Every finding on record at Viridian Wellness & Rehabilitation

Based on interview and record review, the facility failed to complete a discharge summary that included but was not limited to a recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, a final summary of the resident's status, and reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one of (Resident #59) of two residents reviewed for discharge. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #59 when he planned discharge home on [DATE]. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home and/or discharged from the facility. Record review of Resident #59's admission face sheet, dated 06/25/2025, reflected an [AGE] year-old male admitted [DATE]. Resident #59's active diagnoses included Spondylosis (degenerative changes in the spine such as bone spurs and degenerating intervertebral discs between the vertebrae), Alpers Disease (a rare, progressive mitochondrial disorder that primarily affects the brain, liver, and muscles, leading to seizures, liver failure, and cognitive decline), Protein Calorie Malnutrition (a serious condition resulting from insufficient intake of protein and calories), Myopathy (a group of diseases that primarily affect the muscles connected to bones that allow voluntary movement), and Hyperlipidemia (an excess of lipids or fats in your blood). Record review of Resident #59's Quarterly MDS assessment, dated 04/03/2026, reflected he was admitted from a Short-Term General hospital on [DATE]. and a BIMS score of 15, which indicated intact cognition. Record review of Resident #59's Nursing Progress Note, dated 05/24/2026, reflected, The resident discharged home with family members.Record review of Resident #59 Clinical Records reflected a progress note summary of discharge, but no Discharge Summary was in the chart. In an interview with the DON on 07/09/2026 at 12:40 PM, she acknowledged that discharge summaries should be completed for each resident that discharges from the facility. She stated that there was not a Discharge Summary for Resident #59. The DON stated when a resident is discharged , a discharge summary is necessary to make sure everything is in place for resident and services such as home health was set up, DME is ordered, and resident could meet with PCP within 7-14 days and prevent a lapse of continuity of care.In an interview with the SW on 07/09/2026 at 12:55 PM, she acknowledged that discharge summaries should be completed for each resident that discharges from the facility. She stated that there was not a Discharge Summary for Resident #59. The SW stated without a Discharge Summary, the discharged residents would not be able to meet with the staff to discuss their reconciliation of medications and their discharge plans, such as home health and care responsibilities. She stated that if a resident did not have a Discharge Summary, there was potential for there being a gap with follow-up appointments for medical needs. The SW stated that if there was not a Discharge Summary for discharged residents, they would miss the opportunity for any continuous care and appointments. Record review of the facility's policy titled, Transfer and Discharge, dated ??, reflected, IX. Communication with the Receiving ProviderA. To facilitate a smooth transition of care, the Facility will provide a copy of the following information to the receiving entity, as applicable:i. Contact information for the practitioner responsible for the care of the resident;ii. Resident representative information, including contact information;iii. Advance Directive information;iv. Special instructions or precautions for ongoing care, as appropriate;v. Comprehensive care plan goals; andvi. Other necessary information, including a copy of the resident's Discharge Summary, as applicable.B. This information will be provided to the receiving provider as close to the time of transfer as is practicable.XIV. DocumentationA. When the Facility anticipates a resident's discharge to a lower level of care (e.g., private residence, group home or board or care or assisted living) or to another nursing care facility, the Interdisciplinary Team (IDT), with the assistance of the resident and his/herpersonal representative, will develop a Discharge Summary and Post-Discharge Plan to assist the resident to adjust to his or her new living environment.i. Appropriate IDT members will educate the resident or his/her personal representative regarding the Discharge Plan issues and will assist the resident with discharge plans.B. The Director of Social Services or his or her designee will assist in determining:i. The resident's and/or personal representative's preferences for care;ii. Financial issues involving the post-discharge plan of care;iii. Coordination of care between various caregivers and agencies;iv. Identification of post-discharge needs (e.g., personal care, dressings, rehabilitation services, home health care, durable medical equipment);v. Follow-up medical care and appointments; andvi. Preparation needed by the resident and/or family/responsible party for discharge.Prior to discharging the resident, the Facility will prepare a Discharge Summary and will document the summary in the resident's medical record. At a minimum, the Discharge Summary will contain a summary of the resident's status, including a description of the resident's:i. Medically defined condition(s) and prior medical history;ii. Medical status measurement (objective measurements of a resident's physical and mental abilities including, but not limited to, information on vital signs, clinical laboratory values, or diagnostic tests);iii. Physical, mental, psychosocial functional status, including but not limited to, the resident's:a. Ability to perform activities of daily living including, bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems;b. Need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; andc. Ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in day-to-day activities; andd. Attitude toward life, behavior, mood and ability to set goals;iv. Sensory and physical impairments, including neurological, or muscular deficits, e.g. a decrease in vision and hearing, paralysis, and bladder incontinence;v. Nutritional status and requirements;vi. Special treatments or procedures;vii. Discharge potential;viii. Dental condition;ix. Ability to participate in activities;x. Rehabilitation potential;xi. Cognitive status; andxii. Drug therapy, including all prescription and over-the counter medications taken by the resident with information on dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident.I. The resident or his/her personal representative will be provided with a copy of the Discharge Care Plan and Discharge Summary.[K

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #4) reviewed for comprehensive care plans.The facility failed to ensure Resident #4's comprehensive care plans addressed their goals, needs, strengths, medical, nursing, mental, and psychosocial needs. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings included:Record review of Resident #4's MDS assessment, dated 04/08/26, reflected a [AGE] year-old female, admitted [DATE] and re-admitted on [DATE]. The resident's diagnoses included: hemiplegia (complete or severe paralysis) and hemiparesis (moderate muscle weakness), hypertension (high blood pressure), aphasia (a neurological language disorder that impairs a person's ability to speak, understand, read, and write, though it does not affect intelligence or memory), muscle wasting and atrophy (involve the shrinking and weakening of muscle tissue due to injury, disease, or prolonged inactivity) and muscle weakness and dysphasia (difficulty or discomfort in swallowing food or liquids).Record review of Resident #4's Physicians Order Summary dated 07/09/26, reflected an order indicating nothing by mouth related to dysphagia. Record review of Resident #4's comprehensive care plan printed 07/09/26 and signed (dated), reflected the comprehensive care plan did not address the g-tube and contractures. Record review of Resident #4's significant change in status MDS assessment, dated 04/08/26, did not include the BIMS score, as staff selected 0, which indicated the resident was never or rarely understood. The staff assessment indicated the Resident had short and long-term memory problems and was severely cognitively impaired. The resident had feeding tube (e.g., nasogastric or abdominal (peg).Observation on 07/07/26 at 9:56 am of Resident #4 revealed she was contracted to the upper and lower extremities. She had a g-tube and it was on continuous feeding. Observations of Resident #4 on 07/07/26 and 07/08/26 between 10 am and 2pm revealed the resident did not have leg booths on while she was in bed. The booths were in the room in a plastic bag. In an interview on 07/09/2026 at 10:11 AM with CNA E she stated the resident was non-verbal. She stated Resident #4 required total assistance with activities of daily living. CNA E stated Resident #4 had contractures to her hands and legs. CNA E stated the resident used boots and therapy was responsible for putting them on and taking them off. CNA E stated there was no CNA care plan indicating the resident's contractures. In an interview on 07/09/2026 at 10:31 with LVN F revealed she was the nurse for Resident #4. LVN F said Resident #4 was non-verbal with wounds and contractures. LVN F stated therapy applied boots on the resident for about 2 hours, and she was not sure what they used on her hands. LVN F reviewed the clinical records and stated the resident did not have a care plan for the contractures and the G-tube. LVN F stated the resident was supposed to have the care plan and the ADONs or DON were responsible to make sure the care plans were completed. LVN F stated the resident not having a care plan and the staff would miss care that was required for the resident.In an interview on 07/09/2026 at 10:44 AM with the DOR she stated the resident was in therapy, and services were offered three times weekly. She stated therapy offered passive range of motions to the resident. The DOR stated physical therapy staff applied booths to the lower extremities as tolerated by the resident. The DOR stated she was not aware what nursing was doing regarding the contractures. She stated occupational therapy completed the passive range of motions for the resident. She stated therapy was not involved in making sure the care plan was completed.In an interview on 07/09/2026 at 12:42 PM with the DON she stated she had been in the facility for three months. Resident #4 was non-verbal and required total assistance with activities of daily living. The DON said Resident #4 was being treated for wounds. The DON said Resident #4 had contractures and a G-tube, and she was on continuous feeding. The DON reviewed the clinical records and acknowledged the resident did not have the care plans for the G-tube and contractures. She stated there was no reason why the resident did not have the care plan for the two areas. The DON stated the MDS coordinator was responsible for completing the care plan and reviewing the care plan to make sure the areas that were triggered in the MDS were care planned. The DON stated the care plan was required to be completed to guide in the resident's care. In an interview on 07/09/2026 at 1:47 PM, the MDS Coordinator stated she had worked in the facility since November 2025. She stated she was responsible for completing the care plans. She stated she was aware Resident #4 had a G-tube and had contractures to the upper and lower extremities. The MDS Coordinator stated the MDS completed in April the resident triggered for G-tube, and she could not give a reason why she did not complete the care plan for the G-tube and contractures. The MDS Coordinator stated the resident required a care plan to show what care that was to be provided to the resident. The MDS Coordinator said not having the care plan put the resident at risk of not being provided with the care that was required. Record review of the facility policy, revised 06/2020 and dated ??, titled, Care Planning, reflected, Purpose, to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. ii. The care plan serves as a course of action where the resident, resident family/ or a guardian or other legally authorized representative), resident attending Physician and IDT work to help the resident move toward resident - specific goals that addresses the residents medical, nursing, medical and psychological needs.

Based on interviews and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #4) of 5 residents reviewed for mobility. - The facility failed to make sure Resident #4 had heel protectors pressure relief boots on while she was in bed on 07/07/26 and 07/08/26. This failure could place residents at risk for complications that may be related to decreased ROM and/or mobility may include, pain, skin integrity issues, and decreased muscle strength and atrophy. Findings includedRecord review of Resident #4's MDS assessment dated [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE] and then re-admitted on [DATE]. The resident diagnoses included: hemiplegia (complete or severe paralysis) and hemiparesis (moderate muscle weakness), hypertension (high blood pressure), aphasia (a neurological language disorder that impairs a person's ability to speak, understand, read, and write, though it does not affect intelligence or memory), muscle wasting and atrophy (involve the shrinking and weakening of muscle tissue due to injury, disease, or prolonged inactivity) and muscle weakness and dysphasia (difficulty or discomfort in swallowing food or liquids) Record Review of Resident #4's Order Summary dated 04/27/26, reflected an order that stated resident to have bilateral heel protection pressure relief boots on at all times while in bed every shift for wound care management. Record Review of Resident #4's comprehensive care plan printed 07/09/26, reflected the comprehensive care plan did not address the use of bilateral heel protection pressure relief boots. Record review of Resident #4's significant change in status MDS assessment dated [DATE]. The Resident's MDS assessment did not include the BIMS score, as staff selected 0, which indicated the resident was never or rarely understood, which directed the assessment to skip to the staff assessment for mental status. The staff assessment indicated the Resident had short and long-term memory problems and was severely cognitively impaired. Observation on 07/07/26 at 9:56 am of Resident #4 revealed she was contracted to the upper and lower extremities. Observations of Resident #4 on 07/07/26 and 07/08/26 between 10 am and 2pm revealed the resident did not have leg boots on while she was in bed. The boots were in the room in a plastic bag. Observation on 07/08/26 at 10:43 am during wound care revealed the resident had contractures to bilateral lower extremity and had wounds to the left heel and left lateral thigh. In an interview on 07/09/2026 at 10:11 AM with CNA E she stated the resident was non-verbal. She required total assistance with activities of daily living. CNA E stated the resident used boots and therapy were the ones to apply the boots and take them off. CNA E stated the boots were to be used to prevent skin breakdown or the wounds from getting worse and for contractures. In an interview on 07/09/2026 at 10:31 with LVN F revealed she was the nurse of the resident. The resident was non-verbal, she had wounds and contractures. LVN F stated therapy applied boots on the resident for about 2 hours. LVN F stated she had not applied the boots or checked to make sure they were on. She stated the resident used boots to prevent skin breakdown, and the resident had a wound to the heel to prevent it from getting worse and to prevent the contractures from worsening. In an interview on 07/09/2026 at 10:44 AM with DOR she stated the resident was in therapy and services were offered three times weekly. She stated therapy offered passive range of motions to the resident. DOR stated physical therapy staff applied boots to the lower extremities per tolerated by the resident. Regarding the resident's order, she stated she was not aware of the order because it was initiated by the nursing department. The DOR stated the boots were to be used to prevent the skin breakdown and due to the contractures to the bilateral lower extremities. In an interview on 07/09/2026 at 12:42 PM with the DON she stated she had been in the facility for three months. Resident #4 was non-verbal and required total assistance with activities of daily living. The resident was being treated for wounds, she had contractures. Regarding the resident's use of boots after reviewing the orders, she stated the resident was to have boots on while she was in bed The DON stated the boots were to be used to prevent skin breakdown and the resident had wounds, to prevent the wounds from getting worse and from the contractures getting worse. Record review of the facility policy, undated and titled, Contracture - Prevention reflected, Purpose. To prevent the onset and/or worsening of contractures for residents, ensuring quality care and maximizing mobility and function.The Facility will implement proactive, individualized interventions to prevent the development of contractures and to minimize the progression of existing contractures in residents. These interventions will be based on assessments, interdisciplinary planning, and ongoing monitoring to ensure effectiveness and compliance.A. The Interdisciplinary Team (IDT) will develop a Care Plan to prevent and/or minimize contracture. The Care Plan will include but not be limited to the following interventions, as indicated: . iv. Splints and support devices as appropriate.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Treatment Cart #1) of one treatment cart reviewed for medication storage and supplies. The facility failed to ensure Treatment Cart #1 was locked when unattended on 07/07/26. This failure could place residents at risk of having access to unauthorized medications and supplies and lead to possible harm.Findings included: In an observation on 07/07/26 at 09:55 AM, Treatment Cart #1 was observed unlocked and unattended, against the wall on the 400 hall. All drawers were unlocked, and there were bandages, gauze and prescription creams on the cart. The treatment cart was unattended for at least 15 minutes. SS #17 opened the drawers and captured photos of items inside of the cart to be a prescribed ammonium lac lot 12% (topical medication used to deeply hydrate and exfoliate dry, scaly skin and rough, bumpy conditions), adhesive remover spray, antimicrobial skin care wound gel, collagenase Santyl ointment (prescription medication used to clean away dead tissue from chronic skin ulcers and severe burns), gauze, healing ointment, iodine, Thera honey gel (a medical-grade wound dressing containing 100% sterile Manuka honey (special type of honey made by bees In New Zealand and Australia)), moisture barrier ointment, saline and wound care solution. There were no Residents near Treatment Cart #1, however, there were residents on the hall and no visible staff nearby the treatment cart. In an observation and interview on 07/07/26 at 10:10 AM, revealed the ADON pushing Treatment Cart #1 down the hall. The ADON stated she was in a resident's room treating a wound. The ADON stated Treatment Cart #1 was not in view while she was in the resident's room. The ADON stated she should have locked Treatment Cart #1 when she left it unattended to provide care. In an interview on 07/07/26 at 11:40 AM, the ADON stated Treatment Cart #1 was to always be locked except when she was retrieving items or returning items to the cart. The ADON stated it was her responsibility to ensure the treatment cart was locked and secured. The ADON stated she must take all needed supplies into the room and lock the treatment cart. The ADON stated she noticed the treatment cart was unlocked when she exited the room. In an interview on 07/07/26 at 2:15 PM, the DON stated her expectation was for the treatment cart to be locked when the ADON was providing care. The DON stated the treatment cart should be locked at all times even if the ADON was just stepping away and out of sight for a few seconds. The DON stated that the ADON told her that she failed to lock Treatment Cart #1. The DON stated she expected staff to take proper steps and follow procedures when they provided treatment. The DON stated staff should never leave medications nor supplies unattended and ensure the treatment cart was secured at all times. The DON stated the ADON should have made sure Treatment Cart #1 was locked and if not, the ADON should have never left Treatment Cart #1 out of her sight. The DON stated, You never knew when a resident may attempt to gain access to the cart. The DON stated there was potential for a resident to have accessed the treatment cart and sustained adverse effects by digesting, ingesting, or developing a rash and having to be sent out to the hospital. The DON stated she was responsible for monitoring the ADON. In an interview on 07/07/26 at 2:45 PM, the ADON stated the DON completed a one-on-one in-service with her on keeping the cart locked when unattended. The ADON stated she would take more time and triple check everything. The ADON stated the risk of an unlocked treatment cart was a confused resident could open the cart and digest or ingest something dangerous and become harmed or ill. Record review of the facility's policy titled, Medication Storage, with a revised date of 1/2026, reflected the following: Procedure: This policy applies to all licensed nurses, medication aides (where permitted), pharmacy staff, providers, and facility leadership.II. Security & Access1. Medication rooms, carts, and cabinets must remain locked at all times.2. Access is restricted to authorized, licensed staff.3. Medication carts must be locked whenever they are not actively attended.III. Medication Cart Locking Requirements1. The medication cart must be locked under the following conditions:-When entering a resident's room (if the cart remains in the hallway)-When interrupted (e.g., phone calls, staff questions, emergencies)-When turning away from the cart-When more than arm's reach from the cart .

Based on observations, interview and record review the facility failed to ensure a resident who was incontinent received appropriate treatment and services for 1 of 3 (Resident #1) reviewed for quality of care. The facility failed to ensure that CNA A provided perineal care according to professional standards of practice when she cleaned a female resident's (Resident#1) perineal area from back to front, rather than from front to back.This failure could place residents the risk of urinary tract infections and compromised health and safety.Findings included: Record review of Resident #1's Quarterly MDS Assessment, dated 04/15/26, reflected a [AGE] year-old female, admitted [DATE] with reentry on 04/18/2025. There was no BIMS record indicating no interview was conducted. The resident had diagnoses which included neurogenic bladder (a condition where nerve damage disrupts the communication between your brain and bladder, leading to loss of control over storing or emptying urine) and obstructive uropathy (a structural or functional blockage of the urinary tract that restricts the normal flow of urine). Record review of Resident #1's Comprehensive Care Plan, revised 05/25/2026, reflected [NAME] has an actual UTI R/T E coli (bacteria, which normally live in the gut, enter the urethra and multiply) in the urine. Facility interventions included: Administer IV ABX as prescribed Cefepime HCl Intravenous Solution (antibiotic administered intravenously to treat severe bacterial infections, including pneumonia, urinary tract infections). During an observation on 06/04/26 at 11:38 A.M., incontinent care on Resident #1 by CNA A revealed Resident #1 had a bowel movement and her brief was wet. CNA A put on clean gloves, unfastened Resident #1's brief, CNA B assisted with repositioning Resident #1 to the left. CNA A cleaned Resident #1 with cleansing wipe, moving from back to front, with each stroke from the anus (opening at the end of the digestive tract where solid waste (feces) leaves the body) to the urethra (muscular tube that drains urine from the bladder out of the body) and vaginal opening.Resident#1 was non-verbal and un-interviewable. During an interview on 06/04/26 at 11:40 A.M., CNA A stated she cleaned Resident #1 from back to front but swiped to the side and did not reach the urethral or vaginal opening. She stated she had always cleaned residents like that and thought that if she wiped away from the vaginal opening it was okay. She stated the risk to the resident when cleaned from back to front was urinary tract infection. She stated she had a one on one in-serviced on infection control and peri care (he process of washing and gently cleaning the genital and anal areas) by the DON. During an interview on 06/04/26 at 11:18 A.M., CNA B stated while providing peri care to a female resident, the resident should be cleaned from front to back. He stated the risk of cleaning a female resident from back to front was causing urinary tract infection. CNA B stated he was in serviced on infection control and peri care. During an interview on 06/04/26 at 12:28 PM, LVN C, who was in the room while Resident #1 was receiving peri care, stated she observed CNA A clean Resident #1 from back to front. She stated CNA A should have cleaned Resident #1 from front to back. She stated the risk to the resident was getting a urinary tract infection. During an interview on 06/04/26 at 12:38 PM, the ADON stated female residents should be cleaned from front to back. She sated the risk of cleaning a female resident from back to front was stool getting into the urinary and causing the resident to have a UTI. During an interview on 06/04/26 at 1:41 PM, the DON stated her expectation was that the staff should perform peri care on female residents cleaning the resident from front to back. She stated the risk to a female resident being cleaned from back to front was the resident could get recurrent urinary tract infections. She stated the staff started an in-service and was going to have skills checkoffs on infection control and peri care. Record review of the facility policy titled, Perineal Care, dated 06/2020, reflected: Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown.I. Wash hands.II. Explain procedure to residents.III. Gather equipment:IV. Provide privacy.V. Put on gloves.VI. Wash the pubic area.A. For female residents:i. Separate the labia. Wash with soapy washcloth/cleansing wipe, moving from front to back, oneach side of the labia and in the center over the urethra and vaginal opening, using a cleanwashcloth/cleansing wipe for each stroke.ii. Rinse area, moving from front to back, using a clean washcloth/cleansing wipe for each stroke.iii. Dry area moving from front to back, using a blotting motion with towel. Record review of the facility policy titled, Infection Prevention and Control Program, dated 06/2020, reflected: Purpose: The ensure the Facility establishes and maintains an Infection Control Program designed to provide asafe, sanitary, and comfortable environment and to help prevent the development and transmission.of disease and infection in accordance with Federal and State requirementsThe facility must establish an Infection Prevention and Control Program under which it -1. Identifies, investigates, controls, and prevents infections in the Facility;2. Decides what procedures, such as isolation, should be applied to an individual resident; and3. Maintains a record of incidents and corrective actions related to infections.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for two of six residents (Resident #1 and Resident #2) reviewed for reporting of alleged violations. The Administrator failed to report a resident-to-resident altercation between Resident #1 and Resident #2, in which both residents were observed punching each other with closed fists, to the State Survey Agency. This failure could place residents at risk of not receiving timely and appropriate responses to alleged violations of abuse, neglect, and/or exploitation.Findings include: 1. Record review of Resident #1's Face Sheet, dated 04/27/26, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included cerebral palsy (a group of neurological disorders that permanently affect movement, posture, and muscle coordination, usually caused by abnormal brain development or injury before, during, or shortly after birth), moderate intellectual disabilities (a developmental condition marked by significant limitations in intellectual functioning and adaptive skills, often requiring ongoing support for daily living and social interactions), and impulse disorder (a group of disorders that are linked by varying difficulties in controlling aggressive behaviors, self-control, and impulses). Record Review of Resident #1's Quarterly MDS Assessment, dated 04/02/26, reflected he had a BIMS score of 3, which indicated he had severe cognitive impairment. Record review of Resident #1's Care Plan, dated 11/07/25, reflected he had impaired cognition due to his medical conditions, as well as difficulty understanding others at times. The Care Plan noted Resident #1 tended to get frustrated when he felt rushed, hurried, or not listened to by others. Interventions included asking simple yes/no questions, allowing Resident #1 time to make choices, avoiding overstimulation, providing supervision as needed, referring for counseling and medication management, etc. Record review of Resident #1's General Progress Notes (Nurse's Notes), written by LVN B and dated 03/14/26, reflected, .Was informed by nurse that there was a resident to resident incident. Nurse states she saw resident coming around the corner down the hallway, [Resident #1] was wheeling backwards and accidentally hit other resident's [Resident #2] wheelchair. [Resident #2] attempted to push [Resident #1's] wheelchair forward, [Resident #1] stopped wheelchair with his feet and continued to try and wheel backwards. [Resident #2] then hit [Resident #1] twice in the face and [Resident #1] responded by hitting this resident back. This nurse and weekend supervisor came around nurse station to separate residents while residents continued to hit each other. Once separated, this nurse completed head to toe assessments on this resident. Redness noted to left hand knuckle area resident c/o pain 7/10 PRN Tylenol given per order. Vitals BP Pt tolerated well. DON and Administrator notified of incident. 1 on 1 monitoring initiated. MD notified. Message left for RP. Observation of Resident #1 on 04/27/26 at 10:10 AM revealed he displayed no obvious signs or symptoms of distress nor any observed behaviors. There were no concerning marks or bruises noted on his person. An interview with Resident #1 on 04/27/26 at 10:10 AM was attempted but was unsuccessful due to Resident #1's cognitive impairment. Resident #1 did not appear to recall the incident or any previous issues with Resident #2. 2. Record review of Resident #2's Face Sheet, dated 04/27/26, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included vascular dementia (the second most common form of dementia, caused by impaired blood flow to the brain, which deprives brain cells of oxygen and nutrients) and adjustment disorder (a short-term, stress-related mental health condition triggered by a significant life change or event, such as divorce, job loss, or illness). Record review of Resident #2's Quarterly MDS Assessment, dated 04/17/26, reflected he had a BIMS score of 15, which indicated he was cognitively intact. Record review of Resident #2's Care Plan, dated 04/03/26, reflected, .Resident #2 has potential to demonstrate physical behaviors of hitting, striking at or punching other residents when triggered. Interventions included analyzation of key times, places, circumstances, triggers, and what de-escalates behaviors; assessing and anticipating the resident's needs; cognitive assessments; providing physical and verbal cues to alleviate anxiety and encouraging him to seek out a staff member when agitated; referring for counseling and medication management, etc. Record review of Resident #2's General Progress Notes (Nurse's Notes), dated 03/14/26, reflected Resident to resident incident. Nurse saw [Resident #2] coming around the corner down the hallway, [Resident #1] was wheeling backwards and accidentally hit [Resident #2's] wheelchair. [Resident #2] attempted to push [Resident #1's] wheelchair forward, [Resident #1] stopped wheelchair with his feet and continued to try and wheel backwards. [Resident #2] then hit [Resident #1] twice in the face and [Resident #1] responded by hitting [Resident #2] back. This nurse and Weekend Supervisor came around nurse station to separate Residents while residents continued to hit each other. Once separated, this nurse completed head to toe assessment on [Resident #2]. Redness noted to [right] side of forehead, resident c/o pain 2/10 but declines PRN pain medication. DON and Administrator notified of incident. Q15 monitoring initiated. MD notified. Message left with RP. Observation of Resident #2 on 04/27/26 at 10:40 AM revealed he displayed no obvious signs or symptoms of distress nor any observed behaviors. There were no concerning marks or bruises noted on his person. During an interview with Resident #2 on 04/27/26 at 10:40 AM, he stated he had been involved in an isolated resident-to-resident incident involving Resident #1. He stated Resident #1 initiated the altercation by hitting him; he then hit Resident #1 back. He stated facility staff promptly intervened and separated the residents. Resident #1 stated he was placed on increased supervision/monitoring rounds. He denied any injury and stated this was an isolated incident. He denied any mental anguish or being fearful following the incident. During an interview with LVN A on 04/27/26 at 12:06 PM, she stated she witnessed the resident-to-resident altercation between Resident #1 and Resident #2 on 03/14/26. LVN A explained Resident #1 commonly ambulated backwards in his wheelchair. At the time of the incident, Resident #1 was ambulating backwards out of a common area as Resident #2 was ambulating via wheelchair nearby. Resident #1 backed into Resident #2; Resident #2 then pushed Resident #1's wheelchair (non-aggressively; it appeared as though he was just trying to move the wheelchair out of the way). Resident #1 then purposefully pushed his wheelchair against Resident #2. Resident #1 and Resident #2 then began punching each other in the face and arms with closed fists. She stated they appeared to be willfully hitting each other. LVN A stated the incident escalated very quickly; she believed they each hit each other approximately 3-4 times. LVN A stated as soon as she saw the incident begin to escalate, she immediately intervened and separated them. She stated the head-to-toe assessments revealed Resident #2 had a red mark on his face, but it had gone away by the end of the shift. She stated Resident #1 was placed on 1:1 supervision/monitoring, and Resident #2 was placed on scheduled 15-minute rounds/monitoring. The Administrator and the DON were immediately notified. All other appropriate parties, which included the physician and responsible parties were also notified. LVN A stated this was an isolated incident and she was not aware of either resident having a history of physical behaviors. During an interview with the Administrator on 04/27/26 at 2:21 PM, he stated he was made aware of the incident that occurred between Resident #1 and Resident #2 on 03/14/26. He stated he was advised Resident #1 was ambulating backwards out of a common area as Resident #2 was ambulating via wheelchair nearby. Resident #1 collided into Resident #2; Resident #2 attempted to non-aggressively stop Resident #1's wheelchair by pushing it away. Resident #1 then pushed Resident #2, and they began hitting each other. The Administrator stated LVN A witnessed the incident and immediately separated the two residents and placed them on increased supervision/monitoring. He stated all appropriate parties were notified, which included the physician and responsible parties. Lab work was obtained on both residents, and it was found Resident #2 had a UTI; he received treatment for this illness. Facility staff were in-serviced following the incident on abuse/neglect and resident rights, which included resident-to-resident behaviors. The Administrator stated any instances of abuse, neglect, or exploitation were considered reportable to the State Survey Agency and that, as the Administrator, he was responsible for reporting such incidents. He said this included any willful acts of resident-to-resident altercations. The Administrator stated the facility did not feel the incident between Resident #1 and Resident #2 was willful, which was why the incident was not reported. The Administrator stated the risk of not reporting incidents as required included the potential for facility non-compliance and physical/mental harm to residents. During an interview with the Regional [NAME] President of Operations on 04/27/26 at 2:35 PM, he stated he was made aware of the incident that occurred between Resident #1 and Resident #2 on 03/14/26. He said it was his understanding the incident was more of a reaction (as though one of the residents had been startled and unintentionally swung his hands at the other resident) as opposed to a willful/intentional altercation. The Regional [NAME] President of Operations stated his understanding was that willful intent meant someone had to purposefully attempt to hurt or injure someone else, and that person had to have the mental cognition to recognize their actions. The Regional [NAME] President of Operations stated if the incident between Resident #1 and Resident #2 should have been reported, then the facility misinterpreted the Provider Letter referencing reportable incidents. The Regional [NAME] President of Operations stated the risk of not reporting incidents as required included the potential for resident harm. Record review of a file of evidence which was presented to the state surveyor by the Administrator on 04/27/26 reflected the facility investigated the resident-to-resident altercation between Resident #1 and Resident #2 (incident date 03/14/26). Following the resident-to-resident altercation, facility staff immediately intervened and separated the residents. Head-to-toe assessments were completed and identified no major injuries. The residents were placed on increased supervision/monitoring (Resident #1 was placed on 1:1 supervision/monitoring; Resident #2 was placed on scheduled 15-minute rounds/monitoring). All appropriate parties were notified, including the residents' physician and responsible parties. The residents were interviewed and witness statements obtained. Additional lab work was completed, and it was determined Resident #2 had a UTI; treatment was initiated. Facility staff were in-serviced on abuse/neglect/exploitation and resident rights. It was noted that there had been no history of aggression between the residents and there were no pre-meditation or threats leading to the altercation. It was determined that the incident was an unplanned behavioral interaction between the two residents and, per the facility's determination, did not meet the criteria for a reportable incident. Record review of Provider Letter 2024-14, dated 08/29/24, reflected, .Do report: abuse (with or without serious bodily injury. and When to report: Immediately, but not later than two hours after the incident occurs or is suspected. The Provider Letter also reflected, .Allegations or incidents of resident-to-resident behavior may or may not meet the definition of abuse depending on whether a resident acted willfully. As the CFR states: 'Willful, as used in the definition of 'abuse,' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm'. Record review of the facility's undated, Abuse Prevention and Prohibition Program policy, reflected, .The facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime. i. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation). iv. The Administrator will provide the state survey agency, law enforcement and the Ombudsman (if applicable per state regulation) with a copy of the investigative report within 5 days of the incident.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident of 1 of 4 residents reviewed for pharmacy services. The facility failed to ensure an expired Tylenol with Codeine tablet 300-30mg was removed from the 300 hall nurses' medication cart and disposed of. This failure could place residents at risk of receiving ineffective treatment, and potential medication error.Record review of Resident #1's Comprehensive MDS Assessment, dated 03/06/26, reflected Resident #1 was a [AGE] year-old male, admitted [DATE].He had a BIMS score of 15, indicating intact cognition. The resident had diagnoses including muscle weakness, anxiety disorder, depression, seizures, and Post Traumatic Stress Disorder (PTSD). Record review of Resident #1's Comprehensive Care Plan, Revision on: 12/07/2025 reflected Resident #1 is at risk for alteration in comfort Related to: seizures, history of falls, Goal Resident #1's pain will not interfere with functional performance, activity engagement, and/or sleep patterns. Interventions Attempt Pain interview on admission and at least quarterly, observe for and report symptoms of pain such as crying, wincing, guarding, facial expressions etc., in cognitively impaired patients pain meds as ordered, report unrelieved pain to MD. Record review of Resident #1 's active physician orders, dated 08/31/2025, reflected Tylenol with Codeine#3 tablet 300-30mg (acetaminophen-codeine) Give 1 tablet by mouth every 6 hours as needed for pain. During an observation on 03/31/26 at 11:45 am, on 300 hall nurses' carts with LVN A revealed Resident #1's expired Tylenol with Codeine#3 tablet 300-30mg(acetaminophen-codeine) Medication expired on 03/09/2026. During an interview on 03/31/26 at 11:50 am, LVN A stated she was unaware Resident #1's Tylenol with Codeine#3 tablet 300-30mg was expired. She stated expired medication should be removed from the cart immediately and given to the DON for proper disposal by pharmacy. She stated the risk of expired medication in the cart was medication error by administering expired medication which would not be effective to treat the patients' symptoms. She stated the nurses and medication aides were responsible for checking the medication to ensure all medications were not expired. She stated she had been in-serviced on medication labeling and storage. During an interview on 03/31/26 at 12:00pm, with the ADON revealed the nurses and medication aides were responsible for checking the medications to ensure no medication was expired. She stated that the ADONs audited the medication carts weekly, then the Pharmacy consultant audited the carts every other month. She stated expired narcotics were to be removed from the cart immediately and given to the DON for proper disposal. She stated the risk to the patients was medication error by administering expired medication that could be ineffective to the residents' symptoms. She stated the nurses and the Medication Aides had been in-serviced on medication storage. During an interview on 03/31/26 at 2:50 pm, RN B stated she was unaware Resident #1's Tylenol with Codeine#3 tablet 300-30mg was expired. She stated the nurses and medication aides were responsible for checking the medications to ensure no medication was expired. She stated that the risk of an expired medication in the cart was administering it to the resident and the resident suffering side effects that could make them sick. She stated she had been in-serviced on medication storage. During an interview on 03/31/26 at 3:00pm the DON stated that expired medication was not supposed to be in the medication cart. The DON stated the risk would be administering expired medication to the resident that would not be effective. She stated nurses and Medication Aides were responsible for checking the medication to make sure there were no expired medications in the medication carts. The DON stated the ADONs audited the medication carts weekly, then the pharmacy consultant audited the medication room, and the medication carts every other month. She stated the nurses and the MAs had been in-serviced on medication storage. Review of Facility's Medication Storage policy revised 10/2023 reflected:Outdated, contaminated, or deteriorated medication and those in containers that are cracked soiled or without secure closure are immediately removed from stock and disposed according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen services.The facility failed to ensure that 1 of 1 container covered with plastic wrap was dated in the walk-in refrigerator. The facility failed to ensure that 56 of 56 containers in the reach-in refrigerator were labeledThe facility failed to ensure that 3 of 3 containers of salad were labeled and dated.The facility failed to ensure that 2 of 2 dietary staff properly use hair restraints during food preparation. This failure could place all residents at the facility by placing them at risk for food exposed to adulteration or potential contaminants.Findings Included:During an observation and interview on 02/17/26 at 9:19 a.m. with the Food Service Manager in the kitchen. During the brief initial tour of the kitchen, three un-labeled and un-dated containers were revealed in the Reach-in Refrigerator. The Food Service Manager identified the three containers as salads. The Reach-in Refrigerator also revealed 56 unlabeled containers. The Walk-in Refrigerator revealed 1 container covered with plastic wrap without an expiration date. During initial observation 02/17/26 at 9:19am 9:45am and follow up observations of the kitchen dietary staff were observed without properly restraining their facial hair during food preparation. Interview with the Dietary Aid on 2/17/26 at 10:00AM revealed the importance of good hand hygiene such as not touching face, hair, and hand washing prevented cross-contamination. Interview with the Food Service Manager on 2/18/2026 at 10:10 a.m. stated it was important to properly wear hair coverings to not cause cross-contamination. The Food Service Manager stated the unlabeled and undated food items in the refrigerators could cause residents to be served food not to meet their individual dietary requirements. The Food Service Manager stated having food in the refrigerator without an expiration date could cause residents to serve food that could cause negative effects for the residents. The Food Service Manager stated staff were in-serviced on labeling and dating food. The Food Service Manager stated some items were not labeled or dated as an error in properly storing the opened food.During an interview at 9:45 a.m. on 2/19/2026, with The Food Service Area Manager stated there was a food safety concern of something possibly contaminating the food when not wearing hair and facial coverings properly. The Food Service Area Manager stated the kitchen had specific labels purchased for labeling the food as part of ensuring the food was labeled and dated. The Food Service Area Manager stated an in-service that would include use of the special labels would be conducted.Record Review of the facilities undated policy titled Labeling and Dating Inservice revealed under section Guidelines for Labeling and Dating *All foods should be dated upon receipt before being stored. Record Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for one (Resident #62) of five residents reviewed for dignity. The facility failed to ensure Resident #62's intravenous medications were covered with a privacy bag when he was eating lunch in the dining room area with several other residents. This failure could place residents at risk for a lack of privacy or dignity.Findings included: Record review of Resident #62's Face Sheet, dated 02/19/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE], with diagnoses including dementia (the loss of cognitive functioning that interferes with daily life and activities) and cognitive communication deficit (a condition where a person's ability to communicate effectively is impaired due to underlying cognitive difficulties). Record review of Resident #62's MDS Assessment, dated 01/01/26, reflected a Staff Assessment for Mental Status was completed and indicated he was severely cognitively impaired. Record review of Resident #62's Care Plan, undated, reflected .[Resident #62] has impaired skin integrity r/t localized bacterial infection to the left side of his face as evidenced by facial abscess. Interventions included .Administer Vanco ABX as ordered by the physician. Record review of Resident #62's Physician's Orders, dated 02/19/26, reflected he was ordered the following medications/treatments: .Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) - Use one liter intravenously one time only for Hypernatremia (a medical condition characterized by an abnormally high concentration of sodium in the blood) until 02/18/26. [Order Date 02/16/26] .Vancomycin HCl Intravenous Solution Reconstituted 1 GM (Vancomycin HCl) - Use 100 milliliter intravenously two times a day for facial abscess for 7 Days Reconstitute with 100 ml NS. [Order Date 02/17/26] Observation of Resident #62 on 02/17/26 at 12:20 p.m. revealed he was sitting in the dining room, eating lunch. Resident #62 was observed to be connected to intravenous medications; hanging from the IV pole was a bag of Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) and vile of Vancomycin HCl Intravenous Solution Reconstituted 1 GM. There was not a privacy cover for the medications. There were several other residents in the dining room at time of the observation. An attempted interview with Resident #62 on 02/17/26 at 12:25 p.m. revealed he was cognitively impaired and unable to participate in an interview. During an interview with the Director of Nursing on 02/17/26 at 12:40 p.m., she stated the expectation was for intravenous medications to have a privacy cover on them, when the resident who was receiving the medications was outside of his/her room and in a common area. The Director of Nursing stated failing to ensure a privacy cover was in place placed residents at risk of privacy/dignity issues. Record review of the facility's Dignity policy, dated 02/2021, reflected, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. and Staff protect confidential clinical information.

Based on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, for 1 of 5 residents (Resident#63) reviewed for respiratory care. The facility failed to ensure that Resident #63's oxygen tubing's were bagged in a plastic bag and stored in a drawer which was consistent with professional standards and changed and dated per physician orders. This failure could place residents at increased risk of infections. Record review of Resident #63's MDS Assessment, dated 01/09/2026, reflected the resident was a [AGE] year-old female, admitted [DATE]. She had a BIMs score of 10 indicating moderate cognitive impairment. The resident had diagnoses which included respiratory failure (when the respiratory system cannot adequately provide oxygen to the body), heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump enough blood to meet the body's needs for oxygen) and hypertension (a chronic condition defined as consistently high blood pressure). She was coded under Respiratory treatments to be receiving oxygen therapy. Record review of Resident #63's Comprehensive Care Plan revealed a care plan Date Initiated: 1/26/2026 [Resident] has an order for continuous oxygen at 2lpm via NC. [Resident] is noncompliant with the order and drops tubing to the floor. Facility intervention includes: Monitor s/sx of respiratory distress and report to MD: PRN Respiration, pulse oximetry, increased heart rate, Restlessness, diaphoresis(excessive sweating) , lethargy, confusion, atelectasis(the partial or complete collapse of one or more lobes of the lung, occurring when the tiny air sacs (alveoli) become deflated or filled with alveolar fluid), hemoptysis (the coughing up of blood or blood-tinged mucus from the airways, ranging from streaked sputum to life-threatening bleeding), cough Pleuritic pain (a sharp, stabbing chest pain that intensifies with breathing, coughing, or sneezing. It occurs when the pleura-the thin membranes lining the lungs and chest wall), accessory muscle usage, skin color. Record review of Resident #63's active physician orders, dated 02/01/2026, reflected oxygen at 2 l/m continuous via nasal cannula to keep oxygen level above 92% every shift for SOB. Start date 09/27/2023. Record review of Resident #63's active physician orders, dated 02/01/2026, reflected to change and date oxygen/Trach[esotomy] tubing weekly on Sunday 10pm-6am shift. Every night shifts every Sunday night. Start date 01/26/2024. Record review of Resident #63's active physician orders, dated 02/01/2026, reflected check to make sure all tubing for oxygen/Trach[esotomy] humidifier have been changed and dated every shift if not, change and date according. Start date 01/26/2024. During an observation on 2/18/2026 at 1:05 PM Resident 63 revealed the oxygen tubing was not dated or labeled and the nasal cannula was on the floor next to the resident's bed. Another Oxygen tubing was observed on the floor by Resident #63's motorized wheelchair the oxygen tubing was not bagged or stored in a plastic bag. During an interview on 2/18/2026 at 2:02 PM with DON revealed her expectation was the assigned nurse should check the oxygen tubing as part of overall assessment to make sure, the tubing's are dated and stored in plastic bags. She stated that Resident #63 refuses the nurses to change her oxygen tubing's and only wanted it changed by the respiratory therapist. She stated the facility policy was to change oxygen tubing every week on night shift and PRN. She stated that the tubing should be stored in plastic bags in the drawers to prevent it from getting contaminated. She stated the risk to the resident if tubing was not stored in sanitary ways, was infection. She stated that the nurses had been in serviced on infection control and oxygen tubing care. She stated that when tubing is changed the nurse should document the treatment administration record. During an interview on 2/18/2026 at 3:34 PM with LVN C She stated that if she observed oxygen tubing on the floor or contaminated, she would replace it immediately. She stated Resident#63 could remove the nasal cannula and sometimes it could end up on the floor. She stated the oxygen tubing was supposed to be changed weekly and as needed. She stated she usually checked the oxygen tubing to make sure they were dated. She stated the importance of dating oxygen tubing was to track its age so it can be replaced according to the recommended schedule. She stated that she had been in serviced on infection control and oxygen tubing care. During an interview on 2/19/2026 at 1:34 PM with LVN B revealed she was Resident #63 nurse on 2/18/2026 but not aware that Resident #63 oxygen tubing was on the floor. She stated that if she observed oxygen tubing on the floor or contaminated, she would replace it immediately. She stated the oxygen tubing was supposed to be changed weekly and as needed. She stated she usually checked the oxygen tubing to make sure they were dated. She stated the importance of dating oxygen tubing was to track its age so it can be replaced according to the recommended schedule. She stated that she was in-service on infection control and oxygen tubing care. During an interview on 2/19/2026 at 2:34 PM interview with RT revealed the nurses were responsible for changing the oxygen tubing and she was aware the resident sometimes refuses the nurse to change the tubing, but she had educated the resident and reassured Resident #63 that the nurses were skilled to replace oxygen tubing. She stated she was at the facility bi-weekly, and she does replace the tubing and check on any other respiratory issues as needed. She stated that she does the respiratory care services, and the staff had been in serviced respiratory care to include changing oxygen tubing weekly and as needed. Record review of the facility policy titled Oxygen Administration Revised 10/ 2020 reflected: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Documentation The date and time the procedure was performed.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of 1 of 1 medication on 1 of 3 medication carts, reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident#18's Tylenol 300/30mg (controlled medication) by taping a narcotic medication. This failure could place residents at risk of drug diversion and risk of pills contamination due to broken seal. Record review of Resident #18's Quarterly MDS Assessment, dated 12/04/25, reflected the Resident #18 was a [AGE] year-old male, admitted [DATE].He had a BIMs score of 15, indicating cognitively intact. The resident had diagnoses including seizure disorder, anxiety disorder, and muscle weakness. Record review of Resident #18's Comprehensive Care Plan, dated 06/17/2025, reflected [NAME] was at risk for alteration in comfort related to: seizures, history of falls, antidepressant use. Interventions included pain meds as ordered, report unrelieved pain to MD. Record review of Resident #18's active physician orders, dated 02/19/2026, reflected the resident had orders for Tylenol with codeine #3 tablet 300-30mg (Acetaminophen-Codeine). Give 1 tablet by mouth every 6 hours as needed for pain order date 08/31/2025. During an observation on 02/18/26 at 2:45 PM of the 300 Hall Nurses Cart station, revealed Resident #18's Tylenol with codeine #3 tablet 300-30mg (Acetaminophen-Codeine) had 2 blister seals broken and taped. The damaged blister had the pill still inside secured with tape at the time the surveyor inspected the medication cart. In an interview on 02/18/26 at 2:50 PM, LVN I stated she was unaware Resident#18's Tylenol with codeine#3 tablet 300-30mg (Acetaminophen-Codeine) blister pack seal was broken. She stated that the risk of a damaged blister would be potential for drug diversion and contamination of the medication. She stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated she did not see the broken blister during the count. She stated she had been inserviced on medication storage. Interview on 2/18/26 at 2:12 PM with MA D revealed that when a narcotic bubble seal was broken he would notify the charge nurse so that the medication could be discarded. He stated he was in serviced on medication storage. Interview on 2/18/2026 at 2:15 PM with RNA revealed that when a narcotic bubble seal is broken the medication should be discarded wasted and witnessed by two nurses. She stated she had been in serviced on medication storage. In an interview on 02/19/26 at 1:04 PM, the DON stated if the blister pack seal was broken on any controlled medications the pill should be discarded witnessed by two nurses. The DON stated it was not acceptable to keep a pill in a blister pack that was opened. She stated that if a blister pack seal was broken it should not be tapped over with tape. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON audit the medication carts weekly, then the pharmacy consultant checks the medication room and the medication cart every month and the last time the audited the carts was in January 2026.She stated the nurses had been in serviced on medication storage and that narcotics were not to be taped if the blister seal was broken. Review of the facility's policy Medication Storage and Labeling in the Facility Revised February 2023 reflected the following:Medications and biologicals are stored in the packaging containers or other dispensing systems they are received in. only the issuing pharmacy is authorized to transfer medications between containersIf the facility has discontinued, outdated or deteriorated medications or biologicals the dispensing pharmacy is contacted for instructions regarding returning or destroying these itemsControlled substances (listed as Scheduled II-V of the comprehensive Drug Abuse Prevention Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed except when using single unit package drug distribution sys in which the quantity store is minimal and a missing dose cane be readily detected.

Based on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for two (300 hall nurses cart and 300 hall Medication Aides cart) of four medication carts reviewed for medication storage. The facility failed to ensure Resident#19's IV antibiotic was initialed and date/time of administration. The facility failed to ensure Resident#19's IV tubing was dated indicating when it was initiated or last changed. The facility failed to ensure that an unopened vial of Rectacrit was observed stored unrefrigerated in the medication cart. The facility failed to ensure Zofran 4mg was labeled with the residents name. The facility failed to ensure an opened bottle of Keppra 100 mg/ml was labeled with the residents name. These failures could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents. Record review of Resident #19's annual MDS assessment, dated 11/22/25, reflected she was a [AGE] year-old female re-admitted to the facility on [DATE]. Her BIMs score was 15, indicating her cognitive status was intact. Her diagnoses included wound infection, pressure ulcer of sacral region stage 4. Record review of Resident #19's active care plan, as of 02/18/25, revealed:[NAME] has chronic history of infection AEB: UTI with resistive organisms' and sacrum pressure ulcer wound Infection. Facility interventions: Dressing change to IV site per orders/Protocol. Date dressing per facility protocol. Has PICC. Record review of Resident #19's active Physician Order, dated 2/17/26, reflected: Piperaciliin-Tazobactam in dex Intravenous solution (an intravenous antibiotic mixture used to treat severe bacterial infections) 4-0.5 GM/100ML use 1 dose Intravenously start date 2/5/2026. During an observation of Resident#19 on 2/17/26 at 9:37 AM revealed she was receiving Piperaciliin-Tazobactam in dex Intravenous solution 4-0.5 GM/100ML. The IV antibiotic did not have the date/time it was initiated and initial of the nurse administering medication. Surveyor also observed the IV tubing was not dated. During an interview on 2/17/26 at 9:47 AM with theRN A revealed she was the nurse that administered IV antibiotics. She stated that she forgot to date and initial the medication and the IV tubing. She stated the risk to the resident was potential for medication error and it would not be possible to know what time the medication was started and when the IV Tubing was last changed. She sated she had been in serviced on medication storage and labeling. During an observation on 12/17/26 at 2:21 PM with LVN I on the 300 nurses' medication cart revealed Zofran 4mg had no patients label, and an unopened vial of Retacrit (medication that requires refrigeration) stored in the cart and not refrigerated. During an interview on 2/17/26 at 2:12 PM with LVN I revealed she was not aware that the Zofran 4mg had no patients label and the retacrit required refrigeration. She stated the risk to the residents was medication error and medication losing its potency due to being unrefrigerated. She stated that she had been in-serviced on medication storage and labeling. During an observation on 2/17/26 at 2:12 PM the 300-hall medication aide Cart revealed Keppra (medication used to treat seizure) with no patient label. He stated nurses and CMAs were responsible for ensuring the medication carts were clean, all medications were within date, no medications were expired and all over the counter medications were dated when they opened. He stated that he had been in-serviced on medication storage. During an interview on 2/18/26 at 2:12 PM with MA D revealed that he did not know that the Keppra bottle did not have the pharmacy label with the resident's name. MA D stated nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, and all medication that required refrigeration was stored in the refrigerator. He stated risk to the resident was medication error and medication not being effective if it is not well stored. He stated that he had been in-serviced on medication storage. He stated he had been in-serviced on medication storage. During an interview on 2/18/2026 at 2:15 PM with RN A revealed nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, and all medication that required refrigeration was stored in the refrigerator. She stated risk to the residents was medication not being effective if it is not well stored. During an interview on 2/18/2026 at 2:15 PM with LVN C revealed nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, and all medication that required refrigeration was stored in the refrigerator. She sated before administering IV medication after doing all medication rights the administering nurse should initial and date the time of administration. She stated that all IV tubing should be dated when changed because the tube should be changed every 24 hours. She stated risk to the resident was medication would lose its potency if not stored by the manufacturer's recommendations. During an interview on 2/18/2026 at 2:15 PM with MA F revealed nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, and all medication that required refrigeration was stored in the refrigerator. She stated risk to the residents was medication not being effective if it is not well stored. During an interview on 2/19/2026 at 11:15 AM with LVN B revealed nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, and all medication that required refrigeration was stored in the refrigerator. She sated before administering IV medication after doing all medication rights the administering nurse should initial and date the time of administration. She stated that all IV tubing should be dated when changed. She stated risk to the residents was medication not being effective if it is not well stored. Review of the facility's policy Medication Storage and Labeling in the Facility Revised February 2023 reflected the following:1. Medications and biologicals are stored in the packaging containers or other dispensing systems they are received in. Only the issuing pharmacy is authorized to transfer medications between containers3. If the facility has discontinued, outdated or deteriorated medications or biologicals the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.6. Medication requiring refrigeration are stored in a refrigerator located in the medication room at the nurses station or other secured location. Medications are stored separately from food and are labeled accordingly.Medication labeling1. Labeling of medication and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceuticals practices.2. The medication label includes, at a minimum:a. Medication name(generic and /or brand);b. Prescribed dose;c. Strengthd. Expiration date, when applicable;e. Residents' name;f. Route of administration; andg. Appropriate instructions and precautions.8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to ensure they followed professional standards of practice in accordance with physician orders and facility policy for care of PICC lines for 1 of 2 (Resident #19) residents reviewed for parenteral and intravenous care. The facility failed to ensure Resident #19's PICC line dressing was intact. This failure could place the residents at risk of contamination, infection, and complications with their PICC line needed for infusion therapy.Record review of Resident #19's annual MDS assessment, dated 11/22/25, reflected she was a [AGE] year-old female re-admitted to the facility on [DATE]. Her BIMs score was 15, indicating her cognitive status was intact. Her diagnoses included wound infection, pressure ulcer of sacral region stage 4. Record review of Resident #19's active care plan, as of 02/18/25, revealed:[NAME] has chronic history of infection AEB: UTI with resistive organisms' and sacrum pressure ulcer wound Infection. Facility interventions: Dressing change to IV site per orders/Protocol. Date dressing per facility protocol. Has PICC. Record review of Resident #19's active Physician Order, dated 2/17/26, reflected: Piperaciliin-Tazobactam in Dex Intravenous solution (an intravenous antibiotic mixture used to treat severe bacterial infections), 4-0.5 GM/100ML use 1 dose Intravenously start date 2/5/2026. Record review of Resident #19's active Physician Order, dated 2/17/26, reflected: PICC line: Change PICC line dressing Q week and PRN, one time every Tuesday start date 2/2/2026. Record review of Resident #19's active Physician Order, dated 2/17/26, reflected: PICC line: monitor PICC site for s/s of infection. During an observation on 2/17/2026 at 9:37 a.m. Resident #19 IV antibiotic was infusing the PICC dressing edges of the transparent, sticky dressing was peeling away from the skin, curling upward almost exposing the insertion site. In an interview on 02/17/26 at 9:47 AM, RN A stated that she administered Residents#19 IV antibiotic. RN A stated that she observed that the PICC dressing was coming off when she administered the IV antibiotic, but because the PICC line flushed with no problem, she thought it was okay to administer the medication then have the DON change the dressing later. LVN A stated the risk associated with PICC lines was infection and the IV getting dislodged. In an interview on 02/18/26 at 2:24 PM the DON stated she was responsible for changing the PICC line dressings. She stated RN A had notified her the dressing needed to be changed and she was going to change it, but the surveyors got to it before she had a chance to change it. The DON stated nurses were expected to check the dressing every shift and during every antibiotic administration. The DON stated the primary risk associated with PICC lines was infection. She stated that the Nurses had been in serviced on IV administration. In an interview on 02/18/26 at 3:37 PM, LVN C stated before administering IV medication nurses are supposed to assess the IV site including ensuring the PICC dressing is intact. LVN A stated the risk associated with PICC lines was infection and the IV getting dislodged. She stated she had been in serviced on IV administration and IV dressing care. Record review of the facility's Midline IV Dressing Changes policy revised 12/2012 reflected:The purpose of this procedure is to prevent catheter-related infections associated with contaminated loose or soiled catheter-site dressings.

Based on interviews, the facility failed to protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility for 1 of 1 facility reviewed for communication with privacy. The facility failed to deliver mail to residents on Saturdays. This failure infringes on the residents' rights to receive mail and communications. Findings included: During a confidential resident council meeting, the residents in attendance were asked 26 questions. Question 19 asked residents Is mail delivered unopened and on Saturdays? All 8 residents in attendance answered no to question 19. An interview conducted on 09/16/2025 at 9:45am with the BOM revealed she sorts the mail when it arrives at the facility and then it is delivered to the residents. When asked if residents receive mail on Saturdays, the BOM stated they do not, because there is no one at the facility to sort it before it gets distributed to the residents. The BOM further stated there is a possibility of important documents, like Medicaid documents, that could get passed to the resident and then lost. When asked if there was a risk to the residents not receiving mail on Saturdays, she stated she did not think there was. A facility policy related to mail distribution was requested from the Administrator twice on 09/16/2025 and was not provided.

Based on observation, interview and record review, the facility failed to ensure residents were free from any physical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 6 (Resident #70, Resident # 23, Resident # 39, Resident # 36, Resident #25, Resident #63) of 6 residents reviewed for restraints. The facility failed to ensure Resident #70, Resident #23, Resident #39, Resident #36, Resident #25 and Resident #63 were not inhibited from freedom of movement or activity in the secure unit when facility staff pushed two dining tables together and placed them in front of the single entrance to the dining area, to prevent the residents from leaving the area. This failure places the residents at risk of being restrained without medication indication.Findings Included: Record review of Resident #70's MDS, dated [DATE], revealed he admitted to the facility on [DATE]. Resident #70 had primary diagnoses of non-Alzheimer's dementia, and left side paralysis due to cerebral infarction (blood flow to the brain is interrupted, leading to tissue damage). Record review of Resident #23's MDS, dated [DATE], revealed he admitted to the facility on [DATE]. Resident #23 had primary diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion and cognitive decline) and Type 2 diabetes (condition where the body does not use insulin effectively). Record review of Resident #39's MDS, dated [DATE], revealed she admitted to the facility on [DATE]. Resident #39 had primary diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion and cognitive decline) and orthostatic hypotension (condition where blood pressure drops significantly upon standing or sitting up from a lying position.) Record review of Resident #36's MDS, dated [DATE], revealed she admitted to the facility on [DATE]. Resident #36 had primary diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion and cognitive decline) and hypertension (condition in which the force of blood against the artery walls is consistently high). Record review of Resident #25's MDS, dated [DATE], revealed she admitted to the facility on [DATE]. Resident #25 had primary diagnoses of non-Alzheimer's dementia and hypertension (condition in which the force of blood against the artery walls is consistently high). Record review of Resident #63's MDS, dated [DATE], revealed he admitted to the facility on [DATE]. Resident #63 had primary diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion and cognitive decline) and hyperlipidemia (condition characterized by high levels of fats in the blood). Observation on 09/14/2025 at 9:20am in the secure unit revealed two dining tables pushed together, blocking the single entrance to the dining area. CNA G was sitting in the hall on the outside of the dining area, while Resident #70, Resident #23, Resident #39, Resident #36, Resident #25 and Resident #63 were inside the dining area. CNA H was observed sitting in an office down the hall with line of sight for both hallways in the secure unit. During an interview with CNA G on 09/14/2025 at 09:25am, CNA G was asked why the tables were placed in front of the doorway. CNA G stated it was to keep the residents from wandering. During an interview with CNA H 09/14/2025 at 1:40pm, CNA H was asked why the tables were placed in front of the doorway to the dining room earlier in the day. CNA H stated the tables are there to keep them from wandering while they are trying to get residents to the dining room. She further stated sometimes it takes more than one aide to get a resident ready for breakfast, so the tables keep them from wandering while the aides go back to get another resident. If they (the residents) are mobile, they're more likely to have an incident or accident. During an interview with the DON on 09/15/2025 at 2:30pm, the DON stated she did not know the weekend aides in the secure unit were restraining the residents in the dining area and it was not acceptable for them to do that. The DON identified risks for the residents as detrimental in every way. If the resident has the need to use the bathroom or whatever. The DON further stated the secure unit is secure so the residents can wander freely and be safe in their environment. A review of the facility policy titled Identifying Involuntary Seclusion and Unauthorized Restraint revealed the following: Policy Statement: As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify involuntary seclusion and/or unauthorized restraint of residents. 1. Involuntary seclusion is defined as a separation of a resident from other residents or from his or her room or confined to his or her room against the resident's will. 2. Examples of involuntary seclusion include: a. Any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door. 3. Secluding or confining a resident against his or her will is prohibited.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, the facility stored all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of four medication carts (300 hall nurses cart and 400 hall Medication Aides cart) reviewed for medication storage. 1. The facility failed to ensure Resident #64's unopened liquid Lorazepam 2mg /ml was stored in the refrigerator. 2. The facility failed to ensure an opened vial of insulin Lispro 100unit/1ml was properly labeled before storing in the 300-hall medication cart. 3. The facility failed to ensure a bottle of Assure Prism Control solutions (designed to check assure prism [NAME] meter [glucometer] and assure prism test strips) was not expired. These failures could place residents at risk of compromised medication efficacy, unsafe administration and increased harm to residents. The findings include: 1. Record review of Resident #64's Quarterly MDS Assessment, dated 08/22/2025, reflected a [AGE] year-old female. Resident #61 had a BIMs score of 10, which indicated her cognitive function was moderately impaired. The resident had diagnoses which included Malnutrition, anxiety, depression, Pancytopenia (a condition marked by low levels of all three types of blood cells, white blood cells, and platelets), Cirrhosis of the liver (a chronic liver disease characterized by the formation of scar tissue [fibrosis] that replaces healthy liver tissue). Record review of Resident #64's Comprehensive Care Plan, dated 08/27/2025, reflected the [Name ] uses antidepressant medication. Intervention Give antidepressant medications ordered by physicians. Monitor/document side effects and effectiveness. Record review of Resident #64's active Physicians orders, as of 09/15/2025, Lorazepam Intensol Concentrate 2 MG/ML(Lorazepam) Give 0.5 ml by mouth every 4 hours as needed for restlessness/agitation related to Anxiety Disorder, Unspecified for 14 Days Verbal Active 09/07/2025. Lorazepam Intensol Concentrate 2 MG/ML(Lorazepam) Give 0.75 ml by mouth every 4 hours as needed for restlessness/agitation related to Anxiety Disorder, Unspecified for 14 Days Verbal Active 09/07/2025. Lorazepam Intensol Concentrate 2 MG/ML (Lorazepam) Give 1 ml by mouth every 4 hours as needed for restlessness/agitation related To Anxiety Disorder, Unspecified for 14 Days Verbal Active 09/07/2025 . 2. Record review of Resident #11's Quarterly MDS Assessment, dated 07/1/25, reflected Resident #11 was a [AGE] year-old female with a BIMs score of 15, which indicated her cognitive function was intact. The resident had diagnoses which included Anxiety, Depression, Bipolar Disorder, Respiratory Failure. Record review of Resident #11's Comprehensive Care Plan, dated 5/17/24, reflected the Resident was on pain medication therapy opioid narcotics r/t pain and neuropathy. Intervention: Administer analgesic medication as ordered by physician and monitor for side effects adverse. Record review of Resident #11's active Physicians orders, as of 09/15/2025, reflected Lyrica oral capsule 75mg (Pregabalin) give 1 tab by mouth two time a day for pain related to type 2 Diabetes mellitus without complication. Observation on 09/14/25 at 1:42 PM with LVN B on the 300-hallway's medication cart revealed one vial of Insulin Pro 100unit/1ml with no label, Resident #64's Liquid Lorazepam was in the cart (not refrigerated) and Assure Prism Control with an expiration a date of 03/03/2025 and an open date of 06/25/2025. In an interview on 09/14/25 at 1:42 PM with LVN B, she stated she did not realize the Insulin Pro 100unit/ml was missing the patient's label. She also stated she did not realize Resident #64's unopened bottle of Liquid Lorazepam 2mg/ml bottle was required to be stored in the refrigerator. She stated the night shift was responsible for glucometer checks, so she did not realize the Assure prism was expired. She stated having insulin in the medication cart that did not have the proper label could result in administering insulin to the wrong resident which may result in medication error and hospitalization. LVN B stated the risk to the residents if Liquid Lorazepam was not refrigerated was reduced effectiveness of the medication posing a significant risk of therapeutic failure and causing harm to the residents. She stated using expired Assure Prism control solution for glucometer checks could result in inaccurate readings that would affect how much insulin was administered to the residents and could lead to health complications and be fatal. 3. Observation on 09/15/25 at 1:37 PM with CMA D, on the 400-hallway's medication cart, revealed the medication blister pack for Resident #11's Lyrica 75mg oral capsule (controlled medication used for pain related to type 2 Diabetes mellitus) had one damaged blister, the pill was inside secured with tape. At the time the State Surveyor inspected the medication cart; the count for Resident#11's Lyrica 75mg was documented as 7 pills, the actual number of pills counted in the blister pack was 7 pills which included the taped blister bubble. In an interview on 09/15/25 at 1:42 PM with CMA D, she stated she did not realize Residents #11's Lyrica 75 mg had a damaged blister pack and it was secured with tape. She stated narcotic medications should not be taped and if the blister bubble was damaged, the CMA would notify the nurse so the medication could be destroyed by two nurses. She stated the risk of taping narcotics was not knowing if it was the right medication and possible exposure of the medication to contamination. She stated she was in-serviced on medication storage. An interview on 09/15/2025 at 1:47 PM with LVN G (400 hall nurse) revealed he was not aware or had not been notified Resident #11's Lyrica 75mg had a damaged blister bubble that was taped. He stated the policy on narcotics storage was if a blister bubble was broken the medication was to be wasted witnessed by two nurses. He stated the risk of taping narcotics was it could lead to drug diversion and there was no way to know if the medication in the taped bubble had not been compromised. He stated he was in- serviced on medication labeling storage. An interview on 09/15/2025 at 2:13 PM with the DON revealed all medication which included insulin vials should be labeled. She stated her expectations were the nurses and CMAs did the medication rights before administering any medication. The risk of unlabeled medication to the residents was it made it impossible to complete the medication rights checks, and the wrong medication could be given to the wrong resident. The DON stated the night shift nurse was responsible for doing the glucometer checks. She stated using an expired glucometer control solution to do glucometer checks could result in false FSBS reading. She stated the false FSBS readings would risk residents receiving the wrong dose of insulin that would not be therapeutic could lead to other health complications up to hospitalization. The DON stated no narcotic should not be taped. If a medication bubble was tampered with, medication was to be wasted by two nurses. The risk to the patient included cross contamination. The DON stated it was the responsibility of the nurse and the CMAs to ensure the medication carts were cleaned, and all medications were stored according to professional standards. She stated the staff were in-serviced on medication labeling and storage . Record review of the facility's policy titled Medication Labeling and Storage, revised on 02/2023, reflected: The facility stores all medication and biologicals in locked compartments under proper temperature, humidity, and light controls. Policy Interpretation and Implementation 1. Medication and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. Medication requiring refrigeration are stored located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. 7. Controlled substance (listed as schedule II-IV) of the comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution system in which the quantity stores is minimal and a missing does cane be readily detected. Medication Labeling 1. Labeling of medication and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: Medications name. prescribed name. prescribed dose. Strength. Expiration date, when applicable. Residents name. Route of administration; and Appropriate and precautions. If medication containers are missing, incomplete, improper, or incorrect labels contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 facility kitchens reviewed for kitchen sanitation. The facility failed to ensure food items were properly stored in the facility's freezer. 2. The facility failed to ensure food and drink items were properly labeled. 3. The facility failed to ensure no outdated or spoiled foods were present. These failures could place residents at risk for food-borne illnesses. Findings Included: Observation of the facility's freezer on 09/14/24 at 9:12 AM revealed: - 2 bags of lettuce (each bag contained 6 heads of lettuce) visibly decomposed, brown discoloration, wilted and slimy, with liquid seepage. - 1 box lima beans were open and exposed to the air. - 2 gallon jugs of milk, were opened and were not labeled. - 1 container of instant mashed potatoes was not labeled. In an interview with the Dietary Manager on 9/14/2025, at 2:00 p.m., he stated when food deliveries arrived, staff were expected to inspect the food and had the option to reject items for credit if necessary. He reported that an in-service had been provided on dry storage, freezer management, and inspecting food upon delivery. Record review of the facility policy titled Food Storage: Cold Foods dated 2/2023 reflected the following: All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on observation, interview, and record review, the facility failed to ensure residents received services with reasonable accommodations for 2 of 5 residents (Resident #8, and Resident #14) reviewed for call light system access. The facility failed to ensure Resident #8 had access to their call light by allowing it to remain on the floor at the side of the bed, out of the resident's reach. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain between the wall and mattress at the foot of the bed, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. 1.) Record review of Resident #8's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility with an original admission date of 09/20/2024 and had severely impaired cognitive function. Diagnoses included: cerebral palsy (a neurological disorder that affects body movement and muscle coordination). Resident #8 was dependent on staff for all self-care tasks such as eating, oral and toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. He was dependent on staff for mobility tasks such as sitting to lying, lying to sitting on side of the bed, sitting to standing, chair/bed-to-chair transfers, and toilet transfers, tub/shower transfers. Record review of Resident #8's Comprehensive Care plan dated 05/15/2025 showed a medical focus: [Resident] has alteration in musculoskeletal status related to Kyphosis (excessive outward curvature of the spine). Goal: [Resident] will remain free from pain or at a level of discomfort acceptable to the resident. Interventions included: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. During an interview and observation on 09/14/2025 at 2:40 PM, Resident #8 was observed in bed. The call light was on the floor, out of the reach of the resident. He said he was not sure why it was there. He said he was unable to reach it. 2) Record review of Resident #14 annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnosis included unspecified dementia (a term used when a person exhibits symptoms of dementia, but the specific type cannot be identified), chronic kidney disease (gradual loss of kidney function over time), Orthostatic hypotension (a condition characterized by a sudden drop in blood pressure when a person stands up after sitting or lying down), muscle weakness, and repeated falls. Record review of Resident #14's Comprehensive Care plan dated 5/23/2025 showed a fall focus: {Resident] is at risk of falls due to (specify: unsteady gait, decreased balance, medications and poor safety awareness). Goal: [Resident] will have no reports of injuries that requires hospitalization or fractures related to falls through next review date. Interventions included: Call light in reach in room and answered promptly. Encourage and remind resident to use call light to ask for assistance. During an interview and observation on 08/24/2025 at 9:30 AM, Resident #14 was observed in bed. Due to cognitive impairment, he was unable to provide reliable information during the interview. The call light cord was observed at the end of the bed, in between the resident's mattress and wall, hanging down toward the floor. During an interview with CNA A on 09/14/2025 at 3:00 PM, in response to the Resident's call light placements, LVN A reported responsibility for ensuring call lights were within reach of residents fell on the CNA's as well as all staff. CNA A said when she left a resident's room, she always placed the call light within reach. She reported rounds were done frequently and as needed since staff were always present in the hallway. CNA A reported the facility call light policy required staff to make sure call lights were within reach, to encourage residents to use them, and, if a call light was not working, to report it immediately and provide an alternative means for the resident to call for assistance. She reported if a call light was not within reach, the risk to residents was they might not be able to communicate their needs or obtain help in a timely manner. She added staff conducted frequent checks to help minimize that risk. During an interview with DON on 09/16/2025 at 10:50 AM, she indicated she was unsure if the facility had a formal policy regarding keeping call lights within residents' reach but noted that it should be considered basic nursing knowledge. She reported there had been no complaints or incidents related to call lights being inaccessible. However, she acknowledged a potential risk might be unable to call for help if a call light was out of reach. On 09/16/2025 at 11:30 AM, the administrator reported the facility did not have a policy regarding call light accessibility.

Based on observation, interview, and record review the facility failed to ensure residents received the housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Resident #20 & #49) of five residents reviewed for environment. The facility failed to maintain the wall air conditioning unit in Residents #20 and #49's room free of dust buildup. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings included: 1.) Record review of Resident #49's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Primary diagnoses included chronic congestive heart failure (a long-term condition where the heart is unable to pump enough blood to meet the body's needs for blood and oxygen), unspecified cirrhosis of the liver and (liver scarring without a clearly identified cause, leading to significant liver damage). Observation and interview on 09/14/2025 at 10:45 AM with Resident #49, he stated his in-room air conditioning wall unit needed to be cleaned. He stated he did not like the air blowing on him because it was so dirty and missing the filter. The wall air conditioning unit was observed with significant dust and debris buildup on the coils and interior components. Rust was observed along the metal frame, and the blower area contained visible accumulation of dust. A filter was not present in the unit at the time of observation. Record review of Resident #20's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Primary diagnoses included unspecified convulsions (episodes of involuntary muscle contractions and spasms that do not have a specific diagnosis or underlying cause). Observation and interview on 09/14/2025 at 10:55 AM with Resident #20, he stated he did not have any issues at this time. He said at times the cover of the unit would come off. Observation of the unit was observed with significant amounts of dust and debris on the coils. The unit had a clean filter; however, half of a broken filter covered in dust was also inside the filter slot. During an interview on 09/15/2025, at 10:00 AM, maintenance director reported air conditioning unit filters had been inspected and cleaned as needed, typically when a unit was not cooling or heating properly. He stated housekeeping was responsible for removing and cleaning filters, while maintenance pulled entire units from the wall for deeper cleaning when necessary. He stated there was no log in place to track filter changes or unit service. He stated that since starting in February, he had been trying to catch up on overdue work and was working to re-implement a preventive maintenance program that had lapsed under prior ownership due to unpaid accounts and supply cutoffs. When inspecting units, he looked for issues such as loose cords, intact screens and covers, and whether the unit was properly secured in the wall, noting that covers were frequently damaged by residents bumping into them. He reported receiving no training related to infection control or air quality risks and stated that the filters used were not specified by type or replacement schedule. If a unit was missing a filter or had heavy buildup, maintenance would remove the unit from the wall to wash it. He recalled only one recent complaint, from a resident, which turned out to be operator error due to the heat setting. maintenance director confirmed that the facility did not currently follow a preventive maintenance schedule but was in the process of reinstating one. 2.) Record review of Resident #73's Face Sheet, dated 09/16/25, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and need for assistance with personal care (when an individual needs assistance with every day tasks). Record review of Resident #73's MDS Assessment, dated 09/07/25, reflected he had a BIMS score of 14, indicating he was cognitively intact. Observation of Resident #73's room on 09/14/25 at 10:35AM revealed there were several pieces of brown vinyl plank missing from the flooring, exposing the white tile underneath. During an interview with Resident #73 on 09/14/25 at 11:45AM, he stated the vinyl plank from the floor of his room had been missing for a couple of weeks. He said maintenance was supposed to be working on this issue; he was not sure what the timeframe would be, but he wanted the flooring repaired. During an interview with the Maintenance Director on 09/15/25 at 10:09AM, he stated he was not aware of the missing vinyl plank from the flooring of Resident #73's room. He stated he felt as though this must have occurred within the past couple of weeks, as he had been in Resident #73's room two weeks ago to fix his call light and did not note any issues with the flooring. The Maintenance Director stated the risk of the vinyl plank flooring being missing was the potential for an environment that was not homelike. 3.) During an observation and walk through of the secure unit on 09/14/2025 at 9:30am, the sink and vanity unit in the bathroom of room [ROOM NUMBER] were observed to be on the floor. The unit and sink were broken apart, with broken cabinet pieces on the floor, and two screws were observed to be sticking up. Additionally, the rough edges of the cabinet were exposed. room [ROOM NUMBER] is not used by residents, and the room was empty. The door to the room and the bathroom were both observed to be closed. An interview with CNA H on 09/14/2025 at 9:40am revealed she did not know the sink was broken in the bathroom. CNA H was asked if it was possible a resident could wander into the room, and she said it was unlikely because they always have a CNA posted in the corner office, and the aide can see both halls and the entrance to the unit, and it is so close to room [ROOM NUMBER]. During an interview and observation with the administrator on 09/14/2025 at 2:30pm, the administrator was shown the broken sink in room [ROOM NUMBER]. The administrator revealed he did not know the sink was broken and immediately called the maintenance director to remove the vanity and sink. An observation of room [ROOM NUMBER] on 09/15/2025 at 9:30am revealed the broken sink and vanity had been removed, and there no longer appeared to be a potential hazard for a resident. During an interview with CNA I on 09/15/2025 at 9:45am, CNA I was asked if she knew the sink and vanity were broken in room [ROOM NUMBER]. CNA I stated she did not know it was broken and was unaware there was a potential hazard in the bathroom. CNA I further stated they usually have 3 aides on shift, and one is always placed in the corner office with a view of both hallways, which included room [ROOM NUMBER]. CNA I stated she has not ever seen a resident try to go into room [ROOM NUMBER]. During an interview with the maintenance director on 09/15/2025 at 10:15am, the maintenance director revealed he did not know the sink and vanity in room [ROOM NUMBER] were broken and was informed of it the previous afternoon. He reported he had done rounds on the unit; he was not sure when or how the sink broke. The maintenance director was asked if there was a risk to residents and he stated yes and no. He further stated he doesn't think there is because he knows staff are always monitoring the hallway and staff are right there, but if a resident were to wander into that room unnoticed, then there would be a risk for injury. During observations of the secure unit between 09/14/205 to 09/16/205, an aide was always observed to be in the corner office watching both halls. No residents were observed entering or trying to enter room [ROOM NUMBER] over this same period. Record review of the facility's policy titled, Quality of Life - Homelike Environment, revised August 2009, reflected, Residents are provided with a safe, clean, comfortable, and homelike environment .The facility staff and management shall, maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order .

Based on interviews and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident #55) of five residents reviewed for PASRR services. The facility failed to ensure Resident #55 was properly screened for PASRR services. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #55's quarterly MDS Assessment, dated 06/13/25, revealed a [AGE] year-old-female admitted to the facility on [DATE] and had severe cognitive impairment. Diagnoses included Major Depressive Disorder, Recurrent, Moderate (severe, persistent sadness and loss of interest that interferes with daily life). Record review of Resident #55's Comprehensive Care plan dated 08/30/2025 showed a mental health focus: [Resident] has mood problem. Goal: [Resident] will have improved mood state (Specify: happier, calmer, appearance, no symptoms of depression, anxiety or sadness) through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Antidepressant Medication Focus: [Resident] uses antidepressant medication Lexapro (antidepressant medication used to treat certain mental health conditions by balancing serotonin levels in the brain). Goal: [Resident] will be free from discomfort or adverse reactions related to antidepressant therapy through the next review date. Interventions: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. An interview on 09/16/25 at 11:46 AM with MDS Nurse, she reported she was responsible for entering PASRR information. The MDS Nurse reported the PASRR Level 1 for Resident #55 was received from a hospital upon admission to the facility and was documented as it was. The MDS Nurse reported the resident did not receive an updated evaluation based on his diagnosis and she did not receive a PASRR Level 2 screening. The MDS Nurse stated the resident was at risk of not receiving PASRR services. On 09/17/2025 at 3:18 PM, the Administrator reported the facility did not have a policy for resident PASRR process.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Resident #1, Resident #2) reviewed for abuse and/or neglect.The facility failed to ensure Resident #1 was free from abuse when the call device was not functioning and available to call for immediate assistance when she was physically abused by Resident #2. A manual bell had been placed at Resident#1's door and in her drawer, but Resident #1 had not been instructed on how/when to use the bells. On 07/24/25 at 5:20 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/26/25 the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm and a scope of isolated that was not an immediate jeopardy due to the facility's need to monitor the implementation and the effectiveness of their Plan of Removal. This failure could place residents at risk of abuse, neglect, and psychosocial harm.Findings included: Record review of Resident #1's admission record, dated 07/24/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, cognitive communication deficit (communication disorder stemming from cognitive impairments that affect a person's ability to communicate effectively), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), calculus of kidney (small, hard deposit that forms in the kidneys and is often painful when passed), morbid (severe) obesity (a disorder that involves having too much body fat, which increases the risk of health problems), and paraplegia (condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body). Record review of Resident #1's care plan dated 6/13/25 reflected the resident had limited physical mobility, does not walk, used manual wheelchair for locomotion, was totally dependent on staff for repositioning and turning in bed, and totally dependent on (2) staff for transferring. The care plan addressed Resident #1's behavior problem of cursing out the staff when she did not get her way, the facility was to monitor her daily/weekly and administer medications as ordered. The resident's plan did not address her rooming with resident #2, the staff involved in the decision were no longer working at the facility. Record review of Resident #2's admission record, dated 07/24/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included, a diffuse traumatic brain injury (widespread damage to the brain's white matter), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life activities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic pain syndrome (persistent pain that last weeks to years by be caused by inflammation or dysfunctional nerves), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), and antisocial personality disorder (a mental health disorder characterized by disregard for other people).Record review of Resident #2's care plan dated 6/13/25 reflected the resident required limited assistance by (1) staff tomove between surfaces, the resident did not walk, and resident used a manual wheelchair for locomotion. Resident #2's care plan addressed his psychiatric illness and refusing medications and services, staff were to monitor, encourage him to participate, inform him of the danger to his health if he did not participate, staff were to document his refusals. Resident #2's care plan did not address him rooming with Resident #1, the staff involved with that decision were no longer working at the facility. The plan addressed the facility educating Resident #2 on the dangers of sleeping in the bed with Resident #1. Resident #2's care plan did not address him leaving the facility, nor did it address any drug/alcohol use.Current MDS requested for Resident #1 and Resident #2 on 07/26/25 at 2:11 PM, and reminder sent on 07/28/25 at 5:16 PM. Received MDS for Resident #1 and Resident #2 on 07/29/25 at 5:04 PM the BIMS was blank.On 07/31/25 at 6:10 AM emailed Administrator-B and Director of Clinical Services and informed the MDS' for Resident's #1 and #2 had no BIMS and if the admission MDS could be provided. On 08/06/25 at 12:07 PM an email was sent to Administrator-B, the MDS for Residents #1 and #2 were requested and received, noting that Resident #1 and Resident #2 both had a BIMS of 15. Interview on 07/24/25 at 11:04 AM with Resident #1 revealed she and Resident #2 were roommates. She stated he was her fiance. She stated earlier in the day on 07/22/25, Resident #2 was upset with RN-A and called the police on him. She stated Resident #2 left to get some beer and brought it back to the room to drink. She stated another resident's friend gave Resident #2 drugs and when he came to the room to try to smoke it, she told him he could not smoke it and he got upset and began to beat on her. She stated she was yelling for help, she stated RN-B came into the room and screamed for Resident #2 to stop hitting her. She stated Resident #2 did stop hitting her then EMS arrived and took her to the hospital, and she was there for about two hours then she was brought back to the facility. She stated her injuries were a black right eye, a busted upper lip, bruised to both cheeks, and a large bruise to her left breast. She stated she did not feel safe at the facility because someone else could enter the room and she could not protect herself. She stated she and Resident #2 had not had any physical altercations in the past. She stated he had taken care of her he had never hurt her. When asked if she pushed the call light button, she stated the call light had not worked in four months. She stated she was given a bell to ring when she needed assistance, but they had put the bell on the door. She said she also had a bell in the drawer next to her bed. She stated no one had told her she needed to keep the bell out of the drawer. She stated she was given a bell to ring when she needed assistance, but they had put the bell on the door. She said she also had a bell in the drawer next to her bed. Observation on 07/24/25 at 11:30 AM revealed there were two call light cords plugged into the wall in the room of Residents #1 and #2. Observation of the call light cords revealed both cords on the floor. Further observation of the room revealed a bell hanging on a short rope/string on the back of the door to the room, out of reach of the Residents. Resident #1 was observed in her bed. A telephone interview with RN-A on 07/24/25 at 11:51 AM revealed he had worked the 2-10 shift on 07/22/25 when Resident #2 came to him at 6 PM and asked for his pain medication, Resident #2 was informed his pain medication was due at 7:30 PM. He stated 30 minutes later Resident #2 came to him and said that Resident #1 needed her wound dressing changed. He stated when he went to the room of Resident #1 and Resident #2, he started to do the dressing when Resident #2 yelled at him that he was not taking care of the wound. He stated he was treating Resident #1 for the sacrum area, when Resident #2 had informed him (RN-A) that the dressing needed to be changed. RN-A stated while he was changing dressing, Resident #2 informed him (the nurse) that there was another wound that had developed. He stated he informed Resident #2 that Resident #1 did not have another wound and Resident #2 attempted to touch the area the nurse was re-dressing, and RN-A pushed his hand away and became upset saying he (RN-A) had put his hands on him and he (Resident #2) was going to call the police. He stated the police did come to the facility and talked to him and Resident #2, then they left. He stated when he was in a room taking care of a resident who had a G-Tube, he heard noises coming from the room of Resident #1 and Resident #2, he stated when he heard the yelling, he was actively caring for another resident. He stated when he finished with the G-Tube resident he went into the hallway, and he saw RN-B with CNAs in the hallway. He stated he did not see Resident #2 hit Resident #1; the incident ended when RN-B called out Resident #2's name. He stated then RN-B went to the nurses station and called 911. He stated prior to the police arrival Resident #2 came after him and attacked him with a pocketknife and cut his hand. He stated he and Resident #1 went to the hospital for medical attention and Resident #2 was treated and taken to jail. He stated the residents were at risk because Resident #1 did not have a way to call for help other than to yell for help. Face to face interview with Maintenace Director on 07/24/25 at 3:15 PM revealed he had been employed since late February. He stated he knew there were some call lights that were not working throughout the building. He stated he would fix the call lights then they would go out again, because the system was old. He stated if the call light was not working the residents would be given a bell to ring for help until the light could be fixed. He stated he was not sure if the call lights were working in Resident #1 and Resident #2's room. He stated when an aide would report the light was not working, he would fix the light on the spot. He stated he did not believe the light situation got to a point that he needed to notify Administrator-A. He stated there was not any room that had to have the call light fixed more than one time. He stated the staff would come to him face to face to report a call light was not working. He stated the staff could always call him on his cell phone to report issues. He stated when the call light was not working it could delay or not allow a resident to receive help. Face to face interview with Administrator-B on 07/24/25 at 3:36 PM, revealed the day was her fourth day working at the facility. She stated she was not aware Resident #1 and Resident #2 did not have a call light in their room. She stated when she found out about the call light, she was trying to move Resident #1 to another room, but she had refused to move. She stated she did not know how long Resident #1 and Resident #2 had been without a call light or any way to communicate to staff the need for assistance. She stated she did not know how the residents were supposed to let staff know they needed assistance. She stated she did not know there was a bell in the room or that the bell was on the back of the door out of reach of the resident. She stated perhaps the resident put the bell on the back of the door herself. When advised the resident was unable to walk and could not get up without help of staff, she replied, the resident could have put the bell on the door when she was in her wheelchair. She stated she would assume the Maintenace director was responsible to ensure the call lights worked in the rooms. She stated the CNAs and nurses would be responsible to ensure the placement of the bell was in reach of the resident. She stated there was a severe risk of injury or a lack of care to the residents' when they did not have access to communication.A telephone interview with CNA-A on 07/25/25 at 12:09 PM reflected Resident #2 had told him he was upset with RN-A and took his anger out on Resident #1. He stated RN-A had disrespected Resident #1. He stated RN-B was with him when they went to the Resident #1 and #2's door. RN-B asked what was going on and why was Resident #2 hitting Resident #1. He stated Resident #1 said he was not hitting Resident #2, but he could see they were the only two people in the room. CNA-A stated he knew to go to the room because he heard Resident #1 screaming from the room. He stated he did not know the call light was out in the room of Resident #1 and Resident #2. He stated Resident #2 would come out of the room to let the nurse know that Resident #1 needed help. He stated after the incident he was told there was a bell in the room for them to use to let staff know they needed help, but he had never heard it used. He stated when a resident was not able to call for help, they could be at risk of injury. In a telephone interview with RN-B on 07/26/25 at 6:15 PM, reflected she was aware some of the call lights were not working but she was not sure how long the lights had been out. She stated she thought the administrator and Maintenace knew the light was not working but she had not checked with them. She stated the night of the incident between Resident #2 and #1 she was assigned to halls 300 and 500. She stated she was on hall 400 at the time of the incident to get supplies from the supply closet. She stated she heard Resident #1 screaming and went to see what was happening and when she got to the room, she saw Resident #2 hitting Resident #1 in the face. She stated she called the name of Resident #2, and he stopped hitting Resident #1 immediately and started calling her baby. She stated she called 911, Resident #2 came to the nurses station shouting and saying it was RN-A's fault and swung on RN-A and cut his hand with a knife. She stated the police and EMS arrived, and Resident #1 went to the hospital and Resident #2 was arrested. She stated she did not believe if the resident had a call light it would have kept Resident #2 from harming Resident #1.Record review of facility's incident report dated 07/22/25, reflected, [Resident #2's] roommate (Resident #1) screamed for help and when staff responded to the screams for help, [Resident #2] was seen standing over his roommate punching her in the face repeatedly. After his name was called, he (Resident #2) stopped attacking her (Resident #1) and tried to console her. [Resident #2] slit his own throat with a pocketknife and came to the nurses station and began shouting at the male nurse (RN-A) on duty and [he the jumped on top of the counter swung the knife at the nurse and cut the nurse's hand]. 911 was called when the resident (Resident #1) was beating on his roommate (Resident #2), and they were on the phone when he (Resident #2) cut the nurse's (RN-A) hand. The police came and removed the resident (Resident #2) from the building. DON notified via phone of the incident. [No further action taken at this time ].Record review of LE report dated 07/22/25, reflected, On Tuesday July 22nd, 2024, I Officer [#1] was dispatched to [Nursing & Rehab] room [Resident #1 and Resident #2] reference a cutting in progress call at 2359 hours (11:59 pm). Call text stated a residence of the rehab center got in a fight with the nurses and cut himself as well as a nurse with a knife. The complainant did advise both the resident and the nurse have injuries. EMS and Fire were added to the call for medical treatment on both parties. I was equipped with a functioning body worn camera, while wearing a distinct patrol uniform and driving in marked patrol vehicle [#].Upon arrival to the [Nursing & Rehab] center at 0002 hours (12:02 am) on 7/23/2025, I walked inside the main lobby area and was met by the nurse who had been cut by the resident. This nurse was identified as [RN-A]. While I spoke with [RN-A], Officer [#2], Officer [#3], and Sergeant all went to room [Resident #1 and #2] to[ make contact with] the suspect who had cut himself and nurse [RN-A]. As I remained with [RN-A], I could see he was utilizing gauze to tend to his wounds as he was actively bleeding from both his right and left thumbs. [RN-A] informed me that the resident who officers were going to, had cut him with a knife that was on a keychain lanyard. [RN-A] did show me the knife which was a small black knife that attached to a keychain. Officers confiscated the knife as evidence.Officer [#2] later came back to [RN-A] and gathered his statement and what transpired between him and the resident this evening. I took photographs of [RN-A] injuries with my BWC. EMS and Fire arrived on scene and [RN-A] did advise that he wanted to go to the hospital for further treatment on his lacerations. I followed [RN-A] out to the ambulance and later provided him with the report number.Once [RN-A] left in the ambulance, I went back inside the rehab center and to room [Resident 1 & 2]. As I walked into room [Resident 1 & 2], I observed officers on the ground fighting with the suspect. Ofc. [#3] informed me that they went to place the subject under arrest for aggravated assault and he resisted arrest. I observed Ofc. [#2] controlling the subjects legs and Ofc. [#3] controlling the subjects upper body. I asked Ofc. [#3] and Ofc. [#2] if they needed leg restraints to assist with taking the subject into custody. Ofc. [#3] did confirm to utilize leg restraints to which I then ran out to my patrol vehicle to gather the restraints. Once I gathered the leg restraints, I ran back to room [Resident #1 and #2] and assisted Ofc. [#2] with placing them on the subject. Once the subject was in leg restraints and handcuffs, Officers escorted the subject to my patrol vehicle where he was placed in the back seat.Ofc. [#2] informed me that the subject also cut his throat with the knife he used against [RN-A] and was needing to be medically cleared before being transported to the jail. Due to the subject needing medical clearance, I transported him to [Local] Hospital where he was further treated for his injuries. Once at [Local] Hospital, Ofc. [#2] completed a full search incident to arrest on the subject. In Ofc. [#2] search, she located a black circular container inside the subjects pant pockets. I retrieved this container from Ofc. [#2]as she finished searching the subject. I looked inside the container and observed multiple pills inside of it as a well as a [crystal like] substance that appeared to be methamphetamine based on my training and experience. I later called the Poison Control number and was able to identify some of the pills inside of the container. ID [#199] from the Texas Poison Control Center assisted me in identify the pills. 6 yellow circular pills with the lettering of 0.5 was later identified as Clonazepam (can cause paranoid or suicidal ideation and impair memory, judgment, and coordination.) is a benzodiazepine medication (depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures). The second pill was a white circular pill with the lettering of 5.03. This was identified as Tizanidine (it can treat muscle spasms). ID [#199] informed me that this pill is a prescribed muscle relaxer. The third pill was unable to be identified due to no insignia or lettering on it. There were 2 of these pills which were half black and half red capsules. These pills were sent off for further testing. Lastly, I later tested the [crystal like] substance using a presumptive field test kit. The test kit did show to be positive for methamphetamine as it turned dark purple in color. I later booked in and weighed all the pills and methamphetamine into the North Station property room as seized property. The total weight for all pills were as follows: Tizanidine 0.5 grams, Clonazepam 1.0 grams, and the red and black pills weighed 1.7 grams. The total weight of the methamphetamine weighed 0.01 grams. On Tuesday 07-22-25, at approximately 2359 hours (11:59 p.m.), I, Officer [#2], was dispatched to a Cutting in Progress call at [Nursing & Rehab). The call text stated that the complainant advised residents go into a fight. The suspect is cursing in the background and cut both his neck and the nurse. Upon arrival, at approximately 0002 hours (00:02 a.m.), officers [entered into] the facility, and I saw a B/M who appeared to have a few lacerations to both his left and right hands. He later identified himself as [RN-A], and he is a nurse at the location. I was told that the suspect was back in his girlfriend's room and no longer had the knife but had cut himself in the neck with the knife. When I got back to the room and [made contact with] the suspect, he was very animated and irate. I also noticed that he had several lacerations to his neck which he told me were self-inflicted. He was identified to me as [Resident #2] When I tried to ask [Resident #2] what had happened, he would not tell me anything except that it was the nurse's fault, referring to [RN-A], and that he was the reason this happened. Also in the room with [Resident #2] was his girlfriend who was laying in the bed and later identified herself as [Resident #1]. Since [Resident #2] was being uncooperative and not telling me the story of what happened, I went to the front desk where [RN-A] was to ask him what had occurred. [RN-A] told me that the whole situation started at around 1800 hours (6:00 p.m.) this evening and police had been called out at that time too. [RN-A] said that he was changing the dressing on [Resident #1's] wounds when [Resident #2] kept touching the open wound with his bare hands. Since this was not sanitary, [RN-A] advised [Resident #2] to stop and then pushed his hand away. This made [Resident #2] extremely upset and [Resident #2] called the police to try and report an assault. When officers came out, they did not find that any offense occurred and cleared the scene. Still upset about this incident earlier, [Resident #2] ended up coming after [RN-A] with a small knife while he was standing at the nurse's station. [Resident #2] did this after having an altercation with [Resident #1] and then cutting his own neck with the knife. [RN-A] stated that he did want to press charges for the Aggravated Assault and was transported by ambulance to [Local] Hospital. Officer [#1] took pictures of [RN-A's] injuries with his body worn camera. There were two other hospital personnel that stated they were also at the nurse's station with [RN-A] and witnessed the incident. The first nurse identified herself to me as [LVN-A] stated that [Resident #2] came out of his girlfriend's room extremely irate and cussing. He approached [RN-A] and began trying to slice at his face with the knife that was in his hand. [RN-A] ended up putting his hands up to block the blade from striking his face which is how he got the lacerations to his hands. The second nurse identified herself to me as [not listed on employee roster] confirmed the statements from [LVN-A] and added that [Resident #2] was telling [RN-A] that he was going to kill him as he was slashing the knife towards him. I [Ofc. #2] was then informed that there was an additional nurse who had witnessed the beginning of the incident, so I went to talk to her at this time. This nurse identified herself to me as [RN-B]. [RN-B] told me that she heard [Resident #1] screaming so she went to go see what was going on. That's when she witnessed [Resident #2], who was standing beside her bed, punching her repeatedly in the face as she was laying in bed. [RN-B] told me that she began to yell at [Resident #2] to try and get him to stop and he eventually stopped. Once [RN-B] walked away, that is when [Resident #2] grabbed the knife that was attached to his key chain and began slicing his neck before going to the nurse's station, threatening and cutting [RN-A]. When I later spoke to [Resident #1], she confirmed what [RN-B] told me, and I also observed that her face was red and swollen in several spots. I took a picture of [Resident #1's] injuries with my body worn camera. She told me that her and [Resident #2] had gotten in an argument over him trying to bring methamphetamine in the room. [Resident #1] stated that she told [Resident #2] not to bring it in because she is on probation. He then got irate and began punching her in the face several times. She was later transported to [Local hospital] by ambulance for treatment. At this time, I went back to the room where [Resident #2] was being checked out by EMS and placed him under arrest for Aggravated Assault w/Deadly Weapon. Once [Resident #2] was in handcuffs, he began becoming extremely combative. We had him sitting down in chair, but he began trying to get up and at one point got up and attempted to head butt me in the face. This is when Officer [#3], who had hold of his right arm, took him to the ground and secured his upper body while I secured his legs with body weight as taught by the training academy. [Resident #2] began kicking and resisting while still on the ground and was fighting to get out of the grasp of officers. Officer [#1] went to retrieve leg restraints so that we could better secure him and get him out to the patrol vehicle since he was refusing transport by ambulance. While waiting on the leg restraints, Officer [#3] and I continued to hold body weight on him to keep him from assaulting officers. Once Officer [#1] came back with the leg restraints, they were placed on [Resident #2]'s legs and secured. EMS provided a body tarp so that officers could more easily transport [Resident #2] to the vehicle. He was rolled onto the body tarp and picked up by me, Officer [#3], Officer [#1], and Sgt. While we were attempting to carry him on the tarp, he became physically combative again and began kicking at officers. [Resident #2] kicked me with his left foot in the right side of my jaw causing pain. Due to him kicking, we opted to take him off the body tarp and carry him ourselves so that we could secure his legs and keep him from kicking officers. Once [Resident #2] was off the tarp, Officer [#3] and Officer [#1] both grabbed one of his arms, and Sgt. and I got his feet, and we began carrying out to the patrol vehicle outside. [Resident #2] continued to resist by squirming and shrimping up his body in attempts to get officers to drop him. We had to put him down once more and attempt to carry him right side up and were finally able to get him into the back of Officer [#1]'s patrol vehicle for transport to [Local Hospital] for treatment. Once on scene at [Local Hospital], [Resident #2] was removed from the back of the patrol vehicle and taken into the hospital by nursing staff to be treated. Before being placed on the gurney, he was searched incident to arrest where officers located a small black, circular tin containing a small number of unknown pills. This item and its contents were seized for further examination. At one point while in the hospital with officers, [Resident #2] became irate again due to finding out that he was going to be charged with Aggravated Assault. At this time, he only had one hand handcuffed to the bed. When officers entered the room to handcuff the other hand to the bed, [Resident #2] began resisting and would not willingly give his hand to officers. He then pushed himself off the hospital bed and onto the floor while his left hand was still handcuffed to the railing. Nursing staff and hospital security came into assist getting him back into the bed and secured. Once he was medically cleared, he was released from the hospital. I then transported him to the [local] City Jail where he was released to the care, custody, and control of jail staff. Officer [#1] called [local] Texas Poison Control and identified two out of three of the unknown pills. He weighed them, took pictures with his body worn camera, and booked them into the [local] Station Property Room. Please see his supplement to this report regarding his identification of and booking of the substances. Officer [#1] informed me that there was 0.01g of Methamphetamine, .5g of Tizanidine, a dangerous drug, 1g of Clonazepam, and an unknown substance in a red and black capsule that weighed 1.76g. In total [Resident #2] was charged with several charges. First, Assault Family Household W/Previous Conviction for intentionally and knowingly causing bodily injury to [Resident #1] by punching her multiple times in the face. Second, Aggravated Assault W/Deadly Weapon for exhibiting a knife during the commission of an assault and cutting [RN-A] multiple times on the hands with the knife. Third, Assault on Peace Officer for intentionally and knowingly causing pain to a person he knows is a peace officer for kicking me in the jaw while officers were attempting to take him from the location into the patrol vehicle. Fourth, Resist Arrest Search Transport for intentionally obstructing a peace officer from effecting transportation by using force for kicking, squirming, and attempting to get out of the grasp of officers as we were trying to escort him into the patrol vehicle. Lastly, he was charged with the drug offenses Possession of Dangerous Drug, Poss of CS PG 3<28g, and Poss of CS PG 11 <1g for having in his care, custody, and control the Clonazepam, Tizanidine, and Methamphetamine. I seized the small knife that was used in the commission of the Aggravated Assault offense and booked it into the [Local] Station Property Room. It was booked in as item one and placed in the drop box. Hospital staff advised that the Agg Assault would have been captured on surveillance footage and will be able to retrieve it upon the request of detectives if needed. A completed Family Violence Packet was also turned into Jail Central.'Review of facility's Resident-to-Resident Altercations policy dated December 2016 reflected, 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation; b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;Review of facility's Abuse and Neglect-Clinical Protocol, dated March 2018 reflected, 2. Neglect, as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes.Record review of facility Call Lights: Accessibility and Timely Response dated 10/2022 reflected, 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light.2. All residents will be educated on how to call for help by using the resident call system.6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.5. Staff will ensure the call light is within reach of resident and secured, as needed.An IJ was identified on 07/24/25. The IJ template was provided to Administrator-B and Regional Nursing Director on 07/24/25 at 5:20 PM and a Plan of Removal was requested. The POR was accepted on 07/25/25 at 5:47PM.The POR reflected the following: Plan of Removal For F6001. Immediate Corrective Actions Taken Date/Time of IJ Notification: 7/24/25 @5:20 PM Resident Safety: Resident #1 was immediately assessed by bedside staff nurse for injuries and provided appropriate medical care; completed on 7/23/25. Resident #1 was relocated to a private room to ensure safety and prevent further incidents and call light was verified as operational; completed on 7/24/25. Roommate Removal: The male roommate involved in the assault was removed from the facility by law enforcement after evaluation by EMS on 7/23/25. BOM and Social worker provided Notice of immediate discharge to male resident via certified mail to [Local][NAME] County Jail mailed on 7/25/2025. Communication System: All residents' rooms were audited by Maintenance Super to ensure functioning call lights or alternative communication devices were present and accessible; completed 7/25/2025. Temporary communication devices (bells) were installed within reach of residents identified with malfunctioning call system until permanent solutions were in place; completed 7/25/25. Education of each resident with an alternative device (bell) was completed at time of placement by maintenance and will be documented in the EHR by DON; completed 7/25/25.________________________________________2. Systemic Corrective Measures Facility-Wide Audit: A full audit of all resident rooms was completed on 7/25/25 to verify the presence and accessibility of communication systems. Maintenance logs were reviewed by maintenance supervisor to identify any prior reports of malfunctioning call lights. An outside Vendor, was contacted to repair malfunctioning call lights/system on 7/25/25. Init[TRUNCATED]

Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for four residents (Resident #1, Resident #2, Resident #6, and Resident #7) of 83 residents reviewed for resident call system in that: The facility failed to ensure the call lights in Resident #1's and Resident #2's shared room were in working order. Resident #1 was not able to use her call light to call for help when she was physically assaulted by her roommate, Resident #2. On 07/25/25 at 11:20 AM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/26/25 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that was not immediate jeopardy due to the facility's need to monitor the implementation and the effectiveness of their Plan of Removal. The facility failed to ensure call lights were flashing outside Resident #6's and Resident #7's rooms to ensure staff knew the Residents needed assistance. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for four residents (Resident #1, Resident #2, Resident #6, and Resident #7) of 83 residents reviewed for resident call system in that: The facility failed to ensure the call lights in Resident #1's and Resident #2's shared room were in working order. Resident #1 was not able to use her call light to call for help when she was physically assaulted by her roommate, Resident #2.xOn 07/25/25 at 11:20 AM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/26/25 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that was not immediate jeopardy due to the facility's need to monitor the implementation and the effectiveness of their Plan of Removal. The facility failed to ensure call lights were flashing outside Resident #6's and Resident #7's rooms to ensure staff knew the Residents needed assistance . This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.Findings included:Record review of Resident #1's admission record, dated 07/24/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, cognitive communication deficit (communication disorder stemming from cognitive impairments that affect a person's ability to communicate effectively), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), calculus of kidney(small, hard deposit that forms in the kidneys and is often painful when passed), morbid (severe) obesity (a disorder that involves having too much body fat, which increases the risk of health problems), and paraplegia (condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body).Record review of Resident #1's care plan dated 6/13/25 reflected the resident had limited physical mobility, does not walk, used manual wheelchair for locomotion, is totally dependent on staff for repositioning and turning in bed, and totally dependent on (2) staff for transferring. Record review of Resident #2's admission record, dated 07/24/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included, a diffuse traumatic brain injury (widespread damage to the brain's white matter), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life activities), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic pain syndrome (persistent pain that last weeks to years by be caused by inflammation or dysfunctional nerves), bipolar disorder (associated with episode of mood swings ranging from depressive lows to manic highs), and antisocial personality disorder (a mental health disorder characterized by disregard for other people).Record review of Resident #2's care plan dated 6/13/25 reflected the resident requires limited assistance by (1) staff to move between surfaces, the resident does not walk, and resident uses manual wheelchair for locomotion.Record review of Resident #6's admission record, dated 7/24/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included, Depression (the elevation or lowering of a person's mood), Anxiety (intense, excessive, and persistent worry and fear about everyday situations), Cognitive Communication Deficit (difficulties in communication arising from impairments), Type 2 Diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), and Parkinsonism (clinical syndrome characterized by tremor).Record review of Resident #7's admission record, dated 7/24/25, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #7 had diagnoses which included cerebral infarction (a medical condition where brain tissue dies due to a lack of blood supply), Crohn's disease (a chronic inflammatory bowel disease that affects the lining of the digestive tract), Schizophrenia ( a disorder that affects a person's ability to think, feel, and behave clearly), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Current MDS requested for Resident #1, Resident #2, Resident #6, and Resident #7 on 07/26/25 at 2:11 PM, and reminder sent on 07/28/25 at 5:16 PM. Received MDS for Resident #1 and Resident #2 on 07/29/25 at 5:04 PM the BIMS was blank.On 07/31/25 at 6:10 AM emailed Administrator-B and Director of Clinical Services and informed the MDS' for Resident's #1 and #2 had no BIMS and if the admission MDS could be provided. On 08/06/25 at 12:07 PM an email was sent to Administrator-B, the MDS for Residents #1, #2, #6, and #7 were requested but not received.Interview on 07/24/25 at 11:04 AM with Resident #1 revealed she and Resident #2 were roommates. She stated he was her fiance. She stated another resident's friend gave Resident #2 drugs and when he came to the room to try to smoke it, she told him he could not smoke it and got upset and began to beat on her. She stated she was yelling for help, she stated RN-B came into the room and screamed for Resident #2 to stop hitting her. She stated Resident #2 did stop hitting her then EMS arrived and took her to the hospital, and she was there for about two hours then she was brought back to the facility. She stated her injuries were a black right eye, a busted upper lip, bruises to both cheeks, and a large bruise to her left breast. She stated she did not feel safe at the facility because someone else could come in the room and she could not protect herself. She stated they had not had any physical altercations in the past. She stated he had taken care of her he had never hurt her. When asked if she pushed the call light button, she stated the call light had not worked in four months. She stated she was given a bell to ring when she needed assistance, but they had put the bell on the door. She stated no one had told her she needed to keep the bell out of the drawer. Observation on 07/24/25 at 11:30 AM revealed there were two call light cords plugged into the wall in the room of Residents #1 and #2. Observation of the call light cords revealed both cords on the floor. Further observation of the room revealed a bell hanging on a short rope/string on the back of the door to the room, out of reach of the resident. Resident #1 was observed in her bed. Face to face interview with Maintence Director on 07/24/25 at 3:15 PM revealed he had been employed since late February. He stated he knew there were some call lights that were not working throughout the building. He stated he would fix the call lights then they would go out again, because the system was old. He stated if the call light was not working the residents would be given a bell to ring for help until the light could be fixed. He stated he was not sure if the call lights were working in Resident #1's and Resident #2's room. He stated when an aide would report the light was not working, he would fix the light on the spot. He stated he did not believe the light situation got to a point that he needed to notify Administrator - A. He stated there was not any room that had to have the call light fixed more than one time. He stated the staff would come to him face to face to report a call light was not working. He stated the staff could always call him on his cell phone to report issues. He stated when the call light was not working it could delay or not allow a resident to receive help. Face to face interview with Administrator-B on 07/24/25 at 3:36 PM, revealed the day was her fourth day working at the facility. She stated she was not aware Resident #1 and Resident #2 did not have a call light in their room. She stated when she found out about the call light, she was trying to move Resident #1 to another room, but she had refused to move. She stated she did not know how long Resident #1 and Resident #2 had been without a call light or any way to communicate to staff the need for assistance. She stated she did not know how the residents were supposed to let staff know they needed assistance. She stated she would assume the maintence director was responsible to ensure the call light worked in the rooms. She stated the CNAs, and nurses would be responsible to ensure the placement of the bell was in reach of the resident. She stated there was a severe risk of injury or a lack of care to the resident's when they did not have access to communication.Observation and interview on 07/25/25 with Resident #6 at 12:54 PM, revealed when asked to push her call light, the light did not flash above her door. Staff were observed walking throughout the hall, but no one came to Resident #6's room until they were notified in person by the investigator the resident had pushed the call light. Observation and interview with Resident #7 on 07/25/25 at 1:05 PM, revealed Resident #7 was asked to push his call light and the light did not flash above his door. Resident #7 stated he thought the light was working properly. Staff were observed walking throughout the hall, but no one came to Resident #7's room until they were notified in person by the investigator the resident had pushed the call light. In an interview with the Regional Director of Clinical Services on 07/26/25 at 2:15 PM, she stated she was not aware that the resident's (Resident #1 and Resident #2) call light was not working, she stated Resident #1 informed her and wrote a statement that the bell provided to her was in the drawer next to her bed. She stated the maintence director would have been responsible to ensure the call lights were working. She stated it would be the responsibility of the nursing staff to let the maintence director know when the lights are not working. She and the maintence director checked the lights in the rooms of Resident's #6 and #7 and the notification was going to the board at the nurses station, but the light was not lighting up outside the door. She stated Resident #1 was moved to a room with a working call light and Resident #2 was taken to jail and given a discharge notice. She stated if a resident's call light was not working it could delay their care.In a telephone interview with RN-B on 07/26/25 at 6:15 PM, reflected she was aware some of the call lights were not working but she was not sure how long the lights had been out. She stated she thought the administrator and maintence knew the lights were not working but she had not checked with them. She stated when a resident's call light did not work, it could cause the resident to not receive proper care.Record review of Call Light and Communication Device dated/revised 7/25/25, reflected All staff are responsible for responding promptly to resident call lights and communication devices. The facility shall maintain functional systems for resident communication and implement escalation procedures when systems fail, or response times are inadequate.Procedure1. Resident Education Upon admission and as needed, residents will be educated on: The purpose and use of the call light system. The importance of [keeping the call light within reach at all times]. How to request assistance using the call light or other communication devices.2. Call Light Accessibility Staff must ensure the call light is: Within easy reach of the resident [at all times]. Positioned appropriately after any care, repositioning, or transfer. Available in both the bedside and restroom areas.3. Response Expectations All call lights must be answered promptly, ideally within 5 minutes. If the responding staff member is not the assigned caregiver, they must: Address the need if within their scope. Notify the appropriate caregiver immediately if not.4. Escalation ProtocolIf a call light is not answered within 10 minutes or a communication device is non-functional:5. Backup MeasuresIn the event of call light system failure or during power outages: Place manual bells or battery-operated call devices at: Each resident's bedside. Each resident-accessible restroom. Implement Q15-minute visual safety rounds to assess resident needs. Document each round in the designated log.An IJ was identified on 07/25/25. The IJ template was provided to Administrator-B and Regional Nursing Director on 07/25/25 at 11:20 AM and a Plan of Removal was requested. The POR was accepted on 07/25/25 at 5:47PM.The POR reflected the following:Plan of Removal For F9191. Immediate Corrective Actions Taken Date/Time of IJ Notification: 7/25/25 @11:20 AM Resident Safety: Resident #1 was immediately assessed by bedside staff nurse for injuries and provided appropriate medical care; completed on 7/23/25. Resident #1 was relocated to a private room to ensure safety and prevent further incidents and call light was verified as operational; completed on 7/24/25. Roommate Removal: The male roommate involved in the assault was removed from the facility by law enforcement after evaluation by EMS on 7/23/25. BOM and Social worker provided Notice of immediate discharge to male resident via certified mail to [NAME] County Jail mailed on 7/25/2025. Communication System: All residents' rooms were audited by Maintenance Super to ensure functioning call lights or alternative communication devices were present and accessible; completed 7/25/2025. Temporary communication devices (bells) were installed within reach of residents identified with malfunctioning call system until permanent solutions were in place; completed 7/25/25. Education of each resident with an alternative device (bell) was completed at time of placement by maintenance and will be documented in the EHR by DON; completed 7/25/25.2. Systemic Corrective Measures Facility-Wide Audit: A full audit of all resident rooms was completed on 7/25/25 to verify the presence and accessibility of communication systems. Maintenance logs were reviewed by maintenance supervisor to identify any prior reports of malfunctioning call lights. An outside Vendor, Summit Fire and Security was contacted to repair malfunctioning call lights/system on 7/25/25. Initial visit will occur on Monday 7/28/25. Staff Training: All staff will receive re-education on: Resident rights to a safe environment (F600). Proper placement and testing of communication devices (F919). Immediate reporting and escalation procedures for malfunctioning equipment. Started on 7/23/25; ongoing until all staff educated; no staff will be allowed to work their next shift until completed; education by ADON/DON; PRNs via phone if needed. Included education:- Call lights must be in reach and operational. If found to be inoperable then must immediately notify the administrator, DON and Maintenance Supervisor.- Implement an alternate call system; including Q15 min checks until provided.- Maintenance will provide manual bell and education to resident for use until malfunctioning issue is resolved. - Must take manual bell to restroom with resident and place in reach, if toileting is needed and then ensure it is returned to bedside and in reach once done in restroom. Monitoring and Oversight: A designated staff member (e.g., DON or Maintenance Supervisor) will conduct daily rounds for 14 days to ensure compliance; started 7/25/25. Random weekly audits by DON will continue for 4 weeks. Results will be reviewed in QAPI by administrator/DON for 3 months starting with adhoc on July 30th.3. Prevention of Recurrence Resident Interviews: All residents were interviewed to ensure they feel safe and have access to communication systems; started Safe surveys by social worker started on 7/23/25. Ongoing Staff Education: Monthly in-services on abuse prevention, neglect, and emergency response. Next all-staff in-service scheduled for Friday August 8th, 2025. 4. Verification of Compliance Documentation: Audit logs, training rosters, and maintenance reports will be maintained and available for review. Follow-Up: The Administrator and Director of Nursing will verify completion of all corrective actions.Monitoring of the facility plan of removal was as follows: Record review at 9:00 AM on 07/26/25 of facility POR training with staff dated 7/23/25 thru 7/26/25, reflected, the training consisted of ensuring the call light was within reach and operational, if call light was found to be inoperable then DON and Maintenance Supervisor should be notified immediately, and an alternate call system should be implemented including Q15 min. checks until provided. The maintenance staff would provide a manual bell and the resident would be educated to use the bell until the malfunctioned issue was resolved. Staff should remind the resident to take the manual bell with them when toileting and it should be kept until they had returned to their bed.Observation of Resident #1's current room on 07/26/25 revealed she had a working call light. Resident #1 was not in the building at the time of this observation. Interview with CNA-C on 07/26/25 at 10:00 AM reflected she had received training on how to work the call light system, she stated she had not been received training that she needed to check the rooms on hall 200 Q shift when she started her shift on 07/26/25.Interview with CNA-D on 07/26/25 at 10:10 AM reflected she was trained on the call lights, she stated she was told to check rooms every 15 minutes on hall 200 because the residents were not cognitive enough to know how and wen to use the call lights. Interview with CNA-E on 07/26/25 at 11:34 AM, reflected she received training on answering the call lights, when a residents call light was out, she should notify the charge nurse and maintence, provide the resident with a bell and do 15-minute checks on the resident. Additional interview with Interview with CNA-C on 07/26/25 at 11:50 AM, reflected she had been trained to check all rooms on 200 hall every 15-minutes because they may not understand how to use the light, and residents on other halls if a light was not working she would notify the charge nurse and maintence and provide a bell for the resident to notify her when they need help. Interview with LVN-C on 07/26/25 at 12:10 PM reflected, she had received an in-service training on answering the call light, if the light was not working she should check the rooms every 15-minutes and give the resident a bell and notify maintence.Interview with LVN-D on 07/26/25 at 12:23 PM reflected, she had been trained on what to do if the call light was not working, she needed to notify the administrator, the DON, and the maintence director, do 15-minute checks on the resident and provide the resident with a bell and make sure the bell is within reach and not in a drawer. Interview with CNA-G on 07/26/25 at 12:33 PM reflected, she had been trained to make sure the call lights were working and in reach, if the light was not working she must notify the administrator, DON, and maintence, give the resident a bell and make sure it is within reach and when the resident went to the bathroom to make sure the bell was with them if she stepped out of the room, if the resident cannot use the bell to make 15-minute checks in the room. Interview with CNA-H on 07/26/25 at 12:41 PM reflected, she had been trained to provide a bell to the resident if the call light was not working, she should notify the administrator and maintence, the call light should be in reach of the resident, if the light did not work to give the resident a bell and do 15 minute checks to make sure the resident was okay, and make sure the resident had to bell with them if in the bathroom. Interview with CNA-I on 07/26/25 at 12:48 PM reflected, she had been trained to make sure the call light was in reach, if the light was not working to get the resident a bell, notify the administrator and maintence to fix the light, if the resident has a bell make sure the bell is accessible to the resident and not in a drawer, if the resident went to the bathroom to make sure they had the bell. Interview with CNA-J on 07/26/25 at 12:55 PM, reflected she received training that if a call light was not working, she should contact maintence, give the resident a bell and make sure it stayed within reach, and if the resident went to the bathroom wait for them or provide a bell, do 15-minute checks. Interview with LVN-E on 07/26/25 at 1:12 PM, reflected she had been in-serviced on call lights, if they were not working she should notify the administrator, DON and maintence, she should check on the resident every 15-minutes, give the resident a bell and educate the resident to always keep the bell with them. Interview with CNA-K on 07/26/25 at 1:18 PM, reflected he had received training on the call light, that it should be answered by everyone, if the light was not working to report it to the nurse who would give a bell for resident to use, the resident should be checked every 15-minutes until the light is fixed. Interview with LPN-F on 07/26/25 at 1:24 PM, reflected she had received training on the call lights that if she noticed the light was not working, she should give the resident a bell and notify the administrator, the resident should be checked every 15-minutes to ensure safety, if they went to the bathroom to take the bell. Interview with MA-G on 07/26/25 at 1:32 PM, reflected she had received in-service on call lights, if the light was not working, she should notify the DON, administrator, and maintence, give the resident a bell, if the resident cannot use the bell to do 15-minute checks until the light was fixed. Observation of Hall 200 on 07/26/25 from 1:45 PM to 2:15 PM revealed CNA's C and D had walked in rooms in 15-minute intervals. Telephone call from RN-B on 07/26/25 at 6:15 PM, reflected she had received additional training on making sure the call light was within reach of the resident, if the light was not working to provide a bell within reach and notify the nurse and maintence. Review of the facility abuse, and neglect in-service dated 07/23/25-07/26/25 reflected all facility staff had been in-serviced prior to shift on abuse and neglect. An Immediate Jeopardy (IJ) was identified on 07/25/25 at 11:20 AM. While the IJ was removed on 07/26/25 at 2:35 PM the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy.

Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #3) of three residents reviewed for pharmacy services. The facility failed to administer all physician ordered doses of Rifaximin (medication to treat liver failure) to Resident #3 between 01/09/25 - 01/20/25. The failure could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort.An Immediate Jeopardy ( IJ) was identified on 06/05/25. Findings demonstrate that the Immediate Jeopardy began on 01/09/25 and was removed on 01/20/25. The noncompliance continued at a Pattern of Potential for More than Minimal harm that is not Immediate jeopardy.Findings included: Record review of Resident #3's quarterly MDS assessment dated [DATE], reflected she was a [AGE] year-old female who admitted on [DATE]. She had a BIMS score of 13, which indicated she was cognitively intact. The resident's diagnoses included a diagnosis of liver cirrhosis (permanent scarring of the liver) and hepatic encephalopathy (happens when your liver is not filtering toxins as it should. These toxins build up in your blood and affect your brain, causing confusion, disorientation, and other changes.)Record review of Resident #3's January 2025 Physician Orders reflected the following:Start Date 01/09/25 Rifaximin Oral Tablet 550 milligrams two times a day for Hepatic Encephalopathy.Record review of Resident #3's January 2025 Medication Administration Record reflected she had not received Rifaximin on the following dates:01/09/25 4:00 PM - Medication not available from pharmacy - MA H01/10/25 4:00 PM - Medication not available from pharmacy - MA H01/12/25 8:00 AM and 4:00 PM - Medication not available from pharmacy - MA F01/13/25 4:00 PM - Medication not available from pharmacy - MA H01/14/25 8:00 AM and 4:00 PM - Medication not available from pharmacy - MA G01/16/25 4:00 PM - Medication not available from pharmacy - MA H01/17/25 4:00 PM - Medication not available from pharmacy - MA H01/18/25 8:00 AM and 4:00 PM - Medication not available from pharmacy - MA F01/19/25 8:00 AM and 4:00 PM - Medication not available from pharmacy - MA F01/20/25 8:00 AM - MA G and 4:00 PM - Medication not available from pharmacy - MA H Record review of Resident #3's Hospital Records, dated 01/23/25, reflected:The patient was a 60-year -old female with history of cirrhosis came to emergency room after family member had concern for medical management at nursing home. Per family member, patient was newly admitted to this nursing home. She got a call from the nursing home that the patient was found on floor but was doing ok. The family member went to check on the patient and noticed that she had not been getting any meds for three weeks and the patient was confused. An interview on 06/04/25 at 9:45 AM with the family member for Resident #3 revealed the resident was in the hospital and while she was at the facility in January 2025, she missed doses of her medication. The resident admitted to the hospital on [DATE] and discharged on 01/27/25. The resident was sent to a different hospital on [DATE].An interview on 06/05/25 at 10:30 with RN I revealed she did not remember issues with the Rifaximin order for Resident #3 in January 2025. She said if a medication was not available, then the staff would contact the pharmacy to deliver it. RN I said the physician had to be notified if a medication was not available to give to anyone.n interview on 06/05/25 at 10:35 AM with MA F revealed she did not remember passing medication to Resident #3 in January 2025. She said if she documented that she was waiting on the medication from the pharmacy, then she would have told the nurse. She said she only worked weekend shifts. Interviews were attempted on 06/05/2025 with the Medication Aides who were scheduled:MA H on 06/05/25 at 11:15 AM did not return call of the Surveyor.MA G on 06/05/25 at 11:45 AM when MA G hung up the phone on the Surveyor.An interview on 06/04/25 at 2:30 PM with the Physician who was no longer employed with the facility stated he did not remember Resident #3 and was no longer employed at the facility. He said if he had been notified that the Rifaximin was not available, then he would have ordered a different medicine for the resident. The physician said if the resident did not receive the medication it could result in altered mental status. An interview on 06/04/25 at 11:40 AM with the DON revealed she did not work at the facility in January 2025.Record review of the only facility's policy received and was titled, Documentation of Medication Administration, revised April 2007, reflected the following:Policy StatementThe facility shall maintain a medication administration record to document all medications administered.Policy Interpretation and Implementation1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR).2. Administration of medication must be documented immediately after (never before) it is given.3. Documentation must include, as a minimum:a. Name and strength of the drug;b. Dosage;c. Method of administration (e.g., oral, injection (and site), etc.);d. Date and time of administration;e. Reason(s) why a medication was withheld, not administered, or refused (as applicable);f. Signature and title of the person administering the medication; andg. Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.). The facility initiated the following interventions prior to surveyor entry on 05/31/25.Record review revealed Resident #3 was discharged from the facility 05/30/25. Review of Resident #1 and Resident #2's MARs revealed that they did not have any issues with their medications being unavailable.Interviews with staff (ADON, 1 RN, 1 LVN, Regional DON, Interim DON and 1 MA) on 06/04/25 from 11:10 AM - 06/05/25 to 1:30 PM revealed that staff were knowledgeable on the procedure to follow if a medication was not available. An Immediate Jeopardy (IJ) was identified on 06/05/25. Findings demonstrate that the Immediate Jeopardy began on 01/09/25 and was removed on 01/20/25. The noncompliance continued at a Pattern of Potential for More than Minimal harm that is not Immediate Jeopardy.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 2 residents (Residents #1) reviewed for ADL care. The facility failed to ensure Residents #1 was repositioned every 2 hours on 06/04/25, resulting in moisture associated damage to Resident #1's right and left buttocks. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.Findings included: Review of Resident #1's Annual MDS Assessment, dated 04/08/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were severely impaired. The resident had a supra-pubic catheter (catheter inserted into the bladder to drain urine) a colostomy (bag attached to the abdomen to collect bowel movement that excretes from the stoma), and a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, also known as the trachea. Surgeons place a tracheostomy tube into the hole to keep it open for breathing). His diagnoses included stroke, kidney failure, diabetes, and quadriplegia (inability to move arms and legs). The resident was dependent on staff for rolling on back to left and right side and return to lying on back on the bed. The resident did not have any skin conditions listed. Review of Resident #1's Care Plans reflected:Revised 07/01/24 - Resident had an activities of daily living deficit.Facility interventions: The resident was totally dependent on staff for repositioning and turning in bed.12/02/24 - Risk for Impaired Skin IntegrityFacility interventions: Evaluate skin integrity Review of Resident #1's Care Plan, last revised 05/20/25 reflected the following focus, goal, and interventions were in place: - Focus: Resident #1 has potential/actual impairment to skin integrity to bilateral buttocks gran 100% tx per MD ORDER 05/03/23. Goal: Resident #1 Skin will remain intact 03/04/25. Interventions: . Involve/educate resident and/or family/designee Monitor for s/s of infection Monitor pain and administer pain medications/treatments as ordered and/or per pain problem- Focus: . Left buttocks clean area with NS. Pat dry with 4x4. Apply house barrier cream twice daily and PRN if soiled until resolved. 0.8 x 0.7 x 0.1cm Right buttocks Left buttocks clean area with NS. Pat dry with 4x4. Apply house barrier cream twice daily and PRN if soiled until resolved. 2.8 x 0.8 x not measurable in CM 06/05/25.Goal: Wound Will Be Free of Signs or Symptoms of Infection Wound Will Show Signs of Improvement 06/05/25.Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown Inform the resident/family/caregivers of any new area of skin breakdown Notify provider if no signs of improvement on current wound regimen Provide wound care per treatment order- Focus: Resident #1 has an ADL Self Care Performance Deficit r/t Quadriplegia on Restorative LOW AIRLOSS MATTRESS/CHECK FORFUNCTION EVERY SHIFT 05/03/23, revised 05/23/25. Review of Resident #1's BRADEN - Scale for Predicting Pressure Sore Risk was completed on 05/04/25 and indicated Resident #1 was at a high risk for developing pressure sores. An observation and interview on 06/04/25 at 1:45 PM with Resident #1 revealed CNA A was getting ready to perform incontinence care. The resident was awake, alert, and non-verbal. The resident had a supra-pubic catheter and a colostomy. CNA A washed her hands and put on gloves. The resident was not wearing a brief. CNA A cleaned the penis and scrotal area. The resident was rolled to his left side. His buttocks and the back of his thighs were dark red/purple. He had draining wounds on his buttocks that had drained onto the sheets down to the mattress. There was a moderate amount of tan and black drainage. CNA A cleaned the wounds and buttocks. There were 2 open areas, one on each buttock. An interview on 06/04/25 at 2:05 PM with the WCN revealed she was not aware of the wounds on Resident #1, and no one had notified her about the wounds. She said she started a skin sweep (skin assessment of residents) in the building to look for skin issues but had not assessed Resident #1. The WCN said staff were supposed to notify her about the wounds. The WCN measured the wounds:Left 1st toe 0.5 cm x 0.2 cm Right 1st toe 0.6 cm x 0.5 cm Right buttock 1.5 cm x 2.0 cm Left buttock 2.5 cm x 3.0 cm An interview on 06/04/25 at 2:10 PM with CNA B revealed she was assigned to Resident #1 for the 6:00 AM - 2:00 PM shift on 06/04/25. She said the last time she repositioned the resident was between 8:00 AM - 9:00 AM and she saw the wounds on his buttocks. She said she did not tell the nurse about the wounds, because the nurse already knew about the wounds. CNA B said she was supposed to reposition residents every two hours, but she got busy and was not able to reposition the resident after 8:00 AM - 9:00 AM. CNA B said she could ask for help, but another CNA was already helping her. CNA B said if a resident was not repositioned every two hours, then they could develop wounds. In an observation 0n 07/02/2025 at 08:21AM with the Wound Care Doctor of Resident #1 revealed moisture related skin breakdown with some excoriation observed to the resident's sacrum and buttocks. Excoriation area measured by the wound doctor to left buttock 0.6 x 0.7 x N/A and right buttock 1.8 x 0.8x N/A.No open areas noted. A pressure relieving mattress was observed. Resident #1's Nurse's Notes for June 2025 reflected the following:06/04/25: Called to resident room . 3. Open area to left buttocks with 2.5c. x 3.0cm outer slight discoloration and inner 1.5cm x 2.0cm x 0.2cm with scant amount of serous drainage noted. 4. open area to right buttocks outer slight discoloration area noted 1.5cm x 2.0cm with inner open area noted to be 1.3cm x 1.6cm x 0.2cmC06/04/25: Notified wound care physician Dr. [Name] and Primary contact [Name] of patient status change and areas to left and right buttocks and left and right great toe. Resident #1's Physician's Orders for June 2025 reflected the following: o Right buttock clean area with NS. Pat Dry with 4x4. Apply collagen and anasept mixture and cover bordered gauze qd and PRN if soiled until resolved. o Right buttock clean area with NS. Pat Dry with 4x4. Apply collagen and anasept mixture and cover bordered gauze qd and PRN if soiled until resolved. o Left buttocks clean area with NS. Pat dry with 4x4. Apply barrier cream twice daily. Start date 06/18/25. o Right buttocks clean area with NS. Pat dry with 4x4. Apply barrier cream twice daily. Start date 06/18/25.In an interview on 07/02/25 at 9:25AM, the DON stated Resident #1 was totally bed-bound. On 07/02/25 between 9:25AM and 9:35AM, interviews with Resident #1 assigned Charge Nurses and CNAs revealed they were aware of the interventions in place for Resident #1 to maintain skin integrity and prevent any new skin issues. It was reported that Resident #1 was completely bed-bound. In an interview on 07/02/25 at 8:56AM, the Wound Care Physician confirmed he had been providing treatment for both Resident #1. Wound Care Physician stated he felt very confident in the fact that Resident #1 did not have pressure ulcers. He stated Resident #1 had moisture-associated skin damage to his buttocks. He stated both areas were being treated and were improving. The Wound Care Physician stated these types of wounds/skin damage were very common in individuals with similar comorbidities as Resident #1; he did not feel as though any of these wounds/skin damage were caused by a lack of care and/or negligence. He stated he did not feel as though there was likely anything the facility could have done to prevent these wounds/skin damage from occurring. He said they likely occurred in a short amount of time before being first noticed by the surveyor/facility, and they could have occurred during a transfer, due to friction, etc. On 07/02/25 at 10:00AM, Resident #1's physician confirmed he had been providing care for both residents. Regarding Resident #1, the physician stated he was totally bed-bound. He stated he did not think there was anything the facility could have done differently to prevent the wounds/skin damage that Resident #1 had obtained (which were likely obtained due to his comorbidities). The physician stated the facility had been consistently putting interventions in place for residents to maintain their skin integrity/prevent new skin issues; he had no concerns regarding the facility or the treatment provided related to wounds. Record review of the facility policy, Repositioning, revised May 2013, reflected:1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief.2. Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals.3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.4. The care plan for a resident at risk of friction or shearing during repositioning may require the use oflifting (sic)[offloading] devices for repositioning.5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing . Review of the facility's policy titled Activities of Daily Living (ADL), Supporting last revised March 2018, reflected: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary tomaintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. 6. Interventions to improve or minimize a residents functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (Residents #1 and #2) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 did not develop wounds on his toes and moisture associated skin damage on his buttocks. 2. The facility failed to ensure Resident #1 and Resident #2 were repositioned every two hours on 6/4/25. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment.Findings included:1. Review of Resident #1's Annual MDS Assessment, dated 04/08/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were severely impaired. The resident had a supra-pubic catheter (catheter inserted into the bladder to drain urine) a colostomy (bag attached to the abdomen to collect bowel movement that excretes from the stoma), and a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, also known as the trachea. Surgeons place a tracheostomy tube into the hole to keep it open for breathing). His diagnoses included stroke, kidney failure, diabetes, and quadriplegia (inability to move arms and legs). The resident was dependent on staff for rolling on back to left and right side and return to lying on back on the bed. The resident did not have any skin conditions listed. Review of Resident #1's Care Plans reflected:Revised 07/01/24 - Resident had an activities of daily living deficit.Facility interventions: The resident was totally dependent on staff for repositioning and turning in bed.12/02/24 - Risk for Impaired Skin IntegrityFacility interventions: Evaluate skin integrity. Review of Resident #1's Care Plan, last revised 05/20/25 reflected the following focus, goal, and interventions were in place:- Focus: Resident #1 has potential/actual impairment to skin integrity to bilateral buttocks gran 100% tx per MD ORDER 05/03/23. Goal: Resident #1 Skin will remain intact 03/04/25. Interventions: Elevate heels off the bed Involve/educate resident and/or family/designee Monitor for s/s of infection Monitor pain and administer pain medications/treatments as ordered and/or per pain problem- Focus: Wound Management Apply betadine toes qd shift and monitor for sign/symptoms of infection. Apply qd until resolved. right 1st toe 0.75 x 0.5 x nm in cm. Left buttocks clean area with NS. Pat dry with 4x4. Apply house barrier cream twice daily and PRN if soiled until resolved. 0.8 x 0.7 x 0.1cm Right buttocks Left buttocks clean area with NS. Pat dry with 4x4. Apply house barrier cream twice daily and PRN if soiled until resolved. 2.8 x 0.8 x not measurable in CM 06/05/25.Goal: Wound Will Be Free of Signs or Symptoms of Infection Wound Will Show Signs of Improvement 06/05/25.Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown Inform the resident/family/caregivers of any new area of skin breakdown Notify provider if no signs of improvement on current wound regimen Provide wound care per treatment order- Focus: Resident #1 has an ADL Self Care Performance Deficit r/t Quadriplegia on Restorative (having the ability to restore health, strength, or a feeling of well-being.) LOW AIRLOSS MATTRESS/CHECK FOR FUNCTION EVERY SHIFT 05/03/23, revised 05/23/25. Review of Resident #1's BRADEN - Scale for Predicting Pressure Sore Risk completed on 05/04/25 indicated Resident #1 was at a high risk for developing pressure sores. An observation and interview on 06/04/25 at 1:45 PM with Resident #1 revealed CNA A was getting ready to perform incontinence care. The resident was awake, alert, and non-verbal. The resident had a supra-pubic catheter and a colostomy. CNA A washed her hands and put on gloves. The resident was not wearing a brief (for an unknown reason) CNA A cleaned the penis and scrotal area. The resident was rolled to his left side. His buttocks and the back of his thighs were dark red/purple. He had draining wounds on his buttocks that had drained onto the sheets down to the mattress. There was a moderate amount of tan and black drainage. CNA A cleaned the wounds and buttocks. There were 2 open areas, one on each buttock. CNA A said she did not know why there was not a dressing on the wounds. CNA A finished cleaning the buttocks and grabbed a clean brief and placed it under the resident. The resident also had a wound on the tip of both his first toes. The wounds were scabbed and very small. An interview on 06/04/25 at 2:05 PM with the WCN revealed she was not aware of the wounds on Resident #1, and no one had notified her about the wounds. She said she started a skin sweep (skin assessment of residents) in the building to look for skin issues but had not assessed Resident #1. The WCN said staff were supposed to notify her about the wounds. The WCN measured the wounds:Left 1st toe 0.5 cm x 0.2 cm - Stage IIRight 1st toe 0.6 cm x 0.5 cm - Stage IIRight buttock 1.5 cm x 2.0 cm - Stage IILeft buttock 2.5 cm x 3.0 cm - Stage II An interview on 06/04/25 at 2:10 PM with CNA B revealed she was assigned to Resident #1 for the 6:00 AM - 2:00 PM shift on 06/04/25. She said the last time she repositioned the resident was between 8:00 AM - 9:00 AM and she saw the wounds on his buttocks. She said she did not tell the nurse about the wounds, because the nurse already knew about the wounds. The WCN was in the room and told CNA B that she was never made aware of the wounds. CNA B said the resident's wounds were not draining when she repositioned him. CNA B said she was supposed to reposition residents every two hours, but she got busy and was not able to reposition the resident after 8:00 AM - 9:00 AM. CNA B said she could ask for help, but another CNA was already helping her. CNA B said if a resident was not repositioned every two hours, then they could develop wounds. In an interview on 06/05/25 at 11:50 AM LVN C said he was assigned to Resident #1 on 06/04/25. He said he did not know about the wounds and did not do a skin assessment. In an observation on 07/02/2025 at 08:21AM with the Wound Care Doctor of Resident #1 revealed a dark scab was noted to left big toe and a smaller scab to tip of right big toe with no redness noted to the surrounding skin. Moisture related skin breakdown with some excoriation (a raw irritated lesion (as of the skin or a mucosal surface) was observed to the resident's sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) and buttocks (either of the two round fleshy parts that form the lower rear area of a human trunk.). Excoriation area measured by the wound doctor to the left buttock was 0.6 x 0.7 x N/A and right buttock was 1.8 x 0.8x N/A. No open areas were noted. A pressure relieving mattress was observed. Review of Resident #1's Nurse's Notes for June 2025 reflected the following:06/04/25: Called to resident room. Noted 1. left great toe intact scab measuring 0.5cm x0.2cm with no redness or drainage noted. No increased warmth noted to touch. 2.Right great toe noted intact scabbed area 0.6cm x 0.5cm with no drainage/no redness/ and no increased warmth to the touch. 3. Open area to left buttocks with 2.5c. x 3.0cm outer slight discoloration and inner 1.5cm x 2.0cm x 0.2cm with scant amount of serous drainage (thin, watery fluid, often clear or pale yellow, that occurs during the normal healing process of a wound) noted. 4. open area to right buttocks outer slight discoloration area noted 1.5cm x 2.0cm with inner open area noted to be 1.3cm x 1.6cm x 0.2cm06/04/25: Notified wound care physician and Primary contact of patient status change and areas to left and right buttocks and left and right great toe. Review of Resident #1's Physician's Orders for June 2025 reflected the following:o Apply skin prep to toes qd shift and monitor for sign/symptom of infection. Apply qd until resolved left great toe, everyday shift for wound care. Start Date is 06.05.25 End Date is blank.o Apply skin prep to toes qd shift and monitor for sign/symptom of infection. Apply qd until resolved right great toe, everyday shift for wound care. Start Date is 06.05.25 End Date is blank.o Right buttock clean area with NS. Pat Dry with 4x4. Apply collagen and anasept mixture and cover bordered gauze qd and PRN if soiled until resolved.o Left buttock clean area with NS. Pat Dry with 4x4. Apply collagen and anasept mixture and cover bordered gauze qd and PRN if soiled until resolved. o Apply betadine to toes qd shift and monitor for sign/symptoms of infection. Apply qd until resolved. Right great toe. Start date 06/26/25.o Apply betadine to toes qd shift and monitor for sign/symptoms of infection. Apply qd until resolved. left great toe. Start date 06/26/25.o Left buttocks clean area with NS. Pat dry with 4x4. Apply barrier cream twice daily. Start date 06/18/25. Right buttocks clean area with NS. Pat dry with 4x4. Apply barrier cream twice daily. Start date 06/18/25. An interview on 06/04/25 at 3:15 PM with the DON revealed she did not know Resident #1 had wounds. She said if a CNA saw a wound on a resident, then they were supposed to notify the nurse. The DON said staff were supposed to reposition residents every two hours. 2. Review of Resident #2's Annual MDS Assessment, dated 04/24/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making were severely impaired. The resident had a Foley catheter (catheter to drain urine from the bladder) and was always incontinent of bowel movement. Her diagnoses included stroke, diabetes, and non-Alzheimer's disease (form of dementia). The resident was dependent on staff for rolling on back to left and right side and return to lying on back on the bed. Review of Resident #2's Care Plans reflected:Revised 08/02/24 - Resident had an activities of daily living performance deficit related to contracture to upper/lower extremities, non-verbal, history of stroke and total assist with all ADLs.Facility interventions included:Bed mobility: the resident required total assist by one staff.There was not a care plan for repositioning. Review of Resident #2's care plan, undated, reflected:Focus: The resident has Peripheral artery disease with non-healing ulcer of left 1st toe 3/11/2024 angiogram outpatient surgery procedure- 1. left superficial; femoral artery atherectomy, angioplasty 2. left posterior tibial artery atherectomy, angioplasty 3. left anterior tibial artery atherectomy, angioplasty NP will f/u with in 1-2 weeks Plavix n/o vascular NP do follow ups and schedule appt as needed 03/12/25, revised 04/16/25.Goal: [Resident #2] will remain free of complications related to PVD through review date. [Resident #2's] extremities will be free from pain, pallor, rubor, coldness, edema and skin lesions. 03/12/25.Interventions: Give medications for improved blood flow or anticoagulants as ordered Monitor the extremities for s/sx of injury, infection or ulcers. Monitor/document/report to MD PRN any s/sx of complications of extremities: coldness of extremity, pallor, rubor, cyanosis and pain. Monitor/document/report to MD PRN any s/sx of skin problems related to PVD: Redness, Edema, Blistering, Itching, Burning, Bruises, Cuts, other skin lesions. An observation on 06/04/25 at 1:20 PM of incontinence care for Resident #2 by CNA B and CNA D revealed both CNAs washed their hands and put on gloves. CNA D cleaned the peri-area and the buttocks. CNA D placed a clean brief under the resident and began straightening her sheets. The resident did not have any wounds. The staff repositioned the resident. An interview on 06/04/25 at 1:30 PM with CNA D revealed the last time Resident #2 was repositioned was at the time of the incontinence care. An interview on 06/04/25 at 1:35 PM with CNA B revealed the last time Resident #2 was repositioned was at the time of the incontinence care. An interview on 06/04/25 at 2:20 PM with a family member of Resident #2 revealed the resident was supposed to be repositioned every two hours. The family member had a camera in the room and said the resident was repositioned at 9:54 AM and 1:20 PM on 06/04/25. An interview on 06/04/25 at 3:05 PM with CNA B revealed she was assigned to Resident #2 on 06/04/25 for the 6:00 AM - 2:00 PM shift. She said she was not able to reposition Resident #2 every two hours because she was very busy. She said she did not reposition Resident #1 and Resident #2 every two hours and those were the only two residents who did not get repositioned. She said she was too busy to reposition them and the risk to the residents was wound development. Observation on 07/02/25 at 8:21 AM of Resident #2 revealed a healed scab to the right second and fourth toe. There were no open areas or signs/symptoms of infection. A pressure relieving mattress was observed. Review of Resident #2's Nurse's Notes for the month of June 2025 reflected she had a history of wounds to her toes (likely vascular related), dating back to 07/2024:06/16/25: Resident observed with small, reopened sore on the 4th toe, assessment completed, mild bleeding, no indication of pain. Site cleaned with NS, dry dressing applied. Notify wound care nurse for wound care consult. RP family member in the room.06/16/25: Resident observed with small, reopened sore on the 4th toe, assessment completed, mild bleeding, no indication of pain. Site cleaned with NS, dry dressing applied. Notify wound care nurse for wound care consult. NP and DON made aware. RP family member in the room.06/18/25: Wound care rounds made with wound care physician. New order change dressing to M-W-F. Notified facility DON and will notify the POA at this time.06/18/25: Spoke with POA via phone and updated on new toe wound treatment schedule. Resident #2's Physician's Orders reflected the following:- Resident to have pressure off loading boots on while in bed. Every Shift. Start date 01/15/25.- Clean right 2nd toe with NS and pat dry. Apply skin prep qd until resolved. Every day shift for wound care. Start date 06/26/25.- Wound care consult. One time a day every Wed for Wound care. Start date 06/18/25.- Weekly skin assessment every Monday 6-2 shift. Every day shift every Mon for skin assessment. Start date 07/15/24. In an interview on 07/02/25 at 8:56AM, the Wound Care Physician confirmed he had been providing treatment for both Resident #1 and Resident #2. Regarding Resident #1, the Wound Care Physician stated he felt very confident in the fact that Resident #1 did not have pressure ulcers. He stated Resident #1 had an arterial wound to his toe, as well as moisture-associated skin damage to his buttocks. He stated both areas were being treated and were improving. The Wound Care Physician stated these types of wounds/skin damage were very common in individuals with similar comorbidities as Resident #1; he did not feel as though any of these wounds/skin damage were caused by a lack of care and/or negligence. He stated he did not feel as though there was likely anything the facility could have done to prevent these wounds/skin damage from occurring. He said they likely occurred in a short amount of time before being first noticed by the surveyor/facility, and they could have occurred during a transfer, due to friction, etc. Regarding Resident #2, the Wound Care Physician stated he felt very confident in the fact that Resident #2 did not have pressure ulcers, either. He stated Resident #2 had a recently resolved superficial wound to her toe. The Wound Care Physician said Resident #2 had a history of superficial/vascular wounds to her toes; she had a history of hitting her toes on the side of the bed. He stated this was not too concerning, as the areas resolved rather quickly. He stated she had been seen by a vascular specialist and no treatment was recommended. He stated he had not ordered a cradle to help keep her feet free from the bed linens, as he did not see a need at the current time. In an interview on 07/02/25 at 9:25AM, the DON stated Resident #1 was totally bed-bound and Resident #2 got out of bed for four hours every Tuesday, Thursday, and Saturday per her family's request. When Resident #2 was out of bed, she still received positioning adjustments and incontinence care at least every 2 hours. Resident #2 also had heel protectors that were worn when she was out of bed. On 07/02/25 between 9:25AM and 9:35AM, interviews with Resident #1 and Resident #2's assigned Charge Nurses and CNAs revealed they were aware of the interventions in place for both Resident #1 and Resident #2 to maintain skin integrity and prevent any new skin issues. It was reported that Resident #1 was completely bed-bound, and Resident #2 got out of bed for four hours every Tuesday, Thursday, and Saturday per her family's request. On 07/02/25 at 10:00AM, Resident #1 and Resident #2's physician confirmed he had been providing care for both residents. Regarding Resident #1, the physician stated he was totally bed-bound. He stated he did not think there was anything the facility could have done differently to prevent the wounds/skin damage that Resident #1 had obtained (which were likely obtained due to his comorbidities). Regarding Resident #2, he stated he did not think the facility could have done anything differently to prevent the wound to her toe (which was likely caused by trauma, per the wound care physician). The physician stated the facility had been consistently putting interventions in place for residents to maintain their skin integrity/prevent new skin issues; he had no concerns regarding the facility, or the treatment provided related to wounds. Record review of the facility policy, Repositioning, revised May 2013, reflected:1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief.2. Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals.3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.4. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting (sic)[offloading] devices for repositioning.5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing .

Based on observations, interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (Resident #24 and Resident #56) of 8 residents reviewed for quality of care. The facility failed to identify wounds and provide needed care and services to Residents #24 and #56. This failure could prevent the resident from receiving treatments and worsening of their wounds. An IJ was identified on 11/18/24. Administrator B and DON were notified and an IJ Template was provided on 11/18/24 at 1:48 PM. While the Immediate Jeopardy was removed on 11/19/24. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Findings included: 1. Record review of Resident #56's admission MDS assessment, dated 08/14/24, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included heart failure and diabetes. His Brief Interview for Mental Status (BIMS) score of 11 revealed his cognition was moderately impaired. The resident was at risk of developing wounds and pressure ulcers. Record review of Resident #56's Care Plan, dated 10/30/24, revealed the resident had a care plan because he had cellulitis of the right lower extremity related to infection. Record review of Resident #56 skin assessments for the dates of 10/25/24 through 11/08/24 reflected: - 10/25/24 indicated he had redness to his lower abdomen. - 10/30/24 indicated skin tear about 2cm. - 10/30/24 skin tear measuring 2cm, dryness and dryness noted to LLL. - 11/01/24 skin tear measuring about 2 cm in diameter, dry scaly skin. - 11/08/24 redness below abdomen, dryness to bilateral lower extremities An observation and interview on 10/30/24 at 1:07 PM revealed Resident #56 was seated in a wheelchair in his room. The resident was wearing a hospital gown. The resident's right lower leg had multiple open ulcers draining yellow drainage. The circular, open ulcers varied in size from nickel-sized to quarter-sized lesions. The area was red. Resident #56 said the ulcers had been open and draining for one and a half months to two months. LVN G said she was the resident's nurse. She entered the room and put on gloves. She said she did not know that he had the ulcers, and he was not receiving treatment for them. She said she would notify the physician and the ADON/WNC who was also the wound care nurse. An observation and interview on 10/30/24 at 1:12 PM revealed the ADON/WNC entered Resident #56's room wearing gloves, gown, and a mask. The ADON said he did not know the resident had wounds and told the resident, You never told me. and walked out the door to his medication cart. Then Resident #56 became very upset and said he is blaming me. I should not have to tell him I have wounds. The ADON/WNC said the resident did not like him. The ADON/WNC said he did not know why the Surveyor knew about the wounds, but he and his staff did not . The ADON/WNC said the wounds were not on the skin assessment. Resident #56 interrupted and said the wounds were present when the nurse did the skin assessment. An interview on 10/30/24 at 1:32 PM with the DON revealed she was new to the facility, and she did not realize that Resident #56 had open wounds on his right lower leg. The DON assessed the wounds and asked the resident about the wounds. Resident #56 told the DON that the wounds had been there for a while and the staff were not taking care of them. The DON told the resident she would make sure that he got treatments for his wounds. The DON said she was going to do a skin sweep in the building to look for additional residents with wounds and ensure they were being treated. Record review of Resident #56's Order Summary Report, dated 10/30/24, reflected: Cleanse cellulitis wound on the right lower leg with normal saline, pat dry and apply calcium alginate, cover with ABD pad (dressing used for large wounds) and apply adhesive dressing daily for cellulitis to the right lower leg for 23 days, with a start date of 10/31/24. 2. Record review of Resident #24's quarterly MDS assessment, dated 07/06/24, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included stroke, peripheral vascular disease (slow and progressive disorder of the blood vessels), and diabetes. His Brief Interview for Mental Status score was left blank. His cognitive skills for daily decision-making was severely impaired. The resident was at risk of developing wounds and pressure ulcers. Record review of Resident #24's Care Plan, dated 10/30/24, after surveyor intervention, reflected the resident had an actual impaired skin integrity related to an autoimmune disease - induced wound to his left leg. Record review of Resident #24 skin assessments for the dates of 10/21/24 through 11/08/24 reflected: - 10/21/24 no skin issues noted. - 10/28/24 no skin issues noted. - 10/30/24 autoimmune disease induced wound of the left leg, full thickness, redness to the scrotum barrier cream applied. - 10/30/24 redness to scrotum, above knee amputation, below knee amputation with blisters noted. - 11/04/24 Res Noted with recurring open areas to the left leg due to the auto immune disease. on treatment and followed by wound care doctor - 11/08/24 return of rash with scab of BKA site. Autoimmune disease induced wound of the left leg. An observation and interview on 10/30/24 at 11:30 AM revealed Resident #24 was awake, alert, and mostly non-verbal. He was able to communicate with facial expressions and hand movements. The resident pulled up his blanket and exposed his left knee which had a large area, approximately the size of a soft ball area that was red with yellow, scabbed areas. The area was very inflamed. The resident communicated that it was very irritating to him. An observation and interview on 10/30/24 at 11:35 AM revealed LVN G entered the room and she said she was Resident #24's nurse. LVN G looked at the resident's knee and said it was not like that when she did her skin assessment on 10/28/24. She said she did not know the resident had the wound and he was not currently receiving treatment for the wound. She said the resident had a history of an autoimmune disorder that would cause it to flare up. In a follow-up interview on 11/18/24 at 10:56 AM with LVN G revealed that skin assessments were to be completed once a week and all residents had orders for their skin assessments. LVN G stated she was responsible for completing Resident #24's skin assessment each week. LVN G stated that that on Monday (11/28/24) there was not a wound on Resident #24's leg but on 10/30/24 a wound was observed. She stated if a skin impairment was found while doing her skin assessment, she would document it on the skin assessment then she would tell the ADON /WNC so he could assess the skin, obtain orders, and contact the wound doctor. Record review of Resident #24's Order Summary Report, dated 10/30/24, reflected: Clobetasol Propionate External Foam 0.05 % (used to treat skin conditions). Apply to left leg stump topically two times a day for autoimmune disease-induced wound of the left leg for 23 days. In a follow-up interview with ADON /WNC on 11/18/24 at 10:30 AM revealed that all residents have skin assessments once a week completed by the floor nurses. ADON/WNC stated that CNAs are also responsible for observing and reporting any changes in residents' skin when providing care to residents, to the nurse. ADON/WNC stated a skin assessments requires a head-to-toe observation of the residents' skin and nurses should indicate any signs of skin impairment such as bruises, rashes, wound. ADON/WNC stated that once the nurse puts skin assessment into the system with skin impairments noted, it would generate on his 24-hour report that he pulls his next working day. ADON stated once he reviews the 24 hours report, he then goes to complete his own skin assessment of the resident to ensure no areas were missed, he measures the wound and contacts the MD and refer the resident to the Wound MD. ADON/WNC stated that nurses also called the MD to get an order for treatment in the interim and ADON/WNC would go behind and review the order and the wound. ADON/WNC stated that no interventions were put into place for Resident #24 as his wound was autoimmune and it can come and go randomly. ADON stated Resident #56's wound came as a result of cellulitis which the resident admitted with. In a follow-up interview on 11/18/24 at 9:24 AM with the DON revealed that ADON/WNC was responsible for wound care in the facility. DON stated that skin assessments were to be completed on all residents once a week and are documented in the electronic medical record under assessments and in the residents MAR/TAR. DON stated that if skin impairments would find, the nurse would notify he MD, family herself, obtain an order for treatment and contact the Wound MD. DON stated that the Wound MD comes to the facility on ce a week on Wednesdays. DON stated that a skin impairment would be a change in condition and an SBAR should be completed. In an interview on 11/18/24 at 11:50 AM, MD stated he had a few minutes to speak before a meeting. MD stated he did not recall Resident #24 nor his wounds. MD stated that Resident #56 had a chronic venous ulcer on his leg that did not just come about MD stated that it was his expectation that once a wound was founded that they notify him and/or his team so treatment can begin. MD stated that he knew the facility completed skin assessments but could not recall at what frequency. MD then had to leave for his meeting. In a telephone interview on 11/18/24 at 1:42 PM Wound MD stated he could not recall when Resident #56 wounds began but stated the wounds are difficult to avoid and they do improve and redevelop cyclically and depends a lot on the edema Resident #56 has at the time. Wound MD stated Resident #56's wounds were more of a reflection of underlying pathology. Wound MD stated Resident #24's were baffling to him, as he had treated his wounds before with a high dose of ointment which healed the wounds. Wound MD stated once he had taken Resident #24 off the high dose ointment, Resident #24's leg flared up again. Record review of the facility policy, Change in Resident's Condition or Status, dated December 2010, reflected: 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 . The facility did not have a policy on quality of care. Administrator B and DON were notified of the IJ on 11/18/24 at 1:48 PM due to the above failures and provided the IJ template and a POR was requested. The facility's plan of removal was accepted on 11/18/24 at 3:56 PM and included the following: 11/18/2024 F684 IJ POR All residents were at risk of being affected by this alleged deficient allegation. Resident #24 and #56 immediately had a skin assessments performed by the nurse and referred to wound care management for new treatment orders and Plan of Care updated on 10/30/2024. The Medical Director was notified of the IJ. The IJ was issued at 1:45 pm on 11/18/2024. The DON/designee immediately initiated in-services with nursing staff and CNA's on how to identify and manage changes in condition and how to communicate the changes to nurse management via SBAR and complete skin assessments in PCC. Any staff not currently present will be educated prior to working the floor. On 11/18/24 current residents who admitted after 10/30/2024 have been assessed for skin issues. Any issues identified by the nurse were documented in the care plan and interventions carried out by the nurse after being communicated to the wound care physician. The DON/designee will audit 5 random resident skin assessments visually, return demonstration, each week for 4 weeks. The DON will monitor progress in the wound care audit log. The facility's implementation of the IJ Plan of Removal was verified on 11/19/24 through the following: Record review of Resident #56's Order Summary Report dated 11/19/24 reflected: - Cleanse cellulitis wound on the right lower leg with normal saline, pat dry and apply Xeroform gauze three times per week, then cover with ABD pad and wrap with kerlix wrap daily. one time a day every Mon, Wed, Sat for Cellulitis to the right lower leg. for 23 Days, order date 11/13/24, start date 11/16/24, end date 12/09/24. - [Wound Company Name] consult, order date 10/30/24 Record review of Resident #56's Wound Evaluation & Management Summary dated 11/06/24 reflected: Venous Wound of the right shin partial thickness . etiology (quality) venous, wound size (L x W x D) 3.5 x 3.0 x 0.1 cm . Surface Area: 10.50 cm .Cluster Wound: open ulceration area of 7.35 cm . Primary Dressing(s) Xeroform gauze apply three times per week for 30 days, Secondary Dressing(s) Gauze island w/ bdr [sic] apply three times per week for 30 days; ACE bandage 6 apply once weekly for 30 days. Record review of Resident #24's Order Summary Report dated 11/19/24 reflected: - [Wound Company Name] would consult, order date of 10/30/24. - Wound MD Consult as needed, order date 11/04/24. - Clobetasol Propionate External Foam 0.05 %, (Clobetasol Propionate) Apply to left leg stump topically two times a day for AUTOIMMUNE DISEASE-INDUCED WOUND OF THE LEFT LEG FULL THICKN for 23 Days, order date 11/13/24, start date 11/13/24, end date 12/06/24. Record review of Resident #24's Wound Evaluation & Management Summary dated 11/06/24 reflected: Autoimmune disease-induced wound of the left leg . etiology (quality) autoimmune. Wound Size (L x W x D) 6.2 x 13.2 x not measurable cm . Surface Area: 81,84 cm2 Additional Wound Detail: return of rash with scab of BKA site . Primary Dressing(s) Clobetasol apply twice daily for 30 days. Record review of skin assessments for the 74 residents revealed there was not any new skin impairments noted. Interviews were conducted with staff across all shifts on 11/19/24 from 11:30 AM to 2:30 PM and included 1 RN, 1 PRN RN, 2 LVN , Staffing Coordinator/CNA, 2 CNA's, 1 Restorative Aide. revealed they had all been in-serviced by the DON. CNA's and Restorative Aide stated they were in-serviced on reporting any skin impairments to their nurse that they find when providing care to residents, they stated they were educated on completing shower sheets and indicating on the shower sheet if a resident has any skin impairments. They stated a skin impairments were anything that was not normal, such as bruises, skin tears, wounds, rashes. 1 RN, 1 PRN RN, 2 LVN stated that they were in-serviced on identifying and managing changes of conditions, communication the changes to nurse management via SBAR and completing skin assessments accurately and documentation. All nurses stated that if a skin impairment was reported to them or they find a skin impairment doing the weekly skin assessment, they are to document the skin impairment on the skin assessment, call family, the MD and obtain new orders, contact the DON and complete an incident report and an SBAR. In an interview on 11/19/24 at 11:31 AM with Administrator B revealed LVN G and ADON/WNC had been terminated on 11/18/24. Record review of employee termination form date 11/18/24 for ADON/WNC revealed he was terminated on 11/18/24 for failure to meet performance standards Record review of employee termination form date 11/18/24 for LVN G revealed he was terminated on 11/18/24 for failure to meet performance standards In a follow-up interview with Administrator B on 11/19/24 at 12:30 PM revealed that there were not any new skin impairments as a result of the skin sweep. In an interview on 11/19/24 at 1:07 PM DON stated that she in-serviced all nurses and aides on skin impairments, how to follow-up on skin impairments, completing SBAR and incident reports and obtaining treatment orders. DON stated that she told the nurses that they must refer skin issues to the wound care doctor, follow through with treatments that were ordered, notify herself, family and the MD. DON said that RN Z was responsible for wound care since ADON was no longer employed and that the charge nurses were responsible as back up. DON stated that when assessing a resident's skin staff are to take note of any redness, scrabs, open areas, rashes, anything that was not normal. DON stated that aides are to document on the shower sheet, when giving showers, if they notice any skin impairments and report the skin impairment to the nurse. DON stated that skin impairments are discussed during the morning stand-up meeting. DON stated that at the meeting staff will verify an incident reports and SBAR was completed, orders were obtained for treatment, she said if one of the items or none of the items had been completed the facility would immediately complete those tasks. DON stated the skin sweep had no new findings. An observation on 11/18/24 at 9:50 AM ADON/WNC provided wound care to Resident #56's right legs lower shin to outside leg area. An IJ was identified on 11/18/24. Administrator B and DON were notified and an IJ Template was provided on 11/18/24 at 1:48 PM. While the Immediate Jeopardy was removed on 11/19/24. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record reviews, the facility failed to ensure residents receives adequate supervision and assistance devices to prevent accidents for two of three residents (Resident #1 and Resident#16) reviewed for supervision. 1.The facility failed to ensure Resident #1, who was known for seeking alcohol and becoming intoxicated, was adequately supervised to prevent him from leaving the facility without signing out. 2.The facility failed to ensure Resident#16, who was known for seeking alcohol and becoming intoxicated, was adequately supervised to prevent him from leaving the facility without signing out at the front representative desk on 08/09/24. Resident#16 left out the back gate where the residents took smoke breaks at 10:00 PM during staff shift change. An Immediate Jeopardy (IJ) was identified on 07/16/24 at 3:00 PM. While the IJ was removed on 08/12/24 at 12:15 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure placed the residents at risk accidents, injuries, and possible death. Findings included: 1. Review of Resident #1's quarterly MDS assessment, dated 03/28/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included Parkinson's disease, Bipolar disease, and Schizophrenia. The MDS reflected Resident #1 had a BIMS (Brief Interview for Mental Status - is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 12 indicating moderate cognitive impairment, moderately impaired decision-making, and the resident requiring cues/supervision. Review of Resident #1's care plan initiated on 07/07/24 revealed Resident #1 was unsafely leaving the facility and was unaware of physical limitations and poor safety awareness. The facility goal was that the resident would not successfully elope from the facility and would be monitored of his whereabouts on an ongoing basis. Facility interventions included: Facilitate resident to call close family/friend for reassurance when exit-seeking behaviors are occurring. Monitor resident for tail gaiting when visitor and staff are exiting the facility. Place in secured locked unit for safety. Review of Resident #1's Wandering Risk Assessments, dated 07/07/24, reflected Resident #1 was disoriented x3, forgetful, independently ambulating, with a known history of purposeful wandering. Review of the Release of Responsibility for Leave of Absence for Resident #1 reflected: 07/07/24 5:30 PM - Resident signed out of the facility. 07/07/24 6:30 PM - Resident signed back into the facility. Review of Resident #1's progress notes dated: 06/24/24 at 6:35 PM written by the DON reflected, Resident has been leaving facility without signing out. Education provided on needs to sign in and out when leaving facility. Safety risks education provided including risk of death or accident. Verbalized understanding and stated that I'm a grown man. I do what I want. Sister called and notified. Sister informed DON that she does not want him to drink or leave the facility because of history of serious mental issues. Sister does not mind if he smokes but does not want him to drink alcohol. DON educated sister that we cannot hold resident against his will and cannot physically restraint him. Will continue to educate resident and monitor him closely as needed. 07/04/24 at 11:14 AM written by the DON reflected, Pharmacy recommended gradual dose reduction for Olanzapine (antipsychotic medication used to treat schizophrenia and bipolar disorder) 15 milligrams in the morning. Since reduction, resident is more and more agitated, goes to bathroom on the floor in his room, not in the bathroom as he was doing, wandering around and outside facility. Leaves facility by back door without signing in and out. Physician notified. Ordered Olanzapine to previous order of 15 milligrams daily due to failed gradual dose reduction. Family notified that resident is frequently leaving the facility without signing in and out. Will go out and return drunk; sometimes in the middle of the night or when he leaves, he returns too late. He is the one buying cigarettes and alcohol for other residents. In the dining room he was screaming and yelling at staff making other residents and families uncomfortable. DON approached to redirect resident and urged him to calm down. He appeared under the influence of alcohol and cigarettes. Started yelling and cursing at DON. Sister and physician notified. Will continue to redirect as needed; educate resident; and update care as needed. 07/04/24 at 5:14 PM written by the DON reflected, Resident continues to be aggressive and displays apparent erratic behaviors as someone who is under the influence. Yells, screams, and insults staff and other residents. Refuses redirection and starts cursing each time staff approach him. Sister once again notified. Physician updated. Will continue to redirect and educate resident as needed. 07/07/24 at 4:38 PM written by LVN A reflected, Received call from psychiatric hospital around 4:00 PM that the resident was sitting in the lobby stating that he was there to check in. Nurse went to get him to come back to the facility but was unsuccessful. This writer with another employee then drove to the psychiatric hospital. Resident was observed sitting in the lobby drinking coffee. Nurse was able to convince the resident to return to the facility. 07/07/24 at 6:25 PM written by LVN A reflected, Resident observed exiting the building through a side exit door. Informed resident that door was not the correct door to exit the facility. Resident extremely upset. Began cursing and yelling that nobody would give him the code to leave. Resident proceeded to hop the gate and continued walking down the street. Resident's assigned nurse followed him. 07/07/24 at 6:47 PM written by LVN A reflected, Resident brought back to facility with assigned nurse and was placed in the locked unit for safety. 07/07/24 at 10:19 PM written by LVN A reflected, Resident stated he wanted to be out of here. He stated he wants to go to the nearby psychiatric hospital because he wanted 45 dollars for cigarettes. After that he walked to the front door as if he was going to log himself out but instead, he was observed climbing through the fence. This nurse went after him and brought him back. For safety, the management asked if he temporally sleeps in the (secure) unit today until he sees the doctor tomorrow. 07/10/24 at 2:56 PM written by LVN B reflected, Resident calmer this shift, spent majority of the day in his room, and left room for short periods to go smoke with staff accompanying. 07/11/24 at 5:34 PM written by ADON reflected, Resident moved back to his room [ROOM NUMBER]-B due to him hitting the doors and disrupting other residents. Remains calm in his room and promised not to yell, disrupt or go out of the facility unnoticed. Family member notified. No observable distress noted at this time. Review of Resident #1's Behavioral Health Solution Discharge Summary, dated 07/10/24, and written by Licensed Clinical Social Worker reflected: At the time of Discharge: Patient is considered to be at risk of harm to self or others. Verbally aggressive, with aggressive physical behaviors .pt should be monitored and sent out to psychiatric facility. An observation and attempted interview on 07/16/24 at 2:25 PM with Resident #1 revealed he was alert and able to answer questions. The resident had some confusion and spoke about things that did not make sense. He had memory issues and was independently ambulatory. Resident #1 said he would leave the facility. He said he was not supposed to sign out after 6:00 PM, but he would leave at 1:00 AM since it was a new day. Resident #1 said sometimes he would leave without signing out and would leave through a side door and slip through the fence. Resident #1 said he would leave the facility whenever he wanted to and go to the different buildings around the facility. He said he was placed in the secure unit because he was joking about a whiskey song. He said the staff turned over the tables and chairs in the secure unit and he hurt his back putting them back. He said he had been out of the secure unit for about 3 days. He said he went to the psychiatric facility because the DON said he was going to be placed in a rubber room in a mental hospital. He said he went to the psychiatric facility and had a coke (soda drink) with him. He said the coke was made with cocaine in it and the psychiatric facility said they could not take him. An interview on 07/15/24 at 1:35 PM with LVN D revealed Resident #1 was alert and oriented and could differentiate between right and wrong. She said the resident used to sign out and leave the facility but was not safe to leave anymore She said the facility had to place him in the secure unit for a few days. She said she checked on him every hour. An interview on 07/15/24 at 1:45 PM with CNA C revealed she had worked at the facility for two and a half years. CNA C said Resident #1 was safe to leave the facility by himself. She said the resident was placed in the secure unit on 07/07/24 because he tried to leave the facility by going over the fence. She said Resident #1 was not on enhanced supervision. An interview on 07/15/24 at 2:05 PM with the ADON revealed he had worked at the facility for 6 weeks. He said Resident #1 was alert and oriented with intermittent confusion. He said he was safe to leave the facility unsupervised and could sign himself out. The ADON said the resident was placed in the secure unit because he was having confusion. The ADON said the resident was leaving, yelling, and trying to attack other residents. The ADON said on 07/11/24, he found out Resident #1 was in the secure unit and the resident told him he was ready to leave the secure unit and return to his room. The ADON said the resident was on regular supervision, every 2 hours. He said the resident would leave the facility, drink liquor, return to the facility, and be aggressive. The ADON said he did not know the Licensed Clinical Social Worker said on 07/10/24 that the resident was a danger to his self and others and needed to be on monitoring. An interview on 07/15/24 at 2:45 PM with the DON revealed Resident #1 was supposed to sign out to leave, but sometimes he would just walk out. The DON said safety outside the facility was a concern that had been expressed with the resident and his family. He said the resident was alert and oriented, but sometimes would get confused. The DON said on 07/07/24, the facility received three calls from the psychiatric facility because the resident would not return to the facility. The DON said he was supposed to not leave after 6:00 PM but the resident was seen out between 3:00 - 4:00 AM. The DON said the resident would leave and drink alcohol. The DON said on 07/07/24, the resident was placed in the secure unit because he had a change of condition and seemed lost, and the resident was going to the psychiatric hospital. The DON said the decision was made to move the resident back to the regular unit because he was more alert, not confused, and wanted to go outside to smoke. An interview on 7/15/24 at 3:10 PM with the Administrator revealed Resident #1 was safe to leave the facility by himself. She said recently the resident went to the psychiatric hospital three times in one day. She said usually the resident would walk to a fast-food restaurant. She said staff were concerned about him getting lost, but labs were drawn, and he was back to his usual self. An interview on 7/16/24 at 11:05 AM with the Environmental Services Director revealed Resident #1 would leave the facility through the side gate. An interview on 07/16/24 at 11:25 AM with the SW revealed Resident #1 would sign out and leave the facility. She said he would go to the fast-food restaurant and the gas station. She said the resident was going out late at night and returning late at night. The SW said the facility had a care plan meeting and Resident #1 was told not to leave after 6:00 PM. A follow-up interview on 07/16/24 at 1:08 PM with the ADON revealed he did not know why there were no monitoring notes for Resident #1 after 07/11/24. He said Resident #1 would leave and the ADON did not know how long the resident stayed out or if there was a timeframe for him to return. He said there was nothing in place to ensure the resident was safe while he was out. He also said he did not know if the resident had special monitoring in place while in the facility. A follow-up interview on 07/16/24 at 2:20 PM with the DON revealed he did not know why there were no follow-up notes after Resident #1 was seen by the Licensed Clinical Social Worker. The DON said at that time, the resident's behavior was erratic. The DON said the resident was currently back to his regular self. The DON said that it was well documented that the resident would leave the facility without signing out. The DON said the resident would also sign out and go out the front door, then return to the facility by a different door and not sign back in. The DON said the resident would sneak out the back door by the smoking patio and then sneak back in. The DON said the resident was supposed to be back before 6:00 PM but he was non-compliant. The DON said once Resident #1 signed out, he was no longer the facility's responsibility. 2. Review of Resident #16's initial MDS assessment, initiated on 08/08/24 and not completed, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #16's had no diagnoses and BIMS indicated. Review of Resident #16's care plan initiated on 08/08/24 revealed Resident #16 has been advised of smoking policy. The resident requires supervision with smoking. Resident#16 is non-compliant with smoking. He goes out to smoke when it is not time and without supervision. Facility interventions included: Follow facility guidelines for unsafe practice. Review of Resident #16's Wandering Risk Assessments not initiated. Review of the Release of Responsibility for Leave of Absence for Resident #16 reflected: 08/09/24 3:35 PM - Resident signed out of the facility. - Resident did not sign into the facility. Review of Resident #16's progress notes dated: 08/09/24 at 6:35 PM written by the DON reflected, Was reported by nurse last evening that resident signed himself out and has not returned. Staff driving from facility observed resident rolling around corner store. Asked resident to return to facility. He stated that he is going to the store to purchase cigarette. Staff rushed to facility to alert the nurse. By the time they went back, they couldn't see resident. Police was then called. They found resident down the street, smelling alcohol, and appeared intoxicated. Police determined that it was not safe for him to drive his power chair back. He was then assisted in staff vehicle and resident was brought and assisted back in bed safely. Skin assessment completed. No wound, no skin tear, and no apparent injury related to the incident. Resident encouraged not to go out since he still new to the area. Verbalized understanding and stated that I do what I want, and you can't stop me. I have the right to go wherever I want. If I want to go the store, I will go. I don't need your permission. Became upset and stated using derogatory words. De-escalation initiated. Physician notified. Labs ordered. Referred to Psych eval. Incident report completed and care plan updated. Will monitor resident every hour for 3 days. Resident is own RP. Will continue to monitor, encourage resident to stay in facility as much as we could, and update care as needed. Record review Resident#16 of EMR under NMAR revealed updated monitoring of residents Monitor resident every hour. Encourage him to stay in the facility as much as possible. Every hour for 3 days initiated on 08/10/24. An observation on revealed 08/06/24 at 6:15 AM revealed no alarm on the side door adjacent to the piano. Observed an open gate that leads outside of the facility area. Observed a sign on the door that stated, No smoking. An observation on revealed 08/06/24 at 6:23 AM no latch on the actual gate opening and closure section for the smoking area back gate. An observation and record review of leave of absence form reflected on 08/06/24 at 6:30 AM revealed the leave of absence form had not been amended. An observation and record review of leave of absence form reflected on 08/07/24 at 11:00 AM revealed the leave of absence form had not been amended. An interview on 08/06/24 at 9:04 AM with DON revealed not everything from leave of absence form, acknowledge form, door monitor, EMAR monitoring and latch on gate the plan of removal from 07/16/24 had been completed. DON stated he tried to get all the nursing responsibilities done and the Maintenance Director was supposed to complete other duties. The DON stated the facility has been very busy. An interview on 08/11/24 at 5:45 AM with Med aide S who stated Residentt#16 went out the back door. Med aide S stated another nurse got in their car and searched for him. Med aide S stated staff called 911 and he was brought back to the facility. Med aide S stated he was not for sure how long Resident#16 was gone for. Med aide S stated residents are to let staff know when they leave and come back. Med aide S stated residents are supposed to sign in and out on the leave of absence form at the front door. Med aide S stated if Residents do not come back after an hour of the listed time, then staff would start search for resident. An interview on 08/11/24 at 5:58 AM with LVN R who stated Resident#16 went out the back door where residents smoke. LVN R stated she called 911 and reported that Resident#16 left the building. LVN R stated that someone saw him driving his electric wheelchair outside around 10:30 PM. LVN R stated she thinks that Resident#16 was gone for 20 minutes. LVN R stated residents are supposed to sign in and out on the leave of absence form at the front door. LVN R stated if Residents do not come back after an hour of the listed time, then staff would start search for resident. An interview on 08/11/24 at 7:00 AM with Resident#16 stated he went to the store around10:00 PM to get cigarettes and a beer. Resident #16 stated he was okay and did not have any concerns. An interview on 08/11/24 at 8:41 AM with DON who stated Resident#16 signed out and went out the front door to go to the store. DON stated he stated the in-services on exit doors on 08/07/24. DON stated he still needed to overnight staff and PRN. DON stated the MAR needed to be updated to reflect every 2-hour check for residents. DON stated he needed to do in-services for residents on hall 500 and assigned task. DON stated he would send updated information before the end of the day. Policy Statement Staff shall investigate and report all cases of missing residents. Review of the facility policy, Accidents and Hazards, dated 2022, reflected: Policy: The resident environment will remain as free of accident/hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary . 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment. An Immediate Jeopardy (IJ) was identified on 07/16/24 at 3:00 PM. The IJ template was provided to the facility on [DATE] at 3:15 PM and signed by the Administrator. A plan of removal was requested at that time. The facility's plan of removal was accepted on 07/17/24 at 2:35 PM and reflected: Immediate Corrective Action for residents affected by the alleged deficient practice: The residents who sign in and out of the facility had the potential to be affected by this deficient practice. Residents who leave the facility on pass were assessed and noted to be oriented to person and place as of 07/16/24. A review of the resident pass policy conducted by the administrator determined that while there is no specific guidance requiring a resident to state where they are going or how long they will be out, we will amend our leave of absence form to include these as optional fields. The nursing staff will monitor the resident's whereabouts from the hours of 10:00 PM-6:00 AM, this will be done every hour and will populate in our EMR software as an action item to be completed. The administrator and DON will educate the residents on the proper procedure for going out on pass including entering and exiting only through the front door, signing in and out, and letting staff know when they return. Additionally alarms for the doors were purchased by maintenance and will be placed in doors that lead out of other locations. The gate at the back smoking area has been secured and can no longer be pulled open, unless at the actual gate opening and closure which are used in the event of an emergency. Actions taken to prevent a serious adverse outcome from recurring: This deficient practice had the potential to affect all residents who sign in and out of the facility on pass. The administrator and director of nursing were educated on proper out on pass procedure including supervision, by the regional nurse manager on 07/16/24. In turn training of facility staff on resident pass procedures and keeping residents free of accidents and hazards was initiated by the Administrator and DON on 07/16/24. The Administrator has created an education for the residents regarding leaving the facility that includes a signed acknowledgement form. The administrator, DON, or designee will ensure the new sign out sheet is correctly adhered to daily for two weeks, weekly for two weeks and monthly for two months. Any negative findings will be taken to the administrator for immediate correction. Administrator or DON will continue to audit the passbook daily in the morning standup meeting as an ongoing process. The results of the new audit process will be reported to the QAPI team. The Medical Director was notified of the deficiency on 07/16/24. All findings will be reported to the QAPI team monthly for quality assurance. When Actions will be complete: Facility will have completed education by 07/17/24, if any staff member working in the facility is unable to be educated, they will be removed from the schedule until training has been provided. The facility's implementation of the Plan of Removal was verified through the following: An interview on 07/18/24 at 11:15 AM with Resident #1 revealed he had been in-serviced and could only leave the facility during daylight hours. He said he understood he was not supposed to sign out at night and could only exit through the front door. He said he was following the process and signing in and out at the front desk. He said he understood he was not supposed to leave or return to the facility through the side or back door. Record review of the Release of Responsibility for Leave of Absence (sign-in and sign-out book) reflected Resident #1 was signing in and out to leave the facility correctly on 07/17/24 - 07/18/24. Interviews with 13 staff who worked all shifts on 07/17/24 at 3:40 PM through 07/18/24 at 4:00 PM revealed: Staff were able to voice that they were in-serviced regarding the plan of removal and elopements. Staff were able to verbalize the process for a resident to sign out to leave the facility. The facility kept a sign-in and sign-out book at the front desk. Residents had to notify the nurse if they were signing out. Staff said residents were to be checked on every 2 hours throughout their shifts to ensure residents were in the facility. Staff said residents could only leave through the front door of the facility and had to return through the front door of the facility to sign back in. Staff said if residents were gone longer than what they signed out for, staff were to notify the nurse and start the process to search for the resident. Staff interviewed included LVN H, RA I, CNA J, CNA K, CNA L, CNA M, CNA N, the receptionist, CNA O, RN P, RN Q, LVN R, and LVN B. An interview with the ADON on 07/18/24 at 3:25 pm revealed he was responsible for ensuring residents signed out when they left and signed back in. The ADON said if a resident left the facility without notifying staff and signing out, it was considered an elopement. He said if the receptionist was out, then the nurse at the front desk would handle the sign-in and sign-out process. He said the residents were notifying the nursing staff prior to signing out and leaving the facility. He said the residents could only sign-out through the front door. The ADON said the nursing staff were to monitor all residents every 2 hours to ensure they were in the building. He said if a resident was missing and not signed out, then it was considered an elopement. An interview on 07/18/24 at 12:45 PM with the DON revealed his role in the plan of removal was to supervise and ensure documentation was taken care of. He said if a resident left the facility without notifying staff, they were left at risk of being exposed to problems outside of the facility. The DON said the residents had been in-serviced and had to sign out at the front desk and notify the nurse before leaving the facility. The DON said if a resident was gone for an excessive time, the facility staff were to check the sign-out book and start the process to look for the resident. An interview on 07/18/24 at 4:00 PM with the Administrator revealed she was responsible for putting the plan of removal actions in place. She said residents who left the facility without signing out were at risk of coming to harm outside the facility. The Administrator said the residents could sign out at the front door and had to leave and return through the same door. She said residents who were not in the building and were gone longer than expected, staff were to notify the Administrator and start the process of looking for them. Monitoring of the Plan of Removal from [08/07/24 to 08/12/24] included the following: Record review of in-service titled: Exit doors and dated 08/06/24 reflected: All residents who want to go out of the facility must go through the front door. They must also notify staff when they are leaving and returning; where they are going and how long they will be out. Finally, they must sign out and in when they must sign out and in when they leave. Record review of EMR revealed update to residents EMR's related to nursing staff monitoring residents' whereabouts from hours of 10 PM - 6:00 AM initiated on 08/11/24. Record review of signed acknowledgement forms were initiated and signed by Resident #15, Resident #16, Resident#17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29 on 08/11/24. An observation on 08/07/24 at 11:15 AM revealed the one door adjacent to the piano alarm worked properly. An observation and record review of the leave of absence form reflected on 08/09/24 at 10:00AM revealed the leave of absence form had been amended. An observation on 08/12/24 at 10:00 AM revealed the latch for the back gate was in the administrator office that he purchased on 08/12/24. An interview on 08/06/24 at 9:04 AM with DON stated Resident#1 who eloped was transferred to the VA in psych on 07/19/24. An interview on 08/06/24 at 10:15 AM with Administrator revealed he purchased door alarms for side door for the door adjacent to the piano on 08/06/24. An interview on 08/10/24 at 1:30 PM with CNA X who stated residents must sign out in and out at the front desk. An interview on 08/10.24 at 1:37 PM with RN Y who stated residents cannot exit out of the back smoke area. RN Y stated residents must exit out the front doors. RN Y stated residents must let nursing staff know where they are going and plan to be back. An interview on 08/11/24 at 5:45 AM with Med aide S stated residents are to let staff know when they leave and come back. Med aide S stated residents are supposed to sign in and out on the leave of absence form at the front door. Med aide S stated if Residents do not come back after an hour of the listed time, then staff would start search for resident. An interview on 08/11/24 at 5:58 AM with LVN R who stated residents are supposed to sign in and out on the leave of absence form at the front door. LVN R stated if Residents do not come back after an hour of the listed time, then staff would start search for resident. An interview on 08/11/24 at 6:00 AM with CNA T who stated that residents are supposed to let staff know where they wanted to go and would return. CNA T stated residents are supposed to sign in and out at the front desk. An interview on 08/11/24 at 6:00 AM with CNA V who stated that residents are supposed to let staff know where they wanted to go and would return. CNA V stated residents could only sign in and out at the front desk. An interview on 08/11/24 at 6:03 AM with CNA U who stated residents are to sign in and out at the front desk only. An interview on 08/11/24 at 6:03 AM with RN W who stated residents informed the staff about where they are going and when they will be back. RN W stated residents can only leave out the front door. RN W stated residents need to sign in and out at the front desk representative area. An interview on 08/11/24 at 7:00 AM with Resident#16 stated he went to the store around10:00 PM to get cigarettes and a beer. Resident #16 stated he was okay and did not have any concerns. An interview on 08/12/24 at 5:30 AM CNA J stated residents sign in and out at the front door. An interview on 08/12/24 at 6:00 AM LVN J stated residents let the nursing staff know where they are going and plan to be back. LVN J stated residents can only exit the front door and must sign in and out at the front desk. An interview on 08/12/24 at 6:04 AM LVN H stated residents let the nursing staff know where they are going and plan to be back. LVN H stated residents can only exit the front door and must sign in and out at the front desk. An interview on 08/12/24 at 8:00 AM with the Receptionist who stated residents sing in and out at the front desk. Residents should let nursing staff know where they are going and when they plan to be back. The Receptionist stated residents could document that information on the leave of absences form. An interview on 08/12/24 at 10:00 AM with the Administrator who stated he had purchased the latch for the back gate and would have maintenance to install. The Administrator was new to the facility and was completing training on 08/02/24. An observation on 08/14/24 at 9:47 AM - 9:55 AM revealed that the doors that lead to the outside, including the front door, had door alarms that operated immediately once the doors were opened. In an interview on 08/14/24 at 10:09 AM, Maintenance Director stated that all of the doors had alarms that operated when opened. Maintenance Director stated that Life Safety Code had instructed him to remove the latch on the gates as it interfered with egress during an emergency. Attempted to get police report on 08/11/24 at 10:00 AM (Report was not available). The administrator was notified the IJ was removed on 08/12/24 at 12:15 PM. The f [TRUNCATED]

Based on observation, interviews, and record review, it was determined the facility did not have a functional communication system for some residents to call staff for assistance for four (100 hall, 300 hall, 400 hall, and 500 hall) of five halls in the facility. On 08/06/24, some of the rooms on hall 500 did not have working call lights. There was no other option put in place by the facility for all residents to call for assistance. On 08/07/24, some of the rooms on hall 100, hall 300, hall 400 did not have working call light. There was no other option put in place by the facility for all residents to call for assistance. On 09/07/24 at 3:46 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/12/24, the facility remained out of compliance at a severity level of - no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could have caused residents to experience feelings of hopelessness, cause a delay in assistance in the resident room/shower room, and contributed to any falls/injuries when residents did not get assistance. Findings included : Record review of Resident #15 MDS reflected: is a [AGE] year-old female with a BIMS of 13. She is a paraplegia, level of cervical spinal cord lumbar region and PTSD. Record review of Resident #30 MDS reflected: he was [AGE] years and has a BIMS of 15. He had breakdown (mechanical) of implanted electronic neurostimulator spinal cord electrode (Lead), fracture of unspecified part of neck of right femur, and muscle weakness. Record review of Resident#31 MDS reflected: he was a [AGE] year-old female with a BIMS of 14. She had muscle weakness, muscle wasting and atrophy and morbid obese. Record review of Resident#32 MDS reflected: he was a [AGE] year-old male with a BIMS of 14. He had He had muscle wasting, pressure ulcer stage 4 left heel, muscle wasting and atrophy. Record review of Resident#33 MDS reflected: he was a [AGE] year-old male and had a BIMS of 10. He had Acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary chronic disease and muscle weakness and shortness of breath. Record review of in-service titled: Call light and residents' care, dated 08/06/24 reflected: Call lights should be answered in a timely manner without delays by all departments. When answering the call light, please refer to the service resident is requesting. Make sure to return and update resident. Leave the call light on until residents' needs have been met. No staff signatures included with in services. Record review of grievance logs reflected: On 07/22/24 Resident #30 revealed call light was not answered, and no one answered the [facility] phone. No resolution noted. An interview on 08/06/24 at 6:45 AM with Resident #15 was moved to hallway 500 (only resident on the hall) between 1st and 2nd shift. On 08/06/24 at 7:21 AM Resident #15 stated no one had been in to check on her all night. Resident #15 stated she felt abandoned and alone. Resident #15's call light in her room and the bathroom light did not work. An interview on 08/07/24 at 2:00 PM Resident #30 stated it takes staff over an hour at night to unhook his G-Tube so that he can go use the bathroom. An interview on 08/07/24 at 2:10 PM with Resident #31 stated it takes staff 2 hours or so to come check on her when she presses the light. Resident#31 stated she needs help changing and repositioning. An interview on 08/07/24 at 2:20 PM with Resident #32 stated last night he put on his call light to get help with his CPAP machine, and it took over 2 hours for someone to come. It was unplugged and he could not reach it to plug it back up. An interview on 08/07/24 at 2:30 PM Resident #33 stated he had breathing problems and was afraid that he would not be able to get ahold of staff and would need to go to the hospital. An observation on 08/07/24 at 5:45 AM all call lights on hall 300 were not sounding at the nursing station. Not all rooms were visible from the nursing station depending on where you were standing or sitting. An observation on 08/07/24 at 6:30 AM all call lights on hall 400 were not sounding at the nursing station. Not all rooms were visible from the nursing station depending on where you were standing or sitting. An observation on 08/07/24 at 7:00 am on hallway 100 call lights were beeping at the nursing station and no lights were lighting up above the resident's rooms. The nursing station was not facing the hall. This was determined to be an Immediate Jeopardy (IJ) on 08/07/24 at 3:46 PM. The Administrator and DON was notified. The Administrator was provided with the IJ template on 08/07/24 at 4:00 PM. The following Plan of Removal was submitted by the facility and was accepted on 08/09/24 at 3:11 PM and reflected: Immediate Corrective Action for residents affected by the alleged deficient practice: Identified Immediate Jeopardy (IJ) Issues: Policy and procedure have and will be reviewed and will re-in-service if change is required. 2. Noncompliance with S483.12 (F 600) Freedom from Abuse, Neglect, and Exploitation o Resident #1 was not checked on overnight. o Call lights and bathroom lights were not functional. Corrective Actions and Steps for Removal of Immediate Jeopardy: 1. Ensuring Resident Safety and Dignity Immediate Staff Training: o Action: Conduct immediate in-service training for all staff on the importance of resident checks, especially during night shifts, and proper use of the call light system. Review of Policy and Procedure for call light and ADL's o Responsible Party: Director of Nursing (DON) o Completion Date: 08/09/2024 2. Functionality of Call Lights and Electrical Systems Repair Call Lights and Electrical Issues: o Action: Ensure all call lights in resident rooms and bathrooms are fully functional. A certified electrician will repair any non-functional lights immediately. Review of Policy and Procedure for call light and ADL's o Responsible Party: Maintenance Supervisor o Completion Date: 08/09/2024 Routine Maintenance Checks: o Action: Conduct daily checks of call light systems for two weeks, followed by weekly checks to ensure ongoing functionality. o Responsible Party: Maintenance Supervisor o Completion Date: Start immediately and continue weekly o Action: Inform residents and their families about the steps being taken to address the identified issues and ensure their safety and well-being. o Responsible Party: Administrator and Social Worker o Completion Date: 08/09/2024 Monitoring and Verification Regular Audits: o Action: Conduct weekly audits for compliance with the above actions for the next three months, then transition to monthly audits. o Responsible Party: Quality Assurance Team o Completion Date: Ongoing Immediate Reporting: o Action: Any noncompliance or issues identified during audits must be reported to the DON and Administrator immediately for corrective action. o Responsible Party: Audit Team o Completion Date: Ongoing Completion and Documentation Document All Actions: o Action: Maintain thorough documentation of all corrective actions, training sessions, maintenance checks, and communication with residents and families. o Responsible Party: Administrator o Completion Date: Ongoing The facility's implementation of the Plan of Removal was verified through the following: Record review of in-service record sheet dated 08/07/24 titled: call light/check residents. Purpose: plan of correction. Ensure resident safety and dignity: Make sure to check all residents at least every two hours every shift and as needed, especially at night. Before leaving the room make sure call light is working in room and the bathroom and within patients reach. Record review for in-services were initiated on 08/12/24 at 11:11 AM in a message to the team. Message reflected: Good morning Team! Please see in-service regarding call lights/resident rooms from DON We need to answer call light immediately. When we go to room, check to make sure call lights works in the room and bathroom. If it does not report it to charge nurse, DON and/or Maintenance. An observation on 08/08/24 at 7:30 AM revealed some call lights on hall 400 were not working. An observation on 08/08/24 at 7:45 AM revealed call lights on hall 500 were working. An observation on 08/08/24 at 8:00 AM revealed some call lights on hall 300 were not working. An observation on 08/08/24 at 8:15 AM revealed some call lights on hall 100 were not working. An observation on 08/09/24 at 12:30 PM revealed call lights on hall 400 were working. An observation on 08/09/24 at 10:45 PM revealed call lights on hall 500 were working. An observation on 08/09/24 at 12:00 PM revealed some call lights on hall 300 were not working. An observation on 08/09/24 at 12:15 PM revealed some call lights on hall 100 were not working. An observation on 08/10/24 at 10:30 AM revealed call lights on hall 400 were working. An observation on 08/10/24 at 10:45 AM revealed call lights on hall 500 were working. An observation on 08/10/24 at 11:00 AM revealed some call lights on hall 300 were not working. An observation on 08/10/24 at 11:15 AM revealed some call lights on hall 100 were not working. An observation on 08/11/24 at 5:30 AM revealed call lights on hall 400 were working. An observation on 08/11/24 at 5:45 AM revealed call lights on hall 500 were working. An observation on 08/11/24 at 6:00 AM revealed some call lights on hall 300 were not working. An observation on 08/11/24 at 6:15 AM revealed some call lights on hall 100 were not working and observed residents with bells. An observation on 08/12/24 at 9:00 AM revealed call lights on hall 500 were working. An observation on 08/12/24 at 9:20 AM revealed call lights on hall 300 were working. An observation on 08/12/24 at 9:40 AM revealed call lights on hall 400 were working. An observation on 08/12/24 at 9:40 AM revealed some call lights on hall 100 were not working and observed residents with bells. An interview on 08/09/24 at 6:30 AM with Environmental services Director revealed the call lights were being worked on and will do routine checks until the system was updated. The Environmental Services Director revealed residents should be checked on every 30 minutes when the system was down. An interview on 08/10/24 at 9:35 AM with CNA O revealed residents were checked on every 2 hours and as needed. An interview on 08/10/24 at 9:40 AM with CNA L revealed residents were checked on every 2 hours and as needed. An interview on 08/10/24 at 9:55 AM with CNA N revealed residents were checked on every 2 hours and as needed. An interview on 08/10/24 at 1:30 PM with CNA X who stated residents are checked on every 2 hours. CNA X stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/10/24 at 1:37 PM with RN Y who stated residents are checked on every 2 hours. RN Y stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 5:45 AM with Med aide S who stated residents are checked on every 2 hours. Med aide S stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 5:58 AM with LVN R who stated residents are checked on every 2 hours. LVN R stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 6:00 AM with CNA T who stated residents are checked on every 2 hours. CNA T stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 6:00 AM with CNA V who stated residents are checked on every 2 hours. An interview on 08/11/24 at 6:01 AM with CNA M revealed residents were checked on every 2 hours and as needed. An interview on 08/11/24 at 6:03 AM with CNA U who stated residents are checked on every 2 hours. An interview on 08/11/24 at 6:03 AM with RN W who stated residents are checked on every 2 hours. RN W stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 6:05 AM with CNA K revealed residents were checked on every 2 hours and as needed. An interview on 08/12/24 at 5:30 AM CNA J who stated residents are checked on every 2 hours. CNA J stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/12/24 at 6:00 AM LVN B stated who stated residents are checked on every 2 hours. LVN B stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/12/24 at 6:04 AM LVN H who stated residents are checked on every 2 hours. LVN H stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/12/24 with DON at 11:15 AM revealed PRN staff had not been in-serviced on the updated policy. The DON acknowledged that staff would not be able to work until they were in-serviced. The Administrator was notified the IJ was removed on 08/12/24 at 12:15 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of Pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Residents #15) of 4 residents reviewed for quality of care. 1. Resident #15 did not receive care on the overnight shift (10PM-6AM) on 08/05/24. Resident #15's entire, right leg hung from the bed throughout the night and was observed swollen. Resident #15 was in distress, discomfort, pain, shed tears and had a flushed face (blood vessels below the skin dilate and fill with more blood, making the skin appear pink, red.) Resident #15 call light and bathroom call light did not work properly. Resident #15 yelled and cried out for help continuously for thirty minutes at 7:00 AM on 08/06/24. On 08/07/24 at 3:46 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/12/24, the facility remained out of compliance at a severity level of - no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. Findings included: Record review of Resident #15's face sheet, dated 08/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: paraplegia (the loss of muscle function in the lower half of the body, including both legs), abnormalities of gait and mobility, intervertebral disc degeneration (a condition that occurs when the spinal discs break down and lose function), lumbar region (spinal disks wear down), post-traumatic stress disorder (a mental health condition that caused by extremely stressful or terrifying event), pain unspecified, and retention of urine. Record review of Resident #15's initial MDS assessment, dated 06/28/24, reflected her BIMS score was 13, which indicated she was cognitively intact. Record review of Resident #15's care plan, revised on 08/02/24, reflected Resident #15 required skilled nursing care related to paraplegia. Resident #15 will safely transition to long term care. Resident #15 will continue to improve. Resident #15 has limited physical mobility/ADL deficit related to paraplegia, Chronic Obstructive Pulmonary Disease, anxiety, and bipolar disorder. Resident #15 were on skilled services and decided she wanted long term care instead of short stay. Resident #15 had rails on bed for positioning and turning. Resident #15 required bed mobility with 1 staff, transfers with 2 staff with a sliding board and a Hoyer lift with showers, toileting with 1 staff, and dressing/grooming with 1 staff. Goals: free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injury through the next review date. Interventions: Monitor/document/report to MD PRN s/sx of immobility: contractures forming or worsening, thrombus formation, skin break down, and fall related injury .Provide supportive care, assistance with mobility as needed. Document assistance as needed. Record review of Resident #15's progress note, late entry dated 08/08/24 by the social worker, reflected the following: [Resident #15] asked if she had to move rooms. SS explained to the resident that once a resident transition to long-term, they get a roommate. The resident then stated a staff member said she could stay in a private room if her family could pay the difference. When asked who told her that, resident said she could not remember. SS told the resident that they would ask the administrator and see what he says. The [Resident #15] then said she plans on leaving the facility September 1st and will move in with her. Observation on 08/06/24 at 7:00 AM revealed Resident #15 yelled for help from her bedroom. Observed Resident #15 right entire leg hanging out of the bed and appeared to be red and swollen. Observed Resident #15 face was red, in distress and she was crying. Observation on 08/06/24 at 7:30 AM of the social worker went into the room and then walked out. Observed Resident #15 call out for help again. Observation on 08/06/24 at 7:40 AM revealed LVN H and CNA N lifted Resident #15's leg back in the bed and gave her pain medication. LVN H stated to Resident #15 that they will assist her after breakfast with getting dressed and changed. Observation on 08/06/24 at 7:45 AM revealed Resident #15's call light in the room and in the bathroom did not work. Observation on 08/06/24 at 4:30 PM revealed Resident #15's call light worked properly. Interview and observation on 08/06/24 at 7:21 AM with Resident #15 who stated she was not checked on by the overnight shift. Resident #15 stated she had been calling out for help for a while and no one had been by to help her. Resident #15 was distressed and crying. Resident #15 stated that she felt alone and abandoned. Resident #15 stated the last time she saw staff was when she moved into the room. In an interview on 08/06/24 at 7:45 AM Resident #15 stated she did not know why she was moved to hallway 500, she was moved yesterday and was the only resident on that hall. Resident #15 stated her call light in the room and bathroom did not work. Resident #15 stated she had told the DON and other staff that her call light did not work on 08/05/24 around dinner time at 4:30 PM. In an interview on 08/06/24 at 8:10 AM with the social worker revealed Resident #15 was moved to the 500 hall because she wanted to be transferred to long term care and have a single room. In an interview on 08/06/24 at 9:00 AM LVN H stated Resident #15 was transferred to the 500 hall on 08/05/24 between first and second shift. LVN H stated that she was responsible for 300 and 500 hall. LVN H stated the facility had problems in the past with the call lights not working. LVN H stated that if residents were not checked on every 2 hours and as needed, they were in danger of falls and skin break down. In an interview on 08/06/24 at 9:10 AM CNA F revealed she did not know there was a resident on hallway 500. CNA F revealed residents were to be checked on every 2 hours. In an interview over the phone on 08/06/24 at 9:15 AM CNA N (overnight shift) stated she did not know a resident was on 500 hall. In an interview on 08/06/24 at 3:00 PM the DON stated that staff knew Resident #15 was on 500 hall and she had a history of lying, drinking, and smoking in the room and that was part of the reason why she was put on the hall by herself. The DON revealed that Resident #15 was transferring to long term care and wanted to stay in a room by herself. The DON stated the call light system just started to act up on 08/05/24. The DON stated the call light company would be out to repair the system. The DON stated residents are checked on every 2 hours and the residents who call lights did not work then bells would be provided. The DON stated residents are in danger of skin break down or falls if they are not checked every 2 hours. In an interview on 08/06/24 at 3:08 PM with Resident #15 stated that her entire left leg hung out of the bed all night and she did not know until she started to feel pain. Resident #15 stated her pain level this morning was at a ten and now she was down to an 8. Resident #15 stated she expected staff to answer the call light and help her as soon as they could. Resident #15 stated she understood the staff were busy but when they tell her they will come back staff don't. Resident #15 stated the social worker told her she was moved because she wanted to move to long term care and stay in a single room. Resident #15 stated the DON asked her if she wanted to move back to hall 100 and she told him no because she had too much stuff too. In an interview on 08/07/24 at 5:15 AM with LVN R (Overnight shift) stated she was responsible for hall 300, 400, and 500. LVN R revealed she changed Resident #15 once overnight the night before. LVN R stated since Resident #15's call light was not working she was checked on every 2 hours. In an interview on 08/07/24 at 5:20 AM with CNA N (Overnight shift) revealed she worked halls 100, 300, and 500. CNA N revealed that Resident #15 was checked on once. In an interview on 08/07/24 at 7:00 AM with the Maintenance Director stated the facility was in the process of updating the call light system and the owner would know more information about that. The Maintenance Director stated when the call light system did not work resident rounds should be every 30 minutes. The Maintenance Director stated residents could be at risk of not getting care when needed. The Maintenance Director stated the facility had on and off issues with the call lights. The Maintenance Director stated the call light company would be out on 08/07/24 after 12:00 PM to work on the system. Record review of facility in-service dated 08/06/24 titled: call light and resident care reflected: Resident should be up in a WC and back to bed as needed and requested. If a resident wants to get up, we need to do all we can to get him/her up. If they want to go back to bed, assist them back in bed as need. Let us work with our residents to meet their needs. We should always encourage residents to get out if bed; not discourage them. We should also empower residents by allowing them to participate in the decision-making process. For example, we can ask: What time would you like to get up: What time would you like to go back to bed? I know you want to get up at 5 PM. At that time, we are passing dinner on the floor. Is it possible for you to get up earlier or later than 5pm? Make residents feel in control of daily lives. We need to do round on residents all the time and provide incontinent care as needed without delays to all halls INCLUDING 500 HALL Do not delay care or wait for the end of the shift when we know that a resident is wet and needs assistance. We cannot let our residents lie in urine and feces: placing them at remarkably high risks of all types of infection. We should always treat our residents with dignity and respect. DO not display a behavior or attitude that may be misinterpreted or make residents uncomfortable. Do not make fun at residents. When they need something, please take time to explain and answer all their questions to the best of your ability. Call lights should be answered in a timely manner without delays by all departments. When answering the call light, please refer to the service resident is requesting. Make sure to return and update resident. Leave the call light on until residents' needs have been met. No staff signatures included with in services. This was determined to be an Immediate Jeopardy (IJ) on 08/07/24 at 3:46 PM. The Administrator and DON was notified. The Administrator was provided with the IJ template on 08/07/24 at 4:00 PM. The following Plan of Removal was submitted by the facility and was accepted on 08/09/24 at 3:11 PM and reflected: Immediate Corrective Action for residents affected by the alleged deficient practice: Identified Immediate Jeopardy (IJ) Issues: Policy and procedure have and will be reviewed and will be re-in-serviced if change is required. 1. Noncompliance with S483.12 (F 600) Freedom from Abuse, Neglect, and Exploitation o Resident #1 was not checked on the overnight shift. o Call lights and bathroom lights were not functional. Corrective Actions and Steps for Removal of Immediate Jeopardy: 1. Ensuring Resident Safety and Dignity Immediate Staff Training: o Action: Conduct immediate in-service training for all staff on the importance of resident checks, especially during night shifts, and proper use of the call light system. Review of Policy and Procedure for call light and ADL's. o Responsible Party: Director of Nursing (DON) o Completion Date: 08/09/2024 Immediate Resident Checks: o Action: Implement a system to ensure residents are checked every two hours, with documentation of each check. Review of Policy and Procedure ADL's. o Responsible Party: Nursing Staff o Completion Date: Ongoing with immediate effect 2. Functionality of Call Lights and Electrical Systems Repair Call Lights and Electrical Issues: o Action: Ensure all call lights in resident rooms and bathrooms are fully functional. A certified electrician will repair any non-functional lights immediately. Review of Policy and Procedure for call light and ADL's. o Responsible Party: Maintenance Supervisor o Completion Date: 08/09/2024 Routine Maintenance Checks: o Action: Conduct daily checks of call light systems for two weeks, followed by weekly checks to ensure ongoing functionality. o Responsible Party: Maintenance Supervisor o Completion Date: Start immediately and continue weekly 4. Resident Assistance and ADL Care Enhance ADL Care: o Action: Review and revise hall assignments to ensure adequate staffing on all halls, including hall 500. Ensure staff are aware of and meet residents' ADL needs promptly. o Responsible Party: DON and Nursing Supervisor o Completion Date: 08/09/2024 Frequent Monitoring and Assistance: o Action: Implement a policy requiring staff to respond to call lights within 5 minutes. Regularly audit compliance and address any delays promptly. o Responsible Party: Nursing Supervisor o Completion Date: Start immediately with ongoing monitoring 5. Family and Resident Communication Communication with Residents and Families: o Action: Inform residents and their families about the steps being taken to address the identified issues and ensure their safety and well-being. o Responsible Party: Administrator and Social Worker o Completion Date: 08/09/2024 Monitoring and Verification Regular Audits: o Action: Conduct weekly audits for compliance with the above actions for the next three months, then transition to monthly audits. o Responsible Party: Quality Assurance Team o Completion Date: Ongoing Immediate Reporting: o Action: Any noncompliance or issues identified during audits must be reported to the DON and Administrator immediately for corrective action. o Responsible Party: Audit Team o Completion Date: Ongoing Completion and Documentation Document All Actions: o Action: Maintain thorough documentation of all corrective actions, training sessions, maintenance checks, and communication with residents and families. o Responsible Party: Administrator o Completion Date: On going The facility's implementation of the Plan of Removal was verified through the following: Record review of in-service record sheet dated 08/07/24 titled: Call light/check residents. Purpose: plan of correction. Ensure resident safety and dignity: Make sure to check all residents at least every two hours every shift and as needed, especially at night. Before leaving the room make sure call light is working in room and the bathroom and within patients reach. Enhance ADL Care: Check residents in hall 500 at least every two hours every shift and throughout the night. Hall 500 assignments will be added to the staffing book. Check staffing book assignment daily to know who is assigned to hall 500. DO not ignore call light. Call light needs to be answered promptly. Even if you are not assigned to a resident, you must answer call light and address residents needs as much as you could. Provide showers to residents as scheduled and as needed. If a patient missed shower for more some reasons, we should provide it to them when requested even if it's not their shower day. When a patient refuses shower, notify the nurse immediately who will then inform family and document under PCC notes. Frequent Monitoring and assistance: We need to respond to call light immediately; within 5 minutes or less. Any staff that delay care or call light response will face disciplinary action. Record review of NMAR reflected: [ Resident #15] check on resident at least every two hours every shift initiated on 08/08/24. Record review for in-services were initiated on 08/12/24 at 11:11 AM in a message to the team. Message reflected: Good morning, Team! Please see in-service regarding call lights/resident rooms from DON. We need to answer call light immediately. When we go to room, check to make sure call lights works in the room and bathroom. If it does not report it to charge nurse, DON and/or Maintenance. There are patients on 500 hall that need to be monitored as well. Check on all patients including the ones on hall 500 at least every two hours. Hall 500 assignments will be in staffing book. Please check it at the beginning of each shift. Please respond to acknowledge the in-service. An interview on 08/09/24 at 5:15 AM with RN P revealed residents were checked on every 2 hours and as needed. RN P revealed that checks were documented on the EMAR. An interview on 08/09/24 at 5:20 AM with RN Q revealed she worked over night with Resident #15, and she was checked on every 2 hours and as needed. RN Q revealed that checks were documented on the EMAR. An interview on 08/09/24 at 5:25 AM with CNA F revealed residents were checked on every 2 hours and as needed. CNA F revealed that checks were documented on the EMAR. An interview on 08/09/24 at 5:30 AM with LVN A revealed residents were checked on every 2 hours and as needed. LVN A revealed that checks were documented on the EMAR. An interview on 08/09/24 at 6:10 AM with LVN B revealed residents were checked on every 2 hours and as needed. LVN B revealed that checks were documented on the EMAR. An interview on 08/09/24 at 6:20 AM with LVN D revealed she worked with Resident #15 overnight and she was checked on every 2 hours and as needed. LVN D revealed that checks were documented on the EMAR. An interview on 08/10/24 at 1:30 PM with CNA X who stated residents are checked on every 2 hours. CNA X stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/10.24 at 1:37 PM with RN Y who stated residents are checked on every 2 hours. RN Y stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 5:45 AM with Med Aide S who stated residents are checked on every 2 hours. Med Aide S stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 5:58 AM with LVN R who stated residents are checked on every 2 hours. LVN R stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 6:00 AM with CNA T who stated residents are checked on every 2 hours. CNA T stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 6:00 AM with CNA V who stated residents are checked on every 2 hours. An interview on 08/11/24 at 6:03 AM with CNA U who stated residents are checked on every 2 hours. An interview on 08/11/24 at 6:03 AM with RN W who stated residents are checked on every 2 hours. RN W stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/11/24 at 8:41 AM with the DON stated the MAR needed to be updated to reflect every 2-hour check for residents. DON stated he needed to do in-services for residents on hall 500 and assigned task. DON stated he would send updated information before the end of the day. DON stated residents are checked on every 2 hours. DON stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/12/24 at 5:30 AM CNA J who stated residents are checked on every 2 hours. CNA J stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/12/24 at 6:00 AM LVN B stated who stated residents are checked on every 2 hours. LVN B stated if a resident's call light did not work then they should be given a bell until the system was fixed. An interview on 08/12/24 at 6:04 AM LVN H who stated she worked the day shift and is responsible for Resident #15 and she is checked on every 2 hours. LVN H stated if a resident's call light did not work then they should be given a bell until the system was fixed. The Administrator was notified the IJ was removed on 08/12/24 at 12:15 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolation due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, record reviews and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 8 residents reviewed for quality of care. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent her from eloping from the facility on 02/17/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/09/24 and ended on 02/27/24. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review Resident #1's Face sheet dated was admitted to the facility on [DATE]. Resident #1 was diagnosed with unspecified Dementia, major depressive disorder, psychotic disorder with delusions due to known physiological condition, and adjustment disorder with anxiety. Record review of Resident #1's MDS assessment dated [DATE] revealed she had a BIMS score of 0 indicating severe cognitive impairment. She was rarely/never understood. The MDS Assessment indicated she did not exhibit wandering behavior symptoms. The MDS Assessment indicated the resident did not have an electronic device that monitored resident movement and alerted staff. Record review of Resident#1 care plan dated 11/15/21 revealed: Resident #1 was an elopement risk/wander as evidenced by non-goal directed wandering in/out of rooms, exhibited exit seeking behaviors. Resident #1 goals revised on 02/06/24 revealed: Resident #1's safety will be maintained Record review of care plan revealed: Interventions dated 11/15/21: disguise exits, cover doors knobs and handles, tape floor, identify the pattern of wandering and intervene as appropriate. Provide structed activities .reorientation strategies including signs, pictures . Record review of progress notes revealed, no documentation of time when Resident#1 went missing and what time the resident was found and returned to the facility. Record review of the progress note revealed, staff did not notice resident#1 was missing until mealtime. The facility was searched, and a code yellow was called. Progress note revealed Resident #1 was found loitering by the police down the street and staff returned her to the facility with Progress reports revealed, Resident #1 received a skin, pain and elopement risk assessment. Progress note revealed Resident#1's family member, Administrator, acting Director of Nursing, Medical Doctor was notified. Progress notes revealed Resident was monitored every 15 minutes. Record review of the facility's Provider Investigation report undated revealed the following: [Resident#1] was in the dining room, we believe a visitor or staff held the door for [Resident#1], not realizing she was an elopement risk. Staff realized resident was missing approximately 10 minute and called code pink was called She was not located in the facility One staff member got in her vehicle to look for resident. Record review of Provider Investigation Report revealed, Staff flagged a police officer down and the police had located resident at an apartment complex down the street and returned her to the facility. nursing staff did a head to toe skin assessment with no injuries noted, pain assessment . Completed new elopement risk assessment and checked on Resident#1 every 15 minutes Record review of staff in-services dated 02/19/24, 02/20/24 and 02/27/24 revealed, abuse, neglect, resident care and elopement were covered. Observation on 02/28/24 at 8: 20 AM revealed, residents who needed to be in the secure unit were present. Interview on 02/28/24 at 08:30 AM, CNA N stated residents in the secure unit were moved to the general population because of construction that was going on in the facility. General population residents and secure unit's residents were mixed between halls 500, 300 and 400. CNA N stated the risk to the residents was they could escape from the facility. CNA N stated she did not witness the elopement. CNA N stated Resident #1 eloped during dinner on second shift. CNA N stated she was in-serviced on the facility procedures for elopement. Interview on 02/28/24 at 8:40 AM, CNA P stated he was on vacation when Resident #1 eloped from the facility. CNA P stated he was in-serviced on elopement when he returned to the facility and the residents were back in the secure unit. Interview on 02/28/24 at 9:00 AM with LVN X stated the elopement happened around dinner time and staff believed a visitor held the door open for her not knowing she was a resident. LVN X stated she had been in-serviced on elopement and the residents who belong in the secure unit were back in the unit. A telephone interview on 02/28/24 at 1:37 PM with the local police department dispatcher stated, no police report was completed for Resident#1. A telephone interview on 02/28/24 at 2:52 PM with the CNA C revealed she was on break and when she returned, she was told the resident was missing. CNA C stated, she did a head count, and the resident was not found. CNA C stated residents were in danger of elopement if they are not supervised. Certified Nurse Aide C stated she understood the facilities policy and procedures for when a resident elopes. CNA C stated, was in-serviced about elopements. A telephone interview on 02/28/24 at 2:39 PM with LVN D stated, Resident#1 could not be found in the dining room when trays were passed out. Licensed Vocational Nurse D stated, she drove around the neighborhood and met up with a police officer who stated they found a lady wandering in the apartments LVN D followed the police officer to the apartment. LVN D stated Resident#1 was combative and LVN D called the weekend supervisor who drove to the apartments and was able to get Resident#1 into the car. LVN D stated some of the residents were moved back into the secure unit, but she said that they did not get full clearance to put all the residents back. Some of the secure unit residents were left in general population. LVN D stated all residents were returned to the secure unit on 02/18/24. LVN D stated she was in-serviced on elopement before and after Resident #1 left the facility. Interview on 02/28/24 at 3:30 PM with the Administrator revealed residents from the secure unit were brought to general population because of construction and both exits in the secure unit needed to be accessible. The Administrator stated Resident #1 went missing around dinner time 02/17/24, which usually started at 5:30 PM. The Administrator stated Resident#1 was found outside the facility down the street and brought back. The Administrator stated she believed that Resident#1 walked out of the facility with a visitor. Interview on 02/29/24 at 2:15 PM with the Administrator revealed residents from the secure unit were mixed with the general population on 02/09/24 and were able to return to the secure unit on 02/14/24, according to her records. The Administrator stated she did not realize secure unit residents were still in general population until 02/18/24. The Administrator stated that in the future she would have more staff to come in to monitor the exits if the secure unit residents must come back to general population.

Based on observation, interview and record review, the facility failed to ensure each resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 4 (Residents #34, #14, #48, and #16) of 8 residents reviewed for assistive devices. The facility failed to ensure they had a plan to provide Residents #34, #14, #48, and #16, with emergency oxygen if they needed it in case of a power outage. An Immediate Jeopardy situation was identified on 08/30/23 at 4:15 PM. The IJ template was provided to the facility on [DATE] at 4:15 PM. While the Immediate Jeopardy was removed on 09/01/23, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure placed residents at risk of serious injury, hospitalization , or death. Findings included: 1. Review of Resident #34's MDS, dated [DATE] , reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His cognitive skills were severely impaired. His diagnoses included stroke, aphasia (inability to speak), quadriplegia (unable to move arms or legs), chronic respiratory failure with hypoxia (low oxygen level), and tracheostomy (hole in throat that allows person to breathe). The resident used oxygen therapy and had a tracheostomy. Review of Resident #34's Physician Orders for August 2023, reflected tracheostomy care every shift, oxygen administration at 6 liters, and suction tracheostomy as needed. Review of Resident #34's care plan, not dated, reflected he required oxygen through his tracheostomy. The resident did not have a care plan for suctioning or emergency access to oxygen. 2. Review of Resident #14's MDS, dated [DATE], reflected she was admitted on [DATE] and it was incomplete. Review of Resident #14's Face sheet, not dated , reflected she was a [AGE] year-old female and her diagnoses included stroke and seizures. Review of Resident #14's Physician Orders, for August 2023 , reflected administer oxygen at 2 liters per shift. Review of Resident #14's care plan, not dated, reflected she had difficulty breathing and required oxygen per physician orders. The resident did not have a care plan for emergency access to oxygen. 3. Review of Resident #48's MDS, dated [DATE] , reflected he was a [AGE] year-old male who was admitted on [DATE], and his cognitive skills were intact. His diagnoses included paraplegia (unable to move half of body), and acute respiratory failure with hypoxia (low oxygen level). The MDS did not reflect the resident used oxygen therapy. Review of Resident #48's Physician Orders, for August 2023, reflected he had an order for oxygen as needed. Review of Resident #48's care plan, not dated, reflected he had a history of acute respiratory failure and required oxygen as needed. The resident did not have a care plan for emergency access to oxygen. 4. Review of Resident #16's MDS , dated 06/27/23, reflected she was a [AGE] year-old female who was admitted on [DATE], and her cognitive status was moderately impaired. Her diagnoses included Parkinson's disease and acute respiratory failure with hypoxia. The resident used oxygen therapy. Review of Resident #16's Physician Orders, for August 2023 , reflected she had an order for oxygen at 2 liters per minute to keep oxygen level above 90% every shift for shortness of breath. Review of Resident #16's care plan, not dated, reflected she had a history of shortness of breath. The resident did not have a care plan for oxygen or emergency access to oxygen. An interview on 08/30/23 at 11:05 AM with the DON revealed Resident #34 did not have an emergency red plug in his room. The DON said she did not know what the plan was for the resident if the power went out in his room. An observation and interview on 08/30/23 at 11:12 AM with Resident #34 revealed he was in bed asleep. He did not have an emergency red outlet in his room. He had a tracheostomy and was using an oxygen concentrator at 6.5 liters via his tracheostomy. He was also using an oxygen nebulizer, a feeding tube, and a suctioning machine. The resident's equipment was plugged into white power outlets. The DON entered Resident #34's room and said none of the resident rooms on Hall 400 had red power outlets. The DON said if there was a power outage then the facility staff were supposed to plug in an extension cord and extend it out to a red outlet in the hallway and connect it to the resident's oxygen. There was no extension cord in the resident's room. There was an oxygen canister in the room, but it did not have a regulator attached for use. The DON said Hall 600 had red outlets in the room, but the facility did not utilize Hall 600. The DON said she did not know how the facility was supposed to ensure Resident #34 received oxygen in the event the facility lost all power. She said she did not know if the oxygen concentrator had battery back-up power. The resident's nebulizer was turned off. The DON left the room. At 11:16 AM, the DON re-entered the room and said she did not know why the resident's nebulizer was turned off and turned it back on. An interview on 08/30/23 at 11:31 AM with LVN M revealed she entered Resident #34's room. She said she had turned off the resident's nebulizer because she was told they were going to test the power and turn it off. She said she was told to use an extension cord to plug in the resident's oxygen to the red outlet outside the resident's door, but she did not know where the extension cord was. She said if there was a power outage, LVN M thought she was supposed to plug Resident #34's electrical items into the red outlets, but she looked around the room and said there were no red power outlets . At 11:36 AM the DON re-entered Resident #34's room. The DON was asked if the resident had an extension cord and if it was long enough to reach the red power outlet outside of the resident's room. The DON said she thought the extension cord would reach, but there was no extension cord in the room. The DON was asked what the emergency plan was to ensure Resident #34 had oxygen in a power outage. The DON said she was not going to move the resident to Hall 600 and he would remain in his current room. The DON was asked how she was going to ensure the resident had emergency oxygen and she said the issue with red power outlets had come up before and no tags were written. She said the facility was not going to use Hall 600 even though the rooms had red power outlets. An observation on 08/30/23 at 11:51 AM of Resident #14, Hall 400, revealed she was in her room and was using an oxygen concentrator for oxygen. She was not interviewable and was non-verbal. There were no red outlets in the room and there were no oxygen cannisters in her room. The closest red outlet was in the hallway on the opposite wall and down the hall. It was 3 rooms away. An observation and interview on 08/30/23 at 11:55 AM with Resident #48 revealed he was wearing continuous oxygen via oxygen concentrator. He was awake, alert, and oriented. He said he had been wearing his oxygen constantly for a week and would become short of breath if he went 15 minutes without it. The resident did not have a red outlet in his room. There was no extension cord and no oxygen cannisters in the room. There was a red outlet outside of his door. An interview on 08/30/23 at 11:58 AM with the DON revealed the rooms in Hall 400 did not have red outlets because the plan to get them was too expensive. The DON said this issue had come up before . She said the facility had a room in the building that contained emergency oxygen cannisters. She said they did not have attached regulators, but regulators were available. She said the nurses should have the regulator keys. An interview on 08/31/23 at 12:03 PM with MA D for Hall 400 revealed she did not know which residents were using oxygen. She said she thought Resident #34 did. She said if the power went out, she was supposed to plug their oxygen into a red outlet in the hallway. She said she thought they were supposed to have an extension cord in their closet. She said she did not know where emergency oxygen cannisters were. An interview on 08/31/23 at 12:10 PM with RN H for Hall 400 revealed Resident #34 and Resident #14 were using continuous oxygen. He did not know Resident #48 was using continuous oxygen. He said if there was an emergency power outage, he would monitor the resident's oxygen saturation and call 911. RN Hwas asked if the facility had emergency oxygen cannisters and to show them to the Surveyor. An observation on 08/31/23 at 12:15 PM with RN H revealed the facility had one oxygen storage room located close to the nurse station. It contained 7 full oxygen cannisters and 7 regulators, and RN C had a regulator key. An interview on 08/31/23 at 12:25 PM with LVN L revealed on Hall 300, Resident #16 was also using continuous oxygen. She said in case of emergency she would have to get an extension cord from maintenance or to plug the oxygen in to a red plug in the hallway. She said the facility did have emergency oxygen cannisters. An interview on 08/30/23 at approximately 3:00 PM with the Medical Director revealed he considered oxygen to be essential life support for residents who were on continuous oxygen and especially for residents with a tracheostomy. He said oxygen was lifesaving for a resident who required it and the residents needed access to red outlets. A follow-up interview on 08/31/23 at 10:34 AM with the Medical Director revealed he altered his statement and said a resident's oxygen needs could be met with emergency oxygen cannisters and access to a red outlet. An interview on 08/31/23 at 2:28 PM with the Maintenance Director revealed he had worked at the facility since November 2022. He said he used to train staff on which residents had a tracheostomy and what to do if the power went out. He said he had not oriented any new staff since November 2022. He said he had placed an extension cord in the closets of Residents #34, #14, and #48 only and that they were long enough to reach the red outlets in the hallway. He said the facility also had a storage room that had oxygen cannisters. He said the power had never gone out since he was an employee. An interview on 08/31/23 at 3:24 PM with the Administrator revealed she thought the oxygen storage room had 8 full oxygen cannisters and some cannisters that needed to be returned. She said she did not know how many oxygen regulators the facility had. She said she thought the regulator keys were carried by the nurses. The Administrator said she did not know the process or who was responsible for ensuring oxygen was available. She said in case of a power outage the nurses would need to ensure residents received oxygen by using oxygen tanks, ambu-bags (bag used to artificially breathe for the resident) and calling 911. She said if Resident #34 needed emergency suctioning, then the nurse would need to call 911. An interview on 09/01/23 at 11:45 AM with the DON revealed she did not know how Resident #34 would receive emergency suctioning in the event of a full power loss. She said the resident did not need frequent suctioning and, in an emergency, he would be sent out 911. Review of the Facility's Policy, Auxiliary Power for Life-Support Systems, dated 2001, reflected, Auxiliary power will be provided to designated areas within to facility to operate life-support equipment should our normal power supply fail . 1. Should our normal supply of power be disrupted; our emergency generator will provide auxiliary power to established areas within this facility. 2. Areas designated to operate life support systems are: Room _______________, _______________Section The policy left the rooms and sections blank. There were no residents listed. Review of the facility's policy, Oxygen Administration, dated 2022, reflected, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. On 08/30/23 at 4:15 PM, the Administrator, DON, and CEO were notified an Immediate Jeopardy in the area of Quality of Care was identified. The IJ template was provided to the facility on [DATE] at 4:15 PM. A plan of removal was requested at that time. The facility's Plan of Removal was accepted on 09/01/23 at 3:30 PM and reflected: Immediate Corrective Action for residents affected by the alleged deficient practice: This deficient practice had the potential to affect 2 residents receiving continuous oxygen, and 4 residents with orders for as needed oxygen. An assessment of the residents on continuous oxygen concluded that there was no harm caused by this alleged deficient practice. When a test of the resident's equipment on generator power was conducted on 08/31/23 the switch took 58 seconds from nurses' station to plug, and the resident's oxygen saturation did not drop below 97%. This facility would be classed as a type 3 facility, not type 1. We can support all residents in the facility on the red plugs located outside room [ROOM NUMBER] and 415 which are duplex plugs on generator power and other locations listed below. Our Medical Director was called to discuss Resident #34's condition in the event of a power failure. If the facility should lose power the resident would need oxygen but would not immediately suffer death or long-lasting effects in the time it would take to place him on the red plugs, or until an oxygen tank could be taken to their rooms. This has been provided in a written statement. The Medical Director believes every case is subjective, however he believes Resident #34 could be off the oxygen connected to the trach for approximately 20-30 minutes. In the event of an emergency where power and generator are lost the resident could survive on oxygen alone. Actions taken to prevent a serious adverse outcome from recurring: The maintenance director checked the red plugs to ensure they were working appropriately, then he ensured the necessary equipment was located in the residents' closets and that the cords were long enough to stretch to the nearest plug. In the event of an emergency the facility would be able to secure the cords to the floor with painters' tape or to assist residents past cords that may need to stretch across the hall. The director of nursing and charge nurse conducted a check of the resident's equipment on red plugs, from the nurse's station to the resident room and hook up to red plugs was 58 seconds. All equipment functioned as normal at this time. Additional plugs were located outside rooms 305 (duplex), 106 (duplex), 108 (quadplex), 112 (quadplex), 203 (quadplex), 207 (duplex), 21l(quadplex), 217 (duplex), 220 (duplex). As well as rooms 602,604,606, and 608 which are equipped with red plugs. A regional director has educated the administrator, director of nursing, and maintenance director on the proper procedures for emergency preparedness for residents on assistive devices that will need generator power and was completed on 09/01/23. The administrator and DON started an education immediately regarding: - The purpose of the red plugs. - What to do in an emergency for residents on continuous 02. - Where the items necessary for emergency use are located. - The location of the oxygen storage room in the event of complete electric and generator power failure. This training was sent to all staff members via hosted time, our time keeping and payroll app, via text message requiring a response, as well as being taken around the facility to be discussed and signed. The facility will also call all staff members who are not available to come in and educate them by phone. All this education will be completed by 09/01/2023. Facility staff members were also instructed on: - the location of the oxygen storage room in the event of complete electric and generator power failure. - The facility has 16 full oxygen tanks, and 6 empty oxygen tanks available. - Oxygen is scheduled for weekly pickup and drop offs. This should be sufficient to provide necessary oxygen to the residents on both continuous and PRN oxygen. - The facility would also be able to utilize ambu-bags for a short time while we called emergency services. Contingency plans for a complete failure that is expected to be long lasting would be a transfer to the hospital or another skilled nursing facility. In the event that the administrator, DON, and maintenance director are not here when an outage occurs, the charge nurses will complete these emergency procedures. Charge nurses will complete hands on drills to demonstrate competency and understanding. Following the steps set forth for emergency procedure listed above. Corporate nurse management assessed the residents on continuous and PRN oxygen and found no ill effects. The Medical Director was contacted to provide statements that residents requiring continuous oxygen would be capable of surviving until red plugs can be accessed or tanks can be taken to the room. Additionally, all residents in the facility would survive on tank oxygen alone. The facility will continue to educate new staff members as they orientate regarding this process and will complete a hands-on drill for these emergency processes once monthly, with charge nurses in attendance to demonstrate capability. When Actions will be complete: All education completed by 09/01/23, if any staff member is unable to be educated, they will be removed from the schedule until training has been provided. Monitoring of the facility's Plan of Removal included the following: Observations on 09/01/23 from 3:53 PM to 5:23 PM revealed there were extension cords in the closets of residents who had orders for continuous oxygen. The extension cords were long enough to reach the red plugs outside of the rooms. No residents were moved to other rooms. The oxygen storage room had over five full oxygen cannisters with regulators and regulator keys. There were no power outages observed. Interviews were conducted on 09/01/23 from 3:53 PM to 5:23 PM with 10 staff members (5 CNAs, 1 RNs, MDS Nurse, 2 MAs, and 1 Housekeeping staff) from multiple shifts. The staff all indicated they had been in-serviced on emergency oxygen and loss of electricity. The staff knew how to identify resident's requiring continuous oxygen and the steps to take to ensure they received oxygen from red power outlets or emergency oxygen cannisters. An interview with the DON on 09/01/23 at 3:53 PM revealed she was able to identify residents with orders for continuous and as needed oxygen. She was able to verbalize the plan staff were to follow in a power failure. Staff were to access the extension cords from the closets of residents requiring continuous oxygen and plug the oxygen into a red power outlet outside of the resident's room. In the event of a full power failure, emergency oxygen cannisters would be taken to residents requiring them. She said she had completed hands-on drills with the staff to ensure they understood the process. An interview on 09/01/23 at 5:23 PM with the Administrator revealed staff had been in-serviced regarding the Emergency Oxygen and Red Plugs. She said the management team had been in-serviced to make sure staff were educated and people knew where to access extension cords and oxygen supplies in case of emergency. She said the goal was for residents to continue breathing with no gap in services. She said management would continue to provide oversight and perform hands-on drills to ensure competency. Record review of in-service dated 08/30/23 and 08/31/23 on Emergency Oxygen and Red Plugs . Red plugs provide emergency power in the event of a loss to the facility. These plugs run off the generator. All residents with orders for continuous oxygen and other medical equipment have extension cords with surge protectors for the red plugs, these items are located in the closet of these rooms. The plug is located outside room [ROOM NUMBER] and room [ROOM NUMBER]. Additional red plugs can be found on the first four rooms of the 600 hall. Oxygen tanks are located in the oxygen storage room off the main lobby . Charge Nurse Training for Emergency Outage In the event of an emergency where the facility is running on generator power, please take the following steps immediately. Immediately go to the rooms of residents receiving continuous or PRN O2. In particular Resident's #34 and #14. Red plugs that run on generator power are located just outside the door of Resident #34 and across the hall from Resident #14. In the closet of these rooms, you will find an extension cord and a surge protector. Please switch the resident's essential equipment from the regular outlet to the surge protector plugged into the nearest red plug. Ensure all equipment is functioning properly, assess the resident and then continue with emergency procedures. If the red plug is not functioning, please go to the oxygen storage room and retrieve a tank for the residents use. All necessary items should be available in the closet. Place the oxygen in the [NAME] and take it to the resident. Ensure the proper flow of oxygen before proceeding with emergency procedures. revealed 79 signatures from multiple shifts and multiple departments had received in-services which covered all aspects of the plan of removal. An Immediate Jeopardy situation was identified on 08/30/23 at 4:15 PM. While the Immediate Jeopardy was removed on 09/01/23, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1, who resided in the memory care unit, was provided a hazard free environment with adequate supervision when Resident #1 ingested the contents of a deodorant stick on 06/07/2023, which she found while wandering from room in the secured unit. An Immediate Jeopardy situation was identified on 06/08/2023 at 9:45 AM. While the Immediate Jeopardy was removed on 06/09/2023 at 4:18 PM, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures put memory care residents at risk of serious injury, hospitalization , or even death. Findings Included: Record review of Resident #1's electronic face sheet, dated 06/07/2023, revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with agitation (walk up and down, move objects around or fixate on tasks such as tidying), major depressive disorder (mood disorder that interferes with daily life), anxiety disorder (involves persistent and excessive worry that interferes with daily activities), and delusional disorders (type of mental health condition in which a person can't tell what's real from what's imagined). Record review of Resident #1's Quarterly MDS assessment, dated 04/21/2023, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. Review of behaviors reflected physical behavioral symptoms directed toward others and self, wandering occured daily. Record review of Resident #1's care plan, initiated on 05/30/2023, reflected Resident #1 was at risk of elopement / non-goal directed wandering, interventions included Disguise exits .identify pattern of wandering. Is it purposeful? Further review revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes and impaired decision-making skill. Resident #1 exhibited verbal and physical aggression, exhibited hitting and biting during ADL care and interventions included Provide physical and verbal cues to alleviate anxiety .give the resident as many choices as possible about care and activities. The care plan also reflected a diagnosis of dementia and need for a secure environment due to risk of elopement, exit seeking and wandering. Interventions included Assess for reasons for wandering and provide redirection as needed. Resident #1 had a history of resisting or refusing care and became aggressive during care. Record review of Resident #1's Progress Notes dated 04/13/2023, RN A documented, Resident came out from her room and was holding pull up full of feces and writer tried to take it away from her and resident pushed nurse and nurse landed on the floor and hit her right leg on double door. Nurse was assisted off from the floor by two staff members. Resident was then attended by two staff members. Family, Md, and ADON notified. Progress notes dated 05/15/2023, 05/16/2023, 05/16/2023, 05/22/2023, and 05/24/2023 reflected LVN E documented the following on each date, Resident is up wandering up and down the hallway, checked V/S and gave all medications as ordered, tolerated well, resident is at high risk for elopement, requires constant redirection by staff members. Resident requires 2 to 3 staff members to provide cares, resident has a very aggressive behavior, such as kicking and biting. Resident is developing a new habit, messing with her own poop, staff members has to help her thoroughly cleaned her and sanitize all the places she touched. Will continue to monitor. Progress notes dated 06/06/2023 reflected LVN E documented, Resident was seen be states surveyor possibly eating and notified first nurse aide and next the nurse who was told by the DON immediately notified the MD at 12:33PM, that was 3 minutes after this nurse was notified, MD immediately responded and ordered to call poison control center and checked resident's V/S, BP .poison control advised us to rinse resident's mouth and provide more fluids, we did as ordered, no S/S of nausea or vomiting noted at this time. Will continue to monitor resident and continue to encourage fluids. Called poison control regarding possible ingestion of deodorant. Poison control indicated that a possible adverse effect would b, mild GI upset, limited diarrhea, and upset stomach. Was told to monitor for upset stomach and encourage fluids. Case #75554424. Observation and interview on 06/07/2023 at 11:45AM revealed Resident #1, in the hall facing the patio, eating a stick of deodorant with a plastic spoon. Resident #1 turned the deodorant stick up and used the spoon to scoop chunks of the deodorant from the container and then ate it. CNA B and LVN C were observed around the corner on the room hall passing lunch trays. The surveyor called down the hall to notify LVN C and CNA B that Resident #1 was eating the deodorant stick. CNA B came to the hall where Resident #1 was and stated she could not take the deodorant from Resident #1 without assistance because Resident #1 had bitten her in the past when she took something away from her. CNA B called for LVN C to assist. During the time LVN C came to assist, Resident #1 was observed placing the deodorant container in a sock she was holding. LVN C was observed trying to get the sock that contained the deodorant stick from Resident #1. Resident #1 refused to give it and LVN C then distracted Resident #1 from her left side while CNA B took the sock from Residnet#1's grip. Resident #1 still had the plastic spoon in her hand and walked down the hall to the rear door exit area where she began taking items from the trash can. Resident #1 used the spoon to scrape particles of deodorant from her arms and licked the spoon. An observation and interview on 06/07/2023 at 11:50AM, with LVN C and CNA B, revealed the deodorant container was empty. LVN C said Resident #1 could get very aggressive when staff took items from her that she should not have. LVN C said Resident #1 constantly wandered from room to room taking any items she could find. LVN C stated the deodorant stick was not from the facility and may have been brought into the secured unit by another resident's family members. He said there was one resident in the secured unit who did have personal care items in her room because she was only diagnosed with schizophrenia and able to do her own personal care. He said each room had child covers on the doorknob which prevented residents from entering rooms, however, Resident #1 was able to open doors with the child cover on. CNA B stated Resident #1 needed constant supervision because she wandered from room to room taking anything she could find. She stated when staff attempted to redirect Resident #1 or take something from her she would be aggressive. An interview on 06/07/2023 at 12:16PM with the Administrator revealed she was informed that Resident #1 had eaten the deodorant. She stated she did not know where Resident #1 could have gotten the deodorant from because all personal care items should have been secured in the shower room. She said family members often brought items into the secured unit for residents and left the items in their room. She said she directed staff to do a sweep of the secured unit to ensure there were no more hazardous items accessible to residents; she stated they did find additional personal care items in resident rooms and removed them. She said she was not aware of any resident in the secured unit who kept personal care items in their room but the DON may have told her about such a resident but was not sure. She said there were child covers on the doorknobs in the secured unit to prevent residents from entering rooms. She said she had not been informed Resident #1 could open the doors with the child covers on. She stated typically one nurse and two CNAs worked in the secured unit to ensure appropriate supervision of the 17 residents. She stated the facility's policy stated that all personal and hazardous items should be locked to prevent a risk of harm to residents. She said she understood Resident #1's eating deodorant posed an immediate concern for a risk of harm to all the residents in the secured unit. An observation and interview on 06/07/2023 at 12:23PM, in the secured unit, with the Administrator and DON revealed Resident #1 in the room hall with a small can of shaving cream. Resident #1 was trying to push the button at the top of the can and held the can to her mouth but was unsuccessful in getting the contents to come out. The DON was observed taking the can of shaving cream from Resident #1. When asked if they had removed all the hazardous items from the secured unit, The Administrator stated staff had already done that and stated she did not know where Resident #1 got the can of shaving cream from. An observation and interview on 06/07/2023 at 12:25PM with Resident #2 revealed she recently came to the facility. She stated she had her own room and was allowed to keep her personal care items in her room. She stated she hid the items in her dresser drawers as residents often came inter her room and took them. She said she hid her purse under a chair for the same reason. Resident #2's purse was observed stuffed under a chair in her room and personal care items (toothpaste, shampoo, and deodorant) were observed in the top drawer of the dresser in her room. An interview on 06/07/2023 at 12:40PM with LVN C revealed Resident #1 was hard to redirect and constantly wandered from room to room. He said Resident #1 likely got the deodorant from another resident's room. He stated staff do not check rooms regularly for items that may be hazardous to residents. He said residents' family often bring items and leave them in the residents' rooms. He stated he noted Resident #1 started to mess with her poop and said he had never seen her eat anything non-edible before. He stated his note referred to her taking her adult diaper off and smearing poop all over. An interview on 06/07/2023 at 12:52PM with CNA B revealed Resident #1 would get into anything she could including briefs, wipes, and deodorant. She said she had not seen her eat anything hazardous but Resident #1 had to be supervised all the time to ensure her safety. She said she thought Resident #1 may have taken the deodorant from the shower room because she had found the lid to the deodorant stick in the locked shower room when she completed the sweep. She stated the shower room was always locked but this morning a hospice aide was in the secured unit caring for a resident and Resident #1 could have gotten the deodorant while the aide was showering another resident. CNA B stated during her sweep of the secured unit, she found five deodorants in five different rooms, soap, two large bottles of lotion, and three large bottles of shampoo. She said the items were labeled Keep out of reach of children. CNA B stated Resident #1 bit her on her breast, on 04/19/2023, when she tried to take lotion from Resident #1. She stated she informed the DON and Administrator. She stated Human Resources had her go to the hospital for treatment. She stated she had not receive any in-service related to handling Resident #1's aggressive behavior. An interview on 06/07/2023 at 1:41PM with the Administrator revealed when CNA B was bit by Resident #1 she was primarily concerned with ensuring CNA B was taken care of and followed up with human resources. She said she did not follow up with any behaviors that may have led to why Resident #1 bit CNA B and ultimately kept Resident #1 safe. She said in reviewing progress notes, the staff knew Resident #1 wandered and got into any items she could find; all staff could assume Resident #1 could possibly consume them as well. She stated she should have followed up to ensure the safety of Resident #1. She stated the DON and ADON were responsible for reviewing the progress notes to ensure information was brought to her. She stated she was not made aware of an incident where Resident #1 pushed RN A to the ground on 4/13/2023. She said the incident may have been reported to human resources. She said it should have been brought to her attention by staff or the DON because it was documented in the progress notes. She said she expected the DON and ADON to review the progress notes and bring any concerns to her attention. She stated she expected staff to ensure residents, who did not have the cognitive ability to understand their actions, were safe and any hazards were secured to prevent residents from any harm. An interview on 06/07/2023 at 2:25PM with RN A revealed she was pushed to the ground on 4/13/2023, when she tried to take a soiled adult brief from Resident #1. RN A said Resident #1 came out of her room with the soiled brief in her hand. She said the brief was tore and Resident #1 had feces on her hands, face and inside her mouth. She stated she believed Resident #1 was eating the brief. RN A stated she had never seen Resident #1 eat deodorant but was not surprised as she wandered from room to room looking for anything she could find. RN A stated she told the DON, ADON, Administrator and Human Resources about the incident. She stated Human Resources directed her to get medical attention. RN A stated there were no care plan changes, in-services, or direction from the DON or ADON to address Resident #1's behaviors. In an interview on 06/07/2023 at 3:00PM the Social Worker stated she and the MDS Coordinator held a care plan meeting for Resident #1 on 05/23/2023. She stated there was no information about Resident #1 eating poop or any other non-consumable items. She stated she gained resident information from the DON or ADON regarding issues or concerns and concerns of the resident's specific behaviors should have been relayed to her and the MDS Coordinator for care planning. She said Resident #1's aggressiveness was discussed in the care plan but no specific details regarding when aggression occurred or why. An interview on 06/07/2023 at 3:30PM with the DON revealed she had not seen any of the progress notes related to Resident #1. She said it was her and the ADON's responsibility to review the notes and care plans to ensure any concerns were addressed. She said she held a stand-up meeting every morning at 10:00AM where issues would be discussed. She said she was working with staff to ensure they brought concerns to the stand-up meetings but realized they had not always done that. She said she was aware Resident #1 had aggressive behaviors but did not know why. She stated she knew Resident #1 had bitten CNA B but did not why. She said she did not know Resident #1 pushed RN A to the ground when she tried to take a soiled adult diaper from her. The DON said Resident #1's aggressive behaviors that occurred when staff tried to take things from her should have been in the care plan. She stated there should not be any potentially hazardous items accessible to any resident in the secured because they did not have the mental capacity to know what could be consumed. She said Resident #1 eating deodorant posed a potential risk of harm and could have been avoided. An interview on 06/07/2023 at 4:22PM with CNA D revealed Resident #1 was aggressive when staff tried to redirect her or take something she should not have away. She said she had seen Resident #1 eat feces from her adult diaper and told the nursing staff but did not know what was done from there. She stated she did not recall the nurse she told or the time she observed Resident #1 eat feces from her adult diaper. She said Resident #1 needed constant supervision because she constantly looked for anything she could get into. An interview on 06/07/2023 at 4:35PM with MDS Coordinator/LVN revealed she and the SW conducted a care plan meeting for Resident #1 on 05/23/2023. She said information for Resident #1's care plan would be communicated to her by the ADON or the DON during morning meetings. She said she was aware of Resident #1 biting a staff member but was not sure why it occurred. She said she was not informed of specific circumstances that may have caused Resident's #1's behavior. She stated those circumstances should be communicated from nursing staff and reflected in the care plan. An interview on 06/07/2023 at 5:03PM with the ADON revealed she had not reviewed Resident #1's progress notes. She said it was the DON and her responsibility to review them for any concerns related to residents. She said that information would be passed on to the MDS Coordinator to be addressed in care plans. The ADON said she was not aware Resident #1 was messing with her poop and did not know RN A was pushed to the ground by Resident #1 when she took a soiled adult diaper from her. She stated specific interventions should have been reflected in the care plan to ensure Resident #1's safety. She said the facility did not have a system in place to ensure rooms were checked for hazardous items. She said since Resident #1 wandered and got into things, the facility needed to ensure her safety by making sure all potentially hazardous items were secured. In an interview on 06/07/2023 at 5:15PM, the Administrator stated she dropped the ball. She said in hindsight, she should have followed up with the DON regarding Resident #1's aggression. She said she should have investigated as to the circumstances of Resident #1's aggression. She stated there was not an incident report done when Resident #1 bit CNA E or pushed RN A. She said she and the DON should have known about Resident #1 eating a solid adult diaper. She said she felt like she needed to have better communication with nursing staff to ensure all resident's safety. She said the facility should have a system in place to ensure resident did not have access to non-consumable items and ensure their safety. An interview on 06/07/2023 at 5:57PM with the COO revealed he expected staff to ensure all residents were safe. He stated the DON and ADON should have known about the context of Resident #1's behaviors and ensured the care plan reflected specific issues. He stated there seemed to be a breakdown in communication between the front-line staff, nurse management, and the Administrator. Record review of the facility's incident / accident report between 03/01/2023 to 06/07/2023 revealed no record of incidents involving Resident #1, CNA B, or RN A. Record review of the MSDS for the deodorant consumed on 06/07/2023 by Resident #1 revealed Hazards Identification: Eye: Classification Eye Contact may cause mild, transient irritation. Some redness and/or stinging may occur. Ingestion: Product used as intended is not expected to cause gastrointestinal irritation. Accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting and diarrhea. Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated 12/2009 reflected, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.including time and date .nature .circumstances .name of witnesses .complete report sent to the DON within 24 hours .DON shall ensure that the Administrator receives a copy of the Report . Record review of the facility's policy titled, Safety and Supervision of Residents, dated 12/2008 reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA and A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. Staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident, and the MDS. Implementing interventions to reduce accident risk and hazards shall include the following: communicating specific interventions to all relevant staff, providing training .documenting interventions . Record review of the facility's policy titled, Care Plans - Comprehensive, dated 12/2010 reflected, An individualized comprehensive care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental, and psychosocial needs is developed for each resident. Each resident's comprehensive care plan is designed to: .incorporate identified problems .incorporate risk factors associated with identified problems The Administrator was notified on 06/08/2023 at 9:30AM, that an Immediate Jeopardy had been identified due to the above failures. The IJ Template was provided to the Administrator on 06/08/2023 at 9:45AM and she was informed the POR was due to HHSC by 12:00PM on 06/08/2023. The Plan of Removal (POR) was accepted on 06/08/2023 at 4:20PM. The Plan of Removal reflected the following: Immediate Corrective Action for residents affected by the alleged deficient practice: The resident who allegedly ingested deodorant was assessed, all vital signs within normal limits. Despite finding no evidence of deodorant within her mouth, the resident's mouth was rinsed, fluids encouraged. Medical director, poison control, and family were notified. The medical director instructed facility to continue to monitor for signs of GI distress. This deficient practice had the potential to affect 17 residents residing on the secure unit, however, no other resident was found to be affected. The secure unit was swept for personal care items on 06/07/23 and again on 06/08/23. All personal care items found were removed from resident rooms and given to the charge nurse to be secured behind locked doors, including items from resident who was previously reluctant to let them go. All family members were called on 06/07/2023 and informed that personal care items must be labeled and turned into management staff or nursing to be locked for the safety of all residents. Signs were also posted at the front of the building to turn in personal care items which will be made available for use at the appropriate time. Care plans updated to reflect the residents wandering and aggression being further agitated by attempts to remove items or redirect resident. The care plan updated to reflect the residents alleged tendency to ingest non-food items. Staff members in-serviced on the need to lock personal care items out of reach of residents, particularly those who tend to become confused or exhibit behaviors related to wandering and picking up items found in other rooms. Education occurred on 06/07/23 and again on 06/08/23 and will continue. Actions taken to prevent a serious adverse outcome from recurring: Management staff swept the rest of the facility on 06/08/2023 and ensured personal care items were secured appropriately. Anything found not stored appropriately was labeled by resident name and given to charge nurses to secure in locked room on 300 hall. Additional checks were conducted of locked supply, shower, and utility rooms. The facility will continue to monitor to ensure the security of these areas. Additional education completed on the need to keep personal care items away from residents who might become confused or exhibit behaviors. Ad Hoc QAPI Meeting was held on 06/08/2023 to discuss the incident, make staff members aware of the new policy on personal care items. MD and management staff present, corporate staff available by phone. Additional sweeps of the area daily by staff members x 2 weeks, then weekly for 2 weeks, and monthly thereafter. The facility will utilize a daily behavior monitoring sheet for changes in behavior/condition. This sheet will be reviewed weekly and as necessary, changes in behavior or condition will be discussed and care planned appropriately. When will actions be complete: Coral Nursing and Rehabilitation of Arlington requests the removal of the immediate jeopardy on 06/08/2023 Monitoring of the facility's Plan of Removal included the following: An interview on 06/09/2023 at 1:30PM with the Administrator revealed 57 of 110 staff have been in-serviced regarding the Behavior monitoring log and Securing personal care items. She stated the management team had been completed to ensure any hazardous items were secured for the safety of residents. She stated sweeps will be completed daily by the management team for two weeks and then weekly. She said she would be completing the sweeps on weekends until a weekend supervisor was hired. She stated she would be addressing progress notes, the results of sweeps, and any aggressive incidents daily stand-up meetings. She stated the management team participated in an Ad Hoc QUPI meeting on 06/08/2023 wiht the medical director, Corporate RN, DON, ADON, and MDS Coordinator present. She said she had implemented a behavioral log to be completed by staff daily and monitored by the DON in an effort to catch any changes in resident behaviors. She said the DON was expected to report any changes in resident behavior to her, daily. She stated the families of all Secured Unit residents were contacted and instructed that any items they bring to the facility must be secured by staff. A record review of the medical record for Resident #1 revealed she was assessed for complications and ongoing monitoring of adverse effects. Resident #1's care plan was updated to reflect the residents wandering and aggression, further agitated by attempts to remove items or redirect the resident and resident's tendency to ingest non-food items. Observations on 06/09/2023 from 3:00PM to 3:10PM revealed all rooms and areas in the memory care unit were free from hazardous products. Interviews were conducted on 06/09/2023 from 12:40 PM to 3:00 PM with 18 staff members (6 CNAs, 2 RNs, 4 LVNs, 2 MAs, 1 Restorative Aide, and 3 Housekeeping staff) from multiple shifts. The staff all indicated they had been in-serviced on safety awareness, which included a list of prohibited items in memory care, how hazardous items should be stored, the procedures on storing prohibited items that family members might bring for resident use, ongoing sweeps for hazardous items and their security, and procedures in case they were not sure if an item was hazardous. In a telephone interview on 06/09/2023 at 2:55PM, the Corporate RN said he understood the components of the IJ and was not aware the DON and ADON had not been reviewing the progress notes. He said it was impossible to complete a comprehensive care plan without considering behaviors. He said he expected the Administrator to ensure residents were safe from hazardous items. He said he expected the DON to ensure behaviors were monitored and communicated to staff for appropriate care planning. He said he provided a behavior log to the Administrator to assist with this. He said he in-serviced the Administrator, DON, ADON, and MDS Coordinator on the need to address changes in resident behavior in care planning, reviewing progress notes to ensure behaviors are addressed and care planed appropriately, and ensuring resident were cared for in a safe environment. Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Personal Care Items .Inform family members that all personal care items must be labeled and turned into management staff or nursing staff to be locked for the safety of all residents .Personal care items include but are not limited to the following: Soap, shampoo, conditioner, deodorant, lotions, mouthwash, toothpaste, hand sanitizer, and other potentially hazardous chemical items .In continuing sweeps, if such items are found please remove them from the room. Make sure they are labeled and give it to the nursing staff to be secured revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Behavior Monitoring Log .the facility will distribute behaviors monitoring sheets to the nursing staff to be filled out daily. The DON will collect the sheets weekly or as necessary to be discussed at the Standards of Care meeting. Any changes will be communicated to management staff in the meeting and care planned appropriately. Changes will also be discussed in the morning IDT meeting so all staff can be aware of changes, revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. Record review of signed in-service dated 06/09/2023 and conducted by the Corporate RN revealed the Administrator, DON, ADON, and MDS Coordinator were educated on their .responsibility that every resident within my facility receives quality, appropriate care .understand that changes in resident's behavior must be discussed promptly, with the DON, ADON, and IDT team for intervention and appropriate care planning .understand that it is my responsibility to periodically read and review the charts of my residents with behaviors, to ensure completeness and that all behaviors are addressed and care planned appropriately. Record review of the Behavior Monitoring Log reflected behavior, intervention and outcome codes with a monthly calendar noting day, evening, and night shifts. The Administrator was informed the Immediate Jeopardy was removed on 06/09/2023 at 4:18PM; however, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 9 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1, who resided in the memory care unit, had a comprehensive care plan identifying reasons for aggression, appropriate supervision, interventions to prevent Resident #1 from eating non-edible items in order to attain and maintain the highest practicable physical, mental, and psychosocial well-being and safety. An Immediate Jeopardy situation was identified on 06/08/2023 at 9:45 AM. The Immediate Jeopardy was removed on 06/09/2023 at 4:18 PM. The facility remained out of compliance at a scope of Isolated and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk for not being provided necessary care and services. Findings Included: Record review of Resident #1's electronic face sheet, dated 06/07/2023, revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with agitation (walk up and down, move objects around or fixate on tasks such as tidying), major depressive disorder (mood disorder that interferes with daily life), anxiety disorder (involves persistent and excessive worry that interferes with daily activities), and delusional disorders (type of mental health condition in which a person can't tell what's real from what's imagined). Record review of Resident #1's Quarterly MDS assessment, dated 04/21/2023, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. Review of behaviors reflected physical behavioral symptoms directed toward others and self, wandering occured daily. Record review of Resident #1's care plan, initiated on 05/30/2023, reflected Resident #1 was at risk of elopement / non-goal directed wandering, interventions included Disguise exits .identify pattern of wandering. Is it purposeful? Further review revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes and impaired decision-making skill. Resident #1 exhibited verbal and physical aggression, exhibited hitting and biting during ADL care and interventions included Provide physical and verbal cues to alleviate anxiety .give the resident as many choices as possible about care and activities. The care plan also reflected a diagnosis of dementia and need for a secure environment due to risk of elopement, exit seeking and wandering. Interventions included Assess for reasons for wandering and provide redirection as needed. Resident #1 had a history of resisting or refusing care and became aggressive during care. Record review of Resident #1's Progress Notes dated 04/13/2023, RN A documented, Resident came out from her room and was holding pull up full of feces and writer tried to take it away from her and resident pushed nurse and nurse landed on the floor and hit her right leg on double door. Nurse was assisted off from the floor by two staff members. Resident was then attended by two staff members. Family, Md, and ADON notified. Progress notes dated 05/15/2023, 05/16/2023, 05/16/2023, 05/22/2023, and 05/24/2023 reflected LVN E documented the following on each date, Resident is up wandering up and down the hallway, checked V/S and gave all medications as ordered, tolerated well, resident is at high risk for elopement, requires constant redirection by staff members. Resident requires 2 to 3 staff members to provide cares, resident has a very aggressive behavior, such as kicking and biting. Resident is developing a new habit, messing with her own poop, staff members has to help her thoroughly cleaned her and sanitize all the places she touched. Will continue to monitor. Progress notes dated 06/06/2023 reflected LVN E documented, Resident was seen be states surveyor possibly eating and notified first nurse aide and next the nurse who was told by the DON immediately notified the MD at 12:33PM, that was 3 minutes after this nurse was notified, MD immediately responded and ordered to call poison control center and checked resident's V/S, BP .poison control advised us to rinse resident's mouth and provide more fluids, we did as ordered, no S/S of nausea or vomiting noted at this time. Will continue to monitor resident and continue to encourage fluids. Called poison control regarding possible ingestion of deodorant. Poison control indicated that a possible adverse effect would b, mild GI upset, limited diarrhea, and upset stomach. Was told to monitor for upset stomach and encourage fluids. Case #75554424. Observation and interview on 06/07/2023 at 11:45AM revealed Resident #1, in the hall facing the patio, eating a stick of deodorant with a plastic spoon. Resident #1 turned the deodorant stick up and used the spoon to scoop chunks of the deodorant from the container and then ate it. CNA B and LVN C were observed around the corner on the room hall passing lunch trays. The surveyor called down the hall to notify LVN C and CNA B that Resident #1 was eating the deodorant stick. CNA B came to the hall where Resident #1 was and stated she could not take the deodorant from Resident #1 without assistance because Resident #1 had bitten her in the past when she took something away from her. CNA B called for LVN C to assist. During the time LVN C came to assist, Resident #1 was observed placing the deodorant container in a sock she was holding. LVN C was observed trying to get the sock that contained the deodorant stick from Resident #1. Resident #1 refused to give it and LVN C then distracted Resident #1 from her left side while CNA B took the sock from Residnet#1's grip. Resident #1 still had the plastic spoon in her hand and walked down the hall to the rear door exit area where she began taking items from the trash can. Resident #1 used the spoon to scrape particles of deodorant from her arms and licked the spoon. An observation and interview on 06/07/2023 at 11:50AM, with LVN C and CNA B, revealed the deodorant container was empty. LVN C said Resident #1 could get very aggressive when staff took items from her that she should not have. LVN C said Resident #1 constantly wandered from room to room taking any items she could find. LVN C stated the deodorant stick was not from the facility and may have been brought into the secured unit by another resident's family members. He said there was one resident in the secured unit who did have personal care items in her room because she was only diagnosed with schizophrenia and able to do her own personal care. He said each room had child covers on the doorknob which prevented residents from entering rooms, however, Resident #1 was able to open doors with the child cover on. CNA B stated Resident #1 needed constant supervision because she wandered from room to room taking anything she could find. She stated when staff attempted to redirect Resident #1 or take something from her she would be aggressive. An interview on 06/07/2023 at 12:16PM with the Administrator revealed she was informed that Resident #1 had eaten the deodorant. She stated she did not know where Resident #1 could have gotten the deodorant from because all personal care items should have been secured in the shower room. She said family members often brought items into the secured unit for residents and left the items in their room. She said she directed staff to do a sweep of the secured unit to ensure there were no more hazardous items accessible to residents; she stated they did find additional personal care items in resident rooms and removed them. She said she was not aware of any resident in the secured unit who kept personal care items in their room but the DON may have told her about such a resident but was not sure. She said there were child covers on the doorknobs in the secured unit to prevent residents from entering rooms. She said she had not been informed Resident #1 could open the doors with the child covers on. She stated typically one nurse and two CNAs worked in the secured unit to ensure appropriate supervision of the 17 residents. She stated the facility's policy stated that all personal and hazardous items should be locked to prevent a risk of harm to residents. She said she understood Resident #1's eating deodorant posed an immediate concern for a risk of harm to all the residents in the secured unit. An observation and interview on 06/07/2023 at 12:23PM, in the secured unit, with the Administrator and DON revealed Resident #1 in the room hall with a small can of shaving cream. Resident #1 was trying to push the button at the top of the can and held the can to her mouth but was unsuccessful in getting the contents to come out. The DON was observed taking the can of shaving cream from Resident #1. When asked if they had removed all the hazardous items from the secured unit, The Administrator stated staff had already done that and stated she did not know where Resident #1 got the can of shaving cream from. An observation and interview on 06/07/2023 at 12:25PM with Resident #2 revealed she recently came to the facility. She stated she had her own room and was allowed to keep her personal care items in her room. She stated she hid the items in her dresser drawers as residents often came inter her room and took them. She said she hid her purse under a chair for the same reason. Resident #2's purse was observed stuffed under a chair in her room and personal care items (toothpaste, shampoo, and deodorant) were observed in the top drawer of the dresser in her room. An interview on 06/07/2023 at 12:40PM with LVN C revealed Resident #1 was hard to redirect and constantly wandered from room to room. He said Resident #1 likely got the deodorant from another resident's room. He stated staff do not check rooms regularly for items that may be hazardous to residents. He said residents' family often bring items and leave them in the residents' rooms. He stated he noted Resident #1 started to mess with her poop and said he had never seen her eat anything non-edible before. He stated his note referred to her taking her adult diaper off and smearing poop all over. An interview on 06/07/2023 at 12:52PM with CNA B revealed Resident #1 would get into anything she could including briefs, wipes, and deodorant. She said she had not seen her eat anything hazardous but Resident #1 had to be supervised all the time to ensure her safety. She said she thought Resident #1 may have taken the deodorant from the shower room because she had found the lid to the deodorant stick in the locked shower room when she completed the sweep. She stated the shower room was always locked but this morning a hospice aide was in the secured unit caring for a resident and Resident #1 could have gotten the deodorant while the aide was showering another resident. CNA B stated during her sweep of the secured unit, she found five deodorants in five different rooms, soap, two large bottles of lotion, and three large bottles of shampoo. She said the items were labeled Keep out of reach of children. CNA B stated Resident #1 bit her on her breast, on 04/19/2023, when she tried to take lotion from Resident #1. She stated she informed the DON and Administrator. She stated Human Resources had her go to the hospital for treatment. She stated she had not receive any in-service related to handling Resident #1's aggressive behavior. An interview on 06/07/2023 at 1:41PM with the Administrator revealed when CNA B was bit by Resident #1 she was primarily concerned with ensuring CNA B was taken care of and followed up with human resources. She said she did not follow up with any behaviors that may have led to why Resident #1 bit CNA B and ultimately kept Resident #1 safe. She said in reviewing progress notes, the staff knew Resident #1 wandered and got into any items she could find; all staff could assume Resident #1 could possibly consume them as well. She stated she should have followed up to ensure the safety of Resident #1. She stated the DON and ADON were responsible for reviewing the progress notes to ensure information was brought to her. She stated she was not made aware of an incident where Resident #1 pushed RN A to the ground on 4/13/2023. She said the incident may have been reported to human resources. She said it should have been brought to her attention by staff or the DON because it was documented in the progress notes. She said she expected the DON and ADON to review the progress notes and bring any concerns to her attention. She stated she expected staff to ensure residents, who did not have the cognitive ability to understand their actions, were safe and any hazards were secured to prevent residents from any harm. An interview on 06/07/2023 at 2:25PM with RN A revealed she was pushed to the ground on 4/13/2023, when she tried to take a soiled adult brief from Resident #1. RN A said Resident #1 came out of her room with the soiled brief in her hand. She said the brief was tore and Resident #1 had feces on her hands, face and inside her mouth. She stated she believed Resident #1 was eating the brief. RN A stated she had never seen Resident #1 eat deodorant but was not surprised as she wandered from room to room looking for anything she could find. RN A stated she told the DON, ADON, Administrator and Human Resources about the incident. She stated Human Resources directed her to get medical attention. RN A stated there were no care plan changes, in-services, or direction from the DON or ADON to address Resident #1's behaviors. In an interview on 06/07/2023 at 3:00PM the Social Worker stated she and the MDS Coordinator held a care plan meeting for Resident #1 on 05/23/2023. She stated there was no information about Resident #1 eating poop or any other non-consumable items. She stated she gained resident information from the DON or ADON regarding issues or concerns and concerns of the resident's specific behaviors should have been relayed to her and the MDS Coordinator for care planning. She said Resident #1's aggressiveness was discussed in the care plan but no specific details regarding when aggression occurred or why. An interview on 06/07/2023 at 3:30PM with the DON revealed she had not seen any of the progress notes related to Resident #1. She said it was her and the ADON's responsibility to review the notes and care plans to ensure any concerns were addressed. She said she held a stand-up meeting every morning at 10:00AM where issues would be discussed. She said she was working with staff to ensure they brought concerns to the stand-up meetings but realized they had not always done that. She said she was aware Resident #1 had aggressive behaviors but did not know why. She stated she knew Resident #1 had bitten CNA B but did not why. She said she did not know Resident #1 pushed RN A to the ground when she tried to take a soiled adult diaper from her. The DON said Resident #1's aggressive behaviors that occurred when staff tried to take things from her should have been in the care plan. She stated there should not be any potentially hazardous items accessible to any resident in the secured because they did not have the mental capacity to know what could be consumed. She said Resident #1 eating deodorant posed a potential risk of harm and could have been avoided. An interview on 06/07/2023 at 4:22PM with CNA D revealed Resident #1 was aggressive when staff tried to redirect her or take something she should not have away. She said she had seen Resident #1 eat feces from her adult diaper and told the nursing staff but did not know what was done from there. She stated she did not recall the nurse she told or the time she observed Resident #1 eat feces from her adult diaper. She said Resident #1 needed constant supervision because she constantly looked for anything she could get into. An interview on 06/07/2023 at 4:35PM with MDS Coordinator/LVN revealed she and the SW conducted a care plan meeting for Resident #1 on 05/23/2023. She said information for Resident #1's care plan would be communicated to her by the ADON or the DON during morning meetings. She said she was aware of Resident #1 biting a staff member but was not sure why it occurred. She said she was not informed of specific circumstances that may have caused Resident's #1's behavior. She stated those circumstances should be communicated from nursing staff and reflected in the care plan. An interview on 06/07/2023 at 5:03PM with the ADON revealed she had not reviewed Resident #1's progress notes. She said it was the DON and her responsibility to review them for any concerns related to residents. She said that information would be passed on to the MDS Coordinator to be addressed in care plans. The ADON said she was not aware Resident #1 was messing with her poop and did not know RN A was pushed to the ground by Resident #1 when she took a soiled adult diaper from her. She stated specific interventions should have been reflected in the care plan to ensure Resident #1's safety. She said the facility did not have a system in place to ensure rooms were checked for hazardous items. She said since Resident #1 wandered and got into things, the facility needed to ensure her safety by making sure all potentially hazardous items were secured. In an interview on 06/07/2023 at 5:15PM, the Administrator stated she dropped the ball. She said in hindsight, she should have followed up with the DON regarding Resident #1's aggression. She said she should have investigated as to the circumstances of Resident #1's aggression. She stated there was not an incident report done when Resident #1 bit CNA E or pushed RN A. She said she and the DON should have known about Resident #1 eating a solid adult diaper. She said she felt like she needed to have better communication with nursing staff to ensure all resident's safety. She said the facility should have a system in place to ensure resident did not have access to non-consumable items and ensure their safety. An interview on 06/07/2023 at 5:57PM with the COO revealed he expected staff to ensure all residents were safe. He stated the DON and ADON should have known about the context of Resident #1's behaviors and ensured the care plan reflected specific issues. He stated there seemed to be a breakdown in communication between the front-line staff, nurse management, and the Administrator. Record review of the facility's incident / accident report between 03/01/2023 to 06/07/2023 revealed no record of incidents involving Resident #1, CNA B, or RN A. Record review of the MSDS for the deodorant consumed on 06/07/2023 by Resident #1 revealed Hazards Identification: Eye: Classification Eye Contact may cause mild, transient irritation. Some redness and/or stinging may occur. Ingestion: Product used as intended is not expected to cause gastrointestinal irritation. Accidental ingestion of undiluted product may cause mild gastrointestinal irritation with nausea, vomiting and diarrhea. Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated 12/2009 reflected, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.including time and date .nature .circumstances .name of witnesses .complete report sent to the DON within 24 hours .DON shall ensure that the Administrator receives a copy of the Report . Record review of the facility's policy titled, Safety and Supervision of Residents, dated 12/2008 reflected, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA and A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. Staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident, and the MDS. Implementing interventions to reduce accident risk and hazards shall include the following: communicating specific interventions to all relevant staff, providing training .documenting interventions . Record review of the facility's policy titled, Care Plans - Comprehensive, dated 12/2010 reflected, An individualized comprehensive care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental, and psychosocial needs is developed for each resident. Each resident's comprehensive care plan is designed to: .incorporate identified problems .incorporate risk factors associated with identified problems The Administrator was notified on 06/08/2023 at 9:30AM, that an Immediate Jeopardy had been identified due to the above failures. The IJ Template was provided to the Administrator on 06/08/2023 at 9:45AM and she was informed the POR was due to HHSC by 12:00PM on 06/08/2023. The Plan of Removal (POR) was accepted on 06/08/2023 at 4:20PM. The Plan of Removal reflected the following: Immediate Corrective Action for residents affected by the alleged deficient practice: The resident who allegedly ingested deodorant was assessed, all vital signs within normal limits. Despite finding no evidence of deodorant within her mouth, the resident's mouth was rinsed, fluids encouraged. Medical director, poison control, and family were notified. The medical director instructed facility to continue to monitor for signs of GI distress. This deficient practice had the potential to affect 17 residents residing on the secure unit, however, no other resident was found to be affected. The secure unit was swept for personal care items on 06/07/23 and again on 06/08/23. All personal care items found were removed from resident rooms and given to the charge nurse to be secured behind locked doors, including items from resident who was previously reluctant to let them go. All family members were called on 06/07/2023 and informed that personal care items must be labeled and turned into management staff or nursing to be locked for the safety of all residents. Signs were also posted at the front of the building to turn in personal care items which will be made available for use at the appropriate time. Care plans updated to reflect the residents wandering and aggression being further agitated by attempts to remove items or redirect resident. The care plan updated to reflect the residents alleged tendency to ingest non-food items. Staff members in-serviced on the need to lock personal care items out of reach of residents, particularly those who tend to become confused or exhibit behaviors related to wandering and picking up items found in other rooms. Education occurred on 06/07/23 and again on 06/08/23 and will continue. Actions taken to prevent a serious adverse outcome from recurring: Management staff swept the rest of the facility on 06/08/2023 and ensured personal care items were secured appropriately. Anything found not stored appropriately was labeled by resident name and given to charge nurses to secure in locked room on 300 hall. Additional checks were conducted of locked supply, shower, and utility rooms. The facility will continue to monitor to ensure the security of these areas. Additional education completed on the need to keep personal care items away from residents who might become confused or exhibit behaviors. Ad Hoc QAPI Meeting was held on 06/08/2023 to discuss the incident, make staff members aware of the new policy on personal care items. MD and management staff present, corporate staff available by phone. Additional sweeps of the area daily by staff members x 2 weeks, then weekly for 2 weeks, and monthly thereafter. The facility will utilize a daily behavior monitoring sheet for changes in behavior/condition. This sheet will be reviewed weekly and as necessary, changes in behavior or condition will be discussed and care planned appropriately. When will actions be complete: Coral Nursing and Rehabilitation of Arlington requests the removal of the immediate jeopardy on 06/08/2023 Monitoring of the facility's Plan of Removal included the following: An interview on 06/09/2023 at 1:30PM with the Administrator revealed 57 of 110 staff have been in-serviced regarding the Behavior monitoring log and Securing personal care items. She stated the management team had been completed to ensure any hazardous items were secured for the safety of residents. She stated sweeps will be completed daily by the management team for two weeks and then weekly. She said she would be completing the sweeps on weekends until a weekend supervisor was hired. She stated she would be addressing progress notes, the results of sweeps, and any aggressive incidents daily stand-up meetings. She stated the management team participated in an Ad Hoc QUPI meeting on 06/08/2023 wiht the medical director, Corporate RN, DON, ADON, and MDS Coordinator present. She said she had implemented a behavioral log to be completed by staff daily and monitored by the DON in an effort to catch any changes in resident behaviors. She said the DON was expected to report any changes in resident behavior to her, daily. She stated the families of all Secured Unit residents were contacted and instructed that any items they bring to the facility must be secured by staff. A record review of the medical record for Resident #1 revealed she was assessed for complications and ongoing monitoring of adverse effects. Resident #1's care plan was updated to reflect the residents wandering and aggression, further agitated by attempts to remove items or redirect the resident and resident's tendency to ingest non-food items. Observations on 06/09/2023 from 3:00PM to 3:10PM revealed all rooms and areas in the memory care unit were free from hazardous products. Interviews were conducted on 06/09/2023 from 12:40 PM to 3:00 PM with 18 staff members (6 CNAs, 2 RNs, 4 LVNs, 2 MAs, 1 Restorative Aide, and 3 Housekeeping staff) from multiple shifts. The staff all indicated they had been in-serviced on safety awareness, which included a list of prohibited items in memory care, how hazardous items should be stored, the procedures on storing prohibited items that family members might bring for resident use, ongoing sweeps for hazardous items and their security, and procedures in case they were not sure if an item was hazardous. In a telephone interview on 06/09/2023 at 2:55PM, the Corporate RN said he understood the components of the IJ and was not aware the DON and ADON had not been reviewing the progress notes. He said it was impossible to complete a comprehensive care plan without considering behaviors. He said he expected the Administrator to ensure residents were safe from hazardous items. He said he expected the DON to ensure behaviors were monitored and communicated to staff for appropriate care planning. He said he provided a behavior log to the Administrator to assist with this. He said he in-serviced the Administrator, DON, ADON, and MDS Coordinator on the need to address changes in resident behavior in care planning, reviewing progress notes to ensure behaviors are addressed and care planed appropriately, and ensuring resident were cared for in a safe environment. Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Personal Care Items .Inform family members that all personal care items must be labeled and turned into management staff or nursing staff to be locked for the safety of all residents .Personal care items include but are not limited to the following: Soap, shampoo, conditioner, deodorant, lotions, mouthwash, toothpaste, hand sanitizer, and other potentially hazardous chemical items .In continuing sweeps, if such items are found please remove them from the room. Make sure they are labeled and give it to the nursing staff to be secured revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. Record review of in-service dated 06/07/2023, 06/08/2023, and 06/09/2023 on Behavior Monitoring Log .the facility will distribute behaviors monitoring sheets to the nursing staff to be filled out daily. The DON will collect the sheets weekly or as necessary to be discussed at the Standards of Care meeting. Any changes will be communicated to management staff in the meeting and care planned appropriately. Changes will also be discussed in the morning IDT meeting so all staff can be aware of changes, revealed 57 signatures from multiple shifts and multiple departments (RNs, LVNs, CNAs, MAs, Housekeeping, Laundry, and Maintenance) had received in-services which covered all aspects of the POR. Record review of signed in-service dated 06/09/2023 and conducted by the Corporate RN revealed the Administrator, DON, ADON, and MDS Coordinator were educated on their .responsibility that every resident within my facility receives quality, appropriate care .understand that changes in resident's behavior must be discussed promptly, with the DON, ADON, and IDT team for intervention and appropriate care planning .understand that it is my responsibility to periodically read and review the charts of my residents with behaviors, to ensure completeness and that all behaviors are addressed and care planned appropriately. Record review of the Behavior Monitoring Log reflected behavior, intervention and outcome codes with a monthly calendar noting day, evening, and night shifts. The Administrator was informed the Immediate Jeopardy was removed on 06/09/2023 at 4:18PM; however, the facility remained out of compliance at a scope of Pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.

Based on interview and record review, the facility failed to ensure residents had the right to be free from neglect for one (Resident #1) of four residents reviewed for neglect. RN A failed to provide necessary care and services when Resident #1 fell and sustained a hematoma to her forehead on [DATE]. RN A failed to promptly transfer Resident #1 to the hospital when the resident fell and sustained a hematoma to her forehead on [DATE] at approximately 8:30 p.m. The resident was not transferred to the hospital until 10:45 p.m. where she was diagnosed with [REDACTED]. The resident was admitted to the facility's intensive care unit, and she later expired at the hospital on [DATE] as a result of her injuries. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the investigation. These failures could affect the 12 residents who reside on the 100 Hall by placing them at risk for neglect due to a delay in treatment. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was an [AGE] year-old female whose most recent admission to the facility was [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact, able to both understand others and be understood by others, and she had no mood or behavioral symptoms. The resident required extensive assistance with surface-to-surface transfers and mobility via wheelchair. The resident had one fall without injury since her most recent admission to the facility. Resident #1's comprehensive care plan, revised on [DATE], reflected she was at high risk for increased bleeding related to the use of a blood thinning agent, and she was at risk for falls due to an actual fall on [DATE]. Resident #1's electronic nursing Progress Notes, entered by RN A on [DATE] at 6:18 p.m., reflected the following entries: Note Text: Late entry for incident for [DATE]- 2030 (8:30 p.m.) Nurse aide found patient on floor beside bed. Nurse aide called for writer and stated come quick, patient is on the floor. When writer arrived patient was sitting on the side of the bed. Vital signs taken .Patient has hematoma on the left anterior side of forehead. Patient is moaning and states she has a lot of pain. Patient helped back in bed by nurse aide and writer (RN A). Neuro checks initiated per protocol. Patient alert and oriented, no loss of consciousness noted. Ice applied to hematoma. [MEDICATION NAME] given for pain ,[DATE]. 2045 (8:45 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. 2100 (9:00 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. Patients states pain is better. Pain is ,[DATE]. 2105 (9:05 p.m.) Call to (family member). Informed (family member) of patient's fall. 2130 (9:30 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. 2224 (10:24 p.m.) Call placed to NP for (Physician I). Received order from (NP H) to send patient to (hospital). An electronic nursing Progress Note, entered by RN E on [DATE] at 12:44 a.m., reflected: (Patient) transferred to (hospital) at about 10:45 pm for further evaluation post fall at the request of NP. (Responsible Party) made aware. Resident #1's Medication Review Report, dated [DATE], included orders for: [MEDICATION NAME] 40 mg/0.4 ml (anticoagulant-blood thinner), inject 40 mg subcutaneously every morning; Aspirin 81 mg (blood thinner) every morning; [MEDICATION NAME] 75 mg (inhibits blood clotting) every morning; [MEDICATION NAME] 15 mg, (narcotic for pain relief) four times a day; and [MEDICATION NAME] 50 mg (pain relief) one tablet every six hours as needed for pain. An incident report prepared by RN A, dated [DATE] at 8:30 p.m., reflected the following: .Nurse aide found patient on floor beside bed. Nurse aide called writer and stated come quick, patient is on the floor. When writer arrived patient was sitting on the side of the bed. Vital signs taken .Patient has hematoma on the left anterior side of forehead. Patient is moaning and states she has a lot of pain. Patient helped back in bed by nurse aide and writer. The incident report reflected ice was applied to the resident's head, she was administered [MEDICATION NAME], and neurological checks were started per the facility's protocol. Record review of Resident #1's Neurological Evaluation Flow Sheet reflected RN A started neuro checks on [DATE] at 8:30 p.m., 8:45 p.m., 9:00 p.m., 9:15 p.m. and at 9:45 p.m. No further neuro checks were performed prior to the transfer to the hospital at 10:45 p.m. The facility's Provider Investigation Report, signed and dated by the Administrator on [DATE] reflected Resident #1 fell and sustained a subdural hematoma on [DATE] at 8:30 p.m. The facility's Investigation Summary was as follows: The Director of Nursing visited the facility on the 31st of December to review the fall and to begin investigation. The Director of Nursing called the charge nurse on duty when the fall occurred to investigate the circumstances around the fall. The charge nurse was working on her new admit when Resident #1 was found on the floor. The aide that discovered the resident on the floor called the charge nurse who came to the room and began the assessment and neuro checks. The resident had sustained a hematoma on the left forehead. The nurse called the family member and the physician. The family member asked the nurse to send out for a CAT scan to which the nurse replied, I would have to get an order. The nurse continued neuro checks with no abnormal findings. The resident was communicative with the nurse. The doctor/NP was reached and the resident was sent out to the emergency room . The resident was sent to ICU and later moved to med-surg. Summary: Resident #1 got up from bed and fell . The resident hit her head and sustained a hematoma on her left frontal area. Neuros were stated; family and physician notified. Resident was complaining about pain and was given medication which resident stated had help. Resident was later sent to the ER for evaluation. The hospital History & Physical report, dated [DATE], reflected Resident #1 was admitted to the hospital post-fall with a change in mental status. The report reflected the following: .This evening between ,[DATE] (8:30 p.m. - 9:30 p.m.) patient had an unwitnessed GLF (ground level fall) from her bed to the floor. Nursing home staff gave [MEDICATION NAME] post fall fro her pain. EMS estimate patient (sic) that the distance between the bed to the floor was ,[DATE] feet. Patient has a hematoma to to (sic) her left temple Patient is currently on [MEDICATION NAME] for arterial occlusions The hospital History & Physical report, further reflected the following: X-Ray Interpretation: .Interval increase in acute left parafalcine and left tentorial subdural hemorrhage previously measuring 1.6 cm in thickness and now measuring 2.6 cm at the posterior superior left parafalcine space. There is mass effect on the left cerebral hemisphere but no midline shift. There is partial effacement of the posterior left lateral ventricle. The hospital History and Physical reflected Resident #1 was admitted to the intensive care unit and would be receiving a neurosurgical consultation. An interview with RN A on [DATE] at 12:30 p.m. revealed she was very busy on the evening of [DATE] when Resident #1 fell . She stated about 8:15 p.m. that evening she was called down the hall by a CNA, who informed her that Resident #1 was on the floor. RN A stated she assessed the resident, and the resident had a bump on her head and was screaming in pain. She stated she applied ice to the resident's head and medicated the resident with [MEDICATION NAME] 50 mg. RN A stated she was so busy it was somewhat overwhelming. She stated she had new admissions that day including one resident with an IV that she needed to monitor closely, and another resident with behaviors who was striking out at other residents. She stated then Resident #1 fell and hit her head. RN A stated she did not ask for help. She stated she could not keep up with Resident #1's neuro checks, but she did the best she could. RN A stated she never considered that Resident #1 had recently been given [MEDICATION NAME] 15 mg prior to her fall. She stated the resident was in pain so she medicated her with [MEDICATION NAME] 50 mg. She stated Resident #1 was not able to explain what had happened, and the resident could not say what caused her to fall. RN A stated when she assessed Resident #1 she was aware the resident was being treated with [MEDICATION NAME], Aspirin, and [MEDICATION NAME]. She stated she was aware of the bleeding risks associated with anticoagulation therapy. RN A stated she did not think there were any contraindications in medicating Resident #1 for head pain. She stated she did not think about the bleeding risk or giving her pain medication, RN A stated she did not think Resident #1 had any cognitive changes even through Resident #1 could not explain what happened. RN A stated she thought it was because the resident had bumped her head. RN A stated she had only worked at the facility about two weeks and her previous employer's policy was residents could not be sent to the hospital without a physician's orders [REDACTED]. RN A stated it was her mistake, and she should have called 911 and sent the resident to the hospital. RN A stated she got Nurse Practitioner H's cell phone number from the on-coming nurse, and she called her. The Nurse Practitioner H responded with an order to send Resident #1 to the hospital. She stated the EMTs arrived quickly, and transported the resident to the hospital. She stated she monitored Resident #1 as much as possible with everything else that was happening that night. An interview with LVN F on [DATE] at 9:20 a.m. revealed she had worked late on [DATE] until about 8:30 p.m. to help with new admissions. Before she left, RN A told her Resident #1 had fallen and had a bump on her head. LVN F asked RN A if she needed help and was told no, so she left the facility. On her way home, LVN F stated she received a call from RN A. She stated RN A informed her she had tried to contact Resident #1's physician (Physician I), but the Physician I had not returned her call. LVN F told her to call the Physician I's NP (Nurse Practitioner H H). LVN F stated RN A did not inform her Resident #1's family instructed her to send Resident #1 to the hospital emergency room for evaluation because they wanted a CT scan. LVN F stated if she had been aware of the family's wishes she would have directed RN A to send Resident #1 to the hospital emergency room immediately without notifying the physician first. During her conversation with RN A, LVN F stated she was asked what the facility's policy and procedure for unwitnessed falls was. LVN F told her she needed to do an assessment on Resident #1 and start neurological (neuro) checks. She stated RN A told her she was not sure how to perform the neuro checks so LVN F explained what to do and how often she needed to do the neuro checks on Resident #1. LVN F stated Resident #1 could not explain what happened or how she fell . An interview with RN E on [DATE] at 9:00 a.m. revealed she arrived at the facility on [DATE] at approximately 10:00 p.m. She stated RN A gave report and said Resident #1's physician (Physician I) had still not returned her call related to Resident #1's fall. RN E stated at that time she gave RN A Nurse Practitioner H H's cell phone number, and she told her to call Nurse Practitioner H H. RN E stated RN A told her she was calling the physician and the office number, and she did not realize she needed to call the Nurse Practitioner after hours. She stated she prepared all the necessary documents for Resident #1 to transfer to the hospital. RN E stated she knew Resident #1 needed to be sent to the hospital emergency room . She stated resident's family was at the facility and was not happy with the delay in sending Resident #1 to the hospital. RN E stated RN A received an order for [REDACTED].#1 was transferred via ambulance to the hospital. RN E stated she received in-service training on [DATE] related to falls, assessment after falls, assessment before moving a resident, unwitnessed falls, and that neuro checks must be started. She stated she also received instruction that if a family requested a resident to be sent to the hospital for evaluation and treatment, they must honor the request. The were also trained to monitor for cognitive changes with head injuries and to send residents to the hospital within one hour. No pain medications with head injuries respond quickly and look at the whole situation with incidents. If feeling overwhelmed ask for help. An interview with Nurse Practitioner H on [DATE] at 2:45 p.m. revealed she received a call from the facility notifying her Resident #1 fell and had a head injury, a hematoma on [DATE]. She stated she was informed the resident's family wanted the resident sent to the hospital for evaluation and treatment, and she gave the order to transfer the resident to the hospital. Nurse Practitioner H stated she did not evaluate or treat the resident after she fell on [DATE] so there was no way to say if a delay in sending Resident #1 to hospital caused a decline in her condition. An interview with Resident #1's family member on [DATE] at 3:43 p.m. revealed how upset the family was about the delay in treatment for [REDACTED]. The family member stated he/she received a telephone call from another family member, who had been informed Resident #1 had fallen and had a bump on her head with complaints of head pain. The family member stated Resident #1 was diagnosed with [REDACTED]. The family member stated prior to the fall Resident #1 was alert and oriented to person, place, and time; however, since the fall the resident had cognitive changes related to the head injury she sustained from the fall. The family member stated the resident was now in the hospital's hospice unit. An interview with Resident #1's family member on [DATE] at 1:40 p.m. revealed Resident #1 passed away on [DATE] in the hospital's hospice unit. An interview with the Administrator and DON on [DATE] at 10:00 a.m. revealed the Administrator had conducted an investigation into the incident and believed she established a time line of the incident. She stated Resident #1's family was in the facility at the resident's bedside until approximately 7:30 p.m. She stated the CNA, who worked the 100 Hall, had returned to the floor after her lunch break at approximately 8:30 p.m., and that was when she found Resident #1 on the floor during her rounds. The CNA notified the nurse, and after the nurse assessed Resident #1, she medicated her for head pain with [MEDICATION NAME] 100 mg. During this same interview, the DON stated she immediately provided a one-on-one counseling for RN A related to falls with injury, and advised her of what steps needed to be taken per the facility's policy and procedure when a resident was being treated with an anticoagulant and had a head injury. The DON stated she issued a verbal warning to RN A. An interview with the DON on [DATE] at 10:15 a.m. revealed she told RN A if a family expressed the desire for a resident to be sent to the hospital for evaluation and treatment that request was honored, and the physician was notified after the resident was sent to the hospital. The DON stated she told RN A when a resident had a fall the nurse must conduct a full body assessment and review the resident's medications, including always checking for blood thinners. The DON stated she also told RN A that pain medications could mask neurological changes when there was a head injury, and no pain medications should be administered until after the physician assessed the resident. The DON stated RN A told her she gave Resident #1 the pain medication because the resident was screaming in pain. The DON stated RN A should not have delayed Resident #1's transfer to the hospital for over two hours. The DON stated she mentored RN A closely hoping she would grow into a strong RN. The DON said RN A typically worked the 100 Hall and never had more than 12 residents. Interviews with LVN C on [DATE] at 1:50 p.m., RN B on [DATE] at 2:00 p.m., LVN D on [DATE] at 2:10 p.m., and LVN G on [DATE] at 2:25 p.m. revealed they had all received in-service training on [DATE] regarding falls, assessment following a fall, assessment before moving a resident, and neuro checks. The training included honoring family requests for residents to be sent to the hospital for evaluation and treatment, monitoring for cognitive changes with head injuries, and sending residents to the hospital within one hour. In addition, they stated they were also trained not to administer pain medications with head injuries, to respond quickly, looking at the whole situation, and requesting help if they felt overwhelmed. Review of the In-Service Summary and Attendance reports dated [DATE] revealed the facility provided in-service training to all of its licensed nurses on what to do when a resident experiences a fall with injury. The in-service included conducting an immediate assessment; evaluating medications, especially blood thinners; using clinical judgement to sent resident to the hospital; honoring family requests to send a resident to the hospital; and notifying DON or ADONs of all falls with assessment information completed. Review of the In-Service Summary and Attendance reports dated [DATE] revealed the facility provided in-service training to all of its licensed nurses regarding the procedure and assessment following a fall. The in-service training covered the specific expectations regarding conducting a thorough assessment of a resident post-fall to include physical and cognitive assessment of the resident, assessment of change of condition, and notification of physician. The facility's current Abuse Prohibition policy and procedure dated [DATE] reflected the following: .Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness . The facility's current Falls and Fall Risk Managing policy and procedure, revised [DATE], reflected the following: 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 try to minimize complications from falling. Steps in the procedure - After a Fall: .If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. .Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change the nursing staff will notify the practitioner immediately by phone . .Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; any changes in level of consciousness/responsiveness and overall function. It will note the presence or absence of significant change Identifying Complications of Falls: .Additionally staff and physician will identify significant potential complications of falling for each resident at risk for falling; (e.g., fracture in someone with [MEDICAL CONDITION] or bleeding in someone receiving anticoagulation). Falls-Clinical Protocol Assessment and Recognition .In addition, the nurse shall assess and document/report the following: .Neurological Status; .pain; .All current medications, especially those associated with dizziness or lethargy . On [DATE] at 3:30 p.m. the Administrator was notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and the DON stated since Resident #1's incident they had trained the majority of nursing staff on abuse/neglect and continued to monitor and in-service staff on procedure, assessment after falls was provide to all nurses on [DATE]. All this had been completed prior to the surveyor entering the facility on [DATE]. Interviews were conducted on [DATE] at 9:20 a.m. through 2:25 p.m. with the following staff: RN A, RN B, LVN C, LVN D, LVN F, and LVN G and through [DATE] at 9:00 a.m. with RN E. All nurses interviewed stated they received in-services related to abuse/neglect and procedures and assessment after a fall. The National Institutes of Health/U.S. National Library of Medicine Medline Plus, retrieved on [DATE], at https://medlineplus.gov/ency/article/ 3.htm, reflecting the following: Subdural hematoma A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. Causes A subdural hematoma is most often the result of a severe head injury. This type of subdural hematoma is among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in [MEDICAL CONDITION] and may lead to death. With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. In older adults, the veins are often already stretched because of brain shrinkage (atrophy) and are more easily injured. .The following increase the risk for a subdural hematoma: - Medicines that thin the blood (such as [MEDICATION NAME] or aspirin) .Medical conditions that make you blood clot poorly - Repeated head injury, such as from falls - Very young or very old age .Exams and Tests Get medical help right away after a head injury. Do no delay. Older adults should receive medical care if they show signs of memory problems or mental decline, even if they don't seem to have an injury. The health care provider will likely order a brain imaging test, such as a CT or MRI scan . A subdural hematoma is a an emergency condition. .Acute subdural hematomas have high rates of death and [MEDICAL CONDITION]. .A subdural hematoma is a medical emergency. Call 911 or your local emergency number, or go to an emergency room after a head injury. Do not delay. .Alternative Names Subdural hemorrhage . The facility's census, dated [DATE], reflected 115 residents resided in the facility.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #1) of four residents reviewed for abuse and neglect. RN A failed to provide necessary care and services when Resident #1 fell and sustained a hematoma to her forehead on [DATE]. RN A failed to promptly transfer Resident #1 to the hospital when the resident fell and sustained a hematoma to her forehead on [DATE] at approximately 8:30 p.m. The resident was not transferred to the hospital until 10:45 p.m. where she was diagnosed with [REDACTED]. The resident was admitted to the facility's intensive care unit, and she later expired at the hospital on [DATE] as a result of her injuries. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the investigation. These failures could affect the 12 residents who reside on the 100 Hall by placing them at risk for neglect due to a delay in treatment. Findings included: The facility's current Abuse Prohibition policy and procedure dated [DATE] reflected the following: .Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness . Resident #1's MDS assessment dated [DATE] reflected she was an [AGE] year-old female whose most recent admission to the facility was [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact, able to both understand others and be understood by others, and she had no mood or behavioral symptoms. The resident required extensive assistance with surface-to-surface transfers and mobility via wheelchair. The resident had one fall without injury since her most recent admission to the facility. Resident #1's comprehensive care plan, revised on [DATE], reflected she was at high risk for increased bleeding related to the use of a blood thinning agent, and she was at risk for falls due to an actual fall on [DATE]. Resident #1's electronic nursing Progress Notes, entered by RN A on [DATE] at 6:18 p.m., reflected the following entries: Note Text: Late entry for incident for [DATE]- 2030 (8:30 p.m.) Nurse aide found patient on floor beside bed. Nurse aide called for writer and stated come quick, patient is on the floor. When writer arrived patient was sitting on the side of the bed. Vital signs taken .Patient has hematoma on the left anterior side of forehead. Patient is moaning and states she has a lot of pain. Patient helped back in bed by nurse aide and writer (RN A). Neuro checks initiated per protocol. Patient alert and oriented, no loss of consciousness noted. Ice applied to hematoma. [MEDICATION NAME] given for pain ,[DATE]. 2045 (8:45 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. 2100 (9:00 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. Patients states pain is better. Pain is ,[DATE]. 2105 (9:05 p.m.) Call to (family member). Informed (family member) of patient's fall. 2130 (9:30 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. 2224 (10:24 p.m.) Call placed to NP for (Physician I). Received order from (NP H) to send patient to (hospital). An electronic nursing Progress Note, entered by RN E on [DATE] at 12:44 a.m., reflected: (Patient) transferred to (hospital) at about 10:45 pm for further evaluation post fall at the request of NP. (Responsible Party) made aware. Resident #1's Medication Review Report, dated [DATE], included orders for: [MEDICATION NAME] 40 mg/0.4 ml (anticoagulant-blood thinner), inject 40 mg subcutaneously every morning; Aspirin 81 mg (blood thinner) every morning; [MEDICATION NAME] 75 mg (inhibits blood clotting) every morning; [MEDICATION NAME] 15 mg, (narcotic for pain relief) four times a day; and [MEDICATION NAME] 50 mg (pain relief) one tablet every six hours as needed for pain. An incident report prepared by RN A, dated [DATE] at 8:30 p.m., reflected the following: .Nurse aide found patient on floor beside bed. Nurse aide called writer and stated come quick, patient is on the floor. When writer arrived patient was sitting on the side of the bed. Vital signs taken .Patient has hematoma on the left anterior side of forehead. Patient is moaning and states she has a lot of pain. Patient helped back in bed by nurse aide and writer. The incident report reflected ice was applied to the resident's head, she was administered [MEDICATION NAME], and neurological checks were started per the facility's protocol. Record review of Resident #1's Neurological Evaluation Flow Sheet reflected RN A started neuro checks on [DATE] at 8:30 p.m., 8:45 p.m., 9:00 p.m., 9:15 p.m. and at 9:45 p.m. No further neuro checks were performed prior to the transfer to the hospital at 10:45 p.m. The facility's Provider Investigation Report, signed and dated by the Administrator on [DATE] reflected Resident #1 fell and sustained a subdural hematoma on [DATE] at 8:30 p.m. The facility's Investigation Summary was as follows: The Director of Nursing visited the facility on the 31st of December to review the fall and to begin investigation. The Director of Nursing called the charge nurse on duty when the fall occurred to investigate the circumstances around the fall. The charge nurse was working on her new admit when Resident #1 was found on the floor. The aide that discovered the resident on the floor called the charge nurse who came to the room and began the assessment and neuro checks. The resident had sustained a hematoma on the left forehead. The nurse called the family member and the physician. The family member asked the nurse to send out for a CAT scan to which the nurse replied, I would have to get an order. The nurse continued neuro checks with no abnormal findings. The resident was communicative with the nurse. The doctor/NP was reached and the resident was sent out to the emergency room . The resident was sent to ICU and later moved to med-surg. Summary: Resident #1 got up from bed and fell . The resident hit her head and sustained a hematoma on her left frontal area. Neuros were stated; family and physician notified. Resident was complaining about pain and was given medication which resident stated had help. Resident was later sent to the ER for evaluation. The hospital History & Physical report, dated [DATE], reflected Resident #1 was admitted to the hospital post-fall with a change in mental status. The report reflected the following: .This evening between ,[DATE] (8:30 p.m. - 9:30 p.m.) patient had an unwitnessed GLF (ground level fall) from her bed to the floor. Nursing home staff gave [MEDICATION NAME] post fall fro her pain. EMS estimate patient (sic) that the distance between the bed to the floor was ,[DATE] feet. Patient has a hematoma to to (sic) her left temple Patient is currently on [MEDICATION NAME] for arterial occlusions The hospital History & Physical report, further reflected the following: X-Ray Interpretation: .Interval increase in acute left parafalcine and left tentorial subdural hemorrhage previously measuring 1.6 cm in thickness and now measuring 2.6 cm at the posterior superior left parafalcine space. There is mass effect on the left cerebral hemisphere but no midline shift. There is partial effacement of the posterior left lateral ventricle. The hospital History and Physical reflected Resident #1 was admitted to the intensive care unit and would be receiving a neurosurgical consultation. An interview with RN A on [DATE] at 12:30 p.m. revealed she was very busy on the evening of [DATE] when Resident #1 fell . She stated about 8:15 p.m. that evening she was called down the hall by a CNA, who informed her that Resident #1 was on the floor. RN A stated she assessed the resident, and the resident had a bump on her head and was screaming in pain. She stated she applied ice to the resident's head and medicated the resident with [MEDICATION NAME] 50 mg. RN A stated she was so busy it was somewhat overwhelming. She stated she had new admissions that day including one resident with an IV that she needed to monitor closely, and another resident with behaviors who was striking out at other residents. She stated then Resident #1 fell and hit her head. RN A stated she did not ask for help. She stated she could not keep up with Resident #1's neuro checks, but she did the best she could. RN A stated she never considered that Resident #1 had recently been given [MEDICATION NAME] 15 mg prior to her fall. She stated the resident was in pain so she medicated her with [MEDICATION NAME] 50 mg. She stated Resident #1 was not able to explain what had happened, and the resident could not say what caused her to fall. RN A stated when she assessed Resident #1 she was aware the resident was being treated with [MEDICATION NAME], Aspirin, and [MEDICATION NAME]. She stated she was aware of the bleeding risks associated with anticoagulation therapy. RN A stated she did not think there were any contraindications in medicating Resident #1 for head pain. She stated she did not think about the bleeding risk or giving her pain medication, RN A stated she did not think Resident #1 had any cognitive changes even through Resident #1 could not explain what happened. RN A stated she thought it was because the resident had bumped her head. RN A stated she had only worked at the facility about two weeks and her previous employer's policy was residents could not be sent to the hospital without a physician's orders [REDACTED]. RN A stated it was her mistake, and she should have called 911 and sent the resident to the hospital. RN A stated she got Nurse Practitioner H's cell phone number from the on-coming nurse, and she called her. The Nurse Practitioner H responded with an order to send Resident #1 to the hospital. She stated the EMTs arrived quickly, and transported the resident to the hospital. She stated she monitored Resident #1 as much as possible with everything else that was happening that night. An interview with LVN F on [DATE] at 9:20 a.m. revealed she had worked late on [DATE] until about 8:30 p.m. to help with new admissions. Before she left, RN A told her Resident #1 had fallen and had a bump on her head. LVN F asked RN A if she needed help and was told no, so she left the facility. On her way home, LVN F stated she received a call from RN A. She stated RN A informed her she had tried to contact Resident #1's physician (Physician I), but the Physician I had not returned her call. LVN F told her to call the Physician I's NP (Nurse Practitioner H H). LVN F stated RN A did not inform her Resident #1's family instructed her to send Resident #1 to the hospital emergency room for evaluation because they wanted a CT scan. LVN F stated if she had been aware of the family's wishes she would have directed RN A to send Resident #1 to the hospital emergency room immediately without notifying the physician first. During her conversation with RN A, LVN F stated she was asked what the facility's policy and procedure for unwitnessed falls was. LVN F told her she needed to do an assessment on Resident #1 and start neurological (neuro) checks. She stated RN A told her she was not sure how to perform the neuro checks so LVN F explained what to do and how often she needed to do the neuro checks on Resident #1. LVN F stated Resident #1 could not explain what happened or how she fell . An interview with RN E on [DATE] at 9:00 a.m. revealed she arrived at the facility on [DATE] at approximately 10:00 p.m. She stated RN A gave report and said Resident #1's physician (Physician I) had still not returned her call related to Resident #1's fall. RN E stated at that time she gave RN A Nurse Practitioner H H's cell phone number, and she told her to call Nurse Practitioner H H. RN E stated RN A told her she was calling the physician and the office number, and she did not realize she needed to call the Nurse Practitioner after hours. She stated she prepared all the necessary documents for Resident #1 to transfer to the hospital. RN E stated she knew Resident #1 needed to be sent to the hospital emergency room . She stated resident's family was at the facility and was not happy with the delay in sending Resident #1 to the hospital. RN E stated RN A received an order for [REDACTED].#1 was transferred via ambulance to the hospital. RN E stated she received in-service training on [DATE] related to falls, assessment after falls, assessment before moving a resident, unwitnessed falls, and that neuro checks must be started. She stated she also received instruction that if a family requested a resident to be sent to the hospital for evaluation and treatment, they must honor the request. The were also trained to monitor for cognitive changes with head injuries and to send residents to the hospital within one hour. No pain medications with head injuries respond quickly and look at the whole situation with incidents. If feeling overwhelmed ask for help. An interview with Nurse Practitioner H on [DATE] at 2:45 p.m. revealed she received a call from the facility notifying her Resident #1 fell and had a head injury, a hematoma on [DATE]. She stated she was informed the resident's family wanted the resident sent to the hospital for evaluation and treatment, and she gave the order to transfer the resident to the hospital. Nurse Practitioner H stated she did not evaluate or treat the resident after she fell on [DATE] so there was no way to say if a delay in sending Resident #1 to hospital caused a decline in her condition. An interview with Resident #1's family member on [DATE] at 3:43 p.m. revealed how upset the family was about the delay in treatment for [REDACTED]. The family member stated he/she received a telephone call from another family member, who had been informed Resident #1 had fallen and had a bump on her head with complaints of head pain. The family member stated Resident #1 was diagnosed with [REDACTED]. The family member stated prior to the fall Resident #1 was alert and oriented to person, place, and time; however, since the fall the resident had cognitive changes related to the head injury she sustained from the fall. The family member stated the resident was now in the hospital's hospice unit. An interview with Resident #1's family member on [DATE] at 1:40 p.m. revealed Resident #1 passed away on [DATE] in the hospital's hospice unit. An interview with the Administrator and DON on [DATE] at 10:00 a.m. revealed the Administrator had conducted an investigation into the incident and believed she established a time line of the incident. She stated Resident #1's family was in the facility at the resident's bedside until approximately 7:30 p.m. She stated the CNA, who worked the 100 Hall, had returned to the floor after her lunch break at approximately 8:30 p.m., and that was when she found Resident #1 on the floor during her rounds. The CNA notified the nurse, and after the nurse assessed Resident #1, she medicated her for head pain with [MEDICATION NAME] 100 mg. During this same interview, the DON stated she immediately provided a one-on-one counseling for RN A related to falls with injury, and advised her of what steps needed to be taken per the facility's policy and procedure when a resident was being treated with an anticoagulant and had a head injury. The DON stated she issued a verbal warning to RN A. An interview with the DON on [DATE] at 10:15 a.m. revealed she told RN A if a family expressed the desire for a resident to be sent to the hospital for evaluation and treatment that request was honored, and the physician was notified after the resident was sent to the hospital. The DON stated she told RN A when a resident had a fall the nurse must conduct a full body assessment and review the resident's medications, including always checking for blood thinners. The DON stated she also told RN A that pain medications could mask neurological changes when there was a head injury, and no pain medications should be administered until after the physician assessed the resident. The DON stated RN A told her she gave Resident #1 the pain medication because the resident was screaming in pain. The DON stated RN A should not have delayed Resident #1's transfer to the hospital for over two hours. The DON stated she mentored RN A closely hoping she would grow into a strong RN. The DON said RN A typically worked the 100 Hall and never had more than 12 residents. Interviews with LVN C on [DATE] at 1:50 p.m., RN B on [DATE] at 2:00 p.m., LVN D on [DATE] at 2:10 p.m., and LVN G on [DATE] at 2:25 p.m. revealed they had all received in-service training on [DATE] regarding falls, assessment following a fall, assessment before moving a resident, and neuro checks. The training included honoring family requests for residents to be sent to the hospital for evaluation and treatment, monitoring for cognitive changes with head injuries, and sending residents to the hospital within one hour. In addition, they stated they were also trained not to administer pain medications with head injuries, to respond quickly, looking at the whole situation, and requesting help if they felt overwhelmed. Review of the In-Service Summary and Attendance reports dated [DATE] revealed the facility provided in-service training to all of its licensed nurses on what to do when a resident experiences a fall with injury. The in-service included conducting an immediate assessment; evaluating medications, especially blood thinners; using clinical judgement to sent resident to the hospital; honoring family requests to send a resident to the hospital; and notifying DON or ADONs of all falls with assessment information completed. Review of the In-Service Summary and Attendance reports dated [DATE] revealed the facility provided in-service training to all of its licensed nurses regarding the procedure and assessment following a fall. The in-service training covered the specific expectations regarding conducting a thorough assessment of a resident post-fall to include physical and cognitive assessment of the resident, assessment of change of condition, and notification of physician. The facility's current Falls and Fall Risk Managing policy and procedure, revised [DATE], reflected the following: 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 try to minimize complications from falling. Steps in the procedure - After a Fall: .If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. .Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change the nursing staff will notify the practitioner immediately by phone . .Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; any changes in level of consciousness/responsiveness and overall function. It will note the presence or absence of significant change Identifying Complications of Falls: .Additionally staff and physician will identify significant potential complications of falling for each resident at risk for falling; (e.g., fracture in someone with [MEDICAL CONDITION] or bleeding in someone receiving anticoagulation). Falls-Clinical Protocol Assessment and Recognition .In addition, the nurse shall assess and document/report the following: .Neurological Status; .pain; .All current medications, especially those associated with dizziness or lethargy . On [DATE] at 3:30 p.m. the Administrator was notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and the DON stated since Resident #1's incident they had trained the majority of nursing staff on abuse/neglect and continued to monitor and in-service staff on procedure, assessment after falls was provide to all nurses on [DATE]. All this had been completed prior to the surveyor entering the facility on [DATE]. Interviews were conducted on [DATE] at 9:20 a.m. through 2:25 p.m. with the following staff: RN A, RN B, LVN C, LVN D, LVN F, and LVN G and through [DATE] at 9:00 a.m. with RN E. All nurses interviewed stated they received in-services related to abuse/neglect and procedures and assessment after a fall. The National Institutes of Health/U.S. National Library of Medicine Medline Plus, retrieved on [DATE], at https://medlineplus.gov/ency/article/ 3.htm, reflecting the following: Subdural hematoma A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. Causes A subdural hematoma is most often the result of a severe head injury. This type of subdural hematoma is among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in [MEDICAL CONDITION] and may lead to death. With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. In older adults, the veins are often already stretched because of brain shrinkage (atrophy) and are more easily injured. .The following increase the risk for a subdural hematoma: - Medicines that thin the blood (such as [MEDICATION NAME] or aspirin) .Medical conditions that make you blood clot poorly - Repeated head injury, such as from falls - Very young or very old age .Exams and Tests Get medical help right away after a head injury. Do no delay. Older adults should receive medical care if they show signs of memory problems or mental decline, even if they don't seem to have an injury. The health care provider will likely order a brain imaging test, such as a CT or MRI scan . A subdural hematoma is a an emergency condition. .Acute subdural hematomas have high rates of death and [MEDICAL CONDITION]. .A subdural hematoma is a medical emergency. Call 911 or your local emergency number, or go to an emergency room after a head injury. Do not delay. .Alternative Names Subdural hemorrhage . The facility's census, dated [DATE], reflected 115 residents resided in the facility.

Based on interview and record review, the facility failed to provide services, as outlined by the comprehensive care plan, that met professional standards of quality for one (Resident #1) of four residents reviewed for change of condition. RN A failed to provide necessary care and services when Resident #1 fell and sustained a hematoma to her forehead on [DATE]. RN A failed to promptly transfer Resident #1 to the hospital when the resident fell and sustained a hematoma to her forehead on [DATE] at approximately 8:30 p.m. The resident was not transferred to the hospital until 10:45 p.m. where she was diagnosed with [REDACTED]. The resident was admitted to the facility's intensive care unit, and she later expired at the hospital on [DATE] as a result of her injuries. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the investigation. These failures could affect the 12 residents who reside on the 100 Hall by placing them at risk for neglect due to a delay in treatment. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was an [AGE] year-old female whose most recent admission to the facility was [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact, able to both understand others and be understood by others, and she had no mood or behavioral symptoms. The resident required extensive assistance with surface-to-surface transfers and mobility via wheelchair. The resident had one fall without injury since her most recent admission to the facility. Resident #1's comprehensive care plan, revised on [DATE], reflected she was at high risk for increased bleeding related to the use of a blood thinning agent, and she was at risk for falls due to an actual fall on [DATE]. Resident #1's electronic nursing Progress Notes, entered by RN A on [DATE] at 6:18 p.m., reflected the following entries: Note Text: Late entry for incident for [DATE]- 2030 (8:30 p.m.) Nurse aide found patient on floor beside bed. Nurse aide called for writer and stated come quick, patient is on the floor. When writer arrived patient was sitting on the side of the bed. Vital signs taken .Patient has hematoma on the left anterior side of forehead. Patient is moaning and states she has a lot of pain. Patient helped back in bed by nurse aide and writer (RN A). Neuro checks initiated per protocol. Patient alert and oriented, no loss of consciousness noted. Ice applied to hematoma. [MEDICATION NAME] given for pain ,[DATE]. 2045 (8:45 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. 2100 (9:00 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. Patients states pain is better. Pain is ,[DATE]. 2105 (9:05 p.m.) Call to (family member). Informed (family member) of patient's fall. 2130 (9:30 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. 2224 (10:24 p.m.) Call placed to NP for (Physician I). Received order from (NP H) to send patient to (hospital). An electronic nursing Progress Note, entered by RN E on [DATE] at 12:44 a.m., reflected: (Patient) transferred to (hospital) at about 10:45 pm for further evaluation post fall at the request of NP. (Responsible Party) made aware. Resident #1's Medication Review Report, dated [DATE], included orders for: [MEDICATION NAME] 40 mg/0.4 ml (anticoagulant-blood thinner), inject 40 mg subcutaneously every morning; Aspirin 81 mg (blood thinner) every morning; [MEDICATION NAME] 75 mg (inhibits blood clotting) every morning; [MEDICATION NAME] 15 mg, (narcotic for pain relief) four times a day; and [MEDICATION NAME] 50 mg (pain relief) one tablet every six hours as needed for pain. An incident report prepared by RN A, dated [DATE] at 8:30 p.m., reflected the following: .Nurse aide found patient on floor beside bed. Nurse aide called writer and stated come quick, patient is on the floor. When writer arrived patient was sitting on the side of the bed. Vital signs taken .Patient has hematoma on the left anterior side of forehead. Patient is moaning and states she has a lot of pain. Patient helped back in bed by nurse aide and writer. The incident report reflected ice was applied to the resident's head, she was administered [MEDICATION NAME], and neurological checks were started per the facility's protocol. Record review of Resident #1's Neurological Evaluation Flow Sheet reflected RN A started neuro checks on [DATE] at 8:30 p.m., 8:45 p.m., 9:00 p.m., 9:15 p.m. and at 9:45 p.m. No further neuro checks were performed prior to the transfer to the hospital at 10:45 p.m. The facility's Provider Investigation Report, signed and dated by the Administrator on [DATE] reflected Resident #1 fell and sustained a subdural hematoma on [DATE] at 8:30 p.m. The facility's Investigation Summary was as follows: The Director of Nursing visited the facility on the 31st of December to review the fall and to begin investigation. The Director of Nursing called the charge nurse on duty when the fall occurred to investigate the circumstances around the fall. The charge nurse was working on her new admit when Resident #1 was found on the floor. The aide that discovered the resident on the floor called the charge nurse who came to the room and began the assessment and neuro checks. The resident had sustained a hematoma on the left forehead. The nurse called the family member and the physician. The family member asked the nurse to send out for a CAT scan to which the nurse replied, I would have to get an order. The nurse continued neuro checks with no abnormal findings. The resident was communicative with the nurse. The doctor/NP was reached and the resident was sent out to the emergency room . The resident was sent to ICU and later moved to med-surg. Summary: Resident #1 got up from bed and fell . The resident hit her head and sustained a hematoma on her left frontal area. Neuros were stated; family and physician notified. Resident was complaining about pain and was given medication which resident stated had help. Resident was later sent to the ER for evaluation. The hospital History & Physical report, dated [DATE], reflected Resident #1 was admitted to the hospital post-fall with a change in mental status. The report reflected the following: .This evening between ,[DATE] (8:30 p.m. - 9:30 p.m.) patient had an unwitnessed GLF (ground level fall) from her bed to the floor. Nursing home staff gave [MEDICATION NAME] post fall fro her pain. EMS estimate patient (sic) that the distance between the bed to the floor was ,[DATE] feet. Patient has a hematoma to to (sic) her left temple Patient is currently on [MEDICATION NAME] for arterial occlusions The hospital History & Physical report, further reflected the following: X-Ray Interpretation: .Interval increase in acute left parafalcine and left tentorial subdural hemorrhage previously measuring 1.6 cm in thickness and now measuring 2.6 cm at the posterior superior left parafalcine space. There is mass effect on the left cerebral hemisphere but no midline shift. There is partial effacement of the posterior left lateral ventricle. The hospital History and Physical reflected Resident #1 was admitted to the intensive care unit and would be receiving a neurosurgical consultation. An interview with RN A on [DATE] at 12:30 p.m. revealed she was very busy on the evening of [DATE] when Resident #1 fell . She stated about 8:15 p.m. that evening she was called down the hall by a CNA, who informed her that Resident #1 was on the floor. RN A stated she assessed the resident, and the resident had a bump on her head and was screaming in pain. She stated she applied ice to the resident's head and medicated the resident with [MEDICATION NAME] 50 mg. RN A stated she was so busy it was somewhat overwhelming. She stated she had new admissions that day including one resident with an IV that she needed to monitor closely, and another resident with behaviors who was striking out at other residents. She stated then Resident #1 fell and hit her head. RN A stated she did not ask for help. She stated she could not keep up with Resident #1's neuro checks, but she did the best she could. RN A stated she never considered that Resident #1 had recently been given [MEDICATION NAME] 15 mg prior to her fall. She stated the resident was in pain so she medicated her with [MEDICATION NAME] 50 mg. She stated Resident #1 was not able to explain what had happened, and the resident could not say what caused her to fall. RN A stated when she assessed Resident #1 she was aware the resident was being treated with [MEDICATION NAME], Aspirin, and [MEDICATION NAME]. She stated she was aware of the bleeding risks associated with anticoagulation therapy. RN A stated she did not think there were any contraindications in medicating Resident #1 for head pain. She stated she did not think about the bleeding risk or giving her pain medication, RN A stated she did not think Resident #1 had any cognitive changes even through Resident #1 could not explain what happened. RN A stated she thought it was because the resident had bumped her head. RN A stated she had only worked at the facility about two weeks and her previous employer's policy was residents could not be sent to the hospital without a physician's orders [REDACTED]. RN A stated it was her mistake, and she should have called 911 and sent the resident to the hospital. RN A stated she got Nurse Practitioner H's cell phone number from the on-coming nurse, and she called her. The Nurse Practitioner H responded with an order to send Resident #1 to the hospital. She stated the EMTs arrived quickly, and transported the resident to the hospital. She stated she monitored Resident #1 as much as possible with everything else that was happening that night. An interview with LVN F on [DATE] at 9:20 a.m. revealed she had worked late on [DATE] until about 8:30 p.m. to help with new admissions. Before she left, RN A told her Resident #1 had fallen and had a bump on her head. LVN F asked RN A if she needed help and was told no, so she left the facility. On her way home, LVN F stated she received a call from RN A. She stated RN A informed her she had tried to contact Resident #1's physician (Physician I), but the Physician I had not returned her call. LVN F told her to call the Physician I's NP (Nurse Practitioner H H). LVN F stated RN A did not inform her Resident #1's family instructed her to send Resident #1 to the hospital emergency room for evaluation because they wanted a CT scan. LVN F stated if she had been aware of the family's wishes she would have directed RN A to send Resident #1 to the hospital emergency room immediately without notifying the physician first. During her conversation with RN A, LVN F stated she was asked what the facility's policy and procedure for unwitnessed falls was. LVN F told her she needed to do an assessment on Resident #1 and start neurological (neuro) checks. She stated RN A told her she was not sure how to perform the neuro checks so LVN F explained what to do and how often she needed to do the neuro checks on Resident #1. LVN F stated Resident #1 could not explain what happened or how she fell . An interview with RN E on [DATE] at 9:00 a.m. revealed she arrived at the facility on [DATE] at approximately 10:00 p.m. She stated RN A gave report and said Resident #1's physician (Physician I) had still not returned her call related to Resident #1's fall. RN E stated at that time she gave RN A Nurse Practitioner H H's cell phone number, and she told her to call Nurse Practitioner H H. RN E stated RN A told her she was calling the physician and the office number, and she did not realize she needed to call the Nurse Practitioner after hours. She stated she prepared all the necessary documents for Resident #1 to transfer to the hospital. RN E stated she knew Resident #1 needed to be sent to the hospital emergency room . She stated resident's family was at the facility and was not happy with the delay in sending Resident #1 to the hospital. RN E stated RN A received an order for [REDACTED].#1 was transferred via ambulance to the hospital. RN E stated she received in-service training on [DATE] related to falls, assessment after falls, assessment before moving a resident, unwitnessed falls, and that neuro checks must be started. She stated she also received instruction that if a family requested a resident to be sent to the hospital for evaluation and treatment, they must honor the request. The were also trained to monitor for cognitive changes with head injuries and to send residents to the hospital within one hour. No pain medications with head injuries respond quickly and look at the whole situation with incidents. If feeling overwhelmed ask for help. An interview with Nurse Practitioner H on [DATE] at 2:45 p.m. revealed she received a call from the facility notifying her Resident #1 fell and had a head injury, a hematoma on [DATE]. She stated she was informed the resident's family wanted the resident sent to the hospital for evaluation and treatment, and she gave the order to transfer the resident to the hospital. Nurse Practitioner H stated she did not evaluate or treat the resident after she fell on [DATE] so there was no way to say if a delay in sending Resident #1 to hospital caused a decline in her condition. An interview with Resident #1's family member on [DATE] at 3:43 p.m. revealed how upset the family was about the delay in treatment for [REDACTED]. The family member stated he/she received a telephone call from another family member, who had been informed Resident #1 had fallen and had a bump on her head with complaints of head pain. The family member stated Resident #1 was diagnosed with [REDACTED]. The family member stated prior to the fall Resident #1 was alert and oriented to person, place, and time; however, since the fall the resident had cognitive changes related to the head injury she sustained from the fall. The family member stated the resident was now in the hospital's hospice unit. An interview with Resident #1's family member on [DATE] at 1:40 p.m. revealed Resident #1 passed away on [DATE] in the hospital's hospice unit. An interview with the Administrator and DON on [DATE] at 10:00 a.m. revealed the Administrator had conducted an investigation into the incident and believed she established a time line of the incident. She stated Resident #1's family was in the facility at the resident's bedside until approximately 7:30 p.m. She stated the CNA, who worked the 100 Hall, had returned to the floor after her lunch break at approximately 8:30 p.m., and that was when she found Resident #1 on the floor during her rounds. The CNA notified the nurse, and after the nurse assessed Resident #1, she medicated her for head pain with [MEDICATION NAME] 100 mg. During this same interview, the DON stated she immediately provided a one-on-one counseling for RN A related to falls with injury, and advised her of what steps needed to be taken per the facility's policy and procedure when a resident was being treated with an anticoagulant and had a head injury. The DON stated she issued a verbal warning to RN A. An interview with the DON on [DATE] at 10:15 a.m. revealed she told RN A if a family expressed the desire for a resident to be sent to the hospital for evaluation and treatment that request was honored, and the physician was notified after the resident was sent to the hospital. The DON stated she told RN A when a resident had a fall the nurse must conduct a full body assessment and review the resident's medications, including always checking for blood thinners. The DON stated she also told RN A that pain medications could mask neurological changes when there was a head injury, and no pain medications should be administered until after the physician assessed the resident. The DON stated RN A told her she gave Resident #1 the pain medication because the resident was screaming in pain. The DON stated RN A should not have delayed Resident #1's transfer to the hospital for over two hours. The DON stated she mentored RN A closely hoping she would grow into a strong RN. The DON said RN A typically worked the 100 Hall and never had more than 12 residents. Interviews with LVN C on [DATE] at 1:50 p.m., RN B on [DATE] at 2:00 p.m., LVN D on [DATE] at 2:10 p.m., and LVN G on [DATE] at 2:25 p.m. revealed they had all received in-service training on [DATE] regarding falls, assessment following a fall, assessment before moving a resident, and neuro checks. The training included honoring family requests for residents to be sent to the hospital for evaluation and treatment, monitoring for cognitive changes with head injuries, and sending residents to the hospital within one hour. In addition, they stated they were also trained not to administer pain medications with head injuries, to respond quickly, looking at the whole situation, and requesting help if they felt overwhelmed. Review of the In-Service Summary and Attendance reports dated [DATE] revealed the facility provided in-service training to all of its licensed nurses on what to do when a resident experiences a fall with injury. The in-service included conducting an immediate assessment; evaluating medications, especially blood thinners; using clinical judgement to sent resident to the hospital; honoring family requests to send a resident to the hospital; and notifying DON or ADONs of all falls with assessment information completed. Review of the In-Service Summary and Attendance reports dated [DATE] revealed the facility provided in-service training to all of its licensed nurses regarding the procedure and assessment following a fall. The in-service training covered the specific expectations regarding conducting a thorough assessment of a resident post-fall to include physical and cognitive assessment of the resident, assessment of change of condition, and notification of physician. The facility's current Falls and Fall Risk Managing policy and procedure, revised [DATE], reflected the following: 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 try to minimize complications from falling. Steps in the procedure - After a Fall: .If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. .Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change the nursing staff will notify the practitioner immediately by phone . .Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; any changes in level of consciousness/responsiveness and overall function. It will note the presence or absence of significant change Identifying Complications of Falls: .Additionally staff and physician will identify significant potential complications of falling for each resident at risk for falling; (e.g., fracture in someone with [MEDICAL CONDITION] or bleeding in someone receiving anticoagulation). Falls-Clinical Protocol Assessment and Recognition .In addition, the nurse shall assess and document/report the following: .Neurological Status; .pain; .All current medications, especially those associated with dizziness or lethargy . On [DATE] at 3:30 p.m. the Administrator was notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and the DON stated since Resident #1's incident they had trained the majority of nursing staff on abuse/neglect and continued to monitor and in-service staff on procedure, assessment after falls was provide to all nurses on [DATE]. All this had been completed prior to the surveyor entering the facility on [DATE]. Interviews were conducted on [DATE] at 9:20 a.m. through 2:25 p.m. with the following staff: RN A, RN B, LVN C, LVN D, LVN F, and LVN G and through [DATE] at 9:00 a.m. with RN E. All nurses interviewed stated they received in-services related to abuse/neglect and procedures and assessment after a fall. The National Institutes of Health/U.S. National Library of Medicine Medline Plus, retrieved on [DATE], at https://medlineplus.gov/ency/article/ 3.htm, reflecting the following: Subdural hematoma A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. Causes A subdural hematoma is most often the result of a severe head injury. This type of subdural hematoma is among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in [MEDICAL CONDITION] and may lead to death. With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. In older adults, the veins are often already stretched because of brain shrinkage (atrophy) and are more easily injured. .The following increase the risk for a subdural hematoma: - Medicines that thin the blood (such as [MEDICATION NAME] or aspirin) .Medical conditions that make you blood clot poorly - Repeated head injury, such as from falls - Very young or very old age .Exams and Tests Get medical help right away after a head injury. Do no delay. Older adults should receive medical care if they show signs of memory problems or mental decline, even if they don't seem to have an injury. The health care provider will likely order a brain imaging test, such as a CT or MRI scan . A subdural hematoma is a an emergency condition. .Acute subdural hematomas have high rates of death and [MEDICAL CONDITION]. .A subdural hematoma is a medical emergency. Call 911 or your local emergency number, or go to an emergency room after a head injury. Do not delay. .Alternative Names Subdural hemorrhage . The facility's census, dated [DATE], reflected 115 residents resided in the facility.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being consistent with the resident's comprehensive assessment and plan of care, for one (Resident #1) of four residents reviewed for change in condition. RN A failed to provide necessary care and services when Resident #1 fell and sustained a hematoma to her forehead on [DATE]. RN A failed to promptly transfer Resident #1 to the hospital when the resident fell and sustained a hematoma to her forehead on [DATE] at approximately 8:30 p.m. The resident was not transferred to the hospital until 10:45 p.m. where she was diagnosed with [REDACTED]. The resident was admitted to the facility's intensive care unit, and she later expired at the hospital on [DATE] as a result of her injuries. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the investigation. These failures could affect the 12 residents who reside on the 100 Hall by placing them at risk for neglect due to a delay in treatment. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was an [AGE] year-old female whose most recent admission to the facility was [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact, able to both understand others and be understood by others, and she had no mood or behavioral symptoms. The resident required extensive assistance with surface-to-surface transfers and mobility via wheelchair. The resident had one fall without injury since her most recent admission to the facility. Resident #1's comprehensive care plan, revised on [DATE], reflected she was at high risk for increased bleeding related to the use of a blood thinning agent, and she was at risk for falls due to an actual fall on [DATE]. Resident #1's electronic nursing Progress Notes, entered by RN A on [DATE] at 6:18 p.m., reflected the following entries: Note Text: Late entry for incident for [DATE]- 2030 (8:30 p.m.) Nurse aide found patient on floor beside bed. Nurse aide called for writer and stated come quick, patient is on the floor. When writer arrived patient was sitting on the side of the bed. Vital signs taken .Patient has hematoma on the left anterior side of forehead. Patient is moaning and states she has a lot of pain. Patient helped back in bed by nurse aide and writer (RN A). Neuro checks initiated per protocol. Patient alert and oriented, no loss of consciousness noted. Ice applied to hematoma. [MEDICATION NAME] given for pain ,[DATE]. 2045 (8:45 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. 2100 (9:00 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. Patients states pain is better. Pain is ,[DATE]. 2105 (9:05 p.m.) Call to (family member). Informed (family member) of patient's fall. 2130 (9:30 p.m.) Call placed to NP for (Physician I). Awaiting return call. Continued neuro checks within normal limits. 2224 (10:24 p.m.) Call placed to NP for (Physician I). Received order from (NP H) to send patient to (hospital). An electronic nursing Progress Note, entered by RN E on [DATE] at 12:44 a.m., reflected: (Patient) transferred to (hospital) at about 10:45 pm for further evaluation post fall at the request of NP. (Responsible Party) made aware. Resident #1's Medication Review Report, dated [DATE], included orders for: [MEDICATION NAME] 40 mg/0.4 ml (anticoagulant-blood thinner), inject 40 mg subcutaneously every morning; Aspirin 81 mg (blood thinner) every morning; [MEDICATION NAME] 75 mg (inhibits blood clotting) every morning; [MEDICATION NAME] 15 mg, (narcotic for pain relief) four times a day; and [MEDICATION NAME] 50 mg (pain relief) one tablet every six hours as needed for pain. An incident report prepared by RN A, dated [DATE] at 8:30 p.m., reflected the following: .Nurse aide found patient on floor beside bed. Nurse aide called writer and stated come quick, patient is on the floor. When writer arrived patient was sitting on the side of the bed. Vital signs taken .Patient has hematoma on the left anterior side of forehead. Patient is moaning and states she has a lot of pain. Patient helped back in bed by nurse aide and writer. The incident report reflected ice was applied to the resident's head, she was administered [MEDICATION NAME], and neurological checks were started per the facility's protocol. Record review of Resident #1's Neurological Evaluation Flow Sheet reflected RN A started neuro checks on [DATE] at 8:30 p.m., 8:45 p.m., 9:00 p.m., 9:15 p.m. and at 9:45 p.m. No further neuro checks were performed prior to the transfer to the hospital at 10:45 p.m. The facility's Provider Investigation Report, signed and dated by the Administrator on [DATE] reflected Resident #1 fell and sustained a subdural hematoma on [DATE] at 8:30 p.m. The facility's Investigation Summary was as follows: The Director of Nursing visited the facility on the 31st of December to review the fall and to begin investigation. The Director of Nursing called the charge nurse on duty when the fall occurred to investigate the circumstances around the fall. The charge nurse was working on her new admit when Resident #1 was found on the floor. The aide that discovered the resident on the floor called the charge nurse who came to the room and began the assessment and neuro checks. The resident had sustained a hematoma on the left forehead. The nurse called the family member and the physician. The family member asked the nurse to send out for a CAT scan to which the nurse replied, I would have to get an order. The nurse continued neuro checks with no abnormal findings. The resident was communicative with the nurse. The doctor/NP was reached and the resident was sent out to the emergency room . The resident was sent to ICU and later moved to med-surg. Summary: Resident #1 got up from bed and fell . The resident hit her head and sustained a hematoma on her left frontal area. Neuros were stated; family and physician notified. Resident was complaining about pain and was given medication which resident stated had help. Resident was later sent to the ER for evaluation. The hospital History & Physical report, dated [DATE], reflected Resident #1 was admitted to the hospital post-fall with a change in mental status. The report reflected the following: .This evening between ,[DATE] (8:30 p.m. - 9:30 p.m.) patient had an unwitnessed GLF (ground level fall) from her bed to the floor. Nursing home staff gave [MEDICATION NAME] post fall fro her pain. EMS estimate patient (sic) that the distance between the bed to the floor was ,[DATE] feet. Patient has a hematoma to to (sic) her left temple Patient is currently on [MEDICATION NAME] for arterial occlusions The hospital History & Physical report, further reflected the following: X-Ray Interpretation: .Interval increase in acute left parafalcine and left tentorial subdural hemorrhage previously measuring 1.6 cm in thickness and now measuring 2.6 cm at the posterior superior left parafalcine space. There is mass effect on the left cerebral hemisphere but no midline shift. There is partial effacement of the posterior left lateral ventricle. The hospital History and Physical reflected Resident #1 was admitted to the intensive care unit and would be receiving a neurosurgical consultation. An interview with RN A on [DATE] at 12:30 p.m. revealed she was very busy on the evening of [DATE] when Resident #1 fell . She stated about 8:15 p.m. that evening she was called down the hall by a CNA, who informed her that Resident #1 was on the floor. RN A stated she assessed the resident, and the resident had a bump on her head and was screaming in pain. She stated she applied ice to the resident's head and medicated the resident with [MEDICATION NAME] 50 mg. RN A stated she was so busy it was somewhat overwhelming. She stated she had new admissions that day including one resident with an IV that she needed to monitor closely, and another resident with behaviors who was striking out at other residents. She stated then Resident #1 fell and hit her head. RN A stated she did not ask for help. She stated she could not keep up with Resident #1's neuro checks, but she did the best she could. RN A stated she never considered that Resident #1 had recently been given [MEDICATION NAME] 15 mg prior to her fall. She stated the resident was in pain so she medicated her with [MEDICATION NAME] 50 mg. She stated Resident #1 was not able to explain what had happened, and the resident could not say what caused her to fall. RN A stated when she assessed Resident #1 she was aware the resident was being treated with [MEDICATION NAME], Aspirin, and [MEDICATION NAME]. She stated she was aware of the bleeding risks associated with anticoagulation therapy. RN A stated she did not think there were any contraindications in medicating Resident #1 for head pain. She stated she did not think about the bleeding risk or giving her pain medication, RN A stated she did not think Resident #1 had any cognitive changes even through Resident #1 could not explain what happened. RN A stated she thought it was because the resident had bumped her head. RN A stated she had only worked at the facility about two weeks and her previous employer's policy was residents could not be sent to the hospital without a physician's orders [REDACTED]. RN A stated it was her mistake, and she should have called 911 and sent the resident to the hospital. RN A stated she got Nurse Practitioner H's cell phone number from the on-coming nurse, and she called her. The Nurse Practitioner H responded with an order to send Resident #1 to the hospital. She stated the EMTs arrived quickly, and transported the resident to the hospital. She stated she monitored Resident #1 as much as possible with everything else that was happening that night. An interview with LVN F on [DATE] at 9:20 a.m. revealed she had worked late on [DATE] until about 8:30 p.m. to help with new admissions. Before she left, RN A told her Resident #1 had fallen and had a bump on her head. LVN F asked RN A if she needed help and was told no, so she left the facility. On her way home, LVN F stated she received a call from RN A. She stated RN A informed her she had tried to contact Resident #1's physician (Physician I), but the Physician I had not returned her call. LVN F told her to call the Physician I's NP (Nurse Practitioner H). LVN F stated RN A did not inform her Resident #1's family instructed her to send Resident #1 to the hospital emergency room for evaluation because they wanted a CT scan. LVN F stated if she had been aware of the family's wishes she would have directed RN A to send Resident #1 to the hospital emergency room immediately without notifying the physician first. During her conversation with RN A, LVN F stated she was asked what the facility's policy and procedure for unwitnessed falls was. LVN F told her she needed to do an assessment on Resident #1 and start neurological (neuro) checks. She stated RN A told her she was not sure how to perform the neuro checks so LVN F explained what to do and how often she needed to do the neuro checks on Resident #1. LVN F stated Resident #1 could not explain what happened or how she fell . An interview with RN E on [DATE] at 9:00 a.m. revealed she arrived at the facility on [DATE] at approximately 10:00 p.m. She stated RN A gave report and said Resident #1's physician (Physician I) had still not returned her call related to Resident #1's fall. RN E stated at that time she gave RN A Nurse Practitioner H H's cell phone number, and she told her to call Nurse Practitioner H H. RN E stated RN A told her she was calling the physician and the office number, and she did not realize she needed to call the Nurse Practitioner after hours. She stated she prepared all the necessary documents for Resident #1 to transfer to the hospital. RN E stated she knew Resident #1 needed to be sent to the hospital emergency room . She stated resident's family was at the facility and was not happy with the delay in sending Resident #1 to the hospital. RN E stated RN A received an order for [REDACTED].#1 was transferred via ambulance to the hospital. RN E stated she received in-service training on [DATE] related to falls, assessment after falls, assessment before moving a resident, unwitnessed falls, and that neuro checks must be started. She stated she also received instruction that if a family requested a resident to be sent to the hospital for evaluation and treatment, they must honor the request. The were also trained to monitor for cognitive changes with head injuries and to send residents to the hospital within one hour. No pain medications with head injuries respond quickly and look at the whole situation with incidents. If feeling overwhelmed ask for help. An interview with Nurse Practitioner H on [DATE] at 2:45 p.m. revealed she received a call from the facility notifying her Resident #1 fell and had a head injury, a hematoma on [DATE]. She stated she was informed the resident's family wanted the resident sent to the hospital for evaluation and treatment, and she gave the order to transfer the resident to the hospital. Nurse Practitioner H stated she did not evaluate or treat the resident after she fell on [DATE] so there was no way to say if a delay in sending Resident #1 to hospital caused a decline in her condition. An interview with Resident #1's family member on [DATE] at 3:43 p.m. revealed how upset the family was about the delay in treatment for [REDACTED]. The family member stated he/she received a telephone call from another family member, who had been informed Resident #1 had fallen and had a bump on her head with complaints of head pain. The family member stated Resident #1 was diagnosed with [REDACTED]. The family member stated prior to the fall Resident #1 was alert and oriented to person, place, and time; however, since the fall the resident had cognitive changes related to the head injury she sustained from the fall. The family member stated the resident was now in the hospital's hospice unit. An interview with Resident #1's family member on [DATE] at 1:40 p.m. revealed Resident #1 passed away on [DATE] in the hospital's hospice unit. An interview with the Administrator and DON on [DATE] at 10:00 a.m. revealed the Administrator had conducted an investigation into the incident and believed she established a time line of the incident. She stated Resident #1's family was in the facility at the resident's bedside until approximately 7:30 p.m. She stated the CNA, who worked the 100 Hall, had returned to the floor after her lunch break at approximately 8:30 p.m., and that was when she found Resident #1 on the floor during her rounds. The CNA notified the nurse, and after the nurse assessed Resident #1, she medicated her for head pain with [MEDICATION NAME] 100 mg. During this same interview, the DON stated she immediately provided a one-on-one counseling for RN A related to falls with injury, and advised her of what steps needed to be taken per the facility's policy and procedure when a resident was being treated with an anticoagulant and had a head injury. The DON stated she issued a verbal warning to RN A. An interview with the DON on [DATE] at 10:15 a.m. revealed she told RN A if a family expressed the desire for a resident to be sent to the hospital for evaluation and treatment that request was honored, and the physician was notified after the resident was sent to the hospital. The DON stated she told RN A when a resident had a fall the nurse must conduct a full body assessment and review the resident's medications, including always checking for blood thinners. The DON stated she also told RN A that pain medications could mask neurological changes when there was a head injury, and no pain medications should be administered until after the physician assessed the resident. The DON stated RN A told her she gave Resident #1 the pain medication because the resident was screaming in pain. The DON stated RN A should not have delayed Resident #1's transfer to the hospital for over two hours. The DON stated she mentored RN A closely hoping she would grow into a strong RN. The DON said RN A typically worked the 100 Hall and never had more than 12 residents. Interviews with LVN C on [DATE] at 1:50 p.m., RN B on [DATE] at 2:00 p.m., LVN D on [DATE] at 2:10 p.m., and LVN G on [DATE] at 2:25 p.m. revealed they had all received in-service training on [DATE] regarding falls, assessment following a fall, assessment before moving a resident, and neuro checks. The training included honoring family requests for residents to be sent to the hospital for evaluation and treatment, monitoring for cognitive changes with head injuries, and sending residents to the hospital within one hour. In addition, they stated they were also trained not to administer pain medications with head injuries, to respond quickly, looking at the whole situation, and requesting help if they felt overwhelmed. Review of the In-Service Summary and Attendance reports dated [DATE] revealed the facility provided in-service training to all of its licensed nurses on what to do when a resident experiences a fall with injury. The in-service included conducting an immediate assessment; evaluating medications, especially blood thinners; using clinical judgement to sent resident to the hospital; honoring family requests to send a resident to the hospital; and notifying DON or ADONs of all falls with assessment information completed. Review of the In-Service Summary and Attendance reports dated [DATE] revealed the facility provided in-service training to all of its licensed nurses regarding the procedure and assessment following a fall. The in-service training covered the specific expectations regarding conducting a thorough assessment of a resident post-fall to include physical and cognitive assessment of the resident, assessment of change of condition, and notification of physician. The facility's current Falls and Fall Risk Managing policy and procedure, revised [DATE], reflected the following: 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 try to minimize complications from falling. Steps in the procedure - After a Fall: .If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. .Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change the nursing staff will notify the practitioner immediately by phone . .Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; any changes in level of consciousness/responsiveness and overall function. It will note the presence or absence of significant change Identifying Complications of Falls: .Additionally staff and physician will identify significant potential complications of falling for each resident at risk for falling; (e.g., fracture in someone with [MEDICAL CONDITION] or bleeding in someone receiving anticoagulation). Falls-Clinical Protocol Assessment and Recognition .In addition, the nurse shall assess and document/report the following: .Neurological Status; .pain; .All current medications, especially those associated with dizziness or lethargy . On [DATE] at 3:30 p.m. the Administrator was notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and the DON stated since Resident #1's incident they had trained the majority of nursing staff on abuse/neglect and continued to monitor and in-service staff on procedure, assessment after falls was provide to all nurses on [DATE]. All this had been completed prior to the surveyor entering the facility on [DATE]. Interviews were conducted on [DATE] at 9:20 a.m. through 2:25 p.m. with the following staff: RN A, RN B, LVN C, LVN D, LVN F, and LVN G and through [DATE] at 9:00 a.m. with RN E. All nurses interviewed stated they received in-services related to abuse/neglect and procedures and assessment after a fall. The National Institutes of Health/U.S. National Library of Medicine Medline Plus, retrieved on [DATE], at https://medlineplus.gov/ency/article/ 3.htm, reflecting the following: Subdural hematoma A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. Causes A subdural hematoma is most often the result of a severe head injury. This type of subdural hematoma is among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in [MEDICAL CONDITION] and may lead to death. With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. In older adults, the veins are often already stretched because of brain shrinkage (atrophy) and are more easily injured. .The following increase the risk for a subdural hematoma: - Medicines that thin the blood (such as [MEDICATION NAME] or aspirin) .Medical conditions that make you blood clot poorly - Repeated head injury, such as from falls - Very young or very old age .Exams and Tests Get medical help right away after a head injury. Do no delay. Older adults should receive medical care if they show signs of memory problems or mental decline, even if they don't seem to have an injury. The health care provider will likely order a brain imaging test, such as a CT or MRI scan . A subdural hematoma is a an emergency condition. .Acute subdural hematomas have high rates of death and [MEDICAL CONDITION]. .A subdural hematoma is a medical emergency. Call 911 or your local emergency number, or go to an emergency room after a head injury. Do not delay. .Alternative Names Subdural hemorrhage . The facility's census, dated [DATE], reflected 115 residents resided in the facility.

Based on observation, interview and record review, it was determined the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source are reported immediately to the Administrator of the facility, and to other officials in accordance with State law for 1 (Resident #5) of 4 residents reviewed for abuse. Resident #5 was identified to have bruising and swelling on her left upper extremity on 02/28/13. Resident #5 was diagnosed with [REDACTED]. These injuries were not thoroughly investigated by the facility staff. The facility failed to identify and interview potential witnesses to the incident, and staff who routinely cared for Resident #5. Additionally, the facility failed to report the injuries of unknown origin to the State Agency. This failure created an environment where abuse could possibly occur, and placed all 115 residents at risk for possible abuse and neglect which could result in serious mental and/or physical harm. Findings included: 1) During the initial tour with ADON I on 03/12/13 at 10:30 AM, the ADON identified a recent bruise and a fractured Humerus on Resident #5. The ADON stated the resident was fed by a gastrostomy tube and was a two person transfer with a Hoyer lift. Resident #5 was observed at this time to be lying on her back in bed with bruises noted to her left upper extremity. Resident #5's left arm was in an immobilizer, and was resting on a pillow. On 03/12/13 at 12:00 PM, Resident #5 was observed lying in bed moaning with a gastrostomy feeding in progress. LVN H stated at this time that Resident #5 had just received Tylenol for pain. According to the MDS assessment, dated 06/21/12, Resident #5 was a [AGE] year-old female who was orgininally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #5 was severely impaired with both short-term and long-term memory loss. The MDS assessment reflected Resident #5 was always incontinent of bowel and bladder. The MDS assessment further reflected the resident was bedfast and required extensive assistance for bed mobility and activities of daily living. Resident #5 was totally dependent on staff for transfers and required two people to transfer her. The current care plan, dated 07/02/12 and updated 09/27/12 and 12/06/12, reflected Resident #5 was visually impaired, had a "feeding tube, cognitive impairment, physical impairment, [MEDICAL CONDITION], Dysphagia," and was "physically aggressive, resists care, yells out, restless, anxiety, hits at staff, bites self, punches self." The care plan indicated Resident #5 was a total assist for transfers and required at least 2 people to transfer her. Review of the Patient/Resident Incident/Accident Investigation Worksheet, dated 02/28/13, revealed Resident #5 was found with a "faint purple discoloration noted to left upper arm, swelling (1+) to left arm & hand." The injury was reported by staff on 02/28/13 at 10:30 AM. The report reflected the charge nurse notified the physician (no date or time) and the family at 12:30 PM. The lower section of the report, dated 03/04/13 at 11:30 AM, reflected resident "resting in bed c/ (with)eyes closed. Resp even & unlabored. Left arm stabilized c/(with) immobilizer & elevated on pillows. [MEDICAL CONDITION] 3+ to left hand & fingers, pink & warm to touch. Purplish yellow discoloration to (L) upper arm...." During an interview with the Administrator and the DON on 03/14/13 at 2:00 PM, they both stated they did not interview the night staff to find out if the resident had a bruise/injury during the night. They stated they did not interview the nurse aide, CNA G, who reported Resident #5's bruising and swelling to her left arm on 02/28/13. The DON admitted they (facility staff)had not completed the investigation, nor did they report it to the State Agency. The DON stated in addition to the bruising and swelling, the resident was exhibiting signs of pain to her left shoulder by moaning, and that was when the physician was called on 02/28/13. The physician ordered a doppler study, rather than an x-ray. The doppler study revealed Resident #5 had [MEDICAL CONDITION], and the resident was sent to the local emergency roiagnom on [DATE]. The hospital x-rayed the resident's shoulder and discovered Resident #5 had a fracture. The DON learned of the fracture when Resident #5 returned to the facility on [DATE] with the hospital's report of a shoulder fracture. An immobilizer was used to treat the fracture. The DON further stated the facility did not investigate the fracture because LVN C obtained a [DIAGNOSES REDACTED]. During an interview with CNA G on 03/14/13 at 1:30 PM, she stated she transferred the resident from the geri-chair to the bed on 02/27/13, and she did not observe a bruise at that time. However, on 02/28/13, she discovered the bruise and swelling during care and reported it. CNA G went on to say she did not see how the resident could have been hurt being transferred from the lift unless it was done incorrectly. The nurse notes, dated 02/04/13, reflected no signs or symptoms of injury. The next entry was dated 02/28/13, which reflected at 10:30 AM, "called to room to observe resident in bed. Left shoulder to hand 1+ [MEDICAL CONDITION] & painful when touched. Lateral upper arm below shoulder with faint bruising. Resident up in recliner yesterday when room deep cleaned. Hoyer sling used to transfer and discoloration in same location as top of sling when transferring resident. Circulation on left arm may have also been compromised by arm of recliner when up yesterday. LVN to request x-ray from physician, administer pain medication & inform family at this time...." The nurse notes, dated 02/28/13 at 8:35 PM, reflected a venous doppler study was conducted with positive results for a [MEDICAL CONDITION] ([MEDICAL CONDITION]. The physician was notified and the resident was sent to the emergency room . The nurse notes, dated 03/01/13 at 0430, reflected "res returned back from (local hospital) at 0130 DX (diagnosis) left side humerus shaft fx (fracture)...." The radiology report, dated 03/01/13, reflected Resident #5 had an "acute comminuted oblique [MEDICAL CONDITION] humerus." 2) The facility's Abuse Prohibition policy/procedure (P/P) was provided by the Administrator on 03/12/13 and identified as current. The P/P reflected the current revision date was 04/26/2012. The section entitled "Policy" reflected the following: "1. The facility's Leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a patient's/resident's property and/or funds. 2. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or misappropriation of property and/or funds. 3. The facility's Leadership will provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law (F223, F224, F225, and F226). 4. The facility's Leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds. 5. The facility's Leadership will implement appropriate and necessary guideline, which prohibit the mistreatment, neglect, and abuse of the patient/resident including misappropriation of property and/or funds." The section entitled "Procedure Component VI Investigation" reflected in part: "1. The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. If the alleged abuse or neglect involves serious physical harm to the patient/resident, please contact the facility's Clinical Services Director, Regional Vice President of Operations. 2. Additionally, in situations involving allegations of abuse (regardless of harm) and allegations of neglect that involve serious physical harm the Legal Department must be contacted prior to beginning any investigation or if after normal business hours, contact the Situation Response line, so as to ensure protection of the documents generated in anticipation of litigation. 3. The facility conducts an internal investigation through the Legal Department, if applicable, and reports the results to enforcement agencies within five working days or as prescribed by state (sic) law. Enforcement agencies include but are not limited to the State's survey and certification agency. NOTE: Copies of internal Incident Reports should not be disclosed to any person or agency without prior approval from the Legal Department. 4. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions. 5. The investigation may include but is not limited to the following: A. Identification and removal of the alleged perpetrator(s). B. Identification of the alleged victim. C. Type of alleged abuse. D. Where and when the incident occurred. E. Written summaries of interviews with individuals having firsthand knowledge of the incident. NOTE: employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated and signed by the interviewer. F. Resolution/outcome G. Measures taken to prevent future incidents. According to page 6 of the P/P depending on the incident, other residents in the facility might be interviewed." The facility's Abuse Prohibition P/P did not identify the staff member responsible for the initial reporting, investigation of alleged violations including injuries of unknown origin or who would report the results to the proper authorities. There was no information in the P/P related to who would be interviewed if the injury was of an unknown origin. There was no information related to if/or what previous shifts/staff would be interviewed. There was no information related to if/or residents would be interviewed to determine if they had any helpful information or may have witnessed anything. Further review of the P/P revealed there were no specific instructions/procedures for reporting or performing a thorough investigation of injuries of unknown origin in an attempt to determine if abuse and/or neglect had occurred. An interview with the Administrator on 03/13/13 at 1:50 PM revealed she was the person responsible for coordinating the facility's Abuse Prohibition policies and procedures. When queried during interview about how she determined which injuries of unknown origin should be investigated as potential occurrences of abuse, the Administrator stated " Anything I cannot determine how it occurred or reasonably determine how it happened." When queried during this time about Resident #5's fracture of unknown origin not being thoroughly investigated, the Administrator stated "We came up with she (Resident #5) was so osteopenia (sic) we determined that was the probable cause" of the fracture. (Osteopenia is a condition where bone mineral density is lower than normal and is considered to be a precursor to [MEDICAL CONDITION]). ([MEDICAL CONDITION] is a disease of the bones that leads to an increased risk of fracture). During this interview the Administrator further stated, instead of obtaining written statements the facility's corporation required "face-to-face" interviews by either herself or the Assistant Director of Nurses (ADONs). During this interview a request was made of the Administrator for a facility P/P that addressed injuries of unknown origin. An interview was conducted with Licensed Vocational Nurse (LVN) A on 03/14/13 at 10:50 AM about the facility's procedure for investigating injuries of unknown origin. The LVN stated all shifts would follow-up by interviewing their staff who worked on the hall where the incident occurred. LVN A further stated accident/incident reports were picked up each morning and reviewed during the morning meeting. The reports were reviewed and initialed by the Administrator, Director of Nurses (DON), all nurse managers including the Assistant Director of Nurses, and the Minimum Data Set (MDS) nurses. An interview was conducted with LVN B on 03/14/13 at 11:30 AM about investigative procedures for injuries of unknown origin. LVN B stated staff attempted to "figure" out how the injury occurred. If a resident was noted with a bruise and was lying on the side rails, the facility assumed the bruise was caused by the side rails. LVN B further stated sometimes "not all the time" Certified Nurse Aides (CNAs) were questioned about what happened. During this interview LVN B stated she was sorry to say it, but the CNA who reported an incident was usually the person who was suspended during the investigation. A second request for the facility's P/P related to injuries of unknown origin was made from the Administrator on 03/14/13 at 2:30 PM. Prior to the exit on 03/15/13 at 5:30 PM, no additional information was provided. An interview was conducted with LVN D on 03/14/13 at 3:50 PM about the facility's investigative procedures for injuries. LVN D stated she was the nurse who initiated the incident report dated 02/28/13 related to Resident #5's fracture. LVN D stated facility nurses did not investigate incidents other than obtaining information about what happened or who saw it if it was witnessed. Additionally, LVN D stated if a resident was unable to communicate how the injury occurred, she believed the DON performed an investigation. During this interview LVN D stated, "No we (nurses) don't start any interviews with staff or any investigating." The facility's CMS-672 Form, Resident Census and Conditions of Resident, signed by the DON on 03/12/13 reflected 77 residents with Dementia.

Based on observation, interview, and record review, it was determined facility staff physically abused one (Resident #1) of 10 residents reviewed for abuse. 1. Surveillance video tapes showed CNA C pulled Resident #1 up by her hair to almost a sitting position, when she was removing the resident's pillow, then shoved the resident's head back down to the newly placed pillow. 2. Surveillance video tapes showed CNA D pinched Resident #1's left thigh, and she was rough with the resident, shoving her legs around while providing care. These failures resulted in fear, anxiety, skin injuries, and the potential for more serious physical injuries such as fractures and death. An Immediate Jeopardy (IJ) was identified on 08/30/12. While the IJ was removed on 08/31/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the facility's other 134 residents, by placing them at risk for abuse, injuries, fear, anxiety, and a decreased quality of life. Findings included: Resident #1's MDS assessment dated [DATE] revealed Resident #1 was sometimes understood, responded adequately to simple direct communication only. The assessment reflected she rarely or never understood others, her daily cognitive skills were severely impaired, and she never or rarely made decisions. Further review of the MDS assessment revealed Resident #1 did not have a history of physical or verbal aggression directed towards others, and she did not have a history of refusing care. Resident #1's Monthly Nursing Data Collection tool dated 08/20/12 reflected she weighed 108 pounds, she was "on total care," and in addition was incontinent of bowel and bladder, and functionally impaired on both sides of her body. The document also reflected Resident #1 was totally dependent on two staff for bed mobility, turning and repositioning, transfers, toileting, and she needed some assistance with eating. The document was signed by LVN B on "07/15/12." Resident #1's August 2012 physician's orders [REDACTED]. Resident #1's Care Plan dated 08/23/12 reflected a handwritten entry on page 6 of 16 pages, dated 08/26/12, which reflected she resisted ADL care at times and was initialed by LVN E. Review on 08/29/12 of Nurse's Notes for Resident #1 revealed on 08/26/12 at approximately 12:00 PM, she was assisted with incontinent care. The Notes reflected a small, old bruise, and a small, old hematoma (a collection of blood outside of a blood vessel causing a bump and swelling which occurs because the wall of a blood vessel wall, artery, vein, or capillary, has been damaged and blood has leaked into tissues where it does not belong) to her right forearm. The Nurse's Notes also reflected her family was notified, there were no signs/symptoms of infection, and they would continue to monitor. Review of the facility's Injury of Unknown Origin Worksheet dated 08/26/12 revealed LVN E documented a one centimeter fading bruise on Resident #1's right forearm. The Worksheet also reflected a second bruise measuring one centimeter and a hematoma on her right forearm. Further review of the Injury of Unknown Origin Worksheet revealed Resident #1 was dependent on staff for care with transfers and repositioning, and at times she was resistant to care. The Worksheet indicated the causes of the injuries were not known at that time. The Worksheet also reflected Resident #1's family member was notified by Resident #1's other family member two days prior, of the bruise to the resident's arm, but the family member did not notify staff. The Worksheet indicated staff were interviewed, and the resident at times was resistant to care. The worksheet was signed by LVN E, who was the Weekend Supervisor. The spaces for the signatures of the Administrator and DON were blank. Nurse's Notes for Resident #1 dated 08/27/12 reflected there were no signs of pain or signs/symptoms of infection of the area on her right arm. Nurse's Notes for Resident #1 dated 08/28/12 reflected a head-to-toe assessment of the resident was conducted and there were no additional injuries to the resident. The last entry in the Nurse's Notes for Resident #1 was dated 08/29/12 and reflected the bruises to her right forearm were still present. The Notes also reflected a head-to-toe assessment was not conducted until 08/28/12, which revealed some discoloration on her toe and discoloration on her right arm. Observation on 08/29/12 at 1:20 PM revealed Resident #1 in her room in bed and alert. A family member was feeding Resident #1 and stated the incident occurred on Monday 08/27/12 between the hours of 10:00 PM and 6:00 AM. The resident was thin and frail with faded bruises on her right forearm just above the wrist bone about the size of a fingerprint, and further up her outer forearm was a bruise about the size of a nickel. Interview on 08/31/12 at approximately 11:10 AM with Hospice Aide N revealed Resident #1 had two bruises on her arm. She stated she noticed the first one Wednesday, 08/22/12. She revealed she documented it in the Hospice notes and notified LVN H. Hospice Aide N stated on Monday, 08/27/12, further up Resident #1's arm she noticed a blood blister. She also revealed she documented the finding and notified her RN Case Manager. She stated Resident #1 was always nice to her, but she could see a change in her disposition. She also revealed it was more like if someone touched her she was sore or maybe apprehensive. Hospice Aide N stated she had never seen the resident be combative. Interview on 08/31/12 at 11:00 AM with Hospice Aide G revealed she had been a CNA for [AGE] years and came to the facility to provide care to Resident #1 five days a week. She stated she provided showers, bed baths, grooming, and incontinent care to the resident. Hospice Aide G revealed she had worked with Resident #1 for about three months and had not noticed any bruising before now. She stated last week (08/20/12 through 08/25/12) she noticed a red area, closer to the resident's wrist. She also revealed she reported it to LVN H. She then stated she informed her RN Case Manager. Hospice Aide G revealed she approached LVN H again this past Monday, 08/27/12, regarding new bruising, and requested LVN H look at Resident #1's forearm. Hospice Aide G said the bruises were in the same area, one was about the size of a nickel, and the other was oval in shape. She stated LVN H looked at the bruises, but she did not know what LVN H did after that. Hospice Aide G stated Resident #1 was such a sweet lady, and when she first started taking care of her, she (Resident #1) would push her (Hospice Aide G) away. She said now Hospice always had two aides to work with Resident #1 to ensure her safety. She stated Resident #1 was sweet and not combative. Hospice Aide G also revealed at times Resident #1 tried to assist with her care. Interview on 08/30/12 at 9:30 AM with MA J revealed she had been a MA for [AGE] years and had worked at the facility for [AGE] years. She stated she was related to Resident #1, and she was not aware of any bruising before this incident. MA J revealed Hospice Aide G came to her early on the morning of 08/23/12 after Resident #1's shower and asked her if she was aware of the bruising on the resident's arm. MA J said she directed Hospice Aide G to LVN H, who was the Charge Nurse, to tell LVN H about the bruising. MA J stated nothing else was ever said to her about the bruising. She also stated she was not sure if the Charge Nurse assessed Resident #1. MA J revealed she talked to another of Resident #1's family members on Saturday, 08/25/12, and stated that family member asked her about the bruising. She said she did not say anything to the family, because she thought the facility would handle it. MA J stated because she worked at the facility, the staff just assumed she would take care of any problems with the resident. MA J revealed she tried to stay out of it because she was part of Resident #1's family. Interview on 08/31/12 at 9:55 AM with LVN H revealed she had worked at the facility for four years. LVN H stated Hospice Aide K came to her on 08/24/12 and said Resident #1 had a small bruise on her right wrist. LVN H revealed she had spoken to a family member and reported it to MA J. LVN H also stated she did not document the occurrence, nor did she suspect abuse. LVN H revealed she had known CNA C for a couple of years, but they did not work the same shift. Interview on 08/31/12 at approximately 6:00 AM with LVN A revealed he had worked at the facility for nine years. He stated he had known CNA C for about a year, and she was hard working and [MEDICATION NAME]. He said he thought that until he saw the video and now he was disgusted. He revealed Resident #1 had always been calm when he was in there with her, and he had not had any problems with her being combative or aggressive. LVN A stated the family came to him about Resident #1's bruises. He also stated he had a good relationship with the family, and they told him that CNA C was rough with Resident #1 on 08/26/12. LVN A revealed he called the Administrator immediately, but he did not answer the phone. He stated he then called the DON and told him what the family told him. LVN A said the family came in on Monday, 08/27/12. He then revealed he reported for his shift at 10:00 PM, and the DON told him to suspend CNA C until there was an investigation. LVN A stated he had seen the video on the news and he knew who the CNAs involved were, CNA C and CNA D. He said he knew it was CNA C from the blonde hair, and CNA D always wore a back-belt. He revealed both CNAs came to him about a month earlier and asked him what the sign, "This room is under Video Surveillance" on Resident #1's door, meant. He stated because they were both foreign, CNA C and CNA D may not have understood what it meant. LVN A revealed CNA C and CNA D had communication issues, and talking to them was like talking to a "brick wall." LVN A said CNA C and CNA D just say they understand and go ahead and do what they want to do anyway. He stated he had witnessed Resident #1 grab for assistance, when they repositioned her. He revealed he thought she might be scared. He indicated Resident #1 used to yell out a couple years ago for her family, but he had never noticed any aggressive behaviors from her. He stated one time he witnessed Resident #1 trying to pinch CNA D. LVN A also revealed that sometimes Resident #1 was resistant to care. Interview on 08/29/12 at 4:00 PM conducted with LVN E revealed he was the Weekend Supervisor, had worked at the facility for eight years, and had been an LVN for [AGE] years. LVN E stated LVN A came to him on Sunday, 08/26/12, and told him Resident #1's family came to him about the bruises on the resident's forearm. He also stated he assessed the resident, and there was a one centimeter bruise above her wrist and a hematoma on her forearm. LVN E revealed her skin was intact, and there was no swelling noted. He indicated he completed a head-to-toe assessment and did not see any other bruises. He stated he told LVN A to notify the family. LVN E also revealed the family had identified CNA C as being rough with Resident #1 and had been unhappy with her provision of care. The family requested she be moved to another hall away from the resident. LVN E stated since the family said she (the CNA) was rough, he asked the family member if he/she would prefer the CNA be moved. LVN E said the CNA was moved to another hall on Monday, 08/27/12. LVN E revealed he called the Administrator immediately, told him of the occurrence, and the Administrator stated being rough was not in the definition of abuse, and to do a one-on-one in-service with CNA C. LVN E stated he was supposed to talk to the CNA about repositioning and the use of draw sheets and to provide sensitivity training. LVN E revealed he did what the Administrator told him to do the next day 8/27/12. LVN E stated he had not seen the video tape of the abuse, it was "their job," and it was up to them (Administration) to follow-up. LVN E said he in-serviced CNA C the next day, 08/27/12, around 11:00 AM. He revealed he talked to the DON about moving the CNA to another hall because of the family's request, and the DON told him to go ahead and move CNA C to another hall. LVN E said he spoke to the Administrator about not really knowing people and that anything could set them off. He then stated, "She really looked like she was really angry at something on that tape." (LVN E had previously stated he had NOT seen the tape). LVN E stated he approached the DON three times on Monday, 08/27/12, for follow-up and he was never able to communicate with the DON that day. Interview conducted on 08/29/12 at approximately 2:00 PM with the DON regarding Resident #1's bruising of the right forearm. He stated he received a call on Sunday, 08/26/12, afternoon from LVN E, who told him Resident #1 had bruising of an unknown origin on her wrist. The DON said LVN E measured it and told Resident #1's family member. He stated LVN E told him he knew there was a camera in the room and the room was monitored 24/7 (24 hours a day/seven days a week.) The DON revealed he knew the resident was combative with care, and because of that information he did not really think there was a problem. He said he did not suspect abuse, because one of the resident's family members worked in the facility, and he knew the family would have reported it (abuse) if there was a problem. The DON stated the family member worked on the same hall where Resident #1 resided. The DON further revealed he directed LVN E to contact the Administrator to ensure he did everything correctly. The DON was asked why he did not contact the Administrator, and he replied because he really did not think the bruising of unknown origin was an issue. The DON stated he based his decision on what he was told by LVN E. He also stated he wanted to be sure the other dependent residents on that hall were safe, so he directed LVN E to check all the dependent residents on Resident #1's hall. The DON was asked if he followed-up with LVN E regarding the checks of the other residents, and he replied no, because he was out of town. The DON further stated he received a call from LVN A at approximately 10:15 PM on 08/26/12 informing him that LVN A received a call from Resident #1's family member making an allegation of abuse against CNA C. The DON stated CNA C was suspended immediately, and he called the Administrator and briefed him on what occurred. Interview on 08/30/12 at 11:45 AM with the Administrator revealed he was an Interim Administrator. He stated he had [AGE] years of experience and he had been at the facility for about one month and a half. On 08/26/12 at around 2:00 PM, he received a call from the Weekend Supervisor, LVN E. The Administrator revealed LVN E had a resident's family complain to him about CNA C. LVN E told him the family was concerned about CNA C being rough and too fast with the resident. The DON asked LVN E if there had been any bruising on Resident #1, and LVN E told him about the bruising to Resident #1's forearm, which the family brought to his attention. The Administrator stated he could not remember if LVN E assessed Resident #1, but he thought he (LVN E) did. When he went home from the facility on Monday, 08/27/12, he went to bed early, and saw there had been a message from the family he indicated he returned their call right then. The Administrator revealed the family came in with a video on Tuesday, 08/28/12, in the morning. He revealed he had been suspended Tuesday at 6:00 PM. The Administrator was asked if there was a difference in being rough and being abusive, and he stated he never associated bruising with being rough. Observation on 08/29/12 at approximately 10:00 PM of the surveillance video tape, date stamped 08/22/12, provided by Resident #1's family revealed CNA C pulled the resident's head up by her hair on top of her head from a lying position to an almost sitting position. CNA C then removed the pillow from under Resident #1's head and then shoved the resident's head back into the newly placed pillow. Interview on 08/30/12, at 10:28 AM with CNA C revealed she had worked at the facility for five years on the 10:00 PM to 6:00 AM shift and had been a CNA for six years. CNA C also stated she rotated from the 400 Hall to 600 Hall two times a week. She said she was contacted on 08/26/12 and asked to come in by LVN E for training. She revealed she could not come in that day, so she went to the facility on Monday 08/27/12. CNA C stated when she reported for her shift on Monday 08/27/12, her supervisor, LVN A, told her she had to go home and she was suspended. CNA C said she saw the video, and she did "not feel good" about it. She revealed Resident #1 was always fighting, kicking and yelling, and resisting care. She stated she felt that day (day of occurrence of abuse) the resident resisted help and refused care. CNA C revealed there was not enough staff on that shift to get help, and she just wanted to get it done, because the resident always resisted care. CNA C stated her supervisor, LVN A, had witnessed Resident #1 scratching, yelling and hurting her (CNA C). CNA C stated she realized the residents acted like children. CNA C revealed she had been contacted by LVN E and told she would be moved to another hall when she came in to work. CNA C said she knew the video "looked bad." She stated she was just picking up Resident #1's head to change the pillow, the resident pushed back, the resident's head slipped out of her hand, and she caught her by the hair. CNA C revealed she did not think the resident was afraid of her. CNA C was asked what she was trained to do when a resident resisted care. She replied she should have asked for help, but no one was available. CNA C was asked why she did not walk away, and she replied she just wanted to finish her work. CNA C stated she had not had any training before Monday on abuse or neglect. She revealed she preferred to be trained in Spanish and the facility did not train in Spanish, only English. CNA C said her friends helped to translate it into her own language. CNA C was asked if she knew how to deal with residents with behaviors, and she said she did. CNA C stated she could not even explain why she did what she did to Resident #1. Further observation of the surveillance video tape, date stamped 08/23/12, revealed CNA D pushed Resident #1's legs around, while she provided incontinent care. CNA D then moved from one side of the bed to the other and observed to be pinching the resident's thigh. Resident #1's arms were outstretched indicating a defensive move for protection. An interview on 08/30/12 at approximately 2:00 PM with CNA D revealed she had been a CNA for about five or six years, and had been employed by the facility for the same amount of time. She stated Resident #1 was hard to take care of, and LVN A had witnessed the resident fighting with her (CNA D). She revealed when Resident #1 was combative she told the resident, "Be nice and calm down," and continued with the care. CNA D said even if she was fighting, she (CNA D) continued providing care. CNA D stated she could not remember the last time she had training regarding abuse and neglect. She revealed the last time may have been when she was first hired, but not since then. CNA D stated the Administrator told her on 08/28/12 that the family had a video of Resident #1's room, and he knew she was giving the resident's briefs away to other CNAs for their use. CNA D said her supervisor, LVN A, never provided her guidance regarding dealing with residents, who had behaviors. She also stated the CNAs were too busy to get help. CNA D revealed there had been times when she had to pry Resident #1's hands off her arm, and she was afraid the resident would break her wrist. CNA D revealed most of the CNAs knew how Resident #1 was, so people just cared for her by themselves. CNA D did not know what neglect was. CNA D denied ever pinching or pushing Resident #1. An interview on 08/30/12 at 9:40 AM with Resident #1's Family Member #4 revealed a surveillance camera had been in the resident's room for about two months. The Family Member also stated a notification sign was posted on the entrance door to Resident #1's room. Family Member #4 said another family member reviewed the videos briefly every day. Family Member #4 revealed that family member reviewed the video and contacted the police on Monday, 08/27/12, morning regarding abuse of Resident #1. An interview on 08/30/12 at 3:45 PM with Detective #5 of the local police department revealed the original call came in by Resident #1's Family Member #3 on 08/27/12 at 6:20 PM. The Detective stated the call was taken at 12:10 AM on 08/28/12. The Detective said the officers were dispatched to the facility later on during that day to take a report. The Detective revealed CNA C had been suspended. The Detective also stated he received an arrest warrant from the District Attorney based on the surveillance video for the arrest of CNA C for elder abuse. Interview conducted on 08/30/12 at 11:00 AM with the Corporate Regional Vice President revealed she became aware of the incident with CNA C and Resident #1 on 08/28/12. She stated the Administrator called her and told her the family was in the building with a video tape and informed her of the potential situation. The Regional Vice President revealed the Administrator said there was a video, but he did not know what was on it. As soon as she heard that, she got in her car to go to the facility. The Administrator called her after he reviewed the video with the family and told her what he had observed. The Regional Vice President stated the Administrator never used the words abuse. From the information she had gathered, a Hospice Aide went to LVN H on 08/24/12 at approximately 7:30 AM with information Resident #1 had bruises measuring 3.0 x 3.0 centimeters and it was not documented anywhere. She stated she suspended LVN H that day (08/28/12). An interview on 08/31/12 at 6:00 AM with LVN I revealed she had been a nurse since 1984 and had worked at the facility for [AGE] years. LVN I said she was a Charge Nurse on Halls 100 and 200. LVN I stated she knew CNA C, was shocked about the video, CNA C was always considered to be caring and had seemed to be [MEDICATION NAME] with nothing less than that. LVN I stated Resident #1 was pleasantly confused, kind, content, and she had never seen Resident #1 be combative. Interview on 08/31/12 at 6:20 AM with CNA K revealed she had worked at the facility for 1 ? years and worked the 10:00 PM to 6:00 AM shift. She stated CNA C came in once in a while to assist her. She revealed CNA C worked fast. She stated Resident #1 always talked to her. CNA K said she had never seen Resident #1 being aggressive, and about a year ago, Resident #1 would to sing to her. Review of the facility's Abuse, Neglect and Misappropriation of Property dated 2012 revealed, "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse...2. The facility's Leadership would conduct a prompt investigation of any allegation of suspected abuse...3. The facility's Leadership would provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law... Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types if abuse include BUT ARE NOT LIMITED TO: A. Physical assault/abuse: 1) Hitting 2) Slapping 3) Pinching 4) Kicking 5) Controlling behavior through corporal punishment ... Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator or his/her designee and other enforcement agencies according to state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities)... Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting. B. Enforcing a Zero Tolerance standard for retaliation against the alleged victim." Review of the facility's undated policy regarding Resident Rights and taken from the DADS Consumer Rights and Services publication, revealed, "...You have the right to...Be free from abuse, neglect and exploitation Be treated with dignity, courtesy, consideration, and respect...." An IJ was identified on 08/30/12. The Regional Vice President and the Clinical Services Director were notified on 08/30/12 at 9:15 AM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 08/31/12 at 2:30 PM and reflected the following: Resident #1 was assessed for injury by the Weekend Charge Nurse LVN E and no new injury was noted. A psychological assessment was offered to the resident. CNA C and CNA D were suspended pending investigation on 08/28/12 by the ADM and the DON. The ADM and the DON, who were notified of Resident #1's bruising of unknown origin on 08/26/12, were suspended pending investigation on 08/28/12 by the Regional VP. Residents who had received care from CNAs C and D were assessed for potential injury with a completion date of 08/29/12 by the Charge Nurses (on each hall and Administrative Nurses. (Corporate Clinical Services Director and ADON's. No new injuries were noted. Interviewable residents who received care from CNAs C and D were interviewed by Social Services Director T effective 08/29/12. No reports of bruises or injury were given. Families/Responsible Parties of "non-interviewable" residents were to be contacted to address concerns or bruising of unknown origin to be completed by the Administrative Staff and completed 08/31/12. All other facility residents in the facility were assessed for potential injury by the Charge Nurses and Administrative Nurses effective 08/30/12. Incident Reports were reviewed by the Clinical Services Director to determine whether other residents had injuries of unknown origin to be completed by 08/29/12. None were identified. All facility staff were re-educated on abuse including: identifying and reporting abuse and appropriate measures to take when staff disagrees with the Supervisor's response to an allegation of abuse. When an injury of unknown origin, including bruises, is reported, a licensed nurse will assess the resident and report the incident to the Abuse Coordinator and notify the resident's physician and family/Responsible Party. The investigation will be initiated as directed by the Abuse Coordinator/designee. If a staff member had been identified as the alleged perpetrator, he/she will be suspended. The incident will be reported as indicated per the State guidelines. This will be conducted by the facility's Staff Development Coordinator or /designee and was initiated on 08/28/12. A pre and post test will be given to facility staff to assess staff's understanding of the Abuse Prohibition. Newly-hired staff will be educated during orientation and the use of pre and post tests will be utilized. All facility staff will be re-educated on Abuse Prohibition at a minimum of every quarter for two quarters and then annually. The pre and post tests will be utilized. This will be conducted by the facility's Staff Development Coordinator/designee. CNAs were re-educated on proper transfer techniques to include not rushing a resident to prevent injury. This was initiated on 08/30/12 and was conducted by the Therapy Director/Staff Development Coordinator/designee. Nursing staff were to be re-educated on dealing with a resident with Dementia and also exhibits behaviors. This was initiated on 08/31/12 and was conducted by the Staff Development Coordinator/designee. Life Satisfaction rounds were to be conducted with facility residents and/or family members/Responsible Parties weekly for one month by the Department Heads and was initiated 08/28/12. Residents will be requested to identify abuse and to whom they would report it. Any concerns will be addressed immediately and reported to the Administrator/designee. Incident/Accident Reports and Grievance Reports will be reviewed Monday through Friday during Morning Meeting to identify allegations of abuse/neglect. The ADM/DON will be responsible for investigating, reporting and implementing discipline and/or education as needed. The Weekend Supervisor will review Incident/Accident Reports and Grievance Reports on Saturday and Sunday and inform the ADM and the DON of any allegations of abuse/neglect including injuries of unknown origin immediately at the time it is identified. Weekly skin assessments will be reviewed for identification of bruising weekly for one month and then randomly by the DON/designee. Areas identified will be reviewed by the DON/designee for investigation, root cause and prevention. Administrative staff identify will randomly question facility staff on abuse to assess their knowledge during routine rounds and observation of care. Families of residents will also be interviewed to identity issues/concerns and identify deficient practices. They will be addressed immediately and reported to the ADM/designee. The Performance Improvement Team will consist of: the ADM, the DON, the ADON, the Medical Director (when available), the Pharmacy Consultant (if available), the Activity Director, the Social Services Director, the Dietary Manager, the Maintenance Director and the Staff Development Coordinator. Their purpose will be to identify areas of noncompliance, establish a plan for improvement with a goal, develop timeframes and identify who will be responsible for completion of the plan along with QA. The Performance Improvement Team will meet weekly to review the results from Life Satisfaction Rounds and skin assessments. All grievances and allegations of abuse, neglect, mistreatment will be reported as required and a thorough investigation will be conducted. The Medical Director will be invited to attend. Interviews conducted on 08/31/12 at 2:00 PM with eight residents, who were active members of the Resident Council, revealed they had not had any problems with staff in the facility being rough or rude. They stated they loved it there. They also indicated they would go to the Administrator if there was a problem. They revealed they felt safe. Interview conducted on 08/31/12 at 6:00 AM with LVN J revealed the staff on the 10:00 PM to 6:00 AM shift received an in-service on abuse and neglect at the beginning of the shift on 08/30/12. She stated they reviewed signs of abuse of a resident, to contact the Administrator immediately and document in an Incident Report, to contact the family, and remove the perpetrator from the facility. Interview conducted with LVN L on 08/31/12 at 6:35 AM revealed she had in-service training on abuse and neglect at the beginning of her shift on 08/31/12. She stated if abuse was suspected, then an incident report must be completed and the Administrator notified immediately. Interview conducted on 08/30/12 at 10:35 AM revealed she had been in-serviced on abuse and neglect. She stated if there was a suspicion of abuse or neglect, she would contact the Administrator and report it immediately. Interview conducted on 08/30/12 at 10:47 AM with ADON P revealed she was trained in abuse and neglect. She stated to should contact the Administrator and the DON. ADON P stated she was to make sure to always follow-up with the allegations and ensure the resident was safe and conduct a head to toe assessment. Interview conducted on 08/30/12 at 11:00 AM with LVN Q rev

Based on observation, interview and record review, it was determined the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of a unknown source were reported immediately to other officials in accordance with State law through established procedures (including State survey and certification agency), failed to ensure there was evidence of a thorough investigation, and failed to protect residents from potential abuse for one (Resident #1) of 10 residents reviewed for abuse. 1. Surveillance video tapes showed CNA C pulled Resident #1 up by her hair to almost a sitting position, when she was removing the resident's pillow. 2. Surveillance video tapes showed CNA D pinched Resident #1's legs, and she was rough with the resident. 3. The ADM and Don failed to immediately start an investigation and conduct a thorough investigation, when they were notified of bruising of unknown origin and of a hematoma on Resident #1's arm on 08/26/12, and when they were notified of the family's allegation that CNA C was physically abusing Resident #1. 4. The ADM and DON failed to immediately suspend CNA C after Resident #1's family voiced an allegation of physical abuse by CNA C on 08/26/12, and the resident had bruising of unknown origin. CNA C was initially moved to another hall. 5. The DON and ADM failed to immediately report Resident #1's bruising of unknown origin, a hematoma of unknown origin, and an allegation of physical abuse to the State survey and certification agency. These failures resulted in fear, anxiety, skin injuries, and the potential for more serious physical injuries such as fractures and death. An Immediate Jeopardy (IJ) was identified on 08/30/12. While the IJ was removed on 08/31/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the facility's other 133 residents, by placing them at risk for abuse, injuries, fear, anxiety, and a decreased quality of life. Findings included: Resident #1's MDS assessment dated [DATE] revealed Resident #1 was sometimes understood, responded adequately to simple direct communication only. The assessment reflected she rarely or never understood others, her daily cognitive skills were severely impaired, and she never or rarely made decisions. Further review of the MDS assessment revealed Resident #1 did not have a history of physical or verbal aggression directed towards others, and she did not have a history of refusing care. Resident #1's Monthly Nursing Data Collection tool dated 08/20/12 reflected she weighed 108 pounds, she was "on total care," and in addition was incontinent of bowel and bladder, and functionally impaired on both sides of her body. The document also reflected Resident #1 was totally dependent on two staff for bed mobility, turning and repositioning, transfers, toileting, and she needed some assistance with eating. The document was signed by LVN B on "07/15/12." Resident #1's August 2012 physician's orders [REDACTED]. Resident #1's Care Plan dated 08/23/12 reflected a handwritten entry on page 6 of 16 pages, dated 08/26/12, which reflected she resisted ADL care at times and was initialed by LVN E. Review on 08/29/12 of Nurse's Notes for Resident #1 revealed on 08/26/12 at approximately 12:00 PM, she was assisted with incontinent care. The Notes reflected a small, old bruise, and a small, old hematoma (a collection of blood outside of a blood vessel causing a bump and swelling which occurs because the wall of a blood vessel wall, artery, vein, or capillary, has been damaged and blood has leaked into tissues where it does not belong) to her right forearm. The Nurse's Notes also reflected her family was notified, there were no signs/symptoms of infection, and they would continue to monitor. Review of the facility's Injury of Unknown Origin Worksheet dated 08/26/12 revealed LVN E documented a one centimeter fading bruise on Resident #1's right forearm. The Worksheet also reflected a second bruise measuring one centimeter and a hematoma on her right forearm. Further review of the Injury of Unknown Origin Worksheet revealed Resident #1 was dependent on staff for care with transfers and repositioning, and at times she was resistant to care. The Worksheet indicated the causes of the injuries were not known at that time. The Worksheet also reflected Resident #1's family member was notified by Resident #1's other family member two days prior, of the bruise to the resident's arm, but the family member did not notify staff. The Worksheet indicated staff were interviewed, and the resident at times was resistant to care. The worksheet was signed by LVN E, who was the Weekend Supervisor. The spaces for the signatures of the Administrator and DON were blank. Nurse's Notes for Resident #1 dated 08/27/12 reflected there were no signs of pain or signs/symptoms of infection of the area on her right arm. Nurse's Notes for Resident #1 dated 08/28/12 reflected a head-to-toe assessment of the resident was conducted and there were no additional injuries to the resident. The last entry in the Nurse's Notes for Resident #1 was dated 08/29/12 and reflected the bruises to her right forearm were still present. The Notes also reflected a head-to-toe assessment was not conducted until 08/28/12, which revealed some discoloration on her toe and discoloration on her right arm. Observation on 08/29/12 at 1:20 PM revealed Resident #1 in her room in bed and alert. A family member was feeding Resident #1 and stated the incident occurred on Monday 08/27/12 between the hours of 10:00 PM and 6:00 AM. The resident was thin and frail with faded bruises on her right forearm just above the wrist bone about the size of a fingerprint, and further up her outer forearm was a bruise about the size of a nickel. Interview on 08/31/12 at approximately 11:10 AM with Hospice Aide N revealed Resident #1 had two bruises on her arm. She stated she noticed the first one Wednesday, 08/22/12. She revealed she documented it in the Hospice notes and notified LVN H. Hospice Aide N stated on Monday, 08/27/12, further up Resident #1's arm she noticed a blood blister. She also revealed she documented the finding and notified her RN Case Manager. She stated Resident #1 was always nice to her, but she could see a change in her disposition. She also revealed it was more like if someone touched her she was sore or maybe apprehensive. Hospice Aide N stated she had never seen the resident be combative. Interview on 08/31/12 at 11:00 AM with Hospice Aide G revealed she had been a CNA for [AGE] years and came to the facility to provide care to Resident #1 five days a week. She stated she provided showers, bed baths, grooming, and incontinent care to the resident. Hospice Aide G revealed she had worked with Resident #1 for about three months and had not noticed any bruising before now. She stated last week (08/20/12 through 08/25/12) she noticed a red area, closer to the resident's wrist. She also revealed she reported it to LVN H. She then stated she informed her RN Case Manager. Hospice Aide G revealed she approached LVN H again this past Monday, 08/27/12, regarding new bruising, and requested LVN H look at Resident #1's forearm. Hospice Aide G said the bruises were in the same area, one was about the size of a nickel, and the other was oval in shape. She stated LVN H looked at the bruises, but she did not know what LVN H did after that. Hospice Aide G stated Resident #1 was such a sweet lady, and when she first started taking care of her, she (Resident #1) would push her (Hospice Aide G) away. She said now Hospice always had two aides to work with Resident #1 to ensure her safety. She stated Resident #1 was sweet and not combative. Hospice Aide G also revealed at times Resident #1 tried to assist with her care. Interview on 08/30/12 at 9:30 AM with MA J revealed she had been a MA for [AGE] years and had worked at the facility for [AGE] years. She stated she was related to Resident #1, and she was not aware of any bruising before this incident. MA J revealed Hospice Aide G came to her early on the morning of 08/23/12 after Resident #1's shower and asked her if she was aware of the bruising on the resident's arm. MA J said she directed Hospice Aide G to LVN H, who was the Charge Nurse, to tell LVN H about the bruising. MA J stated nothing else was ever said to her about the bruising. She also stated she was not sure if the Charge Nurse assessed Resident #1. MA J revealed she talked to another of Resident #1's family members on Saturday, 08/25/12, and stated that family member asked her about the bruising. She said she did not say anything to the family, because she thought the facility would handle it. MA J stated because she worked at the facility, the staff just assumed she would take care of any problems with the resident. MA J revealed she tried to stay out of it because she was part of Resident #1's family. Interview on 08/31/12 at 9:55 AM with LVN H revealed she had worked at the facility for four years. LVN H stated Hospice Aide K came to her on 08/24/12 and said Resident #1 had a small bruise on her right wrist. LVN H revealed she had spoken to a family member and reported it to MA J. LVN H also stated she did not document the occurrence, nor did she suspect abuse. LVN H revealed she had known CNA C for a couple of years, but they did not work the same shift. Interview on 08/31/12 at approximately 6:00 AM with LVN A revealed he had worked at the facility for nine years. He stated he had known CNA C for about a year, and she was hard working and [MEDICATION NAME]. He said he thought that until he saw the video and now he was disgusted. He revealed Resident #1 had always been calm when he was in there with her, and he had not had any problems with her being combative or aggressive. LVN A stated the family came to him about Resident #1's bruises. He also stated he had a good relationship with the family, and they told him that CNA C was rough with Resident #1 on 08/26/12. LVN A revealed he called the Administrator immediately, but he did not answer the phone. He stated he then called the DON and told him what the family told him. LVN A said the family came in on Monday, 08/27/12. He then revealed he reported for his shift at 10:00 PM, and the DON told him to suspend CNA C until there was an investigation. LVN A stated he had seen the video on the news and he knew who the CNAs involved were, CNA C and CNA D. He said he knew it was CNA C from the blonde hair, and CNA D always wore a back-belt. He revealed both CNAs came to him about a month earlier and asked him what the sign, "This room is under Video Surveillance" on Resident #1's door, meant. He stated because they were both foreign, CNA C and CNA D may not have understood what it meant. LVN A revealed CNA C and CNA D had communication issues, and talking to them was like talking to a "brick wall." LVN A said CNA C and CNA D just say they understand and go ahead and do what they want to do anyway. He stated he had witnessed Resident #1 grab for assistance, when they repositioned her. He revealed he thought she might be scared. He indicated Resident #1 used to yell out a couple years ago for her family, but he had never noticed any aggressive behaviors from her. He stated one time he witnessed Resident #1 trying to pinch CNA D. LVN A also revealed that sometimes Resident #1 was resistant to care. Interview on 08/29/12 at 4:00 PM conducted with LVN E revealed he was the Weekend Supervisor, had worked at the facility for eight years, and had been an LVN for [AGE] years. LVN E stated LVN A came to him on Sunday, 08/26/12, and told him Resident #1's family came to him about the bruises on the resident's forearm. He also stated he assessed the resident, and there was a one centimeter bruise above her wrist and a hematoma on her forearm. LVN E revealed her skin was intact, and there was no swelling noted. He indicated he completed a head-to-toe assessment and did not see any other bruises. He stated he told LVN A to notify the family. LVN E also revealed the family had identified CNA C as being rough with Resident #1 and had been unhappy with her provision of care. The family requested she be moved to another hall away from the resident. LVN E stated since the family said she (the CNA) was rough, he asked the family member if he/she would prefer the CNA be moved. LVN E said the CNA was moved to another hall on Monday, 08/27/12. LVN E revealed he called the Administrator immediately, told him of the occurrence, and the Administrator stated being rough was not in the definition of abuse, and to do a one-on-one in-service with CNA C. LVN E stated he was supposed to talk to the CNA about repositioning and the use of draw sheets and to provide sensitivity training. LVN E revealed he did what the Administrator told him to do the next day 8/27/12. LVN E stated he had not seen the video tape of the abuse, it was "their job," and it was up to them (Administration) to follow-up. LVN E said he in-serviced CNA C the next day, 08/27/12, around 11:00 AM. He revealed he talked to the DON about moving the CNA to another hall because of the family's request, and the DON told him to go ahead and move CNA C to another hall. LVN E said he spoke to the Administrator about not really knowing people and that anything could set them off. He then stated, "She really looked like she was really angry at something on that tape." (LVN E had previously stated he had NOT seen the tape). LVN E stated he approached the DON three times on Monday, 08/27/12, for follow-up and he was never able to communicate with the DON that day. Interview conducted on 08/29/12 at approximately 2:00 PM with the DON regarding Resident #1's bruising of the right forearm. He stated he received a call on Sunday, 08/26/12, afternoon from LVN E, who told him Resident #1 had bruising of an unknown origin on her wrist. The DON said LVN E measured it and told Resident #1's family member. He stated LVN E told him he knew there was a camera in the room and the room was monitored 24/7 (24 hours a day/seven days a week.) The DON revealed he knew the resident was combative with care, and because of that information he did not really think there was a problem. He said he did not suspect abuse, because one of the resident's family members worked in the facility, and he knew the family would have reported it (abuse) if there was a problem. The DON stated the family member worked on the same hall where Resident #1 resided. The DON further revealed he directed LVN E to contact the Administrator to ensure he did everything correctly. The DON was asked why he did not contact the Administrator, and he replied because he really did not think the bruising of unknown origin was an issue. The DON stated he based his decision on what he was told by LVN E. He also stated he wanted to be sure the other dependent residents on that hall were safe, so he directed LVN E to check all the dependent residents on Resident #1's hall. The DON was asked if he followed-up with LVN E regarding the checks of the other residents, and he replied no, because he was out of town. The DON further stated he received a call from LVN A at approximately 10:15 PM on 08/26/12 informing him that LVN A received a call from Resident #1's family member making an allegation of abuse against CNA C. The DON stated CNA C was suspended immediately, and he called the Administrator and briefed him on what occurred. Interview on 08/30/12 at 11:45 AM with the Administrator revealed he was an Interim Administrator. He stated he had [AGE] years of experience and he had been at the facility for about one month and a half. On 08/26/12 at around 2:00 PM, he received a call from the Weekend Supervisor, LVN E. The Administrator revealed LVN E had a resident's family complain to him about CNA C. LVN E told him the family was concerned about CNA C being rough and too fast with the resident. The DON asked LVN E if there had been any bruising on Resident #1, and LVN E told him about the bruising to Resident #1's forearm, which the family brought to his attention. The Administrator stated he could not remember if LVN E assessed Resident #1, but he thought he (LVN E) did. When he went home from the facility on Monday, 08/27/12, he went to bed early, and saw there had been a message from the family he indicated he returned their call right then. The Administrator revealed the family came in with a video on Tuesday, 08/28/12, in the morning. He revealed he had been suspended Tuesday at 6:00 PM. The Administrator was asked if there was a difference in being rough and being abusive, and he stated he never associated bruising with being rough. Observation on 08/29/12 at approximately 10:00 PM of the surveillance video tape, date stamped 08/22/12, provided by Resident #1's family revealed CNA C pulled the resident's head up by her hair on top of her head from a lying position to an almost sitting position. CNA C then removed the pillow from under Resident #1's head and then shoved the resident's head back into the newly placed pillow. Interview on 08/30/12, at 10:28 AM with CNA C revealed she had worked at the facility for five years on the 10:00 PM to 6:00 AM shift and had been a CNA for six years. CNA C also stated she rotated from the 400 Hall to 600 Hall two times a week. She said she was contacted on 08/26/12 and asked to come in by LVN E for training. She revealed she could not come in that day, so she went to the facility on Monday 08/27/12. CNA C stated when she reported for her shift on Monday 08/27/12, her supervisor, LVN A, told her she had to go home and she was suspended. CNA C said she saw the video, and she did "not feel good" about it. She revealed Resident #1 was always fighting, kicking and yelling, and resisting care. She stated she felt that day (day of occurrence of abuse) the resident resisted help and refused care. CNA C revealed there was not enough staff on that shift to get help, and she just wanted to get it done, because the resident always resisted care. CNA C stated her supervisor, LVN A, had witnessed Resident #1 scratching, yelling and hurting her (CNA C). CNA C stated she realized the residents acted like children. CNA C revealed she had been contacted by LVN E and told she would be moved to another hall when she came in to work. CNA C said she knew the video "looked bad." She stated she was just picking up Resident #1's head to change the pillow, the resident pushed back, the resident's head slipped out of her hand, and she caught her by the hair. CNA C revealed she did not think the resident was afraid of her. CNA C was asked what she was trained to do when a resident resisted care. She replied she should have asked for help, but no one was available. CNA C was asked why she did not walk away, and she replied she just wanted to finish her work. CNA C stated she had not had any training before Monday on abuse or neglect. She revealed she preferred to be trained in Spanish and the facility did not train in Spanish, only English. CNA C said her friends helped to translate it into her own language. CNA C was asked if she knew how to deal with residents with behaviors, and she said she did. CNA C stated she could not even explain why she did what she did to Resident #1. Further observation of the surveillance video tape, date stamped 08/23/12, revealed CNA D pushed Resident #1's legs around, while she provided incontinent care. CNA D then moved from one side of the bed to the other and observed to be pinching the resident's thigh. Resident #1's arms were outstretched indicating a defensive move for protection. An interview on 08/30/12 at approximately 2:00 PM with CNA D revealed she had been a CNA for about five or six years, and had been employed by the facility for the same amount of time. She stated Resident #1 was hard to take care of, and LVN A had witnessed the resident fighting with her (CNA D). She revealed when Resident #1 was combative she told the resident, "Be nice and calm down," and continued with the care. CNA D said even if she was fighting, she (CNA D) continued providing care. CNA D stated she could not remember the last time she had training regarding abuse and neglect. She revealed the last time may have been when she was first hired, but not since then. CNA D stated the Administrator told her on 08/28/12 that the family had a video of Resident #1's room, and he knew she was giving the resident's briefs away to other CNAs for their use. CNA D said her supervisor, LVN A, never provided her guidance regarding dealing with residents, who had behaviors. She also stated the CNAs were too busy to get help. CNA D revealed there had been times when she had to pry Resident #1's hands off her arm, and she was afraid the resident would break her wrist. CNA D revealed most of the CNAs knew how Resident #1 was, so people just cared for her by themselves. CNA D did not know what neglect was. CNA D denied ever pinching or pushing Resident #1. An interview on 08/30/12 at 9:40 AM with Resident #1's Family Member #4 revealed a surveillance camera had been in the resident's room for about two months. The Family Member also stated a notification sign was posted on the entrance door to Resident #1's room. Family Member #4 said another family member reviewed the videos briefly every day. Family Member #4 revealed that family member reviewed the video and contacted the police on Monday, 08/27/12, morning regarding abuse of Resident #1. An interview on 08/30/12 at 3:45 PM with Detective #5 of the local police department revealed the original call came in by Resident #1's Family Member #3 on 08/27/12 at 6:20 PM. The Detective stated the call was taken at 12:10 AM on 08/28/12. The Detective said the officers were dispatched to the facility later on during that day to take a report. The Detective revealed CNA C had been suspended. The Detective also stated he received an arrest warrant from the District Attorney based on the surveillance video for the arrest of CNA C for elder abuse. Interview conducted on 08/30/12 at 11:00 AM with the Corporate Regional Vice President revealed she became aware of the incident with CNA C and Resident #1 on 08/28/12. She stated the Administrator called her and told her the family was in the building with a video tape and informed her of the potential situation. The Regional Vice President revealed the Administrator said there was a video, but he did not know what was on it. As soon as she heard that, she got in her car to go to the facility. The Administrator called her after he reviewed the video with the family and told her what he had observed. The Regional Vice President stated the Administrator never used the words abuse. From the information she had gathered, a Hospice Aide went to LVN H on 08/24/12 at approximately 7:30 AM with information Resident #1 had bruises measuring 3.0 x 3.0 centimeters and it was not documented anywhere. She stated she suspended LVN H that day (08/28/12). An interview on 08/31/12 at 6:00 AM with LVN I revealed she had been a nurse since 1984 and had worked at the facility for [AGE] years. LVN I said she was a Charge Nurse on Halls 100 and 200. LVN I stated she knew CNA C, was shocked about the video, CNA C was always considered to be caring and had seemed to be [MEDICATION NAME] with nothing less than that. LVN I stated Resident #1 was pleasantly confused, kind, content, and she had never seen Resident #1 be combative. Interview on 08/31/12 at 6:20 AM with CNA K revealed she had worked at the facility for 1 ? years and worked the 10:00 PM to 6:00 AM shift. She stated CNA C came in once in a while to assist her. She revealed CNA C worked fast. She stated Resident #1 always talked to her. CNA K said she had never seen Resident #1 being aggressive, and about a year ago, Resident #1 would to sing to her. Review of the facility's Abuse, Neglect and Misappropriation of Property dated 2012 revealed, "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse...2. The facility's Leadership would conduct a prompt investigation of any allegation of suspected abuse...3. The facility's Leadership would provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law... Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types if abuse include BUT ARE NOT LIMITED TO: A. Physical assault/abuse: 1) Hitting 2) Slapping 3) Pinching 4) Kicking 5) Controlling behavior through corporal punishment ... Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator or his/her designee and other enforcement agencies according to state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities)... Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting. B. Enforcing a Zero Tolerance standard for retaliation against the alleged victim." Review of the facility's undated policy regarding Resident Rights and taken from the DADS Consumer Rights and Services publication, revealed, "...You have the right to...Be free from abuse, neglect and exploitation Be treated with dignity, courtesy, consideration, and respect...." An IJ was identified on 08/30/12. The Regional Vice President and the Clinical Services Director were notified on 08/30/12 at 9:15 AM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 08/31/12 at 2:30 PM and reflected the following: Resident #1 was assessed for injury by the Weekend Charge Nurse LVN E and no new injury was noted. A psychological assessment was offered to the resident. CNA C and CNA D were suspended pending investigation on 08/28/12 by the ADM and the DON. The ADM and the DON, who were notified of Resident #1's bruising of unknown origin on 08/26/12, were suspended pending investigation on 08/28/12 by the Regional VP. Residents who had received care from CNAs C and D were assessed for potential injury with a completion date of 08/29/12 by the Charge Nurses (on each hall and Administrative Nurses. (Corporate Clinical Services Director and ADON's. No new injuries were noted. Interviewable residents who received care from CNAs C and D were interviewed by Social Services Director T effective 08/29/12. No reports of bruises or injury were given. Families/Responsible Parties of "non-interviewable" residents were to be contacted to address concerns or bruising of unknown origin to be completed by the Administrative Staff and completed 08/31/12. All other facility residents in the facility were assessed for potential injury by the Charge Nurses and Administrative Nurses effective 08/30/12. Incident Reports were reviewed by the Clinical Services Director to determine whether other residents had injuries of unknown origin to be completed by 08/29/12. None were identified. All facility staff were re-educated on abuse including: identifying and reporting abuse and appropriate measures to take when staff disagrees with the Supervisor's response to an allegation of abuse. When an injury of unknown origin, including bruises, is reported, a licensed nurse will assess the resident and report the incident to the Abuse Coordinator and notify the resident's physician and family/Responsible Party. The investigation will be initiated as directed by the Abuse Coordinator/designee. If a staff member had been identified as the alleged perpetrator, he/she will be suspended. The incident will be reported as indicated per the State guidelines. This will be conducted by the facility's Staff Development Coordinator or /designee and was initiated on 08/28/12. A pre and post test will be given to facility staff to assess staff's understanding of the Abuse Prohibition. Newly-hired staff will be educated during orientation and the use of pre and post tests will be utilized. All facility staff will be re-educated on Abuse Prohibition at a minimum of every quarter for two quarters and then annually. The pre and post tests will be utilized. This will be conducted by the facility's Staff Development Coordinator/designee. CNAs were re-educated on proper transfer techniques to include not rushing a resident to prevent injury. This was initiated on 08/30/12 and was conducted by the Therapy Director/Staff Development Coordinator/designee. Nursing staff were to be re-educated on dealing with a resident with Dementia and also exhibits behaviors. This was initiated on 08/31/12 and was conducted by the Staff Development Coordinator/designee. Life Satisfaction rounds were to be conducted with facility residents and/or family members/Responsible Parties weekly for one month by the Department Heads and was initiated 08/28/12. Residents will be requested to identify abuse and to whom they would report it. Any concerns will be addressed immediately and reported to the Administrator/designee. Incident/Accident Reports and Grievance Reports will be reviewed Monday through Friday during Morning Meeting to identify allegations of abuse/neglect. The ADM/DON will be responsible for investigating, reporting and implementing discipline and/or education as needed. The Weekend Supervisor will review Incident/Accident Reports and Grievance Reports on Saturday and Sunday and inform the ADM and the DON of any allegations of abuse/neglect including injuries of unknown origin immediately at the time it is identified. Weekly skin assessments will be reviewed for identification of bruising weekly for one month and then randomly by the DON/designee. Areas identified will be reviewed by the DON/designee for investigation, root cause and prevention. Administrative staff identify will randomly question facility staff on abuse to assess their knowledge during routine rounds and observation of care. Families of residents will also be interviewed to identity issues/concerns and identify deficient practices. They will be addressed immediately and reported to the ADM/designee. The Performance Improvement Team will consist of: the ADM, the DON, the ADON, the Medical Director (when available), the Pharmacy Consultant (if available), the Activity Director, the Social Services Director, the Dietary Manager, the Maintenance Director and the Staff Development Coordinator. Their purpose will be to identify areas of noncompliance, establish a plan for improvement with a goal, develop timeframes and identify who will be responsible for completion of the plan along with QA. The Performance Improvement Team will meet weekly to review the results from Life Satisfaction Rounds and skin assessments. All grievances and allegations of abuse, neglect, mistreatment will be reported as required and a thorough investigation will be conducted. The Medical Director will be invited to attend. Interviews conducted on 08/31/12 at 2:00 PM with eight residents, who were active members of the Resident Council, revealed they had not had any problems with staff in the facility being rough or rude. They stated they loved it there. They also indicated they would go to the Administrator if there was a problem. They revealed they felt safe. Interview conducted on 08/31/12 at 6:00 AM with LVN J revealed the staff on the 10:00 PM to 6:00 AM shift received an in-service on abuse and neglect at the beginning of the shift on 08/30/12. She stated they reviewed signs of abuse of a resid

Based on observation, interview, and record review, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for two (Residents #1 and #2) of 10 residents reviewed for abuse. 1. Surveillance video tapes showed CNA C pulled Resident #1 up by her hair. 2. Surveillance video tapes showed CNA D pinched Resident #1's legs, and she was rough with the resident. 3. The ADM and Don failed to immediately start an investigation and conduct a thorough investigation, when they were notified of bruising of unknown origin and of a hematoma on Resident #1's arm on 08/26/12, and when they were notified of the family's allegation that CNA C was physically abusing Resident #1. 4. The ADM and DON failed to immediately suspend CNA C after Resident #1's family voiced an allegation of physical abuse by CNA C on 08/26/12, and the resident had bruising of unknown origin. CNA C was initially moved to another hall. 5. The DON and ADM failed to immediately report Resident #1's bruising of unknown origin, a hematoma of unknown origin, and an allegation of physical abuse to the State survey and certification agency. 6. The ADM and DON failed to properly investigate Resident #2's allegation of physical abuse by CNA C, when they took CNA C to the resident's room and confronted the resident about the mistreatment. These failures resulted in fear, anxiety, skin injuries, and the potential for more serious physical injuries such as fractures and death. These failures also continued to expose Resident #2 to mistreatment and/or abuse by CNA C who continued to care for Resident #2 after he voiced allegations of mistreatment by her. An Immediate Jeopardy (IJ) was identified on 08/30/12. While the IJ was removed on 08/31/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the facility's other 133 residents, by placing them at risk for abuse, injuries, fear, anxiety, and a decreased quality of life. Findings included: 1. Review of the facility's Abuse, Neglect and Misappropriation of Property dated 2012 revealed, "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse...2. The facility's Leadership would conduct a prompt investigation of any allegation of suspected abuse...3. The facility's Leadership would provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law... Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types if abuse include BUT ARE NOT LIMITED TO: A. Physical assault/abuse: 1) Hitting 2) Slapping 3) Pinching 4) Kicking 5) Controlling behavior through corporal punishment ... Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator or his/her designee and other enforcement agencies according to state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities)... Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting. B. Enforcing a Zero Tolerance standard for retaliation against the alleged victim." 2. Resident #1's MDS assessment dated [DATE] revealed Resident #1 was sometimes understood, responded adequately to simple direct communication only. The assessment reflected she rarely or never understood others, her daily cognitive skills were severely impaired, and she never or rarely made decisions. Further review of the MDS assessment revealed Resident #1 did not have a history of physical or verbal aggression directed towards others, and she did not have a history of refusing care. Resident #1's Monthly Nursing Data Collection tool dated 08/20/12 reflected she weighed 108 pounds, she was "on total care," and in addition was incontinent of bowel and bladder, and functionally impaired on both sides of her body. The document also reflected Resident #1 was totally dependent on two staff for bed mobility, turning and repositioning, transfers, toileting, and she needed some assistance with eating. The document was signed by LVN B on "07/15/12." Resident #1's August 2012 physician's orders [REDACTED]. Resident #1's Care Plan dated 08/23/12 reflected a handwritten entry on page 6 of 16 pages, dated 08/26/12, which reflected she resisted ADL care at times and was initialed by LVN E. Review on 08/29/12 of Nurse's Notes for Resident #1 revealed on 08/26/12 at approximately 12:00 PM, she was assisted with incontinent care. The Notes reflected a small, old bruise, and a small, old hematoma (a collection of blood outside of a blood vessel causing a bump and swelling which occurs because the wall of a blood vessel wall, artery, vein, or capillary, has been damaged and blood has leaked into tissues where it does not belong) to her right forearm. The Nurse's Notes also reflected her family was notified, there were no signs/symptoms of infection, and they would continue to monitor. Review of the facility's Injury of Unknown Origin Worksheet dated 08/26/12 revealed LVN E documented a one centimeter fading bruise on Resident #1's right forearm. The Worksheet also reflected a second bruise measuring one centimeter and a hematoma on her right forearm. Further review of the Injury of Unknown Origin Worksheet revealed Resident #1 was dependent on staff for care with transfers and repositioning, and at times she was resistant to care. The Worksheet indicated the causes of the injuries were not known at that time. The Worksheet also reflected Resident #1's family member was notified by Resident #1's other family member two days prior, of the bruise to the resident's arm, but the family member did not notify staff. The Worksheet indicated staff were interviewed, and the resident at times was resistant to care. The worksheet was signed by LVN E, who was the Weekend Supervisor. The spaces for the signatures of the Administrator and DON were blank. Nurse's Notes for Resident #1 dated 08/27/12 reflected there were no signs of pain or signs/symptoms of infection of the area on her right arm. Nurse's Notes for Resident #1 dated 08/28/12 reflected a head-to-toe assessment of the resident was conducted and there were no additional injuries to the resident. The last entry in the Nurse's Notes for Resident #1 was dated 08/29/12 and reflected the bruises to her right forearm were still present. The Notes also reflected a head-to-toe assessment was not conducted until 08/28/12, which revealed some discoloration on her toe and discoloration on her right arm. Observation on 08/29/12 at 1:20 PM revealed Resident #1 in her room in bed and alert. A family member was feeding Resident #1 and stated the incident occurred on Monday 08/27/12 between the hours of 10:00 PM and 6:00 AM. The resident was thin and frail with faded bruises on her right forearm just above the wrist bone about the size of a fingerprint, and further up her outer forearm was a bruise about the size of a nickel. Interview on 08/31/12 at approximately 11:10 AM with Hospice Aide N revealed Resident #1 had two bruises on her arm. She stated she noticed the first one Wednesday, 08/22/12. She revealed she documented it in the Hospice notes and notified LVN H. Hospice Aide N stated on Monday, 08/27/12, further up Resident #1's arm she noticed a blood blister. She also revealed she documented the finding and notified her RN Case Manager. She stated Resident #1 was always nice to her, but she could see a change in her disposition. She also revealed it was more like if someone touched her she was sore or maybe apprehensive. Hospice Aide N stated she had never seen the resident be combative. Interview on 08/31/12 at 11:00 AM with Hospice Aide G revealed she had been a CNA for [AGE] years and came to the facility to provide care to Resident #1 five days a week. She stated she provided showers, bed baths, grooming, and incontinent care to the resident. Hospice Aide G revealed she had worked with Resident #1 for about three months and had not noticed any bruising before now. She stated last week (08/20/12 through 08/25/12) she noticed a red area, closer to the resident's wrist. She also revealed she reported it to LVN H. She then stated she informed her RN Case Manager. Hospice Aide G revealed she approached LVN H again this past Monday, 08/27/12, regarding new bruising, and requested LVN H look at Resident #1's forearm. Hospice Aide G said the bruises were in the same area, one was about the size of a nickel, and the other was oval in shape. She stated LVN H looked at the bruises, but she did not know what LVN H did after that. Hospice Aide G stated Resident #1 was such a sweet lady, and when she first started taking care of her, she (Resident #1) would push her (Hospice Aide G) away. She said now Hospice always had two aides to work with Resident #1 to ensure her safety. She stated Resident #1 was sweet and not combative. Hospice Aide G also revealed at times Resident #1 tried to assist with her care. Interview on 08/30/12 at 9:30 AM with MA J revealed she had been a MA for [AGE] years and had worked at the facility for [AGE] years. She stated she was related to Resident #1, and she was not aware of any bruising before this incident. MA J revealed Hospice Aide G came to her early on the morning of 08/23/12 after Resident #1's shower and asked her if she was aware of the bruising on the resident's arm. MA J said she directed Hospice Aide G to LVN H, who was the Charge Nurse, to tell LVN H about the bruising. MA J stated nothing else was ever said to her about the bruising. She also stated she was not sure if the Charge Nurse assessed Resident #1. MA J revealed she talked to another of Resident #1's family members on Saturday, 08/25/12, and stated that family member asked her about the bruising. She said she did not say anything to the family, because she thought the facility would handle it. MA J stated because she worked at the facility, the staff just assumed she would take care of any problems with the resident. MA J revealed she tried to stay out of it because she was part of Resident #1's family. Interview on 08/31/12 at 9:55 AM with LVN H revealed she had worked at the facility for four years. LVN H stated Hospice Aide K came to her on 08/24/12 and said Resident #1 had a small bruise on her right wrist. LVN H revealed she had spoken to a family member and reported it to MA J. LVN H also stated she did not document the occurrence, nor did she suspect abuse. LVN H revealed she had known CNA C for a couple of years, but they did not work the same shift. Interview on 08/31/12 at approximately 6:00 AM with LVN A revealed he had worked at the facility for nine years. He stated he had known CNA C for about a year, and she was hard working and [MEDICATION NAME]. He said he thought that until he saw the video and now he was disgusted. He revealed Resident #1 had always been calm when he was in there with her, and he had not had any problems with her being combative or aggressive. LVN A stated the family came to him about Resident #1's bruises. He also stated he had a good relationship with the family, and they told him that CNA C was rough with Resident #1 on 08/26/12. LVN A revealed he called the Administrator immediately, but he did not answer the phone. He stated he then called the DON and told him what the family told him. LVN A said the family came in on Monday, 08/27/12. He then revealed he reported for his shift at 10:00 PM, and the DON told him to suspend CNA C until there was an investigation. LVN A stated he had seen the video on the news and he knew who the CNAs involved were, CNA C and CNA D. He said he knew it was CNA C from the blonde hair, and CNA D always wore a back-belt. He revealed both CNAs came to him about a month earlier and asked him what the sign, "This room is under Video Surveillance" on Resident #1's door, meant. He stated because they were both foreign, CNA C and CNA D may not have understood what it meant. LVN A revealed CNA C and CNA D had communication issues, and talking to them was like talking to a "brick wall." LVN A said CNA C and CNA D just say they understand and go ahead and do what they want to do anyway. He stated he had witnessed Resident #1 grab for assistance, when they repositioned her. He revealed he thought she might be scared. He indicated Resident #1 used to yell out a couple years ago for her family, but he had never noticed any aggressive behaviors from her. He stated one time he witnessed Resident #1 trying to pinch CNA D. LVN A also revealed that sometimes Resident #1 was resistant to care. Interview on 08/29/12 at 4:00 PM conducted with LVN E revealed he was the Weekend Supervisor, had worked at the facility for eight years, and had been an LVN for [AGE] years. LVN E stated LVN A came to him on Sunday, 08/26/12, and told him Resident #1's family came to him about the bruises on the resident's forearm. He also stated he assessed the resident, and there was a one centimeter bruise above her wrist and a hematoma on her forearm. LVN E revealed her skin was intact, and there was no swelling noted. He indicated he completed a head-to-toe assessment and did not see any other bruises. He stated he told LVN A to notify the family. LVN E also revealed the family had identified CNA C as being rough with Resident #1 and had been unhappy with her provision of care. The family requested she be moved to another hall away from the resident. LVN E stated since the family said she (the CNA) was rough, he asked the family member if he/she would prefer the CNA be moved. LVN E said the CNA was moved to another hall on Monday, 08/27/12. LVN E revealed he called the Administrator immediately, told him of the occurrence, and the Administrator stated being rough was not in the definition of abuse, and to do a one-on-one in-service with CNA C. LVN E stated he was supposed to talk to the CNA about repositioning and the use of draw sheets and to provide sensitivity training. LVN E revealed he did what the Administrator told him to do the next day 8/27/12. LVN E stated he had not seen the video tape of the abuse, it was "their job," and it was up to them (Administration) to follow-up. LVN E said he in-serviced CNA C the next day, 08/27/12, around 11:00 AM. He revealed he talked to the DON about moving the CNA to another hall because of the family's request, and the DON told him to go ahead and move CNA C to another hall. LVN E said he spoke to the Administrator about not really knowing people and that anything could set them off. He then stated, "She really looked like she was really angry at something on that tape." (LVN E had previously stated he had NOT seen the tape). LVN E stated he approached the DON three times on Monday, 08/27/12, for follow-up and he was never able to communicate with the DON that day. Interview conducted on 08/29/12 at approximately 2:00 PM with the DON regarding Resident #1's bruising of the right forearm. He stated he received a call on Sunday, 08/26/12, afternoon from LVN E, who told him Resident #1 had bruising of an unknown origin on her wrist. The DON said LVN E measured it and told Resident #1's family member. He stated LVN E told him he knew there was a camera in the room and the room was monitored 24/7 (24 hours a day/seven days a week.) The DON revealed he knew the resident was combative with care, and because of that information he did not really think there was a problem. He said he did not suspect abuse, because one of the resident's family members worked in the facility, and he knew the family would have reported it (abuse) if there was a problem. The DON stated the family member worked on the same hall where Resident #1 resided. The DON further revealed he directed LVN E to contact the Administrator to ensure he did everything correctly. The DON was asked why he did not contact the Administrator, and he replied because he really did not think the bruising of unknown origin was an issue. The DON stated he based his decision on what he was told by LVN E. He also stated he wanted to be sure the other dependent residents on that hall were safe, so he directed LVN E to check all the dependent residents on Resident #1's hall. The DON was asked if he followed-up with LVN E regarding the checks of the other residents, and he replied no, because he was out of town. The DON further stated he received a call from LVN A at approximately 10:15 PM on 08/26/12 informing him that LVN A received a call from Resident #1's family member making an allegation of abuse against CNA C. The DON stated CNA C was suspended immediately, and he called the Administrator and briefed him on what occurred. Interview on 08/30/12 at 11:45 AM with the Administrator revealed he was an Interim Administrator. He stated he had [AGE] years of experience and he had been at the facility for about one month and a half. On 08/26/12 at around 2:00 PM, he received a call from the Weekend Supervisor, LVN E. The Administrator revealed LVN E had a resident's family complain to him about CNA C. LVN E told him the family was concerned about CNA C being rough and too fast with the resident. The DON asked LVN E if there had been any bruising on Resident #1, and LVN E told him about the bruising to Resident #1's forearm, which the family brought to his attention. The Administrator stated he could not remember if LVN E assessed Resident #1, but he thought he (LVN E) did. When he went home from the facility on Monday, 08/27/12, he went to bed early, and saw there had been a message from the family he indicated he returned their call right then. The Administrator revealed the family came in with a video on Tuesday, 08/28/12, in the morning. He revealed he had been suspended Tuesday at 6:00 PM. The Administrator was asked if there was a difference in being rough and being abusive, and he stated he never associated bruising with being rough. Observation on 08/29/12 at approximately 10:00 PM of the surveillance video tape, date stamped 08/22/12, provided by Resident #1's family revealed CNA C pulled the resident's head up by her hair on top of her head from a lying position to an almost sitting position. CNA C then removed the pillow from under Resident #1's head and then shoved the resident's head back into the newly placed pillow. Interview on 08/30/12, at 10:28 AM with CNA C revealed she had worked at the facility for five years on the 10:00 PM to 6:00 AM shift and had been a CNA for six years. CNA C also stated she rotated from the 400 Hall to 600 Hall two times a week. She said she was contacted on 08/26/12 and asked to come in by LVN E for training. She revealed she could not come in that day, so she went to the facility on Monday 08/27/12. CNA C stated when she reported for her shift on Monday 08/27/12, her supervisor, LVN A, told her she had to go home and she was suspended. CNA C said she saw the video, and she did "not feel good" about it. She revealed Resident #1 was always fighting, kicking and yelling, and resisting care. She stated she felt that day (day of occurrence of abuse) the resident resisted help and refused care. CNA C revealed there was not enough staff on that shift to get help, and she just wanted to get it done, because the resident always resisted care. CNA C stated her supervisor, LVN A, had witnessed Resident #1 scratching, yelling and hurting her (CNA C). CNA C stated she realized the residents acted like children. CNA C revealed she had been contacted by LVN E and told she would be moved to another hall when she came in to work. CNA C said she knew the video "looked bad." She stated she was just picking up Resident #1's head to change the pillow, the resident pushed back, the resident's head slipped out of her hand, and she caught her by the hair. CNA C revealed she did not think the resident was afraid of her. CNA C was asked what she was trained to do when a resident resisted care. She replied she should have asked for help, but no one was available. CNA C was asked why she did not walk away, and she replied she just wanted to finish her work. CNA C stated she had not had any training before Monday on abuse or neglect. She revealed she preferred to be trained in Spanish and the facility did not train in Spanish, only English. CNA C said her friends helped to translate it into her own language. CNA C was asked if she knew how to deal with residents with behaviors, and she said she did. CNA C stated she could not even explain why she did what she did to Resident #1. Further observation of the surveillance video tape, date stamped 08/23/12, revealed CNA D pushed Resident #1's legs around, while she provided incontinent care. CNA D then moved from one side of the bed to the other and observed to be pinching the resident's thigh. Resident #1's arms were outstretched indicating a defensive move for protection. An interview on 08/30/12 at approximately 2:00 PM with CNA D revealed she had been a CNA for about five or six years, and had been employed by the facility for the same amount of time. She stated Resident #1 was hard to take care of, and LVN A had witnessed the resident fighting with her (CNA D). She revealed when Resident #1 was combative she told the resident, "Be nice and calm down," and continued with the care. CNA D said even if she was fighting, she (CNA D) continued providing care. CNA D stated she could not remember the last time she had training regarding abuse and neglect. She revealed the last time may have been when she was first hired, but not since then. CNA D stated the Administrator told her on 08/28/12 that the family had a video of Resident #1's room, and he knew she was giving the resident's briefs away to other CNAs for their use. CNA D said her supervisor, LVN A, never provided her guidance regarding dealing with residents, who had behaviors. She also stated the CNAs were too busy to get help. CNA D revealed there had been times when she had to pry Resident #1's hands off her arm, and she was afraid the resident would break her wrist. CNA D revealed most of the CNAs knew how Resident #1 was, so people just cared for her by themselves. CNA D did not know what neglect was. CNA D denied ever pinching or pushing Resident #1. An interview on 08/30/12 at 9:40 AM with Resident #1's Family Member #4 revealed a surveillance camera had been in the resident's room for about two months. The Family Member also stated a notification sign was posted on the entrance door to Resident #1's room. Family Member #4 said another family member reviewed the videos briefly every day. Family Member #4 revealed that family member reviewed the video and contacted the police on Monday, 08/27/12, morning regarding abuse of Resident #1. An interview on 08/30/12 at 3:45 PM with Detective #5 of the local police department revealed the original call came in by Resident #1's Family Member #3 on 08/27/12 at 6:20 PM. The Detective stated the call was taken at 12:10 AM on 08/28/12. The Detective said the officers were dispatched to the facility later on during that day to take a report. The Detective revealed CNA C had been suspended. The Detective also stated he received an arrest warrant from the District Attorney based on the surveillance video for the arrest of CNA C for elder abuse. Interview conducted on 08/30/12 at 11:00 AM with the Corporate Regional Vice President revealed she became aware of the incident with CNA C and Resident #1 on 08/28/12. She stated the Administrator called her and told her the family was in the building with a video tape and informed her of the potential situation. The Regional Vice President revealed the Administrator said there was a video, but he did not know what was on it. As soon as she heard that, she got in her car to go to the facility. The Administrator called her after he reviewed the video with the family and told her what he had observed. The Regional Vice President stated the Administrator never used the words abuse. From the information she had gathered, a Hospice Aide went to LVN H on 08/24/12 at approximately 7:30 AM with information Resident #1 had bruises measuring 3.0 x 3.0 centimeters and it was not documented anywhere. She stated she suspended LVN H that day (08/28/12). An interview on 08/31/12 at 6:00 AM with LVN I revealed she had been a nurse since 1984 and had worked at the facility for [AGE] years. LVN I said she was a Charge Nurse on Halls 100 and 200. LVN I stated she knew CNA C, was shocked about the video, CNA C was always considered to be caring and had seemed to be [MEDICATION NAME] with nothing less than that. LVN I stated Resident #1 was pleasantly confused, kind, content, and she had never seen Resident #1 be combative. Interview on 08/31/12 at 6:20 AM with CNA K revealed she had worked at the facility for 1 ? years and worked the 10:00 PM to 6:00 AM shift. She stated CNA C came in once in a while to assist her. She revealed CNA C worked fast. She stated Resident #1 always talked to her. CNA K said she had never seen Resident #1 being aggressive, and about a year ago, Resident #1 would to sing to her. 3. Resident #2's Resident Admission Record 6/19/2012 reflected he was a [AGE] year-old male and his [DIAGNOSES REDACTED]. Resident #2's Care Plan reflected handwritten notes dated 07/25/12, which reflected the resident complained a CNA was rough and abused him. The handwritten notes also reflected Resident #2 stated he was concerned the staff would be mad at him for reporting the CNA, and the notes were signed by the DON. The facility's Provider Investigation Report dated 07/31/12 reflected the investigation of Resident #2's allegation of abuse. The Report reflected the alleged perpetrator was identified by Resident #2 as CNA C. The report reflected Resident #2 requested the DON bring CNA C to him so he could "ask her why she abused him." The Report also reflected the DON took the perpetrator to the resident and Resident #2 wanted CNA C to continue to provide care to him. A handwritten late entry added to the Report by the DON reflected, "resident also stated since he has been a Resident here, CNA (CNA C) has been an excellent caregiver and wants her back. Revisited the Resident over the next several days and remains content with CNA (C) as a caregiver...." An interview on 08/30/12 at 12:30 PM with the Ombudsman revealed CNA C was taking care of Resident #2 a couple of weeks before and was accused of being rough and hurting the resident's leg. The Ombudsman stated there was no evidence of bruising or fear, but the resident stated he was abused by CNA C. The Ombudsman stated it occurred around the first part of August or the last part of July of 2012. The Ombudsman also stated she could see fear in Resident's #2's eyes. The Ombudsman also stated she was concerned the DON took CNA C (the alleged perpetrator) to Resident #2's room and confronted the resident. The Ombudsman stated CNA C continued to work with Resident #2. Interview on 08/31/12 at 6:35 AM with LVN L revealed she had worked at the facility for four years and five months. She stated CNA C was very nice. She stated CNA C worked a lot and had two jobs. LVN L stated she was familiar with the allegation with Resident #2, and she witnessed Resident #2 after the incident. She stated Resident #2 never took his eyes off the aide when she was in his room. She stated the Administrator and DON took CNA C into Resident #2's and confronted the resident regarding his allegation of abuse. LVN L stated Resident #2 defended CNA C, and she thought the resident may have felt intimidated to react that way to the Administrator and DON's inquiry regarding abuse by CNA C. 4. An IJ was identified on 08/31/12. The Regional Vice President and the Clinical Services Director were notified on 08/30/12 at 9:15 AM of the IJ and a Plan of Removal was requested at that time. 5. The facility's Plan of Removal was accepted on 08/31/12 at 2:30 PM and reflected the following: Resident #1 was assessed for injury by the Weekend Charge Nurse LVN E and no new injury was noted. A psychological assessment was offered to the resident. CNA C and CNA D were suspended pending investigation on 08/28/12 by the ADM and the DON. The ADM and the DON, who were notified of Resident #1's bruising of unknown origin on 08/26/12, were suspended pending investigation on 08/28/12 by the Regional VP. Residents who had received care from CNAs C and D were assessed for potential injury with a completion date of 08/29/12 by the Charge Nurses (on each hall and Administrative Nurses. (Corporate Clinical Services Director and ADON's. No new injuries were noted. Interviewable residents who received care from CNAs C and D were interviewed by Social Services Director T effective 08/29/12. No reports of bruises or injury were given. Families/Responsible Parties of "non-interviewable" residents were to be contacted to address concerns or bruising of unknown origin to be completed by the Administrative Staff and completed 08/31/12. All other facility residents in the facility were assessed for potential injury by the Charge Nurses and Administrative Nurses effective 08/30/12. Incident Reports were reviewed by the Clinical Services Director to determine whether other residents had injuries of unknown origin to be completed by 08/29/12. None were identified. All facility staff were re-educated on abuse including: identifying and reporting abuse and appropriate measures to take when staff disagrees with the Supervisor's response to an allegation of abuse. When an injury of unknown origin, including bruises, is reported, a licensed nurse will assess the resident and report the incident to the Abuse Coordinator and notify the resident's physician and family/Responsible Party. The investigation will be initiated as directed by the Abuse Coordinator/designee. If a staff member had been identified as the alleged perpetrator, he/she will be suspended. The incident will be reported as indicated per the State guidelines. This will be conducted by the facility's Staff Development Coordinator or /designee and was initiated on 08/28/12. A pre and post test will be given to facility staff to assess staff's understanding of the Abuse Prohibition. Newly-hired staff will be educated during orientation and the use of pre and post tests will be utilized. All facility staff will be re-educated on Abuse Prohibition at a minimum of every quarter for two quarters and then annually. The pre and post tests will be utilized. This will be conducted by the facility's Staff Development Coordinator/designee. CNAs were re-educated on proper transfer techniques to include not rushing a resident to prevent injury. This was initiated on 08/30/12 and was conducted by the Therapy Director/Staff Development Coordinator/designee. Nursing staff were to be re-educated on dealing with a resident with Dementia and also exhibits behaviors. This was initiated on 08/31/12 and was conducted by the Staff Development Coordinator/designee. Life Satisfaction rounds were to be conducted with facility residents and/or family members/Responsible Parties weekly for one month by the Department Heads and was initiated 08/28/12. Residents will be requested to identify abuse and to whom they would report it. Any concerns will be addressed immediately and reported to the Administrator/designee. Incident/Accident Reports and Grievance Reports will be reviewed Monday t

Based on observation, interview and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two (Residents #1 and #2) of 10 residents reviewed for abuse. 1. The Administrator failed to implement the facility's written policies and procedures that prohibit mistreatment and abuse of residents. The Administrator failed to immediately report abuse and injuries of unknown origin to the State survey and certification agency, failed to immediately and thoroughly investigate injuries of unknown origin and an allegation of physical abuse. Resident #1 was physically abused by CNAs C and D. The Administrator failed to investigate when he was informed by LVN E of the family's complaint of mistreatment by CNA C and he was told of the bruising and hematoma of unknown origin. The Administrator and DON brought CNA C, an alleged perpetrator, to Resident #2's room, so he could ask the CNA why she abused him. The Administrator and DON allowed CNA C to continue caring for Resident #2. 2. The DON failed to follow the facility's written policies and procedures that prohibit mistreatment and abuse of residents. The DON failed to thoroughly investigate injuries of unknown origin and an allegation of physical abuse. The DON failed to immediately suspend an alleged perpetrator of physical abuse. The DON was not concerned and did not investigate when he was informed of Resident #1's bruising and hematoma of unknown origin. The DON also decided to move CNA C from Resident #1's hall when he was first informed of the alleged mistreatment. The DON and Administrator brought CNA C, an alleged perpetrator, to Resident #2's room, so he could ask the CNA why she abused him. The DON and Administrator allowed CNA C to continue caring for Resident #2. These failures resulted in fear, anxiety, skin injuries, and the potential for more serious physical injuries such as fractures and death These failures also continued to expose Resident #2 to mistreatment and/or abuse by CNA C who continued to care for Resident #2 after he voiced allegations of mistreatment by her. An Immediate Jeopardy (IJ) was identified on 08/30/12. While the IJ was removed on 08/31/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the facility's other 133 residents, by placing them at risk for abuse, injuries, fear, anxiety, and a decreased quality of life. Findings included: 1. Review of the facility's Abuse, Neglect and Misappropriation of Property dated 2012 revealed, "Policy: 1. The facility's Leadership prohibits neglect, mental or physical abuse...2. The facility's Leadership would conduct a prompt investigation of any allegation of suspected abuse...3. The facility's Leadership would provide notification to the proper authorities, and, when required, the release of information to those agencies, pursuant to applicable federal and/or state law... Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types if abuse include BUT ARE NOT LIMITED TO: A. Physical assault/abuse: 1) Hitting 2) Slapping 3) Pinching 4) Kicking 5) Controlling behavior through corporal punishment ... Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator or his/her designee and other enforcement agencies according to state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities)... Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting. B. Enforcing a Zero Tolerance standard for retaliation against the alleged victim." 2. Resident #1's MDS assessment dated [DATE] revealed Resident #1 was sometimes understood, responded adequately to simple direct communication only. The assessment reflected she rarely or never understood others, her daily cognitive skills were severely impaired, and she never or rarely made decisions. Further review of the MDS assessment revealed Resident #1 did not have a history of physical or verbal aggression directed towards others, and she did not have a history of refusing care. Resident #1's Monthly Nursing Data Collection tool dated 08/20/12 reflected she weighed 108 pounds, she was "on total care," and in addition was incontinent of bowel and bladder, and functionally impaired on both sides of her body. The document also reflected Resident #1 was totally dependent on two staff for bed mobility, turning and repositioning, transfers, toileting, and she needed some assistance with eating. The document was signed by LVN B on "07/15/12." Resident #1's August 2012 physician's orders [REDACTED]. Resident #1's Care Plan dated 08/23/12 reflected a handwritten entry on page 6 of 16 pages, dated 08/26/12, which reflected she resisted ADL care at times and was initialed by LVN E. Review on 08/29/12 of Nurse's Notes for Resident #1 revealed on 08/26/12 at approximately 12:00 PM, she was assisted with incontinent care. The Notes reflected a small, old bruise, and a small, old hematoma (a collection of blood outside of a blood vessel causing a bump and swelling which occurs because the wall of a blood vessel wall, artery, vein, or capillary, has been damaged and blood has leaked into tissues where it does not belong) to her right forearm. The Nurse's Notes also reflected her family was notified, there were no signs/symptoms of infection, and they would continue to monitor. Review of the facility's Injury of Unknown Origin Worksheet dated 08/26/12 revealed LVN E documented a one centimeter fading bruise on Resident #1's right forearm. The Worksheet also reflected a second bruise measuring one centimeter and a hematoma on her right forearm. Further review of the Injury of Unknown Origin Worksheet revealed Resident #1 was dependent on staff for care with transfers and repositioning, and at times she was resistant to care. The Worksheet indicated the causes of the injuries were not known at that time. The Worksheet also reflected Resident #1's family member was notified by Resident #1's other family member two days prior, of the bruise to the resident's arm, but the family member did not notify staff. The Worksheet indicated staff were interviewed, and the resident at times was resistant to care. The worksheet was signed by LVN E, who was the Weekend Supervisor. The spaces for the signatures of the Administrator and DON were blank. Nurse's Notes for Resident #1 dated 08/27/12 reflected there were no signs of pain or signs/symptoms of infection of the area on her right arm. Nurse's Notes for Resident #1 dated 08/28/12 reflected a head-to-toe assessment of the resident was conducted and there were no additional injuries to the resident. The last entry in the Nurse's Notes for Resident #1 was dated 08/29/12 and reflected the bruises to her right forearm were still present. The Notes also reflected a head-to-toe assessment was not conducted until 08/28/12, which revealed some discoloration on her toe and discoloration on her right arm. Observation on 08/29/12 at 1:20 PM revealed Resident #1 in her room in bed and alert. A family member was feeding Resident #1 and stated the incident occurred on Monday 08/27/12 between the hours of 10:00 PM and 6:00 AM. The resident was thin and frail with faded bruises on her right forearm just above the wrist bone about the size of a fingerprint, and further up her outer forearm was a bruise about the size of a nickel. Interview on 08/31/12 at approximately 11:10 AM with Hospice Aide N revealed Resident #1 had two bruises on her arm. She stated she noticed the first one Wednesday, 08/22/12. She revealed she documented it in the Hospice notes and notified LVN H. Hospice Aide N stated on Monday, 08/27/12, further up Resident #1's arm she noticed a blood blister. She also revealed she documented the finding and notified her RN Case Manager. She stated Resident #1 was always nice to her, but she could see a change in her disposition. She also revealed it was more like if someone touched her she was sore or maybe apprehensive. Hospice Aide N stated she had never seen the resident be combative. Interview on 08/31/12 at 11:00 AM with Hospice Aide G revealed she had been a CNA for [AGE] years and came to the facility to provide care to Resident #1 five days a week. She stated she provided showers, bed baths, grooming, and incontinent care to the resident. Hospice Aide G revealed she had worked with Resident #1 for about three months and had not noticed any bruising before now. She stated last week (08/20/12 through 08/25/12) she noticed a red area, closer to the resident's wrist. She also revealed she reported it to LVN H. She then stated she informed her RN Case Manager. Hospice Aide G revealed she approached LVN H again this past Monday, 08/27/12, regarding new bruising, and requested LVN H look at Resident #1's forearm. Hospice Aide G said the bruises were in the same area, one was about the size of a nickel, and the other was oval in shape. She stated LVN H looked at the bruises, but she did not know what LVN H did after that. Hospice Aide G stated Resident #1 was such a sweet lady, and when she first started taking care of her, she (Resident #1) would push her (Hospice Aide G) away. She said now Hospice always had two aides to work with Resident #1 to ensure her safety. She stated Resident #1 was sweet and not combative. Hospice Aide G also revealed at times Resident #1 tried to assist with her care. Interview on 08/30/12 at 9:30 AM with MA J revealed she had been a MA for [AGE] years and had worked at the facility for [AGE] years. She stated she was related to Resident #1, and she was not aware of any bruising before this incident. MA J revealed Hospice Aide G came to her early on the morning of 08/23/12 after Resident #1's shower and asked her if she was aware of the bruising on the resident's arm. MA J said she directed Hospice Aide G to LVN H, who was the Charge Nurse, to tell LVN H about the bruising. MA J stated nothing else was ever said to her about the bruising. She also stated she was not sure if the Charge Nurse assessed Resident #1. MA J revealed she talked to another of Resident #1's family members on Saturday, 08/25/12, and stated that family member asked her about the bruising. She said she did not say anything to the family, because she thought the facility would handle it. MA J stated because she worked at the facility, the staff just assumed she would take care of any problems with the resident. MA J revealed she tried to stay out of it because she was part of Resident #1's family. Interview on 08/31/12 at 9:55 AM with LVN H revealed she had worked at the facility for four years. LVN H stated Hospice Aide K came to her on 08/24/12 and said Resident #1 had a small bruise on her right wrist. LVN H revealed she had spoken to a family member and reported it to MA J. LVN H also stated she did not document the occurrence, nor did she suspect abuse. LVN H revealed she had known CNA C for a couple of years, but they did not work the same shift. Interview on 08/31/12 at approximately 6:00 AM with LVN A revealed he had worked at the facility for nine years. He stated he had known CNA C for about a year, and she was hard working and [MEDICATION NAME]. He said he thought that until he saw the video and now he was disgusted. He revealed Resident #1 had always been calm when he was in there with her, and he had not had any problems with her being combative or aggressive. LVN A stated the family came to him about Resident #1's bruises. He also stated he had a good relationship with the family, and they told him that CNA C was rough with Resident #1 on 08/26/12. LVN A revealed he called the Administrator immediately, but he did not answer the phone. He stated he then called the DON and told him what the family told him. LVN A said the family came in on Monday, 08/27/12. He then revealed he reported for his shift at 10:00 PM, and the DON told him to suspend CNA C until there was an investigation. LVN A stated he had seen the video on the news and he knew who the CNAs involved were, CNA C and CNA D. He said he knew it was CNA C from the blonde hair, and CNA D always wore a back-belt. He revealed both CNAs came to him about a month earlier and asked him what the sign, "This room is under Video Surveillance" on Resident #1's door, meant. He stated because they were both foreign, CNA C and CNA D may not have understood what it meant. LVN A revealed CNA C and CNA D had communication issues, and talking to them was like talking to a "brick wall." LVN A said CNA C and CNA D just say they understand and go ahead and do what they want to do anyway. He stated he had witnessed Resident #1 grab for assistance, when they repositioned her. He revealed he thought she might be scared. He indicated Resident #1 used to yell out a couple years ago for her family, but he had never noticed any aggressive behaviors from her. He stated one time he witnessed Resident #1 trying to pinch CNA D. LVN A also revealed that sometimes Resident #1 was resistant to care. Interview on 08/29/12 at 4:00 PM conducted with LVN E revealed he was the Weekend Supervisor, had worked at the facility for eight years, and had been an LVN for [AGE] years. LVN E stated LVN A came to him on Sunday, 08/26/12, and told him Resident #1's family came to him about the bruises on the resident's forearm. He also stated he assessed the resident, and there was a one centimeter bruise above her wrist and a hematoma on her forearm. LVN E revealed her skin was intact, and there was no swelling noted. He indicated he completed a head-to-toe assessment and did not see any other bruises. He stated he told LVN A to notify the family. LVN E also revealed the family had identified CNA C as being rough with Resident #1 and had been unhappy with her provision of care. The family requested she be moved to another hall away from the resident. LVN E stated since the family said she (the CNA) was rough, he asked the family member if he/she would prefer the CNA be moved. LVN E said the CNA was moved to another hall on Monday, 08/27/12. LVN E revealed he called the Administrator immediately, told him of the occurrence, and the Administrator stated being rough was not in the definition of abuse, and to do a one-on-one in-service with CNA C. LVN E stated he was supposed to talk to the CNA about repositioning and the use of draw sheets and to provide sensitivity training. LVN E revealed he did what the Administrator told him to do the next day 8/27/12. LVN E stated he had not seen the video tape of the abuse, it was "their job," and it was up to them (Administration) to follow-up. LVN E said he in-serviced CNA C the next day, 08/27/12, around 11:00 AM. He revealed he talked to the DON about moving the CNA to another hall because of the family's request, and the DON told him to go ahead and move CNA C to another hall. LVN E said he spoke to the Administrator about not really knowing people and that anything could set them off. He then stated, "She really looked like she was really angry at something on that tape." (LVN E had previously stated he had NOT seen the tape). LVN E stated he approached the DON three times on Monday, 08/27/12, for follow-up and he was never able to communicate with the DON that day. Interview conducted on 08/29/12 at approximately 2:00 PM with the DON regarding Resident #1's bruising of the right forearm. He stated he received a call on Sunday, 08/26/12, afternoon from LVN E, who told him Resident #1 had bruising of an unknown origin on her wrist. The DON said LVN E measured it and told Resident #1's family member. He stated LVN E told him he knew there was a camera in the room and the room was monitored 24/7 (24 hours a day/seven days a week.) The DON revealed he knew the resident was combative with care, and because of that information he did not really think there was a problem. He said he did not suspect abuse, because one of the resident's family members worked in the facility, and he knew the family would have reported it (abuse) if there was a problem. The DON stated the family member worked on the same hall where Resident #1 resided. The DON further revealed he directed LVN E to contact the Administrator to ensure he did everything correctly. The DON was asked why he did not contact the Administrator, and he replied because he really did not think the bruising of unknown origin was an issue. The DON stated he based his decision on what he was told by LVN E. He also stated he wanted to be sure the other dependent residents on that hall were safe, so he directed LVN E to check all the dependent residents on Resident #1's hall. The DON was asked if he followed-up with LVN E regarding the checks of the other residents, and he replied no, because he was out of town. The DON further stated he received a call from LVN A at approximately 10:15 PM on 08/26/12 informing him that LVN A received a call from Resident #1's family member making an allegation of abuse against CNA C. The DON stated CNA C was suspended immediately, and he called the Administrator and briefed him on what occurred. Interview on 08/30/12 at 11:45 AM with the Administrator revealed he was an Interim Administrator. He stated he had [AGE] years of experience and he had been at the facility for about one month and a half. On 08/26/12 at around 2:00 PM, he received a call from the Weekend Supervisor, LVN E. The Administrator revealed LVN E had a resident's family complain to him about CNA C. LVN E told him the family was concerned about CNA C being rough and too fast with the resident. The DON asked LVN E if there had been any bruising on Resident #1, and LVN E told him about the bruising to Resident #1's forearm, which the family brought to his attention. The Administrator stated he could not remember if LVN E assessed Resident #1, but he thought he (LVN E) did. When he went home from the facility on Monday, 08/27/12, he went to bed early, and saw there had been a message from the family he indicated he returned their call right then. The Administrator revealed the family came in with a video on Tuesday, 08/28/12, in the morning. He revealed he had been suspended Tuesday at 6:00 PM. The Administrator was asked if there was a difference in being rough and being abusive, and he stated he never associated bruising with being rough. Observation on 08/29/12 at approximately 10:00 PM of the surveillance video tape, date stamped 08/22/12, provided by Resident #1's family revealed CNA C pulled the resident's head up by her hair on top of her head from a lying position to an almost sitting position. CNA C then removed the pillow from under Resident #1's head and then shoved the resident's head back into the newly placed pillow. Interview on 08/30/12, at 10:28 AM with CNA C revealed she had worked at the facility for five years on the 10:00 PM to 6:00 AM shift and had been a CNA for six years. CNA C also stated she rotated from the 400 Hall to 600 Hall two times a week. She said she was contacted on 08/26/12 and asked to come in by LVN E for training. She revealed she could not come in that day, so she went to the facility on Monday 08/27/12. CNA C stated when she reported for her shift on Monday 08/27/12, her supervisor, LVN A, told her she had to go home and she was suspended. CNA C said she saw the video, and she did "not feel good" about it. She revealed Resident #1 was always fighting, kicking and yelling, and resisting care. She stated she felt that day (day of occurrence of abuse) the resident resisted help and refused care. CNA C revealed there was not enough staff on that shift to get help, and she just wanted to get it done, because the resident always resisted care. CNA C stated her supervisor, LVN A, had witnessed Resident #1 scratching, yelling and hurting her (CNA C). CNA C stated she realized the residents acted like children. CNA C revealed she had been contacted by LVN E and told she would be moved to another hall when she came in to work. CNA C said she knew the video "looked bad." She stated she was just picking up Resident #1's head to change the pillow, the resident pushed back, the resident's head slipped out of her hand, and she caught her by the hair. CNA C revealed she did not think the resident was afraid of her. CNA C was asked what she was trained to do when a resident resisted care. She replied she should have asked for help, but no one was available. CNA C was asked why she did not walk away, and she replied she just wanted to finish her work. CNA C stated she had not had any training before Monday on abuse or neglect. She revealed she preferred to be trained in Spanish and the facility did not train in Spanish, only English. CNA C said her friends helped to translate it into her own language. CNA C was asked if she knew how to deal with residents with behaviors, and she said she did. CNA C stated she could not even explain why she did what she did to Resident #1. Further observation of the surveillance video tape, date stamped 08/23/12, revealed CNA D pushed Resident #1's legs around, while she provided incontinent care. CNA D then moved from one side of the bed to the other and observed to be pinching the resident's thigh. Resident #1's arms were outstretched indicating a defensive move for protection. An interview on 08/30/12 at approximately 2:00 PM with CNA D revealed she had been a CNA for about five or six years, and had been employed by the facility for the same amount of time. She stated Resident #1 was hard to take care of, and LVN A had witnessed the resident fighting with her (CNA D). She revealed when Resident #1 was combative she told the resident, "Be nice and calm down," and continued with the care. CNA D said even if she was fighting, she (CNA D) continued providing care. CNA D stated she could not remember the last time she had training regarding abuse and neglect. She revealed the last time may have been when she was first hired, but not since then. CNA D stated the Administrator told her on 08/28/12 that the family had a video of Resident #1's room, and he knew she was giving the resident's briefs away to other CNAs for their use. CNA D said her supervisor, LVN A, never provided her guidance regarding dealing with residents, who had behaviors. She also stated the CNAs were too busy to get help. CNA D revealed there had been times when she had to pry Resident #1's hands off her arm, and she was afraid the resident would break her wrist. CNA D revealed most of the CNAs knew how Resident #1 was, so people just cared for her by themselves. CNA D did not know what neglect was. CNA D denied ever pinching or pushing Resident #1. An interview on 08/30/12 at 9:40 AM with Resident #1's Family Member #4 revealed a surveillance camera had been in the resident's room for about two months. The Family Member also stated a notification sign was posted on the entrance door to Resident #1's room. Family Member #4 said another family member reviewed the videos briefly every day. Family Member #4 revealed that family member reviewed the video and contacted the police on Monday, 08/27/12, morning regarding abuse of Resident #1. An interview on 08/30/12 at 3:45 PM with Detective #5 of the local police department revealed the original call came in by Resident #1's Family Member #3 on 08/27/12 at 6:20 PM. The Detective stated the call was taken at 12:10 AM on 08/28/12. The Detective said the officers were dispatched to the facility later on during that day to take a report. The Detective revealed CNA C had been suspended. The Detective also stated he received an arrest warrant from the District Attorney based on the surveillance video for the arrest of CNA C for elder abuse. Interview conducted on 08/30/12 at 11:00 AM with the Corporate Regional Vice President revealed she became aware of the incident with CNA C and Resident #1 on 08/28/12. She stated the Administrator called her and told her the family was in the building with a video tape and informed her of the potential situation. The Regional Vice President revealed the Administrator said there was a video, but he did not know what was on it. As soon as she heard that, she got in her car to go to the facility. The Administrator called her after he reviewed the video with the family and told her what he had observed. The Regional Vice President stated the Administrator never used the words abuse. From the information she had gathered, a Hospice Aide went to LVN H on 08/24/12 at approximately 7:30 AM with information Resident #1 had bruises measuring 3.0 x 3.0 centimeters and it was not documented anywhere. She stated she suspended LVN H that day (08/28/12). An interview on 08/31/12 at 6:00 AM with LVN I revealed she had been a nurse since 1984 and had worked at the facility for [AGE] years. LVN I said she was a Charge Nurse on Halls 100 and 200. LVN I stated she knew CNA C, was shocked about the video, CNA C was always considered to be caring and had seemed to be [MEDICATION NAME] with nothing less than that. LVN I stated Resident #1 was pleasantly confused, kind, content, and she had never seen Resident #1 be combative. Interview on 08/31/12 at 6:20 AM with CNA K revealed she had worked at the facility for 1 ? years and worked the 10:00 PM to 6:00 AM shift. She stated CNA C came in once in a while to assist her. She revealed CNA C worked fast. She stated Resident #1 always talked to her. CNA K said she had never seen Resident #1 being aggressive, and about a year ago, Resident #1 would to sing to her. 3. Resident #2's Resident Admission Record 6/19/2012 reflected he was a [AGE] year-old male and his [DIAGNOSES REDACTED]. Resident #2's Care Plan reflected handwritten notes dated 07/25/12, which reflected the resident complained a CNA was rough and abused him. The handwritten notes also reflected Resident #2 stated he was concerned the staff would be mad at him for reporting the CNA, and the notes were signed by the DON. The facility's Provider Investigation Report dated 07/31/12 reflected the investigation of Resident #2's allegation of abuse. The Report reflected the alleged perpetrator was identified by Resident #2 as CNA C. The report reflected Resident #2 requested the DON bring CNA C to him so he could "ask her why she abused him." The Report also reflected the DON took the perpetrator to the resident and Resident #2 wanted CNA C to continue to provide care to him. A handwritten late entry added to the Report by the DON reflected, "resident also stated since he has been a Resident here, CNA (CNA C) has been an excellent caregiver and wants her back. Revisited the Resident over the next several days and remains content with CNA (C) as a caregiver...." An interview on 08/30/12 at 12:30 PM with the Ombudsman revealed CNA C was taking care of Resident #2 a couple of weeks before and was accused of being rough and hurting the resident's leg. The Ombudsman stated there was no evidence of bruising or fear, but the resident stated he was abused by CNA C. The Ombudsman stated it occurred around the first part of August or the last part of July of 2012. The Ombudsman also stated she could see fear in Resident's #2's eyes. The Ombudsman also stated she was concerned the DON took CNA C (the alleged perpetrator) to Resident #2's room and confronted the resident. The Ombudsman stated CNA C continued to work with Resident #2. Interview on 08/31/12 at 6:35 AM with LVN L revealed she had worked at the facility for four years and five months. She stated CNA C was very nice. She stated CNA C worked a lot and had two jobs. LVN L stated she was familiar with the allegation with Resident #2, and she witnessed Resident #2 after the incident. She stated Resident #2 never took his eyes off the aide when she was in his room. She stated the Administrator and DON took CNA C into Resident #2's and confronted the resident regarding his allegation of abuse. LVN L stated Resident #2 defended CNA C, and she thought the resident may have felt intimidated to react that way to the Administrator and DON's inquiry regarding abuse by CNA C. 4. An IJ was identified on 08/31/12. The Regional Vice President and the Clinical Services Director were notified on 08/30/12 at 9:15 AM of the IJ and a Plan of Removal was requested at that time. 5. The facility's Plan of Removal was accepted on 08/31/12 at 2:30 PM and reflected the following: Resident #1 was assessed for injury by the Weekend Charge Nurse LVN E and no new injury was noted. A psychological assessment was offered to the resident. CNA C and CNA D were suspended pending investigation on 08/28/12 by the ADM and the DON. The ADM and the DON, who were notified of Resident #1's bruising of unknown origin on 08/26/12, were suspended pending investigation on 08/28/12 by the Regional VP. Residents who had received care from CNAs C and D were assessed for potential injury with a completion date of 08/29/12 by the Charge Nurses (on each hall and Administrative Nurses. (Corporate Clinical Services Director and ADON's. No new injuries were noted. Interviewable residents who received care from CNAs C and D were interviewed by Social Services Director T effective 08/29/12. No reports of bruises or injury were given. Families/Responsible Parties of "non-interviewable" residents were to be contacted to address concerns or bruising of unknown origin to be completed by the Administrative Staff and completed 08/31/12. All other facility residents in the facility were assessed for potential injury by the Charge Nurses and Administrative Nurses effective 08/30/12. Incident Reports were reviewed by the Clinical Services Director to determine whether other residents had injuries of unknown origin to be completed by 08/29/12. None were identified. All facility staff were re-educated on abuse including: identifying and reporting abuse and appropriate measures to take when staff disagrees with the Supervisor's response to an allegation of abuse. When an injury of unknown origin, including bruises, is reported, a licensed nurse will assess the resident and report the incident to the Abuse Coordinator and notify the resident's physician and family/Responsible Party. The investigation will be initiated as directed by the Abuse Coordinator/designee. If a staff member had been identified as the alleged perpetrator, he/she will be suspended. The incident will be reported as indicated per the State guidelines. This will be conducted by the facility's Staff Development Coordinator or /designee and was initiated on 08/28/12. A pre and post test will be given to facility staff to assess staff's understanding of the Abuse Prohibition. Newly-hired staff will be educated during orientation and the use of pre and post tests will be utilized. All facility staff will be re-educated on Abuse Prohibition at a minimum of every quarter for two quarters and then annually. The pre and post tests will be utilized. This will be conducted by the facility's Staff Development Coordinator/designee. CNAs were re-educated on proper transfer techniques to include not rushing a resident to prevent injury. This was initiated on 08/30/12 and was conducted by the Therapy Director/Staff Development Coordinator/designee. Nursing staff were to be re-educated on dealing with a resident with Dementia and also exhibits behaviors

Based on observation, interview and record review, it was determined the facility failed to provide services that met professional standards of quality three (Residents #15, #7, and #12) of three residents with PICC lines (Peripheral Inserted Central Catheter Line: long, slender, small, and a flexible tube that is inserted into a peripheral vein for the purpose of providing intravenous fluids or an access line.) by LVN's L, M, N and O. 1) LVN M was about to inject air into Resident #15's PICC line, the surveyor intervened. LVN M failed to flush Resident #15's PICC line before administering his antibiotic. LVN M cleaned the red port on Resident #15's PICC line, dropped the tubing line on the floor, went out to get another IV tubing, when she returned she connected the IV tubing to the purple port without cleaning the access port, and failed to prime the IV tubing completely of air. LVN M said she had not received much training regarding PICC lines. There were no current physician's orders [REDACTED]. 2) LVN M failed to flush the PICC line before administering Resident #7's antibiotic and failed to properly prime the IVPB (intravenous piggy bag) tubing and the prefilled NS 10 ml syringe before flushing Residents #7's PICC line. LVN M cleaned the purple port with alcohol but went to the other side of the room to connect the old tubing to the new antibiotic bag, primed the tubing with air still in the line. While on the other side of the room, Resident #7 moved his right hand and the PICC line access port touched his body and bed linen. LVN M connected the IV tubing without re-cleaning the port, checking for patency and failed to flush the line before administering the antibiotics. 3) LVN N and LVN O flushed Resident #12's PICC line with only 5 ml of Normal Saline. The physician's orders [REDACTED]. An Immediate Jeopardy (IJ) was identified on 02/08/12. While the IJ was removed on 02/10/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because not all staff had been trained and the facility was still monitoring its Plan of Removal. These failures could affect the five residents, including Residents #15, #7, and #12, who had PICC lines at risk for complications such as infection,[MEDICAL CONDITION], septic shock, fever, air embolism and/or death. Findings included: 1. Review of <http://www.bon.state.tx.us/practice/position.html#15.3> on 02/15/12 revealed, " ...It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. The BON does not define or set qualifications for an "IV Validation Course" or for "LVN IV certification." The LVN who chooses to engage in intravenous therapy must first have been instructed in the principles of intravenous therapy congruent with prevailing nursing practice standards ... All nursing actions related to peripheral and/or central intravenous lines, as well as IV administration of medications, must be completed in accordance with the orders of the prescribing practitioner, as well as written policies, procedures and job descriptions approved by the health care employer .... " Review of <http://firstresponsecs.com/news/article/providing-scrupulous-picc-maintenance on 02/15/12 revealed, " ...Providing scrupulous PICC maintenance. It takes more than new devices, of course, to limit the risk of infection. As you would with a patient with any invasive device, you ' ll need to follow evidence-based infection control guidelines: Hand hygiene, sterile dressing changes, cleaning catheter hubs and caps daily, changing IV fluids and tubing as recommended, and preventing (or eliminating) occlusions all help prevent infections that could lead to [MEDICAL CONDITION] and death ... To prevent occlusion and infection, a PICC must be flushed before all medication administration to check for patency, and after medication administration to prevent medication precipitates from forming ... If not flushed properly, PICCs can become sluggish or completely occluded. Occluded lines attract and trap bacteria that cause dangerous systemic infections...." 2. http://picclinenursing.com reflected, "A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart. However, unlike other central lines, its point of entry is from the periphery of the body ? (sic) the extremities. And typically the upper arm is the area of choice...A PICC line may requested for a variety of treatment options which include some of the following:-Prolonged IV antibiotic treatment...The catheter must be flushed every 12 hours and after each use. This is required to prevent clogging of the catheter. Flushing is done with ...normal saline...If flushing is difficult, this indicates that the PICC is becoming blocked. If it becomes fully blocked, it may not be usable. Report this difficulty in flushing immediately so it can be declotted to regain full functional use...." (retrieved on 02/22/12). 3. Resident #15's hospital Discharge Medications list dated 01/31/12 and signed on 02/01/12 reflected, "[MEDICATION NAME]/Sulbactam, 1.5 gm, IVPB, inj (injection), q8h (hours), continue for 5 weeks..." The Medications list also reflected to flush the PICC line with "Sodium Chloride flush, 10 ml, IV push, inj, q12h..." The Discharge Medications list reflected continue medication and there was yes, no, change and yes was circled for the Sodium Chloride flush. However, a handwritten "D/C (discontinue)" was next to the order. There was not a physician's orders [REDACTED].#15. Review of Resident #15's "Resident Admission Record," dated 02/01/12, revealed Resident #15 was an [AGE] year-old, who was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. Review of Resident #15's clinical record revealed no care plans for Resident #15's PICC line. The interim plan of care dated 02/01/12 revealed Resident #15 had a "PICC line dressing right forearm dressing change weekly." There were no other instructions for the PICC line care. Review of Resident #15's February 2012 physician's orders [REDACTED]. IVPB every eight hours for five weeks. The orders also revealed an order for [REDACTED]. Review of Resident #15's February 2012 Medication Chart Record revealed to flush the IV PICC line site with 10 cc NS before and after medication administration. The flushes were timed for 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. However, the 10:00 p.m. to 6:00 a.m. schedule had a line drawn through it. Further review of the Medication Chart Record revealed the flushes where initialed as completed at 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. for the following dates: 02/01/12, 02/02/12, 02/03/12, 02/04/12, 02/05/12, 02/06/12, and only the 2:00 p.m. to 10:00 p.m. shift was initialed as completed on 02/07/12. The Medication Chart Record reflected the [MEDICATION NAME] was administered at 7:00 a.m., 3:00 p.m. and 11:00 p.m. on the following dates: 02/01/12, 02/02/12, 02/03/12, 02/04/12, and 02/06/12. The Medication Chart Record reflected on 02/05/12 there were no initials for the 11:00 p.m. dose and no initials on 02/07/12 for the 2:00 p.m. to 10:00 p.m. shift. Review of Resident #15's "Clinical Infusion Nursing Documentation" dated 02/10/12 revealed the resident's PICC line had clotted and the Infusion company nurse came to the facility to declot the double lumen PICC line on that date. The surveyor observed Resident #15 during the initial rounds on 02/06/12 at 8:15 a.m. with LVN S. LVN S stated Resident #15 was alert and oriented to person, place and time, and used a wheelchair for locomotion. LVN S stated Resident #15 used a Foley catheter for voiding, and he required assistance with his activities of daily living. LVN S also stated Resident #15 had a PICC line access for antibiotics due to [MEDICAL CONDITION] of the feet. On entering the room, the surveyor observed Resident #15 sitting at the bedside with a left leg brace on his right foot. The surveyor observed Resident #15 during medication administration on 02/07/12 at 3:00 p.m. LVN M brought [MEDICATION NAME] 1.5 gm in a 50 ml IVPB with some alcohol pads and one prefilled NS syringe to the room. The NS syringe contained 5 ml of NS. LVN M placed the items on the resident's over bed table and went to the bathroom to wash her hands. LVN M donned gloves, and cleaned the red port with the alcohol wipes. She turned around to mix the [MEDICATION NAME] powder with the NS and to spike the IVPB tube, when the old IV tubing dropped on the floor. LVN M obtained new IV tubing, spiked the IVPB and primed (removing air from the line) the tubing with the medication to approximately 4 cc from the tip and stopped it. LVN M did not prime the tubing all the way to the tip to ensure the air was completely removed. Perry and Potter's Clinical Nursing Skills & Techniques Fifth Edition 2004, on page 594 reflected, "7. Check for air in tubing. If bubbles form, they can be removed...Reduce air in tubing by priming slowly instead of allowing a wide-open flow." <http://medical-dictionary.thefreedictionary.com/air+embolism> reflected, "air embolism air injected accidentally into veins which may cause temporary paralysis or dyspnea, or may be fatal if the embolism occurs in the heart or brain." (retrieved on 02/24/12.) LVN M proceeded to connect the IVPB tubing to the PICC line port. LVN M accessed and connected the IV tubing to the purple port, instead of the red port she previously cleaned. LVN M accessed the purple port without cleaning or scrubbing the port first. LVN M also failed to flush the PICC line tubing before administering the medication. When the surveyor asked her why she was using the purple port instead of the red port she had cleaned, LVN M stated the red port was for blood draws, and she thought she had cleaned the purple port. The surveyor observed LVN M again on 02/08/12 at 3:35 p.m. administering [MEDICATION NAME] 1.5 gm to Resident #15. LVN M washed her hands, spiked the IVPB, primed the tubing, cleaned the PICC line port and connected the IVPB without flushing the PICC line first and then unclamped the tubing. At 02/08/12 at 4:20 p.m., the surveyor observed Resident #15's PICC line port was connected to the IV tubing with the PICC line hub dangling without protection, which exposed the hub to possible contaminants. The surveyor left his room and found LVN M in another resident's room and asked LVN M if she flushed Resident #15's PICC line. LVN M told the surveyor she had not. She stated she just disconnected the line to come back after caring for another resident. She stated she would flush the line next. LVN M got alcohol pads and one prefilled 10 ml syringe with 5 ml of NS from the treatment cart and went to Resident #15's room. LVN M cleaned the PICC line hub and attempted to flush the PICC line with the hub. However, the syringe could not properly attach to the hub to connect for flushing. LVN M continued to struggle with the syringe and the hub. LVN M then disconnected the port from the tubing and connected it to the hub, and then cleaned the PICC line port. LVN M opened the 5 ml prefilled syringe of NS and proceeded to flush the line without first priming the syringe of the 1 to 2 ml of air in the syringe. Then LVN M had her hand on the syringe plunger and was about to inject air and NS into Resident #15's PICC line, when the surveyor intervened. After the above observation, the surveyor asked LVN M how she checked for patency of the line. LVN M stated she checked patency when she flushed both ports and it "flows freely." The interview revealed LVN M was not aware she could pull back for blood return to check for patency of the PICC line. 4. Review of Resident #7's hospital Facility Transfer Orders dated 01/22/12 revealed [MEDICATION NAME] 150 mg/ml solution, 900 mg IVPB every eight hours for five more weeks. The Transfer Orders reflected [MEDICATION NAME] 750 mg IVPB every 48 hours at the same time for six weeks. (NOTE: The hours were changed from 48 hours to 36 hours after the [MEDICATION NAME] trough level result was obtained 02/05/12.) Further review of the Transfer Orders revealed to flush "all lumens with 10 ml NS every 12 hours and prn." Review of Resident #7's undated "Resident Admission Record" revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. Review of Resident #7's admission physician's orders [REDACTED]." The physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Resident #7's "INTERIM PLAN OF CARE" dated 01/26/12 revealed the section entitled "IV/TPN" was blank. The section of the Plan of Care entitled "INFECTION ALERT" reflected Resident #7 was on [MEDICATION NAME] 750 mg every 48 hours for six weeks and [MEDICATION NAME] 900 mg every eight hours for five weeks. The plan of care did not reflect the approaches to care for Resident #7's PICC line such as when to change the dressing or when to flush the line. Review Resident #7's February 2012 physician's orders [REDACTED]. Resident #7 was observed during the initial rounds on 02/06/12 at 8:05 a.m. in bed in his room. LVN S stated Resident #7 was alert and oriented to person and place. He was mobile in the facility via a wheelchair, was continent of bowel and bladder and he required assistance with his activities of daily living. LVN S stated Resident #7 had some toes amputated on his left foot and he had a double lumen PICC line. The surveyor observed Resident #7's right foot was [MEDICAL CONDITION], the big toe was amputated with eschar on the site. The left foot was observed with four toes. The PICC line dressing was dated 02/05/12 and peeling on the sides. The surveyor observed LVN M on 02/07/12 at 3:20 p.m. administering [MEDICATION NAME] ([MEDICATION NAME]) 900 mg in 50 ml bag to Resident #7. After washing her hands and donning gloves, LVN M cleaned the purple port of Resident #7's PICC line with an alcohol pad. LVN M went to the other side of the room, removed the old IVPB tubing still connected to the old bag, and spiked the new IVPB with the tubing. LVN M did not completely prime the IV tubing when she picked up the PICC line and connected the tubing. The surveyor asked LVN M, at that time, if the tubing was completely primed. LVN M then stopped and looked at the line and then disconnected the tubing to complete the IV tubing priming. While LVN M went to the other side of the room to get the old tubing, the surveyor observed Resident #7 moving his right hand with the PICC line thus re-contaminating the cleaned PICC line access port. LVN M proceeded to connect to the contaminated port without recleaning the port. The surveyor observed LVN M administer the medication without first flushing the PICC line tubing with 10 ml NS as per nursing standards. The surveyor interviewed LVN M on 02/07/12 at 3:40 p.m. The interview revealed she was trained on how to start peripheral IVs. LVN M stated the training consisted of a simulation of a hand to start the IV. LVN M stated she did not receive any training on PICC lines. The surveyor asked LVN M if she had any training on how to hang medications on a PICC line. LVN M stated she knew to flush the line after the medication administration. On 02/08/12 at 7:40 a.m. the surveyor observed LVN L flushing Resident #7's PICC line. LVN L washed her hands and donned gloves and then opened the prefilled 10 ml syringe with 5 ml of NS in the syringe. LVN L clamped the PICC line, cleaned the port by scrubbing it, connected the 10 ml syringe with 5 ml of NS to the port, unclamped the port and flushed the line. Before removing the port, LVN L clamped the PICC line and then removed the syringe. In an interview at this time with LVN L, she told the surveyor she flushed the PICC line with 5 ml of NS and was flushing it again with 5 ml of NS. LVN L stated she used the 5 ml of NS because it was the facility's protocol. The surveyor asked if LVN L if she checked Resident #7's physician's orders [REDACTED]. LVN L stated she did not check the physician's orders [REDACTED]. During an interview at 7:50 a.m. on 02/08/12, LVN L stated she had training three years ago, which was an IV certification training for inserting peripheral IVs. She stated the only training for PICC lines was how to flush the lines. LVN L stated the facility allowed the LVNs to flush and administer medications through the PICC lines. An interview on 02/08/12 at 10:42 a.m. with LVN T revealed she had IV training about one year ago. LVN T stated the training was from a pharmacy, they went over the different types of IVs, how to place a peripheral line, finding a good site for peripheral line placement, and how to assess for infections. LVN T said they did not spend much time on the maintenance of PICC lines, but she understood and remembered how to flush the PICC line. 5. Resident #12 was an [AGE] year-old female and was most recently admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]." Review of Resident #12's Facility Transfer Orders dated 02/03/12 and confirmed by telephone with MD Z, "Flush all lumens with 10 ml NS every 12 hours and PRN" There were no orders for flushing the PICC line before or after medication administration. Resident #12's facility physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of Resident #12's Physician Telephone Orders dated 02/04/12 revealed, "...IV flush per facility protocol." Review of the facility's identified protocol for PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) FLUSHING dated 08/15/08 revealed, "...1. A physician order [REDACTED]. (Refer to Infusion Maintenance Table A. 1) The order must include: Flushing agent, Strength/concentration, Volume, Frequency 2. Only 10 ml syringes or larger will be used to flush catheters. 3. All catheters are flushed between incompatible medications with normal saline and/or [MEDICATION NAME] or other flush solution as recommended by the manufacturer...." Review of Resident #12's clinical record revealed a CENTRAL VENOUS CATHETER-PHYSICIAN ORDER [REDACTED]. These orders were not in the resident's clinical record before 5:00 p.m. on 02/08/12. The PHYSICIAN ORDER [REDACTED]. Review of Resident #12's clinical record revealed there was no documentation revealing the PICC brand, and if the PICC was tunneled or non-tunneled, and if it was non-valved or valved. Observation on 02/08/12 at 2:50 p.m. revealed LVN O flushed Resident #12's PICC line with 5 ml of normal saline before administering one gram of [MEDICATION NAME] via an [MEDICATION NAME] Infusion Device (infusion device which ranges from 30 minutes to 5 hours of continuous infusion). LVN O confirmed she flushed the PICC line with 5 ml of normal saline. Interview on 02/08/12 at 3:00 with LVN N revealed she had PICC line training during nursing school in 2009. LVN N said she had not had any PICC line training since that time. Interview with LVN O on 02/08/12 at 3:05 p.m. revealed the DON "doesn't draw blood from the PICC line because he's not comfortable doing it. The DON before him drew blood all the time. If an RN is on the floor she will draw the blood. He's the only RN on the 6-2 shift during the week." LVN O said she had PICC line training "through the pharmacy." Observation on 02/08/12 at 4:50 p.m. revealed LVN N removed the [MEDICATION NAME] Infusion Device tubing from Resident #12's PICC line. LVN N then flushed the PICC line with 5 ml of normal saline. LVN N confirmed she flushed the PICC line with 5 ml of normal saline. Interview on 02/09/12 at 11:15 a.m. with LVN O revealed when asked why she did not use 10 ml of normal saline to flush Resident #12's PICC line, she said, "Oh because that's what our policy says." LVN O stated she was referring to a pharmacy pre-printed instruction sheet in the MAR binder. When the surveyor asked what Resident #12's physician's flush orders were, LVN O looked at the order on the MAR indicated [REDACTED]. LVN O said, "I need to write a clarification order." LVN O was informed by the surveyor Resident #12 did not have a physician's orders [REDACTED]. LVN O said she would get an order. Interview on 02/09/12 at 11:40 a.m. with LVN O revealed, "I didn't have to write the orders." LVN O found PICC line flushing orders on Resident #12's clinical record dated 02/08/12. Interview on 02/09/12 at 2:10 p.m. with MD CC revealed instead of writing orders for PICC line care and maintenance, he expected the facility to follow their PICC line protocol. When MD CC was informed the facility's protocol instructed the nurses to get specific orders for PICC line flushes, he revealed he was not made aware of that protocol by the facility. MD CC said all other facilities had PICC line protocols in place. MD CC said, "It sounds like to me they need in-services." Interview on 02/10/12 at 3:30 p.m. with MD Z revealed instead of writing orders for PICC line care and maintenance, he expected the facility to follow their PICC line protocol. 6. During the interview with the DON on 02/08/12 at 6:08 p.m., the surveyor inquired about PICC line training for the facility nursing staff. The DON stated the nurses in the facility had IV training. When asked about IV PICC lines, he stated the training involved the PICC lines. The surveyor inquired if he monitored the staff to ensure they were competent in PICC line assessments and how to access the PICC line. The DON stated yes. He stated he had checked a couple of the staff in the Fall of 2011 to ensure they were competent, but he could not remember the staff's names. The DON stated staff were to check the PICC line for patency by drawing back on the syringe for blood return and if blood return was observed, the PICC line was patent and staff should continue with medication administration. The surveyor also asked the DON what size of syringe and how much fluid should be used for flushes. The DON stated "3 cc syringe" and when the surveyors repeated "3 cc," the DON left the surveyors' work room at 6:10 p.m. and stated he would return. When the DON came back to the surveyors' work room at 6:18 p.m., he came back with the facility's policy. The DON stated the staff were to flush the PICC lines with 10 ml NS or whatever the physician ordered. When the DON was informed of how much fluid was in the syringes used by the nurses, the DON stated, "Well they are packaged wrongly and I will call the pharmacy and tell them to send the right amount of fluids." The surveyor asked the DON what the difference was between PICC lines and Peripheral lines, and he responded one had a short line and the other had a longer line. The DON also stated the peripheral lines only involved veins and the PICC lines went into the heart area. (Note: http://picclinenursing.com reflected, "A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart....") The surveyor asked the DON how to check for patency of a PICC line. The DON stated by pulling back with a syringe and getting blood back, meaning the line was patent. After a minute, the DON stated he would "pulsate" the PICC line to check for patency if the line was difficult to flush and/or had some resistance while flushing it, he would stop because it was clogged and call the pharmacy company IV nurses to come and declot the line before continued use, if not he would then flush the line with a prefilled 10 cc NS syringe. The surveyor asked who did the blood draws on the lab work ordered, and the DON replied the lab. The surveyor asked if phlebotomists could draw blood from a PICC line and the DON stated no the phlebotomist drew the blood with needles. The surveyor asked why the DON did not draw blood from the PICC lines and spare the resident the pain of additional punctures. The DON stated he did not have time. He stated he was too busy "running around" and could not be found most of the time when the lab was there. The surveyor asked about labs that were due to be drawn in the afternoons. The DON stated he was too busy to draw the labs, so the phlebotomist drew the blood through another puncture site. 7. An IJ was identified on 02/08/12 in the area of Quality of Care. The ADM and the DON were notified of the IJ on 02/08/12 at 6:40 p.m. 8. The Plan of Removal was accepted on 02/09/12 at 3:30 p.m. and reflected: 1. Residents #7, #12, and #15 were assessed for IV site complications from their PICC lines 2. Physicians were notified of errors reported by the surveyors and orders were received. 3. Physicians were notified for clarification of IV line flush orders. 4. The four identified LVNs would be re-educated on PICC lines to include assessing patency and flushing of the line using 10 cc syringe, ensuring the syringe was primed, before and after IV medication administration with return demonstration. Staff would be re-educated on infection control-cleaning the port prior to accessing. 5. The four identified nurses would not be allowed to administer IV medications until competency was completed 6. DON/designee would perform competency evaluations for the administrative licensed nurses so the administrative nurses could observe the staff. 7. Newly hired licensed staff would be required to provide documentation of IV certification. If unable to provide the documentation, the licensed nurse would be prohibited from administering IV medications until an IV certification class was completed and competency was satisfactory. Staff Development Coordinator/designee would perform competency evaluations for newly hired licensed nursing staff within the first 30 days of working. 8. Administrative nursing would observe each resident receiving IV medication at least once per week for four weeks and then randomly. 9. Interviews conducted on 02/10/12 from 9:00 a.m. through 11:15 a.m. with LVNs F, O, BB, N, and L revealed they had been in-serviced on 02/09/12 on PICC line care and maintenance. 10. On 02/10/12 at 1:40 p.m., during an interview with the DON, the surveyor asked him what training he ensured was provided to the licensed nurses in order to care for residents with PICC lines. The DON stated he went back and did the training and the check-offs for the nurses to ensure proficiency. When the surveyor asked the DON if there had been any in-services on PICC lines, he stated there had been multiple inservices for "many different things." The DON stated all the the nurses had been through the training with an outside healthcare company and they (facility) had put all kinds of check-off systems in place. When the surveyor asked the DON what plan was in place for PICC lines, he stated in-service and training through the outside healthcare company. When the surveyor asked the DON how he ensured the licensed nurses were competent in their skills for providing care to residents with PICC lines, he stated he planned to monitor the nurses' PICC line skills every week for the next four weeks. He stated after that, nursing administration would monitor the nurses. When the surveyor asked the DON how he thought the IJ occurred, he stated, "I don't know what happened with these nurses. They were all trained the same way and they are strong nurses. They just messed up and this all got out of hand and ended up this way. I felt like they were well trained." When asked by the surveyor if PICC lines had been a topic of discussion at the facility's QA meetings, the DON stated, "In the past, our process has not identified any problems in this area, but now I will be taking these problems to the committee." 11. Interview with the CN and the DON on 02/10/12 at 3:40 p.m. revealed the CN said their protocol did not need updating and it was fine the way it was. The CN stated the nurses could review the Infusion Maintenance Table for the protocol on flushing PICC lines. The CN said the type of PICC line should be in the clinical record. The surveyor informed the CN the PICC line information was not found in Residents #7, #12 or #15's clinical records. The surveyor asked the CN if the nurses were interviewed at that time and asked to describe the differences between tunneled, non-tunneled, valved and non-valved would they be able to determine that. The CN said, "They will be, I'm going to take care of that right now." The CN and the DON left to in-service the nurses on the different types of PICC lines. 12. On 02/10/12 at 4:00 p.m., during an interview with the ADM and the Corporate Regional VP of Operations, the ADM stated he ensured the quality of care needs of residents were met by walking around the facility, making sure call lights were answered, meeting with department heads and holding stand-up meetings with staff to discuss care issues with residents, conducting interdisciplinary meetings and discussing 24 hour reports, and talking with residents and families and then following up on any concerns and complaints. When asked by the surveyor how he monitored the DON to ensure the systems the DON monitored were being carried out effectively, the ADM stated he followed the chain of command. He stated he started with the DON by asking him (DON) about any observations he (ADM) had made that he had questions about. The ADM stated, if needed, he would ask the ADONs. He stated it was a "check and balance" system to see where the process was and to see where improvement could be made and what monitoring was needed. The ADM referenced corporate "tools" and "score cards" which were available to him for this process. The ADM stated he was aware there were residents in the facility with PICC lines. When asked by the surveyor how he thought the IJ occurred, he stated, "I don't know" and he did not understand how this occurred. When the surveyor asked the ADM if PICC lines had been a topic of discussion at the facility's QA meetings, he stated PICC lines had not been an issue discussed at the QA meetings. 13. The IV Educat

Based on observation, interview and record review, the facility failed to ensure that residents received proper treatment and care for PICC lines for three (Residents #7, #12, and #15) of three residents who had PICC lines. 1) LVN M was about to inject air into Resident #15's PICC line, the surveyor intervened. LVN M failed to flush Resident #15's PICC line before administering his antibiotic. LVN M cleaned the red port on Resident #15's PICC line, dropped the tubing line on the floor, went out to get another IV tubing, when she returned she connected the IV tubing to the purple port without cleaning the access port, and failed to prime the IV tubing completely of air. There were no current physician's orders [REDACTED]. 2) LVN M failed to flush the PICC line before administering Resident #7's antibiotic and failed to properly prime the IVPB (intravenous piggy bag) tubing and the prefilled NS 10 ml syringe before flushing Residents #7's PICC line. LVN M cleaned the purple port with alcohol but went to the other side of the room to connect the old tubing to the new antibiotic bag, primed the tubing with air still in the line. While on the other side of the room, Resident #7 moved his right hand and the PICC line access port touched his body and bed linen. LVN M connected the IV tubing without re-cleaning the port, checking for patency and failed to flush the line before administering the antibiotics. 3) LVN N and LVN O flushed Resident #12's PICC line with only 5 ml of Normal Saline. The physician's orders [REDACTED]. An Immediate Jeopardy (IJ) was identified on 02/08/12. While the IJ was removed on 02/10/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect the five residents with PICC lines, including Residents #7, #12, and #15, by placing them at risk [MEDICAL CONDITION], septic shock, air embolisms, fever, pain and/or death from the infectious process. Findings included: http://picclinenursing.com reflected, "A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart. However, unlike other central lines, its point of entry is from the periphery of the body ? (sic) the extremities. And typically the upper arm is the area of choice...A PICC line may requested for a variety of treatment options which include some of the following:-Prolonged IV antibiotic treatment...The catheter must be flushed every 12 hours and after each use. This is required to prevent clogging of the catheter. Flushing is done with ...normal saline...If flushing is difficult, this indicates that the PICC is becoming blocked. If it becomes fully blocked, it may not be usable. Report this difficulty in flushing immediately so it can be declotted to regain full functional use...." (retrieved on 02/22/12). 1. Resident #15's hospital Discharge Medications list dated 01/31/12 and signed on 02/01/12 reflected, "[MEDICATION NAME]/Sulbactam, 1.5 gm, IVPB, inj (injection), q8h (hours), continue for 5 weeks..." The Medications list also reflected to flush the PICC line with "Sodium Chloride flush, 10 ml, IV push, inj, q12h..." The Discharge Medications list reflected continue medication and there was yes, no, change and yes was circled for the Sodium Chloride flush. However, a handwritten "D/C (discontinue)" was next to the order. There was not a physician's orders [REDACTED].#15. Review of Resident #15's "Resident Admission Record," dated 02/01/12, revealed Resident #15 was an [AGE] year-old, who was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. Review of Resident #15's clinical record revealed no care plans for Resident #15's PICC line. The interim plan of care dated 02/01/12 revealed Resident #15 had a "PICC line dressing right forearm dressing change weekly." There were no other instructions for the PICC line care. Review of Resident #15's February 2012 physician's orders [REDACTED]. IVPB every eight hours for five weeks. The orders also revealed an order for [REDACTED]. Review of Resident #15's February 2012 Medication Chart Record revealed to flush the IV PICC line site with 10 cc NS before and after medication administration. The flushes were timed for 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. However, the 10:00 p.m. to 6:00 a.m. schedule had a line drawn through it. Further review of the Medication Chart Record revealed the flushes where initialed as completed at 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. for the following dates: 02/01/12, 02/02/12, 02/03/12, 02/04/12, 02/05/12, 02/06/12, and only the 2:00 p.m. to 10:00 p.m. shift was initialed as completed on 02/07/12. The Medication Chart Record reflected the [MEDICATION NAME] was administered at 7:00 a.m., 3:00 p.m. and 11:00 p.m. on the following dates: 02/01/12, 02/02/12, 02/03/12, 02/04/12, and 02/06/12. The Medication Chart Record reflected on 02/05/12 there were no initials for the 11:00 p.m. dose and no initials on 02/07/12 for the 2:00 p.m. to 10:00 p.m. shift. Review of Resident #15's "Clinical Infusion Nursing Documentation" dated 02/10/12 revealed the resident's PICC line had clotted and the Infusion company nurse came to the facility to declot the double lumen PICC line on that date. The surveyor observed Resident #15 during the initial rounds on 02/06/12 at 8:15 a.m. with LVN S. LVN S stated Resident #15 was alert and oriented to person, place and time, and used a wheelchair for locomotion. LVN S stated Resident #15 used a Foley catheter for voiding, and he required assistance with his activities of daily living. LVN S also stated Resident #15 had a PICC line access for antibiotics due to [MEDICAL CONDITION] of the feet. On entering the room, the surveyor observed Resident #15 sitting at the bedside with a left leg brace on his right foot. The surveyor observed Resident #15 during medication administration on 02/07/12 at 3:00 p.m. LVN M brought [MEDICATION NAME] 1.5 gm in a 50 ml IVPB with some alcohol pads and one prefilled NS syringe to the room. The NS syringe contained 5 ml of NS. LVN M placed the items on the resident's over bed table and went to the bathroom to wash her hands. LVN M donned gloves, and cleaned the red port with the alcohol wipes. She turned around to mix the [MEDICATION NAME] powder with the NS and to spike the IVPB tube, when the old IV tubing dropped on the floor. LVN M obtained new IV tubing, spiked the IVPB and primed (removing air from the line) the tubing with the medication to approximately 4 cc from the tip and stopped it. LVN M did not prime the tubing all the way to the tip to ensure the air was completely removed. Perry and Potter's Clinical Nursing Skills & Techniques Fifth Edition 2004, on page 594 reflected, "7. Check for air in tubing. If bubbles form, they can be removed...Reduce air in tubing by priming slowly instead of allowing a wide-open flow." <http://medical-dictionary.thefreedictionary.com/air+embolism> reflected, "air embolism air injected accidentally into veins which may cause temporary paralysis or dyspnea, or may be fatal if the embolism occurs in the heart or brain." (retrieved on 02/24/12.) LVN M proceeded to connect the IVPB tubing to the PICC line port. LVN M accessed and connected the IV tubing to the purple port, instead of the red port she previously cleaned. LVN M accessed the purple port without cleaning or scrubbing the port first. LVN M also failed to flush the PICC line tubing before administering the medication. When the surveyor asked her why she was using the purple port instead of the red port she had cleaned, LVN M stated the red port was for blood draws, and she thought she had cleaned the purple port. The surveyor observed LVN M again on 02/08/12 at 3:35 p.m. administering [MEDICATION NAME] 1.5 gm to Resident #15. LVN M washed her hands, spiked the IVPB, primed the tubing, cleaned the PICC line port and connected the IVPB without flushing the PICC line first and then unclamped the tubing. At 02/08/12 at 4:20 p.m., the surveyor observed Resident #15's PICC line port was connected to the IV tubing with the PICC line hub dangling without protection, which exposed the hub to possible contaminants. The surveyor left his room and found LVN M in another resident's room and asked LVN M if she flushed Resident #15's PICC line. LVN M told the surveyor she had not. She stated she just disconnected the line to come back after caring for another resident. She stated she would flush the line next. LVN M got alcohol pads and one prefilled 10 ml syringe with 5 ml of NS from the treatment cart and went to Resident #15's room. LVN M cleaned the PICC line hub and attempted to flush the PICC line with the hub. However, the syringe could not properly attach to the hub to connect for flushing. LVN M continued to struggle with the syringe and the hub. LVN M then disconnected the port from the tubing and connected it to the hub, and then cleaned the PICC line port. LVN M opened the 5 ml prefilled syringe of NS and proceeded to flush the line without first priming the syringe of the 1 to 2 ml of air in the syringe. Then LVN M had her hand on the syringe plunger and was about to inject air and NS into Resident #15's PICC line, when the surveyor intervened. After the above observation, the surveyor asked LVN M how she checked for patency of the line. LVN M stated she checked patency when she flushed both ports and it "flows freely." The interview revealed LVN M was not aware she could pull back for blood return to check for patency of the PICC line. 2. Review of Resident #7's hospital Facility Transfer Orders dated 01/22/12 revealed [MEDICATION NAME] 150 mg/ml solution, 900 mg IVPB every eight hours for five more weeks. The Transfer Orders reflected [MEDICATION NAME] 750 mg IVPB every 48 hours at the same time for six weeks. (NOTE: The hours were changed from 48 hours to 36 hours after the [MEDICATION NAME] trough level result was obtained 02/05/12.) Further review of the Transfer Orders revealed to flush "all lumens with 10 ml NS every 12 hours and prn." Review of Resident #7's undated "Resident Admission Record" revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. Review of Resident #7's admission physician's orders [REDACTED]." The physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Resident #7's "INTERIM PLAN OF CARE" dated 01/26/12 revealed the section entitled "IV/TPN" was blank. The section of the Plan of Care entitled "INFECTION ALERT" reflected Resident #7 was on [MEDICATION NAME] 750 mg every 48 hours for six weeks and [MEDICATION NAME] 900 mg every eight hours for five weeks. The plan of care did not reflect the approaches to care for Resident #7's PICC line such as when to change the dressing or when to flush the line. Review Resident #7's February 2012 physician's orders [REDACTED]. Resident #7 was observed during the initial rounds on 02/06/12 at 8:05 a.m. in bed in his room. LVN S stated Resident #7 was alert and oriented to person and place. He was mobile in the facility via a wheelchair, was continent of bowel and bladder and he required assistance with his activities of daily living. LVN S stated Resident #7 had some toes amputated on his left foot and he had a double lumen PICC line. The surveyor observed Resident #7's right foot was [MEDICAL CONDITION], the big toe was amputated with eschar on the site. The left foot was observed with four toes. The PICC line dressing was dated 02/05/12 and peeling on the sides. The surveyor observed LVN M on 02/07/12 at 3:20 p.m. administering [MEDICATION NAME] ([MEDICATION NAME]) 900 mg in 50 ml bag to Resident #7. After washing her hands and donning gloves, LVN M cleaned the purple port of Resident #7's PICC line with an alcohol pad. LVN M went to the other side of the room, removed the old IVPB tubing still connected to the old bag, and spiked the new IVPB with the tubing. LVN M did not completely prime the IV tubing when she picked up the PICC line and connected the tubing. The surveyor asked LVN M, at that time, if the tubing was completely primed. LVN M then stopped and looked at the line and then disconnected the tubing to complete the IV tubing priming. While LVN M went to the other side of the room to get the old tubing, the surveyor observed Resident #7 moving his right hand with the PICC line thus re-contaminating the cleaned PICC line access port. LVN M proceeded to connect to the contaminated port without recleaning the port. The surveyor observed LVN M administer the medication without first flushing the PICC line tubing with 10 ml NS as per nursing standards. The surveyor interviewed LVN M on 02/07/12 at 3:40 p.m. The interview revealed she was trained on how to start peripheral IVs. LVN M stated the training consisted of a simulation of a hand to start the IV. LVN M stated she did not receive any training on PICC lines. The surveyor asked LVN M if she had any training on how to hang medications on a PICC line. LVN M stated she knew to flush the line after the medication administration. On 02/08/12 at 7:40 a.m. the surveyor observed LVN L flushing Resident #7's PICC line. LVN L washed her hands and donned gloves and then opened the prefilled 10 ml syringe with 5 ml of NS in the syringe. LVN L clamped the PICC line, cleaned the port by scrubbing it, connected the 10 ml syringe with 5 ml of NS to the port, unclamped the port and flushed the line. Before removing the port, LVN L clamped the PICC line and then removed the syringe. In an interview at this time with LVN L, she told the surveyor she flushed the PICC line with 5 ml of NS and was flushing it again with 5 ml of NS. LVN L stated she used the 5 ml of NS because it was the facility's protocol. The surveyor asked if LVN L if she checked Resident #7's physician's orders [REDACTED]. LVN L stated she did not check the physician's orders [REDACTED]. During an interview at 7:50 a.m. on 02/08/12, LVN L stated she had training three years ago, which was an IV certification training for inserting peripheral IVs. She stated the only training for PICC lines was how to flush the lines. LVN L stated the facility allowed the LVNs to flush and administer medications through the PICC lines. An interview on 02/08/12 at 10:42 a.m. with LVN T revealed she had IV training about one year ago. LVN T stated the training was from a pharmacy, they went over the different types of IVs, how to place a peripheral line, finding a good site for peripheral line placement, and how to assess for infections. LVN T said they did not spend much time on the maintenance of PICC lines, but she understood and remembered how to flush the PICC line. 3. Resident #12 was an [AGE] year-old female and was most recently admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]." Review of Resident #12's Facility Transfer Orders dated 02/03/12 and confirmed by telephone with MD Z, "Flush all lumens with 10 ml NS every 12 hours and PRN" There were no orders for flushing the PICC line before or after medication administration. Resident #12's facility physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of Resident #12's Physician Telephone Orders dated 02/04/12 revealed, "...IV flush per facility protocol." Review of the facility's identified protocol for PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) FLUSHING dated 08/15/08 revealed, "...1. A physician order [REDACTED]. (Refer to Infusion Maintenance Table A. 1) The order must include: Flushing agent, Strength/concentration, Volume, Frequency 2. Only 10 ml syringes or larger will be used to flush catheters. 3. All catheters are flushed between incompatible medications with normal saline and/or [MEDICATION NAME] or other flush solution as recommended by the manufacturer...." Review of Resident #12's clinical record revealed a CENTRAL VENOUS CATHETER-PHYSICIAN ORDER [REDACTED]. These orders were not in the resident's clinical record before 5:00 p.m. on 02/08/12. The PHYSICIAN ORDER [REDACTED]. Review of Resident #12's clinical record revealed there was no documentation revealing the PICC brand, and if the PICC was tunneled or non-tunneled, and if it was non-valved or valved. Observation on 02/08/12 at 2:50 p.m. revealed LVN O flushed Resident #12's PICC line with 5 ml of normal saline before administering one gram of [MEDICATION NAME] via an [MEDICATION NAME] Infusion Device (infusion device which ranges from 30 minutes to 5 hours of continuous infusion). LVN O confirmed she flushed the PICC line with 5 ml of normal saline. Interview on 02/08/12 at 3:00 with LVN N revealed she had PICC line training during nursing school in 2009. LVN N said she had not had any PICC line training since that time. Interview with LVN O on 02/08/12 at 3:05 p.m. revealed the DON "doesn't draw blood from the PICC line because he's not comfortable doing it. The DON before him drew blood all the time. If an RN is on the floor she will draw the blood. He's the only RN on the 6-2 shift during the week." LVN O said she had PICC line training "through the pharmacy." Observation on 02/08/12 at 4:50 p.m. revealed LVN N removed the [MEDICATION NAME] Infusion Device tubing from Resident #12's PICC line. LVN N then flushed the PICC line with 5 ml of normal saline. LVN N confirmed she flushed the PICC line with 5 ml of normal saline. Interview on 02/09/12 at 11:15 a.m. with LVN O revealed when asked why she did not use 10 ml of normal saline to flush Resident #12's PICC line, she said, "Oh because that's what our policy says." LVN O stated she was referring to a pharmacy pre-printed instruction sheet in the MAR binder. When the surveyor asked what Resident #12's physician's flush orders were, LVN O looked at the order on the MAR indicated [REDACTED]. LVN O said, "I need to write a clarification order." LVN O was informed by the surveyor Resident #12 did not have a physician's orders [REDACTED]. LVN O said she would get an order. Interview on 02/09/12 at 11:40 a.m. with LVN O revealed, "I didn't have to write the orders." LVN O found PICC line flushing orders on Resident #12's clinical record dated 02/08/12. Interview on 02/09/12 at 2:10 p.m. with MD CC revealed instead of writing orders for PICC line care and maintenance, he expected the facility to follow their PICC line protocol. When MD CC was informed the facility's protocol instructed the nurses to get specific orders for PICC line flushes, he revealed he was not made aware of that protocol by the facility. MD CC said all other facilities had PICC line protocols in place. MD CC said, "It sounds like to me they need in-services." Interview on 02/10/12 at 3:30 p.m. with MD Z revealed instead of writing orders for PICC line care and maintenance, he expected the facility to follow their PICC line protocol. 4. During the interview with the DON on 02/08/12 at 6:08 p.m., the surveyor inquired about PICC line training for the facility nursing staff. The DON stated the nurses in the facility had IV training. When asked about IV PICC lines, he stated the training involved the PICC lines. The surveyor inquired if he monitored the staff to ensure they were competent in PICC line assessments and how to access the PICC line. The DON stated yes. He stated he had checked a couple of the staff in the Fall of 2011 to ensure they were competent, but he could not remember the staff's names. The DON stated staff were to check the PICC line for patency by drawing back on the syringe for blood return and if blood return was observed, the PICC line was patent and staff should continue with medication administration. The surveyor also asked the DON what size of syringe and how much fluid should be used for flushes. The DON stated "3 cc syringe" and when the surveyors repeated "3 cc," the DON left the surveyors' work room at 6:10 p.m. and stated he would return. When the DON came back to the surveyors' work room at 6:18 p.m., he came back with the facility's policy. The DON stated the staff were to flush the PICC lines with 10 ml NS or whatever the physician ordered. When the DON was informed of how much fluid was in the syringes used by the nurses, the DON stated, "Well they are packaged wrongly and I will call the pharmacy and tell them to send the right amount of fluids." The surveyor asked the DON what the difference was between PICC lines and Peripheral lines, and he responded one had a short line and the other had a longer line. The DON also stated the peripheral lines only involved veins and the PICC lines went into the heart area. (Note: http://picclinenursing.com reflected, "A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart....") The surveyor asked the DON how to check for patency of a PICC line. The DON stated by pulling back with a syringe and getting blood back, meaning the line was patent. After a minute, the DON stated he would "pulsate" the PICC line to check for patency if the line was difficult to flush and/or had some resistance while flushing it, he would stop because it was clogged and call the pharmacy company IV nurses to come and declot the line before continued use, if not he would then flush the line with a prefilled 10 cc NS syringe. The surveyor asked who did the blood draws on the lab work ordered, and the DON replied the lab. The surveyor asked if phlebotomists could draw blood from a PICC line and the DON stated no the phlebotomist drew the blood with needles. The surveyor asked why the DON did not draw blood from the PICC lines and spare the resident the pain of additional punctures. The DON stated he did not have time. He stated he was too busy "running around" and could not be found most of the time when the lab was there. The surveyor asked about labs that were due to be drawn in the afternoons. The DON stated he was too busy to draw the labs, so the phlebotomist drew the blood through another puncture site. 5. An IJ was identified on 02/08/12 in the area of Quality of Care. The ADM and the DON were notified of the IJ on 02/08/12 at 6:40 p.m. 6. The Plan of Removal was accepted on 02/09/12 at 3:30 p.m. and reflected: 1. Residents #7, #12, and #15 were assessed for IV site complications from their PICC lines 2. Physicians were notified of errors reported by the surveyors and orders were received. 3. Physicians were notified for clarification of IV line flush orders. 4. The four identified LVNs would be re-educated on PICC lines to include assessing patency and flushing of the line using 10 cc syringe, ensuring the syringe was primed, before and after IV medication administration with return demonstration. Staff would be re-educated on infection control-cleaning the port prior to accessing. 5. The four identified nurses would not be allowed to administer IV medications until competency was completed 6. DON/designee would perform competency evaluations for the administrative licensed nurses so the administrative nurses could observe the staff. 7. Newly hired licensed staff would be required to provide documentation of IV certification. If unable to provide the documentation, the licensed nurse would be prohibited from administering IV medications until an IV certification class was completed and competency was satisfactory. Staff Development Coordinator/designee would perform competency evaluations for newly hired licensed nursing staff within the first 30 days of working. 8. Administrative nursing would observe each resident receiving IV medication at least once per week for four weeks and then randomly. 7. Interviews conducted on 02/10/12 from 9:00 a.m. through 11:15 a.m. with LVNs F, O, BB, N, and L revealed they had been in-serviced on 02/09/12 on PICC line care and maintenance. 8. On 02/10/12 at 1:40 p.m., during an interview with the DON, the surveyor asked him what training he ensured was provided to the licensed nurses in order to care for residents with PICC lines. The DON stated he went back and did the training and the check-offs for the nurses to ensure proficiency. When the surveyor asked the DON if there had been any in-services on PICC lines, he stated there had been multiple inservices for "many different things." The DON stated all the the nurses had been through the training with an outside healthcare company and they (facility) had put all kinds of check-off systems in place. When the surveyor asked the DON what plan was in place for PICC lines, he stated in-service and training through the outside healthcare company. When the surveyor asked the DON how he ensured the licensed nurses were competent in their skills for providing care to residents with PICC lines, he stated he planned to monitor the nurses' PICC line skills every week for the next four weeks. He stated after that, nursing administration would monitor the nurses. When the surveyor asked the DON how he thought the IJ occurred, he stated, "I don't know what happened with these nurses. They were all trained the same way and they are strong nurses. They just messed up and this all got out of hand and ended up this way. I felt like they were well trained." When asked by the surveyor if PICC lines had been a topic of discussion at the facility's QA meetings, the DON stated, "In the past, our process has not identified any problems in this area, but now I will be taking these problems to the committee." 9. Interview with the CN and the DON on 02/10/12 at 3:40 p.m. revealed the CN said their protocol did not need updating and it was fine the way it was. The CN stated the nurses could review the Infusion Maintenance Table for the protocol on flushing PICC lines. The CN said the type of PICC line should be in the clinical record. The surveyor informed the CN the PICC line information was not found in Residents #7, #12 or #15's clinical records. The surveyor asked the CN if the nurses were interviewed at that time and asked to describe the differences between tunneled, non-tunneled, valved and non-valved would they be able to determine that. The CN said, "They will be, I'm going to take care of that right now." The CN and the DON left to in-service the nurses on the different types of PICC lines. 10. On 02/10/12 at 4:00 p.m., during an interview with the ADM and the Corporate Regional VP of Operations, the ADM stated he ensured the quality of care needs of residents were met by walking around the facility, making sure call lights were answered, meeting with department heads and holding stand-up meetings with staff to discuss care issues with residents, conducting interdisciplinary meetings and discussing 24 hour reports, and talking with residents and families and then following up on any concerns and complaints. When asked by the surveyor how he monitored the DON to ensure the systems the DON monitored were being carried out effectively, the ADM stated he followed the chain of command. He stated he started with the DON by asking him (DON) about any observations he (ADM) had made that he had questions about. The ADM stated, if needed, he would ask the ADONs. He stated it was a "check and balance" system to see where the process was and to see where improvement could be made and what monitoring was needed. The ADM referenced corporate "tools" and "score cards" which were available to him for this process. The ADM stated he was aware there were residents in the facility with PICC lines. When asked by the surveyor how he thought the IJ occurred, he stated, "I don't know" and he did not understand how this occurred. When the surveyor asked the ADM if PICC lines had been a topic of discussion at the facility's QA meetings, he stated PICC lines had not been an issue discussed at the QA meetings. 11. The IV Education PICC Valved and Non-Valved In-service provided by the CN and the DON on 02/10/12 included the following: How to determine what type of flush to use for a PICC line: Utilize the Guidelines per IV infusion table provided. A "valved" PICC was similar to a Groshong, the catheter was valved to prevent blood back flow. A "non-valved" catheter was similar to a general peripheral IV. The in-service instructed the nurses that when they were receiving a resident from the hospital, they need to ask what type of PICC line was in place. The in-service also instructed the nurses that when the IV team arrived to insert a PICC, the nurses should ask what type of catheter was inserted. The in-service also indicated tunneled lines and non-tunneled lines were central lines usually located in the chest wall. The non-tunneled was sutured in place and the tunneled had the Dacron cuff which was palpable just under the skin below the insertion site. The facility's Infusion Maintenance Table dated 2008 referred to Flush Protocols, Site Maintenance and Administration Set Changes. The nurses needed to if the device was a Midline, PICC, Non-Tunneled, Tunneled or an Implanted Venous Portand to be able to follow the instructions. 12. Interview on 02/10/12 at 5:26 p.m. with the MDS Coordinator revealed she had just left the IV Education PICC Inservice and had learned the differences between tunneled, non-tunneled, valved and non-valved PICC lines. 13. While the IJ was removed on 02/10/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because not all staff had been trained and the facility was still monitoring its Plan of Removal. The ADM, DON, ADONs, CN, and the Regional VP of Operations were informed on 02/10/12 at 5:45 p.m. that the IJ was removed. 14. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON and dated 02/07/12, reflected five residents were receiving intravenous therapy, parental nutrition, and/or blood transfusion.

Based on observation, interview and record review, the ADM and the DON failed to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (Residents #7, #12, and #15) of three residents who were reviewed for PICC line care and maintenance. (PICC line was a long, slender, small, and flexible tube inserted into a peripheral vein for the purpose of providing intravenous fluids or to be used as an access line for administration of medications). 1) The Administrator failed to: a) monitor and supervise the DON to ensure the DON carried out his responsibilities to implement the facility's policies for care and maintenance of PICC lines, monitor the supervisory nursing staff, to ensure they were (1) following the facility's written policies for care and maintenance of PICC lines, (2) monitoring the licensed nursing staff in obtaining and/or following physician's orders [REDACTED].#7, #12, and #15 and (3) monitoring care plans and formulating individualized care plans to include goals/approaches specific to the care and maintenance of the PICC lines for Residents #7 and #15. c) monitor and supervise the DON to ensure the DON carried out his responsibilities to monitor the licensed nursing staff to ensure they were educated and competent in providing care and maintenance of the PICC lines for Residents #7, #12, and #15. 2) The DON failed to: a) monitor and supervise the supervisory nursing staff to ensure they were following the facility's written policies for care and maintenance of PICC lines. b) monitor and supervise the supervisory nursing staff to ensure they were monitoring the licensed nursing staff, including LVNs L, M, N, and O, in obtaining and/or following physician's orders [REDACTED].#7, #12, and #15. c) monitor and supervise the supervisory nursing staff to ensure they were monitoring care plans and formulating individualized care plans to include goals/approaches specific to the care and maintenance of the PICC lines for Residents #7 and #15. d) educate, monitor and supervise the facility's licensed nursing staff to ensure they were competent in providing the appropriate care and maintenance of the PICC lines for Residents #7, #12, and #15, including (1) following physician's orders [REDACTED]. medications. 3) LVN M was about to inject air into Resident #15's PICC line, the surveyor intervened. LVN M failed to flush Resident #15's PICC line before administering his antibiotic. LVN M cleaned the red port on Resident #15's PICC line, dropped the tubing line on the floor, went out to get another IV tubing, when she returned she connected the IV tubing to the purple port without cleaning the access port, and failed to prime the IV tubing completely of air. LVN M said she had not received much training regarding PICC lines. There were no current physician's orders [REDACTED]. LVN M failed to flush the PICC line before administering Resident #7's antibiotic and failed to properly prime the IVPB (intravenous piggy bag) tubing and the prefilled NS 10 ml syringe before flushing Residents #7's PICC line. LVN M cleaned the purple port with alcohol but went to the other side of the room to connect the old tubing to the new antibiotic bag, primed the tubing with air still in the line. While on the other side of the room, Resident #7 moved his right hand and the PICC line access port touched his body and bed linen. LVN M connected the IV tubing without re-cleaning the port, checking for patency and failed to flush the line before administering the antibiotics. LVN N and LVN O flushed Resident #12's PICC line with only 5 ml of Normal Saline. The physician's orders [REDACTED]. An Immediate Jeopardy (IJ) was identified on 02/08/12. While the IJ was removed on 02/10/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring its Plan of Removal. These failures could affect the five residents, including Residents #15, #7, and #12 who had PICC lines, by placing them at risk for infection,[MEDICAL CONDITION], septic shock, fever, air embolisms, and/or death. Findings included: http://picclinenursing.com reflected, "A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart. However, unlike other central lines, its point of entry is from the periphery of the body ? (sic) the extremities. And typically the upper arm is the area of choice...A PICC line may requested for a variety of treatment options which include some of the following:-Prolonged IV antibiotic treatment...The catheter must be flushed every 12 hours and after each use. This is required to prevent clogging of the catheter. Flushing is done with ...normal saline...If flushing is difficult, this indicates that the PICC is becoming blocked. If it becomes fully blocked, it may not be usable. Report this difficulty in flushing immediately so it can be declotted to regain full functional use...." (retrieved on 02/22/12). 1. Resident #15's hospital Discharge Medications list dated 01/31/12 and signed on 02/01/12 reflected, "[MEDICATION NAME]/Sulbactam, 1.5 gm, IVPB, inj (injection), q8h (hours), continue for 5 weeks..." The Medications list also reflected to flush the PICC line with "Sodium Chloride flush, 10 ml, IV push, inj, q12h..." The Discharge Medications list reflected continue medication and there was yes, no, change and yes was circled for the Sodium Chloride flush. However, a handwritten "D/C (discontinue)" was next to the order. There was not a physician's orders [REDACTED].#15. Review of Resident #15's "Resident Admission Record," dated 02/01/12, revealed Resident #15 was an [AGE] year-old, who was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. Review of Resident #15's clinical record revealed no care plans for Resident #15's PICC line. The interim plan of care dated 02/01/12 revealed Resident #15 had a "PICC line dressing right forearm dressing change weekly." There were no other instructions for the PICC line care. Review of Resident #15's February 2012 physician's orders [REDACTED]. IVPB every eight hours for five weeks. The orders also revealed an order for [REDACTED]. Review of Resident #15's February 2012 Medication Chart Record revealed to flush the IV PICC line site with 10 cc NS before and after medication administration. The flushes were timed for 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. However, the 10:00 p.m. to 6:00 a.m. schedule had a line drawn through it. Further review of the Medication Chart Record revealed the flushes where initialed as completed at 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. for the following dates: 02/01/12, 02/02/12, 02/03/12, 02/04/12, 02/05/12, 02/06/12, and only the 2:00 p.m. to 10:00 p.m. shift was initialed as completed on 02/07/12. The Medication Chart Record reflected the [MEDICATION NAME] was administered at 7:00 a.m., 3:00 p.m. and 11:00 p.m. on the following dates: 02/01/12, 02/02/12, 02/03/12, 02/04/12, and 02/06/12. The Medication Chart Record reflected on 02/05/12 there were no initials for the 11:00 p.m. dose and no initials on 02/07/12 for the 2:00 p.m. to 10:00 p.m. shift. Review of Resident #15's "Clinical Infusion Nursing Documentation" dated 02/10/12 revealed the resident's PICC line had clotted and the Infusion company nurse came to the facility to declot the double lumen PICC line on that date. The surveyor observed Resident #15 during the initial rounds on 02/06/12 at 8:15 a.m. with LVN S. LVN S stated Resident #15 was alert and oriented to person, place and time, and used a wheelchair for locomotion. LVN S stated Resident #15 used a Foley catheter for voiding, and he required assistance with his activities of daily living. LVN S also stated Resident #15 had a PICC line access for antibiotics due to [MEDICAL CONDITION] of the feet. On entering the room, the surveyor observed Resident #15 sitting at the bedside with a left leg brace on his right foot. The surveyor observed Resident #15 during medication administration on 02/07/12 at 3:00 p.m. LVN M brought [MEDICATION NAME] 1.5 gm in a 50 ml IVPB with some alcohol pads and one prefilled NS syringe to the room. The NS syringe contained 5 ml of NS. LVN M placed the items on the resident's over bed table and went to the bathroom to wash her hands. LVN M donned gloves, and cleaned the red port with the alcohol wipes. She turned around to mix the [MEDICATION NAME] powder with the NS and to spike the IVPB tube, when the old IV tubing dropped on the floor. LVN M obtained new IV tubing, spiked the IVPB and primed (removing air from the line) the tubing with the medication to approximately 4 cc from the tip and stopped it. LVN M did not prime the tubing all the way to the tip to ensure the air was completely removed. Perry and Potter's Clinical Nursing Skills & Techniques Fifth Edition 2004, on page 594 reflected, "7. Check for air in tubing. If bubbles form, they can be removed...Reduce air in tubing by priming slowly instead of allowing a wide-open flow." <http://medical-dictionary.thefreedictionary.com/air+embolism> reflected, "air embolism air injected accidentally into veins which may cause temporary paralysis or dyspnea, or may be fatal if the embolism occurs in the heart or brain." (retrieved on 02/24/12.) LVN M proceeded to connect the IVPB tubing to the PICC line port. LVN M accessed and connected the IV tubing to the purple port, instead of the red port she previously cleaned. LVN M accessed the purple port without cleaning or scrubbing the port first. LVN M also failed to flush the PICC line tubing before administering the medication. When the surveyor asked her why she was using the purple port instead of the red port she had cleaned, LVN M stated the red port was for blood draws, and she thought she had cleaned the purple port. The surveyor observed LVN M again on 02/08/12 at 3:35 p.m. administering [MEDICATION NAME] 1.5 gm to Resident #15. LVN M washed her hands, spiked the IVPB, primed the tubing, cleaned the PICC line port and connected the IVPB without flushing the PICC line first and then unclamped the tubing. At 02/08/12 at 4:20 p.m., the surveyor observed Resident #15's PICC line port was connected to the IV tubing with the PICC line hub dangling without protection, which exposed the hub to possible contaminants. The surveyor left his room and found LVN M in another resident's room and asked LVN M if she flushed Resident #15's PICC line. LVN M told the surveyor she had not. She stated she just disconnected the line to come back after caring for another resident. She stated she would flush the line next. LVN M got alcohol pads and one prefilled 10 ml syringe with 5 ml of NS from the treatment cart and went to Resident #15's room. LVN M cleaned the PICC line hub and attempted to flush the PICC line with the hub. However, the syringe could not properly attach to the hub to connect for flushing. LVN M continued to struggle with the syringe and the hub. LVN M then disconnected the port from the tubing and connected it to the hub, and then cleaned the PICC line port. LVN M opened the 5 ml prefilled syringe of NS and proceeded to flush the line without first priming the syringe of the 1 to 2 ml of air in the syringe. Then LVN M had her hand on the syringe plunger and was about to inject air and NS into Resident #15's PICC line, when the surveyor intervened. After the above observation, the surveyor asked LVN M how she checked for patency of the line. LVN M stated she checked patency when she flushed both ports and it "flows freely." The interview revealed LVN M was not aware she could pull back for blood return to check for patency of the PICC line. 2. Review of Resident #7's hospital Facility Transfer Orders dated 01/22/12 revealed [MEDICATION NAME] 150 mg/ml solution, 900 mg IVPB every eight hours for five more weeks. The Transfer Orders reflected [MEDICATION NAME] 750 mg IVPB every 48 hours at the same time for six weeks. (NOTE: The hours were changed from 48 hours to 36 hours after the [MEDICATION NAME] trough level result was obtained 02/05/12.) Further review of the Transfer Orders revealed to flush "all lumens with 10 ml NS every 12 hours and prn." Review of Resident #7's undated "Resident Admission Record" revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. Review of Resident #7's admission physician's orders [REDACTED]." The physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Resident #7's "INTERIM PLAN OF CARE" dated 01/26/12 revealed the section entitled "IV/TPN" was blank. The section of the Plan of Care entitled "INFECTION ALERT" reflected Resident #7 was on [MEDICATION NAME] 750 mg every 48 hours for six weeks and [MEDICATION NAME] 900 mg every eight hours for five weeks. The plan of care did not reflect the approaches to care for Resident #7's PICC line such as when to change the dressing or when to flush the line. Review Resident #7's February 2012 physician's orders [REDACTED]. Resident #7 was observed during the initial rounds on 02/06/12 at 8:05 a.m. in bed in his room. LVN S stated Resident #7 was alert and oriented to person and place. He was mobile in the facility via a wheelchair, was continent of bowel and bladder and he required assistance with his activities of daily living. LVN S stated Resident #7 had some toes amputated on his left foot and he had a double lumen PICC line. The surveyor observed Resident #7's right foot was [MEDICAL CONDITION], the big toe was amputated with eschar on the site. The left foot was observed with four toes. The PICC line dressing was dated 02/05/12 and peeling on the sides. The surveyor observed LVN M on 02/07/12 at 3:20 p.m. administering [MEDICATION NAME] ([MEDICATION NAME]) 900 mg in 50 ml bag to Resident #7. After washing her hands and donning gloves, LVN M cleaned the purple port of Resident #7's PICC line with an alcohol pad. LVN M went to the other side of the room, removed the old IVPB tubing still connected to the old bag, and spiked the new IVPB with the tubing. LVN M did not completely prime the IV tubing when she picked up the PICC line and connected the tubing. The surveyor asked LVN M, at that time, if the tubing was completely primed. LVN M then stopped and looked at the line and then disconnected the tubing to complete the IV tubing priming. While LVN M went to the other side of the room to get the old tubing, the surveyor observed Resident #7 moving his right hand with the PICC line thus re-contaminating the cleaned PICC line access port. LVN M proceeded to connect to the contaminated port without recleaning the port. The surveyor observed LVN M administer the medication without first flushing the PICC line tubing with 10 ml NS as per nursing standards. The surveyor interviewed LVN M on 02/07/12 at 3:40 p.m. The interview revealed she was trained on how to start peripheral IVs. LVN M stated the training consisted of a simulation of a hand to start the IV. LVN M stated she did not receive any training on PICC lines. The surveyor asked LVN M if she had any training on how to hang medications on a PICC line. LVN M stated she knew to flush the line after the medication administration. On 02/08/12 at 7:40 a.m. the surveyor observed LVN L flushing Resident #7's PICC line. LVN L washed her hands and donned gloves and then opened the prefilled 10 ml syringe with 5 ml of NS in the syringe. LVN L clamped the PICC line, cleaned the port by scrubbing it, connected the 10 ml syringe with 5 ml of NS to the port, unclamped the port and flushed the line. Before removing the port, LVN L clamped the PICC line and then removed the syringe. In an interview at this time with LVN L, she told the surveyor she flushed the PICC line with 5 ml of NS and was flushing it again with 5 ml of NS. LVN L stated she used the 5 ml of NS because it was the facility's protocol. The surveyor asked if LVN L if she checked Resident #7's physician's orders [REDACTED]. LVN L stated she did not check the physician's orders [REDACTED]. During an interview at 7:50 a.m. on 02/08/12, LVN L stated she had training three years ago, which was an IV certification training for inserting peripheral IVs. She stated the only training for PICC lines was how to flush the lines. LVN L stated the facility allowed the LVNs to flush and administer medications through the PICC lines. An interview on 02/08/12 at 10:42 a.m. with LVN T revealed she had IV training about one year ago. LVN T stated the training was from a pharmacy, they went over the different types of IVs, how to place a peripheral line, finding a good site for peripheral line placement, and how to assess for infections. LVN T said they did not spend much time on the maintenance of PICC lines, but she understood and remembered how to flush the PICC line. 3. Resident #12 was an [AGE] year-old female and was most recently admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]." Review of Resident #12's Facility Transfer Orders dated 02/03/12 and confirmed by telephone with MD Z, "Flush all lumens with 10 ml NS every 12 hours and PRN" There were no orders for flushing the PICC line before or after medication administration. Resident #12's facility physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of Resident #12's Physician Telephone Orders dated 02/04/12 revealed, "...IV flush per facility protocol." Review of the facility's identified protocol for PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) FLUSHING dated 08/15/08 revealed, "...1. A physician order [REDACTED]. (Refer to Infusion Maintenance Table A. 1) The order must include: Flushing agent, Strength/concentration, Volume, Frequency 2. Only 10 ml syringes or larger will be used to flush catheters. 3. All catheters are flushed between incompatible medications with normal saline and/or [MEDICATION NAME] or other flush solution as recommended by the manufacturer...." Review of Resident #12's clinical record revealed a CENTRAL VENOUS CATHETER-PHYSICIAN ORDER [REDACTED]. These orders were not in the resident's clinical record before 5:00 p.m. on 02/08/12. The PHYSICIAN ORDER [REDACTED]. Review of Resident #12's clinical record revealed there was no documentation revealing the PICC brand, and if the PICC was tunneled or non-tunneled, and if it was non-valved or valved. Observation on 02/08/12 at 2:50 p.m. revealed LVN O flushed Resident #12's PICC line with 5 ml of normal saline before administering one gram of [MEDICATION NAME] via an [MEDICATION NAME] Infusion Device (infusion device which ranges from 30 minutes to 5 hours of continuous infusion). LVN O confirmed she flushed the PICC line with 5 ml of normal saline. Interview on 02/08/12 at 3:00 with LVN N revealed she had PICC line training during nursing school in 2009. LVN N said she had not had any PICC line training since that time. Interview with LVN O on 02/08/12 at 3:05 p.m. revealed the DON "doesn't draw blood from the PICC line because he's not comfortable doing it. The DON before him drew blood all the time. If an RN is on the floor she will draw the blood. He's the only RN on the 6-2 shift during the week." LVN O said she had PICC line training "through the pharmacy." Observation on 02/08/12 at 4:50 p.m. revealed LVN N removed the [MEDICATION NAME] Infusion Device tubing from Resident #12's PICC line. LVN N then flushed the PICC line with 5 ml of normal saline. LVN N confirmed she flushed the PICC line with 5 ml of normal saline. Interview on 02/09/12 at 11:15 a.m. with LVN O revealed when asked why she did not use 10 ml of normal saline to flush Resident #12's PICC line, she said, "Oh because that's what our policy says." LVN O stated she was referring to a pharmacy pre-printed instruction sheet in the MAR binder. When the surveyor asked what Resident #12's physician's flush orders were, LVN O looked at the order on the MAR indicated [REDACTED]. LVN O said, "I need to write a clarification order." LVN O was informed by the surveyor Resident #12 did not have a physician's orders [REDACTED]. LVN O said she would get an order. Interview on 02/09/12 at 11:40 a.m. with LVN O revealed, "I didn't have to write the orders." LVN O found PICC line flushing orders on Resident #12's clinical record dated 02/08/12. Interview on 02/09/12 at 2:10 p.m. with MD CC revealed instead of writing orders for PICC line care and maintenance, he expected the facility to follow their PICC line protocol. When MD CC was informed the facility's protocol instructed the nurses to get specific orders for PICC line flushes, he revealed he was not made aware of that protocol by the facility. MD CC said all other facilities had PICC line protocols in place. MD CC said, "It sounds like to me they need in-services." Interview on 02/10/12 at 3:30 p.m. with MD Z revealed instead of writing orders for PICC line care and maintenance, he expected the facility to follow their PICC line protocol. 4. During the interview with the DON on 02/08/12 at 6:08 p.m., the surveyor inquired about PICC line training for the facility nursing staff. The DON stated the nurses in the facility had IV training. When asked about IV PICC lines, he stated the training involved the PICC lines. The surveyor inquired if he monitored the staff to ensure they were competent in PICC line assessments and how to access the PICC line. The DON stated yes. He stated he had checked a couple of the staff in the Fall of 2011 to ensure they were competent, but he could not remember the staff's names. The DON stated staff were to check the PICC line for patency by drawing back on the syringe for blood return and if blood return was observed, the PICC line was patent and staff should continue with medication administration. The surveyor also asked the DON what size of syringe and how much fluid should be used for flushes. The DON stated "3 cc syringe" and when the surveyors repeated "3 cc," the DON left the surveyors' work room at 6:10 p.m. and stated he would return. When the DON came back to the surveyors' work room at 6:18 p.m., he came back with the facility's policy. The DON stated the staff were to flush the PICC lines with 10 ml NS or whatever the physician ordered. When the DON was informed of how much fluid was in the syringes used by the nurses, the DON stated, "Well they are packaged wrongly and I will call the pharmacy and tell them to send the right amount of fluids." The surveyor asked the DON what the difference was between PICC lines and Peripheral lines, and he responded one had a short line and the other had a longer line. The DON also stated the peripheral lines only involved veins and the PICC lines went into the heart area. (Note: http://picclinenursing.com reflected, "A PICC line is, by definition and per its acronym, a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart....") The surveyor asked the DON how to check for patency of a PICC line. The DON stated by pulling back with a syringe and getting blood back, meaning the line was patent. After a minute, the DON stated he would "pulsate" the PICC line to check for patency if the line was difficult to flush and/or had some resistance while flushing it, he would stop because it was clogged and call the pharmacy company IV nurses to come and declot the line before continued use, if not he would then flush the line with a prefilled 10 cc NS syringe. The surveyor asked who did the blood draws on the lab work ordered, and the DON replied the lab. The surveyor asked if phlebotomists could draw blood from a PICC line and the DON stated no the phlebotomist drew the blood with needles. The surveyor asked why the DON did not draw blood from the PICC lines and spare the resident the pain of additional punctures. The DON stated he did not have time. He stated he was too busy "running around" and could not be found most of the time when the lab was there. The surveyor asked about labs that were due to be drawn in the afternoons. The DON stated he was too busy to draw the labs, so the phlebotomist drew the blood through another puncture site. 5. An IJ was identified on 02/08/12 in the area of Quality of Care. The ADM and the DON were notified of the IJ on 02/08/12 at 6:40 p.m. 6. The Plan of Removal was accepted on 02/09/12 at 3:30 p.m. and reflected: 1. Residents #7, #12, and #15 were assessed for IV site complications from their PICC lines 2. Physicians were notified of errors reported by the surveyors and orders were received. 3. Physicians were notified for clarification of IV line flush orders. 4. The four identified LVNs would be re-educated on PICC lines to include assessing patency and flushing of the line using 10 cc syringe, ensuring the syringe was primed, before and after IV medication administration with return demonstration. Staff would be re-educated on infection control-cleaning the port prior to accessing. 5. The four identified nurses would not be allowed to administer IV medications until competency was completed 6. DON/designee would perform competency evaluations for the administrative licensed nurses so the administrative nurses could observe the staff. 7. Newly hired licensed staff would be required to provide documentation of IV certification. If unable to provide the documentation, the licensed nurse would be prohibited from administering IV medications until an IV certification class was completed and competency was satisfactory. Staff Development Coordinator/designee would perform competency evaluations for newly hired licensed nursing staff within the first 30 days of working. 8. Administrative nursing would observe each resident receiving IV medication at least once per week for four weeks and then randomly. 7. Interviews conducted on 02/10/12 from 9:00 a.m. through 11:15 a.m. with LVNs F, O, BB, N, and L revealed they had been in-serviced on 02/09/12 on PICC line care and maintenance. 8. On 02/10/12 at 1:40 p.m., during an interview with the DON, the surveyor asked him what training he ensured was provided to the licensed nurses in order to care for residents with PICC lines. The DON stated he went back and did the training and the check-offs for the nurses to ensure proficiency. When the surveyor asked the DON if there had been any in-services on PICC lines, he stated there had been multiple inservices for "many different things." The DON stated all the the nurses had been through the training with an outside healthcare company and they (facility) had put all kinds of check-off systems in place. When the surveyor asked the DON what plan was in place for PICC lines, he stated in-service and training through the outside healthcare company. When the surveyor asked the DON how he ensured the licensed nurses were competent in their skills for providing care to residents with PICC lines, he stated he planned to monitor the nurses' PICC line skills every week for the next four weeks. He stated after that, nursing administration would monitor the nurses. When the surveyor asked the DON how he thought the IJ occurred, he stated, "I don't know what happened with these nurses. They were all trained the same way and they are strong nurses. They just messed up and this all got out of hand and ended up this way. I felt like they were well trained." When asked by the surveyor if PICC lines had been a topic of discussion at the facility's QA meetings, the DON stated, "In the past, our process has not identified any problems in this area, but now I will be taking these problems to the committee." 9. Interview with the CN and the DON on 02/10/12 at 3:40 p.m. revealed the CN said their protocol did not need updating and it was fine the way it was. The CN stated the nurses could review the Infusion Maintenance Table for the protocol on flushing PICC lines. The CN said the type of PICC line should be in the clinical record. The surveyor informed the CN the PICC line information was not found in Residents #7, #12 or #15's clinical records. The surveyor asked the CN if the nurses were interviewed at that time and asked to describe the differences between tunneled, non-tunneled, valved and non-valved would they be able to determine that. The CN said, "They will be, I'm going to take care of that right now." The CN and the DON left to in-service the nurses on the different types of PICC lines. 10. On 02/10/12 at 4:00 p.m., during an interview with the ADM and the Corporate Regional VP of Operations, the ADM stated he ensured the quality of care needs of residents were met by walking around the facility, making sure call lights were answered, meeting with department heads and holding stand-up meetings with staff to discuss care issues with residents, conducting interdisciplinary meetings and discussing 24 hour reports, and talking with residents and families and then following up on any concerns and complaints. When asked by the surveyor how he monitored the DON to ensure the systems the DON monitored were being carried out effectively, the ADM stated he followed the chain of command. He stated he started with the DON by asking him (DON) about any observations he (ADM) had made that he had questions about. The ADM stated, if needed, he would ask the ADONs. He stated it was a "check and balance" system to see where the process was and to see where improvement could be made and what monitoring was needed. The ADM referenced corporate "tools" and "score cards" which were available to him for this process. The ADM stated he was aware there were res