boxes of milk each with 25 cartons of 4oz milk all labeled used by [DATE]. During an interview with the Dietary Manager at 8:48AM, the Dietary Manager said she did not notice the dates on the boxes because, the facility had just received the supply last week. Observation and interview of the dry good storage room revealed ,d+[DATE]Ibs of dented can of banana pudding all stored together with undented cans. The Dietary Manager took out the dented can off the shelve and said they are supposed to be stored separately and returned to the supplier. She said the dented cans would be returned for credit. In an interview with the dietary Manager on [DATE] at 9:00AM, she said the expired milk products and dented can goods, could lead to food born illness. She said she would have an in-service to address all concerns. She said she was off over the weekend and did not have time to go over all the food that were received last week. Record review of facility's policies and procedures for food and safe handling revised [DATE], titled Refrigerators and Freezers read in part, . #8 Supervisors will be responsible for ensuring food items in pantry. Refrigerator and freezers are not expired, or pass perish dates. Supervisor should contact vendors or manufacturers when expiration dates are in question. Further review of the policy did not address dented cans.

Based on interview and record review the facility failed to complete and transmit an MDS for 1 of 3 (CR #90) residents reviewed for closed records. The facility failed to complete and transmit a discharge MDS for CR #90 This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes. Finding included: Record review of CR #90's electronic face sheet, on 02/14/24 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE], readmitted on [DATE], 03/09/23, and discharged from the facility on 09/06//23. His diagnoses included, heart diseases, chronic kidney disease, end stage renal disease, hypertension, anemia, diabetes, Arthritis, lack of coordination, pain, and muscle wasting. Record review of CR #90' last completed MDS was dated ARD 09/06/23 was sign as completed on 02/05/24, 5 months after being discharge from the facility. Record review of nurse's notes dated 09/12/23 undated, unsigned read in part Patient with elevated BUN 113 CR 4.7, unable to obtain IV access. VSS. Patient AOX#, no c/o voiced. Received order to send to local hospital ER for further evaluation. Record review of nurses note dated 9/21/2023 14:12 (2:12PM) unsigned read in part COMMUNICATION - with POA: Tried to LVM for Resident #90's POA to check on CR #90. Was told CR #90 was sent to another facility so I wanted to follow up with POA to discuss why. During an interview with MDS Coordinator B on 02/14/24 at 2: 10PM, stated she was new to the position of MDS and was still in training. She said she could not explain why it was not done but she would complete the MDS and transmit it. Policy on MDS completion was requested from the MDS coordinator. The policy was not provided prior to exit on 02/14/24 at 5:00PM

Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was completed and reviewed and revised by the Interdisciplinary team after each assessment for 1 of 18 residents reviewed for care plan accuracy (Resident # 96). --Resident # 96 comprehensive care plan was not completed by the review date and did not contain goals and interventions as coded in the baseline care plan. This failure placed residents at risk of not receiving proper care and services according to their individual status. Finding include: Record review of Resident # 96's face sheet dated 1/15/24 revealed admitted [DATE] with diagnoses including dementia (loss of cognitive functioning, memory, reasoning), heart disease (conditions affecting the vessels, arteries, structure of the heart), hypertension (high blood pressure), arthritis inflammation or swelling of joints), depression (feeling sad, irritable, empty), and Diabetes (elevated blood glucose levels). Observation and interview of Resident # 96 on 2/12/24 at 9:15 am revealed he was in his room, resting in bed, and was easily awakened. He said he was fine and just came here last month for rehab, which was going well and he was getting stronger. He said he needed the therapy so he could get strong enough to walk after his health decline. Record review of the admission MDS dated [DATE] revealed triggered care areas of functional abilities, cognitive loss/dementia, urinary incontinence, dehydration/fluid maintenance, nutritional status, pressure ulcer, and return to community referral Record review of the Baseline Care Plan dated 1/16/24 revealed the following sections were completed on the following dates: functional abilities and goals (1/16/24), health conditions (1/16/24), dietary/nutritional status, therapy, and social services (1/24/24), and plan of care. . Record review of Resident #96's comprehensive care plan revealed date initiated 1/15/24, and next review date 2/4/24. The comprehensive care plan had not been reviewed by the review date of 2/4/24 and did not contain goals/interventions for MDS triggered care areas of functional abilities, cognitive loss/dementia, urinary incontinence, dehydration/fluid maintenance, nutritional status, pressure ulcer, and return to community. In an interview with the MDS nurse on 2/14/23 at 1:40 pm, she said she just took over this job in January 2024 and had been busy. She said they have 21 days to complete the care plan, and knew it was late, but she did not have time to complete it. She said the other nurses and managers would give her input for the care areas for the residents and she would complete the care plan. She said the risk of having an incomplete care plan would be the resident not receiving correct care, but she would hope the CNAs would ask someone about the care for a certain resident if it was not on the Kiosk. In an interview with the DON on 2/14/23 at 1:55 pm, she said they have had some changes in staff recently, which could be why the comprehensive care plan was late. She said if she revised the Kardex, her name would be listed as reviewer. She said the resident would not receive proper care if the care plan was incomplete. The facility policy on Care Plans was requested from Administration on 2/14/24 but had not been received by the exit.

Based on interview and record review, the facility failed to coordinate an assessment with Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort and for 1 of 1 resident reviewed for PASRR services coordination and assessment. (Resident #1) The facility failed to submit a complete and accurate NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #1 by a specific deadline and, as a result, Resident #1 had not received the CMWC. This failure could place residents with a positive PASRR evaluation at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #1's face sheet dated 07/06/2023 indicated Resident #1 was [AGE] year old male, admitted on [DATE], diagnosis included cerebral palsy. Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 was diagnosed with cerebral palsy, used a wheelchair for mobility. Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had an ADL self-care performance deficit related to impaired balance and limited mobility. Listed interventions indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing and included PT/OT evaluation and treatment. Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had a positive PASRR status due to a diagnosis of cerebral palsy requiring specialized services, CMWC. The listed goal indicated Resident #1 would have all identified needs met. Listed interventions included facility will coordinate services with the local mental health authority. Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had a diagnosis of cerebral palsy. The listed goal was Resident #1 would be able to function at the fullest potential possible as outlined by the treatment team. Listed interventions included: Maintain good body alignment to prevent contractures . OT to monitor/document and treat at indicated .Use assistive devices recommended . PT to monitor/document and treat at indicated . Record review of Resident #1's PCSP form dated 02/08/2023 indicated Resident #1, diagnosed with IDD, had an initial IDT meeting for specialized services review on 02/08/2023. This PCSP form indicated the IDT members recommended Resident #1 receive new services of CMWC, Specialized Assessment OT and Specialized Assessment PT. Record review of a Simple LTC PASRR NFSS Activity for CMWC/DME assessment dated [DATE], signed by OT 05/22/2023 and signed by the physician 06/05/2023 indicated Resident #1 has a history of very thin, fragile skin, increased pressure at bony prominences due to low weight and malnutrition in community prior to entering the facility and decreased skin integrity with history of previous sacral skin breakdowns .due to severity of postural deficits and deformities. The section titled Describe Orthopedic conditions noted Resident #1 presents with severe and significant tightness, tone and contractures .contractures, scoliosis and severe lower extremities contractures .Resident #1 presents with significant deficits, poor balance, diminished sensation/cognitive awareness, very poor upper extremity and lower extremity strength and severe contractures . Per this same assessment the Reason Code for this assessment indicated HHSC did not receive information previously requested from the nursing facility necessary to establish eligibility for the service or item. Record review of PASRR Compliance Call Report for March 2023 spreadsheet for Resident #1's IDD services PASRR Unit indicated the following: *IDT meeting was held on 02/08/2023, *PCSP was created on 02/21/2023, *IDT date plus 30 days was 03/10/2023, *NF contacted 05/16/2023, *Due date for NF to submit NFSS form in LTC portal for DME/CMWC was 05/22/2023. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 06/12/2023 at 10:13 a.m. for Resident #1 indicated the NFSS form request for CMWC/DME was not submitted within 30 calendar days of the IDT meeting. During an interview on 07/06/2023 at 4:15 p.m., the Administrator said OT/PT Specialized Assessment submissions were late in the LTC Portal and Resident #1 had not received the CMWC. During an interview on 07/06/2023 at 5:20 p.m., the MDS/PASRR Nurse said on 05/19/2023 the facility entered the measurements Resident #1's CMWC but had to wait on additional information from DME, which was not received 06.12.2023. The MDS/PASRR said the same day (unknown) the facility received the information from the DME it was submitted in the portal. She said Resident #1 had not received the CMWC. Record review of the March 2019 facility policy entitled Admission Criteria (provided by the facility as the PASRR policy), section Nursing Facility Responsibilities read, 1 .b. admit residents who can be cared for adequately by the facility .6. Residents are admitted to this facility as long as their needs can be met adequately by the facility . Record review the facility provided CMS 672 dated 07/05/2023 indicated there was one resident with intellectual and/or developmental disability.

47277 Based on interview and record review, it was determined the facility failed to immediately report a serious bodily injury of an unknown source to the administrator of the facility and to other officials (including to the State Survey Agency) after the allegation was made in accordance with State law for 1 of 6 residents (CR#1) reviewed for abuse/neglect, mistreatment, including injuries of unknown source. The facility failed to report an allegation of abuse involving (Closed Record) CR#1 to the State Survey Agency that occurred on 10/30/22 when CR#1 sustained major injuries from an unwitnessed fall. This failure could affect residents by placing them at risk of not having incidents of abuse, neglect, or exploitation reviewed and investigated in a timely manner by the facility and State Survey Agency. Findings included: Record review of CR #1's electronic records face sheet revealed he was a[AGE] year-old who was admitted to the facility on [DATE] with a primary diagnosis of Dementia (a group of symptoms affecting memory, thinking and social abilities), severity, without behavioral, psychotic (a condition of the mind that results in difficulties determining what is real and what is not real) mood disturbance, and anxiety. Record review of CR #1's nurse's notes dated 10/30/22, read in part, CR #1 was found in the hallway, on the floor, in a prone (face down on belly) position. Resident sustained injuries to his face, knocked out teeth, and scarred (scraped) his legs. Resident taken to emergency room due to unwitnessed fall. Record review of CR #1's last MDS dated [DATE] revealed a BIMS score of 02, indicating he was severely cognitively impaired. Record review of CR#1's care plan initiated on 11/8/22, reads in part The Focus: the resident has an ADL (Activities of Daily Living) self-care performance deficit related to (r/t) Dementia, Impaired balance, limited mobility. Goal: The resident will improve current level of function through the review date. Interventions: Extensive Assist with Bed Mobility, Transfers, Dressing, Toileting and Personal Hygiene. Record review of CR #1's LVNs notes Late Entry dated 11/1/22, read in part resident fell in his bedroom. The fall was not witnessed. An interview with the Director of Nursing (DON) on 6/29/23 at 2:10PM. The DON stated that she was aware of the incident. She also stated, she is notified immediately of all incidents in the facility. She stated she did not report the incident as she did not deem it a major incident at the time, and she was waiting for the hospital visit/treatment documentation. An interview with the Administrator On 6/29/23 at 3:07pm. The Administrator stated she was not working during this occurrence; however, she became aware of CR #1's fall on 11/1/22 and immediately reported the incident on 11/1/22. She also stated that the incident should have been reported immediately based on the facility's reporting policy and major injury to the resident. Review of the facility's policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation policy. The Policy Interpretation and Implementation defines Immediately as A. within two hours of an allegation involving abuse or result in serious bodily injury; or B. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Residents #3 and #5) reviewed for infection control. 1. The facility failed to ensure the ADON wore proper PPE when entering a resident's room who was positive for COVID-19. 2. The facility failed to ensure the DOR and NP wore proper PPE when entering a resident's room who was presumed positive for COVID-19. These failures could place residents' at risk of further spread of infection. Findings include: 1. Record review of Resident #3's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's MDS revealed the resident had a BIMS score of 15, which indicated there was no significant impairment of her cognition. Record review of the Resident #3's COVID-19 test, dated 02/03/2022, revealed Resident #3 tested positive. Observation of the hot unit, where only COVID positive residents reside, on 02/10/2022 at 11:46 AM revealed the ADON walked into room [ROOM NUMBER] wearing only a N95 mask, face shield in her hand, no gown or gloves, while holding some take-out food. She entered the room to deliver the food to Resident #3. The ADON left Resident #3's room and did not perform hand hygiene and walked off of the hot unit into the warm unit, where a mix of COVID negative and unconfirmed, presumptive positive residents resided. where her office was located. In an interview with the ADON on 02/10/2022 at 11:48 AM, she Resident #3 was positive for COVID-19 and was in isolation. She stated she was the charge nurse for both the warm unit and hot unit while the LVN for the warm hall was on lunch break. She stated to enter into the hot unit, where the COVID-19 patients resided, staff and visitors must wear PPE. She said she did not realize she went in Resident #3's room without any additional PPE, and if she did, it must have been because she did it without thinking because she had gone back there multiple times to deliver things to Resident #3. Said she was trained to put on full PPE which included a face shield, gowns and gloves prior to entering the rooms of COVID-19 positive residents. In an interview with the DON on 02/10/2022 at 12:30 PM, she stated in the hot unit, staff were supposed to wear full PPE which included N95 masks, gloves, face shields and gowns and no resident rooms could be entered without that equipment being worn. She said she could not assume why the ADON entered Resident #3's room without the required PPE but she should have known to wear all of those things. She said she even worked with the ADON on the unit before and observed her wearing all the appropriate PPE at that time. 2. Record review of Resident #5's face sheet revealed a [AGE] year-old female was who was admitted to the facility on [DATE]. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of the warm unit on 02/10/2022 at 5:15 PM revealed the DOR entered the room of Resident #5 with just a N95 mask and face shield, the DOR did not wear gloves and goggles. The DOR leaned down about 6 inches away from Resident #3's to hear what the resident was saying to her. Observation of the warm unit on 02/11/2022 at 10:20 AM, revealed the NP enter Resident #5's room with only a N95 face mask, face shield and gloves. The NP did not wear a gown to provide care to the resident who reported feeling out of breath. In an interview with the DOR on 02/10/2022 at 5:15 PM, she stated she leaned down to hear what Resident #5 was telling her, after that she would decide if she needed additional PPE to engage with the resident. She said standard practice for transmission based precautions was for full PPE to be worn prior to entering the rooms. In an interview with the DON on 02/11/2022 at 9:32 AM, she stated on the warm unit it was required to wear all PPE, which included a gown and gloves prior to entering a resident's room to talk to them. When asked for their policy, she stated they use the state response plan for nursing facilities as their guidance. In an interview with the NP on 02/11/2022 at 10:27 AM, she stated she believed Resident #5 was on the warm unit because Resident #5 was a new patient and she saw the precautions at Resident #5's door. NP stated she should have worn a gown. Record review of the facility's state COVID-19 Response for Nursing Facilities, dated, 07/20/2022, stated, HCW/staff leaving and entering isolation wing/unit . directly after entering the isolation are and prior to donning PPE, perform hand hygiene; put on proper PPE; perform hand hygiene before and after performing resident care; directly before exiting the isolation area, remove PPE; perform hand hygiene Record review of the CDC procedures on Using Personal Protective Equipment (PPE), dated August 19, 2020, stated Healthcare personnel should adhere to Standard and Transmission-based precautions when caring for patients with [CONDITION(S)]-CoV-2 infection. It stated the procedure on donning PPE which included to, .put on isolation gown . put on . N95 filtering face piece respirator or higher (use a face mask if respirator is not available) . put on face shield or goggles . put on gloves .

Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene care for four (Resident #128, Resident #22, Resident # 67, and Resident # 7) of six residents reviewed for ADL care. 1. The facility failed to ensure Resident # 128, Resident #22 and Resident #67 were provided with proper fingernails care. 2. The facility failed to ensure Resident #7 was provided shaving on shower days and as needed. These failures could place residents at risk of not receiving personal care and services. Findings included: 1.Record review of Resident #128's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #128's quarterly MDS, dated on 06/21/21, revealed A BIMS of 04, which indicated severe cognitive impairment. the resident required total assist with personal hygiene with two persons assistance. Record review of Resident #128's care plan dated 09/16/21 revealed the resident required total care with bathing and grooming. it also revealed resident was incontinent of bowel and bladder. Record review of Resident # 128's Bath/Shower completion form dated from 09/03/21 through 09/16/21, revealed Resident #128 fingernails were not cut or trimmed. Observation and interview on 09/15/21 at 10:05 a.m. revealed Resident # 128 fingernails on both hands were about 1. 5 inches long and had dark brown substance underneath the nails. Residnet # 128 was not able to respond during interview. Observation and interview on 09/15/21 at 10:15 a.m., with LVN B, revealed Resident # 128's fingernails on both hands were long and dirty. LVN B said the resident had diabetes, and the nurse was responsible for cutting her nails. LVN B said she wouldn't have any reason why Resident #128's nails were not cut or cleaned. LVA B said she completed an in-service on cutting and cleaning fingernails. She stated the ADON was responsible for monitoring the nurses to ensure diabetic residents were cut and cleaned. LVN B said long fingernails can accumulate dirt and bacteria and resident could break her skin. Observation and interview on 09/15/21 at 10:39 a.m., with CNA P, revealed Resident #128's fingernails on both hands were long and dirty. CNA P said the aides cut and cleaned residents nails on shower days and as needed. She said she did not cut the resident fingernails because she didn't shower her. She stated the evening shift shower's Resident #128. CNA P said completed in service on trimming and cleaning resident nails. She said fingernails were documented on the shower sheet, and the nurses monitored the aides to make sure they were doing nail care. Interview on 09/16/21 at 11:15 a.m., with the DON, she said resident fingernails were cut on shower days, and if the resident had diabetes, the nurse must cut the nails. The DON said the aides were responsible for cleaning fingernails whether they had diabetes or not, and it was done on shower days and as needed. She stated CNA P completed skills check off on fingernail care. 2.Record review of Resident #22's face sheet revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 22's MDS dated [DATE], revealed A BIMS of 09, which indicated moderate cognitive impairment. the resident required supervision with personal hygiene with one person assist. it also revealed she was continent of bowel and bladder. Record review of Resident 22's care plan, dated 09/16/21, revealed resident required set up and supervision for bathing and grooming. it also revealed resident was continent of bowel and bladder. Record review of Resident # 22's Bath/Shower completion form dated 09/02/21 through 09/16/21, revealed Resident #22 fingernails were not cut or trimmed. Observation and interview on 09/15/21 at 10:22 a.m. revealed Resident #22's fingernails on both hands were about one inch long, and the fingernails had some dark brown substance in the nails bed. Resident # 22 said she wanted her fingernails to be trimmed and cleaned. She said she might open her skin when she scratched herself. Observation and interview on 09/15/21 at 10:29 a.m., with LVN B, she said Resident #22 fingernails were long and had dark substance under the fingernails. She stated the CNAs trim the residents nails on shower days if the resident did not have diabetes, but the nurse would cut the resident's nails if the resident had diabetes. She said Resident # 22 was not diabetic, and the aides should have cut her nails on shower days, and the nurses should supervise the aides to make sure CNAs cut the residents' fingernails. LVN B said she did not notice the resident's fingernails. Observation and interview on 09/15/21 at 10:39 a.m., with CNA P she said Resident # 22 fingernails on both hands were dirty and long and fingernails should be cut on shower days and as needed. CNA P stated she was the resident aide, and she just noticed the resident's fingernails, and she would cut them later. She said she had been in serviced and completed skills check off on ADL, and fingernails were included. She said she would report to the charge nurse if any resident refused to trim their fingernails, but Resident #22 had not refused for her fingernails to be cut. CNA P revealed Fingernails were documented on the shower sheets either the resident refused or agreed. Interview on 09/16/21 at 11:15 a.m., with the DON, she said resident nails were cut on shower days and as needed. She said if the resident had diabetes the nurse had to cut the fingernails. DON said Resident # 22 was not diabetic and her aide should had cut her fingernails. She revealed the aides are responsible for cleaning fingernails whether the residents had diabetes or not, and it was done on shower days and as needed. The DON said the charge nurse supervised the aides to make sure they cut resident nails. She stated the ADON monitored the nurse to make sure they cut diabetic residents' fingernails. She said she would check to see if the aides and LVN had completed their skill checkoffs on ADL care which included fingernails care, and she would provide the in-service. Interview on 09/17/21 at 8:59 a.m., the with ADON, she said if the residents do not have diabetes, the aides cut their fingernails on shower days and as needed. She also stated if they had diabetes, the nurses cut the fingernails on shower days, and the nurse also cut residents' nails on Sundays. she said the charge nurse supervised the aides to make sure they cut the resident's fingernails. ADON said she would be the person who watched the nurses and made sure the nurses cut the diabetics' fingernails. She said she didn't check the nurses often because she assumed the nurses were doing their job. However, she may check once every month; she would check every week going forward. 3.Record review of Resident 67's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 67's quarterly MDS, dated on 08/18/21, revealed A BIMS of 04, which indicated severe cognitive impairment. the resident required extensive assist with personal hygiene with one person assist. It also revealed she was incontinent of bowel and bladder. Record review of Resident 67's care plan, dated 09/16/21, revealed the resident required total care with bathing and grooming. it also revealed the resident was incontinent of bowel and bladder. Record review of Resident # 67's Bath/Shower completion form dated 09/03/21 through 09/16/21, revealed Resident #67 fingernails were not cut or trimmed. Record review of Resident #67's progress note dated 09/14/21 revealed RP (responsible party) called for ambassador rounds updates given ordered nail supplies to cut Resident# 67's nails she was concerned about getting them cut. There was no documentation on the progress note from ADON and activity director that responsible party said the facility should not cut, trim or clean Resident #67's fingernails. Observation and interview on 09/15/21 at 11:10 a.m., with Resident #67, revealed three fingernails on the right hand were about 0.75 inches long and calcified, and had brown substances under the nails. The thumb and the last finger on the right-hand fingernails were about 1 inch long and had brown substances under the nails. All the fingernails on the left hand were about one inch long and had some brown substance under all Resident # 67 fingernails. Resident # 67 said she wanted her fingernails to be clipped and cleaned, and ladies' nails should always be clean. Interview on 09/15/21 at 11: 12 a.m., with LVN B, she said her nails were long and dirty, and the residents fingernails should have been cut and cleaned by her aide on shower days and as needed. LVN B said the nurses supervised the aides to make sure they cleaned and cut the residents nails. LVN B said she was supposed to make rounds, check resident fingernails weekly, and do daily spot checks, but she had not been doing it and she did not have any reason for it. Interview on 09/16/21 at 1:21 p.m., with the Administrator, he said the staff had schedules to cut the resident nails on shower days and as needed. In addition, the facility had a nail clinic on Sundays where nurses cut or trimmed residents' nails. He said if a resident refused to cut their nails, the aide should notify the charge nurse. He said the charge nurse should try to assess the resident, and he was not sure if it was in their policy to document the resident refused. Interview on 09/17/21 at 8:52 a.m., with the DON, she said the activity director was the person who talked to the resident's family member about the fingernails. However, she did not see where the activity director or the ADON documented on the progress note the facility staff should not cut Resident # 67 fingernails. Interview on 09/17/21 at 8:59 a.m., with ADON, revealed Resident #67 had a nail technician who came to cut her nails, but she could not remember when she started, and the last time she went to cut Resident #67 nails. She also said the RP said the facility staff should not trim the resident fingernails, because the nail technician would be cutting the resident fingernails, which the activity director documented on her progress note. Interview on 09/17/21 at 9:18 a.m. with, Resident #67'S RP revealed she did not tell the facility not to clean or cut Resident #67's fingernails. she said the facility should cut Resident #67's fingernails and clean the nails when they were dirty. RP said she told the facility she would send a nail technician, and when she didn't come, the facility would still have to cut and clean her fingernails. She said Resident #67 fingernails were long and dirty during the lockdown, and she bought and gave the facility a manicure kit to make sure they kept up with Resident# 67 fingernails. She said the last time the nail technician went to the facility was two months ago and she stopped the nail technician from going to the facility the next month because the facility had COVID - 19 in the building. Interview on 09/17/21 at 2:06 p.m., with the Activity director, she said Resident# 67's RP gave her a nail kit for the facility to use and provide nail care for the resident during the lockdown. She stated the nail technician went to do her nails, and she said the facility staff did not do her nails, and she documented it on the resident's progress note. The activity director said she gave the nail kit to the ADON to cut the resident's fingernails when the nail technician the sister hired, was not available. Interview on 09/17/21 at 2:39 a.m., with the ADON, she said Resident # 67's RP brought the nail kit, and it had a drill. The ADON told the family she could not use it because she was not a nail technician, and ADON thought she gave it back to the RP but kept the nail clippers when she cut Resident # 67 fingernails. The ADON said she could not remember the last time she cut Resident # 67 fingernails, and it may have been a month ago or more. 4.Record review of Resident # 7's face sheet revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . record review of Resident # 7's annual MDS, dated on 08/26/21 revealed A BIMS of 02, indicated severe cognitive impairment. the resident required total assist with bathing and personal hygiene with one person assist. Record review of Resident #7's care plan, dated 09/15/21, revealed the resident required extensive to total care with one-person assistance with personal hygiene. it also revealed the resident was incontinent of bowel and bladder. Observation on 09/15/21 at 11:20 a.m., revealed Resident #7 in bed, and she had facial hairs about one inch long on her chin. Observation and interview on 09/15/21 at 11:23 a.m., with LVN B, she said Resident # 7 had facial hair on her chin, and the aide shaves the residents on their shower days and as needed. LVN B said the charge nurse supervised the aides to make sure they provided care for the residents, and she just saw the facial hair. She would take care of the facial hairs Observation and interview on 09/15/21 at 11:25 a.m., with CNA A, she said she was Resident #7 aide. She could see the facial hair on the resident's chin. However, she did not shave her. CNA A said she did not shave the resident today because she tried to shave Resident # 7 before and she refused CNA A said she had completed skills check off and in serviced on ADL, which included shaving the residents. She said residents are shaved on shower days and as needed. She said she should have tried today and report to the nurse if she had refused. Interview on 09/16/21 at 11:15 a.m., with the DON, she said the facial hair was shaved on shower days and as needed, and the nurses would shave facial hair for the residents with diabetes. The DON said the charge nurse supervised the aide to make sure they shaved the resident's facial hair. She stated the ADON monitored the nurses to make sure they shaved diabetic residents' facial hair. She said she would check to see if the aides and LVN had completed skill check - offs on ADL care. Interview on 09/16/21 at 1:21 p.m., with the Administrator, he said the staff had schedules they followed to shave resident's facial hair on shower days and as needed. He said if a resident refused to be shaved, the aide should notify the charge nurse. He said the charge should try to assess the resident, and he was not sure if it was in their policy to document if the resident refused to be shaved. Interview on 09/17/21 at 8:59 a.m., with ADON, revealed residents are shaved on shower days, and if needed on Sunday by the CNA. she said the CNA shave both diabetic and non-diabetic residents. ADON stated the nurses monitored the aides, and she didn't go behind the nurse to check if the aides were providing shaving care, but she should. Interview on 09/17/21 at 3:50 p.m. with the Administrator revealed the facility did not have a policy on how to provide fingernails and shaving care for the residents.

Based on interview and record review the facility failed to ensure all irregularities identified by the licensed pharmacist were reviewed and action has been taken by the attending physician to minimize or prevent adverse consequences to the extent possible for 2 (Residents #54 and #66) of 16 residents reviewed for drug regimen review. The facility failed to report Pharmacist Consultant recommendation for Resident #54 [MEDICATION(S)] suspension 1%, 1 drop Lt eye every 4 hrs since 1/20/21. Long term use of this med is not recommended because of possible super infections and/or ocular damage from [CONDITION(S)], to physician. The facility failed to report Pharmacist Consultant recommendation for Resident #66 [MEDICATION(S)] ([MEDICATION(S)]) long acting benzodiazepine (with sleep inducing, sedative action) to please consider a change to a shorter acting benzodiazepine, please evaluate current drug therapy benefit versus risk, to physician. These failures could place residents at risk for medication errors, unnecessary medications and incorrect medication administration. Findings include: 1. Record review of Resident #54's clinical record revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], ataxic gait, alcoholic liver [CONDITION(S)] without ascites and unilateral inguinal hernia, without obstruction. He required 1 staff limited assist for most ADLs and was able to make his needs known. Record review of the facility Pharmacist Consultant recommendation, dated 05/2021 and 06/2021, revealed Resident #54 has ordered [MEDICATION(S)] drops, suspension 1%, 1 drop Lt eye every 4 hrs, since 01/20/21. Long term use of this med is not recommended because of possible super infections and/or ocular damage from [CONDITION(S)]. Please evaluate the continued need for this therapy. Record review of Resident #54's Consolidated Physician Order, dated 08/2021 and 09/2021, revealed to give [MEDICATION(S)] drops, suspension 1%, 1 drop, ophthalmic (eye), four times a day, start date 8/26/21 for dx. cataract extraction status, Lt eye. Further review noted no special instruction to give the eyedrop to his Lt eye. Record review of the Medication Administration (MAR), dated 09/2021, revealed Resident #54 received [MEDICATION(S)] drops, suspension 1%, 1 drop, ophthalmic (eye), four times a day, start date 8/26/21 for dx. cataract extraction status, Lt eye. Further review noted no special instruction to give the eyedrop to his Lt eye. During interview on 9/16/21 at 2:40 PM the PA stated on-call PA/NP did not review previously discontinued medication for Resident #54, since after-hours on call NP/PA do not have access to resident's matrix. PA added whoever was on call would just respond yes with facility nurse to continue with the meds, and Resident been in and out of the hospital. PA stated on-call NP/PA missed previously discontinued [MEDICATION(S)] eye drops for Resident #54 that was discontinued since June 2021. PA stated she agreed with the Consultant Pharmacist recommendation and she would discontinue Resident 's [MEDICATION(S)] eyedrops. The PA stated she was at the facility twice a week and she knew where to locate MRR binder for follow-up. Interview on 9/17/21 11:30 AM with the ADON, she stated this was an issue for physician group, since according to PA if whoever was the NP/PA on call, had no access to resident's matrix. She stated she had the binder in her office where she could put the MRR/ physician letters for follow-up. ADON stated she was responsible to follow-up on the MRR, after it was signed by NP/PA or MD, and she would give it to medical records for upload. She stated she would hand the MRR/ physician letter to PA/NP if present in the facility and occasionally she would call. Record review of MRR/Physician letter for Resident #54, dated 6/23/21, revealed [MEDICATION(S)] drops, suspension 1%, 1 drop to Lt eye every 4 hrs, since 01/20/21, and noted MD /prescriber response, a telephone order from PA, to discontinue Resident's [MEDICATION(S)] eyedrops. 2. Record review of Resident #66's admission MDS, dated [DATE], revealed a [AGE] year old female admitted to facility on 8/05/21 with diagnoses of [CONDITION(S)] disease, anxiety disorder, depression other than [CONDITION(S)], unspecified fall, sequela, peripheral autonomic [CONDITION(S)] and [CONDITION(S)] (dizziness). Further review revealed she had not exhibited rejection of care behavior. No hallucination or delusions. She received antianxiety along with antidepressants for 7 days/week. She was able to understand others and make herself understood. She required 1 staff extensive assist for most ADLs. Record review of Resident #66's care plan, dated 8/14/21, revealed she took antianxiety medications and was at risk of adverse side-effects. Further review revealed the Pharmacy Consultant reviewed and monitored, reduce or discontinue if any signs of adverse consequences. Monitor functional status, to determine if status has been maintained or improved with drug use. Record review of the facility Consultant Pharmacist recommendation, dated 08/2021, revealed Resident #66 is receiving [MEDICATION(S)] ([MEDICATION(S)]) 1 mg three times a day. Long acting benzodiazepines (sleep inducing and sedative action) are not recommended in the elderly due to their long half-life leading to sedative side effects such as confusion, cognitive impairment, increased fall risk, and unsteadiness. Please consider a change to a shorter acting benzodiazepine such as Lorazepam or [MEDICATION(S)]. If therapy is to continue, please evaluate current drug therapy benefit versus risk .or .risk (including potential adverse effects noted above) if outweigh the benefits at this time. Please discontinue and change to. Record review of Resident #66's Hospital notes, dated 8/04/21, read in part, Primary Diagnosis: Debility with multiple falls. History of Falls: Multiple falls in last 3 weeks .Physical Therapy inpatient evaluation. Comments: She states that prior to a couple of weeks ago, she was able to walk with a rolling walker. History of Present Illness (HPI) .has worsening gait instability and multiple falls over the past 3 weeks .Her mentation is a little bit off so this is the only history I can get from her. Record review of Resident #66's Consolidated Physician Order, dated September 2021, revealed to give [MEDICATION(S)] ([MEDICATION(S)]) 1 mg 1 tab by mouth every 8 hrs (three times a day), start date 8/06/21 dx. generalized anxiety disorder. Record review of the Medication Administration Record (MAR), dated September 2021, revealed Resident #66 received [MEDICATION(S)] ([MEDICATION(S)]) 1 mg 1 tab by mouth every 8 hrs, start date 8/06/21 dx. generalized anxiety disorder. During interview on 9/16/21 at 2:40 PM with the PA stated this was her first time to see the Consultant Pharmacist had recommended to switch Resident #66's [MEDICATION(S)] from long acting benzodiazepine to a shorter acting benzodiazepine. The PA acknowledged the adverse sedative side effects of benzodiazepines which included drowsiness, dizziness, increased fall risk and unsteadiness. The PA stated she was concerned of her falls and she would consider changing from long acting ([MEDICATION(S)]) to a short acting benzodiazepine for the resident as recommended by Consultant Pharmacist. Interview on 9/17/21 11:30 AM with the ADON, she stated she has the MRR binder in her office where she can put the MRR or physician letters to follow-up on it. She added she kept the copy and Medical records uploads it to the chart. ADON stated that the PA saw Resident #66's MRR or Consultant Pharmacist recommendation for her [MEDICATION(S)], since she handed it to the PA. She stated she would hand the MRR/ physician letter to PA/NP if present in the facility and PA was in the building twice a week. Record review of the facility provided policy titled, Medication Monitoring, Medication Management, dated 2007, read in part, the facility assures that residents are being adequately monitored for adverse consequences .If the [CONDITION(S)] med is identified as possibly causing or contributing to adverse consequences .facility and prescriber must determine whether the med should be continued and document the rationale for the decision .Tapering may be indicated when .the underlying causes of the original target symptoms have resolved and/or Non-pharmacological approaches have been effective in reducing the symptoms.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent injuries for 1 of 3 residents (Resident #1) reviewed for accidents/supervision in that; -PT staff left Resident #1 sitting in his new motorized wheelchair when he was not properly trained resulting in the resident moving the wheelchair, catching his left leg between the wheelchair and door causing a left tibial and fibula fracture. -The facility failed to ensure staff were properly trained to assist Resident #1 with maneuvering or turning off his motorized wheelchair. This failure could affect any resident who received new assistive devices. Findings include: Record review of Resident #1's Facesheet revealed, a [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed, A BIMS score of 14 indicating intact cognition. He required extensive assistance of 1 person for locomotion on and off the unit. He had functional limitations on upper and lower extremities on both sides. The MDS assessment revealed he used a wheelchair. Record review of the facility incident investigation report dated 1/21/2020 read in part, On 01/15/20 the resident (Resident #1) received a new power chair. The DME company representative adjusted the power chair and oriented the resident to the new equipment. The resident was then seen by therapy to continue training. At the conclusion of the training day the therapist took the resident to activities to participate and at the end of the activity the resident became impulsive and impatient when having difficulty maneuvering the chair out of the activities room. Despite being asked by the activities assistant to wait for the therapist to assist him the resident attempted to exit the room catching his chair and foot in the doorway resulting in a fracture to his left ankle. The resident did not realize the extent of his injury as he could not feel any pain in the leg. The resident confirms the event occurred and regrets not waiting for therapy to assist him with the chair. Record review of Resident #1's hospital imaging report dated 1/15/20 read in part, 3V left ankle, 2V left tibia, 2V left knee subacute tibial and fibular fracture deformities, suprapatellar joint effusion. Assessment XXX[AGE] year old male with subacute, closed, tibial shaft fracture with associated subacute proximal fibula fracture. Record review of Resident #1's Care plan dated 1/15/2020 read in part, .Approach Start Date: 01/15/2020 New powered w/c delivered prior to occurrence and set up, therapy to screen for proper management of w/c. Approach Start Date: 01/16/2020 Therapy to keep power w/c in therapy until proper use established as he is impulsive and feels that he can maneuver chair, He is unaware of safety with new w/c. Further record review of the residents' care plan revealed, safety concerns related to the safe use of the motorized w/c use was not addressed until after the incident occurred. Interview on 01/22/2020 at 8:38 AM with the Administrator, he stated Resident #1 was at the facility and was alert and does not have any cognitive impairment, further stating the resident was able to explain the incident that occurred. He stated the resident just received his motorized wheelchair and was in the activity room and was trying to leave. He stated the activity assistant told him to hold on and she would help him out of the room because he was having some difficulty, but the resident stated he didn't need help and continued to attempt to leave. He stated the activities assistant again asked him to wait for her to help, but the resident took off in the chair when his foot became wedged between the door and his motorized chair. He stated the resident had no feeling in his lower extremities due to his paralysis, so when the staff assessed him, he continued to state he was fine. He stated the resident was sent to the ER because of the deformity of his LE and he did sustain a fracture. He stated when the resident came back to the facility he was told that he would only be able to use the motorized chair after he passed several tests and that the chair would remain in PT room. He stated they had a meeting with the family explaining that the resident would need to use the chair supervised until he was able to pass several tests to determine whether he could use it safely without injuring himself or other residents, he stated that the family was on the same page with this plan. Interview and observation on 01/22/2020 at 9:26 AM with Resident #1, the resident was lying in bed watching TV, he was alert and oriented to person, place, and time. His left leg was in a soft below the knee cast and wrapped with an ace bandage. When asked if he could explain the incident that occurred with his motorized chair, he stated he had just received the new chair stating, I just got it that day. He said he was in the activity room and the activity assistant let everyone else out of the room before he tried to leave. He stated he was trying to go out of the door and that the door way was small and his left foot became wedged between the door and the chair causing the fracture. When asked if he had been trained on how to properly use the motorized chair, he stated the representative from the company explained to him how to use the chair but had not explained how to back up the chair. He said they told him he should not back up the chair because he can't see what's behind him. When asked if he was supervised while using the chair, he stated PT supervised him for a short period of time, then someone from the company supervised him, but when he was in the activity room, he was not being supervised. When asked if the activity assistant knew how to use or maneuver the chair, he stated no, she did not know how to use the motorized chair. He stated he had used a motorized chair before, but this chair was different because it was controlled by his head. When asked if he was told that he needed more training on proper use of the chair, he stated yes, the rep with the company told him he needed more training further stating they came yesterday to train him again. Interview on 01/22/2020 at 10:41 AM with the Activities Coordinator, she stated Resident #1 received a new head controlled motorized chair and he was escorted to the activities room in his new chair by PTA A to play Bingo. She said when Bingo was over, she had all the residents leave except for Resident #1. She said Resident #1 was trying to exit the room when the w/c just stopped by the edge of the table stating the lights were all off on the wheelchair and she thought maybe the power went out. She stated she asked the resident what happened, and he stated he didn't know. She said she told the resident she was going to get someone from PT to help because she did not know how to operate the chair and she was not educated on how to use the chair. She stated when she went to the PT gym and told PTA A that the residents chair stopped working. She said PTA A told her when she finished with the resident she was with, she would come to the room and help. She said when she got back to the activity room, the resident had moved himself by the door and had his left foot jammed between the door and chair. She said she told the resident not to move, but he continued to move the chair and laughed and then she too became wedged between the door and chair. She stated he continued to move the chair even though she asked him to stop because he was going to hurt himself, she stated she kept instructing the resident to please stop but he continued to move the chair and wheeled himself to the dining area. She stated at that time his leg was bent back and she went to get the residents nurse to assess him, stating the resident is paralyzed and can't feel anything, but his leg did not look right. Further interview on 01/22/2020 at 10:41 AM with the Activities Coordinator, when asked why she did not call the PTA from the activity room instead of leaving the resident unattended, she stated there is a phone in the activities room, but she did not have PT's extension and stated it was almost 5:00 PM so she thought everyone may have been gone for the day. When asked if there was a call system in the activities room, she stated no. Record review of Resident #1's daily summary note dated 1/15/20 written by OT 1 read in part, Pt education with pt, manufacturer, WC rep, OTR and COT[NAME] Pt was educated on not to use WC outside of therapy. Pt was informed he would need about 1.5 to 2 weeks before being allowed to drive independently. Pt would require passing obstacle course navigation and other tasks to ensure pt was safe. Pt was also stressed the importance of not utilizing independently because he could potentially injure himself or another resident. Pt stated he understood. Interview on 01/22/2020 at 10:52 AM with OT 1, when asked if her progress note on the daily summary dated 1/15/20 was documented before or after the incident involving Resident #1, she stated it was documented after the incident. She stated that day Resident #1 received his w/c from the manufacture company and the rep trained him and showed him how to use the chair. She stated he was told by PT that he could not use the chair until he was completely trained. When asked if this was before or after the incident occurred, she stated after. When asked if he was properly trained by PT or the reps, she stated she was not sure stating the reps showed him how to use the head control. When asked if the resident was asked to demonstrate proper use of the chair, she stated she was not sure stating the rehab director would know that. Interview on 01/22/2020 at 10:57 AM with OT 2, she stated the manufacture company delivered the motorized chair and provided training to Resident #1. When asked if the resident was asked to demonstrate if he was able to safely use the chair, she stated she was not sure because she was not present during the training. She stated she got the resident up and into the chair and made sure he was properly positioned so the reps could ensure correct measurements were made. She stated when she left the reps, they educated the resident on how to use the chair, but again stated she was not present. When asked what the policy was regarding training for residents on new equipment, she stated therapy is supposed to do the training and normally therapy would train the aides and nursing staff on proper equipment use. When asked if therapy saw the resident that day or trained him, she stated he was trained by therapy around 3:30 or 4:00 PM while in the motorized chair. She stated he was trained by therapy and the company. When asked how the resident got to the activities room, she stated PTA A took the resident to the activities room after she completed her session with Resident #1. When asked if he should have been in the activities room unsupervised if he was not properly trained or if staff had not been trained on proper use of the chair, she stated PTA A should have placed the resident back in his bed and not in the activities room. Interview on 01/22/2020 at 11:12 AM with the Rehab Director, she stated both PT staff and Resident #1 were trained on use of the w/c because it was a head controlled motorized chair. She stated in this incident, staffing and PT were trained at the same time on proper use of the w/c. When asked if the activities coordinator would have been trained she stated no. She stated once the resident was set up in the chair, he was instructed he would receive further training with PT staff that day. She stated he did receive training from both PT and the company reps. in the PT gym. She stated once training ended with PT, the resident was taken to the activities gym and was instructed to get PTA A once he was done. She stated because PT was in the building at that time, and because he was not cognitively impaired and was instructed not to use the chair, she felt it was ok for him to stay in the chair and be placed in the activity room. She further stated, hindsight is 20/20. She stated the whole purpose of the resident being left in the chair was to get him used to sitting in it. She stated from her perspective it was ok for him to be left in the chair. Interview on 01/22/2020 at 11:20 AM with LVN A, when asked if she received any training on the proper use of Resident #1's motorized chair, she stated she had not received any training. She stated the day the company was at the facility, they were showing therapy how it worked, not the nursing staff. When asked what the facility policy was regarding training when a resident receives new equipment. She stated it depends on the equipment, but generally PT would do the training and for the motorized chair they usually would try to do 1:1 training. When asked if residents would be expected to use a motorized chair before being properly trained, she stated usually they will do a test first with the resident with cones before the resident uses the equipment. Interview on 01/22/2020 at 11:26 AM with CNA A, when asked if she received any training to properly use or assist Resident #1 with his motorized w/c, she stated no. When asked what the facility's policy was regarding training if a resident receives new equipment, she stated she has never had any training for working a motorized w/c since she has worked at the facility stating she has been at the facility for a little over three years. When asked what she would do if a resident needed assistance with their wheelchair, she stated, I would try to get therapy or cut it off first if something happened. Interview on 01/22/2020 at 12:31 PM with the Rehab Director, when asked what staff are trained on use of Resident #1's motorized chair, she stated the only staff currently trained was PTA A, further stating she is PRN. She stated nurses and CNAs were not trained. Telephone interview on 01/22/2020 at 1:42 PM with Representative A, who was a rep for the wheelchair company, he stated he brought the chair out that morning and briefly did a couple of toggling functions with the chair's head array system and showed the resident how to move the chair forward and back. He stated several therapists were trained as well because the resident was not getting all of it. He stated he advised the staff, stating both PT and nurses that it would be safer for the resident to be out of the chair until he received additional training because he was having difficulty with the toggling functions. He stated the same day around lunch time, some CNAs were briefly trained on how to drive or operate the chair manually using the joy stick since the resident was not able to get it. He said he again told the nursing staff to transfer the resident out of the chair and into his bed or w/c because the resident was not safe operating the equipment. He stated after training they were supposed to have put the chair in the PT room stating this all occurred around 12:30-1:00 PM before the incident occurred. When asked how long it takes to train a resident to properly use the motorized w/c that the resident had, he stated it depends further stating they had previously brought a demo chair and the resident was ok to drive it at that time, but the issue with the resident was having with this chair was toggling through the menu. He stated for this resident he thought he would need an additional training session stating about two sessions. He stated the resident had an Invacare TDX SP 2 head array motorized chair. Interview on 01/22/2020 at 2:37 PM with the DON, when asked what the facility's policy was regarding training for both resident and staff when a resident receives new equipment, she stated for the motorized chair, staff training would be provided after therapy was done with their part and the screening process with the resident was completed further stating that is what they were doing at the time. She stated after PT completes their process, the nursing staff would then be trained. She stated she was not aware of the reps telling nursing staff that Resident #1 should be taken out of chair or that he needed further training. When asked if nurses received any training from the reps, she stated it was just therapy and the resident who received training. When asked if she thinks the resident should have been taken and left in the activity room if staff and the resident were not properly trained, she stated it depended on whether the Rehab Director communicated this to the Activity Assistant. When asked if she thinks this injury would have occurred if the resident was not left unsupervised, she said she thinks the incident would have still occurred because he was determined and wanted to move the chair and was still moving the chair when the activity assistant told him to stop. Telephone interview on 01/22/2020 at 2:58 PM with Representative B, when asked about who received training when Resident #1's motorized chair was delivered to the facility, she stated the resident was trained last Wednesday (1/15/20) and OT 2 and another OT staff were both trained on the use of the machine. When asked how long training typically takes for a resident to be able to use the chair safely, she stated the resident felt fine with the driving, but she did not feel like he was fine with the driving and so she recommended to the staff that he have additional training. She said he almost ran into her a couple of items and the chair had to be powered off using the emergency power button on the chair. She further stated she told staff the resident was not able to safely drive the chair and needed further training and her recommendation was to continue training. She stated she came back on 01/21/2020 to provide additional training to the resident. She stated she felt both the staff and resident needed more training to ensure the chair could be used safely. She said she told the resident he was not safe to drive and should not drive alone until the therapist evaluated him and determined he could drive safely. When asked how long it typically takes for a resident to learn how to safely use the head array motorized chair, she stated it is individualized and the resident stated he had used the head array before, but because he almost ran into things during the test run, he needed additional training. Record review of Resident #1's progress note dated 1/15/2020 written by PTA A read in part, Patient/staff education for proper positioning in w/c. Trunk mobility and stability exercises performed with verbal and tactile cues for pt reaching forward for objects and orientation to midline. Training focusing on maintaining proper wt distribution with sitting balance. Pt left in activities at end of therapy session at approx. 3:05 P.M. CNA had question about how to turn chair on in dining room around 5:00 PM, went to dining room and found chair was turned on. Instructed pt/staff how to go through the scroll menu and left pt in dining room with staff for dinner at 5:10 PM. Interview on 01/22/2020 at 3:19 PM with PTA A, she stated she escorted Resident #1 from the PT gym to the activity room after 3:00 PM. She said she was doing therapy in the gym and allowing him to operate the chair in the PT gym. When asked who trained the resident, she stated the reps who brought the chair fitted the chair and taught him how to use the controls, further stating she was not sure if PT staff was present when the reps trained the resident. She said when she got to the Resident, he was already sitting in the motorized chair in the TV room by the nurses' station. She stated she got him from the TV room and escorted him to therapy for his session. She said a CNA came to get her in the PT gym stating the residents chair was not working, and she told the CNA to give her a minute because she was working with another resident at that time and would be down there when she was done. She said once she got back to the activity room, the resident had already moved to the dining room. She stated when she got to the dining room the w/c was on and working and she went through the control panels with the staff and then went back to the PT gym because she had a resident waiting. Further interview on 01/22/2020 at 3:19 PM with PTA A, she stated she never had any contact with or spoke to the reps from the w/c company, further stating no nursing or PT staff informed her that the resident should remain in his other w/c. She said from her understanding it was ok for the resident to move himself in the motorized w/c with nursing staff and PT because no one had told her otherwise. Record review of the Owner's Manual for the Invacare TDX SP2 Series Power Wheelchair Base dated (YEAR) read in part, .The saftey section contains important information for the safe operation and use of this product. WARNING! Risk of Death, Injury or Damage .Improper use of this product may cause injury or damage. If you are unable to understand the warnings, cautions or instructions, contact a health care professional or Provider before attempting to use this equipment. DO NOT use this product . without first completely reading and understanding these instrucitions and any additional instructional material . Safety and handling of the wheelchair requires the close attention of the wheelchair user as well as the assistant .It is important to practice and master these safe techniques until you are comfortable in maneuvering the wheelchair .Invacare strongly recommends that initial use of wheelchairs be supervised by an assistant .

Based on interview and record review, the facility failed to implement its written policies and procedures that prohibit neglect of residents for 1of 9 residents (CR #1) reviewed for neglect. The facility failed to accurately and comprehensively recognize CR #1's condition and conduct a follow-up assessment on 08/07/16 when CR #1 experienced a change in condition. The facility failed to send CR #1 out for emergency medical treatment when his rash worsened. CR #1 developed a rash on 08/06/16 that worsened over the day into multiple open areas and areas with black center located on his back, neck, chest, groin, upper arms. The skin on his right ear was peeling off and he developed multiple open areas to his lips. CR #1 was transferred to the hospital on [DATE]. This failure affected one resident and placed 84 additional residents who might experience declines or changes in condition at risk of harm from failure to obtain timely assessments and treatment. An Immediate Jeopardy (IJ) was identified on 8/16/16. While the IJ was removed on 8/18/16, the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility needing more time to monitor the plan or removal for effectiveness. Findings include: CR #1 Record review of the clinical chart for CR #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The review revealed the resident was alert and oriented. Record review of the MAR, for the month of August 2016 revealed CR #1 was receiving the following medications at the time of admission: [MEDICATION NAME] 10 mg (medication to treat high blood pressure and chest pains), 1 tab once per day; [MEDICATION NAME] Extended ([MEDICATION NAME] sodium extended, used to treat [MEDICAL CONDITION]) capsule 100 mg 1 cap three times per day; [MEDICATION NAME] tablet (medication used to treat high blood pressure)25 mg 1 tab twice per day; Aspirin 81 mg once per day; [MEDICATION NAME] R (insulin regular human, used to treat diabetes) per sliding scale with parameters; levetiracetam (used to treat [MEDICAL CONDITION]) tablet 500 mg , 1 tablet twice per day; naproxyen sodium, tablet 220 mg 1 tab once per day; pantoprazole (a medication that decreases the amount of acid in the stomach) tablet, delayed release, 40 mg once per day; Vitamin C tablet 500 mg once per day and zinc sulfate tablet 220 mg 1 tablet once per day. [MEDICATION NAME] ([MEDICAL CONDITION] medication used to treat [MEDICAL CONDITION], such as shingles) 400 mg 1 tablet three times per day was added on 8/7/16 to the medication regimen. Record review of CR #1 ' s Progress Notes dated 8/6/16 at 8:12 PM revealed the resident had a temperature of 100.6. The review of the entry for this date and time revealed the physician was consulted and new orders were obtained for [MEDICATION NAME] 650 mg. po q 4 hrs prn temp or mild pain . Record review of CR #1 ' s document entitled Skin Assessment for Rash , dated 8/6/16 read in part, Describe: back, neck, chest, groin upper arms red, raised, warm rash with dark centers Record review of the CR #1 ' s Progress Notes dated 8/6/16 at 10:35 PM read, Pt noted to have rash to abdomen and back. MD notified and order rec'd for [MEDICATION NAME] 400 mg po tid, noted and faxed to pharmacy. Record review of CR #1 ' s clinical record revealed there was no documentation of an assessment or follow-up to the rash for 8/7/16. Interview with the DON on 08/16/16 at 3:05pm she said that there should have been follow-up assessment and documentation on 08/07/16. Record review of an untitled and undated document recived via email from the Vice President of Operations on 08/18/16 read in part . 8/7 no nurse's notes but 24 hour report .initial dose [MEDICATION NAME] given .continues on [MEDICATION NAME] for [MEDICAL CONDITION] type rash . Record review of CR #1 ' s Progress Notes dated 8/8/16 at 10:31 AM read, rec'd resident in room Alert. Resp. even and unlabored no signs of sob. Noted resident has red rash, blisters and black spots all over his back and chest Groin area has multiple open areas. Back has multiple open area with blisters. Blister on left side of abd. Rt ear skin peeled off several open areas. Lips have multiple open areas. Dr was notified he stated he would be in to see (CR #1) at 2pm. will continue to monitor. Record review of CR #1 ' s Progress Notes dated 8/8/16 at 10:47 AM read, Call Dr New order strict contact isolation . Record review of CR #1 ' s of Resident Progress Notes of 8/8/16 at 12:21 PM revealed that at that time Certified Nurse Aide, the DON and employee from the therapy department were in CR #1's room at his bedside. The entry read, writer (LVN B) was told to call Dr to see if he could come sooner, pt has a fever of 104.1 Writer called Dr .he stated he would come in at 1:30 to see resident. PRN APAP 650 mg po given. Family was in building and is aware of what is going on with resident Record review of CR #1 ' s of Resident Progress Notes dated 8/8/16 at 1:30 PM revealed the physician was in the building and assessed the resident. The review further revealed a new order was received to send the resident to a specific hospital, the contract ambulance service was contacted at 1:30pm and the resident left the facility for the hospital at 2:35 PM Record review of CR #1 ' s document entitled History and Physical dated 8/9/16 for CR #1 read, in part, . admitted for PT/OT after resection of [DIAGNOSES REDACTED] . Physical Findings: .Skin W/D/I .Pain: no Rehab potential: Fair. Record review of CR #1 ' s of physician's statement dated 8/16/16 read in part, .I was advised that patient was complaining of some lower extremity pain in the afternoon of 8/6/16 and a rash over his trunk and back described as red with some areas of dark centers about 9 that evening. There was still no [MEDICATION NAME] level available. His vitals were reported as stable at that time and I started [MEDICATION NAME] for possible new onset shingles and planned to evaluate the patient Monday. I was called at 10 am 8/8 and there was request to place patient in isolation for HSV as rash was not improving. I was then called again at 12:20 Pm that patient developed a fever. I arrived within an hour to find that patient had fever but that it was improved. He had worsening condition, [MEDICAL CONDITION] was warm to touch. I advised daughter that I thought patient should be transferred to the hospital for possible [MEDICATION NAME] toxicity or infection/sepsis .orders were placed to transfer to rule out(NAME)Johnso[DIAGNOSES REDACTED]. Interview on 8/16/16 at 2:55 PM with LVN A revealed she was present at the time CR #1 became ill. She stated this occurred on her 2 to 10PM shift and it was either on a Friday or a Saturday. She stated she took the resident's temperature and contacted the physician. She stated she received new orders for a CBC and some Tylenol. When she noticed the resident had developed a rash, she called the doctor again and received orders for [MEDICATION NAME]. LVN A stated it was thought the resident could have a [MEDICAL CONDITION] rash because he had recently had surgery and was under stress. LVN A stated that by the next day, the sores spread to his chest. She further stated he was scratching and had fluid-filled blisters on his back. Interview on 8/16/16 at 2:58 PM with LVN B revealed she took care of CR #1 and was familiar with him. She stated she left notification for the on-coming shift about CR #1's rash and fever and actually texted the physician to make sure he was aware of the situation. LVN B stated she texted the physician on Sunday before she left for the day and CR #1's fever was 100.6. Interview on 8/16/16 at 3:05 PM with the DON revealed she was not present on the day the resident presented with the rash. She stated she received a call either on Saturday the 6th or Sunday the 7th, from nursing staff who informed her physician had prescribed some cream and the resident had a rash and was itching. She stated she was informed the rash was dark and red. She stated she was told the rash was on his chest and a small amount on his back. She further stated it was described as crusty with dark spot in the middle. The DON further stated she came to the facility the following day on the 8th She stated she herself contacted the physician and asked him to come. She stated she informed the physician the patient was peeling and when she touched a blister, it popped. The DON stated she informed the physician the resident is peeling and blisters were popping. She further stated the physician did come out to the facility to assess the patient and sent him to the hospital. She stated she didn't realize it wasn't 911 that was called. She stated they use their contract ambulance for transportation. She further stated that to call 911, the patient should be critical like low O2 stats. The Administrator gets mad if 911 is called .I always intervene if 911 is needed. If I see a patient decline I will call 911. The DON stated that prior to transport CR #1 said to her I'm burning, hurting shivering. She stated she was called out of the room to assess another patient and was not aware that CR #1 did not go to the hospital via 911. The DON also stated that Stevens-Johnson can be caused by long term use of [MEDICATION NAME]--that is why I insisted the doctor come evaluate the resident. She stated. I wanted him to be on the same page, I realized it could be Stevens-Johnson. In an interview on 8/16/16 at 2:32pm with The Administrator, DON and the ADONS, they were informed that an IJ was being called. The Administrator at that time voiced his opposition to the decision stating the facility had done what was needed by assessing CR #1, contacting the family and physician and sending him to the emergency room . In an interview with the Administrator on 8/17/16 at 10:00 AM, the Administrator stated that the situation with CR #1 was not perceived to be a medical emergency and that is the rationale for sending the resident to the hospital via their contract ambulance service vs. 911 ambulance. Record review of the complaint intake dated 8/09/16 read in part . The hospital discovered that he had developed an allergic reaction to diantin and was diagnosed with [REDACTED]. CR #1 was placed in the burn unit and had skin graft surgery on 8/9/16. He had 95% of the skin on his back removed . CR #1 passed away on 8/14/16 from complications of Stevens-Johnso[DIAGNOSES REDACTED]. Record review of the Mayo Clinic website read in part: Stevens-Johnso[DIAGNOSES REDACTED] is a rare, serious disorder of your skin and mucous membranes. It is usually a reaction to medication or an infection . begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Then the top layer of the affected skin dies and sheds. Stevens-Johnso[DIAGNOSES REDACTED] is a medical emergency . http://www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/basics/definition/con- 623 Record review of the facility's written policy and procedures regarding residents experiencing a significant decline or change in condition (not dated) read in part, .A significant change is a decline or improvement in a resident's status that: a will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self- limiting) . Record review of the facility's written policy and procedures regarding abuse and neglect dated 2001 with a revised date of April 2012 read in part, .Neglect is defined as a failure to provide goods and services as necessary to avoid physical harm, pain or mental anguish An IJ was identified on 08/16/16 and the Administrator and DON were notified at 2:30PM. A plan of removal (POR) for the IJ was submitted on 08/17/16 at 8:29AM and after being revised it was accepted on 08/17/16 at 1:07PM. The POR included in part: Immediate Action: 1. All residents will be assessed for unknown skin issues by the Nursing Administration staff. These assessments will be completed on 8/17/2016. The audit will be overseen by the Nursing Administration. DON and/or designee will be responsible to ensure weekly skin audits on an ongoing basis. 2. C N A assignment sheets will be audited on 8/17/2016. The ADON and QA nurse will complete this audit on 8/17/2016. Training 1. Licensed nurses will be in-serviced on resident assessments including skin assessments, reporting changes in condition reporting by subordinate staff, shift communication, daily documentation on skilled patients, and using their nursing judgement on when to send the patient out 911 in an emergent situation. This in-service will be conducted by Administrative nursing staff (DON, ADON, QA, MDS Coordinator and Treatment Nurse). This in-service was started on 8/16/2016 and will be completed on 8/17/2016. 2. Staff will be in-serviced by Administration on the Stop and Watch. This in-service was started on 8/16/2016 and will be completed by 8/17/2016. Monitoring of the Plan of Removal: Monitoring included the addition to the resident sample, 2 residents who had on 8/17/16 and 8/18/16, experienced a change in condition. The review revealed the residents were assessed timely and all protocols were followed. Both residents were sent to hospitals for additional tests and treatment. Interviews conducted on 8/17/16 and 8/18/16 encompassed interviews with direct care staff including Certified Nurse Aides, Medication Aides and licensed nurses on the premises verifying the specific components as outlined in the Plan of Removal and provided by the comprehensive in-servicing of all direct care employees. The interviews confirmed the provision of the new information and protocols and the retention of this information by the employees interviewed. Monitoring conducted on 8/18/16 included record reviews of actual in-service training documentation provided to ensure all components as outlined in the Plan of Removal were presented to all relevant staff as required. The record reviews included review of actual material provided in the trainings (and signatures attesting to staff attendance), a new protocol for recognizing changes in condition specifically skin changes, information on Stevens-Johnso[DIAGNOSES REDACTED],( a potential serious reaction to numerous medications that causes a rash and loss of skin), recognition of nursing staff to utilize their nursing judgment on when to send the patient out 911 in an emergent situation, review testing for staff to ensure retention of material presented and the incorporation of a requirement that aides directly submit shower sheets to nursing staff upon their recognition of any unusual change noted in a resident's skin. While the IJ was removed on 8/18/16 at 1:20PM, the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility needing more time to monitor the plan or removal for effectiveness. The hospital records are still pending and have not been received. According to the facility's resident roster, the census was 84.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical, mental or psycho-social well-being, in accordance with the comprehensive assessment and plan of care for 1 of 9 residents, (CR#1), reviewed for quality of care. The facility failed to accurately and comprehensively recognize CR #1's condition and conduct a follow-up assessment on 08/07/16 when CR #1 experienced a change in condition. The facility failed to send CR #1 out for emergency medical treatment when his rash worsened. CR #1 developed a rash on 08/06/16 that worsened over the day into multiple open areas and areas with black center located on his back, neck, chest, groin, upper arms. The skin on his right ear was peeling off and he developed multiple open areas to his lips. CR #1 was transferred to the hospital on [DATE]. This failure affected one resident and placed 84 additional residents who might experience declines or changes in condition at risk of harm from failure to obtain timely assessments and treatment. An Immediate Jeopardy (IJ) was identified on 8/16/16. While the IJ was removed on 8/18/16, the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility needing more time to monitor the plan or removal for effectiveness. Findings include: CR #1 Record review of the clinical chart for CR #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The review revealed the resident was alert and oriented. Record review of the MAR, for the month of August 2016 revealed CR #1 was receiving the following medications at the time of admission: [MEDICATION NAME] 10 mg (medication to treat high blood pressure and chest pains), 1 tab once per day; [MEDICATION NAME] Extended ([MEDICATION NAME] sodium extended, used to treat [MEDICAL CONDITION]) capsule 100 mg 1 cap three times per day; [MEDICATION NAME] tablet (medication used to treat high blood pressure)25 mg 1 tab twice per day; Aspirin 81 mg once per day; [MEDICATION NAME] R (insulin regular human, used to treat diabetes) per sliding scale with parameters; levetiracetam (used to treat [MEDICAL CONDITION]) tablet 500 mg , 1 tablet twice per day; naproxyen sodium, tablet 220 mg 1 tab once per day; pantoprazole (a medication that decreases the amount of acid in the stomach) tablet, delayed release, 40 mg once per day; Vitamin C tablet 500 mg once per day and zinc sulfate tablet 220 mg 1 tablet once per day. [MEDICATION NAME] ([MEDICAL CONDITION] medication used to treat [MEDICAL CONDITION], such as shingles) 400 mg 1 tablet three times per day was added on 8/7/16 to the medication regimen. Record review of CR #1 ' s Progress Notes dated 8/6/16 at 8:12 PM revealed the resident had a temperature of 100.6. The review of the entry for this date and time revealed the physician was consulted and new orders were obtained for [MEDICATION NAME] 650 mg. po q 4 hrs prn temp or mild pain . Record review of CR #1 ' s document entitled Skin Assessment for Rash , dated 8/6/16 read in part, Describe: back, neck, chest, groin upper arms red, raised, warm rash with dark centers Record review of the CR #1 ' s Progress Notes dated 8/6/16 at 10:35 PM read, Pt noted to have rash to abdomen and back. MD notified and order rec'd for [MEDICATION NAME] 400 mg po tid, noted and faxed to pharmacy. Record review of CR #1 ' s clinical record revealed there was no documentation of an assessment or follow-up to the rash for 8/7/16. Interview with the DON on 08/16/16 at 3:05pm she said that there should have been follow-up assessment and documentation on 08/07/16. Record review of an untitled and undated document recived via email from the Vice President of Operations on 08/18/16 read in part . 8/7 no nurse's notes but 24 hour report .initial dose [MEDICATION NAME] given .continues on [MEDICATION NAME] for [MEDICAL CONDITION] type rash . Record review of CR #1 ' s Progress Notes dated 8/8/16 at 10:31 AM read, rec'd resident in room Alert. Resp. even and unlabored no signs of sob. Noted resident has red rash, blisters and black spots all over his back and chest Groin area has multiple open areas. Back has multiple open area with blisters. Blister on left side of abd. Rt ear skin peeled off several open areas. Lips have multiple open areas. Dr was notified he stated he would be in to see (CR #1) at 2pm. will continue to monitor. Record review of CR #1 ' s Progress Notes dated 8/8/16 at 10:47 AM read, Call Dr New order strict contact isolation . Record review of CR #1 ' s of Resident Progress Notes of 8/8/16 at 12:21 PM revealed that at that time Certified Nurse Aide, the DON and employee from the therapy department were in CR #1's room at his bedside. The entry read, writer (LVN B) was told to call Dr to see if he could come sooner, pt has a fever of 104.1 Writer called Dr .he stated he would come in at 1:30 to see resident. PRN APAP 650 mg po given. Family was in building and is aware of what is going on with resident Record review of CR #1 ' s of Resident Progress Notes dated 8/8/16 at 1:30 PM revealed the physician was in the building and assessed the resident. The review further revealed a new order was received to send the resident to a specific hospital, the contract ambulance service was contacted at 1:30pm and the resident left the facility for the hospital at 2:35 PM Record review of CR #1 ' s document entitled History and Physical dated 8/9/16 for CR #1 read, in part, . admitted for PT/OT after resection of [DIAGNOSES REDACTED] . Physical Findings: .Skin W/D/I .Pain: no Rehab potential: Fair. Record review of CR #1 ' s of physician's statement dated 8/16/16 read in part, .I was advised that patient was complaining of some lower extremity pain in the afternoon of 8/6/16 and a rash over his trunk and back described as red with some areas of dark centers about 9 that evening. There was still no [MEDICATION NAME] level available. His vitals were reported as stable at that time and I started [MEDICATION NAME] for possible new onset shingles and planned to evaluate the patient Monday. I was called at 10 am 8/8 and there was request to place patient in isolation for HSV as rash was not improving. I was then called again at 12:20 Pm that patient developed a fever. I arrived within an hour to find that patient had fever but that it was improved. He had worsening condition, [MEDICAL CONDITION] was warm to touch. I advised daughter that I thought patient should be transferred to the hospital for possible [MEDICATION NAME] toxicity or infection/sepsis .orders were placed to transfer to rule out(NAME)Johnso[DIAGNOSES REDACTED]. Interview on 8/16/16 at 2:55 PM with LVN A revealed she was present at the time CR #1 became ill. She stated this occurred on her 2 to 10PM shift and it was either on a Friday or a Saturday. She stated she took the resident's temperature and contacted the physician. She stated she received new orders for a CBC and some Tylenol. When she noticed the resident had developed a rash, she called the doctor again and received orders for [MEDICATION NAME]. LVN A stated it was thought the resident could have a [MEDICAL CONDITION] rash because he had recently had surgery and was under stress. LVN A stated that by the next day, the sores spread to his chest. She further stated he was scratching and had fluid-filled blisters on his back. Interview on 8/16/16 at 2:58 PM with LVN B revealed she took care of CR #1 and was familiar with him. She stated she left notification for the on-coming shift about CR #1's rash and fever and actually texted the physician to make sure he was aware of the situation. LVN B stated she texted the physician on Sunday before she left for the day and CR #1's fever was 100.6. Interview on 8/16/16 at 3:05 PM with the DON revealed she was not present on the day the resident presented with the rash. She stated she received a call either on Saturday the 6th or Sunday the 7th, from nursing staff who informed her physician had prescribed some cream and the resident had a rash and was itching. She stated she was informed the rash was dark and red. She stated she was told the rash was on his chest and a small amount on his back. She further stated it was described as crusty with dark spot in the middle. The DON further stated she came to the facility the following day on the 8th She stated she herself contacted the physician and asked him to come. She stated she informed the physician the patient was peeling and when she touched a blister, it popped. The DON stated she informed the physician the resident is peeling and blisters were popping. She further stated the physician did come out to the facility to assess the patient and sent him to the hospital. She stated she didn't realize it wasn't 911 that was called. She stated they use their contract ambulance for transportation. She further stated that to call 911, the patient should be critical like low O2 stats. The Administrator gets mad if 911 is called .I always intervene if 911 is needed. If I see a patient decline I will call 911. The DON stated that prior to transport CR #1 said to her I'm burning, hurting shivering. She stated she was called out of the room to assess another patient and was not aware that CR #1 did not go to the hospital via 911. The DON also stated that Stevens-Johnson can be caused by long term use of [MEDICATION NAME]--that is why I insisted the doctor come evaluate the resident. She stated. I wanted him to be on the same page, I realized it could be Stevens-Johnson. In an interview on 8/16/16 at 2:32pm with The Administrator, DON and the ADONS, they were informed that an IJ was being called. The Administrator at that time voiced his opposition to the decision stating the facility had done what was needed by assessing CR #1, contacting the family and physician and sending him to the emergency room . In an interview with the Administrator on 8/17/16 at 10:00 AM, the Administrator stated that the situation with CR #1 was not perceived to be a medical emergency and that is the rationale for sending the resident to the hospital via their contract ambulance service vs. 911 ambulance. Record review of the complaint intake dated 8/09/16 read in part . The hospital discovered that he had developed an allergic reaction to diantin and was diagnosed with [REDACTED]. CR #1 was placed in the burn unit and had skin graft surgery on 8/9/16. He had 95% of the skin on his back removed . CR #1 passed away on 8/14/16 from complications of Stevens-Johnso[DIAGNOSES REDACTED]. Record review of the Mayo Clinic website read in part: Stevens-Johnso[DIAGNOSES REDACTED] is a rare, serious disorder of your skin and mucous membranes. It is usually a reaction to medication or an infection . begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Then the top layer of the affected skin dies and sheds. Stevens-Johnso[DIAGNOSES REDACTED] is a medical emergency . http://www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/basics/definition/con- 623 Record review of the facility's written policy and procedures regarding residents experiencing a significant decline or change in condition (not dated) read in part, .A significant change is a decline or improvement in a resident's status that: a will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self- limiting) . Record review of the facility's written policy and procedures regarding abuse and neglect dated 2001 with a revised date of April 2012 read in part, .Neglect is defined as a failure to provide goods and services as necessary to avoid physical harm, pain or mental anguish An IJ was identified on 08/16/16 and the Administrator and DON were notified at 2:30PM. A plan of removal (POR) for the IJ was submitted on 08/17/16 at 8:29AM and after being revised it was accepted on 08/17/16 at 1:07PM. The POR included in part: Immediate Action: 1. All residents will be assessed for unknown skin issues by the Nursing Administration staff. These assessments will be completed on 8/17/2016. The audit will be overseen by the Nursing Administration. DON and/or designee will be responsible to ensure weekly skin audits on an ongoing basis. 2. C N A assignment sheets will be audited on 8/17/2016. The ADON and QA nurse will complete this audit on 8/17/2016. Training 1. Licensed nurses will be in-serviced on resident assessments including skin assessments, reporting changes in condition reporting by subordinate staff, shift communication, daily documentation on skilled patients, and using their nursing judgement on when to send the patient out 911 in an emergent situation. This in-service will be conducted by Administrative nursing staff (DON, ADON, QA, MDS Coordinator and Treatment Nurse). This in-service was started on 8/16/2016 and will be completed on 8/17/2016. 2. Staff will be in-serviced by Administration on the Stop and Watch. This in-service was started on 8/16/2016 and will be completed by 8/17/2016. Monitoring of the Plan of Removal: Monitoring included the addition to the resident sample, 2 residents who had on 8/17/16 and 8/18/16, experienced a change in condition. The review revealed the residents were assessed timely and all protocols were followed. Both residents were sent to hospitals for additional tests and treatment. Interviews conducted on 8/17/16 and 8/18/16 encompassed interviews with direct care staff including Certified Nurse Aides, Medication Aides and licensed nurses on the premises verifying the specific components as outlined in the Plan of Removal and provided by the comprehensive in-servicing of all direct care employees. The interviews confirmed the provision of the new information and protocols and the retention of this information by the employees interviewed. Monitoring conducted on 8/18/16 included record reviews of actual in-service training documentation provided to ensure all components as outlined in the Plan of Removal were presented to all relevant staff as required. The record reviews included review of actual material provided in the trainings (and signatures attesting to staff attendance), a new protocol for recognizing changes in condition specifically skin changes, information on Stevens-Johnso[DIAGNOSES REDACTED],( a potential serious reaction to numerous medications that causes a rash and loss of skin), recognition of nursing staff to utilize their nursing judgment on when to send the patient out 911 in an emergent situation, review testing for staff to ensure retention of material presented and the incorporation of a requirement that aides directly submit shower sheets to nursing staff upon their recognition of any unusual change noted in a resident's skin. While the IJ was removed on 8/18/16 at 1:20PM, the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility needing more time to monitor the plan or removal for effectiveness. The hospital records are still pending and have not been received. According to the facility's resident roster, the census was 84.

Based on observations, interview and record review, the facility failed to ensure the right to be free from neglect for one of 14 residents (Resident #12) reviewed for neglect as evidenced by: The facility failed to have CNA Z trained to immediately report any signs of resident abuse/neglect or injuries of unknown origin. CNA Z became aware at 2:00 p.m. of Resident #12 ' s bruise to the right eye and eyebrow, from an unknown origin, and did not report it to the charge nurse or administration. The facility failed to have staff trained to conduct a complete assessment of residents after an injury of unknown origin has been identified. Resident #12 was not completely assessed after an injury of her right eye and eyebrow were identified by LVN Y at 9:00 p.m. Resident #12 had large bruised areas in the pubic area and on her thighs that were not identified until Resident #12 was assessed in the hospital seven hours after the bruises to her eye were noted by CNA Z. These failures resulted in an identification of an Immediate Jeopardy on 4/14/16. While the IJ was removed on 4/16/16, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated. The facility was continuing to monitor their plan to ensure staff were trained on reporting injuries of unknown origin and complete assessments of residents. This failure affected one resident who was transferred to the hospital with injuries to her head and pubic area and placed 78 residents who required assistance from staff or had a history of [REDACTED]. Intake #: 2, 4 Findings Include: Resident #12 Record review of face sheet for Resident #12 revealed an admission date of [DATE] with a readmitted [DATE] to the facility. Resident #12 was a [AGE] year old woman. Her [DIAGNOSES REDACTED]. Record review of Resident #12 ' s clinical record revealed she was appointed Guardianship by Harris County Guardianship Program on August 19, 2015. Record review of Resident #12 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS dated [DATE] for Resident #12 further revealed the resident required limited assistance of one staff physical assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #12's care plan dated 08/18/15 revealed a problem of Falls, resident is at risk for falling related to unsteady gait and [MEDICAL CONDITION] drug use. The goal was for the Resident to remain free from injury. Approaches included: observe freequently and placce in supervised area when out of bed, mattress on the floor, fall mats beside mattress, monitor resident every 30 minutes or more .place resident in a fall prevention program . Record review of the care plan for Resident #12 dated 1/21/2016 revealed she was a fall risk related to history of falls. Actual falls documented on the care plan had occurred on 1/13/2016, 2/08/2016, 2/19/2016, and 2/21/2016. Approaches included: keep bed in lowest position with brakes locked, keep call light in reach, keep personal items and frequently used items within reach, observe frequently and place in supervised area when out of bed, place resident in fall prevention program, provide proper well maintained footwear, and provide resident an environment free of clutter. Record review of a previous care plan for Resident #12 dated 7/31/2015 with a last conference date of 1/25/2016 revealed Resident #12 had [DIAGNOSES REDACTED]. Approaches included: Administer medications, assess for symptoms of toxicity, if [MEDICAL CONDITION] occurs, remove all restrictive clothing and objects of potential harm, turn head to side to maintain patent airway, keep bed in lowest position, keep call light in reach, suction resident as needed, and assess characteristics before, during and after [MEDICAL CONDITION]. Observation on 4/11/2016 at 10:00 am of Resident #12 ' s room revealed a mattress on the floor with a floor mat on both sides of mattress. Observation on 4/11/2016 at 10:05 am revealed Resident #12 in a wheelchair in the general living area with other residents. No bruising noted on the resident ' s face or right eye. Record review of Resident #12 ' s Patient Narrative dated 4/11/2016 read: hematoma visualized at 2:00 pm. The resident was alert and oriented to self and ambulates with a wheelchair. Bruising was noted to the left arm, antecubital (front of the elbow) region and hematoma to the right eye was noted on the diagram. Record review of Resident #12 ' s nurses notes dated 4/11/2016 at 9:33 pm read: In to see patient, patient noted to have a bruise over her right eye lid. Eye swollen with a large knot over corner of eye, eyebrow area. Patient stated pain at a 3 on a scale of 1-10. (Vital signs) 140/80-67-20-97.8. Asked patient if she knew how she obtained the areas, stated, it was earlier, she did not know when. NP (Nurse Practitioner) notified. New orders received to send patient to ER (emergency room ) for eval and treat. ADON notified. RP (responsible party) called. Message left for her to call facility. Record review of the written statement by LVN Y dated 4/11/2016 revealed: LVN Y worked the 2:00 pm -10:00 pm shift on 4/11/2016. LVN Y wrote that she checked on Resident #12 during rounds and again between 4:50 pm and 5:00 pm. LVN Y asked Resident #12 if she was going to eat in her room or dining room and Resident #12 said she would eat in her room. LVN Y then left the room. The written statement further revealed after LVN Y did a medication pass she checked on Resident #12 who was in her room sitting Indian style on the mattress on the floor in the dark. LVN Y asked if she could turn on the light in her room and Resident #12 said yes and LVN Y noted bruise, swelling and knot to right eye. LVN Y asked CNA Z, who was in the hall if he knew Resident #12 had the bruising and swelling. CNA Z replied that the bruise had been there since the beginning of his shift. LVN Y then called the Nurse Practitioner and received orders to send Resident #12 to the hospital for an evaluation. Record review of EMS (Emergency Medical System) transfer form dated 4/11/2016 revealed: Ambulance was dispatched at 9:15 pm and arrived at the facility at 9:45 pm. Transfer form revealed that swelling and contusions were noted but area not specified. Mechanism of injury was noted as a fall. Record review of Resident #12 ' s hospital cat scan (CT) report dated 4/11/2016 of head, face, cervical spine, abdomen, and pelvis with and without contrast revealed: CT of face; mild right periorbital soft tissue swelling was identified. No evidence of facial fracture. CT of abdomen/pelvis revealed: hypodense area within the region of the right labia was identified measuring 5.9 x 4.9 cm and appeared fairly well contained, most consistent with hematoma. Overlying soft tissue swelling and subcutaneous [MEDICAL CONDITION] was also seen over the lower anterior pelvis. Impression: Right labial hematoma that appeared fairly well-contained. Additional overlying subcutaneous [MEDICAL CONDITION] and inflammation may correlate with trauma. Clinical correlation recommended. Record review of Resident #12 ' s Neurological Assessment Flow Sheet dated 4/12/2016 at 9:15 (does not distinguish if it was am or pm), revealed: Resident was alert, pupils were equal and reactive. Vitals: 140/80, 97.8, 67, 20. Record review of a Complaint Investigation Worksheet dated 4/12/2016 read: Resident (#12) was admitted to the hospital. The resident had a history of [REDACTED]. The complainant reported there was also swelling to the mons pubis (mound of flesh found on the female ' s pubic bone) and labia majora (the major external visible portion of the woman ' s vulva) were suspect, and would not occur quickly. The complainant reported they felt if this swelling and discoloration were actually caused by a fall, the resident would have had to hit something hard. The reporter stated they suspected something else (besides the fall) had caused the bruising and swelling. Record review of Incident reported to DADS dated 4/12/2016 called in by the facility ' s Regional Director read: Resident #12, was a cognitively impaired resident. She had a history of [REDACTED]. The facility indicated there were no identifiable perpetrators, or that the event was not an environmental or other issue. Resident was observed on the floor beside her bed. She had a hematoma to the right forehead. She was sent to the local hospital for treatment. Family, Physician, and surveyors (in the facility conducting an annual survey) were notified. Harris County Guardianship was not notified. Interview on 4/13/2016 at 9:45 am with Resident #12 at the hospital revealed she was unsure of how she acquired bruising to her right eye, right brow and left antecubital region of arm. Resident #12 said she thought maybe she fell out of her wheelchair earlier in the day when she was trying to reach for her breakfast. When Resident #12 was asked how she obtained bruising to her vaginal area she said she did not know that she had bruising in that area or how it got there. Observation on 4/13/2016 at 9:58 am of Resident #12 ' s vaginal area revealed a large (lemon size) bright purple hematoma on mons pubis and swelling with deep purple bruising to right labia majora with swelling. Purple bruising was noted from left inner thigh to right inner thigh. Quarter sized purple/blue bruise noted to right mid inner thigh. A large knot (ping pong ball size) was noted on the right brow area with dark purple bruising around the diameter of the right eye. In an interview with a hospital charge nurse on 4/13/2016 at 10:30 am he revealed he thought the bruising to the mons pubis and the injury was questionable as to how they occurred. Interview on 4/13/2016 at 11:29 am with facility LVN Y revealed her shift started at 2:00 pm on 4/11/2016. LVN Y said she took report from the out-going nurse and nothing was mentioned about a fall or injury to Resident #12. LVN Y said she checked on Resident #12 at the beginning of the shift to make sure her oxygen was on. LVN Y said the light was off in the room and Resident #12 was lying on her left side facing the window. She stated she looked at the Resident ' s ear and could see that the oxygen was on the Resident #12 via the nasal cannula. LVN Y said she did not notice any bruising on Resident #12 at that time, but said she did not turn on the light in Resident #12 ' s room. LVN Y said she checked on Resident #12 again around 5:00 pm and the light was still off in the room and the resident ' s oxygen was in place. LVN Y said she did not turn on the light in Resident #12's room at that time and talked to her from the door. Resident #12 was awake at 5:00 pm and had said she was alright and wanted to eat dinner in her room. LVN Y said she left the room and returned at 6:30 pm and the light was off, but did see that the oxygen was in place. LVN Y said she went to check on Resident #12 at approximately 9:00 pm and the door was closed. She stated she knocked on the door and then opened it. Resident #12 was sitting crossed legged on the mattress on the floor. LVN Y said she turned on the light in Resident #12 ' s room and noticed bruising and swelling to the resident ' s right eyebrow. LVN Y said Resident #12 was not sure how the bruise and swelling was obtained. LVN Y revealed she went out in the hall and found CNA Z and asked him if he was aware of the bruising and swelling to Resident #12 ' s right eye and he said he was aware and noticed it at 2:00 pm when his shift began. LVN Y said CNA Z told her he did not say anything because he thought she already knew. LVN Y then checked Resident #12 ' s chart for any documentation of the injury and said there was no injury or falls noted during the previous shift. LVN Y said she then went back to Resident #12 ' s room and assessed her, performed neurological vital signs, called the nurse practitioner and received orders to send the resident to the hospital for an evaluation. LVN Y said she performed a range of motion assessment on Resident #12, neurological assessment, and assessed her right eye but did not assess any other region of Resident #12 ' s body. LVN Y said she called the ADON to report the injury, called an ambulance service and left a messages for Resident #12 ' s family but the call was not returned. Observation on 4/13/16 at 11:45am of Resident #12 ' s room revealed the blinds were closed and the room was dark. Observation revealed it was so dark in the room to see discoloration of tissue or an injury to a resident would be difficult without turning on the light or standing directly over the resident. In interview on 4/14/2016 at 9:45 am the DON said no full assessment was completed by LVN Y when the bruise and swelling was discovered to right eye of Resident #12. The DON said the neurological checks were completed and an assessment of the head wound along with range of motion was completed by LVN Y. The DON further revealed the investigation regarding the injury of unknown origin to Resident #12 ' s right eye and right brow had not been started because the facility was concentrating on the survey and not the investigation. In an interview with CNA Z on 4/13/2016 at 12:10 pm revealed he worked the 2:00 pm to 10:00 pm shift on 4/11/2016. CNA Z said he noted a small swollen black eye to the right eye of Resident #12. CNA Z said It didn ' t look serious . CNA Z revealed Resident #12 was in bed all day and he brought her a dinner tray about 5:00 pm. CNA Z said he set Resident #12 ' s dinner tray on the mattress on the floor so she could eat and left the room. CNA Z said Resident #12 feeds herself. CNA Z said he returned at approximately 5:40 pm to pick up her dinner tray and she had only eaten 30 % of her meal. CNA Z said he did not provide any incontinent care to Resident #12 as she remained clean all day. When asked why he did not notify LVN Y of the swelling and bruising to Resident #12 ' s eye he said It didn ' t occur to me to tell anyone because she always has bruises due to bumping into things . CNA Z said he did notify LVN Y that Resident #12 had trouble breathing during the shift and LVN Y told CNA Z to put the oxygen on Resident #12 but was not sure if LVN Y assessed Resident #12 for breathing issues. When asked about abuse and neglect policy and procedures CNA Z said he knew that he should report bruising but did not think it was important and he thought LVN Y already knew about it. In an interview on 4/13/2016 at 12:35 pm RN Q. said she cared for Resident #12 on 4/11/2016 on the 6:00 am-2:00 pm shift. RN Q revealed that no bruising to face, head, or vaginal area was noted during the day on Resident #12. RN Q further revealed she was not sure if Resident #12 needed assistance with feeding or incontinent care as RN Q had only worked at the facility for 3 weeks. In an interview on 4/13/2016 at 12:56pm CNA U, said Resident #12 had been declining recently and eating less. CNA U said she took care of Resident #12 on 4/11/2016 during the 6:00 am -2:00 pm shift and did not notice any bruising to Resident #12 ' s face. CNA U said at 9:00 am on 04/11/2016 she was passing Resident #12's room when she noticed the Resident had removed her brief and her butt cheeks were hanging out so she provided incontinent care and put a brief back on the Resident. She also said that she checked Resident #12 at 1:30pm and provided incontinent care and replaced her brief. CNA U said there was no bruising in the vaginal area either time. In an interview on 4/13/2016 at 1:45 pm the DON revealed Resident #12 self-propelled herself in a wheelchair but was incontinent and needed assistance. In an interview on 4/13/2016 at 2:10 pm LVN Y revealed Resident #12 needed assistance to the bathroom and was incontinent at times. LVN Y said Resident #12 was confused at times but not always. LVN Y said Resident #12 prefers to eat in her room at times and staff would bring in her trays and set them on the mattress so she could eat. LVN Y did not say if Resident #12 needed assistance eating. In an interview with CNA R on 4/13/2016 at 2:15 pm, CNA R said she checked on Resident #12 often because she had a habit of removing her oxygen nasal cannula. CNA R said Resident #12 was incontinent and required assistance with activities of daily living. In an interview on 4/13/2016 at 3:00 pm, when asked for the ADL documentation for Resident #12, the Regional RN revealed the computer system was not working very well and the facility was having problems with the computers and having trouble obtaining documentation, but she was working on the issue. In an interview on 4/14/2016 at 9:00 am. the DON was asked for CNA documentation regarding how often Resident #12 was checked on during the day and any CNA documentation regarding incontinent care, meal times and assisting with meals. The DON said the facility was having computer problems and the system was messed up and slow . The DON further revealed the facility did not have any documentation of activities of daily living (ADL ' s) or when CNA ' s check on the residents. The DON said the corporate nurse was currently working on the situation and trying to retrieve information. In an interview with the DON on 4/14/2016 at 10:30 am, he said he was notified by the nurse that Resident #12 was found with a bruise to her head on 4/11/2016 between 7:00 pm and 9:00 pm. The DON revealed he was not aware that the injury was noted by CNA Z at 2:00 pm who had not reported it to the nurse. The DON further revealed Resident #12 was a fall risk and should be checked on frequently and as needed per care plan. The DON said that he was aware that a complete head to toe assessment did not occur on 4/11/2016 when the bruises were noted by the nurse. He stated I don ' t understand why a nurse with a resident with a head injury of unknown origin would not complete a full head to toe assessment . The DON further revealed the facility started complete skin assessments on all residents on 4/13/2016. In an interview on 4/15/2016 at 1:27 pm via telephone with hospital case manager, regarding Resident #12, she said facility had not notified guardian of injury or hospital admission. Hospital case manager said she was able to notify Resident #12 ' s guardian on 4/15/2016 after requesting guardianship information from facility. In an interview on 4/15/2016 at 3:45 pm the Regional Director said that he did not understand why this situation was an IJ. He said he could not understand how it is a system failure . The Regional Director further said that CNA Z had been suspended pending investigation and said that if surveyors were to question CNA Z, he would be able to give you the correct answers on what to do regarding an injury of unknown origin. Record review of Assistance with Meals policy and procedure provided by facility dated 2001 with a revised date of September 2013 revealed: Policy Statement; Residents shall receive assistance with meals in a manner that meets individual needs of each resident. 2. Residents confined to bed: b. The nursing staff will prepare residents for eating. Record review of Investigating Unexplained Injuries policy and procedures dated 2001 with a revised date of April 2012 revealed: Policy Statement; An investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation: 1. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident ' s clinical record. 2. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) The extent of the injury; or (2) The location of the injury (e.g., the injury located in an area not generally vulnerable to trauma); or (3) The number of injuries observed at one particular point in time; . Record review of Recognizing Signs and Symptoms of Abuse/Neglect policy and procedures provided by facility dated 2001 with a revised date of April 2012 revealed: Policy statement; Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor, the Director of Nursing Services, and Administrator immediately. Policy Interpretation and Implementation: 1. Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it. a. Signs of Actual/Physical Abuse: (1) Welts or bruises . (4) Black eyes or broken teeth; .(6) Sexual exploitation; (7) Rape; . b. Signs of /Actual Physical Neglect: . (6) Inadequate provision of care; (7) Caregiver indifference to resident ' s personal care and needs; . (9) Leaving someone unattended who needs supervision. The facility ' s Regional Director of Operations, Regional RN, DON, and ADON were notified on 4/14/2016 at 10:00 am that an Immediate Jeopardy situation had been identified due to the above failures. The facility submitted a plan of removal for the IJ and it was accepted on 4/16/2016 at 12:36 P.M. Plan to Lower the Immediate Jeopardy Immediate Action: 1. All residents were assessed for unknown skin issues by the nursing staff. These assessments were completed on 04/13/16. This audit was overseen by the Nursing Administration. DON and/or designee will be responsible to ensure weekly skin audits on an ongoing basis. 2. CNA assignment sheets have been audited. The ADON and QA nurse completed this audit on 04/14/16. Assignment sheets will be updated daily by the ADON and/or designee for changes. 3. 100% review of Care Plans for appropriateness and accuracy related to assistance with meals and supervision. Accuracy and appropriateness was determined through direct observation, meal service and interviews with direct care staff and licensed nurses. This review was started on 04/14/16 and completed on 04/15/16 by the MDS coordinators and the Corporate Reimbursement Specialists. 4. Upon notification of the initial bruise: resident was assessed and sent to the hospital. Abuse Coordinator was notified and a report was made to DADS. Abuse Coordinator and Regional Director of Operations began investigating the cause of the bruise. Staff was interviewed that was on duty April 11, 2016. The investigation began 04/12/16 and will be completed by 04/19/16. The Abuse Coordinator and Regional Director of Operations will review the investigation for completeness prior to submitting to DADS. 5. Upon discovery of the bruising to the peri area, local police department was called by the RDO, male staff member that was on duty (and failed to report the discovery of the bruise to the head) was immediately removed from the facility and suspended, administrative nursing staff was sent to the hospital to assess and evaluate the bruising to the peri area. All residents were assessed for unknown skin issues on 04/13/16. Training: 1. All licensed nurses will be inserviced on assessing residents when an injury of unknown origin is reported. Assessment procedure will be to conduct a complete head-to-toe assessment. This includes full vital signs. This inservice will be conducted by Administrative nursing staff (DON, ADON, QA, Staffing Coordinator, MDS Coordinator and Treatment Nurse). This inservice was started on 04/14/16 and will be completed by 04/15/16. (Procedure for head-to-toe assessment is attached.) 2. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the Stop and Watch. This inservice was started on 04/14/16 and to be completed 04/15/16. (Program is attached.) 3. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the location and accessibility of care plans. Care plans are located in the Matrix system under the RAI tab. This inservice was started on 04/14/16 and completed on 04/15/16. 4. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on following the plan of care specific to assistance with meals and supervision. The CNA assignment sheets will be utilized to indicate the level of assistance and supervision. This inservice is to be conducted by Nursing Administration. This inservice was started on 04/14/16 and will be completed by 04/15/16. 5. All staff (all departments) will be inserviced on the Abuse/Neglect policy. This inservice will be conducted by the Regional Director of Operations and/or designee. This inservice will start on 04/14/16 and be completed on 04/15/16. Inservice to include: a. definition of abuse and neglect b. examples of abuse and neglect c. signs and symptoms of abuse and neglect (to include injuries of unknown origin) d. responsibility of staff to report signs, symptoms and allegations of abuse and neglect e. responsibility to inform Abuse Coordinator of allegations of abuse and neglect f. identification of Abuse Coordinator g. reporting change of conditions and/or injuries 6. Licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the Falling Star/fall prevention program (attached). This inservice will start on 04/15/16 and be completed on 04/15/16. Monitoring: 1. Administrator and/or designee will monitor for abuse and neglect policy comprehension and adherence through daily rounds, staff interviews and staff huddles beginning 04/15/16 and was completed the same day. 2. DON and/or designee will monitor daily those residents that require assistance and/or supervision with meals beginning 04/14/16. Monitoring was completed 04/14/16. 3. DON and/or designee will evaluate care plans for accuracy and completeness on initiation, at change of condition and quarterly beginning 04/15/16. DON completed evaluation on 04/15/16. 4. Fall prevention will be monitored by DON and/or designee through daily rounds, staff re-education and incident report reviews beginning 04/15/16. Rounds, re-education and incident report review was completed on 04/15/16. 5. Stop and Watch will be monitored by the DON and/or designee through review of Stop and Watch forms on a daily basis beginning 04/15/16. DON completed Stop and Watch monitoring on 04/15/16. Monitoring of the plan: Record review of Stop and Watch form, not dated, read: If you identify a change while caring for and or observing patient/resident, please complete this form entirely, circle the change, and notify and give form to Nurse. Record review of facility in-service records revealed staff was in-serviced on Abuse/Neglect on 4/14/2016. Record review of facility in-service records revealed staff was in-serviced on Stop and Watch on 4/14/2016. Record review of facility in-service records revealed licensed staff was in-serviced on assessments of residents. Record review of facility in-service records revealed licensed staff and certified nurse aides were in-serviced on following care plans and assisting residents with meals. In an interview on 4/15/2016 at10:36 am LVN A revealed that staff had been in serviced on Abuse/Neglect on 4/14/2016. LVN A said if she found a resident with an injury she would assess immediately and notify the DON. LVN A said if the resident was alert, she would interview the resident to see what happened. LVN A said Neurological checks were always completed with head injuries. In an interview on 4/15/2016 at 10:40 am CNA W said the facility had an in-service on Abuse/Neglect on 4/14/2016 and 4/15/2016. She said if a resident was noted with any type of injury it should be reported to the nurse immediately and a Stop and Watch form should be filled out. In an interview on 4/15/2016 at 10:46 am with CNA V, she said she was in-serviced on Abuse/Neglect the day before. She said any injury should be conveyed to the nurse and a Stop and Watch form should be filled out. In an interview on 4/15/2016 at 12:01 pm the Director of Therapy, said the staff had been in serviced on Abuse and neglect on 4/14/2016. The Director of Therapy said all injuries were reported immediately and a Stop and Watch form was completed. In an interview on 4/15/2016 at 12:15 pm the Social Worker revealed the staff was in-serviced on Abuse/Neglect and reporting injuries on 4/14/2016. The Social Worker further revealed the facility had implemented a Stop and Watch form that was completed by any staff member who witnessed a change of condition on any resident. Interviews of staff who work two different shift concerning the assessments of residents who had a change of condition revealed that training had been conducted and staff were able to explain the process of complete assessments. On 4/16/2016 at 3:09 pm, the Regional Director of Operations and the DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated. The facility was continuing to monitor to ensure staff displayed a good knowledge of recognizing and reporting abuse and neglect, resident ' s changes of condition were reported, complete assessments of residents were conducted and medical care was provided promptly. The facility ' s CMS 672 form revealed 79 residents required assistance from staff with ADLs including transferring and eating.

Based on observation, interview and record review, the facility failed to ensure staff reported and thoroughly investigated incidents of possible abuse and neglect for one of fourteen residents (Resident #12) who were reviewed for neglect. The facility failed to have CNA Z trained to immediately report any signs of resident abuse/neglect or injuries of unknown origin. CNA Z became aware at 2:00 p.m. of Resident #12 ' s bruise to the right eye and eyebrow, from an unknown origin, and did not report it to the charge nurse or administration. The facility failed to have staff trained to conduct a complete assessment of residents after an injury of unknown origin has been identified. Resident #12 was not completely assessed after an injury of her right eye and eyebrow were identified by LVN Y at 9:00 p.m. Resident #12 had large bruised areas in the pubic area and on her thighs that were not identified until Resident #12 was assessed in the hospital seven hours after the bruises to her eye were noted by CNA Z. These failures resulted in an identification of an Immediate Jeopardy on 4/14/16. While the IJ was removed on 4/16/16, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated. The facility was continuing to monitor their plan to ensure staff were trained on reporting injuries of unknown origin and complete assessments of residents. This failure affected one resident who was transferred to the hospital with injuries to her head and pubic area and placed 78 residents who required assistance from staff or had a history of [REDACTED]. Intake #: 2, 4 Findings Include: Resident #12 Record review of face sheet for Resident #12 revealed an admission date of [DATE] with a readmitted [DATE] to the facility. Resident #12 was a [AGE] year old woman. Her [DIAGNOSES REDACTED]. Record review of Resident #12 ' s clinical record revealed she was appointed Guardianship by Harris County Guardianship Program on August 19, 2015. Record review of Resident #12 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS dated [DATE] for Resident #12 further revealed the resident required limited assistance of one staff physical assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #12's care plan dated 08/18/15 revealed a problem of Falls, resident is at risk for falling related to unsteady gait and [MEDICAL CONDITION] drug use. The goal was for the Resident to remain free from injury. Approaches included: observe freequently and placce in supervised area when out of bed, mattress on the floor, fall mats beside mattress, monitor resident every 30 minutes or more .place resident in a fall prevention program . Record review of the care plan for Resident #12 dated 1/21/2016 revealed she was a fall risk related to history of falls. Actual falls documented on the care plan had occurred on 1/13/2016, 2/08/2016, 2/19/2016, and 2/21/2016. Approaches included: keep bed in lowest position with brakes locked, keep call light in reach, keep personal items and frequently used items within reach, observe frequently and place in supervised area when out of bed, place resident in fall prevention program, provide proper well maintained footwear, and provide resident an environment free of clutter. Record review of a previous care plan for Resident #12 dated 7/31/2015 with a last conference date of 1/25/2016 revealed Resident #12 had [DIAGNOSES REDACTED]. Approaches included: Administer medications, assess for symptoms of toxicity, if [MEDICAL CONDITION] occurs, remove all restrictive clothing and objects of potential harm, turn head to side to maintain patent airway, keep bed in lowest position, keep call light in reach, suction resident as needed, and assess characteristics before, during and after [MEDICAL CONDITION]. Observation on 4/11/2016 at 10:00 am of Resident #12 ' s room revealed a mattress on the floor with a floor mat on both sides of mattress. Observation on 4/11/2016 at 10:05 am revealed Resident #12 in a wheelchair in the general living area with other residents. No bruising noted on the resident ' s face or right eye. Record review of Resident #12 ' s Patient Narrative dated 4/11/2016 read: hematoma visualized at 2:00 pm. The resident was alert and oriented to self and ambulates with a wheelchair. Bruising was noted to the left arm, antecubital (front of the elbow) region and hematoma to the right eye was noted on the diagram. Record review of Resident #12 ' s nurses notes dated 4/11/2016 at 9:33 pm read: In to see patient, patient noted to have a bruise over her right eye lid. Eye swollen with a large knot over corner of eye, eyebrow area. Patient stated pain at a 3 on a scale of 1-10. (Vital signs) 140/80-67-20-97.8. Asked patient if she knew how she obtained the areas, stated, it was earlier, she did not know when. NP (Nurse Practitioner) notified. New orders received to send patient to ER (emergency room ) for eval and treat. ADON notified. RP (responsible party) called. Message left for her to call facility. Record review of the written statement by LVN Y dated 4/11/2016 revealed: LVN Y worked the 2:00 pm -10:00 pm shift on 4/11/2016. LVN Y wrote that she checked on Resident #12 during rounds and again between 4:50 pm and 5:00 pm. LVN Y asked Resident #12 if she was going to eat in her room or dining room and Resident #12 said she would eat in her room. LVN Y then left the room. The written statement further revealed after LVN Y did a medication pass she checked on Resident #12 who was in her room sitting Indian style on the mattress on the floor in the dark. LVN Y asked if she could turn on the light in her room and Resident #12 said yes and LVN Y noted bruise, swelling and knot to right eye. LVN Y asked CNA Z, who was in the hall if he knew Resident #12 had the bruising and swelling. CNA Z replied that the bruise had been there since the beginning of his shift. LVN Y then called the Nurse Practitioner and received orders to send Resident #12 to the hospital for an evaluation. Record review of EMS (Emergency Medical System) transfer form dated 4/11/2016 revealed: Ambulance was dispatched at 9:15 pm and arrived at the facility at 9:45 pm. Transfer form revealed that swelling and contusions were noted but area not specified. Mechanism of injury was noted as a fall. Record review of Resident #12 ' s hospital cat scan (CT) report dated 4/11/2016 of head, face, cervical spine, abdomen, and pelvis with and without contrast revealed: CT of face; mild right periorbital soft tissue swelling was identified. No evidence of facial fracture. CT of abdomen/pelvis revealed: hypodense area within the region of the right labia was identified measuring 5.9 x 4.9 cm and appeared fairly well contained, most consistent with hematoma. Overlying soft tissue swelling and subcutaneous [MEDICAL CONDITION] was also seen over the lower anterior pelvis. Impression: Right labial hematoma that appeared fairly well-contained. Additional overlying subcutaneous [MEDICAL CONDITION] and inflammation may correlate with trauma. Clinical correlation recommended. Record review of Resident #12 ' s Neurological Assessment Flow Sheet dated 4/12/2016 at 9:15 (does not distinguish if it was am or pm), revealed: Resident was alert, pupils were equal and reactive. Vitals: 140/80, 97.8, 67, 20. Record review of a Complaint Investigation Worksheet dated 4/12/2016 read: Resident (#12) was admitted to the hospital. The resident had a history of [REDACTED]. The complainant reported there was also swelling to the mons pubis (mound of flesh found on the female ' s pubic bone) and labia majora (the major external visible portion of the woman ' s vulva) were suspect, and would not occur quickly. The complainant reported they felt if this swelling and discoloration were actually caused by a fall, the resident would have had to hit something hard. The reporter stated they suspected something else (besides the fall) had caused the bruising and swelling. Record review of Incident reported to DADS dated 4/12/2016 called in by the facility ' s Regional Director read: Resident #12, was a cognitively impaired resident. She had a history of [REDACTED]. The facility indicated there were no identifiable perpetrators, or that the event was not an environmental or other issue. Resident was observed on the floor beside her bed. She had a hematoma to the right forehead. She was sent to the local hospital for treatment. Family, Physician, and surveyors (in the facility conducting an annual survey) were notified. Harris County Guardianship was not notified. Interview on 4/13/2016 at 9:45 am with Resident #12 at the hospital revealed she was unsure of how she acquired bruising to her right eye, right brow and left antecubital region of arm. Resident #12 said she thought maybe she fell out of her wheelchair earlier in the day when she was trying to reach for her breakfast. When Resident #12 was asked how she obtained bruising to her vaginal area she said she did not know that she had bruising in that area or how it got there. Observation on 4/13/2016 at 9:58 am of Resident #12 ' s vaginal area revealed a large (lemon size) bright purple hematoma on mons pubis and swelling with deep purple bruising to right labia majora with swelling. Purple bruising was noted from left inner thigh to right inner thigh. Quarter sized purple/blue bruise noted to right mid inner thigh. A large knot (ping pong ball size) was noted on the right brow area with dark purple bruising around the diameter of the right eye. In an interview with a hospital charge nurse on 4/13/2016 at 10:30 am he revealed he thought the bruising to the mons pubis and the injury was questionable as to how they occurred. Interview on 4/13/2016 at 11:29 am with facility LVN Y revealed her shift started at 2:00 pm on 4/11/2016. LVN Y said she took report from the out-going nurse and nothing was mentioned about a fall or injury to Resident #12. LVN Y said she checked on Resident #12 at the beginning of the shift to make sure her oxygen was on. LVN Y said the light was off in the room and Resident #12 was lying on her left side facing the window. She stated she looked at the Resident ' s ear and could see that the oxygen was on the Resident #12 via the nasal cannula. LVN Y said she did not notice any bruising on Resident #12 at that time, but said she did not turn on the light in Resident #12 ' s room. LVN Y said she checked on Resident #12 again around 5:00 pm and the light was still off in the room and the resident ' s oxygen was in place. LVN Y said she did not turn on the light in Resident #12's room at that time and talked to her from the door. Resident #12 was awake at 5:00 pm and had said she was alright and wanted to eat dinner in her room. LVN Y said she left the room and returned at 6:30 pm and the light was off, but did see that the oxygen was in place. LVN Y said she went to check on Resident #12 at approximately 9:00 pm and the door was closed. She stated she knocked on the door and then opened it. Resident #12 was sitting crossed legged on the mattress on the floor. LVN Y said she turned on the light in Resident #12 ' s room and noticed bruising and swelling to the resident ' s right eyebrow. LVN Y said Resident #12 was not sure how the bruise and swelling was obtained. LVN Y revealed she went out in the hall and found CNA Z and asked him if he was aware of the bruising and swelling to Resident #12 ' s right eye and he said he was aware and noticed it at 2:00 pm when his shift began. LVN Y said CNA Z told her he did not say anything because he thought she already knew. LVN Y then checked Resident #12 ' s chart for any documentation of the injury and said there was no injury or falls noted during the previous shift. LVN Y said she then went back to Resident #12 ' s room and assessed her, performed neurological vital signs, called the nurse practitioner and received orders to send the resident to the hospital for an evaluation. LVN Y said she performed a range of motion assessment on Resident #12, neurological assessment, and assessed her right eye but did not assess any other region of Resident #12 ' s body. LVN Y said she called the ADON to report the injury, called an ambulance service and left a messages for Resident #12 ' s family but the call was not returned. Observation on 4/13/16 at 11:45am of Resident #12 ' s room revealed the blinds were closed and the room was dark. Observation revealed it was so dark in the room to see discoloration of tissue or an injury to a resident would be difficult without turning on the light or standing directly over the resident. In interview on 4/14/2016 at 9:45 am the DON said no full assessment was completed by LVN Y when the bruise and swelling was discovered to right eye of Resident #12. The DON said the neurological checks were completed and an assessment of the head wound along with range of motion was completed by LVN Y. The DON further revealed the investigation regarding the injury of unknown origin to Resident #12 ' s right eye and right brow had not been started because the facility was concentrating on the survey and not the investigation. In an interview with CNA Z on 4/13/2016 at 12:10 pm revealed he worked the 2:00 pm to 10:00 pm shift on 4/11/2016. CNA Z said he noted a small swollen black eye to the right eye of Resident #12. CNA Z said It didn ' t look serious . CNA Z revealed Resident #12 was in bed all day and he brought her a dinner tray about 5:00 pm. CNA Z said he set Resident #12 ' s dinner tray on the mattress on the floor so she could eat and left the room. CNA Z said Resident #12 feeds herself. CNA Z said he returned at approximately 5:40 pm to pick up her dinner tray and she had only eaten 30 % of her meal. CNA Z said he did not provide any incontinent care to Resident #12 as she remained clean all day. When asked why he did not notify LVN Y of the swelling and bruising to Resident #12 ' s eye he said It didn ' t occur to me to tell anyone because she always has bruises due to bumping into things . CNA Z said he did notify LVN Y that Resident #12 had trouble breathing during the shift and LVN Y told CNA Z to put the oxygen on Resident #12 but was not sure if LVN Y assessed Resident #12 for breathing issues. When asked about abuse and neglect policy and procedures CNA Z said he knew that he should report bruising but did not think it was important and he thought LVN Y already knew about it. In an interview on 4/13/2016 at 12:35 pm RN Q. said she cared for Resident #12 on 4/11/2016 on the 6:00 am-2:00 pm shift. RN Q revealed that no bruising to face, head, or vaginal area was noted during the day on Resident #12. RN Q further revealed she was not sure if Resident #12 needed assistance with feeding or incontinent care as RN Q had only worked at the facility for 3 weeks. In an interview on 4/13/2016 at 12:56pm CNA U, said Resident #12 had been declining recently and eating less. CNA U said she took care of Resident #12 on 4/11/2016 during the 6:00 am -2:00 pm shift and did not notice any bruising to Resident #12 ' s face. CNA U said at 9:00 am on 04/11/2016 she was passing Resident #12's room when she noticed the Resident had removed her brief and her butt cheeks were hanging out so she provided incontinent care and put a brief back on the Resident. She also said that she checked Resident #12 at 1:30pm and provided incontinent care and replaced her brief. CNA U said there was no bruising in the vaginal area either time. In an interview on 4/13/2016 at 1:45 pm the DON revealed Resident #12 self-propelled herself in a wheelchair but was incontinent and needed assistance. In an interview on 4/13/2016 at 2:10 pm LVN Y revealed Resident #12 needed assistance to the bathroom and was incontinent at times. LVN Y said Resident #12 was confused at times but not always. LVN Y said Resident #12 prefers to eat in her room at times and staff would bring in her trays and set them on the mattress so she could eat. LVN Y did not say if Resident #12 needed assistance eating. In an interview with CNA R on 4/13/2016 at 2:15 pm, CNA R said she checked on Resident #12 often because she had a habit of removing her oxygen nasal cannula. CNA R said Resident #12 was incontinent and required assistance with activities of daily living. In an interview on 4/13/2016 at 3:00 pm, when asked for the ADL documentation for Resident #12, the Regional RN revealed the computer system was not working very well and the facility was having problems with the computers and having trouble obtaining documentation, but she was working on the issue. In an interview on 4/14/2016 at 9:00 am. the DON was asked for CNA documentation regarding how often Resident #12 was checked on during the day and any CNA documentation regarding incontinent care, meal times and assisting with meals. The DON said the facility was having computer problems and the system was messed up and slow . The DON further revealed the facility did not have any documentation of activities of daily living (ADL ' s) or when CNA ' s check on the residents. The DON said the corporate nurse was currently working on the situation and trying to retrieve information. In an interview with the DON on 4/14/2016 at 10:30 am, he said he was notified by the nurse that Resident #12 was found with a bruise to her head on 4/11/2016 between 7:00 pm and 9:00 pm. The DON revealed he was not aware that the injury was noted by CNA Z at 2:00 pm who had not reported it to the nurse. The DON further revealed Resident #12 was a fall risk and should be checked on frequently and as needed per care plan. The DON said that he was aware that a complete head to toe assessment did not occur on 4/11/2016 when the bruises were noted by the nurse. He stated I don ' t understand why a nurse with a resident with a head injury of unknown origin would not complete a full head to toe assessment . The DON further revealed the facility started complete skin assessments on all residents on 4/13/2016. In an interview on 4/15/2016 at 1:27 pm via telephone with hospital case manager, regarding Resident #12, she said facility had not notified guardian of injury or hospital admission. Hospital case manager said she was able to notify Resident #12 ' s guardian on 4/15/2016 after requesting guardianship information from facility. In an interview on 4/15/2016 at 3:45 pm the Regional Director said that he did not understand why this situation was an IJ. He said he could not understand how it is a system failure . The Regional Director further said that CNA Z had been suspended pending investigation and said that if surveyors were to question CNA Z, he would be able to give you the correct answers on what to do regarding an injury of unknown origin. Record review of Assistance with Meals policy and procedure provided by facility dated 2001 with a revised date of September 2013 revealed: Policy Statement; Residents shall receive assistance with meals in a manner that meets individual needs of each resident. 2. Residents confined to bed: b. The nursing staff will prepare residents for eating. Record review of Investigating Unexplained Injuries policy and procedures dated 2001 with a revised date of April 2012 revealed: Policy Statement; An investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation: 1. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident ' s clinical record. 2. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) The extent of the injury; or (2) The location of the injury (e.g., the injury located in an area not generally vulnerable to trauma); or (3) The number of injuries observed at one particular point in time; . Record review of Recognizing Signs and Symptoms of Abuse/Neglect policy and procedures provided by facility dated 2001 with a revised date of April 2012 revealed: Policy statement; Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor, the Director of Nursing Services, and Administrator immediately. Policy Interpretation and Implementation: 1. Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it. a. Signs of Actual/Physical Abuse: (1) Welts or bruises . (4) Black eyes or broken teeth; .(6) Sexual exploitation; (7) Rape; . b. Signs of /Actual Physical Neglect: . (6) Inadequate provision of care; (7) Caregiver indifference to resident ' s personal care and needs; . (9) Leaving someone unattended who needs supervision. The facility ' s Regional Director of Operations, Regional RN, DON, and ADON were notified on 4/14/2016 at 10:00 am that an Immediate Jeopardy situation had been identified due to the above failures. The facility submitted a plan of removal for the IJ and it was accepted on 4/16/2016 at 12:36 P.M. Plan to Lower the Immediate Jeopardy Immediate Action: 1. All residents were assessed for unknown skin issues by the nursing staff. These assessments were completed on 04/13/16. This audit was overseen by the Nursing Administration. DON and/or designee will be responsible to ensure weekly skin audits on an ongoing basis. 2. CNA assignment sheets have been audited. The ADON and QA nurse completed this audit on 04/14/16. Assignment sheets will be updated daily by the ADON and/or designee for changes. 3. 100% review of Care Plans for appropriateness and accuracy related to assistance with meals and supervision. Accuracy and appropriateness was determined through direct observation, meal service and interviews with direct care staff and licensed nurses. This review was started on 04/14/16 and completed on 04/15/16 by the MDS coordinators and the Corporate Reimbursement Specialists. 4. Upon notification of the initial bruise: resident was assessed and sent to the hospital. Abuse Coordinator was notified and a report was made to DADS. Abuse Coordinator and Regional Director of Operations began investigating the cause of the bruise. Staff was interviewed that was on duty April 11, 2016. The investigation began 04/12/16 and will be completed by 04/19/16. The Abuse Coordinator and Regional Director of Operations will review the investigation for completeness prior to submitting to DADS. 5. Upon discovery of the bruising to the peri area, local police department was called by the RDO, male staff member that was on duty (and failed to report the discovery of the bruise to the head) was immediately removed from the facility and suspended, administrative nursing staff was sent to the hospital to assess and evaluate the bruising to the peri area. All residents were assessed for unknown skin issues on 04/13/16. Training: 1. All licensed nurses will be inserviced on assessing residents when an injury of unknown origin is reported. Assessment procedure will be to conduct a complete head-to-toe assessment. This includes full vital signs. This inservice will be conducted by Administrative nursing staff (DON, ADON, QA, Staffing Coordinator, MDS Coordinator and Treatment Nurse). This inservice was started on 04/14/16 and will be completed by 04/15/16. (Procedure for head-to-toe assessment is attached.) 2. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the Stop and Watch. This inservice was started on 04/14/16 and to be completed 04/15/16. (Program is attached.) 3. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the location and accessibility of care plans. Care plans are located in the Matrix system under the RAI tab. This inservice was started on 04/14/16 and completed on 04/15/16. 4. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on following the plan of care specific to assistance with meals and supervision. The CNA assignment sheets will be utilized to indicate the level of assistance and supervision. This inservice is to be conducted by Nursing Administration. This inservice was started on 04/14/16 and will be completed by 04/15/16. 5. All staff (all departments) will be inserviced on the Abuse/Neglect policy. This inservice will be conducted by the Regional Director of Operations and/or designee. This inservice will start on 04/14/16 and be completed on 04/15/16. Inservice to include: a. definition of abuse and neglect b. examples of abuse and neglect c. signs and symptoms of abuse and neglect (to include injuries of unknown origin) d. responsibility of staff to report signs, symptoms and allegations of abuse and neglect e. responsibility to inform Abuse Coordinator of allegations of abuse and neglect f. identification of Abuse Coordinator g. reporting change of conditions and/or injuries 6. Licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the Falling Star/fall prevention program (attached). This inservice will start on 04/15/16 and be completed on 04/15/16. Monitoring: 1. Administrator and/or designee will monitor for abuse and neglect policy comprehension and adherence through daily rounds, staff interviews and staff huddles beginning 04/15/16 and was completed the same day. 2. DON and/or designee will monitor daily those residents that require assistance and/or supervision with meals beginning 04/14/16. Monitoring was completed 04/14/16. 3. DON and/or designee will evaluate care plans for accuracy and completeness on initiation, at change of condition and quarterly beginning 04/15/16. DON completed evaluation on 04/15/16. 4. Fall prevention will be monitored by DON and/or designee through daily rounds, staff re-education and incident report reviews beginning 04/15/16. Rounds, re-education and incident report review was completed on 04/15/16. 5. Stop and Watch will be monitored by the DON and/or designee through review of Stop and Watch forms on a daily basis beginning 04/15/16. DON completed Stop and Watch monitoring on 04/15/16. Monitoring of the plan: Record review of Stop and Watch form, not dated, read: If you identify a change while caring for and or observing patient/resident, please complete this form entirely, circle the change, and notify and give form to Nurse. Record review of facility in-service records revealed staff was in-serviced on Abuse/Neglect on 4/14/2016. Record review of facility in-service records revealed staff was in-serviced on Stop and Watch on 4/14/2016. Record review of facility in-service records revealed licensed staff was in-serviced on assessments of residents. Record review of facility in-service records revealed licensed staff and certified nurse aides were in-serviced on following care plans and assisting residents with meals. In an interview on 4/15/2016 at10:36 am LVN A revealed that staff had been in serviced on Abuse/Neglect on 4/14/2016. LVN A said if she found a resident with an injury she would assess immediately and notify the DON. LVN A said if the resident was alert, she would interview the resident to see what happened. LVN A said Neurological checks were always completed with head injuries. In an interview on 4/15/2016 at 10:40 am CNA W said the facility had an in-service on Abuse/Neglect on 4/14/2016 and 4/15/2016. She said if a resident was noted with any type of injury it should be reported to the nurse immediately and a Stop and Watch form should be filled out. In an interview on 4/15/2016 at 10:46 am with CNA V, she said she was in-serviced on Abuse/Neglect the day before. She said any injury should be conveyed to the nurse and a Stop and Watch form should be filled out. In an interview on 4/15/2016 at 12:01 pm the Director of Therapy, said the staff had been in serviced on Abuse and neglect on 4/14/2016. The Director of Therapy said all injuries were reported immediately and a Stop and Watch form was completed. In an interview on 4/15/2016 at 12:15 pm the Social Worker revealed the staff was in-serviced on Abuse/Neglect and reporting injuries on 4/14/2016. The Social Worker further revealed the facility had implemented a Stop and Watch form that was completed by any staff member who witnessed a change of condition on any resident. Interviews of staff who work two different shift concerning the assessments of residents who had a change of condition revealed that training had been conducted and staff were able to explain the process of complete assessments. On 4/16/2016 at 3:09 pm, the Regional Director of Operations and the DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated. The facility was continuing to monitor to ensure staff displayed a good knowledge of recognizing and reporting abuse and neglect, resident ' s changes of condition were reported, complete assessments of residents were conducted and medical care was provided promptly. The facility ' s CMS 672 form revealed 79 residents required assistance from staff with ADLs including transferring and eating.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of 14 residents (Resident #12) reviewed for quality of care. The facility failed to have CNA Z trained to immediately report any signs of resident abuse/neglect or injuries of unknown origin. CNA Z became aware at 2:00 p.m. of Resident #12 ' s bruise to the right eye and eyebrow, from an unknown origin, and did not report it to the charge nurse or administration. The facility failed to have staff trained to conduct a complete assessment of residents after an injury of unknown origin has been identified. Resident #12 was not completely assessed after an injury of her right eye and eyebrow were identified by LVN Y at 9:00 p.m. Resident #12 had large bruised areas in the pubic area and on her thighs that were not identified until Resident #12 was assessed in the hospital seven hours after the bruises to her eye were noted by CNA Z. These failures resulted in an identification of an Immediate Jeopardy on 4/14/16. While the IJ was removed on 4/16/16, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated. The facility was continuing to monitor their plan to ensure staff were trained on reporting injuries of unknown origin and complete assessments of residents. This failure affected one resident who was transferred to the hospital with injuries to her head and pubic area and placed 78 residents who required assistance from staff or had a history of [REDACTED]. Intake #: 2, 4 Findings Include: Resident #12 Record review of face sheet for Resident #12 revealed an admission date of [DATE] with a readmitted [DATE] to the facility. Resident #12 was a [AGE] year old woman. Her [DIAGNOSES REDACTED]. Record review of Resident #12 ' s clinical record revealed she was appointed Guardianship by Harris County Guardianship Program on August 19, 2015. Record review of Resident #12 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS dated [DATE] for Resident #12 further revealed the resident required limited assistance of one staff physical assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #12's care plan dated 08/18/15 revealed a problem of Falls, resident is at risk for falling related to unsteady gait and [MEDICAL CONDITION] drug use. The goal was for the Resident to remain free from injury. Approaches included: observe freequently and placce in supervised area when out of bed, mattress on the floor, fall mats beside mattress, monitor resident every 30 minutes or more .place resident in a fall prevention program . Record review of the care plan for Resident #12 dated 1/21/2016 revealed she was a fall risk related to history of falls. Actual falls documented on the care plan had occurred on 1/13/2016, 2/08/2016, 2/19/2016, and 2/21/2016. Approaches included: keep bed in lowest position with brakes locked, keep call light in reach, keep personal items and frequently used items within reach, observe frequently and place in supervised area when out of bed, place resident in fall prevention program, provide proper well maintained footwear, and provide resident an environment free of clutter. Record review of a previous care plan for Resident #12 dated 7/31/2015 with a last conference date of 1/25/2016 revealed Resident #12 had [DIAGNOSES REDACTED]. Approaches included: Administer medications, assess for symptoms of toxicity, if [MEDICAL CONDITION] occurs, remove all restrictive clothing and objects of potential harm, turn head to side to maintain patent airway, keep bed in lowest position, keep call light in reach, suction resident as needed, and assess characteristics before, during and after [MEDICAL CONDITION]. Observation on 4/11/2016 at 10:00 am of Resident #12 ' s room revealed a mattress on the floor with a floor mat on both sides of mattress. Observation on 4/11/2016 at 10:05 am revealed Resident #12 in a wheelchair in the general living area with other residents. No bruising noted on the resident ' s face or right eye. Record review of Resident #12 ' s Patient Narrative dated 4/11/2016 read: hematoma visualized at 2:00 pm. The resident was alert and oriented to self and ambulates with a wheelchair. Bruising was noted to the left arm, antecubital (front of the elbow) region and hematoma to the right eye was noted on the diagram. Record review of Resident #12 ' s nurses notes dated 4/11/2016 at 9:33 pm read: In to see patient, patient noted to have a bruise over her right eye lid. Eye swollen with a large knot over corner of eye, eyebrow area. Patient stated pain at a 3 on a scale of 1-10. (Vital signs) 140/80-67-20-97.8. Asked patient if she knew how she obtained the areas, stated, it was earlier, she did not know when. NP (Nurse Practitioner) notified. New orders received to send patient to ER (emergency room ) for eval and treat. ADON notified. RP (responsible party) called. Message left for her to call facility. Record review of the written statement by LVN Y dated 4/11/2016 revealed: LVN Y worked the 2:00 pm -10:00 pm shift on 4/11/2016. LVN Y wrote that she checked on Resident #12 during rounds and again between 4:50 pm and 5:00 pm. LVN Y asked Resident #12 if she was going to eat in her room or dining room and Resident #12 said she would eat in her room. LVN Y then left the room. The written statement further revealed after LVN Y did a medication pass she checked on Resident #12 who was in her room sitting Indian style on the mattress on the floor in the dark. LVN Y asked if she could turn on the light in her room and Resident #12 said yes and LVN Y noted bruise, swelling and knot to right eye. LVN Y asked CNA Z, who was in the hall if he knew Resident #12 had the bruising and swelling. CNA Z replied that the bruise had been there since the beginning of his shift. LVN Y then called the Nurse Practitioner and received orders to send Resident #12 to the hospital for an evaluation. Record review of EMS (Emergency Medical System) transfer form dated 4/11/2016 revealed: Ambulance was dispatched at 9:15 pm and arrived at the facility at 9:45 pm. Transfer form revealed that swelling and contusions were noted but area not specified. Mechanism of injury was noted as a fall. Record review of Resident #12 ' s hospital cat scan (CT) report dated 4/11/2016 of head, face, cervical spine, abdomen, and pelvis with and without contrast revealed: CT of face; mild right periorbital soft tissue swelling was identified. No evidence of facial fracture. CT of abdomen/pelvis revealed: hypodense area within the region of the right labia was identified measuring 5.9 x 4.9 cm and appeared fairly well contained, most consistent with hematoma. Overlying soft tissue swelling and subcutaneous [MEDICAL CONDITION] was also seen over the lower anterior pelvis. Impression: Right labial hematoma that appeared fairly well-contained. Additional overlying subcutaneous [MEDICAL CONDITION] and inflammation may correlate with trauma. Clinical correlation recommended. Record review of Resident #12 ' s Neurological Assessment Flow Sheet dated 4/12/2016 at 9:15 (does not distinguish if it was am or pm), revealed: Resident was alert, pupils were equal and reactive. Vitals: 140/80, 97.8, 67, 20. Record review of a Complaint Investigation Worksheet dated 4/12/2016 read: Resident (#12) was admitted to the hospital. The resident had a history of [REDACTED]. The complainant reported there was also swelling to the mons pubis (mound of flesh found on the female ' s pubic bone) and labia majora (the major external visible portion of the woman ' s vulva) were suspect, and would not occur quickly. The complainant reported they felt if this swelling and discoloration were actually caused by a fall, the resident would have had to hit something hard. The reporter stated they suspected something else (besides the fall) had caused the bruising and swelling. Record review of Incident reported to DADS dated 4/12/2016 called in by the facility ' s Regional Director read: Resident #12, was a cognitively impaired resident. She had a history of [REDACTED]. The facility indicated there were no identifiable perpetrators, or that the event was not an environmental or other issue. Resident was observed on the floor beside her bed. She had a hematoma to the right forehead. She was sent to the local hospital for treatment. Family, Physician, and surveyors (in the facility conducting an annual survey) were notified. Harris County Guardianship was not notified. Interview on 4/13/2016 at 9:45 am with Resident #12 at the hospital revealed she was unsure of how she acquired bruising to her right eye, right brow and left antecubital region of arm. Resident #12 said she thought maybe she fell out of her wheelchair earlier in the day when she was trying to reach for her breakfast. When Resident #12 was asked how she obtained bruising to her vaginal area she said she did not know that she had bruising in that area or how it got there. Observation on 4/13/2016 at 9:58 am of Resident #12 ' s vaginal area revealed a large (lemon size) bright purple hematoma on mons pubis and swelling with deep purple bruising to right labia majora with swelling. Purple bruising was noted from left inner thigh to right inner thigh. Quarter sized purple/blue bruise noted to right mid inner thigh. A large knot (ping pong ball size) was noted on the right brow area with dark purple bruising around the diameter of the right eye. In an interview with a hospital charge nurse on 4/13/2016 at 10:30 am he revealed he thought the bruising to the mons pubis and the injury was questionable as to how they occurred. Interview on 4/13/2016 at 11:29 am with facility LVN Y revealed her shift started at 2:00 pm on 4/11/2016. LVN Y said she took report from the out-going nurse and nothing was mentioned about a fall or injury to Resident #12. LVN Y said she checked on Resident #12 at the beginning of the shift to make sure her oxygen was on. LVN Y said the light was off in the room and Resident #12 was lying on her left side facing the window. She stated she looked at the Resident ' s ear and could see that the oxygen was on the Resident #12 via the nasal cannula. LVN Y said she did not notice any bruising on Resident #12 at that time, but said she did not turn on the light in Resident #12 ' s room. LVN Y said she checked on Resident #12 again around 5:00 pm and the light was still off in the room and the resident ' s oxygen was in place. LVN Y said she did not turn on the light in Resident #12's room at that time and talked to her from the door. Resident #12 was awake at 5:00 pm and had said she was alright and wanted to eat dinner in her room. LVN Y said she left the room and returned at 6:30 pm and the light was off, but did see that the oxygen was in place. LVN Y said she went to check on Resident #12 at approximately 9:00 pm and the door was closed. She stated she knocked on the door and then opened it. Resident #12 was sitting crossed legged on the mattress on the floor. LVN Y said she turned on the light in Resident #12 ' s room and noticed bruising and swelling to the resident ' s right eyebrow. LVN Y said Resident #12 was not sure how the bruise and swelling was obtained. LVN Y revealed she went out in the hall and found CNA Z and asked him if he was aware of the bruising and swelling to Resident #12 ' s right eye and he said he was aware and noticed it at 2:00 pm when his shift began. LVN Y said CNA Z told her he did not say anything because he thought she already knew. LVN Y then checked Resident #12 ' s chart for any documentation of the injury and said there was no injury or falls noted during the previous shift. LVN Y said she then went back to Resident #12 ' s room and assessed her, performed neurological vital signs, called the nurse practitioner and received orders to send the resident to the hospital for an evaluation. LVN Y said she performed a range of motion assessment on Resident #12, neurological assessment, and assessed her right eye but did not assess any other region of Resident #12 ' s body. LVN Y said she called the ADON to report the injury, called an ambulance service and left a messages for Resident #12 ' s family but the call was not returned. Observation on 4/13/16 at 11:45am of Resident #12 ' s room revealed the blinds were closed and the room was dark. Observation revealed it was so dark in the room to see discoloration of tissue or an injury to a resident would be difficult without turning on the light or standing directly over the resident. In interview on 4/14/2016 at 9:45 am the DON said no full assessment was completed by LVN Y when the bruise and swelling was discovered to right eye of Resident #12. The DON said the neurological checks were completed and an assessment of the head wound along with range of motion was completed by LVN Y. The DON further revealed the investigation regarding the injury of unknown origin to Resident #12 ' s right eye and right brow had not been started because the facility was concentrating on the survey and not the investigation. In an interview with CNA Z on 4/13/2016 at 12:10 pm revealed he worked the 2:00 pm to 10:00 pm shift on 4/11/2016. CNA Z said he noted a small swollen black eye to the right eye of Resident #12. CNA Z said It didn ' t look serious . CNA Z revealed Resident #12 was in bed all day and he brought her a dinner tray about 5:00 pm. CNA Z said he set Resident #12 ' s dinner tray on the mattress on the floor so she could eat and left the room. CNA Z said Resident #12 feeds herself. CNA Z said he returned at approximately 5:40 pm to pick up her dinner tray and she had only eaten 30 % of her meal. CNA Z said he did not provide any incontinent care to Resident #12 as she remained clean all day. When asked why he did not notify LVN Y of the swelling and bruising to Resident #12 ' s eye he said It didn ' t occur to me to tell anyone because she always has bruises due to bumping into things . CNA Z said he did notify LVN Y that Resident #12 had trouble breathing during the shift and LVN Y told CNA Z to put the oxygen on Resident #12 but was not sure if LVN Y assessed Resident #12 for breathing issues. When asked about abuse and neglect policy and procedures CNA Z said he knew that he should report bruising but did not think it was important and he thought LVN Y already knew about it. In an interview on 4/13/2016 at 12:35 pm RN Q. said she cared for Resident #12 on 4/11/2016 on the 6:00 am-2:00 pm shift. RN Q revealed that no bruising to face, head, or vaginal area was noted during the day on Resident #12. RN Q further revealed she was not sure if Resident #12 needed assistance with feeding or incontinent care as RN Q had only worked at the facility for 3 weeks. In an interview on 4/13/2016 at 12:56pm CNA U, said Resident #12 had been declining recently and eating less. CNA U said she took care of Resident #12 on 4/11/2016 during the 6:00 am -2:00 pm shift and did not notice any bruising to Resident #12 ' s face. CNA U said at 9:00 am on 04/11/2016 she was passing Resident #12's room when she noticed the Resident had removed her brief and her butt cheeks were hanging out so she provided incontinent care and put a brief back on the Resident. She also said that she checked Resident #12 at 1:30pm and provided incontinent care and replaced her brief. CNA U said there was no bruising in the vaginal area either time. In an interview on 4/13/2016 at 1:45 pm the DON revealed Resident #12 self-propelled herself in a wheelchair but was incontinent and needed assistance. In an interview on 4/13/2016 at 2:10 pm LVN Y revealed Resident #12 needed assistance to the bathroom and was incontinent at times. LVN Y said Resident #12 was confused at times but not always. LVN Y said Resident #12 prefers to eat in her room at times and staff would bring in her trays and set them on the mattress so she could eat. LVN Y did not say if Resident #12 needed assistance eating. In an interview with CNA R on 4/13/2016 at 2:15 pm, CNA R said she checked on Resident #12 often because she had a habit of removing her oxygen nasal cannula. CNA R said Resident #12 was incontinent and required assistance with activities of daily living. In an interview on 4/13/2016 at 3:00 pm, when asked for the ADL documentation for Resident #12, the Regional RN revealed the computer system was not working very well and the facility was having problems with the computers and having trouble obtaining documentation, but she was working on the issue. In an interview on 4/14/2016 at 9:00 am. the DON was asked for CNA documentation regarding how often Resident #12 was checked on during the day and any CNA documentation regarding incontinent care, meal times and assisting with meals. The DON said the facility was having computer problems and the system was messed up and slow . The DON further revealed the facility did not have any documentation of activities of daily living (ADL ' s) or when CNA ' s check on the residents. The DON said the corporate nurse was currently working on the situation and trying to retrieve information. In an interview with the DON on 4/14/2016 at 10:30 am, he said he was notified by the nurse that Resident #12 was found with a bruise to her head on 4/11/2016 between 7:00 pm and 9:00 pm. The DON revealed he was not aware that the injury was noted by CNA Z at 2:00 pm who had not reported it to the nurse. The DON further revealed Resident #12 was a fall risk and should be checked on frequently and as needed per care plan. The DON said that he was aware that a complete head to toe assessment did not occur on 4/11/2016 when the bruises were noted by the nurse. He stated I don ' t understand why a nurse with a resident with a head injury of unknown origin would not complete a full head to toe assessment . The DON further revealed the facility started complete skin assessments on all residents on 4/13/2016. In an interview on 4/15/2016 at 1:27 pm via telephone with hospital case manager, regarding Resident #12, she said facility had not notified guardian of injury or hospital admission. Hospital case manager said she was able to notify Resident #12 ' s guardian on 4/15/2016 after requesting guardianship information from facility. In an interview on 4/15/2016 at 3:45 pm the Regional Director said that he did not understand why this situation was an IJ. He said he could not understand how it is a system failure . The Regional Director further said that CNA Z had been suspended pending investigation and said that if surveyors were to question CNA Z, he would be able to give you the correct answers on what to do regarding an injury of unknown origin. Record review of Assistance with Meals policy and procedure provided by facility dated 2001 with a revised date of September 2013 revealed: Policy Statement; Residents shall receive assistance with meals in a manner that meets individual needs of each resident. 2. Residents confined to bed: b. The nursing staff will prepare residents for eating. Record review of Investigating Unexplained Injuries policy and procedures dated 2001 with a revised date of April 2012 revealed: Policy Statement; An investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation: 1. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident ' s clinical record. 2. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) The extent of the injury; or (2) The location of the injury (e.g., the injury located in an area not generally vulnerable to trauma); or (3) The number of injuries observed at one particular point in time; . Record review of Recognizing Signs and Symptoms of Abuse/Neglect policy and procedures provided by facility dated 2001 with a revised date of April 2012 revealed: Policy statement; Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor, the Director of Nursing Services, and Administrator immediately. Policy Interpretation and Implementation: 1. Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it. a. Signs of Actual/Physical Abuse: (1) Welts or bruises . (4) Black eyes or broken teeth; .(6) Sexual exploitation; (7) Rape; . b. Signs of /Actual Physical Neglect: . (6) Inadequate provision of care; (7) Caregiver indifference to resident ' s personal care and needs; . (9) Leaving someone unattended who needs supervision. The facility ' s Regional Director of Operations, Regional RN, DON, and ADON were notified on 4/14/2016 at 10:00 am that an Immediate Jeopardy situation had been identified due to the above failures. The facility submitted a plan of removal for the IJ and it was accepted on 4/16/2016 at 12:36 P.M. Plan to Lower the Immediate Jeopardy Immediate Action: 1. All residents were assessed for unknown skin issues by the nursing staff. These assessments were completed on 04/13/16. This audit was overseen by the Nursing Administration. DON and/or designee will be responsible to ensure weekly skin audits on an ongoing basis. 2. CNA assignment sheets have been audited. The ADON and QA nurse completed this audit on 04/14/16. Assignment sheets will be updated daily by the ADON and/or designee for changes. 3. 100% review of Care Plans for appropriateness and accuracy related to assistance with meals and supervision. Accuracy and appropriateness was determined through direct observation, meal service and interviews with direct care staff and licensed nurses. This review was started on 04/14/16 and completed on 04/15/16 by the MDS coordinators and the Corporate Reimbursement Specialists. 4. Upon notification of the initial bruise: resident was assessed and sent to the hospital. Abuse Coordinator was notified and a report was made to DADS. Abuse Coordinator and Regional Director of Operations began investigating the cause of the bruise. Staff was interviewed that was on duty April 11, 2016. The investigation began 04/12/16 and will be completed by 04/19/16. The Abuse Coordinator and Regional Director of Operations will review the investigation for completeness prior to submitting to DADS. 5. Upon discovery of the bruising to the peri area, local police department was called by the RDO, male staff member that was on duty (and failed to report the discovery of the bruise to the head) was immediately removed from the facility and suspended, administrative nursing staff was sent to the hospital to assess and evaluate the bruising to the peri area. All residents were assessed for unknown skin issues on 04/13/16. Training: 1. All licensed nurses will be inserviced on assessing residents when an injury of unknown origin is reported. Assessment procedure will be to conduct a complete head-to-toe assessment. This includes full vital signs. This inservice will be conducted by Administrative nursing staff (DON, ADON, QA, Staffing Coordinator, MDS Coordinator and Treatment Nurse). This inservice was started on 04/14/16 and will be completed by 04/15/16. (Procedure for head-to-toe assessment is attached.) 2. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the Stop and Watch. This inservice was started on 04/14/16 and to be completed 04/15/16. (Program is attached.) 3. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the location and accessibility of care plans. Care plans are located in the Matrix system under the RAI tab. This inservice was started on 04/14/16 and completed on 04/15/16. 4. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on following the plan of care specific to assistance with meals and supervision. The CNA assignment sheets will be utilized to indicate the level of assistance and supervision. This inservice is to be conducted by Nursing Administration. This inservice was started on 04/14/16 and will be completed by 04/15/16. 5. All staff (all departments) will be inserviced on the Abuse/Neglect policy. This inservice will be conducted by the Regional Director of Operations and/or designee. This inservice will start on 04/14/16 and be completed on 04/15/16. Inservice to include: a. definition of abuse and neglect b. examples of abuse and neglect c. signs and symptoms of abuse and neglect (to include injuries of unknown origin) d. responsibility of staff to report signs, symptoms and allegations of abuse and neglect e. responsibility to inform Abuse Coordinator of allegations of abuse and neglect f. identification of Abuse Coordinator g. reporting change of conditions and/or injuries 6. Licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the Falling Star/fall prevention program (attached). This inservice will start on 04/15/16 and be completed on 04/15/16. Monitoring: 1. Administrator and/or designee will monitor for abuse and neglect policy comprehension and adherence through daily rounds, staff interviews and staff huddles beginning 04/15/16 and was completed the same day. 2. DON and/or designee will monitor daily those residents that require assistance and/or supervision with meals beginning 04/14/16. Monitoring was completed 04/14/16. 3. DON and/or designee will evaluate care plans for accuracy and completeness on initiation, at change of condition and quarterly beginning 04/15/16. DON completed evaluation on 04/15/16. 4. Fall prevention will be monitored by DON and/or designee through daily rounds, staff re-education and incident report reviews beginning 04/15/16. Rounds, re-education and incident report review was completed on 04/15/16. 5. Stop and Watch will be monitored by the DON and/or designee through review of Stop and Watch forms on a daily basis beginning 04/15/16. DON completed Stop and Watch monitoring on 04/15/16. Monitoring of the plan: Record review of Stop and Watch form, not dated, read: If you identify a change while caring for and or observing patient/resident, please complete this form entirely, circle the change, and notify and give form to Nurse. Record review of facility in-service records revealed staff was in-serviced on Abuse/Neglect on 4/14/2016. Record review of facility in-service records revealed staff was in-serviced on Stop and Watch on 4/14/2016. Record review of facility in-service records revealed licensed staff was in-serviced on assessments of residents. Record review of facility in-service records revealed licensed staff and certified nurse aides were in-serviced on following care plans and assisting residents with meals. In an interview on 4/15/2016 at10:36 am LVN A revealed that staff had been in serviced on Abuse/Neglect on 4/14/2016. LVN A said if she found a resident with an injury she would assess immediately and notify the DON. LVN A said if the resident was alert, she would interview the resident to see what happened. LVN A said Neurological checks were always completed with head injuries. In an interview on 4/15/2016 at 10:40 am CNA W said the facility had an in-service on Abuse/Neglect on 4/14/2016 and 4/15/2016. She said if a resident was noted with any type of injury it should be reported to the nurse immediately and a Stop and Watch form should be filled out. In an interview on 4/15/2016 at 10:46 am with CNA V, she said she was in-serviced on Abuse/Neglect the day before. She said any injury should be conveyed to the nurse and a Stop and Watch form should be filled out. In an interview on 4/15/2016 at 12:01 pm the Director of Therapy, said the staff had been in serviced on Abuse and neglect on 4/14/2016. The Director of Therapy said all injuries were reported immediately and a Stop and Watch form was completed. In an interview on 4/15/2016 at 12:15 pm the Social Worker revealed the staff was in-serviced on Abuse/Neglect and reporting injuries on 4/14/2016. The Social Worker further revealed the facility had implemented a Stop and Watch form that was completed by any staff member who witnessed a change of condition on any resident. Interviews of staff who work two different shift concerning the assessments of residents who had a change of condition revealed that training had been conducted and staff were able to explain the process of complete assessments. On 4/16/2016 at 3:09 pm, the Regional Director of Operations and the DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated. The facility was continuing to monitor to ensure staff displayed a good knowledge of recognizing and reporting abuse and neglect, resident ' s changes of condition were reported, complete assessments of residents were conducted and medical care was provided promptly. The facility ' s CMS 672 form revealed 79 residents required assistance from staff with ADLs including transferring and eating.

Based on observation, interview and record review the facility administration failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for one of fourteen residents (Resident #12) reviewed for quality of care. The Administrator failed to: -To implement the facility's policy and procedure on abuse and neglect. -Supervise the DON to ensure nursing staff reported injuries of unknown origin. -Supervise the DON to ensure nursing staff conducted accurate assessments of residents, when they had a change in condition or injury. -Supervise the DON to ensure nursing staff monitor and notify physician and document resident's assessment of residents when they had a change in condition. These failures resulted in an identification of an Immediate Jeopardy on 4/14/16. While the IJ was removed on 4/16/16, the facility remained out of compliance at a severity of actual harm that is not immediate jeoparday with a scope identified as wide spread. The facility was continuing to monitor their plan to ensure staff were trained on reporting injuries of unknown origin and complete assessments of residents. This failure affected one resident who was transferred to the hospital with injuries to her head and pubic area and placed 82 residents who require staff to be trained and monitored in reporting abuse and neglect, assessing residents, and providing care to residents to ensure their highest practical physical, mental and psychosocial well-being was achieved. Intake #: 2, 4 Findings Include: Resident #12 Record review of face sheet for Resident #12 revealed an admission date of [DATE] with a readmitted [DATE] to the facility. Resident #12 was a [AGE] year old woman. Her [DIAGNOSES REDACTED]. Record review of Resident #12 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS dated [DATE] for Resident #12 further revealed the resident required limited assistance of one staff physical assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of the care plan for Resident #12 dated 1/21/2016 revealed she was a fall risk related to history of falls. Actual falls documented on the care plan had occurred on 1/13/2016, 2/08/2016, 2/19/2016, and 2/21/2016. Approaches included: keep brakes in lowest position with brakes locked, keep call light in reach, keep personal items and frequently used items within reach, observe frequently and place in supervised area when out of bed, place resident in fall prevention program, provide proper well maintained footwear, and provide resident an environment free of clutter. Observation on 4/11/2016 at 10:00 am of Resident #12 ' s room revealed a mattress on the floor with a floor mat on both sides of mattress. Observation on 4/11/2016 at 10:05 am revealed Resident #12 in a wheelchair in the general living area with other residents. No bruising noted on the resident ' s face or right eye. Record review of Resident #12's Patient Narrative dated 4/11/2016 read: hematoma visualized at 2:00 pm. The resident was alert and oriented to self and ambulates with a wheelchair. Bruising was noted to the left arm, antecubital (front of the elbow) region and hematoma to the right eye was noted on the diagram. Record review of Resident #12 ' s nurses notes dated 4/11/2016 at 9:33 pm read: In to see patient, patient noted to have a bruise over her right eye lid. Eye swollen with a large knot over corner of eye, eyebrow area. Patient stated pain at a 3 on a scale of 1-10. (Vital signs) 140/80-67-20-97.8. Asked patient if she knew how she obtained the areas, stated, it was earlier, she did not know when. NP (Nurse Practitioner) notified. New orders received to send patient to ER (emergency room ) for eval and treat. ADON notified. RP (responsible party) called. Message left for her to call facility. Record review of Resident #12 ' s hospital cat scan (CT) report dated 4/11/2016 of head, face, cervical spine, abdomen, and pelvis with and without contrast revealed: CT of face; mild right periorbital soft tissue swelling was identified. No evidence of facial fracture. CT of abdomen/pelvis revealed: hypodense area within the region of the right labia was identified measuring 5.9 x 4.9 cm and appeared fairly well contained, most consistent with hematoma. Overlying soft tissue swelling and subcutaneous [MEDICAL CONDITION] was also seen over the lower anterior pelvis. Impression: Right labial hematoma that appeared fairly well-contained. Additional overlying subcutaneous [MEDICAL CONDITION] and inflammation may correlate with trauma. Clinical correlation recommended. Interview on 4/13/2016 at 9:45 am with Resident #12 at the hospital revealed she was unsure of how she acquired bruising to her right eye, right brow and left antecubital region of arm. Resident #12 said she thought maybe she fell out of her wheelchair earlier in the day when she was trying to reach for her breakfast. When Resident #12 was asked how she obtained bruising to her vaginal area she said she did not know that she had bruising in that area or how it got there. Observation on 4/13/2016 at 9:58 am of Resident #12 ' s vaginal area revealed a large (lemon size) bright purple hematoma on mons pubis and swelling with deep purple bruising to right labia majora with swelling. Purple bruising was noted from left inner thigh to right inner thigh. Quarter sized purple/blue bruise noted to right mid inner thigh. A large knot (ping pong ball size) was noted on the right brow area with dark purple bruising around the diameter of the right eye. Interview on 4/13/2016 at 11:29 am with facility LVN Y revealed her shift started at 2:00 pm on 4/11/2016. LVN Y said she took report from the out-going nurse and nothing was mentioned about a fall or injury to Resident #12. LVN Y said she checked on Resident #12 at the beginning of the shift to make sure her oxygen was on. LVN Y said the light was off in the room and Resident #12 was lying on her left side facing the window. She stated she looked at the Resident ' s ear and could see that the oxygen was on the Resident #12 via the nasal cannula. LVN Y said she did not notice any bruising on Resident #12 at that time, but said she did not turn on the light in Resident #12 ' s room. LVN Y said she checked on Resident #12 again around 5:00 pm and the light was still off in the room and the resident ' s oxygen was in place. LVN Y said she did not turn on the light in Resident #12's room at that time and talked to her from the door. Resident #12 was awake at 5:00 pm and had said she was alright and wanted to eat dinner in her room. LVN Y said she left the room and returned at 6:30 pm and the light was off, but did see that the oxygen was in place. LVN Y said she went to check on Resident #12 at approximately 9:00 pm and the door was closed. She stated she knocked on the door and then opened it. Resident #12 was sitting crossed legged on the mattress on the floor. LVN Y said she turned on the light in Resident #12 ' s room and noticed bruising and swelling to the resident ' s right eyebrow. LVN Y said Resident #12 was not sure how the bruise and swelling was obtained. LVN Y revealed she went out in the hall and found CNA Z and asked him if he was aware of the bruising and swelling to Resident #12 ' s right eye and he said he was aware and noticed it at 2:00 pm when his shift began. LVN Y said CNA Z told her he did not say anything because he thought she already knew. LVN Y then checked Resident #12 ' s chart for any documentation of the injury and said there was no injury or falls noted during the previous shift. LVN Y said she then went back to Resident #12 ' s room and assessed her, performed neurological vital signs, called the nurse practitioner and received orders to send the resident to the hospital for an evaluation. LVN Y said she performed a range of motion assessment on Resident #12, neurological assessment, and assessed her right eye but did not assess any other region of Resident #12 ' s body. LVN Y said she called the ADON to report the injury, called an ambulance service and left a messages for Resident #12 ' s family but the call was not returned. Observation on 4/13/16 at 11:45am of Resident #12 ' s room revealed the blinds were closed and the room was dark. Observation revealed it was so dark in the room to see discoloration of tissue or an injury to a resident would be difficult without turning on the light or standing directly over the resident. In interview on 4/14/2016 at 9:45 am the DON said no full assessment was completed by LVN Y when the bruise and swelling was discovered to right eye of Resident #12. The DON said the neurological checks were completed and an assessment of the head wound along with range of motion was completed by LVN Y. The DON further revealed the investigation regarding the injury of unknown origin to Resident #12 ' s right eye and right brow had not been started because the facility was concentrating on the survey and not the investigation. In an interview with CNA Z on 4/13/2016 at 12:10 pm revealed he worked the 2:00 pm to 10:00 pm shift on 4/11/2016. CNA Z said he noted a small swollen black eye to the right eye of Resident #12. CNA Z said It didn ' t look serious . CNA Z revealed Resident #12 was in bed all day and he brought her a dinner tray about 5:00 pm. CNA Z said he set Resident #12 ' s dinner tray on the mattress on the floor so she could eat and left the room. CNA Z said Resident #12 feeds her-self. CNA Z said he returned at approximately 5:40 pm to pick up her dinner tray and she had only eaten 30 % of her meal. CNA Z said he did not provide any incontinent care to Resident #12 as she remained clean all day. When asked why he did not notify LVN Y of the swelling and bruising to Resident #12 ' s eye he said It didn ' t occur to me to tell anyone because she always has bruises due to bumping into things . CNA Z said he did notify LVN Y that Resident #12 had trouble breathing during the shift and LVN Y told CNA Z to put the oxygen on Resident #12 but was not sure if LVN Y assessed Resident #12 for breathing issues. In an interview on 4/13/2016 at 2:10 pm LVN Y revealed Resident #12 needed assistance to the bathroom and was incontinent at times. LVN Y said Resident #12 was confused at times but not always. LVN Y said Resident #12 prefers to eat in her room at times and staff would bring in her trays and set them on the mattress so she could eat. LVN Y did not say if Resident #12 needed assistance eating. In an interview on 4/13/2016 at 3:00 pm, the Corporate Nurse revealed the computer system was not working very well and the facility was having problems with the computers and having trouble obtaining documentation, but she was working on the issue. In an interview on 4/14/2016 at 9:00 am. the DON was asked for CNA documentation regarding how often Resident #12 was checked on during the day and any CNA documentation regarding incontinent care, meal times and assisting with meals. The DON said the facility was having computer problems and the system was messed up and slow . The DON further revealed the facility did not have any documentation of activities of daily living (ADL ' s) or when CNA ' s check on the residents. The DON said the corporate nurse was currently working on the situation and trying to retrieve information. In an interview with the DON on 4/14/2016 at 10:30 am, he said he was notified by the nurse that Resident #12 was found with a bruise to her head on 4/11/2016 between 7:00 pm and 9:00 pm. The DON revealed he was not aware that the injury was noted by CNA Z at 2:00 pm who had not reported it to the nurse. The DON further revealed Resident #12 was a fall risk and should be checked on frequently and as needed per care plan. The DON said that he was aware that a complete head to toe assessment did not occur on 4/11/2016 when the bruises were noted by the nurse. He stated I don ' t understand why a nurse with a resident with a head injury of unknown origin would not complete a full head to toe assessment . The DON further revealed the facility started complete skin assessments on all residents on 4/13/2016. Interview on 4/15/2016 at 12:19pm revealed the DON said the IJ occurred because a staff member failed to report the bruising to a Resident ' s face. The DON said that nursing staff was trained during orientation and then with in-service throughout the year on abuse/neglect and assessment of a resident with injuries of an unknown origin. When asked how he ensure nurses were competent in providing care to the residents he said by providing in-services and training when needed. Interview on 4/15/2016 at 12:37pm with the Regional Director revealed that he thought the IJ occurred because a CNA did not report when he found facial bruising on Resident #12. When asked he said that the following procedures were used to ensure residents ' needs were met: following up with staff after an in-service, resident questionnaires, making rounds, the stop and watch program and their Quality Assurance (QA) committee. He said that he monitored the DON through weekly Interdisciplinary Team (IDT) meetings and reports from the department. In an interview on 4/15/2016 at 3:45 pm the Regional Director said that he did not understand why this situation was an IJ. He said he could not understand how it is a system failure . The Regional Director further said that CNA Z had been suspended pending investigation and said that if surveyors were to question CNA Z, he would be able to give you the correct answers on what to do regarding an injury of unknown origin. Record review of Neurological Assessment policy and procedure provided by the facility dated 2001 with a revised date of October 2010 revealed: Purpose of this procedure is to provide guidelines for a neurological assessment: General Guidelines: 1. Neurological assessments indicated: .b. Following an witnessed fall; c. Following a fall or other accident/injury involving head trauma; or d. When indicated by resident's condition. Record review of Change in a Resident's Condition or Status policy and procedure provided by the facility dated 2001 with a revised date of November 2015 revealed: Policy Statement; Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 2. A significant change of condition is a decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident ' s family or representative (sponsor) when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; . e. It is necessary to transfer the resident to a hospital/treatment center. Record review of Acute Condition Changes-Clinical Protocol policy provided by facility dated 2001 and revised December 2015 read: .3. Direct care staff, including Nursing Assistants will be trained in recognizing subtle significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and to communicate these changes to the Nurse . Record review of Charting and Documentation policy and procedure dated 2001 with a revised date of April 2008 provided by facility revealed: Policy Statement: All services provided to the resident, or any changes in the resident ' s medical or mental condition, shall be documented in the resident ' s medical record. 1. All observations, medications administered, services performed, etc., must be documented in the resident clinical records. 2. Entries may only be recorded in the resident ' s clinical record by licensed personnel, in accordance with state law and facility policy. Certified Nursing Assistants may only make entries in the resident ' s medical chart as permitted by facility policy. 3. All incidents, accidents, or changes in the resident ' s condition must be recorded. Record review of Assistance with Meals policy and procedure provided by facility dated 2001 with a revised date of September 2013 revealed: Policy Statement; Residents shall receive assistance with meals in a manner that meets individual needs of each resident. 2. Residents confined to bed: b. The nursing staff will prepare residents for eating. Record review of Falls and Fall Risks, Managing policy and procedure dated 2001 with a revised date of December 2007 revealed: Policy Statement; Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If systematic evaluation of a resident ' s fall risk identifies several possible interventions, the staff may choose to prioritize interventions . 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . Record review of Investigating Unexplained Injuries policy and procedures dated 2001 with a revised date of April 2012 revealed: Policy Statement; An investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized. Policy Interpretation and Implementation: 1. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident ' s clinical record. 2. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) The extent of the injury; or (2) The location of the injury (e.g., the injury located in an area not generally vulnerable to trauma); or (3) The number of injuries observed at one particular point in time; . Record review of Recognizing Signs and Symptoms of Abuse/Neglect policy and procedures provided by facility dated 2001 with a revised date of April 2012 revealed: Policy statement; Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor, the Director of Nursing Services, and Administrator immediately. Policy Interpretation and Implementation: 1. Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it. a. Signs of Actual/Physical Abuse: (1) Welts or bruises . (4) Black eyes or broken teeth; .(6) Sexual exploitation; (7) Rape; . b. Signs of /Actual Physical Neglect: . (6) Inadequate provision of care; (7) Caregiver indifference to resident ' s personal care and needs; . (9) Leaving someone unattended who needs supervision. The facility ' s Regional Director of Operations, Regional RN, DON, and ADON were notified on 4/14/2016 at 10:00 am that an Immediate Jeopardy situation had been identified due to the above failures. The facility submitted a plan of removal for the IJ and it was accepted on 4/16/2016 at 12:36 P.M. Plan to Lower the Immediate Jeopardy Immediate Action: 1. All residents were assessed for unknown skin issues by the nursing staff. These assessments were completed on 04/13/16. This audit was overseen by the Nursing Administration. DON and/or designee will be responsible to ensure weekly skin audits on an ongoing basis. 2. CNA assignment sheets have been audited. The ADON and QA nurse completed this audit on 04/14/16. Assignment sheets will be updated daily by the ADON and/or designee for changes. 3. 100% review of Care Plans for appropriateness and accuracy related to assistance with meals and supervision. Accuracy and appropriateness was determined through direct observation, meal service and interviews with direct care staff and licensed nurses. This review was started on 04/14/16 and completed on 04/15/16 by the MDS coordinators and the Corporate Reimbursement Specialists. 4. Upon notification of the initial bruise: resident was assessed and sent to the hospital. Abuse Coordinator was notified and a report was made to DADS. Abuse Coordinator and Regional Director of Operations began investigating the cause of the bruise. Staff was interviewed that was on duty April 11, 2016. The investigation began 04/12/16 and will be completed by 04/19/16. The Abuse Coordinator and Regional Director of Operations will review the investigation for completeness prior to submitting to DADS. 5. Upon discovery of the bruising to the peri area, local police department was called by the RDO, male staff member that was on duty (and failed to report the discovery of the bruise to the head) was immediately removed from the facility and suspended, administrative nursing staff was sent to the hospital to assess and evaluate the bruising to the peri area. All residents were assessed for unknown skin issues on 04/13/16. Training: 1. All licensed nurses will be inserviced on assessing residents when an injury of unknown origin is reported. Assessment procedure will be to conduct a complete head-to-toe assessment. This includes full vital signs. This inservice will be conducted by Administrative nursing staff (DON, ADON, QA, Staffing Coordinator, MDS Coordinator and Treatment Nurse). This inservice was started on 04/14/16 and will be completed by 04/15/16. (Procedure for head-to-toe assessment is attached.) 2. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the Stop and Watch. This inservice was started on 04/14/16 and to be completed 04/15/16. (Program is attached.) 3. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the location and accessibility of care plans. Care plans are located in the Matrix system under the RAI tab. This inservice was started on 04/14/16 and completed on 04/15/16. 4. All licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on following the plan of care specific to assistance with meals and supervision. The CNA assignment sheets will be utilized to indicate the level of assistance and supervision. This inservice is to be conducted by Nursing Administration. This inservice was started on 04/14/16 and will be completed by 04/15/16. 5. All staff (all departments) will be inserviced on the Abuse/Neglect policy. This inservice will be conducted by the Regional Director of Operations and/or designee. This inservice will start on 04/14/16 and be completed on 04/15/16. Inservice to include: a. definition of abuse and neglect b. examples of abuse and neglect c. signs and symptoms of abuse and neglect (to include injuries of unknown origin) d. responsibility of staff to report signs, symptoms and allegations of abuse and neglect e. responsibility to inform Abuse Coordinator of allegations of abuse and neglect f. identification of Abuse Coordinator g. reporting change of conditions and/or injuries 6. Licensed nurses, medication aides and certified nurse aides will be inserviced by Nursing Administration on the Falling Star/fall prevention program (attached). This inservice will start on 04/15/16 and be completed on 04/15/16. Monitoring: 1. Administrator and/or designee will monitor for abuse and neglect policy comprehension and adherence through daily rounds, staff interviews and staff huddles beginning 04/15/16 and was completed the same day. 2. DON and/or designee will monitor daily those residents that require assistance and/or supervision with meals beginning 04/14/16. Monitoring was completed 04/14/16. 3. DON and/or designee will evaluate care plans for accuracy and completeness on initiation, at change of condition and quarterly beginning 04/15/16. DON completed evaluation on 04/15/16. 4. Fall prevention will be monitored by DON and/or designee through daily rounds, staff re-education and incident report reviews beginning 04/15/16. Rounds, re-education and incident report review was completed on 04/15/16. 5. Stop and Watch will be monitored by the DON and/or designee through review of Stop and Watch forms on a daily basis beginning 04/15/16. DON completed Stop and Watch monitoring on 04/15/16. Monitoring of the plan: Record review of Stop and Watch form, not dated, read: If you identify a change while caring for and or observing patient/resident, please complete this form entirely, circle the change, and notify and give form to Nurse. Record review of facility in-service records revealed staff was in-serviced on Abuse/Neglect on 4/14/2016. Record review of facility in-service records revealed staff was in-serviced on Stop and Watch on 4/14/2016. Record review of facility in-service records revealed licensed staff was in-serviced on assessments of residents. Record review of facility in-service records revealed licensed staff and certified nurse aides were in-serviced on following care plans and assisting residents with meals. In an interview on 4/15/2016 at10:36 am LVN A revealed that staff had been in serviced on Abuse/Neglect on 4/14/2016. LVN A said if she found a resident with an injury she would assess immediately and notify the DON. LVN A said if the resident was alert, she would interview the resident to see what happened. LVN A said Neurological checks were always completed with head injuries. In an interview on 4/15/2016 at 10:40 am CNA W said the facility had an in-service on Abuse/Neglect on 4/14/2016 and 4/15/2016. She said if a resident was noted with any type of injury it should be reported to the nurse immediately and a Stop and Watch form should be filled out. In an interview on 4/15/2016 at 10:46 am with CNA V, she said she was in-serviced on Abuse/Neglect the day before. She said any injury should be conveyed to the nurse and a Stop and Watch form should be filled out. In an interview on 4/15/2016 at 12:01 pm the Director of Therapy, said the staff had been in serviced on Abuse and neglect on 4/14/2016. The Director of Therapy said all injuries were reported immediately and a Stop and Watch form was completed. In an interview on 4/15/2016 at 12:15 pm the Social Worker revealed the staff was in-serviced on Abuse/Neglect and reporting injuries on 4/14/2016. The Social Worker further revealed the facility had implemented a Stop and Watch form that was completed by any staff member who witnessed a change of condition on any resident. Interviews of staff who work two different shift concerning the assessments of residents who had a change of condition revealed that training had been conducted and staff were able to explain the process of complete assessments. On 4/16/2016 at 3:09 pm, the Regional Director of Operations and the DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as wide spread. The facility was continuing to monitor to ensure staff displayed a good knowledge of recognizing and reporting abuse and neglect, resident ' s changes of condition were reported, complete assessments of residents were conducted and medical care was provided promptly. The facility ' s CMS 672 form revealed 83 residents resided in the facility.