Every finding on record at Vista Ridge Nursing & Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #1) of 6 residents reviewed for reasonable accommodation of needs.The facility failed to ensure the call light system for Resident #1 was in a position that was accessible to the resident on 08/11/26.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: Record review of Resident #1's Face Sheet, dated 08/11/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and history of falling.Record review of Resident #1's Initial MDS assessment, dated 07/13/26, reflected a BIMS score of 9 (moderate cognitive impairment). The resident's ADL care reflected the resident required substantial assistance, and active diagnoses of history of falling and muscle weakness. Record review of Resident #1's Comprehensive Care Plan, dated 07/28/26, reflected educated the resident to call for assistance.Record review of the facility's incident logs for the month of July 2026, revealed Resident #1 had an unwitnessed fall on 07/28/26 and 07/29/26. The resident had no injuries because of the falls. During an interview and observation on 08/11/26 at 11:43 a.m., Resident #1 was observed sitting in her wheelchair and her call light was lying on the floor near her bed. She stated staff had transferred her from her bed to the wheelchair about two hours ago.During an interview and observation on 08/11/26 at 11:45 a.m., CNA C stated she was the CNA for Hall 100. She observed Resident #1 sitting in her wheelchair and the call light positioned on the floor near her bed. She stated the therapy department had transferred her out of her bed and into the wheelchair and did not place the call light within reach of the resident. She stated the call light needed to be within reach of the resident so she could contact staff if she needed help. She stated staff should be checking for this when making their rounds. During an interview on 08/11/26 at 11:50 a.m., LVN V was advised of Resident #1's call light being out of her reach and he stated the call light was required to be within reach of the resident so she could be able to call for assistance if she needed it. He stated staff were required to check for this when making rounds.During an interview on 08/11/26 at 1:22 p.m., ADON K stated she was the ADON for the skilled residents and she covered the 100 and 400 halls. She was informed of Resident #1 not having her call light within her reach. She stated the call light should have been placed near the resident. She stated staff should ensure the call lights were within the resident's reach prior to leaving the resident's room. She stated staff should check at least every two hours. She stated if the call light was not within the resident's reach, they could be in distress and unable to contact staff.During an interview on 08/11/26 at 1:35 p.m., the Interim DON stated she was informed of Resident #1's call light not being within her reach. She stated the call light should have been within the resident's reach so she could contact someone if she needed help. She stated it was all staff's responsibility to ensure the call light was within the residents' reach.Record review of the facility's policy on Resident Call Light System, dated 06/2023, revealed A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities. Ensure that the call light is easily reachable by the resident.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 a resident for 1 of 6 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's care plan for fall prevention included interventions of fall mats and bed placed in the lowest position. This failure could place residents at risk of not being in a safe environment to limit injury because of a fall. Findings include:Record review of Resident #2's Face Sheet, dated 08/11/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses of a history of falls and lack of coordination.Record review of Resident #2's Quarterly MDS Assessment, dated 06/16/26, reflected the resident had a BIMS score of 7 (severe cognitive impairment). The resident's ADL care reflected the resident required moderate assistance, and active diagnoses of repeated falls and muscle weakness.Record review of Resident #2's Comprehensive Care Plan, dated 05/24/26, reflected the resident was a fall risk; however, the care plan did not include the intervention of a fall mat to be placed alongside her bed and the bed to be placed in the lowest position when she was lying in bed. During an observation on 08/11/266 at 11:20 a.m., Resident #2 was not in her bed, but a fall mat was placed alongside the bed. Record review of the facility's incident logs for the month of July 2026, revealed Resident #1 had falls on 07/03/26 and 07/21/26. The resident had no injuries because of the falls.During an interview on 08/11/26 at 11:30 a.m., RN S stated Resident #2 was a fall risk and while she was in bed, the bed needed to be in its lowest position and the fall mat needed to be placed alongside her bed. She stated she did not know if this was care planned but it needed to be for the resident's care. She stated the MDS nurse updated the care plans.During an interview on 08/11/26 at 12:59 p.m., MDS nurse D stated she updated care plans as events occur or when notified by the nursing staff. She was informed of RN S stating Resident 2's bed should be placed in the lowest position and fall mat placed alongside her bed when she was lying in bed; however, these interventions were not observed on the resident's care plan. She stated this should be care planned, but it was not. She stated it should be care planned so the nursing staff would know the plan of care.During an interview on 08/11/26 at 1:29 p.m., ADON M stated she was responsible for the residents on Hall 200. She stated the MDS nurses were responsible for updating care plans. She stated the MDS nurse would usually receive reports in the morning meetings or when the nurses or ADONS notify them. She stated Resident #2 was a fall risk and the bed should be in the lowest position and fall mat in place. She stated those interventions should also be care planned to ensure the resident was safe.During an interview on 08/11/26 at 1:35 p.m., the Interim DON stated if the resident was a fall risk and the interventions of the bed being in the lowest position and fall mat on the side of the bed should be care planned because they were interventions needed for the resident's plan of care.Record review of facility's policy, Comprehensive Care Plans, dated 2022, reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's CPAP mask was properly stored in a bag when not in use on 08/11/26. This failure could place the resident at risk for respiratory infection and not having her respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 08/11/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included acute and chronic respiratory failure (trouble breathing).Record review of Resident #1's Initial MDS assessment, dated 07/13/26, reflected a BIMS score of 9 (moderate cognitive impairment). The resident had an active diagnosis of acute and chronic respiratory failure. Record review of Resident #1's Physician orders, dated 08/11/26, reflected CPAP every evening. Ensure CPAP mask when dry and not in use, stored in a covered device. During an interview and observation on 08/11/26 at 11:43 a.m., Resident #1's CPAP mask was observed sitting on top of her nightstand unbagged. She stated she had not used the mask in 3-4 days.During an interview and observation on 08/11/26 at 11:45 a.m., LVN V was shown Resident #1's CPAP mask sitting on top of her nightstand unbagged. He stated the mask should be bagged when not in use to avoid the mask from getting contaminated.During an interview on 08/11/26 at 1:22 p.m., ADON K stated she was the ADON for the skilled residents and she covered the 100 and 400 halls. She was informed of Resident #1's CPAP mask not being bagged when not in use. She was informed of Resident #1 stating she had not used the mask in the past 3-4 days. ADON K stated the mask should have been bagged to avoid the resident from getting an infection. She stated it was the nurses' and leadership's responsibility to ensure the mask was bagged when not in use.During an interview on 08/11/26 at 1:35 p.m., the Interim DON stated she was informed of Resident #1's CPAP Mask not bagged when not in use. She stated the mask should be bagged when not in use because it has the potential for contamination.Review of the facility's policy Oxygen Use (Respiratory Therapy) Prevention of Infection, November 2011, reflected The purpose of this procedure is to guide prevention of infection associated with the respiratory tasks and equipment, including ventilators, among residents and staff.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for one of seven residents (Resident #1) reviewed for abuse.The facility failed to ensure Resident #1 was free from verbal abuse by CNA A. This failure could place residents at risk for abuse or neglect that could lead to serious harm. Findings included: Record review of Resident #1's face sheet, dated 06/09/26, reflected a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dysarthria (a motor speech disorder caused by nervous system damage that weakens, paralyzes, or reduces coordination of the muscles used for speech) and anarthria (the complete loss of the ability to produce articulate speech due to severe neuromuscular damage), cognitive communication deficit (an underlying disruption in thinking like poor memory, attention, or executive functioning impairs a person's ability to effectively speak, listen, read, or write), muscle weakness, muscle wasting, lack of coordination, dementia (decline in mental ability), hyperlipidemia (high levels of lipids (fats), such as cholesterol and triglycerides, in the blood), depression (a serious mood disorder that causes persistent sadness, loss of interest, and physical fatigue), anxiety disorder (mental health conditions characterized by excessive, persistent, and overwhelming worry or fear that interferes with daily activities), dystonia (a neurological movement disorder that causes involuntary, sustained, or repetitive muscle contractions), insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and being unable to get back to sleep), spastic hemiplegia (muscle stiffness and paralysis on one side of the body) affecting dominant side, fusion of spine (a surgical procedure that permanently connects two or more vertebrae in your spine using bone grafts and metal hardware), contracture of right upper arm and right lower leg, dysphagia (difficulty or discomfort in swallowing food, liquids, or even saliva), pain and anorexia (an eating disorder and serious mental health condition). Record review of Resident #1's Quarterly MDS assessment, dated 05/01/26, reflected a BIMS score of 12, which indicated moderate cognitive impairment. The MDS assessment under Section GG-Functional Abilities, reflected Resident #1 needed partial assistance with eating and oral hygiene, substantial assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, rolling left and right, sitting to lying, chair/bed-to-chair transfer and tub/shower transfer. The MDS assessment under Section E-Behavior, reflected Resident #1 did not exhibit any physical, verbal or other behavior symptoms directed towards others. Record review of Resident #1's care plan, revised 01/05/26, reflected Resident #1 used psychotropic medications related to behavior management. Interventions included: administering psychotropic medications as ordered by physician, discussing with MD, family ongoing need for use of medication, reviewing behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy and monitoring/documenting/reporting PRN any adverse reactions of psychotropic medications. Record review of CNA A's statement taken on 05/18/26 by the SW, reflected the following: [CNA A] stated that [Resident #1] came to smoke at the end of the smoke break, when other smokers were going in the building. The CNA from [Resident #1's] hall did not stay so [CNA A] stated he took [Resident #1] out but asked him to hurry so he could get back on the hall. [Resident #1] stated that he would and [CNA A] pushed him to the designated smoking area. [CNA A] stated that he asked [Resident #1] if he could get off his phone so he could smoke faster. [CNA A] stated that [Resident #1] got angry and began to yell at him. [CNA A] stated he tried explaining that he was the only CNA working the 400 hall but [Resident #1] continued to cuss at him and then called him a son of a bitch. [CNA A] asked resident, did you call me a son of a bitch? [CNA A] stated [Resident #1] said, yes, you are mother fucking son of a bitch. [CNA A] stated he responded, I am not a son of a bitch, maybe you are a son of a bitch. Record review of Resident #1's statement taken on 05/18/26 by the SW, reflected the following: [Resident #1] stated that when he went to smoke the other smokers were coming in but [CNA A] said he could take him out real quick. [Resident #1] stated that he told [CNA A] he would be fast. [Resident #1] stated he was smoking [when] [CNA A] asked him to get off his phone so that he could smoke faster in which [Resident #1] stated No and I smoke slow. [Resident #1] stated that [CNA A] started talking louder to him and called him a son of a bitch. [Resident #1] stated that pissed him off so he began yelling and cussing back at [CNA A]. On 06/09/26 at 11:18 AM attempted to contact CNA A but no answer. A message was left with call back details. During an interview on 06/09/26 at 12:16 PM, the Social Worker stated she was told by both Resident #1 and CNA A that Resident #1 had gone out late for a smoke break. The SW stated she received somewhat of the same story from Resident #1 and CNA A. The SW stated CNA A told her he asked Resident #1 to hurry because he was taking long to smoke due to playing on his phone. The SW stated CNA A told her that he asked Resident #1 to get off his phone. The SW also stated CNA A told her he did not ask Resident #1 in a rude manner. The SW stated CNA A stated Resident #1 did not like asking him to hurry, so Resident #1 called him a son of a bitch. The SW stated CNA A told her he asked Resident #1 for clarification on what he said. The SW stated CNA A stated Resident #1 repeated it and CNA A said, I am not a son of a bitch, maybe you are a son of a bitch. The SW stated Resident #1 reported to her that CNA A told him to hurry, and Resident #1 told CNA A not to tell him what to do. She stated Resident #1 stated CNA A yelled at him and called him a son of a bitch. The SW stated Resident #1 told her he responded to CNA A by telling him he was a son of a bitch. During an interview on 06/09/26 at 12:46 PM, Resident #1 stated he had gone to the smoking area late. Resident #1 stated the other residents were returning from the smoke break, but CNA A stayed to allow him to smoke. Resident #1 stated he was not smoking fast enough, and CNA A yelled at him and told him to hurry. Resident #1 stated CNA A also threatened to hit him. Resident #1 stated CNA A called him a son of a bitch bastard. Resident #1 stated he replied to CNA A saying, fuck you. Resident #1 stated there were no other residents or staff around them at the time of the incident. Resident #1 also stated that was the first time CNA A had disrespected him. During an interview on 06/09/26 at 1:15 PM, the Administrator stated the facility's Social Worker informed of the incident with Resident #1 and CNA A. The Administrator stated the Social Woker informed her that the incident occurred on the weekend of 05/16/26 and reported to the Social Worker days later. The Administrator stated it was the protocol for staff to report it to management then complete any investigation of any alleged verbal abuse. She stated CNA A was terminated because he admitted to responding to Resident #1. On 06/09/26 at 2:46 PM, a second attempt to contact CNA A was made but no answer. A message was left with call back details. Record review if the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised 10/15/22, reflected in part the following: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation Staff to Resident Abuse of any Types: The facility assumes responsibility upon admission of ensuring safety and well-being of the resident. Staff are expected to be in control of their behavior and behave professionally. The facility will not accept for an employee to claim his/her action was reflexive or a knee-jerk reaction and was not intended to cause harm. Record review if the facility's policy titled, Abuse Prevention Program, revised October 2022, reflected in part the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual and physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse program, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 5 residents (Resident #5) reviewed for reporting according to the facility policy.The facility failed to follow the facility's policy to report allegation of abuse when Resident #5 made an outcry to the Psychologist regarding sexual abuse from her FM on 3/24/26.This failure could place residents in the facility at risk of abuse and lack of timely reporting of incidents.Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which meant she had moderate cognitive impairment. Resident #5 had unclear speech, sometimes made herself understood and usually understood others. Resident #5 needed substantial/maximal assistance for oral hygiene, toileting hygiene, showering, upper body dressing, and personal hygiene. Resident #5 needed substantial assistance to roll left and right and to sit to lying.Record review of Resident #5's Care Plan, dated 3/25/26, revealed she had voiced some concern regarding the conduct of her (FM) towards her to the staff when he visits her. The care plan stated interventions were to have the FM visits to be supervised in common areas during the daytime when administration is present and police were notified. Resident #5's care plan revealed the following care areas:- ADL deficit- Severe Mental Illness; took antidepressant and anti-anxiety medications- Communications problems - Aphasia- Fall risk- Mood and psychosocial problems; had APS and psychological services involved.Record Review of TULIP showed no incident report regarding the incident was reported.Interview on 4/9/26 at 2:45 p.m., the Admin stated the Psychologist reported to her that Resident #5 told him the FM was touching her inappropriately sexually. She stated calling the state regarding allegations of abuse or neglect was her job. The Admin stated she did not report this to the state because Resident #5 said the FM always did this and he thought it was funny. She stated Resident #5 did not tell her it was without consent and that was why she did not report it to the state as she did not think it was abuse.Interview on 4/9/26 at 3:48 p.m., the Admin stated she did do an investigation, but she did not think it was abuse so she did not report it or turn the investigation into the state. Record review of the facility's Abuse Prevention Program, dated 2001, revealed under Policy Interpretation and Implementation 6. Investigate and report any allegations of abuse within timeframes as required by federal requirements.Policy StatementAll reports of resident abuse.shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting1. All alleged violations involving abuse.will be reported by the facility Administrator, or his/her designee, to the following persons or agencies; a. the State licensing/certification agency responsible for surveying/licensing the facility.2. An alleged violation of abuse.will be reported immediately, but not later than:a. Two (2) hours if the alleged violation involves abuse.4. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse 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 other officials (including the State Survey Agency where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 out of 5 residents (Resident #5) reviewed for abuse or neglect.The facility failed to report an allegation of abuse to the State Survey Agency (HHSC) after they learned Resident #5 had made an allegation of sexual abuse against her FM on 3/24/26. These failures could place residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychological harm. Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included: Aphasia (a communication disorder resulting from damage to brain areas responsible for language) following Cerebral Infarction (stroke), Dysphagia (a language disorder characterized by partial impairment of comprehension or expression of spoken words) following Cerebral Infarction, Major Depressive Disorder (mental health condition characterized by a persistent, intense and often disabling low mood and feeling of worthlessness) and Generalized Anxiety Disorder (a mental health condition characterized by persistent, excessive and uncontrollable worry about everyday things).Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which meant she had moderate cognitive impairment. Resident #5 had unclear speech, sometimes made herself understood and usually understood others. Resident #5 needed substantial/maximal assistance for oral hygiene, toileting hygiene, showering, upper body dressing, and personal hygiene. Resident #5 needed substantial assistance to roll left and right and to sit to lying. Record review of Resident #5's Care Plan, dated 3/25/26, revealed she had voiced some concern regarding the conduct of her (FM) towards her to the staff when he visits her. The care plan stated interventions were to have the FM visits to be supervised in common areas during the daytime when administration is present and police were notified. Resident #5's care plan revealed the following care areas: ADL deficitSevere Mental Illness; took antidepressant and anti-anxiety medicationsCommunications problems - Aphasia Fall riskMood and psychosocial problems; had APS and psychological services involved. Record review of the Police Report revealed on 3/24/26, Resident #5 told the Psychologist the FM had been touching her vaginal area. The police report revealed she stated the FM would put his hand underneath her clothing causing direct contact with her vaginal area without her consent. The police report revealed Resident #5 stated she did not want to pursue criminal charges, and she still wanted the FM to visit her. The police report revealed facility staff advised all further visits from the FM would be supervised.Record review of Resident #5's Progress notes, on 3/25/26 at 1:08 p.m. by the SW, revealed Resident (#5) reported inappropriate behaviors in regard to (the FM) to the Psychologist. The Psychologist reached out to SW and SW met with resident to clarify concerns. APS was notified and the PD was called.Resident stated that she did not want charges pressed against (the FM) but wanted supervised visitations when he came. SW notified DON, Admin, and charge nurse. SW and DON will meet with partner (the FM) to discuss new visitation parameters.Record Review of TULIP showed no incident report regarding the incident was reported. Interview on 4/9/26 at 11:08 a.m., the RN stated Resident #5 had to have visits with the FM in the common area and they had to be supervised. The RN stated Resident #5 told the Psychologist the FM had touched her inappropriately. The RN stated she had not seen anything herself.Interview on 4/9/26 at 11:46 a.m., the SW stated about two weeks ago, around 3/23/26, Resident #5 reported to the Psychologist that the FM was touching her inappropriately. The SW stated she talked to Resident #5, and she did not want anything reported to the police. She stated Resident #5 stated the inappropriate/intimate touching had taken place since she admitted to the facility but she did not want to tell anyone. The SW stated the FM was only able to visit Monday - Friday between 9 a.m. and 5 p.m. when leadership was in the facility. The SW stated Resident #5 told the police she did not want to press charges but wanted him to be able to visit with supervision. She stated the police told the FM if there were any more incidents, a no trespass order would be put in place. Interview on 4/9/26 at 12:42 p.m., the Psychologist stated Resident #5 had told him the FM was touching her inappropriately. He stated he was not sure of the exact date at that time but stated he let the SW at the facility, the police and APS know the same day. The Psychologist stated to his knowledge, the facility was having supervised visits between Resident #5 and the FM. Interview on 4/9/26 at 1:59 p.m., the ADON stated she heard there were allegations Resident #5's FM was touching her inappropriately. The ADON stated the allegations should have been called into the state by the Admin and anytime there were allegations of abuse or neglect. Interview on 4/9/26 at 2:22 p.m., the DON stated she received a call from the SW regarding the allegations of sexual abuse Resident #5 told to the Psychologist. The facility made sure Resident #5 was safe. She stated the police and APS were called. She stated the FM was on supervised visitation as Resident #5 still wanted him to visit. The DON stated Resident #5 never reported anything to her. The DON stated the Admin was responsible for reporting allegations of abuse and neglect to the state and this should have been reported. Interview on 4/9/26 at 2:45 p.m., the Admin stated the Psychologist reported to her that Resident #5 told him the FM was touching her inappropriately. She stated the police and APS were called. The Admin stated she talked to Resident #5, and she told her she did not want to press charges, did not want the police called and still wanted the FM to visit. The Admin stated the facility put supervised visitation between Resident #5 and the FM. She stated the visitation could only occur Monday - Friday from 9 a.m. - 5 p.m. in the common area when management was in the building. The Admin stated Resident #5 told her she felt safe and did not want to be supervised. She stated calling the state regarding allegations of abuse or neglect was her job. The Admin stated she did not report this to the state because Resident #5 said the FM always did this and he thought it was funny. She stated Resident #5 did not tell her it was without consent and that was why she did not report it to the state as she did not think it was abuse. Interview on 4/9/26 at 3:48 p.m., with the Admin stated she did do an investigation, but she did not think it was abuse so she did not report it. Record review of the facility's Abuse Prevention Program, dated 2001, revealed under Policy Interpretation and Implementation 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .6. Investigate and report any allegations of abuse within timeframes as required by federal requirements.Policy StatementAll reports of resident abuse.shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting 1. All alleged violations involving abuse.will be reported by the facility Administrator, or his/her designee, to the following persons or agencies; a. the State licensing/certification agency responsible for surveying/licensing the facility.2. An alleged violation of abuse.will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse.b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. 4. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on interview and record review, the facility failed to report the results of all investigations to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident.The facility failed to submit a completed investigation regarding the allegation sexual abuse of Resident #5 by her FM to the State Survey Agency.This failure placed residents at risk of further abuse and a lack of oversight by the State Survey Agency.Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included: Aphasia (a communication disorder resulting from damage to brain areas responsible for language) following Cerebral Infarction (stroke), Dysphagia (a language disorder characterized by partial impairment of comprehension or expression of spoken words) following Cerebral Infarction, Major Depressive Disorder (mental health condition characterized by a persistent, intense and often disabling low mood and feeling of worthlessness) and Generalized Anxiety Disorder (a mental health condition characterized by persistent, excessive and uncontrollable worry about everyday things).Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which meant she had moderate cognitive impairment. Resident #5 had unclear speech, sometimes made herself understood and usually understood others. Resident #5 needed substantial/maximal assistance for oral hygiene, toileting hygiene, showering, upper body dressing, and personal hygiene. Resident #5 needed substantial assistance to roll left and right and to sit to lying.Record review of Resident #5's Care Plan, dated 3/25/26, revealed she had voiced some concern regarding the conduct of her (FM) towards her to the staff when he visits her. The care plan stated interventions were to have the FM visits to be supervised in common areas during the daytime when administration is present and police were notified. Resident #5's care plan revealed the following care areas:- ADL deficit- Severe Mental Illness; took antidepressant and anti-anxiety medications- Communications problems - Aphasia- Fall risk- Mood and psychosocial problems; had APS and psychological services involved.Record review of the Police Report revealed on 3/24/26, Resident #5 told the Psychologist the FM had been touching her vaginal area. The police report revealed she stated the FM would put his hand underneath her clothing causing direct contact with her vaginal area without her consent. The police report revealed Resident #5 stated she did not want to pursue criminal charges, and she still wanted the FM to visit her. The police report revealed facility staff advised all further visits from the FM would be supervised.Record review of Resident #5's Progress notes, on 3/25/26 at 1:08 p.m. by the SW, revealed Resident (#5) reported inappropriate behaviors in regard to (the FM) to the Psychologist. The Psychologist reached out to SW and SW met with resident to clarify concerns. APS was notified and the PD was called.Resident stated that she did not want charges pressed against (the FM) but wanted supervised visitations when he came. SW notified DON, Admin, and charge nurse. SW and DON will meet with partner (the FM) to discuss new visitation parameters.Record Review of the facility's Investigation, undated revealed the Admin was notified by the SW the allegations of inappropriate behavior by Resident #5's FM. The Admin had the police and APS contacted. The Admin interviewed Resident #5, and she stated he did not want to be supervised with the FM. The Admin and Resident #5 agreed that the FM would have supervised visitation, Monday - Friday from 9 a.m. - 5 p.m. when management was in the building.Record Review of TULIP showed no incident report regarding the incident was reported.Interview on 4/9/26 at 11:08 a.m., the RN stated Resident #5 had to have visits with the FM in the common area and they had to be supervised. The RN stated Resident #5 told the Psychologist the FM had touched her inappropriately. The RN stated she had not seen anything herself.Interview on 4/9/26 at 11:46 a.m., the SW stated about two weeks ago, around 3/23/26, Resident #5 reported to the Psychologist that the FM was touching her inappropriately. The SW stated she talked to Resident #5, and she did not want anything reported to the police. She stated Resident #5 stated the inappropriate/intimate touching had taken place since she admitted to the facility, but she did not want to tell anyone. The SW stated the FM was only able to visit Monday - Friday between 9 a.m. and 5 p.m. when leadership was in the facility. The SW stated Resident #5 told the police she did not want to press charges but wanted him to be able to visit with supervision. She stated the police told the FM if there were any more incidents, a no trespass order would be put in place.Interview on 4/9/26 at 12:42 p.m., the Psychologist stated Resident #5 had told him the FM was touching her inappropriately. He stated he was not sure of the exact date at that time but stated he the SW at the facility, the police and APS know the same day. The Psychologist stated to his knowledge, the facility was having supervised visits between Resident #5 and the FM.Interview on 4/9/26 at 1:59 p.m., the ADON stated she heard there were allegations Resident #5's FM was touching her inappropriately. The ADON stated the allegations should have been called into the state by the Admin and anytime there were allegations of abuse or neglect.Interview on 4/9/26 at 2:22 p.m., the DON stated she received a call from the SW regarding the allegations of sexual abuse Resident #5 told to the Psychologist. The facility made sure Resident #5 was safe. She stated the police and APS were called. She stated the FM was on supervised visitation as Resident #5 still wanted him to visit. The DON stated Resident #5 never reported anything to her. The DON stated the Admin was responsible for reporting allegations of abuse and neglect to the state and this should have been reported.Interview on 4/9/26 at 2:45 p.m., the Admin stated the Psychologist reported to her that Resident #5 told him the FM was touching her inappropriately. She stated the police and APS were called. The Admin stated she talked to Resident #5, and she told her she did not want to press charges, did not want the police called and still wanted the FM to visit. The Admin stated the facility put supervised visitation between Resident #5 and the FM. She stated the visitation could only occur Monday - Friday from 9 a.m. - 5 p.m. in the common area when management was in the building. The Admin stated Resident #5 told her she felt safe and did not want to be supervised. She stated calling the state regarding allegations of abuse or neglect was her job. The Admin stated she did not report this to the state because Resident #5 said the FM always did this and he thought it was funny. She stated Resident #5 did not tell her it was without consent and that was why she did not report it to the state as she did not think it was abuse.Interview on 4/9/26 at 3:48 p.m., the Admin stated she did do an investigation, but she did not think it was abuse so she did not report it. Record review of the facility's Abuse Prevention Program, dated 2001, revealed under Policy Interpretation and Implementation 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .6. Investigate and report any allegations of abuse within timeframes as required by federal requirements.Policy StatementAll reports of resident abuse.shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting1. All alleged violations involving abuse.will be reported by the facility Administrator, or his/her designee, to the following persons or agencies; a. the State licensing/certification agency responsible for surveying/licensing the facility.2. An alleged violation of abuse.will be reported immediately, but not later than:a. Two (2) hours if the alleged violation involves abuse.b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.4. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of four staff members (MA A, MA B and CNA C) and six of six residents (Resident #71, #89, #4, #13, #88 and #76) reviewed for infection control procedures. 1. The facility failed to ensure MA A performed hand hygiene after direct contact with Resident #71, while serving meals in the dining room. 2. The facility failed to ensure MA A disinfected the blood pressure cuff in between vital sign checks for Resident #89 and Resident #4. 3. The facility failed to ensure MA B disinfected the blood pressure cuff in between vital sign checks for Resident #13 and Resident #88. 4. The facility failed to ensure CNA C changed their soiled gloves and performed hand hygiene during incontinent care on Residents #76. These failures could place residents at risk for healthcare associated cross contamination and infections. Findings include: Record review of Resident #71's admission MDS assessment, dated 01/16/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnsoes which included: heart failure (weak heart muscle), malnutrition (poor weight and nutrition), dementia (forgetfulness), and hypertension (increased blood pressure). Resident #71 had severe cognitive impairment and required assistance of one staff for activities of daily living.Observation on 03/17/2026 beginning at 12:18 p.m., revealed MA A entered the main dining room, and did not use hand sanitizer. MA A took a tray from the kitchen, used no hand sanitizer and served a lunch tray to Resident #71, touched the table in the dining room, touched the hand and shoulder of Resident #71 and prepared the meal tray for the resident to eat her lunch. MA A did not have gloves on. MA A was observed not to wash his hands or use hand sanitizer, available in the dining room. In an interview on 03/17/2026 at 1:00 p.m., CNA A stated she did not complete hand hygiene after having direct contact with residents. CNA A stated she was supposed to use the hand sanitizer in between serving each tray. CNA A said she was educated on completing hand hygiene. CNA A stated she did not sanitize her hands, because she was trying to get the lunch trays served, so the food would not be cold. Record review of Resident #89's Medicare-A MDS assessment, dated 03/23/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included: fracture of the pelvis (broken pelvis), hypertension (high blood pressure), and chronic pain (hurting all the time). Resident #71 was moderately cognitively impaired and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #89's physician orders, dated 03/18/26, reflected Cozaar (High blood pressure medication) tablet; 50 mg, give 1 tablet by mouth one time a day for elevated blood pressure. Hold for systolic blood pressure less than 110. Observation on 03/18/2026 at 9:22 a.m. revealed MA A performed morning medication pass, during which time she checked the blood pressure on Resident #89. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #89. Record review of Resident #4's quarterly MDS Assessment, dated 03/08/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included: End stage renal disease (kidneys are not working), hypertension (increased blood pressure), and diabetes (increased sugar). Resident #4 was alert and oriented and able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #4's physician orders, dated 02/03/26, reflected Candesarten (High blood pressure medication) tablet; 16 mg, give 1 tablet by mouth one time a day on non-dialysis days for elevated blood pressure. Hold for systolic blood pressure less than 110. Observation on 03/18/2026 at 9:38 a.m. revealed MA A performed morning medication pass, during which time she checked the blood pressure on Resident #4. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #4. In an interview on 03/18/2026 at 9:40 a.m., MA A stated she did not think about cleaning the blood pressure cuff between usage, she did not know she needed to. MA A stated she used hand sanitize between each usage when she took the blood pressure. MA A stated if the cuff was on the residents and then not cleaned it could spread germs to others. MA A stated in the past three months she had not had any in-services on infection control and blood pressure cuffs, but in the past she recalled having an in-service concerning cleaning the cuffs, when one of the other DONs was here. Record review of Resident #13's admission MDS Assessment, dated 01/06/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included: Cancer (killing of tissue), hypertension (increased blood pressure), and atrial fibrillation (fast heartbeat). Resident #13 was alert and oriented and able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #13's physician orders, dated 07/25/24, reflected Metoprolol (High blood pressure medication) tablet; 12.5 mg, give 1 tablet by mouth one time a day for elevated blood pressure, and midodrine (for low blood pressure) tablet; give one tablet three times a day. Check blood pressure each morning prior to giving metoprolol for orthostatic hypotension (low blood pressure). Observation on 03/18/2026 at 9:52 a.m. revealed MA B performed morning medication pass, during which time he checked the blood pressure on Resident #13. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #13. Record review of Resident #88's non-Medicare MDS Assessment, dated 03/13/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #88 had diagnoses which included: Hypertension (high blood pressure) and Parkinson's Disease (disease of the muscles). Resident #88 was alert and able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident 88's physician orders, dated 03/14/26, reflected Losartan (High blood pressure medication) tablet; 50 mg, give 1 tablet by mouth one time a day for elevated blood pressure. Hold for systolic blood pressure less than 110. Observation on 03/18/2026 at 9:56 a.m. revealed MA B performed morning medication pass, during which time he checked the blood pressure on Resident #88. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #88. In an interview on 03/18/2026 at 10:50 a.m., MA B stated he did not think about cleaning the blood pressure cuff between usage, he did not know he needed to. MA B stated he used hand sanitize between each usage when he took the blood pressure and he wore gloves. MA B stated if the cuff was on the residents and then not cleaned it could spread germs to others. MA B could not recall if he had any in-service training on cleaning the blood pressure cuff in the past three months. Record review of Resident #76's quarterly MDS Assessment, dated 12/24/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #76 had diagnoses which included: Heart failure (weak heart muscle), malnutrition (low weight), and (fast heartbeat). Resident #76 was alert and oriented and able to make decisions and required one staff for assistance with activities of daily living, which included incontinent care for bladder. Observation of incontinence care on 03/18/2026 at 10:06 a.m. revealed CNA C used hand gel in the hallway and donned a gown and clean gloves. CNA C positioned Resident #76 on her back. CNA C unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarded the wipe. CNA C then wiped Resident #76's abdomen and the folds of her groin inguinal (abdomen) area using disposable wipes. CNA C then proceeded with her soiled gloves and helped Resident #76 turn and held the resident onto her right side. CNA C cleaned the buttocks area, which was soiled from urine, with a disposable wipe. CNA C then removed the soiled brief and discarded it into a trash bag. CNA C continued with care without discarding her soiled gloves. CNA C placed a clean brief under the resident's buttocks. CNA C fastened the clean brief. CNA C covered the resident while still wearing the soiled gloves. CNA C placed the bagged dirty brief in the waste can in the room, then removed her dirty gloves, washed her hands and left the room. In an interview on 03/18/2026 at 10:40 a.m., CNA C stated she was to perform hand hygiene before and after the procedure and between changes of gloves. The glove changes should occur at the beginning and at the end of the incontinent care. She said she did not do it this time because she was nervous. She stated the risk would be spread of infection. CNA C stated in the past three months no one had in-serviced her on infection control concerning incontinent care. An interview with the DON, who was the infection control preventionist, on 03/19/25 at 10:33 a.m., revealed the DON stated all direct care staff must clean equipment, which included blood pressure cuffs after having contact with each resident. The DON stated the staff had available disinfectant wipes that would kill all germs. The DON stated the staff when performing incontinent care should be changing gloves from dirty to clean and washing their hands or using the available hand sanitizer. The DON stated if they do not clean the blood pressure cuffs appropriately and change glovers and clean their hands when they should, they could spread germs to themselves and the residents. Record review of an in-service, dated 2/07/2026, revealed MA A, MA B, and CNA C received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted on 1/10/2026 reflected: when passing trays in the dining room, sanitize after serving every tray. MA A, MA B, and CNA C received this training after state surveyor intervention. Record review of the facility's Policy titled Infection Prevention and Control Policies, revised December 2023, reflected: Subject: Handwashing/Hand Policy: Proper hand hygiene/hand washing technique will be accomplished at all times that handwashing is indicate. Hand Hygiene/Hand washing is the most important component for preventing the spread of infection, Maintaining clean hands is important for patients/residents/visitors/ as well as staff. 1. Hand hygiene/handwashing is done A. before patient /resident contact.After. B. After patient/resident contact.J. Contact with environmental surfaces in the immediate vicinity of patients/residents. Record review of the facility's Policy titled Cleaning and Disinfecting Resident Care items and Equipment, dated December 2023, reflected: Resident care equipment, including reusable items. Will be cleaned an disinfected . 4. Reusable resident care equipment with be decontaminated and/or sterilized between residents . Record review of the facility's Policy titled Perineal/Incontinent Care, dated December 2024, reflected: Purpose: The purposes of this procedure are to provide cleanliness an discomfort to the resident t, to prevent infections and skin irritations, and to observe the resident's skin condition. Steps to procedure 1. Place equipment on bedside. 2. Wash and dry your hands thoroughly. 7. Put on gloves. [steps to perform incontinent care for male/female] . 12. Remove gloves and discard into designated container. Wash and dry hands thoroughly. 13. Replace the bed covers. Make the resident comfortable. 17. Wash and dry hands thoroughly. Record review of the Facility's Policy titled Handwashing/Hand Hygiene, dated December 2023, reflected: the facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedure s to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap and water. b. after contact with a resident. 7. Use hand rub (hand sanitizer) b. before and after direct contact with residents. i. before and after gloves . p. before and after assisting a resident with meals.9. The use of gloves does not replace handwashing/hand hygiene.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure stored canned goods had uncompromised seals and were free from dents.The facility failed to ensure the handwashing sink #2 of #2 garbage receptacle contained only paper towels.These failures could place residents at risk for food-borne illness, cross contamination, and infection.findings included: During an observation of the #1 handwashing sink's garbage receptacle on 03/17/2026 at 11:15 a.m., the following was revealed: #1 of #2 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, which included styrofoam cups, used gloves, and coffee grounds.During an observation of the dry storage room on 03/17/2026 at 11:48 a.m., the following was revealed:1 Lemon pie filling or topping 116 oz (7 lbs. 4 oz) dent on the top seal, delivery date written 12/29/2025, no expiration date.3x Fruit Mix in Extra light syrup 104 oz (6 lbs. 10 oz) dent on the bottom and top seal delivery date written 02/23/2026, no expiration date.2x Mild Cheddar cheese sauce 106 oz (6 lbs. 10 oz) dent on the bottom and top seal delivery date written 03/02/2026, no expiration date.During an interview on 03/17/2026 at 11:55 a.m., the Dietary Manager stated she unloads the truck on Wednesdays, and the cook does it on Saturdays and they are responsible for inspecting cans for dents. She explained the size of the dent did not matter. She said damaged cans were placed on a designated dented-can shelf and returned to the vendor for credit. She further stated the use of dented or damaged cans could result in residents becoming seriously ill. She said that the identified dented cans must have been damaged on the storage rack when they were placed in it. During an interview on 03/17/2026 at 12:19 p.m., the Dietary Aide stated she assisted with unloading the delivery truck and was responsible for inspecting cans for dents. She explained the size of the dent did not matter and that no damaged cans were used. She stated all dented cans were placed on a designated dented-can shelf. She further stated that if residents were served damaged canned food, they could become seriously ill or die. Record review of the facility's Food Deliveries policy, dated October 1, 2018, revealed Procedures:.2(c) All cans must be in good condition and not dented.Record review of the U.S. FDA Food Code 2022, Chapter 3, 3-202.15 Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants.may find their way into the food.During an observation of the #2 handwashing sink garbage receptacle on 02/17/2026 at 12:06 p.m., the following was revealed: #2 of #2 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, including plastic wrap, used gloves, and a plastic cup.During an interview on 03/17/2026 at 12:15 p.m., the Dietary Manager stated she didn't notice there was other trash in the handwashing receptacles and would have the trash removed immediately.Record review of the U.S. FDA Food Code 2022 reflected: .Section 6-301.20 Disposable Towels, Waste Receptacle. Waste Receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 13 residents (Resident #55, and Resident #71) reviewed for rights. The facility failed to ensure the staff in the main dining room served Resident #55, and Resident #71, at the same time the other residents were served the lunch meal. These failures could place residents at risk of feeling like their dignity was being invaded or the facility was not their home. Findings included: Record review of Resident #55's admission MDS assessment, dated 03/06/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #55 had diagnoses which included: Cancer (degeneration of tissue), dementia (forgetfulness), and malnutrition (low in weight and nutrition). Resident #55 had moderate cognitive impairment and required assistance of one staff for activities of daily living, including eating assistance. Record review of Resident #71's admission MDS assessment, dated 01/16/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included: heart failure (weak heart muscle), malnutrition (poor weight and nutrition), dementia (forgetfulness), and hypertension (increased blood pressure). Resident #71 had severe cognitive impairment and required assistance of one staff for activities of daily living. Observation on 03/17/2026 at 12:18 p.m. the lunch service begun in the main dining room. Observation on 03/17/2026 beginning at 12:28 p.m. revealed the other residents at Resident #71's table were served their lunch meal, and the resident was sitting at the table. As the other residents received their meals they began to eat. Resident #71 continued to sit at the table watching the other residents eat. Observation on 03/17/2026 at 12:40 p.m. Resident #71 was served her lunch tray. Observation on 03/17/2026 at 12:30 p.m. revealed other residents at Resident #55's table had begun to receive their lunch meals. The staff served the entire table of residents except Resident #55. Resident #55 continued to sit at the table and watch the other residents eat their meals. One of the residents at Resident #55's table was trying to give her food to Resident #55 so he could have something to eat. Observation on 03/17/2026 at 12:39 p.m. Resident #55 was served his lunch meal. In an interview and observation on 03/17/2026 at 12:29 p.m. it was revealed Resident #71 was very unhappy she had not received her meal yet. Resident #71 stated this happened all the time (being served late after everyone else is already eating) and she had said something about being served late, to the staff, but it continued to happen. A meal tray was served to Resident #71 as the interview occurred. In an interview on 03/17/2026 with Resident #55 at 12:39 p.m. revealed the resident could understand but could only nod yes and no. The resident communicated he received his meal on most days at the same time, but not all the time and the other residents at the table just went on eating. He indicated it was frustrating for him, because when he did not get his food and the other resident at the table was always trying to feed him her food. In an interview on 03/17/2026 with CNA D revealed he served the trays the table all at one time and Resident #55 was given his tray at the same time. When the CNA was informed Resident #55 had not been served until serval minutes later, CNA D stated he had served all the trays at the same time, because that was what he was supposed to do. In an interview on 03/19/2026 at 10:33 a.m. with the DON revealed when servicing meals in the dining room all tables should be served at the same time, even if another resident joined the table later or ordered a specialty item the tray should be brought to that resident when they joined the table. It was the right of the residents to not have to sit at the table and watch someone else eat, when they had nothing to eat themselves. In an interview on 03/19/2026 at 3:30 p.m. the Administrator stated the facility did not have a policy on meal service. Record review of Policy titled Resident Rights. dated revised October 2023, revealed Employees shall treat all residents with kindness, respect, and dignity. a. a dignified existence.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 5%, based on 34 opportunities, which involved 1 of 7 residents (Residents #47) and one of two staff (MA A) observed during medication administration for medication error. 1. MA A failed to administer Resident #47's Miralax Oral powder 17grm (for constipation) with the appropriate amount of fluid. 2. MA A failed to confirm Resident #47's MiraLAX Oral powder 17grm (for constipation) was administered. MA A left the cup of medication with Resident # 47. These failures could place residents at risk for not receiving the therapeutic dosages of their medications as ordered by the physician and a decreased health status. Findings include: Record review of Resident #47'squaterly MDS assessment dated [DATE], revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47had diagnosis which include: Hypertension(high blood pressure), cerebral vascular accident (stroke), and constipation (hard stool). Resident #47 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #47's physician's order, dated 02/23/2026, reflected MiraLAX Oral Powder 17 gm/scoop give one scoop every 24 hours as needed for constipation mix with four to eight ounces of fluid. Observation on 03/18/2026 at 9:40 a.m., revealed MA A administered the following medication to Resident #47: MiraLAX 17 gm. was administered to Resident #47 by MA A with an undetermined amount of fluid. Observation on 03/18/2026 at 9:40 a.m., revealed MA A administered the following medication to Resident #47: MiraLAX 17 gm, leaving the resident with the medication in her room, with no follow-up to assure the resident took the medication. Record review of the plan of care for Resident #47 dated 01/02/2026 reflected no goals related to self-administration of medications. Further review revealed no assessments related to self-administration of medicines for Resident #47. In an interview on 03/18/2026 at 10:15 a.m., MA A stated she knew better. MA A stated the cups she thought offered 4 ounces of fluid, but was not sure, she had never measured the fluid, she just filled the unmarked cup up and gave it to Resident #47 to drink. MA A stated she would have to slow down and be more thorough and stay with the residents while they take their medication. In an interview on 03/19/2026 at 10:33 a.m., the DON revealed the staff should be reading the medication administration record prior to and after giving the medication to be assured they were giving the correct medicines at the right time. The DON stated the medication administration record gave the staff all the information for type of medication, how much to give, and if it was by mouth, topical, or eye drops or nose spray. The MiraLAX was to be given with 4 to 6 ounces of fluid and if the cups were not marked, they should be measuring the amount the cup would hold to make sure the resident was getting the correct amount of fluid. The DON stated the staff should never leave the resident with their medications; part of the medication pass was to assure the resident received the correct medication and assured they were taking it. Record review of the facility's policy and procedure Administering Medications, dated revised April 2019, reflected, Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications are administered in accordance with the prescriber orders. 9. The individual administering the medications must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #71) reviewed for food and nutrition services. The facility failed to provide Resident #71 with her regular ground foods (mechanically altered diet that was prescribed for individuals who have difficulty chewing or swallowing food) as designated on her meal ticket on 03/17/2026. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met.The findings include: Record review of Resident #71's admission MDS assessment, dated 01/16/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included: heart failure (weak heart muscle), malnutrition (poor weight and nutrition), dementia (forgetfulness), and hypertension (increased blood pressure). Resident #71 had severe cognitive impairment and required assistance of one staff for activities of daily living. Record review of Residents #71's physician orders, dated 02/26/2026, reflected a diet for: Regular enhanced diet-Mechanical Soft Texture, Regular consistency. Record Review of Resident's #71's plan of care dated 03/10/2026 reflected a goal . will maintain adequate nutritional status, .interventions. Provide , serve diet as ordered. Observation and interview on 03/19/2026 at 12:28 p.m., revealed Resident #71 was provided with regular consistency meal. The lunch meal consisted of regular texture meatloaf, scalloped potatoes and green beans. Resident #71 stated, to the state surveyor, look at this, it is not mine. Resident #71 stated she could not eat the big piece of meat. When the meal ticket was reviewed it was not the meal consistency that was ordered for the resident and was not her name. The staff arrived at the table and asked Resident #71 what was wrong and why she was not eating. Resident #71 stated it was not her meat and she could not eat it and did not understand why she got this diet served to her. Observation and interview on 03/17/2026 at 12:28 p.m., the ADON reviewed Resident #71's meal ticket, observed the resident lunch and revealed Resident #71 was provided with the wrong food texture. The ADON stated Resident #71 should be on regular ground meat and not regular meat. Resident #71 was provided with the correct meal texture. Interview on 03/18/2026 at 12:47 p.m., Resident #71 stated her getting the wrong meal served to her had never happened before and she was glad she knew what she was supposed to eat. Resident #71 stated being served the wrong meal was confusing at first, then it just made her mad. Interview on 03/18/2026 at 10:33 a.m., the DON stated there was a nurse who should be responsible for verifying meal tickets. She stated when reviewing the meal tickets that ensured the food being plated matched the meal ticket. The DON stated if the resident did not receive the appropriate meal then that could be dangerous for the residents depending on how alert they were. The residents could choke, if the incorrect diet was served. Record review of the facility's Therapeutic Diets policy, revised October 2017, reflected the following: 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will be determined whether the resident is prescribed a therapeutic diet. 5. If a mechanically altered diet is ordered, the provider will specify the texture modifications.

Based on observation, interview, and record review the facility failed to ensure the nurse call system was accessible for residents to call for staff assistance through a communication system which relays the call directly to a staff member of a centralized staff work area for seven of ten residents (Residents #1, #2, #4, #5, #6, #7, and #9) reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Residents #1, #2, #4, #5, #6, #7, and #9's rooms were in a position accessible to the residents on 10/07/25 on the 200, 300, and 400 halls. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: 1. Record review of Resident #1's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and need for assistance with personal care. Record review of Resident #1's Quarterly MDS assessment, dated 8/22/25, reflected a BIMS score of 11 indicating moderate cognitive impairment. For ADL care, this MDS reflected Resident#1 required extensive assistance, and an active diagnosis of need for assistance with personal care. Record review of Resident #1's Comprehensive Care Plan, dated 8/17/25, reflected no plan of care for the resident having the call light within reach. In an observation on 10/07/25 at 8:22 AM, Resident #1's call light was hanging over a chair next to the bed, out of reach of the resident. 2. Record review of Resident #2's Face Sheet, dated 10/07/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and a history of falls. Record review of Resident #2's Quarterly MDS assessment, dated 09/10/25, reflected a BIMS score of 11 indicating moderate cognitive impairment. For ADL care, this MDS reflected the Resident #2 required total assistance. Resident #2's active diagnoses included lack of coordination and difficulty walking. Record review of Resident #2's Comprehensive Care Plan, dated 8/05/25, reflected the resident was a fall risk and an intervention included ensuring the call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/07/25 at 8:22 AM, Resident #2's call light was hanging from the lower left side of the bed frame out of reach of the resident. 3. Record review of Resident #4's Face Sheet, dated 10/07/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and a history of falls. Record review of Resident #4's Quarterly MDS assessment, dated 09/04/25, reflected a BIMS score of 12 indicating moderate cognitive impairment. For ADL care, it reflected the resident required substantial assistance. Resident #4's active diagnoses included lack of coordination and muscle weakness. Record review of Resident #4's Comprehensive Care Plan, dated 4/01/25, reflected the resident was a fall risk and an intervention included ensuring the call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/07/25 at 8:32 AM, Resident #4 was lying in bed and the call light was on the floor, near the foot of the bed, out of reach of the resident. 4. Record review of Resident #5's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and repeated falls. Record review of Resident #5's Quarterly MDS assessment, dated 7/15/25, reflected a BIMS score of 11 indicating moderate cognitive impairment. For ADL care, it reflected the resident required limited assistance. Resident #5's active diagnoses included lack of coordination and repeated falls. Record review of Resident #5's Comprehensive Care Plan, dated 7/11/25, reflected the resident was a fall risk and an intervention included ensuring the call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/07/25 at 8:33 AM, Resident #5 was lying in bed and the call light was on top of a wheelchair, and out of reach of the resident. 5. Record review of Resident #6's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and a history of falls. Record review of Resident #6's Quarterly MDS assessment, dated 9/05/25, reflected a BIMS score of 13 indicating intact cognitive response. For ADL care, it reflected the resident required substantial assistance. Active diagnoses included lack of coordination and muscle weakness. Record review of Resident #6's Comprehensive Care Plan, dated 9/17/25, reflected the resident was a fall risk and an intervention included ensuring the call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/07/25 at 8:33 AM, Resident #6 was in bed and the call light was on the floor, near a waste basket, out of the resident's reach. 6. Record review of Resident #7's Face Sheet, dated 10/07/25, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and a history of falls. Record review of Resident #7's Quarterly MDS assessment, dated 7/13/25, reflected a BIMS score of 11 indicating moderate cognitive impairment. For ADL care, it reflected the resident required moderate assistance. Active diagnoses included lack of coordination and history of falls. Record review of Resident #7's Comprehensive Care Plan, dated 8/27/25, reflected the resident was a fall risk and an intervention included ensuring the call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/07/25 at 8:40 AM, Resident #7 was lying in bed and his call light was on the floor, under the bed, and out of his reach. 7. Record review of Resident #9's Face Sheet, dated 10/07/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and muscle weakness. Record review of Resident #9's Quarterly MDS assessment, dated 9/17/25, reflected a BIMS score of 5 indicating severe cognitive impairment. For ADL care, it reflected the resident required substantial assistance. Active diagnoses included lack of coordination and muscle weakness. Record review of Resident #9's Comprehensive Care Plan, dated 8/17/25, reflected the resident was a fall risk and an intervention included ensuring the call light was within reach of the resident and to encourage the resident to use it. In an observation on 10/07/25 at 8:40 AM, Resident #9 was in bed and the call light was on the floor, behind the head of the bed, and out of the resident's reach. In an interview and observation on 10/07/25 at 8:28 AM, LVN I was shown by the Surveyor the call light location for Resident #1 and #2. She stated the call lights should be in reach of the residents so they could contact staff if they needed help and she placed the call lights near the residents. She stated she and the CNAs normally checked for this during their rounds. In an interview and observation on 10/07/25 at 8:38 AM, RN S was shown by the Surveyor the call light location for Resident #4, #5 and #6. She stated the call lights should be in reach of the residents so they could contact staff if they needed help. She stated sometimes the residents moved the call lights or knocked them off the bed. She stated they had clips for them. She stated she and the CNAs normally checked for this during their rounds, which was usually every two hours. In an interview and observation on 10/07/25 at 8:48 AM, LVN B was shown by the Surveyor the call light location for Resident #7 and #9. She stated the call lights should be in reach of the residents so they could contact staff if they needed help. She stated sometimes the residents moved the call lights or knocked them off the bed. She stated she and the CNAs normally checked for this during their rounds, which was usually every two hours. In an interview on 10/07/25 at 12:33 PM, the interim DON was told about Resident #1, #2, #4, #5, #6, #7, and #9 not having their call lights within their reach. She stated the expectation was for call lights to be answered timely. She stated the call lights needed to be within the reach of the resident. She stated the resident may misplace it, but the nursing staff should check to ensure the call light was in reach of the resident when they made their rounds. She stated she could not predict if something would happen to the resident, so she did not know the risk of not having the call light within reach of the resident, however the expectation was for the residents to have their call light within reach if they need anything. Record review of the facility's policy on Answering Call Lights, dated September 2022, revealed, The purpose of this policy is to assure timely responses to the resident's requests and needs. Ensure the call light is assessable to the resident when in bed.

Based on observation, interview and record review the facility failed to ensure the resident free from physical restraints not required to treat the residents' medical symptoms as was possible for one of three residents (Resident #3) reviewed for restraints. The facility failed to ensure Resident #3 had physician orders for the bolster mattresses on her bed. This failure could place residents at risk of not having an environment free from physical restraints.Findings included: Record review of Resident #3's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included lack of coordination and seizures (uncontrolled movements). Record review of Resident #3's Quarterly MDS assessment, dated 9/01/25, reflected a BIMS score of 9 indicating moderate cognitive impairment. The resident had active diagnoses of muscle weakness and seizures. Record review of Resident #3's Comprehensive Care Plan, dated 10/05/25, reflected a plan of care for risk of falls and seizures. None of the care plans reflected an intervention for the use of a bolster mattress. For ADL care, it reflected the resident required total assistance Record review of Resident #3's physician orders, dated 10/07/25, reflected no physician order for the bolster mattress. In an observation on 10/07/25 at 8:26 AM, Resident #3 was observed with a bolster mattress on her bed. In an interview and observation on 10/07/25 at 8:30 AM, LVN I stated she was not sure if Resident #3 had physician orders for the bolster mattress but would check. LVN I checked and she stated the resident had the bolster mattress care planned but she did not have physician orders. In an interview on 10/07/25 at 8:45 AM, the Interim DON and LVN I stated they were not sure if Resident #3 needed physician orders for the bolster mattress on her bed. The DON stated hospice may have orders for the device. They stated they were not aware of any risk to the resident if she did not have the physician orders but would work on obtaining orders for the bolster mattress. The facility's policy, Physical Restraints Application, dated October 2010, reflected, The purpose of this procedure is to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of six residents (Resident #3, #8, and #10) reviewed for respiratory care. The facility failed to ensure Resident #3 and #8's nebulizer mask was properly stored in a bag when not in use on 10/07/25. The facility failed to ensure Resident #10's CPAP mask was properly stored in a bag when not in use on 10/07/25. These failures could place residents at risk for respiratory infection and not having his respiratory needs met.Findings included: 1. Record review of Resident #3's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included chronic cough and shortness of breath. Record review of Resident #3's Quarterly MDS assessment, dated 9/01/25, reflected her BIMS score of 9 indicating moderate cognitive impairment. The resident had active diagnoses of chronic cough and shortness of breath. Record review of Resident #3's Comprehensive Care Plan, dated 10/05/25, reflected a plan of care for oxygen therapy. Record Review of Resident #3's physician orders, dated 10/07/25, reflected Ipratropium -Albuterol Sulfate Inhalation Solution 0.5-2.5 (3) MG/3 ML 1 Vial orally every 6 hours as needed for SOB. In an observation on 10/07/25 at 8:26 AM, Resident #3 was observed with a nebulizer mask sitting on top of a nightstand unbagged. In an interview and observation on 10/07/25 at 8:30 AM, LVN I was shown by the Surveyor Resident #3's nebulizer mask unbagged. She stated the resident normally used the mask throughout the day and forgot to bag it. She stated it was the nursing staff's responsibility to ensure the mask was bagged to avoid an infection. 2. Record review of Resident #8's Face Sheet, dated 10/07/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included COPD (shortness of breath). Record review of Resident #8's Quarterly MDS assessment, dated 7/13/25, reflected her BIMS score of 13 indicating intact cognition. The resident had active diagnoses of COPD (shortness of breath). Record review of Resident #8's Comprehensive Care Plan, dated 3/14/25, reflected a plan of care for oxygen therapy by way of a nebulizer. Record Review of Resident #8's physician orders, dated 10/07/25, reflected Ipratropium -Albuterol Sulfate Inhalation Solution 0.5-2.5 (3) MG/3 ML 1 Vial orally every 6 hours as needed for SOB. In an observation on 10/07/25 at 8:41 AM, Resident #8 was observed with a nebulizer mask sitting in the drawer of her nightstand, unbagged. 3. Record review of Resident #10's Face Sheet, dated 10/07/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included sleep apnea (sleep disorder). Record review of Resident #10's Quarterly MDS assessment, dated 9/11/25, reflected her BIMS score of 12 indicating moderate cognitive impairment. The resident had an active diagnosis of sleep apnea. Record review of Resident #10's Comprehensive Care Plan, dated 3/14/25, reflected a plan of care for sleep apnea with the use of a CPAP machine. Record Review of Resident #10's physician orders, dated 10/07/25, reflected CPAP to be applied at bedtime on setting 14. In an observation on 10/07/25 at 8:41 AM, Resident #10 was observed with a CPAP mask sitting on top of her nightstand, unbagged. In an interview and observation on 10/07/25 at 8:48 AM, LVN B was shown by the Surveyor the nebulizer mask for Resident #8 and the CPAP mask for resident #10 unbagged. She stated the residents used the masks throughout the day and she had to remind them to place them into a bag when they were done. She stated it was overall the nurse's responsibility to ensure the masks were bagged to avoid infections. In an interview on 10/07/25 at 12:33 PM, the interim DON was told by the Surveyor about Resident #3, #8, and #10 not having their mask bagged when not in use. She stated she expected the resident's mask to be air dried and then bagged after breathing treatments. When asked the risk of not bagging the mask, the DON just stared at me and initially did not say anything. She then repeated her expectations and stated sometimes the residents removed the mask from the bag. Review of the facility's policy Oxygen Use (Respiratory Therapy) Prevention of Infection, dated November 2011, reflected, The purpose of this procedure is to guide prevention of infection associated with the respiratory tasks and equipment, including ventilators, among residents and staff.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of five residents reviewed supervision. The facility failed to ensure Resident #1 (who was ordered a pureed diet and was a known aspiration risk) was provided with adequate supervision during the lunch meal on 04/01/25. Resident #1 was sat at a table with another resident who offered her a cookie, which Resident #1 accepted and ate, which led to her coughing several times before finishing the cookie. Five staff were in the dining room but no one was supervising the resident at the time to ensure safety or noticed she was eating outside her modified diet texture. An IJ was identified on 04/01/25 at 4:55 PM. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 04/02/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The failures placed residents at risk of harm, including aspiration, choking and possible death. Findings included: Record review of Resident #1's Face Sheet dated 04/01/25 revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included pneumonia (an infection in the lungs caused by bacteria, viruses or fungi), functional dyspepsia (a chronic condition characterized by persistent discomfort or pain in the upper abdomen, without an underlying organic cause), aphasia (a language disorder that affects a person's ability to communicate), cerebral palsy (a neurological condition that affects movement, posture, and muscle control), severe intellectual disabilities. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 01, which indicated severe cognitive impairment. Resident #1 had no symptoms of psychosis, verbal/physical behaviors or rejection of care. She required partial/moderate assistance of staff with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed). Resident #1 was on a mechanically altered diet and received speech therapy. Record review of Resident #1's care plan initiated 08/30/24 reflected she had the potential for a nutritional problem related to a pureed texture. The care plan also reflected under the focus area that on 03/30/24 she was noncompliant with her pureed diet and would grab sandwiches from the snack cart. On 05/29/24, the care plan reflected she continued to grab sandwiches off the snack cart and would not let staff take it. Interventions included to provide and serve diet as ordered, monitor intake and record every meal. Resident #1 also had a care planned focus area which indicated she had an ADL self-care deficit related to dementia. Interventions reflected, Resident requires assistance with eating. Record review of Resident #1's CNA Kardex (the facility's CNA care plan-not dated) in the e-chart reflected Resident #1 required assistance with eating. Record review of a physician's order for Resident #1 dated 09/20/24 reflected a regular/enhanced diet with pureed texture. An interview with Resident #1 was attempted on 04/01/25 at 12:10 PM and revealed she was not interviewable. When asked questions, she just smiled and laughed. Record review of Resident #2's Face Sheet (dated 04/11/25) reflected she was an [AGE] year old female who admitted to the facility on [DATE] with active diagnoses of dementia (a syndrome that can be caused by a number of diseases which over time destroy nerve cells and damage the brain), Parkinsonism (a clinical syndrome characterized by movement disorders similar to those seen in Parkinson's disease) and schizoaffective disorder-bipolar type (a mental health condition characterized by symptoms of both schizophrenia and bipolar disorder, specifically involving periods of mania or hypomania alongside depressive episodes, along with psychotic symptoms like hallucinations and delusions). Record review of Resident #2's April 2025 MAR reflected she was ordered regular enhanced diet with regular texture (start date 09/13/24). Record review of Resident #2's care plan dated 08/26/24 reflected, Focus: The resident has impaired cognitive function impaired thought processes related to dementia .Intervention: Cue, re-orient and supervise as needed. An observation on 04/01/25 at 12:28 PM revealed the LVN A was at the lunch service and was checking and verifying the meal tickets on the trays coming out of the kitchen. Resident #1's meal ticket was observed to be correct with a pureed textured, however, the kitchen staff failed to place a pureed bowl of cookie on her tray, which was listed as the dessert of the day. Resident #1's tray was checked by LVN A and taken to the resident. Resident #1 was sitting at a table with Resident #2. No staff were observed to sit with Resident #1 or assist her to eat. She was able to feed herself using utensils and was able to drink from a cup independently. She was not observed to cough or struggle with eating and appeared to have a strong appetite. At the same time, the resident sitting at the table with her (Resident #2) did not like her meal and wanted a baked potato. The facility staff removed Resident #2's tray but left the sugar cookie and brought her a baked potato which she did not like either and picked at it, eating only a few bites. During this time, Resident #2 was observed to offer bites of food on her spoon to various staff that walked by her table. Some staff were observed to encourage Resident #2 to eat it herself, but she continued to try and give it away. At one point, Resident #2 was eating her cookie and then stopped and held it out towards Resident #1. Resident #1 immediately took the cookie and at a bite and started coughing. When that occurred, there were three staff who had been at a table next to her (assisted feeding table) who did not notice she had taken Resident #2's cookie and was eating it and coughing. Resident #1 then took several drinks of her juice and cleared the impediment. Then she continued eating the cookie. At that moment, SDC D walked over to the table to check on the other resident because she was not eating (Resident #2) and was talking to her. While SDC D was at the table, she was observed to glance at Resident #1, who still had her hand up to her mouth with the cookie but did not intervene to remove it. LVN A was not present due to going back and forth into the kitchen to assist resident food requests. Resident #1 finished eating the cookie and her meal. She did not have any other coughing episodes during the meal. An interview with SDC D on 04/01/25 at 12:30 PM revealed her job in the dining room was to collect tickets, monitor the residents' intake and write it on the tickets. She said she did not notice Resident #1 was eating Resident #2's cookie and had she realized it, she would have politely removed it and gotten her a pureed cookie. An interview with LVN A on 04/01/25 at 12:31 PM revealed his job was to check meal tickets at the time of the meal being serves and all the staff in the dining room were supposed to watch and monitor/supervise the residents. He stated Resident #1 was not supposed to have anything other than pureed because she could choke and aspirate if she did. LVN A did not know why her pureed cookie was not provided to her on her tray and brought it to her which she was observed to eat 100%. LVN A stated Resident #1 had never aspirated before. Review of the following progress notes related to Resident #1's previous aspiration episode reflected: -A nursing progress note dated 01/9/25 the nurse practitioner was made aware of Resident #1 continuously coughing after lunch, her chest sounds were wet and congested. A stat chest x-ray was ordered and showed Resident #1 had left lung opacities (a white spot on the lung with uncertain significance) which could be due to atelectasis (the collapse of a lung) or pneumonia. Resident #1 was placed on antibiotic, nebulizer treatments, probiotics and cough/congestion medication for the next two weeks. -An infectious disease physician consultation note dated 01/12/25 reflected Resident #1 had a history of oropharyngeal dysphagia (a medical condition characterized by difficulty in swallowing due to issues in the oropharynx, which is the part of the throat located behind the mouth) and recent pneumonia as her recent chest x-ray showed opacities to the left lower base. The physician noted Resident #1 had a history of oropharyngeal dysphagia, history of cerebral palsy, a severe intellectual disability and cognitive and communication deficit. An interview with the DON on 04/01/25 at 12:40 PM she was notified about the incident with Resident #1 not being supervised during lunch. The DON stated there was no set number of staff that needed to be physically present in the facility's dining room, it just depended on how many residents were eating in dining room and needed assistance versus in their rooms. For the lunch meal service on 04/01/25, she stated LVN A and the new ADON were assigned to the dining room to supervise and check meal tickets, but it was the responsibility of all staff present to observe residents to ensure they were eating the correct diet texture/consistency. The DON stated she had a plan to implement a seating chart where residents who needed to be assisted would be placed at certain tables so it would be easier for PRN staff and newer staff to know those residents needed additional assistance and supervision. However, the DON stated she had not implemented that seating system yet. An interview with the SLP on 04/01/25 at 1:25 PM revealed both Resident #1 and Resident #2 were not supposed to be seated together as they were both cognitively impaired. The SLP stated Resident #1's diet texture was pureed and she had tried mechanical soft in past evals, but the resident would cough, so the SLP did not want to upgrade her diet as a result. She stated Resident #1 was in a wheelchair and could self-propel and wanted to eat anything that was out for residents, but due to her cognition, the staff had to take food away from her when she grabbed it from the snack cart or nurse station. The SLP stated, I educated staff about her pureed diet and how they are supposed to divert her or take her away, but that is her behavior unless she is a one on one. The SLP stated Resident #1's swallowing ability was not consistent, but because she had aspiration pneumonia before, a dry sugar cookie could cause her to have that happen again. She stated if Resident #1 ate a non-pureed food, such as the cookie, it could go down into her lungs if she could not clear if by coughing. Once it went down into her lungs, it could cause an infection such as pneumonia. The SLP stated one cookie would be enough to cause Resident #1 to aspirate. If it occurred, the SLP stated the resident may start turning blue and be struggling to breathe. She stated, But she should be fine now if she coughed and cleared it (the cookie). If someone gets into that situation, we usually call for the nurse or we can do the Heimlich manually. The SLP stated Resident #1 was currently on speech services to maintain her current functioning level. She stated, There is nothing to be improved because we tried everything, so when we see her, we try trials and cueing. The SLP stated Resident #1 did not have a waiver for pleasure feeds outside a pureed texture. She stated when that type of waiver was used, the responsible party would have to sign and acknowledge they understood the risks it posed to the resident. Once that was signed, the SLP stated the resident could then have whatever they wanted and in whatever consistency they liked. She stated Resident #1 did not have such a waiver. Record review of Resident #1's Speech Therapy Progress Report dated 02/20/25 through 03/18/25 reflected diagnoses of dementia and dysphagia. The goals Resident #1 was working on included, 1) Pt will demonstrate safe and functional swallow on LRD [least restrictive diet] utilizing safe swallow strategies and compensatory strategies maintaining safety without any overt s/s of aspirations. An interview with the ADM on 04/01/25 at 2:50 PM revealed Resident #1 was known to take food that she should not be eating and that the family had been notified of what happened earlier (04/01/25 at lunch) and they were going to be asked if they want to have a diet waiver signed since this is something she will continue doing. The ADM said she asked the SLP why a waiver was not tried prior, but the SLP had no answer for her. The ADM stated they were going to try to have residents sitting at tables based on their diet texture/supervision needs, so they could be supervised easier. An interview with CNA B on 04/01/25 at 3:05 PM revealed Resident #1 should not have been seated at a table with any resident that had a regular tray. CNA B stated, She [Resident #1] has a condition, maybe autism, that makes her always reach out to grab things. CNA B stated she asked the three staff who were at the assisted feeding table why Resident #1 was not sat with them. Their response was that Resident #1 was not a resident who needed to be fed and it was the therapy team who brought Resident #1 into the dining room late for lunch and placed her at the table with Resident #2. CNA B stated, Even though they don't have to feed her, she is supposed to be assisted and that is the table it happens at. If her care plan is saying she needs to be watched, then she needs to be at a table with a CNA. CNA B stated if Resident #1 did not get a bowl of pureed cookie on her lunch tray for herself, that was probably why she was eager to eat the one that Resident #2 gave her, because she likes the taste of sweets. CNA B stated she used to work as the staff development coordinator before she went PRN so she knew that SDC D's job was to ensure staff were trained and during the meal timesmealtimes. The SDC was responsible for looking at meal tickets, ensuring the residents were eating the correct meals, provide supervision and observation. CNA B stated on 04/01/25 she was assigned to work the halls for lunch even though she was assigned as Resident #1's CNA that morning shift, so she was not in the dining room. CNA B stated Resident #1 should have been taken to the table of residents who needed to be fed/assisted. CNA B stated she was told by various staff that there were too many staff working in the dining room on 04/01/25 during lunch due to HHSC investigator's observation of lunch and it was chaotic and stressful because of the amount of staff in there, which was not the norm. CNA B stated maybe if the facility would not have tried to put that many staff in the dining room who were not normally there, maybe the incident with Resident #1 would not have happened. She stated the facility should have let routine staff who were normally assigned in the dining room for lunch do their job they way they normally did, and possibly the incident would not have happened. A confidential interview on 04/01/25 at 7:30 PM revealed there had been numerous concerns voiced to the facility staff about Resident #1 being on a pureed diet, but still taking snacks of the snack cart or sandwiches that were kept at the nurse station that she could not eat safely. The individual stated they had observed Resident #1 take food that was not pureed, such as an apple, bite into it and then spit it out. Resident #1 would also open cracker packages from the snack cart as well and staff had to be vigilant to intervene before she could eat it. The individual stated the nurses were aware and tried to redirect, but they were not being provided any pureed snacks to give Resident #1 as an alternative. The individual stated they had tried to communicate the concern to staff because Resident #1 was known to be noncompliant with the diet due to her cognition and limited understanding of the safety risks. The individual stated a waiver had previously been discussed with the facility but they did not have one, even though Resident #1 was clearly eating things she could not have and she was aspirating and could not be watched her all the time. The individual felt Resident #1's life had been put in danger as a result of the facility staff not supervising her more closely with her food intake. An interview with the C-RN on 04/01/25 at 6:09 PM revealed Resident #1's family had been contacted about the incident and they stated going forward, they did not want to limit what she ate because she was in her 90s. As a result they agreed to sign a diet waiver. Review of the facility's policy titled, Therapeutic Diets, revised October 2017 reflected, Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences . 4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example .Altered consistency diet. The facility ADM was asked for a policy on Accidents/Hazard on 04/02/25 at 3:05 PM but did not have one specific to that topic. An Immediate Jeopardy (IJ) situation was identified on 04/01/25 at 4:55 PM. The IJ template was provided to the facility's ADM on 04/01/25 at 4:57 PM. The following plan of removal submitted by the facility was accepted on 04/02/25 at 2:36 PM and reflected: [Facility name] Tuesday April 1, 2025 Res identified was immediately assessed by nursing and doctor and family were notified. New orders were given for a Stat chest x-ray, family requested them to pls let their [Resident #1] have what she wants as she is [AGE] years old. Family aware of risks April 1, 2025 and waiver requested and signed 4/1/25. All res have the potential to be affected by this deficient practice Diets reviewed to ensure accuracy; no other res were identified as taking food off tray. Snacks were removed from accessibility, for all res. Snacks will be available to nutrition area for availability. April 1, 2025. Staff in service on o Monitoring res while in dining room during meal service to ensure ALL res are not sharing food April 1 initiated o Observe res for any coughing, runny nose, any signs of distress while they are eating notify Nurse immediately o Res who offers their food attempting to give it away could be at risk for giving to another res staff are to take the snack who should not have it. o Snacks will be located in the nutrition room and offered to res Q shift o Supervision of res while in dining room to provide adequate supervision if a nurse must notify other personnel prior to exiting DON/ Designee in serviced 4/2/25. o Tables allocated for res who are identified that need/identified at risk assistance and supervision, April 1, 2025. And allocated by IDT team. o Supervision assignments for Dining room, reviewed and re-educated in-service April 2, 2025. o All mechanical diets were reviewed for compliance, completed by DON and Dietary manager 4/1/25. o Diet waivers will be continue to be on 24 hour report, for nursing identification, it was added to special instructions as well added to the tray card staff in served completed 4/2/25. Administrator and DON/ Designee will monitor, compliance and do random checks no less than weekly of dining room and process. Areas noted of concern will be added to QAPI to monthly X6 months. Monitoring: An interview with LVN A on 04/02/25 at 10:25 AM revealed he was the nurse assigned to the dining room for lunch on 04/01/25. He stated having a nurse present for meals was helpful to prevent any incidents with choking or any diet miscommunications. LVN A stated the residents with a pureed diet would have that indicated on their meal ticket coming from the kitchen. LVN A stated on 04/01/25, he remembered that Resident #1 had been in therapy and then they brought her into the dining room and placed her next to Resident #2, but going forward they were going to have assigned seating where staff could watch over her. LVN A stated out of the residents that were on pureed diets, Resident #1 was the only one that had the behavior of taking food off other residents' trays. An interview with SDC D on 04/02/25 at 11:38 AM revealed a resident was ordered a pureed diet but ate a non-pureed food could aspirate. SDC D stated it was important to supervise residents during mealtimes in the dining room to ensure there were no episode of choking. If a resident on a pureed diet was trying to eat another resident's food, she stated they cannot share so she would explain and separate them, especially if they had dementia and could not understand. Record review of a chest x-ray completed for Resident #1 on 04/01/25 at 6:48 PM revealed her lungs were clear and well inflated bilaterally and there was no evidence of acute pulmonary issues. Record review of Resident #1 and Resident #2's care plans reflected they were updated to reflect their increased need for supervision. A monitoring observation of the lunch meal service on 04/02/25 at 12:00 PM revealed the facility had re-arranged the dining room where three tables were lined up in a row for the residents who needed to be fed or assisted. At the table were four residents who were being fed by four staff. At the table also sat Resident #1, with a pureed meal tray. The SLP was nearby observing the Resident #1 as well as the other staff at the table. The resident ate her pureed meal without incident, although she continued to cough a few times while eating, she was able to clear the food from her throat and swallow it. Observation of Resident #1's revised meal ticket on 04/02/25 at 12:05 PM revealed under special notes, ***Assistant Dining***Waiver***Pleasure Feeding*** and it was highlighted in yellow. Her meal ticket continued to reflect a pureed diet at the top. Record review of the facility's diet waiver titled, Acknowledgement for Recommended Treatment Plan for Dietary dated 04/01/25 after the IJ was identified, reflected the resident's RP was declining the recommended treatment for a dysphagia diet of pureed. The DON, ADM, rehab therapist, and doctor all signed the form as well as the RP. Record review of the facility in-services were reviewed on 04/02/25 and reflected the staff were in-serviced on new supervision requirements for residents who need assistance, to be fed, or to be monitored for safety issue. The facility also provided three videos that reflected training on the Heimlich maneuver, signs and symptoms of choking and how to enter resident diet orders into the online e-chart. The facility also in-services staff on the new location of snack carts, protocol for dining room supervision, protocol for notifying the nurse in the dining room during meals, diet waiver protocol and implementation, Resident #1's supervision needs and diet texture and general supervision requirements for residents during meals in the dining room. Monitoring interviews for the Immediate Jeopardy were completed on 04/02/25 with 16 staff from 10:00 AM through 2:00 PM on all shifts to include: ADM, DON, LVN A, CNA B, SDC D, DM E, C-RN, AD, MA F, PT G, RN H, CNA I, LVN J, AIT, CNA K and CNA L. All staff interviewed were able to provide competency of supervision requirements in the dining room, new protocol for assisted feeding/supervision table, signs/symptoms of aspiration and choking and interventions and how to implement waiver request for special diets and know when a resident had one. The staff also demonstrated understanding of the facility's policy of the Heimlich maneuver, restrictions on resident food sharing, and new location of snacks and protocols for snacks for residents with a pureed diet. An interview with the DON on 04/02/25 at 2:50 PM revealed the facility received an IJ due to the staff not seeing Resident #1 eat a non-pureed item in the dining room as well as not supervising her when she was care planned to be observed. The DON stated a resident who was ordered a pureed diet and ate non-pureed food could aspirate, choke and die. The DON stated it was important to supervise residents during mealtimes in the dining room because they depended on the staff, were sometimes forgetful and do not always know what is right for them, So we are their eyes and care for them. The DON stated going forward, she would be monitoring how the dining room was running and ensure the schedule was followed with a nurse present during all meals, and any issues noted would be addressed in the daily management stand up meetings. An interview with the ADM on 04/02/25 at 3:04 PM revealed the facility received an IJ due to staff not observing Resident #1 eat a cookie in the dining room when she was supposed to have a pureed diet. She stated going forward with the new waiver in place, Resident #1 would be allowed to have pleasure feedings of regular texture if she or her family requested it. The ADM stated if a resident had a waiver in the future, it would be notated on the Kardex, which was what the CNAs referred to when referring to resident care needs. The ADM also stated the facility implemented a new process where residents who need to be fed, assisted or supervised while eating would be sat at a long table in the dining room and their meal tickets would be modified and highlighted so the nurse checking trays would know they needed to sit there. The ADM stated it was important to supervise residents during mealtimes in the dining room in order to look for any changes of condition and any signs/symptoms of choking or aspiration, as well as to check textures and liquid consistencies. She stated management was going to QAPI all their findings and do random audit checks in the dining room between herself and the DON/designees through the week. Those checks would include ensuring no residents were sharing food, correct diets/textures were being served and resident with feeding assistance/supervision needs were being placed at the designated table, as well as ensure staff members also know which resident need supervision and assistance when in the dining room. The ADM was informed the Immediate Jeopardy was removed on 04/02/25 at 1:03 PM. The Facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and at 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 review, the facility failed to ensure that residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #1, Resident #2, and Resident #3) of eight residents reviewed for quality of care. 1. The facility failed to ensure Resident #1's nasal cannula nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly. 2. The facility failed to ensure Resident #1's nasal cannula and humidifier were changed weekly. 3. The facility failed to ensure there was an Oxygen in Use sign outside Resident #1's door. 4. The facility failed to ensure Resident #2's nasal cannula was stored properly. 5. The facility failed to ensure Resident #3's mask for BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) was cleaned and stored properly. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #1 Review of Resident #1's Face Sheet, dated 05/22/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. One of the relevant diagnoses included chronic pulmonary embolism (blockage in the artery of the lungs that stops blood flow). Review of Resident #1's Quarterly MDS Assessment, dated 04/22/2024, reflected resident had a severe impairment in cognition with a BIMS score of 04. Review of Resident 1's Comprehensive Care Plan, dated 05/19/2024, reflected resident had oxygen therapy related to shortness of breath and one of the interventions was interventions was oxygen via nasal prongs at 2 liters per minute as needed. Review of Resident 1's Physician Order, dated 05/07/2024, reflected O2 @ 2L as needed only if O2% is lower than 92% every 24 hours as needed. Review of Resident 1's Physician Order, dated 05/22/2024, reflected Oxygen: O2 tubing and water bottle q Sunday night every night shift every Sun weekly. Observation and interview with Resident #1 on 05/22/2024 at 7:38 AM, revealed Resident #1 was on his bed awake. Resident #1 had an oxygen concentrator at bedside. One end of the nasal cannula was attached to the oxygen concentrator while the other end was coiled on the grab bars of the resident's bed. It was also observed that the date of the nasal cannula and the humidifier were dated 05/12/2024. Resident #1 stated he was on oxygen because he had respiratory issues but said he used oxygen at night most of the time. He said he was not aware if the nurses were changing his nasal cannula and the bottle with water. The resident also said he never saw a plastic bag for the nasal cannula. It was also noted that there was no Oxygen in Use outside the resident's door. Observation and interview with the ADON on 05/22/2024 at 10:25 AM, the ADON stated there should be an Oxygen in Use sign outside the door of the residents who were on oxygen therapy to make sure appropriate precautions were followed. She said which ever staff that received the order for oxygen use should had put the sign outside the door. She also acknowledged that the nasal cannula was not bagged. She said it should be bagged when not in use to prevent contamination. The ADON looked for the bag behind the concentrator and inside the drawer of the bedside table and said there was no bag available. The ADON then checked the dates on the tubing of the nasal cannula and on the humidifier. She said both were dated 05/12/2024 and said the date should be 05/19/2024. She said the nasal cannula and the humidifier should be changed weekly to prevent infection and not to compromise the resident's breathing pattern. She said the expectation was for the staff to make sure the nasal cannula was bagged when not in use and to change the nasal cannula and the humidifier weekly and to put a date on it. The ADON disconnected the nasal cannula and the humidifier and said she would change them. She said she would also get an Oxygen in Use sign and place it outside the door. Resident #2 Review of Resident #2's Face Sheet, dated 05/23/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) . Review of Resident #2's Quarterly MDS Assessment, dated 05/04/2024, reflected that Resident #2 was cognitively intact with a BIMS score of 14. The Quarterly MDS also indicated that the resident was on oxygen therapy. Review of Resident #2's Comprehensive Care Plan dated 05/21/2024 reflected resident had oxygen therapy at 2 liter per minute (prn) via nasal cannula for SOB one of the interventions was OXYGEN SETTINGS: O2 via nasal cannula @ 2 LPM (prn). Review of Resident #2's Physician Order dated 10/25/2023 reflected, O2 @ 2L/Min via NC PRN to maintain O2 sats > 90% every shift. Observation and interview with Resident #2 on 05/22/2024 at 9:02 AM, revealed Resident #2 was in her wheelchair. It was noted that she had a nasal cannula attached to an oxygen concentrator. The prongs of the nasal cannula were on the bed. The nasal cannula was not bagged. She stated she only used her oxygen at night. She said the staff never gave her a bag for the nasal cannula. She said she was not aware the nasal cannula should not be left anywhere. She said it makes sense that the nasal cannula be bagged so it will not be dirty. Resident #3 Review of Resident #3's Face Sheet, dated 05/21/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #3's Quarterly MDS Assessment, dated 05/04/2024, reflected that Resident #3 had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS also indicated that the resident was on BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs). Review of Resident #3's Comprehensive Care Plan, dated 03/14/2024, reflected resident had altered respiratory status/difficulty breathing r/t Sleep Apnea and was on BIPAP as ordered ON Q HS AND OFF IN AM. Review of Resident #3's Physician Order dated 10/16/2023 reflected, BIPAP ON Q HS OFF AT AM at bedtime related to SLEEP APNEA. Observation and interview with Resident #3 on 05/22/2024 at 9:10 AM, revealed Resident #3 was awake. It was noted that there was a BiPAP machine on top of the resident's side table with its connecting tube inside the drawer of the side table. A BiPAP mask was connected to the tube, the mask was not bagged. The mask also had three small and hard white substance She stated she used her BiPAP at night but sometimes she would refuse to wear it because it was so noisy. She said the staff would put it on and take it off. She said she was not aware if the staff would put it on a bag after taking it off. Observation and interview with RN A on 05/22/2024 at 10:17 AM, RN A stated the resident used a BiPAP at night. RN A opened the drawer and acknowledged the BiPAP mask was not bagged. She also saw the plague on the BiPAP mask of the resident. She stated it should be bagged to prevent contamination and potential infection. She said she would clean the mask and then put it in a plastic bag. She said she would check if there was a new mask and would replace the BiPAP mask. In an interview with the Administrator on 05/022/24 at 10:55 AM, the Administrator stated the humidifier and the nasal cannula should be changed every week as per order. She added the mask for the BiPAP should be bagged as well. The Administrator said not bagging the nasal cannula and the BiPAP mask could lead to contamination and infection. She said the nasal cannula and the humidifier were changed weekly to prevent the growth of microorganism that could compromise the lungs of the residents. She said there should be an Oxygen in Use sign outside the room of the residents using oxygen to prevent any incident of fire. She said the expectation was for the staff to change the humidifier and the nasal cannula weekly and to bag the nasal cannula and the BiPAP mask. She concluded that they would do an in-service about respiratory care to remind them to change the humidifier and the nasal cannula weekly and to put the nasal cannula and the BiPAP mask in a bag when not in use. In an interview with the DON on 05/22/24 at 11:40 AM, the DON stated the humidifier and the nasal cannula should be changed weekly because the moisture in the humidifier and the nasal cannula were susceptible for mold growth. She said the nasal cannula and the mask should be bagged when not in use to prevent contact with dirty surfaces. She added the mask should be cleaned before putting it inside the plastic bag. She also said there should be sign outside the door for oxygen use as a precautionary measure. She said the sign was to remind the staff and the visitors that oxygen was being used in the building and any minimal spark could cause fire and explosion. The DON said all the staff were equally responsible in checking if the humidifier and the nasal cannula were changed weekly and if the nasal cannula and the mask were bagged when not in use. She said the expectation was for the staff to bag the BiPAP mask and the nasal cannula and to change the nasal cannula and the humidifier weekly. She also said another expectation would be a sign would be placed outside the door for oxygen use. She said they would do an in-service about respiratory care with the nurses and the CNAs. In an interview with LVN B on 05/22/2024 at 2:20 PM, LVN B said she put on Resident #3's BiPAP mask at night if the resident allowed her. She said she would usually get the BiPAP mask from the drawer of the side table. She said the mask was not bagged in the drawer. She said it should be cleaned and bagged after every use to prevent any respiratory infection. Record review of facility's policy, Oxygen Administration 2001 MED-PASS, Inc. rev. October 2010 revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure . 2. Place an Oxygen in Use sign in a designated place outside resident room. Record review of facility's policy, Departmental (Respiratory Therapy) - Prevention of Infection 2001 MED-PASS, Inc. rev. November 2011 revealed Purpose: The purpose of this procedure is to guide prevention of infection . Steps in the Procedure . 3. [NAME] bottle with date . 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed . 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use. Record review of facility's policy, CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open)/BiPAP Support 2001 MED-PASS, Inc. rev. March 2015 revealed Purpose: 1. To provide the spontaneously breathing . General Guidelines for Cleaning . 7. Masks . Rinse with warm water . between uses.

Based on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #1 reviewed for Care Plans. The facility failed to ensure Resident #1 Care Plan was reviewed and updated quarterly. This failure could place residents at risk of their needs not being met. Findings included: Record review of Resident #1's electronic face sheet printed 4/16/2024 revealed 86 -year-old male admitted on [DATE] and discharged on [DATE] with diagnosis that included but not limited to dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic kidney disease stage 3(mild to moderate loss of kidney functions), benign prostatic hyperplasia with lower urinary tract symptoms(frequent or urgent need to urinate) Record review of Resident #1's quarterly MDS date 2/21/2024 revealed a BIMS score of 13 which indicated the resident was cognitively intact and Resident #1 required 1 person assist for activities of daily living assistance. Record review of Resident #1's Care Conference meeting notes completed 02/15/2023. There was not a care plan conference completed in 2024. Interview on 04/16/2024 at 1:00PM with Resident #1 revealed he wanted to obtain a copy of his medication list because he felt he was taking too many medications. Resident #1 stated he also wanted to discuss his discharge plan with the facility. He stated he informed the facility last year that he wanted to go to a assisted living and that he needed hearing aids. Resident #1 stated he had not been involved in a care plan meeting since last year to follow up on his concerns. Interview on 04/16/2024 at 3:17PM with the Social Worker revealed she thought the last care plan meeting was held sometime last year however she was not sure of the exact date. She stated Resident #1 was always involved in his care plan meetings and very involved in his care. She stated due to the facility changing systems in which resident records are uploaded she was not able to access the last care plan conference. The Social worker stated Resident #1 had not had a care plan conference this year and she would be scheduling a care plan conference for him soon. Interview on 04/16/2024 at 3:50 PM with the DON revealed she was sure the resident had a care plan meeting this year however the were not able to access the records. The DON stated she remembered talking to the resident about his care this year however whether it was formally documented she was not sure. Interview on 04/16/2024 at 3:50 PM with the Administrator revealed due to the system change over that occurred around April 8th, 2024, they were not able to access previous resident records. She stated if a care plan conference was completed this year they would not have access to it. The Administrator stated they were moving forward with trying to complete care plan this quarter due to not being able to access the ones completed prior to April 8th, 2024. The Administrator did not acknowledge any risk to residents due o not being able to access care plans. Review of the facility policy Care planning- interdisciplinary team revised January 21,2024 revealed in part The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Care Plan Review will be completed and signed by all attending persons using the Multi-Disciplinary Care Plan Conference Form or equivalent.

Based on interviews and record review the facility failed to ensure the resident had the right to participate in the development and implementation of his person-centered plan of care for one (Resident #1) of five resident reviewed for person-centered plans of care. The facility failed to include Resident #1 in his Care Plan Conference. This failure could affect residents and place them at-risk by contributing to inadequate care. The findings included: Record review of Resident #1's electronic face sheet printed 4/16/2024 revealed an 86 -year-old male admitted on [DATE] and discharged on [DATE] with diagnoses that included to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic kidney disease stage 3 (mild to moderate loss of kidney functions), and benign prostatic hyperplasia with lower urinary tract symptoms(frequent or urgent need to urinate). Record review of Resident #1's quarterly MDS date 2/21/2024 revealed a BIMS score of 13 which indicated the resident was cognitively intact. Review of Resident #1's most recent care plan did not discuss Resident #1 being involved in the care plan. Record review of Resident #1's Care Conference meeting notes completed 02/15/2023 revealed the resident was not checked at being in attendance under the meeting attendance section. Interview on 04/16/2024 at 1:00PM with Resident #1 revealed he wanted to obtain a copy of his medication list because he felt he was taking too many medications. Resident #1 stated he also wanted to discuss his discharge plan with the facility. He stated that he informed the facility last year that he wanted to go to an assisted living and that he needed hearing aids. Resident #1 stated he had not been involved in a care plan meeting since last year to follow up on his concerns. Interview on 04/16/2024 at 3:17PM with the Social Worker revealed that she thought the last care plan meeting was held sometime last year however she was not sure of the exact date. She stated Resident #1 was always involved in his care plan meetings and very involved in his care. She stated due to the facility changing systems in which resident records were uploaded, she was not able to access the last care plan conference. The Social worker stated Resident #1 had not had a care plan conference this year and she would be scheduling a care plan conference for him soon. Interview on 04/16/2024 at 3:50 PM with the DON revealed she was sure the resident had a care plan meeting this year however the were not able to access the records. The DON stated she remembered talking to the resident about his care this year however whether it was formally documented she was not sure. Interview on 04/16/2024 at 3:50 PM with the Administrator revealed due to the system change over that occurred around April 8th, 2024, they were not able to access previous resident records. She stated if a care plan conference was completed this year, they would not have access to it. The Administrator stated they were moving forward with trying to complete care plan this quarter due to not being able to access the ones completed prior to April 8th, 2024. The Administrator did not acknowledge any risk to residents due to not being able to access care plans. Review of the facility policy Care planning- interdisciplinary team revised January 21,2024 revealed in part The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Care Plan Review will be completed and signed by all attending persons using the Multi-Disciplinary Care Plan Conference Form or equivalent.

Based on observations, interviews, and record review the facility failed to protect the confidentiality of personal health care information for one (CMA B) of three staff observed for confidentiality of records. The facility failed to ensure CMA B locked and closed the laptop during the medication pass exposing all resident on the hall's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: Observation on 04/16/24 at 12:40PM revealed the computer on Medication Cart 1 was unlocked and unattended on Hall 300. The computer was unattended while CMA B was in a resident room for approximately two minutes. There were residents and a house keeper walking past the unlocked computer which displayed the residents on hall 300's name and medication due. Interview on 04/16/24 at 12:43PM with CMA B revealed she had worked the facility for 4 months. She stated she was aware the computer should have been locked however she went to help a resident that needed assistance in the restroom. She stated normally she would have locked the computer, but she forgot. She stated the risk of not locking the computer would be resident information would be accessible to others. Interview on 04/16/2024 at 3:50PM with the Administrator revealed computer screen on the medication cart were to be locked whenever not in sight. She stated the CMA that left the computer unlocked was pulled from the floor and in-serviced already. The Administrator stated the risk of leaving the computer unlocked would be that resident information could be accessed. Review of the facility policy Resident rights revised October 4,2022 revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include privacy and confidentiality.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #1) of five residents reviewed for quality of care. The facility failed to ensure Resident #1 received an x-ray as ordered following a fall on 05/29/20. An x-ray was ordered on [DATE] of Resident #1's right hip, but the x-ray was not obtained until the resident was transferred to the hospital on [DATE]. At the hospital the resident was diagnosed with [REDACTED]. This failure placed residents at risk of not receiving treatment for [REDACTED]. Findings included: Review of Resident #1's MDS assessment dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's cognition was moderately impaired, and her [DIAGNOSES REDACTED]. The resident required the extensive assistance of one staff for transfers. Review of Resident #1's Current Care Plans dated 02/13/20 and revised on 05/31/20, reflected the resident had a fall due to impaired mobility, weakness, and impaired safety awareness. Facility interventions included X-ray as order to rule out any fracture. Review of Resident #1's Incident Report dated 05/29/20 reflected the resident was found on the floor during rounds. an order for [REDACTED]. Review of Resident #1's Physician order [REDACTED]. Review of the 24-hour report dated 05/29/20 through 05/31/30 reflected Resident #1 had X-rays ordered on [DATE]. No results were noted. Review of Resident #1's Progress Notes dated 05/29/20 through 05/31/20 reflected: 05/29/20 5:00 a.m. Resident #1 was found on the floor during rounds, the physician was notified about the resident fall. The physician ordered X-ray for right hips two views. No other additional notes were documented concerning the follow-up of the x-ray. 05 /31/20 at 11:34 a.m. Resident #1 complaining of back pain, physician notified STAT X-ray ordered for pain in back. X-rays were not able to provide ETA (estimated time of arrival). A new order received to send resident to the ER (emergency room ) for pain evaluation and treatment. Review of Resident #1's hospital records revealed a Radiological report for a CT Scan of the [MEDICATION NAME] and lumbar spine dated 05/31/20. which reflected acute superior T12 end plate fracture An observation on 06/03/20 at 11:05 a.m. revealed Resident #1 was lying in her bed. She said that she recalled falling, but did not recall going to the hospital. The resident said she did not want to get up today. When Resident #1 was asked why she did not want to get up she said it was because she had fallen. An interview with LVN B on 06/03/20 at 12:15 p.m. revealed he was assigned to Resident #1 on 05/28/20 and 05/29/20 for the 10:00 p.m. - 6:00 a.m. shift. LVN B said he was informed by the CNA around 5:00 a.m. that Resident #1 was on the floor. LVN B said he assessed Resident #1 and she appeared to have no injuries. He stated he assisted her back into the bed, called the physician, completed the incident report, and called the responsible party. LVN B said the physician ordered an X-ray of the right hip. LVN B stated he called the X-ray company, completed the paperwork, reported to the oncoming nurse in charge and went home. LVN B said he was not in charge of Resident #1 again. LVN B was asked what the policy for physician orders [REDACTED]. An interview with LVN C on 06/03/20 at 12:43 p.m. revealed on 05/29/20, she was the nurse in charge for Resident #1 for the 6:00 a.m.-2:00 p.m. shift. LVN C said she was aware that Resident #1 had fallen but did not recall any x-rays that had been ordered. LVN C was asked about following up on the fall and physician orders [REDACTED].#1 had x-rays the day before (05/28/20). LVN C said the X-Rays were negative, she did not think about looking for any other orders. LVN C said she followed up on her assessment for pain of Resident #1 due to the fall on 05/28/20. LVN C said the resident did not complain of any pain and she was up walking with her walker. LVN C was asked about the policy for physician orders, she said when you receive an order for [REDACTED]. An interview with RN D on 06/03/20 at 2:20 p.m. revealed she was the charge nurse on the 2:00 p.m.-10:00 p.m. shift on 05/29/20. RN D said she was told that Resident #1 had fallen, but she was not told about any X-rays that had been ordered. RN D said she assessed and followed-up on Resident #1 for a change in condition. RN D stated if she knew there were X-rays ordered she would have called and found out why the X-rays had not been done, but no one told her. RN D was asked if she checked the 24-hour report and she said, no she did not. An interview with LVN E on 06/03/20 at 12:43 p.m. revealed she was the nurse in charge on 05/30/20 for the day shift and 05/31/20 for the day shift. LVN E said that she had assessed and followed-up on Resident #1 after her fall on 05/29/20. LVN E said that she had called and spoken to the X-ray company about the X-rays that had not been completed on 05/30/20 and was told the X-ray company was backed-up. LVN E stated she had not reported this delay to the physician. LVN E said Resident #1 appeared fine and she thought the Administrator knew about the X-rays not being done. LVN E said on 05/31/20 she assessed Resident #1 in the morning and she was fine, offering no complaint, but around 11:00 a.m. Resident #1 started complaining of pain in her low back. LVN E had the RN weekend supervisor assessed the resident. LVN E said the resident was sent to the hospital for further assessment. An interview with LVN F on 06/03/20 at 2:24 p.m. reflected she was the charge nurse for Resident #1 on 05/30/20 from 2:00 p.m. -10:00 p.m. LVN F said she was unaware that Resident #1 had any X-rays ordered. LVN F was asked what the policy for physician orders [REDACTED]. An interview with RN G on 06/03/20 at 3:30 p.m. revealed she was the weekend RN supervisor on 05/30/20 and 05/31/20. RN G said she had assessed Resident #1 on 05/31/20 when LVN E had reported the resident was experiencing pain in her back. RN G said she assessed the resident and called the physician about getting an X-Ray for her back. RN G was told by the X-ray company they were backed-up. When the Administrator had called to check on the other X-rays, RN G said the Administrator made it STAT, but the X-ray company could not give an ETA on when the x-ray would be performed. The Administrator said to call the physician and send Resident #1 to the hospital. RN G said she was aware of the X-rays that had been ordered on [DATE].She stated she had been on the phone for 45 minutes on 05/30/30 trying to follow-up on those x-rays. RN G stated the Administrator had texted her about it, but she had not gotten back with him. An interview with LVN A on 06/03/20 at 11:20 a.m. revealed she was off on 05/29/20 when Resident #1 had fallen, when she returned to work on Monday 06/01/20 it was reported to her that Resident #1 had a Compression Fracture of T-12. When LVN A was asked about the policy for following physician orders, LVN A said if you get an order you were to see that the order was followed. The LVN said if you could not complete the physician order [REDACTED]. LVN A said she had previously had problems with getting X-rays completed at the facility. An interview with the Administrator on 06/04/20 at 11:45 a.m. revealed he had called to check and had sent a text concerning the results of Resident #1's X-rays on Saturday morning, 05/30/20, but the weekend RN supervisor said she had no results and would call and check. The Administrator stated he did not hear anything back. On Sunday morning, 05/31/20, he called to check on the results of the X-rays and was told by the RN supervisor that she had an order for [REDACTED]. The Administrator said he called back and found out about no ETA given, so he told her to call the family and send her to the hospital. The Administrator said he did not understand why they did not follow-up, it was in the 24-hour report. An interview with the primary care Physician on 06/04/20 at 1:00 p.m. revealed he was aware that both sets of X-rays had been ordered for Resident #1. The Physician said once he gave the orders to the nurse, it was up to the facility to get the test completed and to follow-up on the results and let him know. If the facility did not follow-up, the Physician would have no way of knowing if the tests were completed or not. The Physician said he was aware that Resident #1 had a fracture of T-12 and was to see an Orthopedic Surgeon for a follow-up, but the facility had not contacted him to let him know the hip X-rays were not getting done. When the Physician was asked about the length of time that the facility let pass without completing the hip X-ray, he replied he was glad her hip was not broken. An interview with the DON on 06/04/20 at 12:00 p.m. revealed she expected her nurses to follow physician orders. The DON said if the nurse could not complete the order, the nurse should communicate with the physician, Administrator and the DON. When ask concerning time frames for x-rays, the DON said if the x-ray is ordered non-STAT, the x-ray is completed within 24 hours, but if the x-ray is ordered STAT then it has to be completed within 5 hours. Review of the facility's policy for Radiology and other Diagnostic Services, undated, revealed, Radiology and other diagnostic services are available to residents to meet their needs for diagnostic, treatment and prevention. The facility is responsible for the quality and timeliness of the services. Review of the facility's policy for Quality of Care, undated, revealed, The facility provides the necessary care and services to ensure that each resident attains or maintains the highest practicable physician, mental, and psychological well-being in accordance with the resident's comprehensive assessment and plan of care

Based on interviews and record reviews the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for one (Resident #1) of ten residents reviewed for a change in condition. The facility failed to ensure Resident #1 was assessed, monitored and received intervention when a direct care staff identified a bruise on the resident's right leg, and the resident displayed obvious signs of pain and distress. Resident #1 went without interventions for over 24 hours despite continued displays of pain until x-ray results revealed a fracture to her right leg when she was transferred to the hospital on [DATE]. As a result of these failures, Resident #1 experienced significant pain on 11/16/19 and 11/17/19. On 11/16/19 an x-ray taken at 11:15 p.m. identified a fractured right leg, but the results of the x-rays were delayed being read until 11/17/19 at approximately 10:00 a.m. The resident was then sent to the hospital on [DATE] at 12:15 p.m. after the injury was first discovered on 11/16/19 at 5:00 a.m. An Immediate Jeopardy (IJ) existed from 11/16/19 to 11/22/19. The IJ was determined to be past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, the need for hospitalization or death. Findings included: Review of Resident #1's Minimum Data Set (MDS), Quarterly assessment dated [DATE], revealed Resident #1 was an 88- year- old female with her most recent re-admission on 05/12/15. The resident's active [DIAGNOSES REDACTED]., anxiety disorder, depression, [MEDICAL CONDITION], cognitive communication deficit, [MEDICAL CONDITION], restless and agitation, presence of a cardiac pacemaker. Resident #1 was assessed as having severe cognitive impairment, requiring extensive assistance by two staff during transfers. Review of Resident #1's Care Plan, initiated 11/26/18, revealed under the heading of Problem, Resident #1 yells and screams periodically. This affects other residents. She occasionally states 'you are hurting me . when there is not anyone near her. Interventions developed by the facility for this problem included, you are hurting me . might be her way of expressing that she is in pain; charge nurse to assess for pain and administer pain medication as needed and also reposition her in the chair. These interventions were initiated 02/22/19. Review of Provider Investigation Report, revealed a statement taken from CNA A by the DON on 11/18/19. The CNA worked the overnight shift, 10 p.m. to 6 a.m. beginning on 11/15/19. CNA A reported the first time she checked Resident #1's brief, she did it without exposing her leg which was under the cover. The CNA reported the next time she checked the resident at 11/16/19 at 5:00 a.m. she noticed the discoloration on her right leg. She described the bruise as being the size of her fist, red, hot and swollen. She said the resident sat up in a sitting position and grabbed her right leg saying, it hurts, don't hurt me. CNA A reported the resident yelled all of the time, but there was something different in the way she was yelling at this time. The CNA reported to RN B who was the overnight charge nurse. The CNA reported RN B entered the room and bent over to look at the resident's leg. RN B did not say anything, and the CNA left the nurse in the room. The CNA continued to hear the resident screaming as she walked down the hall. Interview with CNA A on 02/04/20 at 1:59 p.m. confirmed she observed the bruise on the right leg of Resident #1 on 11/16/19 at 5:00 a.m., and she did report it to RN B. Interview with RN B on 02/03/20 at 4:18 p.m. revealed she went in to look at Resident #1's bruise and noted the resident's right lower leg was bruised and swollen, however, as she was observing Resident #1's bruise, another resident fell on the same hall. She said she had to go help with the resident who had fallen. She asked CNA A if anyone from the previous shift had reported a bruise on Resident #1's leg, and the CNA told her there was no report from anyone. RN B confirmed she did not document observation of Resident #1's bruise on the 24-hour report, and her intentions were to call the on-call, physician, but she failed to make that call. Review of the Provider Investigation Report revealed RN B's written statement, dated 11/18/19. RN B wrote, at the change of shift, the resident that had fallen earlier, fell again, and unfortunately, I forgot to follow-up with Resident #1's bruising after the other tasks were completed. Interview with LVN [NAME] on 02/02/20, at 11:21 a.m. revealed he came to work the morning of 11/16/19, and RN B was attending to a resident who had fallen. He said he went to help her. He said RN B never reported anything to him regarding Resident #1. LVN [NAME] revealed at approximately 1:15 p.m. CNA C came to him and told him Resident #1 had a bruise on her leg. He said the resident was in the dining room, and he went to her and raised her pant leg and reported that all he saw was an old bruise. He said he had received instructions at approximately 1:30 p.m. on 11/16/19 from the RN Supervisor to check on Resident #1. LVN [NAME] stated he decided to call the nurse that worked Friday, 11/15/19, with Resident #1, but before he could do that, he had a new admission that wanted to speak with him. LVN [NAME] stated he never returned to see Resident #1. The LVN said no one had reported to him that Resident #1 had pain. Interview with CNA C on 02/05/20 at 7:50 a.m. revealed she noticed the bruise on Resident #1's right leg and reported it to LVN [NAME] on 11/16/19 at 7:00 a.m. LVN [NAME] told CNA C that it was an old bruise on the resident's leg. The resident was in such pain when she was moved, the CNA said she left her in bed for breakfast. CNA C revealed while getting Resident #1 up for lunch, she approached LVN [NAME] and reported again the bruising, and the CNA felt the resident was experiencing pain. LVN [NAME] came to the resident in the dining room, lifted the resident's arm, and LVN [NAME] said the resident yelled the same when he touched her arm as when he touched her leg. CNA C reported to the RN Supervisor that Resident #1 had a bruise, and the CNA believed the resident was experiencing pain. CNA C revealed the RN Supervisor looked at the resident's bruise, and she heard her scream. The RN Supervisor told CNA C that Resident #1 sounded the same way every day. Interview with CNA D on 02/05/20 at 8:18 a.m. revealed during lunch on 11/16/19 Resident #1 was hollering. The CNA described the resident's yelling as different than normal. She went to help CNA C adjust the geri-chair so the resident could eat. The resident began to scream. CNA D said she and CNA C reported this to the RN Supervisor who said nothing about the bruise, and she seemed to dismiss it by saying that was the way the resident always sounded. CNA D revealed the resident was saying, my leg hurts, and the resident was also holding her leg. Interview with the RN Supervisor on 02/04/20 at 2:09 p.m. revealed she went into the facility on [DATE] at 8:30 a.m., and one of the CNAs approached her and reported one of the residents was experiencing pain. The RN Supervisor told LVN [NAME] to follow-up with the resident and give the resident some pain medication if the resident needed it. The RN Supervisor revealed during lunch she was feeding Resident #1, and she did not feel like the resident was in pain. The RN Supervisor said she did not see the bruise, and she did not hear the resident scream. The RN Supervisor said she would have followed up with the resident if she had believed it was something serious. The RN Supervisor stated if she had to do this all over again and knew what she knew now, she would do things differently. Review of a statement taken by the DON from the RN Supervisor, undated, concerning the incident with Resident #1, revealed she was making her rounds and CNA C told her Resident #1 was behaving differently. The RN Supervisor told LVN [NAME] to follow-up with the resident. The resident was in the dining room at this time. I moved her leg and it was hanging on the other side of the foot rest. It was her right leg. When I moved it, she acted like she always does; she started cursing and was real protective. Interview with CNA F on 02/01/20 at 2:23 p.m. revealed Resident #1 was in the dining room at the same time as the CNA for the evening meal on 11/16/19. The CNA said the resident was screaming so she went to the resident. The CNA described the resident's scream as different than usual. Resident #1's right leg was hanging off the foot rest, and she replaced the resident's leg on the footrest, and the resident screamed more. CNA F reported to LVN H, and the LVN went to the resident and raised the leg of her pants, and they could see the discoloration on her right leg. Review of a statement signed by LVN H, dated 11/17/19 revealed at approximately 5:00 p.m. on 11/16/19 CNA F and CNA G came to him and reported Resident #1 had a large bruise on her right leg. LVN H said he went to the resident, and when he tried to touch it, Resident #1 screamed. He said the resident always said, don't touch me and leave me alone, however this time it sounded differently, more intense and specific to the right leg. LVN H stated Resident #1 was guarding her right leg and had it hanging down over the foot rest on the geri-chair. He tried to bring the resident's leg back onto the foot rest, and the resident screamed. He called the DON, and she instructed him to order stat x-rays and start an incident report and try to find the cause of the bruise. He stated he assisted the CNAs to return the resident to bed and gave her a pain pill. He said he checked on her several times before he went home, and she appeared comfortable as long as she was not moved. He questioned both CNAs as to the cause of the bruise, and both CNAs reported the bruise was there when they came to work. He said RN B was on shift when they came to take x-rays of the resident's right leg. Interview with LVN H on 02/04/20 at 9:00 a.m. revealed he was not informed by LVN [NAME] who had worked the shift before him, of any concerns regarding Resident #1. LVN H said information should have been shared via the 24- hour report as well as shared verbally. He said LVN [NAME] did not call him, but he actually called LVN E. LVN H said he had already assessed the resident and found her shin bruised and swollen. He called the DON. LVN H stated he called in orders for x-rays, documented on the 24-hour report and when RN B came on the overnight shift, he told her x-rays had been ordered for Resident #1. Review of the incident report, dated 11/16/19 completed at 7:30 p.m. by LVN H revealed Resident #1 was in the dining room when CNA F approached LVN B to ask about the discoloration of the resident's right shin. The resident was assessed and extensive discoloration to her right shin, some swelling to the ankle and facial grimacing was noted. Review of the progress notes, dated 11/16/19, completed by LVN H, revealed Resident #1 was in the dining room for dinner, and CNA F asked the nurse about the discoloration on Resident #1's right shin. They took the resident back to her room and assessed her. The assessment revealed an extensive discoloration to the resident's right shin, some swelling to the ankle and facial grimacing showing pain when the resident's leg was touched. The resident was unable to give a correct description or scale at this time. Tylenol #3 was administered at 6:22 p.m. Responsible party, Administrator, DON were notified and x-rays for her right shin and ankle were ordered. No other progress note was documented prior to this progress note for 11/15/19 or 11/16/19. Review of Resident #1's Order Summary Report, printed 02/02/20, revealed Resident #1 had orders for Tylenol with [MEDICATION NAME] #3 300-30 mg starting 04/02/18. The order instructed to give Resident #1 one tablet by mouth every eight hours as needed for pain. Review of Resident #1's (MONTH) 2019 Medication Administration Record [REDACTED]. LVH H assessed her pain at a level 7 at that time. No other pain medication was administered prior to that date and time. Review of Resident #1's Narcotic Count sheet, Tylenol with [MEDICATION NAME] #3, revealed one tablet was administered on 11/16/19 at 6:22 p.m. The last tablet administered before this date was 10/28/19. Review of the facility's 24-hour report, dated 11/16/19 and documented at 7:10 p.m., notes, revealed Resident #1 was sitting in the dining room for dinner when CNA F approached LVN H and asked about the discoloration to Resident #1's right shin. Resident #1 was taken to her room and assessed. LVN discovered extensive discoloration to her right shin, some swelling to her ankle and facial grimacing when the area was touched. Resident #1 was unable to give a description of pain scale. Tylenol #3, prn, was administered at 6:22. The DON, administrator and family member were notified. X-ray of the resident's shin and ankle were ordered. No other documentation on 11/15/19 or 11/16/19 was charted in the progress notes, incident reports, or 24-hour report relating to Resident #1's bruising or pain. Interview with RN B on 02/03/20 at 4:18 p.m. regarding the events of her overnight shift beginning 11/16/19, revealed she knew Resident #1 was having x-rays as the information was shared with her by the nurse working the previous shift. RN B said she was there when the x-ray tech came to take the x-rays, and she could remember seeing him leave the facility. The RN said she was used to the lab calling, if there were critical x-rays, but they did not call, and she forgot that she could go to her computer and see the results of the x-rays. The RN said she reported to LVN I who was working the next shift, 6:00 a.m. to 2:00 p.m. that x-rays had been taken of Resident #1's leg. Interview with CNA C on 02/05/19 at 7:50 a.m. regarding the events of 11/17/19, revealed Resident #1 was experiencing pain on Sunday, 11/17/19, morning. She said she did report it to LVN I as she was passing medications. Interview with LVN I on 02/03/19 at 4:18 p.m. revealed during shift change on 11/17/19, RN B, who had worked the overnight shift, told LVN I, who worked first shift, Resident #1 had a bruise on her leg and to monitor it. LVN I said she made her rounds at 6:15 a.m. on 11/17/19, but she did not look at the bruise. She was never told x-rays had been completed, and she did not learn about the x-rays that had been taken until the resident's Responsible Party entered the facility and asked her about the results of the x-ray. After she was informed of the x-rays, she viewed about the results of the X-rays, she viewed the results of the x-rays and told the Responsible Party that Resident #1 had a fracture. Interview with the Resident #1's Responsible Party on 02/02/20 at 12:10 p.m. revealed he received a call at approximately 6:00 p.m. on 11/16/19 from the nursing staff reporting Resident #1's change in condition. He asked what happened, and the reporter said they did not know, but they were having x-rays completed. The Responsible Party arrived at the facility 11/17/19 at approximately 9:00 a.m., and he went straight to the dining room area where Resident #1 was usually sitting. The Responsible Party said he did not see the resident, so he returned to her room where he described his observation of the resident as out of her mind. He said he tried to take off her sock and Resident #1 screamed. He said he went to the nurse's station and told her to give the resident some pain medication and asked about the results of the x-ray. He stated the nurse responded she knew nothing of x-rays for Resident #1. The Responsible Party told the nurse she needed to call 911, and the nurse told him she could not call 911; she had to call the transport service. He stated he agreed, but he told her if they did not come quickly, 911 needed to be called. The Responsible Party said the paramedics that arrived from the transport service said they could not believe she was not transported. The Responsible Party stated Resident #1's normal behavior was different from what he witnessed on the morning of 11/17/19. He said normally Resident #1's scream would have been, don't touch me, but on 11/17/19 when he saw her, the resident's eyes looked as if she had been shot and she was gritting her teeth. He said this was not her normal screaming. Observation of a photo provided by the Responsible Party of Resident #1's right leg with a bruise, appearing dark in color. The Responsible Party reported this photo was taken on 11/17/19 prior to the resident's transport to the hospital. Review of the Resident #1's radiology results report dated 11/16/19 at 11:15 p.m. for the examination date and time, and 11/16/19 at 11:43 p.m. for the report date and time revealed the reason for the x-ray was pain in the right lower leg and pain in the right ankle and joints of the right foot. Results of the x-rays revealed an acute right lower leg fracture. Review of Resident #1's (MONTH) 2019 Medication Administration Record, [REDACTED]. LVN I assessed the resident's pain as a level 7 at this time. Review of Resident #1's progress notes, dated 11/17/19 at 12:15 p.m. revealed the ambulance was at the facility and assessing the resident at that time. Resident #1 was sent to the hospital. Review of the Change in Condition Evaluation, completed by the DCO on 11/17/19 at 10:36 a.m. revealed Resident #1's change of condition was indicated as trauma. Her vital signs included blood pressure, 100/56 at 10:55 a.m. and pulse at 10:56 a.m. was 91 bpm. Resident #1 was showing signs of pain and a bruise on her right lower leg described as deep dark purple. Interview with the DCO on 02/05/20 revealed when a resident had a change in condition, the nurses should document on the e-interact which prompts the nurse to take vital signs of the resident, and CNAs should have documented at their kiosk on the Stop and Watch. She said there was no documentation on the Stop and Watch for Resident #1 for 11/15/19-11/17/19. The DCO said it was the charge nurse's responsibility to check on x-ray results regardless of the x-ray lab calls. She said being too busy to check was not a viable excuse for not checking to see if the x-ray results have arrived at the facility. Interview with the DON on 02/02/20 at 5:00 p.m. revealed she knew nothing about Resident #1's condition until LVN H called her at approximately 5:00 p.m. on 11/16/19 and reported Resident #1 had a big bruise on her leg. The DON told LVN H to order x-rays, and if the x-rays could not be done until the next day or the day after, to go ahead and send the resident to the hospital. The DON said she did not follow up with nursing staff because the nurses were supposed to call if there was a critical value. The DON said in RN B's statement, she admitted to seeing the bruise on the morning of 11/16/19, and she felt like RN B should have antennas up because the facility staff was still talking about Resident #1, when she was the first nurse to see it according to statements and interviews. She said RN B should have checked for the x-rays and called to see why she had not received a call from the lab concerning the results. The DON stated LVN [NAME] and RN Supervisor were neglect in their duties, and that is why they were terminated. LVN I who worked the first shift on 11/17/19 reported the results of the x-rays to the DON. Review of the facility's policy, undated, and developed by the DON in an effort to give the level of care expected, the facility was initiating the following: .911 emergencies are .excruciating pain not relieved by pain medication. If a family or the resident requests that the resident be sent to the ER, take the resident's vital signs and pull the latest tabs for the resident. Call the physician and inform the physician of the resident's condition, vital signs, the latest lab, the reason or the family request and follow the physician's orders [REDACTED]. Review of the facility's policy to Prohibit the .Neglect .of Residents, undated, revealed, .each resident has the right to be free from .neglect. Residents will not be subjected to neglect by anyone, including staff, volunteers, families. Review of the facility's policy for Pain Management, undated, revealed, it is the policy for this center to have an effective pain recognition and management that requires an on-going facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain and to addressing any misconceptions that residents, families and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. It is important, therefore, that a resident's reports of pain or non-verbal signs suggesting pain be evaluated. Review of the facility's policy for Radiology and other Diagnostic Services, undated, revealed, Radiology and other diagnostic services are available to residents to meet their needs for diagnostic, treatment and prevention. The facility is responsible for the quality and timeliness of the services. Review of the facility's policy for Change in Condition, undated, revealed, it is the policy of this center to ensure the resident receives necessary care as needed, by observation, assessment, intervention and reevaluation of a change of the resident's physical and/or mental condition. Documentation regarding the change of condition is documented in the resident record as to date, time, all pertinent observations noted, all unusual information obtained from the complete physical and mental assessment done, and an accurate record of all interventions initiated including time of notification of physicians and responsible party. An Immediate Jeopardy (IJ) existed from 11/16/19 to 11/22/19. The IJ was determined to be past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. The following actions were taken by the facility to correct the non-compliance: RN Supervisor was terminated on 11/16/19, and that was her last day of work. LVN [NAME] was terminated on 11/16/19, and that was his last day of work. RN B was terminated 11/18/19, and her last day of work was 11/16/19 In-services on Pain, Abuse/Neglect, Incident Reports, Change of Condition/notification, and Transfers were held on 11/18/19. In-services on Shift Change/Lab and X-rays were held on 11/22/19. The Administrator addressed the X-ray agency failing to call to notify of the critical findings. The x-ray agency reported to the Administrator that following the agency's internal investigation it was determined that the agency did not call the facility to report critical x-rays. Interviews conducted with staff on 02/01/2020 to 02/05/2020 revealed they had received in-services following the incident with Resident #1. The LVNs and RNs during the interviews cited information that had been provided to them during the in-services. The topics were shift change/lab/ x-rays, communication, pain, and abuse and neglect, change of condition and notification and transfers. The staff were knowledgeable in the topics discussed during the trainings.

Based on observation, interview and record review, the facility failed to ensure that one (Resident #1) of ten residents reviewed for pain management received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure Resident #1 was assessed, monitored and received pain medication when direct care staff identified a bruise on the resident's right leg, and the resident displayed obvious signs of pain and distress. Resident #1 went was administered one pain medication for pain in more than a 24-hour period despite continued displays of pain. X-rays revealed REsident #1 had a fracture to her right leg and was transferred to the hospital on [DATE]. As a result of these failures, Resident #1 experienced significant pain on 11/16/19 and 11/17/19. On 11/16/19 an x-ray taken at 11:15 p.m. identified a fractured right leg, but the results of the x-rays were delayed being read until 11/17/19 at approximately 10:00 a.m. The resident was then sent to the hospital on [DATE] at 12:15 p.m. after the injury was first discovered on 11/16/19 at 5:00 a.m. An Immediate Jeopardy (IJ) existed from 11/16/19 to 11/22/19. The IJ was determined to be past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, the need for hospitalization or death. Findings included: Review of Resident #1's Minimum Data Set (MDS), Quarterly assessment dated [DATE], revealed Resident #1 was an 88- year- old female with her most recent re-admission on 05/12/15. The resident's active [DIAGNOSES REDACTED]., anxiety disorder, depression, [MEDICAL CONDITION], cognitive communication deficit, [MEDICAL CONDITION], restless and agitation, presence of a cardiac pacemaker. Resident #1 was assessed as having severe cognitive impairment, requiring extensive assistance by two staff during transfers. Review of Resident #1's Care Plan, initiated 11/26/18, revealed under the heading of Problem, Resident #1 yells and screams periodically. This affects other residents. She occasionally states 'you are hurting me . when there is not anyone near her. Interventions developed by the facility for this problem included, you are hurting me . might be her way of expressing that she is in pain; charge nurse to assess for pain and administer pain medication as needed and also reposition her in the chair. These interventions were initiated 02/22/19. Review of Provider Investigation Report, revealed a statement taken from CNA A by the DON on 11/18/19. The CNA worked the overnight shift, 10 p.m. to 6 a.m. beginning on 11/15/19. CNA A reported the first time she checked Resident #1's brief, she did it without exposing her leg which was under the cover. The CNA reported the next time she checked the resident at 11/16/19 at 5:00 a.m. she noticed the discoloration on her right leg. She described the bruise as being the size of her fist, red, hot and swollen. She said the resident sat up in a sitting position and grabbed her right leg saying, it hurts, don't hurt me. CNA A reported the resident yelled all of the time, but there was something different in the way she was yelling at this time. The CNA reported to RN B who was the overnight charge nurse. The CNA reported RN B entered the room and bent over to look at the resident's leg. RN B did not say anything, and the CNA left the nurse in the room. The CNA continued to hear the resident screaming as she walked down the hall. Interview with CNA A on 02/04/20 at 1:59 p.m. confirmed she observed the bruise on the right leg of Resident #1 on 11/16/19 at 5:00 a.m., and she did report it to RN B. Interview with RN B on 02/03/20 at 4:18 p.m. revealed she went in to look at Resident #1's bruise and noted the resident's right lower leg was bruised and swollen, however, as she was observing Resident #1's bruise, another resident fell on the same hall. She said she had to go help with the resident who had fallen. She asked CNA A if anyone from the previous shift had reported a bruise on Resident #1's leg, and the CNA told her there was no report from anyone. RN B confirmed she did not document observation of Resident #1's bruise on the 24-hour report, and her intentions were to call the on-call, physician, but she failed to make that call. Review of the Provider Investigation Report revealed RN B's written statement, dated 11/18/19. RN B wrote, at the change of shift, the resident that had fallen earlier, fell again, and unfortunately, I forgot to follow-up with Resident #1's bruising after the other tasks were completed. Interview with LVN [NAME] on 02/02/20, at 11:21 a.m. revealed he came to work the morning of 11/16/19, and RN B was attending to a resident who had fallen. He said he went to help her. He said RN B never reported anything to him regarding Resident #1. LVN [NAME] revealed at approximately 1:15 p.m. CNA C came to him and told him Resident #1 had a bruise on her leg. He said the resident was in the dining room, and he went to her and raised her pant leg and reported that all he saw was an old bruise. He said he had received instructions at approximately 1:30 p.m. on 11/16/19 from the RN Supervisor to check on Resident #1. LVN [NAME] stated he decided to call the nurse that worked Friday, 11/15/19, with Resident #1, but before he could do that, he had a new admission that wanted to speak with him. LVN [NAME] stated he never returned to see Resident #1. The LVN said no one had reported to him that Resident #1 had pain. Interview with CNA C on 02/05/20 at 7:50 a.m. revealed she noticed the bruise on Resident #1's right leg and reported it to LVN [NAME] on 11/16/19 at 7:00 a.m. LVN [NAME] told CNA C that it was an old bruise on the resident's leg. The resident was in such pain when she was moved, the CNA said she left her in bed for breakfast. CNA C revealed while getting Resident #1 up for lunch, she approached LVN [NAME] and reported again the bruising, and the CNA felt the resident was experiencing pain. LVN [NAME] came to the resident in the dining room, lifted the resident's arm, and LVN [NAME] said the resident yelled the same when he touched her arm as when he touched her leg. CNA C reported to the RN Supervisor that Resident #1 had a bruise, and the CNA believed the resident was experiencing pain. CNA C revealed the RN Supervisor looked at the resident's bruise, and she heard her scream. The RN Supervisor told CNA C that Resident #1 sounded the same way every day. Interview with CNA D on 02/05/20 at 8:18 a.m. revealed during lunch on 11/16/19 Resident #1 was hollering. The CNA described the resident's yelling as different than normal. She went to help CNA C adjust the geri-chair so the resident could eat. The resident began to scream. CNA D said she and CNA C reported this to the RN Supervisor who said nothing about the bruise, and she seemed to dismiss it by saying that was the way the resident always sounded. CNA D revealed the resident was saying, my leg hurts, and the resident was also holding her leg. Interview with the RN Supervisor on 02/04/20 at 2:09 p.m. revealed she went into the facility on [DATE] at 8:30 a.m., and one of the CNAs approached her and reported one of the residents was experiencing pain. The RN Supervisor told LVN [NAME] to follow-up with the resident and give the resident some pain medication if the resident needed it. The RN Supervisor revealed during lunch she was feeding Resident #1, and she did not feel like the resident was in pain. The RN Supervisor said she did not see the bruise, and she did not hear the resident scream. The RN Supervisor said she would have followed up with the resident if she had believed it was something serious. The RN Supervisor stated if she had to do this all over again and knew what she knew now, she would do things differently. Review of a statement taken by the DON from the RN Supervisor, undated, concerning the incident with Resident #1, revealed she was making her rounds and CNA C told her Resident #1 was behaving differently. The RN Supervisor told LVN [NAME] to follow-up with the resident. The resident was in the dining room at this time. I moved her leg and it was hanging on the other side of the foot rest. It was her right leg. When I moved it, she acted like she always does; she started cursing and was real protective. Interview with CNA F on 02/01/20 at 2:23 p.m. revealed Resident #1 was in the dining room at the same time as the CNA for the evening meal on 11/16/19. The CNA said the resident was screaming so she went to the resident. The CNA described the resident's scream as different than usual. Resident #1's right leg was hanging off the foot rest, and she replaced the resident's leg on the footrest, and the resident screamed more. CNA F reported to LVN H, and the LVN went to the resident and raised the leg of her pants, and they could see the discoloration on her right leg. Review of a statement signed by LVN H, dated 11/17/19 revealed at approximately 5:00 p.m. on 11/16/19 CNA F and CNA G came to him and reported Resident #1 had a large bruise on her right leg. LVN H said he went to the resident, and when he tried to touch it, Resident #1 screamed. He said the resident always said, don't touch me and leave me alone, however this time it sounded differently, more intense and specific to the right leg. LVN H stated Resident #1 was guarding her right leg and had it hanging down over the foot rest on the geri-chair. He tried to bring the resident's leg back onto the foot rest, and the resident screamed. He called the DON, and she instructed him to order stat x-rays and start an incident report and try to find the cause of the bruise. He stated he assisted the CNAs to return the resident to bed and gave her a pain pill. He said he checked on her several times before he went home, and she appeared comfortable as long as she was not moved. He questioned both CNAs as to the cause of the bruise, and both CNAs reported the bruise was there when they came to work. He said RN B was on shift when they came to take x-rays of the resident's right leg. Interview with LVN H on 02/04/20 at 9:00 a.m. revealed he was not informed by LVN [NAME] who had worked the shift before him, of any concerns regarding Resident #1. LVN H said information should have been shared via the 24- hour report as well as shared verbally. He said LVN [NAME] did not call him, but he actually called LVN E. LVN H said he had already assessed the resident and found her shin bruised and swollen. He called the DON. LVN H stated he called in orders for x-rays, documented on the 24-hour report and when RN B came on the overnight shift, he told her x-rays had been ordered for Resident #1. Review of the incident report, dated 11/16/19 completed at 7:30 p.m. by LVN H revealed Resident #1 was in the dining room when CNA F approached LVN B to ask about the discoloration of the resident's right shin. The resident was assessed and extensive discoloration to her right shin, some swelling to the ankle and facial grimacing was noted. Review of the progress notes, dated 11/16/19, completed by LVN H, revealed Resident #1 was in the dining room for dinner, and CNA F asked the nurse about the discoloration on Resident #1's right shin. They took the resident back to her room and assessed her. The assessment revealed an extensive discoloration to the resident's right shin, some swelling to the ankle and facial grimacing showing pain when the resident's leg was touched. The resident was unable to give a correct description or scale at this time. Tylenol #3 was administered at 6:22 p.m. Responsible party, Administrator, DON were notified and x-rays for her right shin and ankle were ordered. No other progress note was documented prior to this progress note for 11/15/19 or 11/16/19. Review of Resident #1's Order Summary Report, printed 02/02/20, revealed Resident #1 had orders for Tylenol with [MEDICATION NAME] #3 300-30 mg starting 04/02/18. The order instructed to give Resident #1 one tablet by mouth every eight hours as needed for pain. Review of Resident #1's (MONTH) 2019 Medication Administration Record [REDACTED]. LVH H assessed her pain at a level 7 at that time. No other pain medication was administered prior to that date and time. Review of Resident #1's Narcotic Count sheet, Tylenol with [MEDICATION NAME] #3, revealed one tablet was administered on 11/16/19 at 6:22 p.m. The last tablet administered before this date was 10/28/19. Review of the facility's 24-hour report, dated 11/16/19 and documented at 7:10 p.m., notes, revealed Resident #1 was sitting in the dining room for dinner when CNA F approached LVN H and asked about the discoloration to Resident #1's right shin. Resident #1 was taken to her room and assessed. LVN discovered extensive discoloration to her right shin, some swelling to her ankle and facial grimacing when the area was touched. Resident #1 was unable to give a description of pain scale. Tylenol #3, prn, was administered at 6:22. The DON, administrator and family member were notified. X-ray of the resident's shin and ankle were ordered. No other documentation on 11/15/19 or 11/16/19 was charted in the progress notes, incident reports, or 24-hour report relating to Resident #1's bruising or pain. Interview with RN B on 02/03/20 at 4:18 p.m. regarding the events of her overnight shift beginning 11/16/19, revealed she knew Resident #1 was having x-rays as the information was shared with her by the nurse working the previous shift. RN B said she was there when the x-ray tech came to take the x-rays, and she could remember seeing him leave the facility. The RN said she was used to the lab calling, if there were critical x-rays, but they did not call, and she forgot that she could go to her computer and see the results of the x-rays. The RN said she reported to LVN I who was working the next shift, 6:00 a.m. to 2:00 p.m. that x-rays had been taken of Resident #1's leg. Interview with CNA C on 02/05/19 at 7:50 a.m. regarding the events of 11/17/19, revealed Resident #1 was experiencing pain on Sunday, 11/17/19, morning. She said she did report it to LVN I as she was passing medications. Interview with LVN I on 02/03/19 at 4:18 p.m. revealed during shift change on 11/17/19, RN B, who had worked the overnight shift, told LVN I, who worked first shift, Resident #1 had a bruise on her leg and to monitor it. LVN I said she made her rounds at 6:15 a.m. on 11/17/19, but she did not look at the bruise. She was never told x-rays had been completed, and she did not learn about the x-rays that had been taken until the resident's Responsible Party entered the facility and asked her about the results of the x-ray. After she was informed of the x-rays, she viewed about the results of the X-rays, she viewed the results of the x-rays and told the Responsible Party that Resident #1 had a fracture. Interview with the Resident #1's Responsible Party on 02/02/20 at 12:10 p.m. revealed he received a call at approximately 6:00 p.m. on 11/16/19 from the nursing staff reporting Resident #1's change in condition. He asked what happened, and the reporter said they did not know, but they were having x-rays completed. The Responsible Party arrived at the facility 11/17/19 at approximately 9:00 a.m., and he went straight to the dining room area where Resident #1 was usually sitting. The Responsible Party said he did not see the resident, so he returned to her room where he described his observation of the resident as out of her mind. He said he tried to take off her sock and Resident #1 screamed. He said he went to the nurse's station and told her to give the resident some pain medication and asked about the results of the x-ray. He stated the nurse responded she knew nothing of x-rays for Resident #1. The Responsible Party told the nurse she needed to call 911, and the nurse told him she could not call 911; she had to call the transport service. He stated he agreed, but he told her if they did not come quickly, 911 needed to be called. The Responsible Party said the paramedics that arrived from the transport service said they could not believe she was not transported. The Responsible Party stated Resident #1's normal behavior was different from what he witnessed on the morning of 11/17/19. He said normally Resident #1's scream would have been, don't touch me, but on 11/17/19 when he saw her, the resident's eyes looked as if she had been shot and she was gritting her teeth. He said this was not her normal screaming. Observation of a photo provided by the Responsible Party of Resident #1's right leg with a bruise, appearing dark in color. The Responsible Party reported this photo was taken on 11/17/19 prior to the resident's transport to the hospital. Review of the Resident #1's radiology results report dated 11/16/19 at 11:15 p.m. for the examination date and time, and 11/16/19 at 11:43 p.m. for the report date and time revealed the reason for the x-ray was pain in the right lower leg and pain in the right ankle and joints of the right foot. Results of the x-rays revealed an acute right lower leg fracture. Review of Resident #1's (MONTH) 2019 Medication Administration Record, [REDACTED]. LVN I assessed the resident's pain as a level 7 at this time. Review of Resident #1's progress notes, dated 11/17/19 at 12:15 p.m. revealed the ambulance was at the facility and assessing the resident at that time. Resident #1 was sent to the hospital. Review of the Change in Condition Evaluation, completed by the DCO on 11/17/19 at 10:36 a.m. revealed Resident #1's change of condition was indicated as trauma. Her vital signs included blood pressure, 100/56 at 10:55 a.m. and pulse at 10:56 a.m. was 91 bpm. Resident #1 was showing signs of pain and a bruise on her right lower leg described as deep dark purple. Interview with the DCO on 02/05/20 revealed when a resident had a change in condition, the nurses should document on the e-interact which prompts the nurse to take vital signs of the resident, and CNAs should have documented at their kiosk on the Stop and Watch. She said there was no documentation on the Stop and Watch for Resident #1 for 11/15/19-11/17/19. The DCO said it was the charge nurse's responsibility to check on x-ray results regardless of the x-ray lab calls. She said being too busy to check was not a viable excuse for not checking to see if the x-ray results have arrived at the facility. Interview with the DON on 02/02/20 at 5:00 p.m. revealed she knew nothing about Resident #1's condition until LVN H called her at approximately 5:00 p.m. on 11/16/19 and reported Resident #1 had a big bruise on her leg. The DON told LVN H to order x-rays, and if the x-rays could not be done until the next day or the day after, to go ahead and send the resident to the hospital. The DON said she did not follow up with nursing staff because the nurses were supposed to call if there was a critical value. The DON said in RN B's statement, she admitted to seeing the bruise on the morning of 11/16/19, and she felt like RN B should have antennas up because the facility staff was still talking about Resident #1, when she was the first nurse to see it according to statements and interviews. She said RN B should have checked for the x-rays and called to see why she had not received a call from the lab concerning the results. The DON stated LVN [NAME] and RN Supervisor were neglect in their duties, and that is why they were terminated. LVN I who worked the first shift on 11/17/19 reported the results of the x-rays to the DON. Review of the facility's policy, undated, and developed by the DON in an effort to give the level of care expected, the facility was initiating the following: .911 emergencies are .excruciating pain not relieved by pain medication. If a family or the resident requests that the resident be sent to the ER, take the resident's vital signs and pull the latest tabs for the resident. Call the physician and inform the physician of the resident's condition, vital signs, the latest lab, the reason or the family request and follow the physician's orders [REDACTED]. Review of the facility's policy to Prohibit the .Neglect .of Residents, undated, revealed, .each resident has the right to be free from .neglect. Residents will not be subjected to neglect by anyone, including staff, volunteers, families. Review of the facility's policy for Pain Management, undated, revealed, it is the policy for this center to have an effective pain recognition and management that requires an on-going facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain and to addressing any misconceptions that residents, families and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. It is important, therefore, that a resident's reports of pain or non-verbal signs suggesting pain be evaluated. Review of the facility's policy for Radiology and other Diagnostic Services, undated, revealed, Radiology and other diagnostic services are available to residents to meet their needs for diagnostic, treatment and prevention. The facility is responsible for the quality and timeliness of the services. Review of the facility's policy for Change in Condition, undated, revealed, it is the policy of this center to ensure the resident receives necessary care as needed, by observation, assessment, intervention and reevaluation of a change of the resident's physical and/or mental condition. Documentation regarding the change of condition is documented in the resident record as to date, time, all pertinent observations noted, all unusual information obtained from the complete physical and mental assessment done, and an accurate record of all interventions initiated including time of notification of physicians and responsible party. An Immediate Jeopardy (IJ) existed from 11/16/19 to 11/22/19. The IJ was determined to be past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. The following actions were taken by the facility to correct the non-compliance: RN Supervisor was terminated on 11/16/19, and that was her last day of work. LVN [NAME] was terminated on 11/16/19, and that was his last day of work. RN B was terminated 11/18/19, and her last day of work was 11/16/19 In-services on Pain, Abuse/Neglect, Incident Reports, Change of Condition/notification, and Transfers were held on 11/18/19. In-services on Shift Change/Lab and X-rays were held on 11/22/19. The Administrator addressed the X-ray agency failing to call to notify of the critical findings. The x-ray agency reported to the Administrator that following the agency's internal investigation it was determined that the agency did not call the facility to report critical x-rays. Interviews conducted with staff on 02/01/2020 to 02/05/2020 revealed they had received in-services following the incident with Resident #1. The LVNs and RNs during the interviews cited information that had been provided to them during the in-services. The topics were shift change/lab/ x-rays, communication, pain, and abuse and neglect, change of condition and notification and transfers. The staff were knowledgeable in the topics discussed during the trainings.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing based on the comprehensive assessment for one (Resident #4) of 10 residents reviewed for pressure ulcers. CNA A and CNA B failed to promptly notify the nurse when Resident #4 was found to have six newly identified Stage 2 pressure ulcers on her buttocks, which resulted in worsening of the wounds to include bleeding from the open areas and development of additional pinpoint-sized open areas. The failure placed the five residents, who had pressure ulcers, at risk for worsening and/or development of pressure ulcers. Findings included: Resident #4's MDS assessment, dated 08/02/17, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was totally dependent upon staff for assistance with bed mobility and required staff assistance with toileting and personal hygiene. The resident was at risk for developing pressure ulcers, had one healed Stage 3 pressure ulcer, and had moisture associated skin damage which was treated with application of ointment/medication. Resident #4's Care Plan, dated 05/05/17, reflected the resident was at risk for pressure ulcers due to mobility, incontinence, and diabetes. Facility interventions included monitoring and examining skin per facility protocol for breakdown and to notify the physician of changes in skin integrity. Resident #4's Physician Orders, dated 08/01/17, reflected to apply skin protectant to the coccyx every shift. An observation on 10/25/17 at 9:20 a.m. revealed CNA A and CNA B providing Resident #4 with incontinence care. During this observation, the resident had six Stage 2 pressure ulcers, which were approximately the size of a nickel. The skin tissue surrounding tissue the ulcers was pink. Four of the pressure ulcers were on the right buttock and two of the pressure ulcers were on the left buttock. Skin protectant was applied to the buttocks after incontinence care. Both CNAs reported they did not know how long the pressure ulcers had been present and would tell the nurse about the pressure ulcers. Resident #4's Nurse Notes for 10/01/17-10/25/17 revealed no documentation reflecting the resident had any newly developed and/or existing pressure ulcers on her buttocks. An interview with Resident #4's assigned nurses, LVN C and LVN D, on 10/25/17 at 2:25 p.m. revealed they were not aware the resident had pressure ulcers. They reported they were not notified about any new pressure ulcers and did not have a treatment ordered to treat them. An interview with the DON on 10/25/17 at 2:30 p.m. revealed the facility procedure for reporting pressure ulcers was the CNA was supposed to report the issue to the nurse when it was found. She reported the facility did not have an assigned wound care nurse, but the facility did have a new Wound Care Physician, who could see the resident on 10/26/17. The DON reported she would assess Resident #4 immediately. An interview with CNA F on 10/25/17 at 2:45 p.m. revealed she was assigned to Resident #4 for the 2:00 p.m. to 10:00 p.m. shift and was not aware of the resident having any pressure ulcers. An interview with LVN E on 10/25/17 at 2:50 p.m. revealed she completed Resident #4's weekly skin assessment on 10/20/17, and the resident did not have any pressure ulcers at that time. An observation of Resident #4 on 10/25/17 at 2:55 p.m. revealed the resident was in bed. The DON, LVN C, and LVN E were present to assess the resident's pressure ulcers. The resident was positioned on her right side and her brief was opened. The resident had a small amount of stool in her brief. The resident had multiple open areas on her coccyx area and buttocks that were bleeding. There were greater than six open areas and the surrounding tissue was very reddened and excoriated. The open areas ranged in size from the size of a pinpoint to the size of a nickel. The DON measured the wound redness and excoriation to be 8.0 cm x 9.0 cm in size and reported the open areas were all Stage 2 pressure ulcers. The area had worsened since it was initially observed at 9:20 a.m. on 10/25/17. An interview with the DON on 10/25/17 at 3:30 p.m. revealed she obtained a physician's orders [REDACTED]. An observation of Resident #4 on 10/26/17 at 9:20 a.m. revealed the resident was in bed. The Wound Care Physician and LVN C were present to assess the resident's pressure ulcers. The resident had a peeling Duoderm in place. The Duoderm was removed and revealed the resident still had multiple open areas on her coccyx area and buttocks. The open areas ranged in size from the size of a pinpoint to the size of a penny. The surrounding tissue was less red than on 10/25/17. The open areas were no longer bleeding. The Wound Care Physician reported the size of the wound redness was still 8.0 cm x 9.0 cm in size. An interview with the DON on 10/27/17 at 9:30 a.m. revealed she spoke to CNA A and CNA B about the new pressure ulcers on Resident #4. She reported the CNAs told her they got very busy and forgot to tell the nurse about the new open areas on the resident. An interview with CNA A on 10/27/17 at 2:20 p.m. revealed she was going to tell the charge nurse about Resident #4's pressure ulcers on 10/25/17, but she could not find the nurse. CNA A stated when she did find the nurse, the surveyor was already talking to the nurse about the pressure ulcers. An attempt was made to contact CNA B via telephone on 10/27/17 at 1:20 p.m. The facility's current Stop and Watch, Early Warning Tool, dated December 2014, reflected the following: If you have identified a change while caring for or observing a resident, circle the change and notify the nurse .Change in skin color or condition . The Resident Census and Conditions of Residents Form CMS-672, signed and dated by LVN G on 10/24/17, reflected five residents had pressure ulcers.

Based on interview and record review, the facility failed to ensure all allegations involving neglect were immediately reported to the Administrator and the State survey and certification agency and failed to have evidence of a thorough investigation for one (Resident #1) of 11 residents reviewed for neglect. 1. LVN A failed to immediately report the bruise of unknown origin to the Administrator, who was the Abuse Coordinator and the DON. 2. The facility failed to immediately report the incident to the State survey and certification agency. 3. The facility failed to have evidence of thorough investigation into Resident #1's [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on 11/20/14. While the IJ was removed on 11/23/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "widespread" due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the other 84 residents in the facility by placing them at risk for neglect resulting in injuries and /or death. Findings included: Resident #1's Face Sheet, dated 09/11/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/13/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired and he did not refuse care. Resident #1 was totally dependent on staff for bed mobility, dressing, toilet use, personal hygiene and bathing. Resident #1 had impairments of his upper and lower extremity on one side. Resident #1's care plan, dated 09/24/14 and reviewed on 10/24/14, reflected the resident exhibited aggressive behaviors and resisted care at times. The approaches were to approach with a calm and quiet demeanor, talk in a calm voice when behavior was disruptive, redirect and reapproach as indicated. The care plan also reflected Resident #1 was unable to respond to questions and commands verbally and was unable to make needs known related to [MEDICAL CONDITION]/Dysphasia, history [MEDICAL CONDITION] cognitive impairment. The approaches were to position self to have eye contact with resident, use touch and a calm voice, explain all procedures and allow resident to respond through gestures, facial expressions or eye contact. The care plan also reflected Resident #1 had contractures and was at risk for skin breakdown/pain and further decline in mobility. The approaches were to assist with positioning and repositioning, to monitor skin integrity and notify the physician of changes in skin and to monitor for pain/discomfort and intervene as indicated. Further review of Resident #1's care plan revealed a problem area dated 10/24/14, which reflected he exhibited non-verbal indicators of pain and the approaches were to evaluate pain using 1-10 scale, assist with repositioning as needed and monitor for worsening of non-verbal indicators of pain. Resident #1 was observed in bed in his room on 11/21/14 at 10:00 AM with the facility Regional Clinical Operations Nurse (RCON) and LVN Y. Resident #1 was awake in bed, [MEDICATION NAME] HN 1.2 was infusing at 60cc/hr (cubic centimeter/hour.) Head of bed was elevated 35 degrees. Resident #1's left hand was contracted from the wrist area and the fingers too. The left leg was hyperextended out to the ankle and toes. Resident #1 was observed able to move the right hand and the fingers. However, the right leg was observed to be flexed at the knee. Resident #1 was non-verbal and unable to assist with the transfers. An incident report, dated 10/18/14 at 10:00 AM, completed by LVN A, Charge nurse for Resident #1, reflected an unwitnessed incident type of bruising. The Brief description reflected, "Noted bruise or discoloration 10 cm along the lateral R (right) hip by 4 cm, Res (Resident) is bed bound appear to be from pressure from pillows used to position." The description did not reflect the color of the bruise. An attached Pain Evaluation, 10/18/14, reflected "unknown" location of current pain and a "0, No pain" on the scale. It further reflected a Non-Verbal Scale of "1", "Tense. Distressed pacing. Fidgeting". The summary reflected, "... may have been laying on R (right) side pressing on bony prominence for too long need to reposition every 2 hours and monitor the site". The report also reflected CNA B and CNA C were assigned to the hall at the time of the incident. The prior level of function and/or comments section reflected, "No change res (resident) [MEDICAL CONDITION] bedbound, multiple contractures, [MEDICAL CONDITION] c (with) L (left) sided weakness". Interview with LVN A on 11/20/14 at 12:35 PM via telephone revealed he made the incident report regarding Resident #1's bruise. LVN A stated he was alerted of the bruise by a CNA and he looked at the resident "head to toe". LVN A stated he did not touch the bruised area as it was "not necessary" as "you can look at it" to make an assessment. LVN A stated Resident #1 was able to verbalize pain, but "not too much". Another interview with LVN A was conducted on 11/21/14 at 8:47 AM in the facility. LVN A stated he called the injury "bruising" but it was more of a "discoloration" that was red in color. He revealed he did not check range of motion during his assessment and did not press on the bruised area to see if there was any pain. LVN A stated Resident #1 usually struck out with his right hand if he did not like something. LVN A revealed his initial thought was that the bruise was from too much pressure due to not being repositioned. LVN A stated he got an order for [REDACTED]. LVN A stated Resident #1 was bed bound, could not self transfer and he did not think Resident #1 could have fallen. LVN A stated at that time "no abuse crossed my mind". Interview with the DON on 11/20/14 at 2:45 PM revealed when asked about expectations during an assessment of an injury, the DON stated as part of the assessment she expected the nurse to look at the injury, evaluate what they saw, to touch the area to see if it was warm or cold and to check for any sensation or pain. The DON stated it concerned her if a nurse did not touch the area during the assessment. Interview with CNA B on 11/20/14 at 1:47 PM via telephone revealed she discovered a big bruise on Resident #1's right hip. CNA B stated she was surprised when she saw the bruise and did not know what happened. She stated Resident #1 was grimacing and she notified LVN A. CNA B stated LVN A told her he would make the incident report. CNA B stated she knew the resident was in pain on 10/19/14 because he was fighting, punching and was aggressive with her during care. CNA B stated Resident #1 knew her, she spoke to him in their same language and he was not aggressive with her before. She asked LVN A if Resident #1 had any pain medication. CNA B stated LVN A responded, "I'll see if he had anything". Review of the facility's 24 Hour Report for Hall 300 revealed on 10/18/14, under "Unusual Behaviors", Resident #1, "Monitor bruising on R (right) hip lateral side". Resident #1's physician's orders [REDACTED]. The facility's 24 Hour Report for Hall 300 on 10/19/14 reflected, "Bruise to lateral side of R hip" with no additional information. Resident #1's Nurse's Notes, dated 10/19/14 and written by LVN A, reflected, "... F/U (follow up) bruising to the R lateral side of the hip, repositioned q (every) 2 (hours), denies pain, discoloration healing well and beginning to fade will cont (continue) to monitor." Interview with LVN A on 11/21/14 at 8:47 AM revealed on 10/19/14 he felt the bruise was healing well and he did not think Resident #1 was in pain. LVN A denied CNA B reported to him Resident #1 was in pain. Interview with LVN D on 11/20/14 at 2:22 PM via telephone revealed she worked on 10/19/14 during the overnight shift. LVN D stated LVN A reported to her about Resident #1's bruise on the right hip. LVN D stated she was told it "might be from not repositioning". LVN D stated she looked at the bruise and was surprised how "bad" the bruise looked. She revealed she did not think the bruise was from not repositioning the resident. LVN D stated Resident #1 was usually "a fighter" however, that night he was calm. LVN D did not think he was in pain. Resident #1's physician's orders [REDACTED]. Resident #1's October 2014 MAR indicated [REDACTED]. According to the MAR, he did not receive any other pain medication from 10/18/14 through 10/20/14. The MAR indicated [REDACTED]. It further reflected a pain assessment was completed, as indicated by LVN A's initials during the day and evening shift on 10/18/14 and 10/19/14, with no pain level indication documented. It also reflected a pain assessment was completed during the night shift, as indicated by "N" for "non-verbal assessment tool for the cognitively impaired" was used, with no pain level indication documented. Resident #1's Nurse's Notes revealed on 10/20/14 at 10:15 AM: "This ADON (Assistant Director of Nursing) went to speak to 300 Hall charge nurse (LVN Y) regarding skin issue reported during Monday's morning standup meeting. Nurse confirmed that he saw the bruising for the first time this morning. ADON went to resident room to do a skin assessment. Met two CNAs in the room completing incontinent care upon inspection noted that bruising was located on the lateral posterior R (right) thigh between trocanter (sic) and knee. The bruising was dark purple in appearance, the patient moaned & (and) grimaced upon tactil (sic) assessment. On the patient upper hip area there was also a bruise area round in shape, light purple c (with) peticia (sic) (red or purple spot on the skin, caused by a minor hemorrhage (broken capillary blood vessels)) area. Requested 300 Hall nurse to order STAT xray..."; Interview with LVN E on 11/20/14 at 4:07 PM via telephone revealed she was the ADON who re-assessed Resident #1 on 10/20/14. LVN E stated she worked as the ADON, however, had since taken a different position. LVN E revealed she was asked by the DON to re-assess Resident #1 because of the incident report that was made. LVN E stated she looked at the injury and felt it was more than a bruise. LVN E said it was on the underside of the leg too. She stated an x-ray was ordered immediately. LVN E stated she participated in the investigation and the facility did identify a concern about LVN A's assessment of the injury. LVN E revealed CNA B felt Resident #1 was in pain, however LVN A did not think there was any pain. Resident #1's radiology report, dated 10/20/14, reflected, "...There is a right base of femoral neck fracture of unknown age, new finding since prior examination. No dislocation is seen". Interview with LVN Y on 11/20/14 at 11:59 AM revealed he was the charge nurse assigned to Resident #1 on 10/20/14. LVN Y revealed the bruise was brought to his attention that day and he observed the resident's thigh was swollen, bruised and when it was touched the resident grimaced. LVN Y stated the injury was assessed by the ADON at the time and an x-ray was ordered. LVN Y stated he did not know how Resident #1 received the fracture. Resident #1's hospital Radiology report, dated 10/20/14, reflected, "Injury...Fall...impacted (fracture in which the bone is broken and one end is wedged into the interior of the other) slightly comminuted (fracture in which the bone is broken or splintered into pieces) and displaced [MEDICAL CONDITION] right femur (thigh bone, which is the longest and strongest bone in the skeleton) involving the intertrochanteric region. The proximal fracture fragment is impacted with the distal fracture fragment and the distal fracture fragment is migrated in a cephalad (toward the head) direction." Resident #1's hospital Operative Report, dated 10/21/14, reflected he had surgery on 10/21/14 to repair the fracture. The facility's Provider Investigation Report, reported to DADS on 10/20/14, reflected on 10/18/14 Resident #1 had an injury of unknown source. On 10/18/14 at 10:00 AM, bruising was observed by CNA B and reported to LVN A. LVN A assessed the resident who did not exhibit any signs or symptoms of pain during peri-care that was provided by CNA B. On 10/19/14, Resident #1 was monitored by LVN A and other nurses and no pain medication was administered as "the assessment or resident" did not identify a need for pain medication. On 10/20/14 an x-ray was completed, which revealed a femoral neck fracture of unknown age. The report's Investigation Summary reflected, "Interviews were done via telephone and in person with all staff who provided care for the resident during the time frame from Thursday, october 16th to October 20th. This interview (of employees who did and/or had the potential to come in contact with resident) was done to ascertain facts which may have contributed to residents femoral fracture. Findings of the interviews revealed that the resident was not dropped. Nurses who assessed the resident deny seeing any evidence of pain between the dates of October 18th and October 19th. On October 20, 2014, LVN E went in to check the site of resident's bruise and observed with tactile assessment that the resident exhibited moaning and grimacing." Provider Action Taken Post Investigation reflected, "...In-Service regarding positioning and providing peri-care to residents with severe contractures. (Facility) at this time has no reason to believe that the resident was dropped or by any means intentional (sic) harmed by staff. He is bed bound and requires positioning for comfort and frequent peri-care." Attached to the Provider Investigation Report, reported to DADS on 10/20/14, were the following statements taken by the facility during the investigation and written as a summary of the facility's interview with the staff: LVN A's statement, dated 10/22/14, reflected, "...X-ray not called because they did not expect him to have had a fall due to the fact he is total care. States that he attributes this to the fact that they may have to open his leg to do peri care." LVN H's statement, dated 10/18/14, reflected, "...I did notice a moderate sized purplish-yellow bruise to his R (right) hip. I did not turn the resident or notice any s/s (signs/symptoms) of pain." CNA C's written statement, dated 10/22/14, reflected, "...States Saturday (10/18/14) gave bed bath & (and) noted that rt. (right) leg was swollen...I found out when (CNA B) came & (and) told me & (and) (LVN A) about the leg of (Resident #1) was swollen... I noticed that the leg was swollen during bed bath...states he usually thrusts but did not that day." Interview with CNA C on 11/20/14 at 1:38 PM revealed CNA B told him about the bruise and the swelling. CNA C stated he gave Resident #1 a bed bath on 10/18/14 and during repositioning he observed the swelling. CNA B's written statement, dated 10/22/14, reflected, "...Saturday morning (10/18/14) that resident had a purple bruise on thigh. I went got nurse & (and) told him (LVN A). I thought he was in pain and I asked the nurse both Sat/Sun (Saturday/Sunday) to give pain med (medication). When I turned him over he started kicking/fighting. The nurse and I turned him together and I showed him. I opened the brief and his leg was swollen." Interview with CNA O on 11/23/14 at 12:59 PM revealed Resident #1 did not speak English and she spoke the same language as the resident. CNA O stated she had taken care of Resident #1 for two years and he knew her. CNA O revealed the resident was not combative with her during care. CNA O stated at times Resident #1 would try to hit his family member, however, when they talked to him he relaxed. Interview with CNA P on 11/23/14 at 1:15 PM revealed Resident #1 was combative with her when she tried to provide care without telling him what she was going to do. CNA P stated as long as she spoke to him telling him what she needed to do he was not combative. CNA JJ's written statement, dated 10/22/14, reflected, "...She saw the bruise on his leg on Sunday. States that she went to help (CNA B) (change) resident and she showed me the bruise...." Interview with CNA JJ on 11/20/14 at 11:20 AM revealed she observed Resident #1 on Sunday (10/19/14). CNA JJ stated she saw the bruise and reported it to the nurse. CNA JJ stated she saw purple bruises on Resident #1's hip. CNA JJ revealed she could see on Resident #1's face that he was in pain. Interview with the DON on 11/20/14 at 2:45 PM revealed on Monday 10/20/14, she reviewed the Incident Report regarding Resident #1's bruise and asked the then ADON, who was now LVN E, to follow up. Regarding the incident investigation, the DON stated LVN A notified the physician, and LVN A did not see the need for an x-ray at the time. The DON revealed LVN A felt it was from the resident kicking, the pillow or that the resident hit his leg. The DON stated it could have occurred during peri-care as staff needed to move the resident's legs. The DON stated she was not aware that LVN A did not touch the bruised area at assessment. The DON stated they interviewed staff and found nothing to conclude harm was caused to the resident. The DON stated the staff was educated on transfers, turning and being gentle with peri-care. The DON revealed based on the assessment by LVN E on 10/20/14, she asked for an x-ray. The DON said she was not notified of the bruise, and stated she did not know about it until she reviewed the Incident Report on 10/20/14. Interview with the ADM on 11/20/14 at 4:20 PM revealed the investigation into the unknown injury was completed by herself, the DON, ADON (LVN E) and RCON. The ADM stated LVN A should have notified the DON about the bruise; however, they did not identify any concerns or issues with the initial assessment. The ADM stated Resident #1 did sustain a fracture, however, she did not know how it happened. The ADM stated Resident #1 had [MEDICAL CONDITION] and contractures, but she could not conclude how the fracture occurred. The ADM stated they provided education to staff on peri-care with residents who have contractures and transfers. The ADM denied LVN A received any training following the incident. Regarding CNA B's statement which noted Resident #1 was in pain, the ADM stated "She's a CNA, that's her opinion." Interview with Physician II on 11/20/14 at 2:12 PM via telephone revealed he was notified on 10/18/14 by LVN A that Resident #1 had a bruise. Physician II stated he did not know the circumstances and there was no documented fall. Physician II stated LVN A notified him and stated they would monitor. Physician II called back on 11/20/14 at 2:39 PM and after reviewing his notes, stated LVN A felt it was a bruise and there was no need for an x-ray. Physician II stated he had "no tendency to question" LVN A. The facility's undated "Policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Property", provided as current policy by the ADM, reflected the following: "Investigation... All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time are to report it to their immediate supervisor... The facility delegates the administrator as the abuse coordinator... An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator..." "Reporting...to follow state guidelines as outlined... for reporting incidents...Upon completion of the investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences..." An IJ was identified on 11/20/14. On 11/20/14 at 4:40 PM, the ADM and the DON were notified of the IJ and a Plan of Removal was requested at that time. Following the notification of the IJ, the ADM on 11/20/14 at 4:40 PM revealed LVN A was talked to by the RCON following the incident. The facility provided a Record of In-Service, dated 11/21/14 at 8:30 AM for LVN A, which reflected, "On October 22, 2014 the following discussion, education session was held c (with) LVN A...1. Completion of incident reports...2. Notification of DON of incidents/Abuse Coordinator...3. Using good critical thinking/judgment ...4. Unidentified bruising must be reported to Abuse Coordinator...." Interview with the RCON on 11/21/14 at 10:05 AM revealed she did not feel LVN A's assessment of Resident #1 was poor. The RCON stated the facility in-serviced LVN A on 10/22/14 about not reporting the unknown injury to the DON, however, they did not have any documentation from that day. The RCON stated they had documentation that was completed today and signed by LVN A, which showed he was trained on 10/22/14. Further review of LVN A's personnel file revealed an Employee Counseling Form, dated 11/20/14, which reflected, "...Suspension, pending outcome of investigation...Failed to notify Supervisor of bruise of unknown origin...Impact on Department: Resident Safety...." Interview with the ADM on 11/21/14 at 11:35 AM, revealed when queried how the IJ occurred, the ADM replied, "Because (LVN A) failed to notify supervisor about the injury." The ADM stated she did not feel the IJ was justified as LVN A did the assessment, assessed for pain, wrote an Incident Report and notified the physician and the family. The ADM stated the only thing LVN A failed to do was notify the DON. To prevent reoccurrence, the ADM stated Incident Reports would be followed up on within 24 hours and the 24 hour notes would be reviewed by Nurse Managers. The ADM stated the facility educated and would continue to educate staff on Abuse, notifications and assessments of injuries. The ADM revealed LVN A was suspended on 11/21/14 due to the IJ and due to his failure to notify the DON of the bruise. When asked why LVN A was not suspended during the incident investigation when it was discovered he did not notify the DON, the ADM stated LVN A was suspended in light of the IJ situation, due to the surveyors monitoring that weekend and LVN A would not be in the facility. The ADM also stated LVN A was talked to during the investigation; however the facility did not have an IJ then. Interview with the DON on 11/21/14 at 2:48 PM, revealed when queried how the IJ occurred, the DON replied the IJ was called as the facility was out of compliance according to the investigation conducted by the surveyors. The DON stated she did not feel the IJ was justified. The DON stated she felt there were always "opportunities for improvement," but did not feel the IJ was justified. The facility's Plan of Removal accepted on 11/21/14 at 1:34 PM reflected Resident #1 was assessed from head to toe including a Pain Evaluation by LVN E on 11/20/14 at 8:30 PM. His pain assessment scored was a four on the cognitively impaired scale, the physician was notified and ordered [MEDICATION NAME] 50 mg twice a day for 14 days and then re-evaluate. Resident #1's (Responsible Party) was notified of the new order. The DON and ADON F were re-inserviced on performing the "Pain Evaluation" form to include Verbal and Non-verbal pain evaluation by the RCON on 11/20/14 at 7:30 PM. October and November 2014 Incident Reports were reviewed by the DON on 11/20/14, to ensure pertinent data was documented and reported appropriately. Resident #1's care plan was updated on 11/21/14 to include his behaviors of resisting care, moaning/groaning, and hitting staff. The care plan for pain was also updated to include his new order of pain medication [MEDICATION NAME] 50 mg 14 days and then re-evaluate his pain. The DON and ADONs would be responsible for re-educating all licensed nurses, starting on 11/20/14 regarding "Pain Evaluation" to include residents who were capable of verbally expressing pain and residents who were cognitively impaired. The re-education would include Post test instructions on how to properly assess after an injury. The DON/ADON would re-educate all licensed staff, starting on 11/20/14, on a timely and proper assessment after injury, to include: bruising, [MEDICAL CONDITION], redness, misalignment, pain, bleeding, abnormal vital signs, abrasion, and current level of consciousness, level of orientation, pallor, numbness, tingling, external rotation or shortened leg, with x-rays if indicated. The DON/ADON will re-educate all staff starting on 11/20/14, on reporting alleged Abuse and Neglect, to include bruises of unknown origin, immediately to the Abuse Coordinator, the ADM. Based on interviews conducted with DA W, Therapy Staff V, MA X, CNAs I, J, O, P, Q, R, S, T, and U, LVNs N, M, H, Y, Z, AA, DD, RNs K and BB, Housekeeper L, and MAs FF and HH, and record reviews of In-Services conducted, it was determined the IJ was removed on 11/23/14. The ADM was notified on 11/23/14 at 3:40 PM, the IJ was removed. While the IJ was removed on 11/23/14, the facility remained out of compliance a severity level of "actual harm that is not immediate jeopardy" and a scope of "widespread" due to the facility needed to monitor the effectiveness of the Plan of Removal. The Daily Census sheet, dated 11/20/14, reflected 84 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 11 residents reviewed for neglect. 1. LVN A failed to assess a bruise of unknown origin found on 10/18/14 on the right hip of Resident #1, who was non-verbal and unable to make his needs known. Resident #1 exhibited signs of pain on 10/18/14 and 10/19/14. On 10/20/14 following a re-assessment by LVN E, an x-ray was ordered, which indicated Resident #1 had a right hip impacted, slightly comminuted and displaced fracture. 2. LVN A failed to immediately report the bruise of unknown origin to the Administrator, who was the Abuse Coordinator and the DON. 3. The facility failed to immediately report the incident to the State survey and certification agency. 4. The facility failed to have evidence of thorough investigation into Resident #1's [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on 11/20/14. While the IJ was removed on 11/23/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "widespread" due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the other 84 residents in the facility by placing them at risk for neglect resulting in injuries and/or death. Findings included: The facility's undated "Policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Property", provided as current policy by the ADM, reflected the following: "Each resident has the right to be free from abuse...free from mistreatment, neglect...The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences..." "Investigation... All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time are to report it to their immediate supervisor...The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will then report the allegation to the director of nursing, or the assistant director of nursing, and/or the administrator...The administrator or his/her designee will report this allegation of abuse immediately to the state agency... The facility delegates the administrator as the abuse coordinator... An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator..." "Reporting...to follow state guidelines as outlined... for reporting incidents...Upon completion of the investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences..." Resident #1's Face Sheet, dated 09/11/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/13/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired and he did not refuse care. Resident #1 was totally dependent on staff for bed mobility, dressing, toilet use, personal hygiene and bathing. Resident #1 had impairments of his upper and lower extremity on one side. Resident #1's care plan, dated 09/24/14 and reviewed on 10/24/14, reflected the resident exhibited aggressive behaviors and resisted care at times. The approaches were to approach with a calm and quiet demeanor, talk in a calm voice when behavior was disruptive, redirect and reapproach as indicated. The care plan also reflected Resident #1 was unable to respond to questions and commands verbally and was unable to make needs known related to [MEDICAL CONDITION]/Dysphasia, history [MEDICAL CONDITION] cognitive impairment. The approaches were to position self to have eye contact with resident, use touch and a calm voice, explain all procedures and allow resident to respond through gestures, facial expressions or eye contact. The care plan also reflected Resident #1 had contractures and was at risk for skin breakdown/pain and further decline in mobility. The approaches were to assist with positioning and repositioning, to monitor skin integrity and notify the physician of changes in skin and to monitor for pain/discomfort and intervene as indicated. Further review of Resident #1's care plan revealed a problem area dated 10/24/14, which reflected he exhibited non-verbal indicators of pain and the approaches were to evaluate pain using 1-10 scale, assist with repositioning as needed and monitor for worsening of non-verbal indicators of pain. Resident #1 was observed in bed in his room on 11/21/14 at 10:00 AM with the facility Regional Clinical Operations Nurse (RCON) and LVN Y. Resident #1 was awake in bed, [MEDICATION NAME] HN 1.2 was infusing at 60cc/hr (cubic centimeter/hour.) Head of bed was elevated 35 degrees. Resident #1's left hand was contracted from the wrist area and the fingers too. The left leg was hyperextended out to the ankle and toes. Resident #1 was observed able to move the right hand and the fingers. However, the right leg was observed to be flexed at the knee. Resident #1 was non-verbal and unable to assist with the transfers. An incident report, dated 10/18/14 at 10:00 AM, completed by LVN A, Charge nurse for Resident #1, reflected an unwitnessed incident type of bruising. The Brief description reflected, "Noted bruise or discoloration 10 cm along the lateral R (right) hip by 4 cm, Res (Resident) is bed bound appear to be from pressure from pillows used to position." The description did not reflect the color of the bruise. An attached Pain Evaluation, 10/18/14, reflected "unknown" location of current pain and a "0, No pain" on the scale. It further reflected a Non-Verbal Scale of "1", "Tense. Distressed pacing. Fidgeting". The summary reflected, "... may have been laying on R (right) side pressing on bony prominence for too long need to reposition every 2 hours and monitor the site". The report also reflected CNA B and CNA C were assigned to the hall at the time of the incident. The prior level of function and/or comments section reflected, "No change res (resident) [MEDICAL CONDITION] bedbound, multiple contractures, [MEDICAL CONDITION] c (with) L (left) sided weakness". Interview with LVN A on 11/20/14 at 12:35 PM via telephone revealed he made the incident report regarding Resident #1's bruise. LVN A stated he was alerted of the bruise by a CNA and he looked at the resident "head to toe". LVN A stated he did not touch the bruised area as it was "not necessary" as "you can look at it" to make an assessment. LVN A stated Resident #1 was able to verbalize pain, but "not too much". Another interview with LVN A was conducted on 11/21/14 at 8:47 AM in the facility. LVN A stated he called the injury "bruising" but it was more of a "discoloration" that was red in color. He revealed he did not check range of motion during his assessment and did not press on the bruised area to see if there was any pain. LVN A stated Resident #1 usually struck out with his right hand if he did not like something. LVN A revealed his initial thought was that the bruise was from too much pressure due to not being repositioned. LVN A stated he got an order for [REDACTED]. LVN A stated Resident #1 was bed bound, could not self transfer and he did not think Resident #1 could have fallen. LVN A stated at that time "no abuse crossed my mind". Interview with the DON on 11/20/14 at 2:45 PM revealed when asked about expectations during an assessment of an injury, the DON stated as part of the assessment she expected the nurse to look at the injury, evaluate what they saw, to touch the area to see if it was warm or cold and to check for any sensation or pain. The DON stated it concerned her if a nurse did not touch the area during the assessment. Interview with CNA B on 11/20/14 at 1:47 PM via telephone revealed she discovered a big bruise on Resident #1's right hip. CNA B stated she was surprised when she saw the bruise and did not know what happened. She stated Resident #1 was grimacing and she notified LVN A. CNA B stated LVN A told her he would make the incident report. CNA B stated she knew the resident was in pain on 10/19/14 because he was fighting, punching and was aggressive with her during care. CNA B stated Resident #1 knew her, she spoke to him in their same language and he was not aggressive with her before. She asked LVN A if Resident #1 had any pain medication. CNA B stated LVN A responded, "I'll see if he had anything". Review of the facility's 24 Hour Report for Hall 300 revealed on 10/18/14, under "Unusual Behaviors", Resident #1, "Monitor bruising on R (right) hip lateral side". Resident #1's physician's orders [REDACTED]. The facility's 24 Hour Report for Hall 300 on 10/19/14 reflected, "Bruise to lateral side of R hip" with no additional information. Resident #1's Nurse's Notes, dated 10/19/14 and written by LVN A, reflected, "... F/U (follow up) bruising to the R lateral side of the hip, repositioned q (every) 2 (hours), denies pain, discoloration healing well and beginning to fade will cont (continue) to monitor." Interview with LVN A on 11/21/14 at 8:47 AM revealed on 10/19/14 he felt the bruise was healing well and he did not think Resident #1 was in pain. LVN A denied CNA B reported to him Resident #1 was in pain. Interview with LVN D on 11/20/14 at 2:22 PM via telephone revealed she worked on 10/19/14 during the overnight shift. LVN D stated LVN A reported to her about Resident #1's bruise on the right hip. LVN D stated she was told it "might be from not repositioning". LVN D stated she looked at the bruise and was surprised how "bad" the bruise looked. She revealed she did not think the bruise was from not repositioning the resident. LVN D stated Resident #1 was usually "a fighter" however, that night he was calm. LVN D did not think he was in pain. Resident #1's physician's orders [REDACTED]. Resident #1's October 2014 MAR indicated [REDACTED]. According to the MAR, he did not receive any other pain medication from 10/18/14 through 10/20/14. The MAR indicated [REDACTED]. It further reflected a pain assessment was completed, as indicated by LVN A's initials during the day and evening shift on 10/18/14 and 10/19/14, with no pain level indication documented. It also reflected a pain assessment was completed during the night shift, as indicated by "N" for "non-verbal assessment tool for the cognitively impaired" was used, with no pain level indication documented. Resident #1's Nurse's Notes revealed on 10/20/14 at 10:15 AM: "This ADON (Assistant Director of Nursing) went to speak to 300 Hall charge nurse (LVN Y) regarding skin issue reported during Monday's morning standup meeting. Nurse confirmed that he saw the bruising for the first time this morning. ADON went to resident room to do a skin assessment. Met two CNAs in the room completing incontinent care upon inspection noted that bruising was located on the lateral posterior R (right) thigh between trocanter (sic) and knee. The bruising was dark purple in appearance, the patient moaned & (and) grimaced upon tactil (sic) assessment. On the patient upper hip area there was also a bruise area round in shape, light purple c (with) peticia (sic) (red or purple spot on the skin, caused by a minor hemorrhage (broken capillary blood vessels)) area. Requested 300 Hall nurse to order STAT xray..."; Interview with LVN E on 11/20/14 at 4:07 PM via telephone revealed she was the ADON who re-assessed Resident #1 on 10/20/14. LVN E stated she worked as the ADON, however, had since taken a different position. LVN E revealed she was asked by the DON to re-assess Resident #1 because of the incident report that was made. LVN E stated she looked at the injury and felt it was more than a bruise. LVN E said it was on the underside of the leg too. She stated an x-ray was ordered immediately. LVN E stated she participated in the investigation and the facility did identify a concern about LVN A's assessment of the injury. LVN E revealed CNA B felt Resident #1 was in pain, however LVN A did not think there was any pain. Resident #1's radiology report, dated 10/20/14, reflected, "...There is a right base of femoral neck fracture of unknown age, new finding since prior examination. No dislocation is seen". Interview with LVN Y on 11/20/14 at 11:59 AM revealed he was the charge nurse assigned to Resident #1 on 10/20/14. LVN Y revealed the bruise was brought to his attention that day and he observed the resident's thigh was swollen, bruised and when it was touched the resident grimaced. LVN Y stated the injury was assessed by the ADON at the time and an x-ray was ordered. LVN Y stated he did not know how Resident #1 received the fracture. Resident #1's hospital Radiology report, dated 10/20/14, reflected, "Injury...Fall...impacted (fracture in which the bone is broken and one end is wedged into the interior of the other) slightly comminuted (fracture in which the bone is broken or splintered into pieces) and displaced [MEDICAL CONDITION] right femur (thigh bone, which is the longest and strongest bone in the skeleton) involving the intertrochanteric region. The proximal fracture fragment is impacted with the distal fracture fragment and the distal fracture fragment is migrated in a cephalad (toward the head) direction." Resident #1's hospital Operative Report, dated 10/21/14, reflected he had surgery on 10/21/14 to repair the fracture. The facility's Provider Investigation Report, reported to DADS on 10/20/14, reflected on 10/18/14 Resident #1 had an injury of unknown source. On 10/18/14 at 10:00 AM, bruising was observed by CNA B and reported to LVN A. LVN A assessed the resident who did not exhibit any signs or symptoms of pain during peri-care that was provided by CNA B. On 10/19/14, Resident #1 was monitored by LVN A and other nurses and no pain medication was administered as "the assessment or resident" did not identify a need for pain medication. On 10/20/14 an x-ray was completed, which revealed a femoral neck fracture of unknown age. The report's Investigation Summary reflected, "Interviews were done via telephone and in person with all staff who provided care for the resident during the time frame from Thursday, October 16th to October 20th. This interview (of employees who did and/or had the potential to come in contact with resident) was done to ascertain facts which may have contributed to residents femoral fracture. Findings of the interviews revealed that the resident was not dropped. Nurses who assessed the resident deny seeing any evidence of pain between the dates of October 18th and October 19th. On October 20, 2014, LVN E went in to check the site of resident's bruise and observed with tactile assessment that the resident exhibited moaning and grimacing." Provider Action Taken Post Investigation reflected, "...In-Service regarding positioning and providing peri-care to residents with severe contractures. (Facility) at this time has no reason to believe that the resident was dropped or by any means intentional (sic) harmed by staff. He is bed bound and requires positioning for comfort and frequent peri-care." Attached to the Provider Investigation Report, reported to DADS on 10/20/14, were the following statements taken by the facility during the investigation and written as a summary of the facility's interview with the staff: LVN A's statement, dated 10/22/14, reflected, "...X-ray not called because they did not expect him to have had a fall due to the fact he is total care. States that he attributes this to the fact that they may have to open his leg to do peri care." LVN H's statement, dated 10/18/14, reflected, "...I did notice a moderate sized purplish-yellow bruise to his R (right) hip. I did not turn the resident or notice any s/s (signs/symptoms) of pain." CNA C's written statement, dated 10/22/14, reflected, "...States Saturday (10/18/14) gave bed bath & (and) noted that rt. (right) leg was swollen...I found out when (CNA B) came & (and) told me & (and) (LVN A) about the leg of (Resident #1) was swollen... I noticed that the leg was swollen during bed bath...states he usually thrusts but did not that day." Interview with CNA C on 11/20/14 at 1:38 PM revealed CNA B told him about the bruise and the swelling. CNA C stated he gave Resident #1 a bed bath on 10/18/14 and during repositioning he observed the swelling. CNA B's written statement, dated 10/22/14, reflected, "...Saturday morning (10/18/14) that resident had a purple bruise on thigh. I went got nurse & (and) told him (LVN A). I thought he was in pain and I asked the nurse both Sat/Sun (Saturday/Sunday) to give pain med (medication). When I turned him over he started kicking/fighting. The nurse and I turned him together and I showed him. I opened the brief and his leg was swollen." Interview with CNA O on 11/23/14 at 12:59 PM revealed Resident #1 did not speak English and she spoke the same language as the resident. CNA O stated she had taken care of Resident #1 for two years and he knew her. CNA O revealed the resident was not combative with her during care. CNA O stated at times Resident #1 would try to hit his family member, however, when they talked to him he relaxed. Interview with CNA P on 11/23/14 at 1:15 PM revealed Resident #1 was combative with her when she tried to provide care without telling him what she was going to do. CNA P stated as long as she spoke to him telling him what she needed to do he was not combative. CNA JJ's written statement, dated 10/22/14, reflected, "...She saw the bruise on his leg on Sunday. States that she went to help (CNA B) (change) resident and she showed me the bruise...." Interview with CNA JJ on 11/20/14 at 11:20 AM revealed she observed Resident #1 on Sunday (10/19/14). CNA JJ stated she saw the bruise and reported it to the nurse. CNA JJ stated she saw purple bruises on Resident #1's hip. CNA JJ revealed she could see on Resident #1's face that he was in pain. Interview with the DON on 11/20/14 at 2:45 PM revealed on Monday 10/20/14, she reviewed the Incident Report regarding Resident #1's bruise and asked the then ADON, who was now LVN E, to follow up. Regarding the incident investigation, the DON stated LVN A notified the physician, and LVN A did not see the need for an x-ray at the time. The DON revealed LVN A felt it was from the resident kicking, the pillow or that the resident hit his leg. The DON stated it could have occurred during peri-care as staff needed to move the resident's legs. The DON stated she was not aware that LVN A did not touch the bruised area at assessment. The DON stated they interviewed staff and found nothing to conclude harm was caused to the resident. The DON stated the staff was educated on transfers, turning and being gentle with peri-care. The DON revealed based on the assessment by LVN E on 10/20/14, she asked for an x-ray. The DON said she was not notified of the bruise, and stated she did not know about it until she reviewed the Incident Report on 10/20/14. Interview with the ADM on 11/20/14 at 4:20 PM revealed the investigation into the unknown injury was completed by herself, the DON, ADON (LVN E) and RCON. The ADM stated LVN A should have notified the DON about the bruise; however, they did not identify any concerns or issues with the initial assessment. The ADM stated Resident #1 did sustain a fracture, however, she did not know how it happened. The ADM stated Resident #1 had [MEDICAL CONDITION] and contractures, but she could not conclude how the fracture occurred. The ADM stated they provided education to staff on peri-care with residents who have contractures and transfers. The ADM denied LVN A received any training following the incident. Regarding CNA B's statement which noted Resident #1 was in pain, the ADM stated "She's a CNA, that's her opinion." Interview with Physician II on 11/20/14 at 2:12 PM via telephone revealed he was notified on 10/18/14 by LVN A that Resident #1 had a bruise. Physician II stated he did not know the circumstances and there was no documented fall. Physician II stated LVN A notified him and stated they would monitor. Physician II called back on 11/20/14 at 2:39 PM and after reviewing his notes, stated LVN A felt it was a bruise and there was no need for an x-ray. Physician II stated he had "no tendency to question" LVN A. An IJ was identified on 11/20/14. On 11/20/14 at 4:40 PM, the ADM and the DON were notified of the IJ and a Plan of Removal was requested at that time. Following the notification of the IJ, the ADM on 11/20/14 at 4:40 PM revealed LVN A was talked to by the RCON following the incident. The facility provided a Record of In-Service, dated 11/21/14 at 8:30 AM for LVN A, which reflected, "On October 22, 2014 the following discussion, education session was held c (with) LVN A...1. Completion of incident reports...2. Notification of DON of incidents/Abuse Coordinator...3. Using good critical thinking/judgment ...4. Unidentified bruising must be reported to Abuse Coordinator...." Interview with the RCON on 11/21/14 at 10:05 AM revealed she did not feel LVN A's assessment of Resident #1 was poor. The RCON stated the facility in-serviced LVN A on 10/22/14 about not reporting the unknown injury to the DON, however, they did not have any documentation from that day. The RCON stated they had documentation that was completed today and signed by LVN A, which showed he was trained on 10/22/14. Further review of LVN A's personnel file revealed an Employee Counseling Form, dated 11/20/14, which reflected, "...Suspension, pending outcome of investigation...Failed to notify Supervisor of bruise of unknown origin...Impact on Department: Resident Safety...." Interview with the ADM on 11/21/14 at 11:35 AM, revealed when queried how the IJ occurred, the ADM replied, "Because (LVN A) failed to notify supervisor about the injury." The ADM stated she did not feel the IJ was justified as LVN A did the assessment, assessed for pain, wrote an Incident Report and notified the physician and the family. The ADM stated the only thing LVN A failed to do was notify the DON. To prevent reoccurrence, the ADM stated Incident Reports would be followed up on within 24 hours and the 24 hour notes would be reviewed by Nurse Managers. The ADM stated the facility educated and would continue to educate staff on Abuse, notifications and assessments of injuries. The ADM revealed LVN A was suspended on 11/21/14 due to the IJ and due to his failure to notify the DON of the bruise. When asked why LVN A was not suspended during the incident investigation when it was discovered he did not notify the DON, the ADM stated LVN A was suspended in light of the IJ situation, due to the surveyors monitoring that weekend and LVN A would not be in the facility. The ADM also stated LVN A was talked to during the investigation; however the facility did not have an IJ then. Interview with the DON on 11/21/14 at 2:48 PM, revealed when queried how the IJ occurred, the DON replied the IJ was called as the facility was out of compliance according to the investigation conducted by the surveyors. The DON stated she did not feel the IJ was justified. The DON stated she felt there were always "opportunities for improvement," but did not feel the IJ was justified. The facility's Plan of Removal accepted on 11/21/14 at 1:34 PM reflected Resident #1 was assessed from head to toe including a Pain Evaluation by LVN E on 11/20/14 at 8:30 PM. His pain assessment scored was a four on the cognitively impaired scale, the physician was notified and ordered [MEDICATION NAME] 50 mg twice a day for 14 days and then re-evaluate. Resident #1's (Responsible Party) was notified of the new order. The DON and ADON F were re-inserviced on performing the "Pain Evaluation" form to include Verbal and Non-verbal pain evaluation by the RCON on 11/20/14 at 7:30 PM. October and November 2014 Incident Reports were reviewed by the DON on 11/20/14, to ensure pertinent data was documented and reported appropriately. Resident #1's care plan was updated on 11/21/14 to include his behaviors of resisting care, moaning/groaning, and hitting staff. The care plan for pain was also updated to include his new order of pain medication [MEDICATION NAME] 50 mg 14 days and then re-evaluate his pain. The DON and ADONs would be responsible for re-educating all licensed nurses, starting on 11/20/14 regarding "Pain Evaluation" to include residents who were capable of verbally expressing pain and residents who were cognitively impaired. The re-education would include Post test instructions on how to properly assess after an injury. The DON/ADON would re-educate all licensed staff, starting on 11/20/14, on a timely and proper assessment after injury, to include: bruising, [MEDICAL CONDITION], redness, misalignment, pain, bleeding, abnormal vital signs, abrasion, and current level of consciousness, level of orientation, pallor, numbness, tingling, external rotation or shortened leg, with x-rays if indicated. The DON/ADON will re-educate all staff starting on 11/20/14, on reporting alleged Abuse and Neglect, to include bruises of unknown origin, immediately to the Abuse Coordinator, the ADM. Based on interviews conducted with DA W, Therapy Staff V, MA X, CNAs I, J, O, P, Q, R, S, T, and U, LVNs N, M, H, Y, Z, AA, DD, RNs K and BB, Housekeeper L, and MAs FF and HH, and record reviews of In-Services conducted, it was determined the IJ was removed on 11/23/14. The ADM was notified on 11/23/14 at 3:40 PM, the IJ was removed. While the IJ was removed on 11/23/14, the facility remained out of compliance a severity level of "actual harm that is not immediate jeopardy" and a scope of "widespread" due to the facility needed to monitor the effectiveness of the Plan of Removal. The Daily Census sheet, dated 11/20/14, reflected 84 residents resided in the facility.

Based on interview and record review, the Administrator, the DON and LVN A failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for one (Resident #1) of 11 residents reviewed for Neglect. 1. The Administrator failed to implement the facility's Abuse (and Neglect) Policy. A thorough investigation was not conducted when Resident #1 was discovered with a bruise of unknown origin because the ADM was not as involved in the investigation as she usually was. 2. Charge nurse, LVN A, who was also the prior Staff Coordinator who conducted in-service training regarding abuse and neglect, failed to follow the facility's Abuse Policy, when he did not immediately report Resident #1's bruise of unknown origin to the DON on 10/18/14. 3. The DON failed to supervise and monitor LVN A. LVN A failed to conduct a thorough assessment of Resident #1's bruise of unknown origin on 10/18/14. On 10/20/14, following a re-assessment by LVN E an x-ray was ordered, which indicated Resident #1 had a right hip impacted, slightly comminuted and displaced fracture. An Immediate Jeopardy (IJ) was identified on 11/20/14. While the IJ was removed on 11/23/14, the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy," and a scope of "widespread" due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the other 84 residents in the facility by placing them at risk for neglect resulting in injuries and/or death. Findings included: Resident #1's Face Sheet, dated 09/11/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/13/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired and he did not refuse care. Resident #1 was totally dependent on staff for bed mobility, dressing, toilet use, personal hygiene and bathing. Resident #1 had impairments of his upper and lower extremity on one side. Resident #1's care plan, dated 09/24/14 and reviewed on 10/24/14, reflected the resident exhibited aggressive behaviors and resisted care at times. The approaches were to approach with a calm and quiet demeanor, talk in a calm voice when behavior was disruptive, redirect and reapproach as indicated. The care plan also reflected Resident #1 was unable to respond to questions and commands verbally and was unable to make needs known related to [MEDICAL CONDITION]/Dysphasia, history [MEDICAL CONDITION] cognitive impairment. The approaches were to position self to have eye contact with resident, use touch and a calm voice, explain all procedures and allow resident to respond through gestures, facial expressions or eye contact. The care plan also reflected Resident #1 had contractures and was at risk for skin breakdown/pain and further decline in mobility. The approaches were to assist with positioning and repositioning, to monitor skin integrity and notify the physician of changes in skin and to monitor for pain/discomfort and intervene as indicated. Further review of Resident #1's care plan revealed a problem area dated 10/24/14, which reflected he exhibited non-verbal indicators of pain and the approaches were to evaluate pain using 1-10 scale, assist with repositioning as needed and monitor for worsening of non-verbal indicators of pain. Resident #1 was observed in bed in his room on 11/21/14 at 10:00 AM with the facility Regional Clinical Operations Nurse (RCON) and LVN Y. Resident #1 was awake in bed, [MEDICATION NAME] HN 1.2 was infusing at 60cc/hr (cubic centimeter/hour.) Head of bed was elevated 35 degrees. Resident #1's left hand was contracted from the wrist area and the fingers too. The left leg was hyperextended out to the ankle and toes. Resident #1 was observed able to move the right hand and the fingers. However, the right leg was observed to be flexed at the knee. Resident #1 was non-verbal and unable to assist with the transfers. An incident report, dated 10/18/14 at 10:00 AM, completed by LVN A, Charge nurse for Resident #1, reflected an unwitnessed incident type of bruising. The Brief description reflected, "Noted bruise or discoloration 10 cm along the lateral R (right) hip by 4 cm, Res (Resident) is bed bound appear to be from pressure from pillows used to position." The description did not reflect the color of the bruise. An attached Pain Evaluation, 10/18/14, reflected "unknown" location of current pain and a "0, No pain" on the scale. It further reflected a Non-Verbal Scale of "1", "Tense. Distressed pacing. Fidgeting". The summary reflected, "... may have been laying on R (right) side pressing on bony prominence for too long need to reposition every 2 hours and monitor the site". The report also reflected CNA B and CNA C were assigned to the hall at the time of the incident. The prior level of function and/or comments section reflected, "No change res (resident) [MEDICAL CONDITION] bedbound, multiple contractures, [MEDICAL CONDITION] c (with) L (left) sided weakness". Interview with LVN A on 11/20/14 at 12:35 PM via telephone revealed he made the incident report regarding Resident #1's bruise. LVN A stated he was alerted of the bruise by a CNA and he looked at the resident "head to toe". LVN A stated he did not touch the bruised area as it was "not necessary" as "you can look at it" to make an assessment. LVN A stated Resident #1 was able to verbalize pain, but "not too much". Another interview with LVN A was conducted on 11/21/14 at 8:47 AM in the facility. LVN A stated he called the injury "bruising" but it was more of a "discoloration" that was red in color. He revealed he did not check range of motion during his assessment and did not press on the bruised area to see if there was any pain. LVN A stated Resident #1 usually struck out with his right hand if he did not like something. LVN A revealed his initial thought was that the bruise was from too much pressure due to not being repositioned. LVN A stated he got an order for [REDACTED]. LVN A stated Resident #1 was bed bound, could not self transfer and he did not think Resident #1 could have fallen. LVN A stated at that time "no abuse crossed my mind". Interview with the DON on 11/20/14 at 2:45 PM revealed when asked about expectations during an assessment of an injury, the DON stated as part of the assessment she expected the nurse to look at the injury, evaluate what they saw, to touch the area to see if it was warm or cold and to check for any sensation or pain. The DON stated it concerned her if a nurse did not touch the area during the assessment. Interview with CNA B on 11/20/14 at 1:47 PM via telephone revealed she discovered a big bruise on Resident #1's right hip. CNA B stated she was surprised when she saw the bruise and did not know what happened. She stated Resident #1 was grimacing and she notified LVN A. CNA B stated LVN A told her he would make the incident report. CNA B stated she knew the resident was in pain on 10/19/14 because he was fighting, punching and was aggressive with her during care. CNA B stated Resident #1 knew her, she spoke to him in their same language and he was not aggressive with her before. She asked LVN A if Resident #1 had any pain medication. CNA B stated LVN A responded, "I'll see if he had anything". Review of the facility's 24 Hour Report for Hall 300 revealed on 10/18/14, under "Unusual Behaviors", Resident #1, "Monitor bruising on R (right) hip lateral side". Resident #1's physician's orders [REDACTED]. The facility's 24 Hour Report for Hall 300 on 10/19/14 reflected, "Bruise to lateral side of R hip" with no additional information. Resident #1's Nurse's Notes, dated 10/19/14 and written by LVN A, reflected, "... F/U (follow up) bruising to the R lateral side of the hip, repositioned q (every) 2 (hours), denies pain, discoloration healing well and beginning to fade will cont (continue) to monitor." Interview with LVN A on 11/21/14 at 8:47 AM revealed on 10/19/14 he felt the bruise was healing well and he did not think Resident #1 was in pain. LVN A denied CNA B reported to him Resident #1 was in pain. Interview with LVN D on 11/20/14 at 2:22 PM via telephone revealed she worked on 10/19/14 during the overnight shift. LVN D stated LVN A reported to her about Resident #1's bruise on the right hip. LVN D stated she was told it "might be from not repositioning". LVN D stated she looked at the bruise and was surprised how "bad" the bruise looked. She revealed she did not think the bruise was from not repositioning the resident. LVN D stated Resident #1 was usually "a fighter" however, that night he was calm. LVN D did not think he was in pain. Resident #1's physician's orders [REDACTED]. Resident #1's October 2014 MAR indicated [REDACTED]. According to the MAR, he did not receive any other pain medication from 10/18/14 through 10/20/14. The MAR indicated [REDACTED]. It further reflected a pain assessment was completed, as indicated by LVN A's initials during the day and evening shift on 10/18/14 and 10/19/14, with no pain level indication documented. It also reflected a pain assessment was completed during the night shift, as indicated by "N" for "non-verbal assessment tool for the cognitively impaired" was used, with no pain level indication documented. Resident #1's Nurse's Notes revealed on 10/20/14 at 10:15 AM: "This ADON (Assistant Director of Nursing) went to speak to 300 Hall charge nurse (LVN Y) regarding skin issue reported during Monday's morning standup meeting. Nurse confirmed that he saw the bruising for the first time this morning. ADON went to resident room to do a skin assessment. Met two CNAs in the room completing incontinent care upon inspection noted that bruising was located on the lateral posterior R (right) thigh between trocanter (sic) and knee. The bruising was dark purple in appearance, the patient moaned & (and) grimaced upon tactil (sic) assessment. On the patient upper hip area there was also a bruise area round in shape, light purple c (with) peticia (sic) (red or purple spot on the skin, caused by a minor hemorrhage (broken capillary blood vessels)) area. Requested 300 Hall nurse to order STAT xray..."; Interview with LVN E on 11/20/14 at 4:07 PM via telephone revealed she was the ADON who re-assessed Resident #1 on 10/20/14. LVN E stated she worked as the ADON, however, had since taken a different position. LVN E revealed she was asked by the DON to re-assess Resident #1 because of the incident report that was made. LVN E stated she looked at the injury and felt it was more than a bruise. LVN E said it was on the underside of the leg too. She stated an x-ray was ordered immediately. LVN E stated she participated in the investigation and the facility did identify a concern about LVN A's assessment of the injury. LVN E revealed CNA B felt Resident #1 was in pain, however LVN A did not think there was any pain. Resident #1's radiology report, dated 10/20/14, reflected, "...There is a right base of femoral neck fracture of unknown age, new finding since prior examination. No dislocation is seen". Interview with LVN Y on 11/20/14 at 11:59 AM revealed he was the charge nurse assigned to Resident #1 on 10/20/14. LVN Y revealed the bruise was brought to his attention that day and he observed the resident's thigh was swollen, bruised and when it was touched the resident grimaced. LVN Y stated the injury was assessed by the ADON at the time and an x-ray was ordered. LVN Y stated he did not know how Resident #1 received the fracture. Resident #1's hospital Radiology report, dated 10/20/14, reflected, "Injury...Fall...impacted (fracture in which the bone is broken and one end is wedged into the interior of the other) slightly comminuted (fracture in which the bone is broken or splintered into pieces) and displaced [MEDICAL CONDITION] right femur (thigh bone, which is the longest and strongest bone in the skeleton) involving the intertrochanteric region. The proximal fracture fragment is impacted with the distal fracture fragment and the distal fracture fragment is migrated in a cephalad (toward the head) direction." Resident #1's hospital Operative Report, dated 10/21/14, reflected he had surgery on 10/21/14 to repair the fracture. The facility's Provider Investigation Report, reported to DADS on 10/20/14, reflected on 10/18/14 Resident #1 had an injury of unknown source. On 10/18/14 at 10:00 AM, bruising was observed by CNA B and reported to LVN A. LVN A assessed the resident who did not exhibit any signs or symptoms of pain during peri-care that was provided by CNA B. On 10/19/14, Resident #1 was monitored by LVN A and other nurses and no pain medication was administered as "the assessment or resident" did not identify a need for pain medication. On 10/20/14 an x-ray was completed, which revealed a femoral neck fracture of unknown age. The report's Investigation Summary reflected, "Interviews were done via telephone and in person with all staff who provided care for the resident during the time frame from Thursday, October 16th to October 20th. This interview (of employees who did and/or had the potential to come in contact with resident) was done to ascertain facts which may have contributed to residents femoral fracture. Findings of the interviews revealed that the resident was not dropped. Nurses who assessed the resident deny seeing any evidence of pain between the dates of October 18th and October 19th. On October 20, 2014, LVN E went in to check the site of resident's bruise and observed with tactile assessment that the resident exhibited moaning and grimacing." Provider Action Taken Post Investigation reflected, "...In-Service regarding positioning and providing peri-care to residents with severe contractures. (Facility) at this time has no reason to believe that the resident was dropped or by any means intentional (sic) harmed by staff. He is bed bound and requires positioning for comfort and frequent peri-care." Attached to the Provider Investigation Report, reported to DADS on 10/20/14, were the following statements taken by the facility during the investigation and written as a summary of the facility's interview with the staff: LVN A's statement, dated 10/22/14, reflected, "...X-ray not called because they did not expect him to have had a fall due to the fact he is total care. States that he attributes this to the fact that they may have to open his leg to do peri care." LVN H's statement, dated 10/18/14, reflected, "...I did notice a moderate sized purplish-yellow bruise to his R (right) hip. I did not turn the resident or notice any s/s (signs/symptoms) of pain." CNA C's written statement, dated 10/22/14, reflected, "...States Saturday (10/18/14) gave bed bath & (and) noted that rt. (right) leg was swollen...I found out when (CNA B) came & (and) told me & (and) (LVN A) about the leg of (Resident #1) was swollen... I noticed that the leg was swollen during bed bath...states he usually thrusts but did not that day." Interview with CNA C on 11/20/14 at 1:38 PM revealed CNA B told him about the bruise and the swelling. CNA C stated he gave Resident #1 a bed bath on 10/18/14 and during repositioning he observed the swelling. CNA B's written statement, dated 10/22/14, reflected, "...Saturday (10/18/14) morning that resident had a purple bruise on thigh. I went got nurse & (and) told him (LVN A). I thought he was in pain and I asked the nurse both Sat/Sun (Saturday/Sunday) to give pain med (medication). When I turned him over he started kicking/fighting. The nurse and I turned him together and I showed him. I opened the brief and his leg was swollen." Interview with CNA O on 11/23/14 at 12:59 PM revealed Resident #1 did not speak English and she spoke the same language as the resident. CNA O stated she had taken care of Resident #1 for two years and he knew her. CNA O revealed the resident was not combative with her during care. CNA O stated at times Resident #1 would try to hit his family member, however, when they talked to him he relaxed. Interview with CNA P on 11/23/14 at 1:15 PM revealed Resident #1 was combative with her when she tried to provide care without telling him what she was going to do. CNA P stated as long as she spoke to him telling him what she needed to do he was not combative. CNA JJ's written statement, dated 10/22/14, reflected, "...She saw the bruise on his leg on Sunday. States that she went to help (CNA B) (change) resident and she showed me the bruise...." Interview with CNA JJ on 11/20/14 at 11:20 AM revealed she observed Resident #1 on Sunday (10/19/14). CNA JJ stated she saw the bruise and reported it to the nurse. CNA JJ stated she saw purple bruises on Resident #1's hip. CNA JJ revealed she could see on Resident #1's face that he was in pain. Interview with the DON on 11/20/14 at 2:45 PM revealed on Monday 10/20/14, she reviewed the Incident Report regarding Resident #1's bruise and asked the then ADON, who was now LVN E, to follow up. Regarding the incident investigation, the DON stated LVN A notified the physician, and LVN A did not see the need for an x-ray at the time. The DON revealed LVN A felt it was from the resident kicking, the pillow or that the resident hit his leg. The DON stated it could have occurred during peri-care as staff needed to move the resident's legs. The DON stated she was not aware that LVN A did not touch the bruised area at assessment. The DON stated they interviewed staff and found nothing to conclude harm was caused to the resident. The DON stated the staff was educated on transfers, turning and being gentle with peri-care. The DON revealed based on the assessment by LVN E on 10/20/14, she asked for an x-ray. The DON said she was not notified of the bruise, and stated she did not know about it until she reviewed the Incident Report on 10/20/14. Interview with the ADM on 11/20/14 at 4:20 PM revealed the investigation into the unknown injury was completed by herself, the DON, ADON (LVN E) and RCON. The ADM stated LVN A should have notified the DON about the bruise; however, they did not identify any concerns or issues with the initial assessment. The ADM stated Resident #1 did sustain a fracture, however, she did not know how it happened. The ADM stated Resident #1 had [MEDICAL CONDITION] and contractures, but she could not conclude how the fracture occurred. The ADM stated they provided education to staff on peri-care with residents who have contractures and transfers. The ADM denied LVN A received any training following the incident. Regarding CNA B's statement which noted Resident #1 was in pain, the ADM stated "She's a CNA, that's her opinion." Interview with the ADM on 11/21/14 at 11:15 AM revealed LVN A was the Staff Coordinator who was in charge of conducting in-service training until about the end of September 2014. The ADM stated LVN A trained staff on Abuse and Neglect. The ADM revealed she demoted LVN A at that time due to the facility's budget. The ADM stated LVN A then made a complaint against her and when this incident occurred, she was not as involved in the investigation as she would have been. Interview with Physician II on 11/20/14 at 2:12 PM via telephone revealed he was notified on 10/18/14 by LVN A that Resident #1 had a bruise. Physician II stated he did not know the circumstances and there was no documented fall. Physician II stated LVN A notified him and stated they would monitor. Physician II called back on 11/20/14 at 2:39 PM and after reviewing his notes, stated LVN A felt it was a bruise and there was no need for an x-ray. Physician II stated he had "no tendency to question LVN A". The facility's undated "Policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Property", provided as current policy by the ADM, reflected the following: "Investigation... All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time are to report it to their immediate supervisor... The facility delegates the administrator as the abuse coordinator... An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator..." "Reporting...to follow state guidelines as outlined... for reporting incidents...Upon completion of the investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences..." An IJ was identified on 11/20/14. On 11/20/14 at 4:40 PM, the ADM and the DON were notified of the IJ and a Plan of Removal was requested at that time. Following the notification of the IJ, the ADM on 11/20/14 at 4:40 PM revealed LVN A was talked to by the RCON following the incident. The facility provided a Record of In-Service, dated 11/21/14 at 8:30 AM for LVN A, which reflected, "On October 22, 2014 the following discussion, education session was held c (with) LVN A...1. Completion of incident reports...2. Notification of DON of incidents/Abuse Coordinator...3. Using good critical thinking/judgment ...4. Unidentified bruising must be reported to Abuse Coordinator...." Interview with the RCON on 11/21/14 at 10:05 AM revealed she did not feel LVN A's assessment of Resident #1 was poor. The RCON stated the facility in-serviced LVN A on 10/22/14 about not reporting the unknown injury to the DON, however, they did not have any documentation from that day. The RCON stated they had documentation that was completed today and signed by LVN A, which showed he was trained on 10/22/14. Further review of LVN A's personnel file revealed an Employee Counseling Form, dated 11/20/14, which reflected, "...Suspension, pending outcome of investigation...Failed to notify Supervisor of bruise of unknown origin...Impact on Department: Resident Safety...." Interview with the ADM on 11/21/14 at 11:35 AM, revealed when queried how the IJ occurred, the ADM replied, "Because (LVN A) failed to notify supervisor about the injury." The ADM stated she did not feel the IJ was justified as LVN A did the assessment, assessed for pain, wrote an Incident Report and notified the physician and the family. The ADM stated the only thing LVN A failed to do was notify the DON. To prevent reoccurrence, the ADM stated Incident Reports would be followed up on within 24 hours and the 24 hour notes would be reviewed by Nurse Managers. The ADM stated the facility educated and would continue to educate staff on Abuse, notifications and assessments of injuries. The ADM revealed LVN A was suspended on 11/21/14 due to the IJ and due to his failure to notify the DON of the bruise. When asked why LVN A was not suspended during the incident investigation when it was discovered he did not notify the DON, the ADM stated LVN A was suspended in light of the IJ situation, due to the surveyors monitoring that weekend and LVN A would not be in the facility. The ADM also stated LVN A was talked to during the investigation; however the facility did not have an IJ then. Interview with the DON on 11/21/14 at 2:48 PM, revealed when queried how the IJ occurred, the DON replied the IJ was called as the facility was out of compliance according to the investigation conducted by the surveyors. The DON stated she did not feel the IJ was justified. The DON stated she felt there were always "opportunities for improvement," but did not feel the IJ was justified. The facility's Plan of Removal accepted on 11/21/14 at 1:34 PM reflected Resident #1 was assessed from head to toe including a Pain Evaluation by LVN E on 11/20/14 at 8:30 PM. His pain assessment scored was a four on the cognitively impaired scale, the physician was notified and ordered [MEDICATION NAME] 50 mg twice a day for 14 days and then re-evaluate. Resident #1's (Responsible Party) was notified of the new order. The DON and ADON F were re-inserviced on performing the "Pain Evaluation" form to include Verbal and Non-verbal pain evaluation by the RCON on 11/20/14 at 7:30 PM. October and November 2014 Incident Reports were reviewed by the DON on 11/20/14, to ensure pertinent data was documented and reported appropriately. Resident #1's care plan was updated on 11/21/14 to include his behaviors of resisting care, moaning/groaning, and hitting staff. The care plan for pain was also updated to include his new order of pain medication [MEDICATION NAME] 50 mg 14 days and then re-evaluate his pain. The DON and ADONs would be responsible for re-educating all licensed nurses, starting on 11/20/14 regarding "Pain Evaluation" to include residents who were capable of verbally expressing pain and residents who were cognitively impaired. The re-education would include Post test instructions on how to properly assess after an injury. The DON/ADON would re-educate all licensed staff, starting on 11/20/14, on a timely and proper assessment after injury, to include: bruising, [MEDICAL CONDITION], redness, misalignment, pain, bleeding, abnormal vital signs, abrasion, and current level of consciousness, level of orientation, pallor, numbness, tingling, external rotation or shortened leg, with x-rays if indicated. The DON/ADON will re-educate all staff starting on 11/20/14, on reporting alleged Abuse and Neglect, to include bruises of unknown origin, immediately to the Abuse Coordinator, the ADM. Based on interviews conducted with DA W, Therapy Staff V, MA X, CNAs I, J, O, P, Q, R, S, T, and U, LVNs N, M, H, Y, Z, AA, DD, RNs K and BB, Housekeeper L, and MAs FF and HH, and record reviews of In-Services conducted, it was determined the IJ was removed on 11/23/14. The ADM was notified on 11/23/14 at 3:40 PM, the IJ was removed. While the IJ was removed on 11/23/14, the facility remained out of compliance a severity level of "actual harm that is not immediate jeopardy" and a scope of "widespread" due to the facility needed to monitor the effectiveness of the Plan of Removal. The Daily Census sheet, dated 11/20/14, reflected 84 residents resided in the facility.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 11 residents reviewed for neglect. On 10/18/14, LVN A failed to assess a bruise of unknown origin found on the right hip of Resident #1, who was non-verbal and unable to make needs known. Resident #1 exhibited signs of pain on 10/18/14 and 10/19/14. On 10/20/14 following a re-assessment by LVN E, an x-ray was ordered, which indicated Resident #1 had a right hip impacted, slightly comminuted and displaced fracture. An Immediate Jeopardy (IJ) was identified on 11/20/14. While the IJ was removed on 11/23/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern" due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the 28 residents, according to the facility's census report dated 11/20/14, residing on the hall assigned to LVN A. Findings included: Resident #1's Face Sheet, dated 09/11/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/13/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired and he did not refuse care. Resident #1 was totally dependent on staff for bed mobility, dressing, toilet use, personal hygiene and bathing. Resident #1 had impairments of his upper and lower extremity on one side. Resident #1's care plan, dated 09/24/14 and reviewed on 10/24/14, reflected the resident exhibited aggressive behaviors and resisted care at times. The approaches were to approach with a calm and quiet demeanor, talk in a calm voice when behavior was disruptive, redirect and reapproach as indicated. The care plan also reflected Resident #1 was unable to respond to questions and commands verbally and was unable to make needs known related to [MEDICAL CONDITION]/Dysphasia, history [MEDICAL CONDITION] cognitive impairment. The approaches were to position self to have eye contact with resident, use touch and a calm voice, explain all procedures and allow resident to respond through gestures, facial expressions or eye contact. The care plan also reflected Resident #1 had contractures and was at risk for skin breakdown/pain and further decline in mobility. The approaches were to assist with positioning and repositioning, to monitor skin integrity and notify the physician of changes in skin and to monitor for pain/discomfort and intervene as indicated. Further review of Resident #1's care plan revealed a problem area dated 10/24/14, which reflected he exhibited non-verbal indicators of pain and the approaches were to evaluate pain using 1-10 scale, assist with repositioning as needed and monitor for worsening of non-verbal indicators of pain. Resident #1 was observed in bed in his room on 11/21/14 at 10:00 AM with the facility Regional Clinical Operations Nurse (RCON) and LVN Y. Resident #1 was awake in bed, [MEDICATION NAME] HN 1.2 was infusing at 60cc/hr (cubic centimeter/hour.) Head of bed was elevated 35 degrees. Resident #1's left hand was contracted from the wrist area and the fingers too. The left leg was hyperextended out to the ankle and toes. Resident #1 was observed able to move the right hand and the fingers. However, the right leg was observed to be flexed at the knee. Resident #1 was non-verbal and unable to assist with the transfers. An incident report, dated 10/18/14 at 10:00 AM, completed by LVN A, Charge nurse for Resident #1, reflected an unwitnessed incident type of bruising. The Brief description reflected, "Noted bruise or discoloration 10 cm along the lateral R (right) hip by 4 cm, Res (Resident) is bed bound appear to be from pressure from pillows used to position." The description did not reflect the color of the bruise. An attached Pain Evaluation, 10/18/14, reflected "unknown" location of current pain and a "0, No pain" on the scale. It further reflected a Non-Verbal Scale of "1", "Tense. Distressed pacing. Fidgeting". The summary reflected, "... may have been laying on R (right) side pressing on bony prominence for too long need to reposition every 2 hours and monitor the site". The report also reflected CNA B and CNA C were assigned to the hall at the time of the incident. The prior level of function and/or comments section reflected, "No change res (resident) [MEDICAL CONDITION] bedbound, multiple contractures, [MEDICAL CONDITION] c (with) L (left) sided weakness". Interview with LVN A on 11/20/14 at 12:35 PM via telephone revealed he made the incident report regarding Resident #1's bruise. LVN A stated he was alerted of the bruise by a CNA and he looked at the resident "head to toe". LVN A stated he did not touch the bruised area as it was "not necessary" as "you can look at it" to make an assessment. LVN A stated Resident #1 was able to verbalize pain, but "not too much". Another interview with LVN A was conducted on 11/21/14 at 8:47 AM in the facility. LVN A stated he called the injury "bruising" but it was more of a "discoloration" that was red in color. He revealed he did not check range of motion during his assessment and did not press on the bruised area to see if there was any pain. LVN A stated Resident #1 usually struck out with his right hand if he did not like something. LVN A revealed his initial thought was that the bruise was from too much pressure due to not being repositioned. LVN A stated he got an order for [REDACTED]. LVN A stated Resident #1 was bed bound, could not self transfer and he did not think Resident #1 could have fallen. LVN A stated at that time "no abuse crossed my mind". Interview with the DON on 11/20/14 at 2:45 PM revealed when asked about expectations during an assessment of an injury, the DON stated as part of the assessment she expected the nurse to look at the injury, evaluate what they saw, to touch the area to see if it was warm or cold and to check for any sensation or pain. The DON stated it concerned her if a nurse did not touch the area during the assessment. Interview with CNA B on 11/20/14 at 1:47 PM via telephone revealed she discovered a big bruise on Resident #1's right hip. CNA B stated she was surprised when she saw the bruise and did not know what happened. She stated Resident #1 was grimacing and she notified LVN A. CNA B stated LVN A told her he would make the incident report. CNA B stated she knew the resident was in pain on 10/19/14 because he was fighting, punching and was aggressive with her during care. CNA B stated Resident #1 knew her, she spoke to him in their same language and he was not aggressive with her before. She asked LVN A if Resident #1 had any pain medication. CNA B stated LVN A responded, "I'll see if he had anything". Review of the facility's 24 Hour Report for Hall 300 revealed on 10/18/14, under "Unusual Behaviors", Resident #1, "Monitor bruising on R (right) hip lateral side". Resident #1's physician's orders [REDACTED]. The facility's 24 Hour Report for Hall 300 on 10/19/14 reflected, "Bruise to lateral side of R hip" with no additional information. Resident #1's Nurse's Notes, dated 10/19/14 and written by LVN A, reflected, "... F/U (follow up) bruising to the R lateral side of the hip, repositioned q (every) 2 (hours), denies pain, discoloration healing well and beginning to fade will cont (continue) to monitor." Interview with LVN A on 11/21/14 at 8:47 AM revealed on 10/19/14 he felt the bruise was healing well and he did not think Resident #1 was in pain. LVN A denied CNA B reported to him Resident #1 was in pain. Interview with LVN D on 11/20/14 at 2:22 PM via telephone revealed she worked on 10/19/14 during the overnight shift. LVN D stated LVN A reported to her about Resident #1's bruise on the right hip. LVN D stated she was told it "might be from not repositioning". LVN D stated she looked at the bruise and was surprised how "bad" the bruise looked. She revealed she did not think the bruise was from not repositioning the resident. LVN D stated Resident #1 was usually "a fighter" however, that night he was calm. LVN D did not think he was in pain. Resident #1's physician's orders [REDACTED]. Resident #1's October 2014 MAR indicated [REDACTED]. According to the MAR, he did not receive any other pain medication from 10/18/14 through 10/20/14. The MAR indicated [REDACTED]. It further reflected a pain assessment was completed, as indicated by LVN A's initials during the day and evening shift on 10/18/14 and 10/19/14, with no pain level indication documented. It also reflected a pain assessment was completed during the night shift, as indicated by "N" for "non-verbal assessment tool for the cognitively impaired" was used, with no pain level indication documented. Resident #1's Nurse's Notes revealed on 10/20/14 at 10:15 AM: "This ADON (Assistant Director of Nursing) went to speak to 300 Hall charge nurse (LVN Y) regarding skin issue reported during Monday's morning standup meeting. Nurse confirmed that he saw the bruising for the first time this morning. ADON went to resident room to do a skin assessment. Met two CNAs in the room completing incontinent care upon inspection noted that bruising was located on the lateral posterior R (right) thigh between trocanter (sic) and knee. The bruising was dark purple in appearance, the patient moaned & (and) grimaced upon tactil (sic) assessment. On the patient upper hip area there was also a bruise area round in shape, light purple c (with) peticia (sic) (red or purple spot on the skin, caused by a minor hemorrhage (broken capillary blood vessels)) area. Requested 300 Hall nurse to order STAT xray..."; Interview with LVN E on 11/20/14 at 4:07 PM via telephone revealed she was the ADON who re-assessed Resident #1 on 10/20/14. LVN E stated she worked as the ADON, however, had since taken a different position. LVN E revealed she was asked by the DON to re-assess Resident #1 because of the incident report that was made. LVN E stated she looked at the injury and felt it was more than a bruise. LVN E said it was on the underside of the leg too. She stated an x-ray was ordered immediately. LVN E stated she participated in the investigation and the facility did identify a concern about LVN A's assessment of the injury. LVN E revealed CNA B felt Resident #1 was in pain, however LVN A did not think there was any pain. Resident #1's radiology report, dated 10/20/14, reflected, "...There is a right base of femoral neck fracture of unknown age, new finding since prior examination. No dislocation is seen". Interview with LVN Y on 11/20/14 at 11:59 AM revealed he was the charge nurse assigned to Resident #1 on 10/20/14. LVN Y revealed the bruise was brought to his attention that day and he observed the resident's thigh was swollen, bruised and when it was touched the resident grimaced. LVN Y stated the injury was assessed by the ADON at the time and an x-ray was ordered. LVN Y stated he did not know how Resident #1 received the fracture. Resident #1's hospital Radiology report, dated 10/20/14, reflected, "Injury...Fall...impacted (fracture in which the bone is broken and one end is wedged into the interior of the other) slightly comminuted (fracture in which the bone is broken or splintered into pieces) and displaced [MEDICAL CONDITION] right femur (thigh bone, which is the longest and strongest bone in the skeleton) involving the intertrochanteric region. The proximal fracture fragment is impacted with the distal fracture fragment and the distal fracture fragment is migrated in a cephalad (toward the head) direction." Resident #1's hospital Operative Report, dated 10/21/14, reflected he had surgery on 10/21/14 to repair the fracture. The facility's Provider Investigation Report, reported to DADS on 10/20/14, reflected on 10/18/14 Resident #1 had an injury of unknown source. On 10/18/14 at 10:00 AM, bruising was observed by CNA B and reported to LVN A. LVN A assessed the resident who did not exhibit any signs or symptoms of pain during peri-care that was provided by CNA B. On 10/19/14, Resident #1 was monitored by LVN A and other nurses and no pain medication was administered as "the assessment or resident" did not identify a need for pain medication. On 10/20/14 an x-ray was completed, which revealed a femoral neck fracture of unknown age. The report's Investigation Summary reflected, "Interviews were done via telephone and in person with all staff who provided care for the resident during the time frame from Thursday, October 16th to October 20th. This interview (of employees who did and/or had the potential to come in contact with resident) was done to ascertain facts which may have contributed to residents femoral fracture. Findings of the interviews revealed that the resident was not dropped. Nurses who assessed the resident deny seeing any evidence of pain between the dates of October 18th and October 19th. On October 20, 2014, LVN E went in to check the site of resident's bruise and observed with tactile assessment that the resident exhibited moaning and grimacing." Provider Action Taken Post Investigation reflected, "...In-Service regarding positioning and providing peri-care to residents with severe contractures. (Facility) at this time has no reason to believe that the resident was dropped or by any means intentional (sic) harmed by staff. He is bed bound and requires positioning for comfort and frequent peri-care." Attached to the Provider Investigation Report, reported to DADS on 10/20/14, were the following statements taken by the facility during the investigation and written as a summary of the facility's interview with the staff: LVN A's statement, dated 10/22/14, reflected, "...X-ray not called because they did not expect him to have had a fall due to the fact he is total care. States that he attributes this to the fact that they may have to open his leg to do peri care." LVN H's statement, dated 10/18/14, reflected, "...I did notice a moderate sized purplish-yellow bruise to his R (right) hip. I did not turn the resident or notice any s/s (signs/symptoms) of pain." CNA C's written statement, dated 10/22/14, reflected, "...States Saturday (10/18/14) gave bed bath & (and) noted that rt. (right) leg was swollen...I found out when (CNA B) came & (and) told me & (and) (LVN A) about the leg of (Resident #1) was swollen... I noticed that the leg was swollen during bed bath...states he usually thrusts but did not that day." Interview with CNA C on 11/20/14 at 1:38 PM revealed CNA B told him about the bruise and the swelling. CNA C stated he gave Resident #1 a bed bath on 10/18/14 and during repositioning he observed the swelling. CNA B's written statement, dated 10/22/14, reflected, "...Saturday morning (10/18/14) that resident had a purple bruise on thigh. I went got nurse & (and) told him (LVN A). I thought he was in pain and I asked the nurse both Sat/Sun (Saturday/Sunday) to give pain med (medication). When I turned him over he started kicking/fighting. The nurse and I turned him together and I showed him. I opened the brief and his leg was swollen." Interview with CNA O on 11/23/14 at 12:59 PM revealed Resident #1 did not speak English and she spoke the same language as the resident. CNA O stated she had taken care of Resident #1 for two years and he knew her. CNA O revealed the resident was not combative with her during care. CNA O stated at times Resident #1 would try to hit his family member, however, when they talked to him he relaxed. Interview with CNA P on 11/23/14 at 1:15 PM revealed Resident #1 was combative with her when she tried to provide care without telling him what she was going to do. CNA P stated as long as she spoke to him telling him what she needed to do he was not combative. CNA JJ's written statement, dated 10/22/14, reflected, "...She saw the bruise on his leg on Sunday. States that she went to help (CNA B) (change) resident and she showed me the bruise...." Interview with CNA JJ on 11/20/14 at 11:20 AM revealed she observed Resident #1 on Sunday (10/19/14). CNA JJ stated she saw the bruise and reported it to the nurse. CNA JJ stated she saw purple bruises on Resident #1's hip. CNA JJ revealed she could see on Resident #1's face that he was in pain. Interview with the DON on 11/20/14 at 2:45 PM revealed on Monday 10/20/14, she reviewed the Incident Report regarding Resident #1's bruise and asked the then ADON, who was now LVN E, to follow up. Regarding the incident investigation, the DON stated LVN A notified the physician, and LVN A did not see the need for an x-ray at the time. The DON revealed LVN A felt it was from the resident kicking, the pillow or that the resident hit his leg. The DON stated it could have occurred during peri-care as staff needed to move the resident's legs. The DON stated she was not aware that LVN A did not touch the bruised area at assessment. The DON stated they interviewed staff and found nothing to conclude harm was caused to the resident. The DON stated the staff was educated on transfers, turning and being gentle with peri-care. The DON revealed based on the assessment by LVN E on 10/20/14, she asked for an x-ray. The DON said she was not notified of the bruise, and stated she did not know about it until she reviewed the Incident Report on 10/20/14. Interview with the ADM on 11/20/14 at 4:20 PM revealed the investigation into the unknown injury was completed by herself, the DON, ADON (LVN E) and RCON. The ADM stated LVN A should have notified the DON about the bruise; however, they did not identify any concerns or issues with the initial assessment. The ADM stated Resident #1 did sustain a fracture, however, she did not know how it happened. The ADM stated Resident #1 had [MEDICAL CONDITION] and contractures, but she could not conclude how the fracture occurred. The ADM stated they provided education to staff on peri-care with residents who have contractures and transfers. The ADM denied LVN A received any training following the incident. Regarding CNA B's statement which noted Resident #1 was in pain, the ADM stated "She's a CNA, that's her opinion." Interview with Physician II on 11/20/14 at 2:12 PM via telephone revealed he was notified on 10/18/14 by LVN A that Resident #1 had a bruise. Physician II stated he did not know the circumstances and there was no documented fall. Physician II stated LVN A notified him and stated they would monitor. Physician II called back on 11/20/14 at 2:39 PM and after reviewing his notes, stated LVN A felt it was a bruise and there was no need for an x-ray. Physician II stated he had "no tendency to question" LVN A. The facility's undated "Policy to Prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Property", provided as current policy by the ADM, reflected the following: "Investigation... All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time are to report it to their immediate supervisor... The facility delegates the administrator as the abuse coordinator... An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator..." "Reporting...to follow state guidelines as outlined... for reporting incidents...Upon completion of the investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences..." An IJ was identified on 11/20/14. On 11/20/14 at 4:40 PM, the ADM and the DON were notified of the IJ and a Plan of Removal was requested at that time. Following the notification of the IJ, the ADM on 11/20/14 at 4:40 PM revealed LVN A was talked to by the RCON following the incident. The facility provided a Record of In-Service, dated 11/21/14 at 8:30 AM for LVN A, which reflected, "On October 22, 2014 the following discussion, education session was held c (with) LVN A...1. Completion of incident reports...2. Notification of DON of incidents/Abuse Coordinator...3. Using good critical thinking/judgment ...4. Unidentified bruising must be reported to Abuse Coordinator...." Interview with the RCON on 11/21/14 at 10:05 AM revealed she did not feel LVN A's assessment of Resident #1 was poor. The RCON stated the facility in-serviced LVN A on 10/22/14 about not reporting the unknown injury to the DON, however, they did not have any documentation from that day. The RCON stated they had documentation that was completed today and signed by LVN A, which showed he was trained on 10/22/14. Further review of LVN A's personnel file revealed an Employee Counseling Form, dated 11/20/14, which reflected, "...Suspension, pending outcome of investigation...Failed to notify Supervisor of bruise of unknown origin...Impact on Department: Resident Safety...." Interview with the ADM on 11/21/14 at 11:35 AM, revealed when queried how the IJ occurred, the ADM replied, "Because (LVN A) failed to notify supervisor about the injury." The ADM stated she did not feel the IJ was justified as LVN A did the assessment, assessed for pain, wrote an Incident Report and notified the physician and the family. The ADM stated the only thing LVN A failed to do was notify the DON. To prevent reoccurrence, the ADM stated Incident Reports would be followed up on within 24 hours and the 24 hour notes would be reviewed by Nurse Managers. The ADM stated the facility educated and would continue to educate staff on Abuse, notifications and assessments of injuries. The ADM revealed LVN A was suspended on 11/21/14 due to the IJ and due to his failure to notify the DON of the bruise. When asked why LVN A was not suspended during the incident investigation when it was discovered he did not notify the DON, the ADM stated LVN A was suspended in light of the IJ situation, due to the surveyors monitoring that weekend and LVN A would not be in the facility. The ADM also stated LVN A was talked to during the investigation; however the facility did not have an IJ then. Interview with the DON on 11/21/14 at 2:48 PM, revealed when queried how the IJ occurred, the DON replied the IJ was called as the facility was out of compliance according to the investigation conducted by the surveyors. The DON stated she did not feel the IJ was justified. The DON stated she felt there were always "opportunities for improvement," but did not feel the IJ was justified. The facility's Plan of Removal accepted on 11/21/14 at 1:34 PM reflected Resident #1 was assessed from head to toe including a Pain Evaluation by LVN E on 11/20/14 at 8:30 PM. His pain assessment scored was a four on the cognitively impaired scale, the physician was notified and ordered [MEDICATION NAME] 50 mg twice a day for 14 days and then re-evaluate. Resident #1's (Responsible Party) was notified of the new order. The DON and ADON F were re-inserviced on performing the "Pain Evaluation" form to include Verbal and Non-verbal pain evaluation by the RCON on 11/20/14 at 7:30 PM. October and November 2014 Incident Reports were reviewed by the DON on 11/20/14, to ensure pertinent data was documented and reported appropriately. Resident #1's care plan was updated on 11/21/14 to include his behaviors of resisting care, moaning/groaning, and hitting staff. The care plan for pain was also updated to include his new order of pain medication [MEDICATION NAME] 50 mg 14 days and then re-evaluate his pain. The DON and ADONs would be responsible for re-educating all licensed nurses, starting on 11/20/14 regarding "Pain Evaluation" to include residents who were capable of verbally expressing pain and residents who were cognitively impaired. The re-education would include Post test instructions on how to properly assess after an injury. The DON/ADON would re-educate all licensed staff, starting on 11/20/14, on a timely and proper assessment after injury, to include: bruising, [MEDICAL CONDITION], redness, misalignment, pain, bleeding, abnormal vital signs, abrasion, and current level of consciousness, level of orientation, pallor, numbness, tingling, external rotation or shortened leg, with x-rays if indicated. The DON/ADON will re-educate all staff starting on 11/20/14, on reporting alleged Abuse and Neglect, to include bruises of unknown origin, immediately to the Abuse Coordinator, the ADM. Based on interviews conducted with DA W, Therapy Staff V, MA X, CNAs I, J, O, P, Q, R, S, T, and U, LVNs N, M, H, Y, Z, AA, DD, RNs K and BB, Housekeeper L, and MAs FF and HH, and record reviews of In-Services conducted, it was determined the IJ was removed on 11/23/14. The ADM was notified on 11/23/14 at 3:40 PM, the IJ was removed. While the IJ was removed on 11/23/14, the facility remained out of compliance a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needed to monitor the effectiveness of the Plan of Removal. The Daily Census sheet, dated 11/20/14, reflected 28 residents resided on Hall 300, assigned to LVN A.

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of six residents reviewed for change in condition. LVN A failed to thoroughly assess Resident#1's bruise of unknown origin on the right hip, which was discovered on 10/18/14. LVN A failed to touch the bruised area to check the temperature of the area and to determine any sensation or pain. Resident #1 had no further assessment of the bruised area for two days. Two staff identified Resident #1 was in pain during that time. On 10/20/14 following a re-assessment by LVN E an x-ray was ordered, which indicated Resident #1 had a right hip impacted, slightly comminuted and displaced fracture. An Immediate Jeopardy (IJ) was identified on 11/20/14. While the IJ was removed on 11/23/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" due to the facility needed to monitor the effectiveness of the Plan of Removal. These failures could affect the 28 residents, according to the facility's census report dated 11/20/14, residing on the hall assigned to LVN A. Findings included: Resident #1's Face Sheet, dated 09/11/14, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1's comprehensive MDS assessment, dated 09/13/14, reflected his [DIAGNOSES REDACTED]. Resident #1's cognitive skills for daily decision-making were severely impaired and he did not refuse care. Resident #1 was totally dependent on staff for bed mobility, dressing, toilet use, personal hygiene and bathing. Resident #1 had impairments of his upper and lower extremity on one side. Resident #1's care plan, dated 09/24/14 and reviewed on 10/24/14, reflected the resident exhibited aggressive behaviors and resisted care at times. The approaches were to approach with a calm and quiet demeanor, talk in a calm voice when behavior was disruptive, redirect and reapproach as indicated. The care plan also reflected Resident #1 was unable to respond to questions and commands verbally and was unable to make needs known related to [MEDICAL CONDITION]/Dysphasia, history [MEDICAL CONDITION] cognitive impairment. The approaches were to position self to have eye contact with resident, use touch and a calm voice, explain all procedures and allow resident to respond through gestures, facial expressions or eye contact. The care plan also reflected Resident #1 had contractures and was at risk for skin breakdown/pain and further decline in mobility. The approaches were to assist with positioning and repositioning, to monitor skin integrity and notify the physician of changes in skin and to monitor for pain/discomfort and intervene as indicated. Further review of Resident #1's care plan revealed a problem area dated 10/24/14, which reflected he exhibited non-verbal indicators of pain and the approaches were to evaluate pain using 1-10 scale, assist with repositioning as needed and monitor for worsening of non-verbal indicators of pain. Resident #1 was observed in bed in his room on 11/21/14 at 10:00 AM with the facility Regional Clinical Operations Nurse (RCON) and LVN Y. Resident #1 was awake in bed, [MEDICATION NAME] HN 1.2 was infusing at 60cc/hr (cubic centimeter/hour.) Head of bed was elevated 35 degrees. Resident #1's left hand was contracted from the wrist area and the fingers too. The left leg was hyperextended out to the ankle and toes. Resident #1 was observed able to move the right hand and the fingers. However, the right leg was observed to be flexed at the knee. Resident #1 was non-verbal and unable to assist with the transfers. An incident report, dated 10/18/14 at 10:00 AM, completed by LVN A, Charge nurse for Resident #1, reflected an unwitnessed incident type of bruising. The Brief description reflected, "Noted bruise or discoloration 10 cm along the lateral R (right) hip by 4 cm, Res (Resident) is bed bound appear to be from pressure from pillows used to position." The description did not reflect the color of the bruise. An attached Pain Evaluation, dated 10/18/14, reflected "unknown" location of current pain and a "0, No pain" on the scale. It further reflected a Non-Verbal Scale of "1", "Tense. Distressed pacing. Fidgeting". The summary reflected, "... may have been laying on R (right) side pressing on bony prominence for too long need to reposition every 2 hours and monitor the site". The report also reflected CNA B and CNA C were assigned to the hall at the time of the incident. The prior level of function and/or comments section reflected, "No change res (resident) [MEDICAL CONDITION] bedbound, multiple contractures, [MEDICAL CONDITION] c (with) L (left) sided weakness". Interview with LVN A on 11/20/14 at 12:35 PM via telephone revealed he made the incident report regarding Resident #1's bruise. LVN A stated he was alerted of the bruise by a CNA and he looked at the resident "head to toe". LVN A stated he did not touch the bruised area as it was "not necessary" as "you can look at it" to make an assessment. LVN A stated Resident #1 was able to verbalize pain, but "not too much". Another interview with LVN A was conducted on 11/21/14 at 8:47 AM in the facility. LVN A stated he called the injury "bruising" but it was more of a "discoloration" that was red in color. He revealed he did not check range of motion during his assessment and did not press on the bruised area to see if there was any pain. LVN A stated Resident #1 usually struck out with his right hand if he did not like something. LVN A revealed his initial thought was that the bruise was from too much pressure due to not being repositioned. LVN A stated he got an order for [REDACTED]. LVN A stated Resident #1 was bed bound, could not self transfer and he did not think Resident #1 could have fallen. LVN A stated at that time "no abuse crossed my mind". Interview with the DON on 11/20/14 at 2:45 PM revealed when asked about expectations during an assessment of an injury, the DON stated as part of the assessment she expected the nurse to look at the injury, evaluate what they saw, to touch the area to see if it was warm or cold and to check for any sensation or pain. The DON stated it concerned her if a nurse did not touch the area during the assessment. Interview with CNA B on 11/20/14 at 1:47 PM via telephone revealed she discovered a big bruise on Resident #1's right hip. CNA B stated she was surprised when she saw the bruise and did not know what happened. She stated Resident #1 was grimacing and she notified LVN A. CNA B stated LVN A told her he would make the incident report. CNA B stated she knew the resident was in pain on 10/19/14 because he was fighting, punching and was aggressive with her during care. CNA B stated Resident #1 knew her, she spoke to him in their same language and he was not aggressive with her before. She asked LVN A if Resident #1 had any pain medication. CNA B stated LVN A responded, "I'll see if he had anything". Review of the facility's 24 Hour Report for Hall 300 revealed on 10/18/14, under "Unusual Behaviors", Resident #1, "Monitor bruising on R (right) hip lateral side". Resident #1's physician's orders [REDACTED]. The facility's 24 Hour Report for Hall 300 on 10/19/14 reflected, "Bruise to lateral side of R hip" with no additional information. Resident #1's Nurse's Notes, dated 10/19/14 and written by LVN A, reflected, "... F/U (follow up) bruising to the R lateral side of the hip, repositioned q (every) 2 (hours), denies pain, discoloration healing well and beginning to fade will cont (continue) to monitor." Interview with LVN A on 11/21/14 at 8:47 AM revealed on 10/19/14 he felt the bruise was healing well and he did not think Resident #1 was in pain. LVN A denied CNA B reported to him Resident #1 was in pain. Interview with LVN D on 11/20/14 at 2:22 PM via telephone revealed she worked on 10/19/14 during the overnight shift. LVN D stated LVN A reported to her about Resident #1's bruise on the right hip. LVN D stated she was told it "might be from not repositioning". LVN D stated she looked at the bruise and was surprised how "bad" the bruise looked. She revealed she did not think the bruise was from not repositioning the resident. LVN D stated Resident #1 was usually "a fighter" however, that night he was calm. LVN D did not think he was in pain. Resident #1's physician's orders [REDACTED]. Resident #1's October 2014 MAR indicated [REDACTED]. According to the MAR, he did not receive any other pain medication from 10/18/14 through 10/20/14. The MAR indicated [REDACTED]. It further reflected a pain assessment was completed, as indicated by LVN A's initials during the day and evening shift on 10/18/14 and 10/19/14, with no pain level indication documented. It also reflected a pain assessment was completed during the night shift, as indicated by "N" for "non-verbal assessment tool for the cognitively impaired" was used, with no pain level indication documented. Resident #1's Nurse's Notes revealed on 10/20/14 at 10:15 AM: "This ADON (Assistant Director of Nursing) went to speak to 300 Hall charge nurse (LVN Y) regarding skin issue reported during Monday's morning standup meeting. Nurse confirmed that he saw the bruising for the first time this morning. ADON went to resident room to do a skin assessment. Met two CNAs in the room completing incontinent care upon inspection noted that bruising was located on the lateral posterior R (right) thigh between trocanter (sic) and knee. The bruising was dark purple in appearance, the patient moaned & (and) grimaced upon tactil (sic) assessment. On the patient upper hip area there was also a bruise area round in shape, light purple c (with) peticia (sic)(red or purple spot on the skin, caused by a minor hemorrhage (broken capillary blood vessels)) area. Requested 300 Hall nurse to order STAT xray..."; Interview with LVN E on 11/20/14 at 4:07 PM via telephone revealed she was the ADON who re-assessed Resident #1 on 10/20/14. LVN E stated she worked as the ADON, however, had since taken a different position. LVN E revealed she was asked by the DON to re-assess Resident #1 because of the incident report that was made. LVN E stated she looked at the injury and felt it was more than a bruise. LVN E said it was on the underside of the leg too. She stated an x-ray was ordered immediately. LVN E stated she participated in the investigation and the facility did identify a concern about LVN A's assessment of the injury. LVN E revealed CNA B felt Resident #1 was in pain, however LVN A did not think there was any pain. Resident #1's radiology report, dated 10/20/14, reflected, "...There is a right base of femoral neck fracture of unknown age, new finding since prior examination. No dislocation is seen". Interview with LVN Y on 11/20/14 at 11:59 AM revealed he was the charge nurse assigned to Resident #1 on 10/20/14. LVN Y revealed the bruise was brought to his attention that day and he observed the resident's thigh was swollen, bruised and when it was touched the resident grimaced. LVN Y stated the injury was assessed by the ADON at the time and an x-ray was ordered. LVN Y stated he did not know how Resident #1 received the fracture. Resident #1's hospital Radiology report, dated 10/20/14, reflected, "Injury...Fall...impacted (fracture in which the bone is broken and one end is wedged into the interior of the other) slightly comminuted (fracture in which the bone is broken or splintered into pieces) and displaced [MEDICAL CONDITION] right femur (thigh bone, which is the longest and strongest bone in the skeleton) involving the intertrochanteric region. The proximal fracture fragment is impacted with the distal fracture fragment and the distal fracture fragment is migrated in a cephalad (toward the head) direction." Resident #1's hospital Operative Report, dated 10/21/14, reflected he had surgery on 10/21/14 to repair the fracture. The facility's Provider Investigation Report, reported to DADS on 10/20/14, reflected on 10/18/14 Resident #1 had an injury of unknown source. On 10/18/14 at 10:00 AM, bruising was observed by CNA B and reported to LVN A. LVN A assessed the resident who did not exhibit any signs or symptoms of pain during peri-care that was provided by CNA B. On 10/19/14, Resident #1 was monitored by LVN A and other nurses and no pain medication was administered as "the assessment or resident" did not identify a need for pain medication. On 10/20/14 an x-ray was completed, which revealed a femoral neck fracture of unknown age. The report's Investigation Summary reflected, "Interviews were done via telephone and in person with all staff who provided care for the resident during the time frame from Thursday, October 16th to October 20th. This interview (of employees who did and/or had the potential to come in contact with resident) was done to ascertain facts which may have contributed to residents femoral fracture. Findings of the interviews revealed that the resident was not dropped. Nurses who assessed the resident deny seeing any evidence of pain between the dates of October 18th and October 19th. On October 20, 2014, LVN E went in to check the site of resident's bruise and observed with tactile assessment that the resident exhibited moaning and grimacing." Provider Action Taken Post Investigation reflected, "...In-Service regarding positioning and providing peri-care to residents with severe contractures. (Facility) at this time has no reason to believe that the resident was dropped or by any means intentional (sic) harmed by staff. He is bed bound and requires positioning for comfort and frequent peri-care." Attached to the Provider Investigation Report, reported to DADS on 10/20/14, were the following statements taken by the facility during the investigation and written as a summary of the facility's interview with the staff: LVN A's statement, dated 10/22/14, reflected, "...X-ray not called because they did not expect him to have had a fall due to the fact he is total care. States that he attributes this to the fact that they may have to open his leg to do peri care." LVN H's statement, dated 10/18/14, reflected, "...I did notice a moderate sized purplish-yellow bruise to his R (right) hip. I did not turn the resident or notice any s/s (signs/symptoms) of pain." CNA C's written statement, dated 10/22/14, reflected, "...States Saturday (10/18/14) gave bed bath & (and) noted that rt. (right) leg was swollen...I found out when (CNA B) came & (and) told me & (and) (LVN A) about the leg of (Resident #1) was swollen... I noticed that the leg was swollen during bed bath...states he usually thrusts but did not that day." Interview with CNA C on 11/20/14 at 1:38 PM revealed CNA B told him about the bruise and the swelling. CNA C stated he gave Resident #1 a bed bath on 10/18/14 and during repositioning he observed the swelling. CNA B's written statement, dated 10/22/14, reflected, "...Saturday morning (10/18/14) that resident had a purple bruise on thigh. I went got nurse & (and) told him (LVN A). I thought he was in pain and I asked the nurse both Sat/Sun (Saturday/Sunday) to give pain med (medication). When I turned him over he started kicking/fighting. The nurse and I turned him together and I showed him. I opened the brief and his leg was swollen." Interview with CNA O on 11/23/14 at 12:59 PM revealed Resident #1 did not speak English and she spoke the same language as the resident. CNA O stated she had taken care of Resident #1 for two years and he knew her. CNA O revealed the resident was not combative with her during care. CNA O stated at times Resident #1 would try to hit his family member, however, when they talked to him he relaxed. Interview with CNA P on 11/23/14 at 1:15 PM revealed Resident #1 was combative with her when she tried to provide care without telling him what she was going to do. CNA P stated as long as she spoke to him telling him what she needed to do he was not combative. CNA JJ's written statement, dated 10/22/14, reflected, "...She saw the bruise on his leg on Sunday. States that she went to help (CNA B) (change) resident and she showed me the bruise...." Interview with CNA JJ on 11/20/14 at 11:20 AM revealed she observed Resident #1 on Sunday (10/19/14). CNA JJ stated she saw the bruise and reported it to the nurse. CNA JJ stated she saw purple bruises on Resident #1's hip. CNA JJ revealed she could see on Resident #1's face that he was in pain. Interview with the DON on 11/20/14 at 2:45 PM revealed on Monday 10/20/14, she reviewed the Incident Report regarding Resident #1's bruise and asked the then ADON, who was now LVN E, to follow up. Regarding the incident investigation, the DON stated LVN A notified the physician, and LVN A did not see the need for an x-ray at the time. The DON revealed LVN A felt it was from the resident kicking, the pillow or that the resident hit his leg. The DON stated it could have occurred during peri-care as staff needed to move the resident's legs. The DON stated she was not aware that LVN A did not touch the bruised area at assessment. The DON stated they interviewed staff and found nothing to conclude harm was caused to the resident. The DON stated the staff was educated on transfers, turning and being gentle with peri-care. The DON revealed based on the assessment by LVN E on 10/20/14, she asked for an x-ray. The DON said she was not notified of the bruise, and stated she did not know about it until she reviewed the Incident Report on 10/20/14. Interview with the ADM on 11/20/14 at 4:20 PM revealed the investigation into the unknown injury was completed by herself, the DON, ADON (LVN E) and RCON. The ADM stated LVN A should have notified the DON about the bruise; however, they did not identify any concerns or issues with the initial assessment. The ADM stated Resident #1 did sustain a fracture, however, she did not know how it happened. The ADM stated Resident #1 had [MEDICAL CONDITION] and contractures, but she could not conclude how the fracture occurred. The ADM stated they provided education to staff on peri-care with residents who have contractures and transfers. The ADM denied LVN A received any training following the incident. Regarding CNA B's statement which noted Resident #1 was in pain, the ADM stated "She's a CNA, that's her opinion." Interview with Physician II on 11/20/14 at 2:12 PM via telephone revealed he was notified on 10/18/14 by LVN A that Resident #1 had a bruise. Physician II stated he did not know the circumstances and there was no documented fall. Physician II stated LVN A notified him and stated they would monitor. Physician II called back on 11/20/14 at 2:39 PM and after reviewing his notes, stated LVN A felt it was a bruise and there was no need for an x-ray. Physician II stated he had "no tendency to question" LVN A. An IJ was identified on 11/20/14. On 11/20/14 at 4:40 PM, the ADM and the DON were notified of the IJ and a Plan of Removal was requested at that time. Following the notification of the IJ, the ADM on 11/20/14 at 4:40 PM revealed LVN A was talked to by the RCON following the incident. The facility provided a Record of In-Service, dated 11/21/14 at 8:30 AM for LVN A, which reflected, "On October 22, 2014 the following discussion, education session was held c (with) LVN A...1. Completion of incident reports...2. Notification of DON of incidents/Abuse Coordinator...3. Using good critical thinking/judgment ...4. Unidentified bruising must be reported to Abuse Coordinator...." Interview with the RCON on 11/21/14 at 10:05 AM revealed she did not feel LVN A's assessment of Resident #1 was poor. The RCON stated the facility in-serviced LVN A on 10/22/14 about not reporting the unknown injury to the DON, however, they did not have any documentation from that day. The RCON stated they had documentation that was completed today and signed by LVN A, which showed he was trained on 10/22/14. Further review of LVN A's personnel file revealed an Employee Counseling Form, dated 11/20/14, which reflected, "...Suspension, pending outcome of investigation...Failed to notify Supervisor of bruise of unknown origin...Impact on Department: Resident Safety...." Interview with the ADM on 11/21/14 at 11:35 AM, revealed when queried how the IJ occurred, the ADM replied, "Because (LVN A) failed to notify supervisor about the injury." The ADM stated she did not feel the IJ was justified as LVN A did the assessment, assessed for pain, wrote an Incident Report and notified the physician and the family. The ADM stated the only thing LVN A failed to do was notify the DON. To prevent reoccurrence, the ADM stated Incident Reports would be followed up on within 24 hours and the 24 hour notes would be reviewed by Nurse Managers. The ADM stated the facility educated and would continue to educate staff on Abuse, notifications and assessments of injuries. The ADM revealed LVN A was suspended on 11/21/14 due to the IJ and due to his failure to notify the DON of the bruise. When asked why LVN A was not suspended during the incident investigation when it was discovered he did not notify the DON, the ADM stated LVN A was suspended in light of the IJ situation, due to the surveyors monitoring that weekend and LVN A would not be in the facility. The ADM also stated LVN A was talked to during the investigation; however the facility did not have an IJ then. Interview with the DON on 11/21/14 at 2:48 PM, revealed when queried how the IJ occurred, the DON replied the IJ was called as the facility was out of compliance according to the investigation conducted by the surveyors. The DON stated she did not feel the IJ was justified. The DON stated she felt there were always "opportunities for improvement," but did not feel the IJ was justified. The facility's Plan of Removal accepted on 11/21/14 at 1:34 PM reflected Resident #1 was assessed from head to toe including a Pain Evaluation by LVN E on 11/20/14 at 8:30 PM. His pain assessment scored was a four on the cognitively impaired scale, the physician was notified and ordered [MEDICATION NAME] 50 mg twice a day for 14 days and then re-evaluate. Resident #1's (Responsible Party) was notified of the new order. The DON and ADON F were re-inserviced on performing the "Pain Evaluation" form to include Verbal and Non-verbal pain evaluation by the RCON on 11/20/14 at 7:30 PM. October and November 2014 Incident Reports were reviewed by the DON on 11/20/14, to ensure pertinent data was documented and reported appropriately. Resident #1's care plan was updated on 11/21/14 to include his behaviors of resisting care, moaning/groaning, and hitting staff. The care plan for pain was also updated to include his new order of pain medication [MEDICATION NAME] 50 mg 14 days and then re-evaluate his pain. The DON and ADONs would be responsible for re-educating all licensed nurses, starting on 11/20/14 regarding "Pain Evaluation" to include residents who were capable of verbally expressing pain and residents who were cognitively impaired. The re-education would include Post test instructions on how to properly assess after an injury. The DON/ADON would re-educate all licensed staff, starting on 11/20/14, on a timely and proper assessment after injury, to include: bruising, [MEDICAL CONDITION], redness, misalignment, pain, bleeding, abnormal vital signs, abrasion, and current level of consciousness, level of orientation, pallor, numbness, tingling, external rotation or shortened leg, with x-rays if indicated. The DON/ADON will re-educate all staff starting on 11/20/14, on reporting alleged Abuse and Neglect, to include bruises of unknown origin, immediately to the Abuse Coordinator, the ADM. Based on interviews conducted with DA W, Therapy Staff V, MA X, CNAs I, J, O, P, Q, R, S, T, and U, LVNs N, M, H, Y, Z, AA, DD, RNs K and BB, Housekeeper L, and MAs FF and HH, and record reviews of In-Services conducted, it was determined the IJ was removed on 11/23/14. The ADM was notified on 11/23/14 at 3:40 PM, the IJ was removed. While the IJ was removed on 11/23/14, the facility remained out of compliance a severity level of "actual harm that is not immediate jeopardy," and a scope of "pattern," due to the facility needed to monitor the effectiveness of the Plan of Removal. The Daily Census sheet, dated 11/20/14, reflected 84 residents resided in the facility.

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 each resident for one (Resident #1) of five residents reviewed for abuse. The Administrator failed to implement the facility's Abuse Policies and Procedures. Resident #1 reported to the SW Resident #2 made crude, sexual remarks to her and continued to try and grab her breasts. The Administrator did not conduct a thorough investigation, protect Resident #1, or report the allegation to the State survey and certification agency. These failures resulted in Resident #1 feeling "dirty," frustrated, angry, and retaliated against by the facility. An Immediate Jeopardy (IJ) situation was identified on 04/19/13. While the IJ was removed on 04/21/13, 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 other 68 female residents by placing them at risk for being touched inappropriately, feelings of guilt, and decreased self-esteem and quality of life. Findings included: The facility's current undated policy and procedure on Abuse and Neglect Prohibition reflected: "Our residents have the right to be free from abuse, neglect misappropriation of resident's property, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family member or legal guardians, friends, or other individuals...Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault...3. PREVENTION Provide residents, families and staff information on how to and to whom they may report concerns, incidents and grievances without the fear of retribution, and provide feedback regarding the concerns that have been expressed...The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect...INVESTIGATION...The facility will conduct an investigation of all alleged abuse/neglect...in accordance with state law....Facility will report all allegations and all investigation findings to the state as per state regulations...Details of activity that was occurring at the time of the alleged incident. The names and statements of staff members working on the unit at the time...Statements or interviews from the witness, other residents, and the alleged violator...Be sure to document the entire investigation thoroughly, then take corrective action in order to assure residents protection...PROTECTION...The facility will protect residents from harm during the investigation by removing the alleged abuser from contact with other residents as appropriate to a monitored location. Interview all residents possibly involved with the incident or the aggressor...." The facility's undated Reporting Abuse and Neglect Policy reflected, "Any facility staff member who has cause to believe that the physical or mental health or welfare of any resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately...1. For staff notify Facility Abuse/Neglect Coordinator, the Administrator and DON immediately. 2. Administrator and DON notify your direct report/supervisor immediately to determine if event meets DADS current reportable criteria...1. If resident to resident altercation - separate the residents. You may have to assign staff to do 1:1, until receive further direction...The following incidents of abuse and/or neglect must be reported to the DADS (Department of Aging and Disability Services) State Office, Austin, TX, immediately upon learning of the incident. A written investigation report must be sent no later that the fifth working day after the oral report. The facility Investigation Report (see attachment 1) must be used to document facility investigations. Abuse 1. The facility staff will follow the state regulatory agency requirements for identifying and reporting Resident to resident incidents...Neglect 1. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident...." Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected her cognition was moderately impaired, she used a wheelchair for locomotion, and she needed the assistance of one person with ADLs. Resident #1's Care Plan dated 02/23/13 reflected Resident #1 had short-term memory deficits and required assistance with decision making in some situations. Resident #1 had a [DIAGNOSES REDACTED]. The Facility's Concern Resolution Record dated 04/13/13 reflected Resident #1 wrote a complaint that Resident #2 was harassing her and attempted to grab her. The Record reflected the SW "...spoke with (Resident #2) about keeping his hands to himself. He denies touching others. I spoke with (DON) and she will talk to the staff about this issue." The Concern Resolution Record further reflected, "(Resident #1) is happy that the staff will keep a closer eye on him and his interactions (with) others." The Record was signed by the Administrator on 04/18/13. Resident #2's MDS assessment dated [DATE] reflected Resident #2 was an [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected his cognition was severely impaired, he used a walker for ambulation, and he needed the assistance of one person for ADLs. The MDS assessment did not reflect that Resident #2 had any behavior problems. Resident #2's Care Plan dated 01/04/13 reflected he had moderate cognitive impairments. According to Resident #2's care plan, he wandered throughout the facility and wandered into unsafe areas. The Care Plan Approaches included redirecting him to an area that was frequently monitored, alert staff to his behavior, provide diversional activities, and monitor and document behavior. The facility's Incident/Accident Report dated 04/19/13 reflected, "(Resident #1) complained that another male resident touched her inappropriately. Upon assessment no injuries, no bruises noted." The Report did not identify who the other resident was or where Resident #1 was touched. The "FINAL DISPOSITION ACTIONS TO MINIMIZE REOCCURRENCE: Administration aware...." Interview on 04/19/13 at 11:15 AM with Resident #1, who was sitting in her wheelchair in the hall, revealed when asked if she was ok , the resident replied, "I am not okay." When asked what was wrong, Resident #1 responded, "(Resident #2) touched and grabbed me. I told them and they did nothing about it." Resident #1 stated she completed a grievance form reflecting Resident #2 touched her inappropriately on 04/13/13. Resident #1 stated she dropped the complaint slip in a box by the Social Worker's office. Resident #1 stated when the Social Worker saw her, she did not ask her (Resident #1) about the allegation she dropped in the concern box. Resident #1 revealed the Social Worker asked, "When are you going to be discharged ?" Resident #1 also revealed, "I'm upset and I said to her 'Is the facility retaliating for me filing a complaint?" The Social Worker replied she was coming to ask her about the discharge planning. Interview on 04/19/13 at 1:00 PM with the Social Worker revealed Resident #1 said Resident #2 attempted to touch her. She stated there was no discharge planning on Resident #1's chart on admission, and she needed to discuss discharge planning with Resident #1. The Social Worker revealed when she went to talk with Resident #1, the resident started complaining about Resident #2's behavior. She stated after Resident #1 finished talking to her, she asked Resident #1 about her discharge planning. The Social Worker revealed Resident #1 replied, "Is that because I complained about Resident #2, so you want to discharge me from the facility?" The social worker stated the only reason she asked her about the discharge planning was because there was no discharge planning on her chart when she was admitted to the facility. The Social Worker stated she told the DON about the abuse allegation and she (the DON) said she would take care of it. The SW provided the surveyor with Social Progress Notes for Resident #1 dated 04/15/13, which she considered her investigation of the allegation. Resident #1's Social Progress Notes dated 04/15/13 reflected, "(Resident #1) states that (Resident #2) has been harassing her. She states that he has grabbed on her and squeezed her breasts while saying 'nice titties.' I have asked the staff about this but they have not seen him behave this way. I gave the grievance form to the D.O.N. She states she will put a plan of action in place. I also spoke (with) (Resident #2) about this situation and he denies ever putting his hands on her. I asked her who else he has been putting his hands on inappropriately and she stated she knows the residents but refuses to tell me their names." Resident #1's Social Progress Notes dated 04/19/13 reflected, "Late entry and clarification: In reference to the statement on the 3rd line, correction, should say, 'she states that he has grabbed on her (family member) and squeezed her (family member's) breast while saying 'nice titties.'" Interview with the DON on 04/19/13 at 1:43 PM revealed an investigation was conducted, and there were no witnesses of Resident #2 touching Resident #1 inappropriately. When asked for the investigation, the DON stated the SW conducted the investigation. Interview on 04/19/13 at 11:30 AM with the Administrator revealed Resident #2 did not touch Resident #1. The Administrator stated Resident #2 was a quiet man and he did not bother any resident. She revealed, "Can I show you what (Resident #2) does to people?" The surveyor replied, "Yes." The Administrator left her chair and bent forward in front of the surveyor. The Administrator looked directly into the surveyor's eyes and said, "Hi." The Administrator stated, "That is what he does. He just says hi to people." When asked if she investigated the allegation of Resident #2 inappropriately touching Resident #1, she replied, "Yes." The Administrator stated none of the staff or residents witnessed Resident #2 touching Resident #1. When asked if she reported the allegation to the state agency, she replied no because it was not a reportable incident because there were no witnesses. Further interview on 04/20/13 at 11:05 AM with Resident #1 revealed, "I feel like they did not care. I felt like dirt when (Resident #2) touched me." She stated the Administrator did not ask her what happened. Resident #1 revealed Resident #2 told her "Pretty boobies," and he touched her one time on her breasts. She stated Resident #2 attempted to touch her on four other occasions, and he called her "Fat cow, fat grandma." Resident #1 revealed other residents and staff witnessed Resident #2's inappropriate behavior. She said sometimes when Resident #2 misbehaved, some of the staff laughed and tried to stop him from harassing her. Resident #1 revealed the staff thought Resident #2's behavior was funny. Resident #1 stated Resident #2 yelled at her to shut up. Resident #1 stated sometimes Resident #2 stood in front of the television in the waiting area and turned off the television. Resident #1 stated this was directed to her. Resident #1 stated Resident #2 always did this when she was watching the television. A handwritten statement from Resident #1 dated 04/22/13 at 2:02 PM reflected, " 1) I felt helpless, and like anything can happen and no one will put a stop to it. 2) I felt uncomfortable and violated for him to come reach for my chest. 3) Well the main one that would see a lot was (Activity Director)... nite (sic) nurses after 10 pm. 4)once and then the rest of the time he would just come fighting and cursing at me and would try to eat my food. 5) Fat cow, [***] ...." Resident #1's family member on 04/20/13 at 2:15 PM revealed Resident #2 grabbed her breast, attempted to grab her chest several times, and he pulled her hair. She stated Resident #2 called her the following names: [***] , Big Booty and big tittie girl. She revealed when she was watching television, Resident #2 turned off the television. Resident #1's family member stated the 10:00 PM to 6:00 AM staff witnessed Resident #2's inappropriate behaviors. She stated, "mostly the night crew after 10:00 PM knew about it and just take him away like it was funny or joke. I don't think it was a problem to anyone, but it was for us." She stated the problem was for her and Resident #1. Resident #1's family member revealed Resident #5 witnessed Resident #2's inappropriate behavior. A handwritten statement from Resident #1's family member dated 04/20/13 at 2:15 PM reflected, "1) I felt so uncomfortable and violated that this strange man came at me trying to grab on my chest. Another day not paying attention he came up behind and pulled on my hair and actually grabbed my BooB. After that I screamed at him and he left. Everyday after that he sees me and curses at me and calls me names like [***] , Big Booty, Big Tittie girl. When we watch TV at night he would go turn the TV off on use just to mess with us. Mostly the night crew after 10 pm knew about it and just take him away like it was Funny or a joke. I don't think it was problem to anyone but it was us." An interview with Resident #16's family member on 04/19/13 at 12:07 PM revealed he/she witnessed Resident #2 sexually harassing Resident #1. He/she stated Resident #2 focused his harassment on Resident #1 and her family, and Resident #2 constantly harassed Resident #1 several times a day. The family member revealed Resident #2 grabbed his female victim on the breast and also verbally abused her. Resident #16's family member stated Resident #2 should be reprimanded and be removed from the rest of the residents. A handwritten statement dated 04/19/13 from Resident #16's family member reflected, "This statement will document the habitual sexual harassment which (Resident #2) has imposed on residents and guests of Vista Ridge Nursing & Rehab Center in recent weeks. He has focused his harassment on (Resident #1) and her family guests, usually several times a day. He physically grabs his female victims by their breasts, and also verbally abuses them. Despite our strongly rebuking his approaches he continues to repeat his offenses over & over. He needs to be severely reprimanded and kept isolated from all other female residents until he discontinues this abusive behavior. If he will not cooperate he should be discharged to the care of his family or other legal guardians...." Interview on 04/19/13 at 1:00 PM with Resident #3 revealed she witnessed Resident #2 touch Resident #1 inappropriately and harass Resident #1. Resident #3 stated she heard Resident #2 say bad things to Resident #1. Resident #3's handwritten statement dated 04/19/13 reflected, "I have been a Witness to the problems on the other side. This need to be stopped because (Resident #2) has been coming up to (Resident #1) and saying bad things to her and her (family member)...he is a bad trouble maker...." Interview on 04/19/13 at 1:30 PM with Resident #4 revealed he witnessed Resident #2 touching Resident #1. Resident #4 stated Resident #2 yelled at Resident #1 when they were watching TV and eating pizza in the TV room. Resident #4 also stated Resident #2 tried to grab the pizza off his plate. Resident #4 revealed Resident #2 asked Resident #1 "What's up sexy?" Resident #4 stated Resident #2 constantly barked like a dog when he saw Resident #1. A handwritten statement from Resident #4 dated 04/19/13 at 1:30 PM reflected, "I seen a couple of times Bothering and touching (Resident #1) Barking and yelling and her (Resident #1's member) when We had pizza and movie night he try to grab food off her plate." Interview on 04/21/13 at 1:30 AM with LVN T revealed she worked the 10:00 PM to 6:00 AM shift. LVN T stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:35 AM with CNA U revealed she worked the 10:00 PM to 6:00 AM shift. CNA U stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:40 AM with CNA V revealed she worked the 10:00 PM to 6:00 AM shift. CNA V stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:47 AM with CNA W revealed she worked the 10:00 PM to 6:00 AM shift. CNA W stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:55 AM with CNA X revealed she worked the 10:00 PM to 6:00 AM shift. CNA X stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 2:00 AM with CNA Y revealed she worked the 10:00 PM to 6:00 AM shift. CNA Y stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 2:10 AM with CNA H revealed she worked the 10:00 PM to 6:00 AM shift. CNA H stated she did not observe Resident #2 harassing or touching anyone inappropriately. The Administrator requested on 04/19/13 at approximately 1:00 PM a list of residents who were interviewed by the surveyor. On 04/20/13 at 12:00 PM, the Administrator returned with additional Social Progress Notes with no names in the blocks at the end of the form, which the facility considered their investigation. The Administrator stated, "Here are the notes from the Social Worker. I don't know why she did not give them to you." Resident #8's Social Progress Notes dated 04/15/13 reflected, "I was told by (Resident #8) that 'he heard one time a long time ago,' a woman say 'leave me alone.' But he is blind and could not tell who the woman was but he thinks (Resident #2) is who the woman was telling that to.'" Social Progress Notes dated 04/15/13 reflected, "I spoke with (Resident #16's family member) about (Resident #2) bothering (Resident #1) and he stated that he has witnessed (Resident #2) aggrivating (sic) and bothering (Resident #1). He stated that he got angry one time when (Resident #2) was bothering people in the common areas that he wanted to hit (Resident #2) with a 9-iron. He did not state that he witnessed (Resident #2) touching (Resident #1's family member). (Resident #16) was sitting next to her (family member) when she stated 'yes, I seen it too.' 'He is always bothering us.'" Social Progress Notes dated 04/15/13 reflected, "I spoke with (Wound Nurse) and asked her if she noticed (Resident #2) behavior inappropriate (with) any residents. She stated she has not seen anything nor has residents informed her of these kinds of behaviors. I spoke with (Activity Director) about the concern. She stated that she has not seen anything other than (Resident #2) standing close to (Resident #1) but not touching her. I spoke with (LVN J) and she stated that she has not witnessed any inappropriate behavior from (Resident #2) towards any other staff." Resident #4's Social Progress Notes dated 04/19/13 reflected, "...late at night, around 11-12 pm, (Resident #2) annoys the people in the common area. He states that one time it was late at night and (Resident #2) tried grabbing food off her plate. Another time he stood close to her and started barking like a dog. (Resident #4) states that (Resident #2) has tried to grab at (Resident #1) and had grabbed her shoulder when her back was to him. He also states this happens when her (family member) is here and (Resident #2) does these things to her too. (Resident #4) states that (Resident #1) tells staff and they are always good about redirecting him. He states that (Resident #2) mostly barks like a dog at people and is aggravating (people?) when they are watching movies or playing dominoes." A typewritten statement signed by the Activity Director dated 04/19/13 reflected, "Last week while in the TV lounge, a couple of minutes before lunch, (Resident #1) was sitting at the craft table with her (family member). (Resident #2) walked in and went to sit next to the TV and watched it for a while. Which is his regular routine before lunch and after lunch. Then he got up and walked over to (Resident #1) smiling but without saying anything. (Resident #1) started screaming 'get away from me' then she said something to her (family member). (Resident #2) started laughing and walked back to his seat next to the TV. I observed him for the next couple of days and didn't notice any more interactions between them." The Activity Director's Statement did not reflect if she spoke to Resident #1 to see why she "screamed" at Resident #2 to get away from her. The statement also did not reflect if she reported this event to anyone prior to being questioned by the SW. An unsigned typewritten statement dated 04/19/13 reflected, "I spoke to (Resident #1's family member) about the concerns (Resident #1) expressed. (Resident #1's family member) states that (Resident #2) has been bothering her and (Resident #1). She states that (Resident #2) attempted to grab at (Resident #1's) breast but she moved her body/arm and he missed her breast but grabbed her arm. This is the arm that has a pic line and they were concerned he would pull it out. When asked 'has he ever actually touched (Resident #1's) breast?' she stated that he has not been able to because (Resident #1) moved in time, but he has tried. (Resident #1's family member) stated that (Resident #2) has grabbed and touched her breast several times. (Resident #1's family member) states that he has come up from behind her and pulled her hair. She states the other night, she came to watch a movie with (Resident #1) and (Resident #2) tried to sit by them and he was getting up and turning the TV off. He continues to aggravate and annoy others in the common area but she feels (Resident #2) has a fixation on her and (Resident #1). I hand wrote this statement when the conversation occurred but it cannot be located at this time." The statement also reflected a handwritten statement signed by the Administrator which reflected, "I was unable to locate the written statement by (SW) so I requested she email the above statement which I received at 4-20-13 at 10:09 am." There were no interviews with CNAs or other potential residents who may have been bothered by Resident #2. Interview on 04/20/13 at 3:30 PM with RN D revealed the DON told her to keep an eye on Resident #2 on 04/19/13 at 3:30 PM. RN D stated she was also to inform the oncoming shift nurse to keep an eye on Resident #2. She revealed if she knew Resident #2 touched Resident #1 inappropriately, she would have completed the investigation report. Interview on 04/19/13 at 3:00 PM with Resident #5 revealed Resident #2 tried to grab her one time previously. Resident #5 stated she smacked Resident #2's hand when he tried to touch her. Resident #5 also revealed Resident #2 touched other residents in the facility inappropriately. Interview on 04/19/13 at 5:15 PM with CNA B revealed she always gave Resident #2 showers. CNA B stated she witnessed Resident #2 attempting to touch CNA C's buttocks. CNA B revealed she and CNA C told the Charge Nurse, LVN A, about Resident #2's inappropriate behavior. CNA B stated she could not remember the date for the incident. Interview on 04/20/13 at 12:15 PM with CNA C, a former employee, revealed she worked with CNA B on the 300 hall. CNA C stated she was not comfortable sharing any information with the surveyor. Interview on 04/19/13 at 5:22 PM with LVN A revealed he was Resident #2's Charge Nurse on the 2:00 PM to 10:00 PM shift, and he was not aware Resident #2 attempted to touch CNA C's buttocks. LVN A stated the DON did not tell him to put Resident #2 on one-on-one supervision. He also revealed he did not know Resident #2 was touching other residents. On 04/19/13 an IJ was identified. On 04/19/13 at 6:30 PM, the Administrator, DON, and the RNC were informed of the IJ at that time and a Plan of Removal was requested at that time. The Administrator stated she did not understand what an IJ was. While the surveyor attempted to explain what an IJ was to the Administrator, the DON told the surveyor to "Shut-up! I am talking." At this time, the DON stated this situation was not an IJ. She revealed the staff and the residents did not witness anything. The DON revealed, "I have been a DON for [AGE] years and had not had an IJ." The DON also revealed the incident was not reportable because it was not abuse. She stated it was not abuse because Resident #2 did not touch Resident #1. The facility's accepted Plan of Removal dated 04/20/13 reflected Resident #2 was placed on 1:1 supervision and would remain on 1:1 supervision until investigation was completed and behavior subsided. Resident #2's medication regimen was reviewed by the facility's contracted pharmacist with no recommendations. Also Resident #2 was discharged to a psychiatric hospital for an evaluation and medication management. Resident #1 was offered psychological services to help her cope, but she refused. The Administrator was in-serviced by the Regional Nurse Consultant on 1:1, abuse/neglect definitions, and reporting with a follow-up test to ensure understanding. The Administrator was also in-serviced on incident reporting, identification, and reporting inappropriate behaviors. following staff was in-serviced on abuse and neglect by the regional nurse consultant. The facility's staff development/service attendance sheet reflected all facility staff including the DON were re-educated on 04/20/13, 04/21/13, 04/22/13, and 04/23/13 on abuse. The title of the in-service was Report of Abuse and Neglect, Definition of Abuse, Abuse Coordinator, Reporting Sexual Abuse, Abuse, Neglect Prohibition, Information, Accident/Incident Reporting. The DON/designee would monitor new hires for compliance for 3 months to ensure the new hire was in compliance. If a new hire did not pass the test, the new hire would be re-educated. The DON would ensure residents who exhibited inappropriate behaviors would be placed on increased supervision as appropriate for unsafe behavior until intervention was effective and behaviors would be documented on behavior monitoring sheets. The had a QA meeting on 04/23/13 at 10:00 AM with the Medical Director. During the end of the day conference on 04/21/13 at 2:00 PM, the administrator was informed the residents did not know whom to report abuse and who the abuse coordinator was. Some residents stated if they were abused, they would call the police and the legal authorities. The Administrator stated she did not educate the residents on whom to report abuse, even if she did, the residents would still call the police. The Administrator revealed she would not inform the residents to report abuse to her. Interview on 04/21/13 at 9:45 AM with Dishwasher K revealed he received in-service on abuse. Dishwasher K stated the abuse coordinator was the Administrator. Dishwasher K stated he would report abuse immediately. Interview on 04/21/13 at 9:59 AM with Cook L revealed she was in-serviced on abuse. Cook L stated the abuse coordinator was the administrator. Cook L stated she would report abuse to the Administrator. Interview on 04/21/13 at 10:00 AM with PT N revealed she was in-serviced on abuse. PT N stated the abuse coordinator was the Administrator. PT N stated he would report abuse to the Administrator. Interview on 04/21/13 at 1:48 PM with CNA Z revealed she would report abuse to the administrator. CNA Z state she received abuse training yesterday. An interview on 04/22/13 at approximately 9:30 AM with the Administrator revealed she spoke with the Program Manager in the local DADS office and was told she needed to educate the residents on whom to report abuse. Interview on 04/22/13 at 9:54 AM with CNA BB revealed the abuse coordinator was the Administrator. CNA BB stated she was in-serviced on abuse two weeks ago. Interview on 04/22/13 at 9:59 AM with LVN AA revealed the Administrator was the abuse coordinator. LVN AA stated she had abuse training less than one week ago. LVN AA stated if she witnessed sexual abuse, she would report it to the Administrator Interview on 04/22/13 at 10:05 AM with RN D revealed she had sexual abuse training this morning at 5:55 AM. RN D said if she witnessed resident-to-resident sexual abuse, she would separate the residents and report the abuse to the Administrator. RN D said she would do assessments and report to the DON and the physician. Interview on 04/22/13 at 10:15 AM with PT O revealed the abuse coordinator was the Administrator. PT O sated if she witnessed abuse, she would notify the Administrator. Interview on 04/22/13 at 10:20 AM with OT P revealed the abuse coordinator was the Administrator. OT P stated if she witnessed abuse, she would notify the Administrator. Interview on 04/22/13 at 10:30 AM with MA Q revealed the abuse coordinator was the Administrator. MA Q stated if he witnessed abuse, he would notify the Administrator. On 04/23/13 at approximately 10:30 AM, the Administrator told the surveyors she had distributed fliers with her name and phone numbers as the Abuse Coordinator to the residents in their rooms. The administrator finally educated the resident on the abuse coordinator. The administrator printed information identifying the abuse coordinator with her phone number. The administrator left the information in all the residents' rooms. The IJ was removed on 04/23/13 at 10:55 AM and the Administrator was informed at that time. While the IJ was removed, 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. The facility's resident roster dated 04/18/13 reflected 69 female residents.

Based on observation, interview and record review, it was determined the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse were immediately reported to the Administrator of the facility and to other officials in accordance with State law through established procedures including to the State survey and certification agency, failed to have evidence of a thorough investigation, and failed to prevent further potential abuse while the investigation was in progress for one (Resident #1) of five residents reviewed for abuse. 1. The Administrator and the DON failed to immediately report to the State survey and certification agency and thoroughly investigate an allegation of sexual harassment made by Resident #1. Resident #1 reported to the SW that Resident #2 made sexually crude remarks to her and continued to try and grab her breasts. 2. Facility staff failed to report Resident #2's sexually inappropriate behavior toward Resident #1 to the Administrator, who was also the Abuse Coordinator. 3. The facility failed to protect Resident #1 and other residents from Resident #2. Resident #2 was not frequently monitored until surveyor intervention. These failures resulted in Resident #1 feeling "dirty," frustrated, angry, and retaliated against by the facility. These failures resulted in an Immediate Jeopardy (IJ) on 04/19/13. While the IJ was removed on 04/21/13, 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 other 68 female residents by placing them at risk for being touched inappropriately, feelings of guilt, and decreased self-esteem and quality of life. Findings included: Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected her cognition was moderately impaired, she used a wheelchair for locomotion, and she needed the assistance of one person with ADLs. Resident #1's Care Plan dated 02/23/13 reflected Resident #1 had short-term memory deficits and required assistance with decision making in some situations. Resident #1 had a [DIAGNOSES REDACTED]. The Facility's Concern Resolution Record dated 04/13/13 reflected Resident #1 wrote a complaint that Resident #2 was harassing her and attempted to grab her. The Record reflected the SW "...spoke with (Resident #2) about keeping his hands to himself. He denies touching others. I spoke with (DON) and she will talk to the staff about this issue." The Concern Resolution Record further reflected, "(Resident #1) is happy that the staff will keep a closer eye on him and his interactions (with) others." The Record was signed by the Administrator on 04/18/13. Resident #2's MDS assessment dated [DATE] reflected Resident #2 was an [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected his cognition was severely impaired, he used a walker for ambulation, and he needed the assistance of one person for ADLs. The MDS assessment did not reflect that Resident #2 had any behavior problems. Resident #2's Care Plan dated 01/04/13 reflected he had moderate cognitive impairments. According to Resident #2's care plan, he wandered throughout the facility and wandered into unsafe areas. The Care Plan Approaches included redirecting him to an area that was frequently monitored, alert staff to his behavior, provide diversional activities, and monitor and document behavior. The facility's Incident/Accident Report dated 04/19/13 reflected, "(Resident #1) complained that another male resident touched her inappropriately. Upon assessment no injuries, no bruises noted." The Report did not identify who the other resident was or where Resident #1 was touched. The "FINAL DISPOSITION ACTIONS TO MINIMIZE REOCCURRENCE: Administration aware...." Interview on 04/19/13 at 11:15 AM with Resident #1, who was sitting in her wheelchair in the hall, revealed when asked if she was ok , the resident replied, "I am not okay." When asked what was wrong, Resident #1 responded, "(Resident #2) touched and grabbed me. I told them and they did nothing about it." Resident #1 stated she completed a grievance form reflecting Resident #2 touched her inappropriately on 04/13/13. Resident #1 stated she dropped the complaint slip in a box by the Social Worker's office. Resident #1 stated when the Social Worker saw her, she did not ask her (Resident #1) about the allegation she dropped in the concern box. Resident #1 revealed the Social Worker asked, "When are you going to be discharged ?" Resident #1 also revealed, "I'm upset and I said to her 'Is the facility retaliating for me filing a complaint?" The Social Worker replied she was coming to ask her about the discharge planning. Interview on 04/19/13 at 1:00 PM with the Social Worker revealed Resident #1 said Resident #2 attempted to touch her. She stated there was no discharge planning on Resident #1's chart on admission, and she needed to discuss discharge planning with Resident #1. The Social Worker revealed when she went to talk with Resident #1, the resident started complaining about Resident #2's behavior. She stated after Resident #1 finished talking to her, she asked Resident #1 about her discharge planning. The Social Worker revealed Resident #1 replied, "Is that because I complained about Resident #2, so you want to discharge me from the facility?" The social worker stated the only reason she asked her about the discharge planning was because there was no discharge planning on her chart when she was admitted to the facility. The Social Worker stated she told the DON about the abuse allegation and she (the DON) said she would take care of it. The SW provided the surveyor with Social Progress Notes for Resident #1 dated 04/15/13, which she considered her investigation of the allegation. Resident #1's Social Progress Notes dated 04/15/13 reflected, "(Resident #1) states that (Resident #2) has been harassing her. She states that he has grabbed on her and squeezed her breasts while saying 'nice titties.' I have asked the staff about this but they have not seen him behave this way. I gave the grievance form to the D.O.N. She states she will put a plan of action in place. I also spoke (with) (Resident #2) about this situation and he denies ever putting his hands on her. I asked her who else he has been putting his hands on inappropriately and she stated she knows the residents but refuses to tell me their names." Resident #1's Social Progress Notes dated 04/19/13 reflected, "Late entry and clarification: In reference to the statement on the 3rd line, correction, should say, 'she states that he has grabbed on her (family member) and squeezed her (family member's) breast while saying 'nice titties.'" Interview with the DON on 04/19/13 at 1:43 PM revealed an investigation was conducted, and there were no witnesses of Resident #2 touching Resident #1 inappropriately. When asked for the investigation, the DON stated the SW conducted the investigation. Interview on 04/19/13 at 11:30 AM with the Administrator revealed Resident #2 did not touch Resident #1. The Administrator stated Resident #2 was a quiet man and he did not bother any resident. She revealed, "Can I show you what (Resident #2) does to people?" The surveyor replied, "Yes." The Administrator left her chair and bent forward in front of the surveyor. The Administrator looked directly into the surveyor's eyes and said, "Hi." The Administrator stated, "That is what he does. He just says hi to people." When asked if she investigated the allegation of Resident #2 inappropriately touching Resident #1, she replied, "Yes." The Administrator stated none of the staff or residents witnessed Resident #2 touching Resident #1. When asked if she reported the allegation to the state agency, she replied no because it was not a reportable incident because there were no witnesses. Further interview on 04/20/13 at 11:05 AM with Resident #1 revealed, "I feel like they did not care. I felt like dirt when (Resident #2) touched me." She stated the Administrator did not ask her what happened. Resident #1 revealed Resident #2 told her "Pretty boobies," and he touched her one time on her breasts. She stated Resident #2 attempted to touch her on four other occasions, and he called her "Fat cow, fat grandma." Resident #1 revealed other residents and staff witnessed Resident #2's inappropriate behavior. She said sometimes when Resident #2 misbehaved, some of the staff laughed and tried to stop him from harassing her. Resident #1 revealed the staff thought Resident #2's behavior was funny. Resident #1 stated Resident #2 yelled at her to shut up. Resident #1 stated sometimes Resident #2 stood in front of the television in the waiting area and turned off the television. Resident #1 stated this was directed to her. Resident #1 stated Resident #2 always did this when she was watching the television. A handwritten statement from Resident #1 dated 04/22/13 at 2:02 PM reflected, " 1) I felt helpless, and like anything can happen and no one will put a stop to it. 2) I felt uncomfortable and violated for him to come reach for my chest. 3) Well the main one that would see a lot was (Activity Director)... nite (sic) nurses after 10 pm. 4)once and then the rest of the time he would just come fighting and cursing at me and would try to eat my food. 5) Fat cow, [***] ...." Resident #1's family member on 04/20/13 at 2:15 PM revealed Resident #2 grabbed her breast, attempted to grab her chest several times, and he pulled her hair. She stated Resident #2 called her the following names: [***] , Big Booty and big tittie girl. She revealed when she was watching television, Resident #2 turned off the television. Resident #1's family member stated the 10:00 PM to 6:00 AM staff witnessed Resident #2's inappropriate behaviors. She stated, "mostly the night crew after 10:00 PM knew about it and just take him away like it was funny or joke. I don't think it was a problem to anyone, but it was for us." She stated the problem was for her and Resident #1. Resident #1's family member revealed Resident #5 witnessed Resident #2's inappropriate behavior. A handwritten statement from Resident #1's family member dated 04/20/13 at 2:15 PM reflected, "1) I felt so uncomfortable and violated that this strange man came at me trying to grab on my chest. Another day not paying attention he came up behind and pulled on my hair and actually grabbed my BooB. After that I screamed at him and he left. Everyday after that he sees me and curses at me and calls me names like [***] , Big Booty, Big Tittie girl. When we watch TV at night he would go turn the TV off on use just to mess with us. Mostly the night crew after 10 pm knew about it and just take him away like it was Funny or a joke. I don't think it was problem to anyone but it was us." An interview with Resident #16's family member on 04/19/13 at 12:07 PM revealed he/she witnessed Resident #2 sexually harassing Resident #1. He/she stated Resident #2 focused his harassment on Resident #1 and her family, and Resident #2 constantly harassed Resident #1 several times a day. The family member revealed Resident #2 grabbed his female victim on the breast and also verbally abused her. Resident #16's family member stated Resident #2 should be reprimanded and be removed from the rest of the residents. A handwritten statement dated 04/19/13 from Resident #16's family member reflected, "This statement will document the habitual sexual harassment which (Resident #2) has imposed on residents and guests of Vista Ridge Nursing & Rehab Center in recent weeks. He has focused his harassment on (Resident #1) and her family guests, usually several times a day. He physically grabs his female victims by their breasts, and also verbally abuses them. Despite our strongly rebuking his approaches he continues to repeat his offenses over & over. He needs to be severely reprimanded and kept isolated from all other female residents until he discontinues this abusive behavior. If he will not cooperate he should be discharged to the care of his family or other legal guardians...." Interview on 04/19/13 at 1:00 PM with Resident #3 revealed she witnessed Resident #2 touch Resident #1 inappropriately and harass Resident #1. Resident #3 stated she heard Resident #2 say bad things to Resident #1. Resident #3's handwritten statement dated 04/19/13 reflected, "I have been a Witness to the problems on the other side. This need to be stopped because (Resident #2) has been coming up to (Resident #1) and saying bad things to her and her (family member)...he is a bad trouble maker...." Interview on 04/19/13 at 1:30 PM with Resident #4 revealed he witnessed Resident #2 touching Resident #1. Resident #4 stated Resident #2 yelled at Resident #1 when they were watching TV and eating pizza in the TV room. Resident #4 also stated Resident #2 tried to grab the pizza off his plate. Resident #4 revealed Resident #2 asked Resident #1 "What's up sexy?" Resident #4 stated Resident #2 constantly barked like a dog when he saw Resident #1. A handwritten statement from Resident #4 dated 04/19/13 at 1:30 PM reflected, "I seen a couple of times Bothering and touching (Resident #1) Barking and yelling and her (Resident #1's member) when We had pizza and movie night he try to grab food off her plate." Interview on 04/21/13 at 1:30 AM with LVN T revealed she worked the 10:00 PM to 6:00 AM shift. LVN T stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:35 AM with CNA U revealed she worked the 10:00 PM to 6:00 AM shift. CNA U stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:40 AM with CNA V revealed she worked the 10:00 PM to 6:00 AM shift. CNA V stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:47 AM with CNA W revealed she worked the 10:00 PM to 6:00 AM shift. CNA W stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:55 AM with CNA X revealed she worked the 10:00 PM to 6:00 AM shift. CNA X stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 2:00 AM with CNA Y revealed she worked the 10:00 PM to 6:00 AM shift. CNA Y stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 2:10 AM with CNA H revealed she worked the 10:00 PM to 6:00 AM shift. CNA H stated she did not observe Resident #2 harassing or touching anyone inappropriately. The Administrator requested on 04/19/13 at approximately 1:00 PM a list of residents who were interviewed by the surveyor. On 04/20/13 at 12:00 PM, the Administrator returned with additional Social Progress Notes with no names in the blocks at the end of the form, which the facility considered their investigation. The Administrator stated, "Here are the notes from the Social Worker. I don't know why she did not give them to you." Resident #8's Social Progress Notes dated 04/15/13 reflected, "I was told by (Resident #8) that 'he heard one time a long time ago,' a woman say 'leave me alone.' But he is blind and could not tell who the woman was but he thinks (Resident #2) is who the woman was telling that to.'" Social Progress Notes dated 04/15/13 reflected, "I spoke with (Resident #16's family member) about (Resident #2) bothering (Resident #1) and he stated that he has witnessed (Resident #2) aggrivating (sic) and bothering (Resident #1). He stated that he got angry one time when (Resident #2) was bothering people in the common areas that he wanted to hit (Resident #2) with a 9-iron. He did not state that he witnessed (Resident #2) touching (Resident #1's family member). (Resident #16) was sitting next to her (family member) when she stated 'yes, I seen it too.' 'He is always bothering us.'" Social Progress Notes dated 04/15/13 reflected, "I spoke with (Wound Nurse) and asked her if she noticed (Resident #2) behavior inappropriate (with) any residents. She stated she has not seen anything nor has residents informed her of these kinds of behaviors. I spoke with (Activity Director) about the concern. She stated that she has not seen anything other than (Resident #2) standing close to (Resident #1) but not touching her. I spoke with (LVN J) and she stated that she has not witnessed any inappropriate behavior from (Resident #2) towards any other staff." Resident #4's Social Progress Notes dated 04/19/13 reflected, "...late at night, around 11-12 pm, (Resident #2) annoys the people in the common area. He states that one time it was late at night and (Resident #2) tried grabbing food off her plate. Another time he stood close to her and started barking like a dog. (Resident #4) states that (Resident #2) has tried to grab at (Resident #1) and had grabbed her shoulder when her back was to him. He also states this happens when her (family member) is here and (Resident #2) does these things to her too. (Resident #4) states that (Resident #1) tells staff and they are always good about redirecting him. He states that (Resident #2) mostly barks like a dog at people and is aggravating (people?) when they are watching movies or playing dominoes." A typewritten statement signed by the Activity Director dated 04/19/13 reflected, "Last week while in the TV lounge, a couple of minutes before lunch, (Resident #1) was sitting at the craft table with her (family member). (Resident #2) walked in and went to sit next to the TV and watched it for a while. Which is his regular routine before lunch and after lunch. Then he got up and walked over to (Resident #1) smiling but without saying anything. (Resident #1) started screaming 'get away from me' then she said something to her (family member). (Resident #2) started laughing and walked back to his seat next to the TV. I observed him for the next couple of days and didn't notice any more interactions between them." The Activity Director's Statement did not reflect if she spoke to Resident #1 to see why she "screamed" at Resident #2 to get away from her. The statement also did not reflect if she reported this event to anyone prior to being questioned by the SW. An unsigned typewritten statement dated 04/19/13 reflected, "I spoke to (Resident #1's family member) about the concerns (Resident #1) expressed. (Resident #1's family member) states that (Resident #2) has been bothering her and (Resident #1). She states that (Resident #2) attempted to grab at (Resident #1's) breast but she moved her body/arm and he missed her breast but grabbed her arm. This is the arm that has a pic line and they were concerned he would pull it out. When asked 'has he ever actually touched (Resident #1's) breast?' she stated that he has not been able to because (Resident #1) moved in time, but he has tried. (Resident #1's family member) stated that (Resident #2) has grabbed and touched her breast several times. (Resident #1's family member) states that he has come up from behind her and pulled her hair. She states the other night, she came to watch a movie with (Resident #1) and (Resident #2) tried to sit by them and he was getting up and turning the TV off. He continues to aggravate and annoy others in the common area but she feels (Resident #2) has a fixation on her and (Resident #1). I hand wrote this statement when the conversation occurred but it cannot be located at this time." The statement also reflected a handwritten statement signed by the Administrator which reflected, "I was unable to locate the written statement by (SW) so I requested she email the above statement which I received at 4-20-13 at 10:09 am." There were no interviews with CNAs or other potential residents who may have been bothered by Resident #2. Interview on 04/20/13 at 3:30 PM with RN D revealed the DON told her to keep an eye on Resident #2 on 04/19/13 at 3:30 PM. RN D stated she was also to inform the oncoming shift nurse to keep an eye on Resident #2. She revealed if she knew Resident #2 touched Resident #1 inappropriately, she would have completed the investigation report. Interview on 04/19/13 at 3:00 PM with Resident #5 revealed Resident #2 tried to grab her one time previously. Resident #5 stated she smacked Resident #2's hand when he tried to touch her. Resident #5 also revealed Resident #2 touched other residents in the facility inappropriately. Interview on 04/19/13 at 5:15 PM with CNA B revealed she always gave Resident #2 showers. CNA B stated she witnessed Resident #2 attempting to touch CNA C's buttocks. CNA B revealed she and CNA C told the Charge Nurse, LVN A, about Resident #2's inappropriate behavior. CNA B stated she could not remember the date for the incident. Interview on 04/20/13 at 12:15 PM with CNA C, a former employee, revealed she worked with CNA B on the 300 hall. CNA C stated she was not comfortable sharing any information with the surveyor. Interview on 04/19/13 at 5:22 PM with LVN A revealed he was Resident #2's Charge Nurse on the 2:00 PM to 10:00 PM shift, and he was not aware Resident #2 attempted to touch CNA C's buttocks. LVN A stated the DON did not tell him to put Resident #2 on one-on-one supervision. He also revealed he did not know Resident #2 was touching other residents. The facility's current undated policy and procedure on Abuse and Neglect Prohibition reflected: "Our residents have the right to be free from abuse, neglect misappropriation of resident's property, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family member or legal guardians, friends, or other individuals...Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault...3. PREVENTION Provide residents, families and staff information on how to and to whom they may report concerns, incidents and grievances without the fear of retribution, and provide feedback regarding the concerns that have been expressed...The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect...INVESTIGATION...The facility will conduct an investigation of all alleged abuse/neglect...in accordance with state law....Facility will report all allegations and all investigation findings to the state as per state regulations...Details of activity that was occurring at the time of the alleged incident. The names and statements of staff members working on the unit at the time...Statements or interviews from the witness, other residents, and the alleged violator...Be sure to document the entire investigation thoroughly, then take corrective action in order to assure residents protection...PROTECTION...The facility will protect residents from harm during the investigation by removing the alleged abuser from contact with other residents as appropriate to a monitored location. Interview all residents possibly involved with the incident or the aggressor...." The facility's undated Reporting Abuse and Neglect Policy reflected, "Any facility staff member who has cause to believe that the physical or mental health or welfare of any resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately...1. For staff notify Facility Abuse/Neglect Coordinator, the Administrator and DON immediately. 2. Administrator and DON notify your direct report/supervisor immediately to determine if event meets DADS current reportable criteria...1. If resident to resident altercation - separate the residents. You may have to assign staff to do 1:1, until receive further direction...The following incidents of abuse and/or neglect must be reported to the DADS (Department of Aging and Disability Services) State Office, Austin, TX, immediately upon learning of the incident. A written investigation report must be sent no later that the fifth working day after the oral report. The facility Investigation Report (see attachment 1) must be used to document facility investigations. Abuse 1. The facility staff will follow the state regulatory agency requirements for identifying and reporting Resident to resident incidents...Neglect 1. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident...." On 04/19/13 an IJ was identified. On 04/19/13 at 6:30 PM, the Administrator, DON, and the RNC were informed of the IJ at that time and a Plan of Removal was requested at that time. The Administrator stated she did not understand what an IJ was. While the surveyor attempted to explain what an IJ was to the Administrator, the DON told the surveyor to "Shut-up! I am talking." At this time, the DON stated this situation was not an IJ. She revealed the staff and the residents did not witness anything. The DON revealed, "I have been a DON for [AGE] years and had not had an IJ." The DON also revealed the incident was not reportable because it was not abuse. She stated it was not abuse because Resident #2 did not touch Resident #1. The facility's accepted Plan of Removal dated 04/20/13 reflected Resident #2 was placed on 1:1 supervision and would remain on 1:1 supervision until investigation was completed and behavior subsided. Resident #2's medication regimen was reviewed by the facility's contracted pharmacist with no recommendations. Also Resident #2 was discharged to a psychiatric hospital for an evaluation and medication management. Resident #1 was offered psychological services to help her cope, but she refused. The Administrator was in-serviced by the Regional Nurse Consultant on 1:1, abuse/neglect definitions, and reporting with a follow-up test to ensure understanding. The Administrator was also in-serviced on incident reporting, identification, and reporting inappropriate behaviors. following staff was in-serviced on abuse and neglect by the regional nurse consultant. The facility's staff development/service attendance sheet reflected all facility staff including the DON were re-educated on 04/20/13, 04/21/13, 04/22/13, and 04/23/13 on abuse. The title of the in-service was Report of Abuse and Neglect, Definition of Abuse, Abuse Coordinator, Reporting Sexual Abuse, Abuse, Neglect Prohibition, Information, Accident/Incident Reporting. The DON/designee would monitor new hires for compliance for 3 months to ensure the new hire was in compliance. If a new hire did not pass the test, the new hire would be re-educated. The DON would ensure residents who exhibited inappropriate behaviors would be placed on increased supervision as appropriate for unsafe behavior until intervention was effective and behaviors would be documented on behavior monitoring sheets. The had a QA meeting on 04/23/13 at 10:00 AM with the Medical Director. During the end of the day conference on 04/21/13 at 2:00 PM, the administrator was informed the residents did not know whom to report abuse and who the abuse coordinator was. Some residents stated if they were abused, they would call the police and the legal authorities. The Administrator stated she did not educate the residents on whom to report abuse, even if she did, the residents would still call the police. The Administrator revealed she would not inform the residents to report abuse to her. Interview on 04/21/13 at 9:45 AM with Dishwasher K revealed he received in-service on abuse. Dishwasher K stated the abuse coordinator was the Administrator. Dishwasher K stated he would report abuse immediately. Interview on 04/21/13 at 9:59 AM with Cook L revealed she was in-serviced on abuse. Cook L stated the abuse coordinator was the administrator. Cook L stated she would report abuse to the Administrator. Interview on 04/21/13 at 10:00 AM with PT N revealed she was in-serviced on abuse. PT N stated the abuse coordinator was the Administrator. PT N stated he would report abuse to the Administrator. Interview on 04/21/13 at 1:48 PM with CNA Z revealed she would report abuse to the administrator. CNA Z state she received abuse training yesterday. An interview on 04/22/13 at approximately 9:30 AM with the Administrator revealed she spoke with the Program Manager in the local DADS office and was told she needed to educate the residents on whom to report abuse. Interview on 04/22/13 at 9:54 AM with CNA BB revealed the abuse coordinator was the Administrator. CNA BB stated she was in-serviced on abuse two weeks ago. Interview on 04/22/13 at 9:59 AM with LVN AA revealed the Administrator was the abuse coordinator. LVN AA stated she had abuse training less than one week ago. LVN AA stated if she witnessed sexual abuse, she would report it to the Administrator Interview on 04/22/13 at 10:05 AM with RN D revealed she had sexual abuse training this morning at 5:55 AM. RN D said if she witnessed resident-to-resident sexual abuse, she would separate the residents and report the abuse to the Administrator. RN D said she would do assessments and report to the DON and the physician. Interview on 04/22/13 at 10:15 AM with PT O revealed the abuse coordinator was the Administrator. PT O sated if she witnessed abuse, she would notify the Administrator. Interview on 04/22/13 at 10:20 AM with OT P revealed the abuse coordinator was the Administrator. OT P stated if she witnessed abuse, she would notify the Administrator. Interview on 04/22/13 at 10:30 AM with MA Q revealed the abuse coordinator was the Administrator. MA Q stated if he witnessed abuse, he would notify the Administrator. On 04/23/13 at approximately 10:30 AM, the Administrator told the surveyors she had distributed fliers with her name and phone numbers as the Abuse Coordinator to the residents in their rooms. The administrator finally educated the resident on the abuse coordinator. The administrator printed information identifying the abuse coordinator with her phone number. The administrator left the information in all the residents' rooms. The IJ was removed on 04/23/13 at 10:55 AM and the Administrator was informed at that time. While the IJ was removed, 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. The facility's resident roster dated 04/18/13 reflected 69 female residents.

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 one (Resident #1) of five residents reviewed for abuse. 1. The Administrator and the DON failed to immediately report to the State survey and certification agency and thoroughly investigate an allegation of sexual harassment made by Resident #1. Resident #1 reported to the SW that Resident #2 made sexually crude remarks to her and continued to try and grab her breasts. 2. Facility staff failed to report Resident #2's sexually inappropriate behavior toward Resident #1 to the Administrator, who was also the Abuse Coordinator. 3. The facility failed to protect Resident #1 and other residents from Resident #2. Resident #2 was not frequently monitored until surveyor intervention. These failures resulted in Resident #1 feeling "dirty," frustrated, angry, and retaliated against by the facility. These failures resulted in an Immediate Jeopardy (IJ) on 04/19/13. While the IJ was removed on 04/21/13, 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 other 68 female residents by placing them at risk for being touched inappropriately, feelings of guilt, and decreased self-esteem and quality of life. Findings included: The facility's current undated policy and procedure on Abuse and Neglect Prohibition reflected: "Our residents have the right to be free from abuse, neglect misappropriation of resident's property, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family member or legal guardians, friends, or other individuals...Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault...3. PREVENTION Provide residents, families and staff information on how to and to whom they may report concerns, incidents and grievances without the fear of retribution, and provide feedback regarding the concerns that have been expressed...The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect...INVESTIGATION...The facility will conduct an investigation of all alleged abuse/neglect...in accordance with state law....Facility will report all allegations and all investigation findings to the state as per state regulations...Details of activity that was occurring at the time of the alleged incident. The names and statements of staff members working on the unit at the time...Statements or interviews from the witness, other residents, and the alleged violator...Be sure to document the entire investigation thoroughly, then take corrective action in order to assure residents protection...PROTECTION...The facility will protect residents from harm during the investigation by removing the alleged abuser from contact with other residents as appropriate to a monitored location. Interview all residents possibly involved with the incident or the aggressor...." The facility's undated Reporting Abuse and Neglect Policy reflected, "Any facility staff member who has cause to believe that the physical or mental health or welfare of any resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately...1. For staff notify Facility Abuse/Neglect Coordinator, the Administrator and DON immediately. 2. Administrator and DON notify your direct report/supervisor immediately to determine if event meets DADS current reportable criteria...1. If resident to resident altercation - separate the residents. You may have to assign staff to do 1:1, until receive further direction...The following incidents of abuse and/or neglect must be reported to the DADS (Department of Aging and Disability Services) State Office, Austin, TX, immediately upon learning of the incident. A written investigation report must be sent no later that the fifth working day after the oral report. The facility Investigation Report (see attachment 1) must be used to document facility investigations. Abuse 1. The facility staff will follow the state regulatory agency requirements for identifying and reporting Resident to resident incidents...Neglect 1. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident...." Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected her cognition was moderately impaired, she used a wheelchair for locomotion, and she needed the assistance of one person with ADLs. Resident #1's Care Plan dated 02/23/13 reflected Resident #1 had short-term memory deficits and required assistance with decision making in some situations. Resident #1 had a [DIAGNOSES REDACTED]. The Facility's Concern Resolution Record dated 04/13/13 reflected Resident #1 wrote a complaint that Resident #2 was harassing her and attempted to grab her. The Record reflected the SW "...spoke with (Resident #2) about keeping his hands to himself. He denies touching others. I spoke with (DON) and she will talk to the staff about this issue." The Concern Resolution Record further reflected, "(Resident #1) is happy that the staff will keep a closer eye on him and his interactions (with) others." The Record was signed by the Administrator on 04/18/13. Resident #2's MDS assessment dated [DATE] reflected Resident #2 was an [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected his cognition was severely impaired, he used a walker for ambulation, and he needed the assistance of one person for ADLs. The MDS assessment did not reflect that Resident #2 had any behavior problems. Resident #2's Care Plan dated 01/04/13 reflected he had moderate cognitive impairments. According to Resident #2's care plan, he wandered throughout the facility and wandered into unsafe areas. The Care Plan Approaches included redirecting him to an area that was frequently monitored, alert staff to his behavior, provide diversional activities, and monitor and document behavior. The facility's Incident/Accident Report dated 04/19/13 reflected, "(Resident #1) complained that another male resident touched her inappropriately. Upon assessment no injuries, no bruises noted." The Report did not identify who the other resident was or where Resident #1 was touched. The "FINAL DISPOSITION ACTIONS TO MINIMIZE REOCCURRENCE: Administration aware...." Interview on 04/19/13 at 11:15 AM with Resident #1, who was sitting in her wheelchair in the hall, revealed when asked if she was ok , the resident replied, "I am not okay." When asked what was wrong, Resident #1 responded, "(Resident #2) touched and grabbed me. I told them and they did nothing about it." Resident #1 stated she completed a grievance form reflecting Resident #2 touched her inappropriately on 04/13/13. Resident #1 stated she dropped the complaint slip in a box by the Social Worker's office. Resident #1 stated when the Social Worker saw her, she did not ask her (Resident #1) about the allegation she dropped in the concern box. Resident #1 revealed the Social Worker asked, "When are you going to be discharged ?" Resident #1 also revealed, "I'm upset and I said to her 'Is the facility retaliating for me filing a complaint?" The Social Worker replied she was coming to ask her about the discharge planning. Interview on 04/19/13 at 1:00 PM with the Social Worker revealed Resident #1 said Resident #2 attempted to touch her. She stated there was no discharge planning on Resident #1's chart on admission, and she needed to discuss discharge planning with Resident #1. The Social Worker revealed when she went to talk with Resident #1, the resident started complaining about Resident #2's behavior. She stated after Resident #1 finished talking to her, she asked Resident #1 about her discharge planning. The Social Worker revealed Resident #1 replied, "Is that because I complained about Resident #2, so you want to discharge me from the facility?" The social worker stated the only reason she asked her about the discharge planning was because there was no discharge planning on her chart when she was admitted to the facility. The Social Worker stated she told the DON about the abuse allegation and she (the DON) said she would take care of it. The SW provided the surveyor with Social Progress Notes for Resident #1 dated 04/15/13, which she considered her investigation of the allegation. Resident #1's Social Progress Notes dated 04/15/13 reflected, "(Resident #1) states that (Resident #2) has been harassing her. She states that he has grabbed on her and squeezed her breasts while saying 'nice titties.' I have asked the staff about this but they have not seen him behave this way. I gave the grievance form to the D.O.N. She states she will put a plan of action in place. I also spoke (with) (Resident #2) about this situation and he denies ever putting his hands on her. I asked her who else he has been putting his hands on inappropriately and she stated she knows the residents but refuses to tell me their names." Resident #1's Social Progress Notes dated 04/19/13 reflected, "Late entry and clarification: In reference to the statement on the 3rd line, correction, should say, 'she states that he has grabbed on her (family member) and squeezed her (family member's) breast while saying 'nice titties.'" Interview with the DON on 04/19/13 at 1:43 PM revealed an investigation was conducted, and there were no witnesses of Resident #2 touching Resident #1 inappropriately. When asked for the investigation, the DON stated the SW conducted the investigation. Interview on 04/19/13 at 11:30 AM with the Administrator revealed Resident #2 did not touch Resident #1. The Administrator stated Resident #2 was a quiet man and he did not bother any resident. She revealed, "Can I show you what (Resident #2) does to people?" The surveyor replied, "Yes." The Administrator left her chair and bent forward in front of the surveyor. The Administrator looked directly into the surveyor's eyes and said, "Hi." The Administrator stated, "That is what he does. He just says hi to people." When asked if she investigated the allegation of Resident #2 inappropriately touching Resident #1, she replied, "Yes." The Administrator stated none of the staff or residents witnessed Resident #2 touching Resident #1. When asked if she reported the allegation to the state agency, she replied no because it was not a reportable incident because there were no witnesses. Further interview on 04/20/13 at 11:05 AM with Resident #1 revealed, "I feel like they did not care. I felt like dirt when (Resident #2) touched me." She stated the Administrator did not ask her what happened. Resident #1 revealed Resident #2 told her "Pretty boobies," and he touched her one time on her breasts. She stated Resident #2 attempted to touch her on four other occasions, and he called her "Fat cow, fat grandma." Resident #1 revealed other residents and staff witnessed Resident #2's inappropriate behavior. She said sometimes when Resident #2 misbehaved, some of the staff laughed and tried to stop him from harassing her. Resident #1 revealed the staff thought Resident #2's behavior was funny. Resident #1 stated Resident #2 yelled at her to shut up. Resident #1 stated sometimes Resident #2 stood in front of the television in the waiting area and turned off the television. Resident #1 stated this was directed to her. Resident #1 stated Resident #2 always did this when she was watching the television. A handwritten statement from Resident #1 dated 04/22/13 at 2:02 PM reflected, " 1) I felt helpless, and like anything can happen and no one will put a stop to it. 2) I felt uncomfortable and violated for him to come reach for my chest. 3) Well the main one that would see a lot was (Activity Director)... nite (sic) nurses after 10 pm. 4)once and then the rest of the time he would just come fighting and cursing at me and would try to eat my food. 5) Fat cow, [***] ...." Resident #1's family member on 04/20/13 at 2:15 PM revealed Resident #2 grabbed her breast, attempted to grab her chest several times, and he pulled her hair. She stated Resident #2 called her the following names: [***] , Big Booty and big tittie girl. She revealed when she was watching television, Resident #2 turned off the television. Resident #1's family member stated the 10:00 PM to 6:00 AM staff witnessed Resident #2's inappropriate behaviors. She stated, "mostly the night crew after 10:00 PM knew about it and just take him away like it was funny or joke. I don't think it was a problem to anyone, but it was for us." She stated the problem was for her and Resident #1. Resident #1's family member revealed Resident #5 witnessed Resident #2's inappropriate behavior. A handwritten statement from Resident #1's family member dated 04/20/13 at 2:15 PM reflected, "1) I felt so uncomfortable and violated that this strange man came at me trying to grab on my chest. Another day not paying attention he came up behind and pulled on my hair and actually grabbed my BooB. After that I screamed at him and he left. Everyday after that he sees me and curses at me and calls me names like [***] , Big Booty, Big Tittie girl. When we watch TV at night he would go turn the TV off on use just to mess with us. Mostly the night crew after 10 pm knew about it and just take him away like it was Funny or a joke. I don't think it was problem to anyone but it was us." An interview with Resident #16's family member on 04/19/13 at 12:07 PM revealed he/she witnessed Resident #2 sexually harassing Resident #1. He/she stated Resident #2 focused his harassment on Resident #1 and her family, and Resident #2 constantly harassed Resident #1 several times a day. The family member revealed Resident #2 grabbed his female victim on the breast and also verbally abused her. Resident #16's family member stated Resident #2 should be reprimanded and be removed from the rest of the residents. A handwritten statement dated 04/19/13 from Resident #16's family member reflected, "This statement will document the habitual sexual harassment which (Resident #2) has imposed on residents and guests of Vista Ridge Nursing & Rehab Center in recent weeks. He has focused his harassment on (Resident #1) and her family guests, usually several times a day. He physically grabs his female victims by their breasts, and also verbally abuses them. Despite our strongly rebuking his approaches he continues to repeat his offenses over & over. He needs to be severely reprimanded and kept isolated from all other female residents until he discontinues this abusive behavior. If he will not cooperate he should be discharged to the care of his family or other legal guardians...." Interview on 04/19/13 at 1:00 PM with Resident #3 revealed she witnessed Resident #2 touch Resident #1 inappropriately and harass Resident #1. Resident #3 stated she heard Resident #2 say bad things to Resident #1. Resident #3's handwritten statement dated 04/19/13 reflected, "I have been a Witness to the problems on the other side. This need to be stopped because (Resident #2) has been coming up to (Resident #1) and saying bad things to her and her (family member)...he is a bad trouble maker...." Interview on 04/19/13 at 1:30 PM with Resident #4 revealed he witnessed Resident #2 touching Resident #1. Resident #4 stated Resident #2 yelled at Resident #1 when they were watching TV and eating pizza in the TV room. Resident #4 also stated Resident #2 tried to grab the pizza off his plate. Resident #4 revealed Resident #2 asked Resident #1 "What's up sexy?" Resident #4 stated Resident #2 constantly barked like a dog when he saw Resident #1. A handwritten statement from Resident #4 dated 04/19/13 at 1:30 PM reflected, "I seen a couple of times Bothering and touching (Resident #1) Barking and yelling and her (Resident #1's member) when We had pizza and movie night he try to grab food off her plate." Interview on 04/21/13 at 1:30 AM with LVN T revealed she worked the 10:00 PM to 6:00 AM shift. LVN T stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:35 AM with CNA U revealed she worked the 10:00 PM to 6:00 AM shift. CNA U stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:40 AM with CNA V revealed she worked the 10:00 PM to 6:00 AM shift. CNA V stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:47 AM with CNA W revealed she worked the 10:00 PM to 6:00 AM shift. CNA W stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 1:55 AM with CNA X revealed she worked the 10:00 PM to 6:00 AM shift. CNA X stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 2:00 AM with CNA Y revealed she worked the 10:00 PM to 6:00 AM shift. CNA Y stated she did not observe Resident #2 harassing or touching anyone inappropriately. Interview on 04/21/13 at 2:10 AM with CNA H revealed she worked the 10:00 PM to 6:00 AM shift. CNA H stated she did not observe Resident #2 harassing or touching anyone inappropriately. The Administrator requested on 04/19/13 at approximately 1:00 PM a list of residents who were interviewed by the surveyor. On 04/20/13 at 12:00 PM, the Administrator returned with additional Social Progress Notes with no names in the blocks at the end of the form, which the facility considered their investigation. The Administrator stated, "Here are the notes from the Social Worker. I don't know why she did not give them to you." Resident #8's Social Progress Notes dated 04/15/13 reflected, "I was told by (Resident #8) that 'he heard one time a long time ago,' a woman say 'leave me alone.' But he is blind and could not tell who the woman was but he thinks (Resident #2) is who the woman was telling that to.'" Social Progress Notes dated 04/15/13 reflected, "I spoke with (Resident #16's family member) about (Resident #2) bothering (Resident #1) and he stated that he has witnessed (Resident #2) aggrivating (sic) and bothering (Resident #1). He stated that he got angry one time when (Resident #2) was bothering people in the common areas that he wanted to hit (Resident #2) with a 9-iron. He did not state that he witnessed (Resident #2) touching (Resident #1's family member). (Resident #16) was sitting next to her (family member) when she stated 'yes, I seen it too.' 'He is always bothering us.'" Social Progress Notes dated 04/15/13 reflected, "I spoke with (Wound Nurse) and asked her if she noticed (Resident #2) behavior inappropriate (with) any residents. She stated she has not seen anything nor has residents informed her of these kinds of behaviors. I spoke with (Activity Director) about the concern. She stated that she has not seen anything other than (Resident #2) standing close to (Resident #1) but not touching her. I spoke with (LVN J) and she stated that she has not witnessed any inappropriate behavior from (Resident #2) towards any other staff." Resident #4's Social Progress Notes dated 04/19/13 reflected, "...late at night, around 11-12 pm, (Resident #2) annoys the people in the common area. He states that one time it was late at night and (Resident #2) tried grabbing food off her plate. Another time he stood close to her and started barking like a dog. (Resident #4) states that (Resident #2) has tried to grab at (Resident #1) and had grabbed her shoulder when her back was to him. He also states this happens when her (family member) is here and (Resident #2) does these things to her too. (Resident #4) states that (Resident #1) tells staff and they are always good about redirecting him. He states that (Resident #2) mostly barks like a dog at people and is aggravating (people?) when they are watching movies or playing dominoes." A typewritten statement signed by the Activity Director dated 04/19/13 reflected, "Last week while in the TV lounge, a couple of minutes before lunch, (Resident #1) was sitting at the craft table with her (family member). (Resident #2) walked in and went to sit next to the TV and watched it for a while. Which is his regular routine before lunch and after lunch. Then he got up and walked over to (Resident #1) smiling but without saying anything. (Resident #1) started screaming 'get away from me' then she said something to her (family member). (Resident #2) started laughing and walked back to his seat next to the TV. I observed him for the next couple of days and didn't notice any more interactions between them." The Activity Director's Statement did not reflect if she spoke to Resident #1 to see why she "screamed" at Resident #2 to get away from her. The statement also did not reflect if she reported this event to anyone prior to being questioned by the SW. An unsigned typewritten statement dated 04/19/13 reflected, "I spoke to (Resident #1's family member) about the concerns (Resident #1) expressed. (Resident #1's family member) states that (Resident #2) has been bothering her and (Resident #1). She states that (Resident #2) attempted to grab at (Resident #1's) breast but she moved her body/arm and he missed her breast but grabbed her arm. This is the arm that has a pic line and they were concerned he would pull it out. When asked 'has he ever actually touched (Resident #1's) breast?' she stated that he has not been able to because (Resident #1) moved in time, but he has tried. (Resident #1's family member) stated that (Resident #2) has grabbed and touched her breast several times. (Resident #1's family member) states that he has come up from behind her and pulled her hair. She states the other night, she came to watch a movie with (Resident #1) and (Resident #2) tried to sit by them and he was getting up and turning the TV off. He continues to aggravate and annoy others in the common area but she feels (Resident #2) has a fixation on her and (Resident #1). I hand wrote this statement when the conversation occurred but it cannot be located at this time." The statement also reflected a handwritten statement signed by the Administrator which reflected, "I was unable to locate the written statement by (SW) so I requested she email the above statement which I received at 4-20-13 at 10:09 am." There were no interviews with CNAs or other potential residents who may have been bothered by Resident #2. Interview on 04/20/13 at 3:30 PM with RN D revealed the DON told her to keep an eye on Resident #2 on 04/19/13 at 3:30 PM. RN D stated she was also to inform the oncoming shift nurse to keep an eye on Resident #2. She revealed if she knew Resident #2 touched Resident #1 inappropriately, she would have completed the investigation report. Interview on 04/19/13 at 3:00 PM with Resident #5 revealed Resident #2 tried to grab her one time previously. Resident #5 stated she smacked Resident #2's hand when he tried to touch her. Resident #5 also revealed Resident #2 touched other residents in the facility inappropriately. Interview on 04/19/13 at 5:15 PM with CNA B revealed she always gave Resident #2 showers. CNA B stated she witnessed Resident #2 attempting to touch CNA C's buttocks. CNA B revealed she and CNA C told the Charge Nurse, LVN A, about Resident #2's inappropriate behavior. CNA B stated she could not remember the date for the incident. Interview on 04/20/13 at 12:15 PM with CNA C, a former employee, revealed she worked with CNA B on the 300 hall. CNA C stated she was not comfortable sharing any information with the surveyor. Interview on 04/19/13 at 5:22 PM with LVN A revealed he was Resident #2's Charge Nurse on the 2:00 PM to 10:00 PM shift, and he was not aware Resident #2 attempted to touch CNA C's buttocks. LVN A stated the DON did not tell him to put Resident #2 on one-on-one supervision. He also revealed he did not know Resident #2 was touching other residents. On 04/19/13 an IJ was identified. On 04/19/13 at 6:30 PM, the Administrator, DON, and the RNC were informed of the IJ at that time and a Plan of Removal was requested at that time. The Administrator stated she did not understand what an IJ was. While the surveyor attempted to explain what an IJ was to the Administrator, the DON told the surveyor to "Shut-up! I am talking." At this time, the DON stated this situation was not an IJ. She revealed the staff and the residents did not witness anything. The DON revealed, "I have been a DON for [AGE] years and had not had an IJ." The DON also revealed the incident was not reportable because it was not abuse. She stated it was not abuse because Resident #2 did not touch Resident #1. The facility's accepted Plan of Removal dated 04/20/13 reflected Resident #2 was placed on 1:1 supervision and would remain on 1:1 supervision until investigation was completed and behavior subsided. Resident #2's medication regimen was reviewed by the facility's contracted pharmacist with no recommendations. Also Resident #2 was discharged to a psychiatric hospital for an evaluation and medication management. Resident #1 was offered psychological services to help her cope, but she refused. The Administrator was in-serviced by the Regional Nurse Consultant on 1:1, abuse/neglect definitions, and reporting with a follow-up test to ensure understanding. The Administrator was also in-serviced on incident reporting, identification, and reporting inappropriate behaviors. following staff was in-serviced on abuse and neglect by the regional nurse consultant. The facility's staff development/service attendance sheet reflected all facility staff including the DON were re-educated on 04/20/13, 04/21/13, 04/22/13, and 04/23/13 on abuse. The title of the in-service was Report of Abuse and Neglect, Definition of Abuse, Abuse Coordinator, Reporting Sexual Abuse, Abuse, Neglect Prohibition, Information, Accident/Incident Reporting. The DON/designee would monitor new hires for compliance for 3 months to ensure the new hire was in compliance. If a new hire did not pass the test, the new hire would be re-educated. The DON would ensure residents who exhibited inappropriate behaviors would be placed on increased supervision as appropriate for unsafe behavior until intervention was effective and behaviors would be documented on behavior monitoring sheets. The had a QA meeting on 04/23/13 at 10:00 AM with the Medical Director. During the end of the day conference on 04/21/13 at 2:00 PM, the administrator was informed the residents did not know whom to report abuse and who the abuse coordinator was. Some residents stated if they were abused, they would call the police and the legal authorities. The Administrator stated she did not educate the residents on whom to report abuse, even if she did, the residents would still call the police. The Administrator revealed she would not inform the residents to report abuse to her. Interview on 04/21/13 at 9:45 AM with Dishwasher K revealed he received in-service on abuse. Dishwasher K stated the abuse coordinator was the Administrator. Dishwasher K stated he would report abuse immediately. Interview on 04/21/13 at 9:59 AM with Cook L revealed she was in-serviced on abuse. Cook L stated the abuse coordinator was the administrator. Cook L stated she would report abuse to the Administrator. Interview on 04/21/13 at 10:00 AM with PT N revealed she was in-serviced on abuse. PT N stated the abuse coordinator was the Administrator. PT N stated he would report abuse to the Administrator. Interview on 04/21/13 at 1:48 PM with CNA Z revealed she would report abuse to the administrator. CNA Z state she received abuse training yesterday. An interview on 04/22/13 at approximately 9:30 AM with the Administrator revealed she spoke with the Program Manager in the local DADS office and was told she needed to educate the residents on whom to report abuse. Interview on 04/22/13 at 9:54 AM with CNA BB revealed the abuse coordinator was the Administrator. CNA BB stated she was in-serviced on abuse two weeks ago. Interview on 04/22/13 at 9:59 AM with LVN AA revealed the Administrator was the abuse coordinator. LVN AA stated she had abuse training less than one week ago. LVN AA stated if she witnessed sexual abuse, she would report it to the Administrator Interview on 04/22/13 at 10:05 AM with RN D revealed she had sexual abuse training this morning at 5:55 AM. RN D said if she witnessed resident-to-resident sexual abuse, she would separate the residents and report the abuse to the Administrator. RN D said she would do assessments and report to the DON and the physician. Interview on 04/22/13 at 10:15 AM with PT O revealed the abuse coordinator was the Administrator. PT O sated if she witnessed abuse, she would notify the Administrator. Interview on 04/22/13 at 10:20 AM with OT P revealed the abuse coordinator was the Administrator. OT P stated if she witnessed abuse, she would notify the Administrator. Interview on 04/22/13 at 10:30 AM with MA Q revealed the abuse coordinator was the Administrator. MA Q stated if he witnessed abuse, he would notify the Administrator. On 04/23/13 at approximately 10:30 AM, the Administrator told the surveyors she had distributed fliers with her name and phone numbers as the Abuse Coordinator to the residents in their rooms. The administrator finally educated the resident on the abuse coordinator. The administrator printed information identifying the abuse coordinator with her phone number. The administrator left the information in all the residents' rooms. The IJ was removed on 04/23/13 at 10:55 AM and the Administrator was informed at that time. While the IJ was removed, 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. The facility's resident roster dated 04/18/13 reflected 69 female residents.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well- being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of five residents reviewed for assessment and/or treatment of [REDACTED]. When Resident #1 was admitted to the facility for rehabilitation for a [MEDICAL CONDITION] ankle, the facility failed to ensure: 1) Full head to toe skin assessments were conducted. 2) Orders were received from the surgeon following the application of the boot. 3) The boot was removed to assess the resident's skin below the boot and for ADLs. 4) Did not clarify with the surgeon no orders were given in regard to the care of Resident #1's left foot and ankle following the application of the boot. 5) Resident #1 did not develop a wound/pressure ulcer, which resulted in staff being able to visualize the metal hardware used to repair the fracture. 6) Resident #1 did not develop a bone infection. These failures resulted in Resident #1 developing a wound/pressure ulcer in which the metal hardware was clearly visible to the naked eye and an infection of the bone, which may result in the amputation of the resident's left foot. These failures could affect the four residents identified with surgical wounds and the three residents identified with pressure ulcers and placed them at risk for not having full head to toe skin assessments including those areas covered by dressings or boots, etc., resulting in the potential for infection, pain, development of wounds/pressure ulcers, which might be untreated and the need for surgical intervention in the hospital. Findings included: Resident #1's admission orders [REDACTED]. No orders were included related to monitoring cast/orthotic boot, assessing the surgical area, or treatment to the surgical area. A hospital Medications Reconciliation Report dated 01/08/13 reflected Resident #1 had a follow-up appointment with the orthopedic surgeon on 01/21/13 for staple removal. Resident 1's Face Sheet dated 01/25/13 had [DIAGNOSES REDACTED]. An undated, unsigned Nurse Note in Resident #1's clinical record reflected the resident was non-weight bearing on the left ankle and had a cast on the left foot and ankle. Resident #1's Admission/Readmission Data Summary dated 01/08/13 reflected she had a cast on the left foot/ankle. Resident #1 was described as bedfast and required the assistance of one for transfers prior to sustaining the fracture. The Summary included the following: Resident #1 fell at home resulting in a left ankle fracture, ORIF of the left ankle, non-weight bearing to left ankle, elevate left leg at all times in bed. Resident #1's MDS assessment dated [DATE] reflected she was admitted to the facility with [DIAGNOSES REDACTED]. The MDS assessment identified Resident #1 as being at risk for development of pressure ulcers, had other skin problems, surgical wounds, and was receiving surgical wound care. Resident #1's care plan meeting notes and care plan dated 01/29/13 reflected the facility was aware Resident #1 was wearing a soft cast. The facility was also aware Resident #1 had an upcoming appointment to the orthopedics office. There were no goals or approaches in the care plan concerning an assessment of the soft cast, the Cam-Walking Boot or the surgical wound on the left ankle. Review of Resident #1's Physician Telephone Orders dated from 01/08/13 through 02/04/13 revealed no orders concerning skin assessment of the surgical area or wound care to the surgical area. Resident #1's nurses note dated 01/09/12 reflected she needed extensive assistance to transfer with her cast identified as other concerns. The note reflected Resident #1's cast was on the left lower leg. Resident #1's Non-pressure Skin Condition Report dated 01/10/13 reflected a Left Ankle Fracture. The remaining part of the form was blank on the front and the back. Nurse's notes dated 01/11/13 through 01/13/13 reflected, nurses on all three shifts (day shift, evening shift, and night shift) documented the left lower extremity had a cast with and ace wrap. The nurses documented checking capillary refills to the toes. Resident #1's Treatment Record for January 2013 reflected to elevate her left foot/ankle at all times, in bed, every shift. The left leg cast was to be monitored every shift for C[DIAGNOSES REDACTED] (Cast Complicatio[DIAGNOSES REDACTED]). Nurse's notes dated 01/17/13 reflected Resident #1 had returned from her orthopedic appointment at 11:00 a.m., and she had a boot on her left lower leg. It was further documented Resident #1's family told staff the boot should remain on at all times and not be removed. The note was signed by LVN C. During an interview on 02/09/13 at 3:15 p.m. with LVN C, she said she had been involved with the nursing care for Resident #1's incision during the time she was her nurse. LVN C said the treatment nurse was out, and she was helping with the wound care. The surveyor queried what that involved, and LVN C replied, it was making sure Resident #1 had her foot elevated and she got to the orthopedic appointment, which the LVn did. LVN C said on 01/17/13, Resident #1 went to her orthopedic appointment, and the family came back with the resident with no orders "in hand." LVN C said the family said the boot should stay on, and she was to go to therapy with the boot on. The surveyor queried if LVN C had called and verified the physician orders, which the family had told her. LVN C replied, "No. It was the end of my shift." LVN C said the next day (01/18/13), somebody called from the orthopedic surgeon's office. LVN C said she called them back, left a message and never heard back from them. The surveyor queried whether LVN C followed-up on the phone call or told anyone else to follow-up. LVN C replied, "No. I did not. I used to work with these boots before, and I know all about them, You are not supposed to take them off." LVN C said she did inform the primary care physician about Resident #1's visit to the orthoped's office, the resident returning with a boot on the left foot, and the boot was supposed to stay on all the time. LVN C said the physician said, "OK." LVN C said she continued to follow physician orders, and on Monday (02/04/13), when she returned to work, the Physician Assistant (PA) was there to evaluate Resident #1, and the resident was sent to the emergency room . The surveyor queried what LVN C saw when she removed the dressing to let the PA look at the ankle. LVN C said she saw the hardware in the ankle. Review of nurses note dated 01/17/13 reflected documentation from LVN B concerning Resident #1's boot. LVN B documented she was informed by the previous nurse on duty the boot on Resident #1's leg should not be taken off. LVN B also documented the Occupational Therapist opened the boot and upon assessment, resident's skin was noted as being clean, dry and intact, no swelling, and no redness noted. Interview on 02/09/13 at 3:40 p.m. with LVN B revealed Resident #1 came back from the orthopedic surgeon's office with a left leg boot. LVN B stated LVN C was there when Resident #1 told her the surgical wound was healing very well and the resident had on a boot. LVN B said she asked LVN C what they were supposed to do with the boot. LVN B said LVN C told her there was no order, but the family said not to remove the boot for any reason. LVN B said she asked ask LVN C if she was sure, and she said, "Yes," that was what Resident #1's family member said. The first time LVN B went into Resident #1's room, she said the Occupational Therapist (OT) came into the room and opened the boot. They could see the resident's skin was "ok." LVN B said she told the OT she should not open the boot up, but she did any way. LVN B said she kept watching Resident #1's leg to make sure nothing was wrong. LVN B said Resident #1 always told her (the LVN) everything was fine and she did not need anything. The surveyor queried about the documentation in the nurses notes concerning Resident #1 not wanting LVN B to touch her leg. LVN B said, "I was told not to touch it (the boot). The other nurse told me the physician orders [REDACTED]." The surveyor queried, "Did you ever tell anyone (Resident #1) would not let you touch her leg?" LVN B said, "I never told anyone." The surveyor queried, "Did you ever check to see if there were any physician orders?" LVN B said, no she did not, and when the surveyor queried did LVN B ever see the wound on Resident #1 ' s ankle, LVN B said, "No." The surveyor queried what "C[DIAGNOSES REDACTED]" meant as LVN B was the only nurse to use the term. LVN B said it was to assess Resident #1 for pulses, circulation in her foot and capillary refill. Resident #1's nurse's notes reflected: 01/20/13 - Resident #1 has refused to let LVN A dress her left lower ankle. 01/21/13 - LVN B was unable to assess Resident #1's leg with the boot due to the resident's refusal. 01/22/13 - LVN B was unable to assess Resident #1's leg with boot due to resident's refusal. 01/23/13 - LVN B was unable to assess Resident #1's left leg due to refusal. 01/29/13 - Resident #1 refused assessment of the left leg with boot Says "I am fine." Further review of Resident #1's nurse's notes dated from 01/20/13 through 01/29/13 revealed documentation on other shifts reflected nurses documented the boot was on the foot "as physician ordered." There were no skin assessments for Resident #1 and/or removal of the boot toassess the resident's skin below the boot. Resident #1's Physician Consolidated Orders for February 2013 reflected there were no treatments or orders for monitoring the skin/cast on the left ankle. Resident #1's Treatment Record for February 2013 reflected nothing concerning the left ankle. Resident #1's nurse's notes reflected on 02/02/13, day shift, LVN A documented Resident #1's "...complaint of severe pain to left lateral ankle, greenish drainage to left ankle. Severe pain when palpated " LVN A documented she had notified the PA and had followed the PA's orders. Further review reflected on 02/02/13, night shift, Resident #1 did not allow the nurse to check the leg. Interview on 02/09/13 at 3:30 p.m. with the Physical Therapist (PT) revealed Resident #1 was non-weight bearing on the left foot because of her ankle fracture. The PT said he had gone in the morning of 02/02/13 to get Resident #1 up to take her to therapy. "When I tried to get her up, (Resident #1) was "screaming" in pain and she told me not to touch her at all." The PT said, "I thought maybe the boot was too tight, so I started removing the boot. That is when I saw this drainage, so I went and got the nurse. The nurse came and I helped remove the ace bandage. There was no dressing on the wound, it was very raw, red, lots of serous drainage and a very foul odor. The nurse left to call the physician. I stayed and helped to clean the boot up, because it was very dirty with all the dried, hard cracked drainage and blood and the very foul odor. These boots are washable." The surveyor queried what type of boot was it? The PT said it was a "Cam-Walker Boot," that was used so the resident could walk, and the reason the physician had probably put this type of boot on Resident #1 was because she kept trying to put pressure on the foot and stand." The surveyor asked if one could you remove these types of boots to assess the skin. The PT said, "Yes, you should, because the area around the ankle is very firm (like vinyl) and can get tight. There are metal straps to hold the boot on and the top part of the boot is mesh." Interview on 02/09/13 at 1:00 p.m. with LVN A revealed she had never seen anything on the 24 hour report concerning Resident #1's boot. LVN A said she just took the boot off because of the pain Resident #1 was feeling; the pain was more than usual, which was when she saw her foot and called the PA, the ADON, and the family. LVN A stated, "I got all the orders and took care of them and I made sure to tell the staff the Monday nurse really needed to have the PA see (Resident #1's) ankle, because the PA comes on Monday." The surveyor queried whether LVN A thought the pressure ulcer was bad enough for Resident #1 to go the hospital? LVN A said, "I just did what the PA told me to do." Interview on 02/09/13 at 1:40 p.m. with the ADON revealed the ADON had evaluated Resident #1 one time on 01/31/13 concerning the staff giving Resident #1 [MEDICATION NAME] (antianxiety med) for anxiety, shakiness, and giddy behavior. The ADON stated, "I did a neurological assessment, because the staff thought she was acting different from the medication and did not seem as alert. (Resident #1) did fine, she answered all the appropriate questions. No staff ever told me anything about an assessment of the wound or lack of. I heard about the wound (pressure ulcer) when they called me over the weekend. I never saw the wound (pressure ulcer). On 02/03/13, LVN A charted in the nurse's notes, "left ankle incision site has moderate amount of bloody greenish drainage ...area also very painful to touch, and foul smelling." LVN A documented she had notified the PA and the ADON, no new orders received, just to continue to monitor and wait on the results from the lab. Further review of nurse's notes reflected on other shifts on 02/03/13, the brace continued to be left on, was taken off one time, when the family requested, but later, the brace was back on. Interview on 02/09/13 at 4:00 p.m. with LVN D revealed she was helping out at the facility as treatment nurse, because the current treatment nurse was out on leave. The surveyor queried how the treatment nurse's position worked. LVN D said she saw all the pressure wounds in the facility with the wound care physician, and if there was a problem with a new area or something else, the nurses told her to look at the area. LVN D said she had not seen the pressure ulcer until right before Resident #1 was going to the hospital. LVN D said Resident #1 definitely needed to go the hospital, because the pressure ulcer was very "bad." Resident #1's SBAR form (document for new symptoms, signs, and other changes in condition) dated 02/04/13 reflected LVN C documented, "...symptoms started on 02/02/13 possible osteo[DIAGNOSES REDACTED] to left ankle, (Resident #1) was wearing boot ...as ordered, boot caused pressure area to ankle, hardware from surgery is exposed." Further review of the SBAR form reflected LVN C documented, "...wound red and painful, hardware is exposed... in more pain, wound appears infected." Resident #1's final nurse's note prior to discharge to the hospital on [DATE] was documented by LVN C, "PA in the room to assess left ankle. Old dressing removed. Pressure wound noted to outer side of the left ankle. Hardware placed from surgery visible at site." On 02/09/13 at 9:18 a.m., during initial tour of the facility, RN A told the surveyor each nurse was responsible on the weekends for the care of the residents, and if the resident had a wound, they were supposed to do the treatment and assess the wound. RN A said during the week, the facility had a treatment nurse, who took care of the wounds. RN A informed the surveyor she had four residents, who had surgical wounds, and Resident #1, who had a surgical wound for an ankle fracture, was in the hospital. When the surveyor queried as to why Resident #1 was in the hospital, RN A said she was unclear. RN A stated she worked on the weekends and when she came back she (Resident #1) was gone to the hospital. Interview on 02/09/13 at 7:45 a.m. with a family member revealed, to the family member's knowledge, they had only removed the boot on Resident #1's foot one time, and that was by a therapist. The family member said he/she came in when the therapist was removing the boot from Resident#1's left leg. The family member said the area on the ankle looked terrible, it smelled really bad and the hardware (used to repair the fracture) was visible in the the resident's ankle. He/She stated the nurse called the doctor and got a treatment order for the ankle and ordered x-rays, blood work and antibiotics. He/She said after the weekend, they sent Resident #1 to the hospital, because she would not take her antibiotic, and the PA said to call the surgeon. The doctor at the hospital told the family member Resident #1 would have to have more surgery. The doctor told the family member he (the doctor) had to remove the hardware, which was placed to repair the fracture. The physician also told the family member he hoped the infection cleared and, if not, the doctor said he might have to amputate her foot. The family member stated they put a Wound Vac (Wound Care Treatment Machine) on Resident #1's ankle at the hospital and transferred the resident to another specialty place for treatment for [REDACTED]. Interview on 02/09/13 at 11:05 a.m. with LVN F revealed each nurse had to do their own treatments and skin assessments on the weekend. If the nurse found a problem, they must call the physician and get a treatment for [REDACTED]. Interview on 02/09/13 at 4:10 p.m. with LVN E revealed each nurse had skin assessment assignments they were supposed to do according to the shift they worked. The skin assessments were divided up between two shifts and by rooms. LVN E said if there wasf a problem with a resident's skin, we tell the treatment nurse. Interview on 02/09/13 at 4:23 p.m. with the Administrator and the ADON revealed they had plenty of nurses to come to work. The Administrator said the nurses were required to come into the focus meeting daily during the week, read from the 24 hour reports and then we discuss the areas. The ADON agreed this was what happened. The Administrator and the ADON said they thought there were still problems with the staff communicating to each other the residents' problems and maybe some of the newer nurses took the older staff nurses at their word. Interview on 02/13/13 at 2:05 p.m. with the PA revealed he had seen Resident #1 when she first entered the facility. The PA said he saw Resident #1 on the Monday (02/04/13) after they had found the area on Resident #1's ankle. The PA said, "I asked the nurse if she had seen this before," referring to LVN C, and the nurse said, "No." "The nurse and I cleaned up the area with normal saline and placed Kerlix around the wound, and I told the nurse to call the surgeon immediately." The PA said he could see "the metal inside the wound." Interview on 02/18/13 at 11:14 a.m. with the surgeon reveaeld he had performed surgery on Resident #1 earlier in January 2013. He said Resident #1 went to the facility for rehabilitation. She was a compromised resident with complications from other medical problems and normally surgery would not have been performed, but with Resdient #1 walking before the surgery, "I felt it weas necessary to take the risk. Resident #1 did very nicely with her surgery and at the two weeks checkup, the surgical incision was healing well, and I removed the sutures. My office sent back orders concerning the boot. I have a copy of them here. I do not know if the facility lost them or the family lost them, but no one contacted our office for any oders, so I preusmed they were following my orders. The orders were for the boot to stay on, but could be removed for assessing of the area, showering, dressing, and range of motion. I did not see Resident #1 again until she returned to the hospital (on 02/04/13). I had to readmit Resident #1 to the hospital and remove the hardware I had placed in the ankle." The surgeon said ususally, "...when you have to remove the hardware, the patient has already devopled osteomylitis (bone infection) and (Resident #1) was no different, so I began to treat that and told the family that if we can clear up the infection, we would be able to work toward rehabilitation and walking. With (Resident #1's) mutiple medical problems, it may be difficult to do this, so I did tell the family we would have to take it slow, and as a last resort, the foot might have to amputated." 2) The facility's current policy entitled Skin Reviews/Checks dated December 2008, reflected the following policy: "To promote interpretive guidelines related to skin assessment scores to assure the proper evaluation of all residents' skin and potential skin breakdown. Also to ensure timely identification and notification of newly identified skin problems." Procedure Residents must be checked at time of admission and weekly thereafter by a licensed nurse. The anatomical figure will be marked to identify any skin condition with each area labeled in alphabetical order in the event more than one area is present. Each identified skin area should be labeled as to its causal origin if non-pressure related; e.g., surgical incision... This information will be documented in the site section." 3) The CMS 672, Resident Census and Conditions of Residents, dated 02/09/13, reflected three residents were identified with pressure ulcers. The facility census was 102.

Based on observation, interview, and record review, it was determined the facility failed to ensure, based on the comprehensive assessment of a resident, the facility ensured a resident who entered the facility without pressure sores did not develop pressure sores unless they were unavoidable, and a resident with pressure sores received the necessary treatment and services to promote healing for one (Resident #1) of five residents reviewed for assessment and/or treatment of [REDACTED]. When Resident #1 was admitted to the facility for rehabilitation for a [MEDICAL CONDITION] ankle, the facility failed to ensure: 1) Full head to toe skin assessments were conducted. 2) Orders were received from the surgeon following the application of the boot. 3) The boot was removed to assess the resident's skin below the boot and for ADLs. 4) Did not clarify with the surgeon no orders were given in regard to the care of Resident #1's left foot and ankle following the application of the boot. 5) Resident #1 did not develop a wound/pressure ulcer, which resulted in staff being able to visualize the metal hardware used to repair the fracture. 6) Resident #1 did not develop a bone infection. These failures resulted in Resident #1 developing a wound/pressure ulcer in which the metal hardware was clearly visible to the naked eye when an Ace bandage and boot was removed and an infection of the bone, which might result in the amputation of the resident's left foot. These failures could affect the four residents identified with surgical wounds and the three residents identified with pressure ulcers and placed them at risk for not having full head to toe skin assessments including those areas covered by dressings or boots, etc., resulting in the potential for infection, pain, development of wounds/pressure ulcers, which might be untreated and the need for surgical intervention in the hospital. Findings included: Resident #1's admission orders [REDACTED]. No orders were included related to monitoring cast/orthotic boot, assessing the surgical area, or treatment to the surgical area. A hospital Medications Reconciliation Report dated 01/08/13 reflected Resident #1 had a follow-up appointment with the orthopedic surgeon on 01/21/13 for staple removal. Resident 1's Face Sheet dated 01/25/13 had [DIAGNOSES REDACTED]. An undated, unsigned Nurse Note in Resident #1's clinical record reflected the resident was non-weight bearing on the left ankle and had a cast on the left foot and ankle. Resident #1's Admission/Readmission Data Summary dated 01/08/13 reflected she had a cast on the left foot/ankle. Resident #1 was described as bedfast and required the assistance of one for transfers prior to sustaining the fracture. The Summary included the following: Resident #1 fell at home resulting in a left ankle fracture, ORIF of the left ankle, non-weight bearing to left ankle, elevate left leg at all times in bed. Resident #1's MDS assessment dated [DATE] reflected she was admitted to the facility with [DIAGNOSES REDACTED]. The MDS assessment identified Resident #1 as being at risk for development of pressure ulcers, had other skin problems, surgical wounds, and was receiving surgical wound care. Resident #1's care plan meeting notes and care plan dated 01/29/13 reflected the facility was aware Resident #1 was wearing a soft cast. The facility was also aware Resident #1 had an upcoming appointment to the orthopedics office. There were no goals or approaches in the care plan concerning an assessment of the soft cast, the Cam-Walking Boot or the surgical wound on the left ankle. Review of Resident #1's Physician Telephone Orders dated from 01/08/13 through 02/04/13 revealed no orders concerning skin assessment of the surgical area or wound care to the surgical area. Resident #1's nurses note dated 01/09/12 reflected she needed extensive assistance to transfer with her cast identified as other concerns. The note reflected Resident #1's cast was on the left lower leg. Resident #1's Non-pressure Skin Condition Report dated 01/10/13 reflected a Left Ankle Fracture. The remaining part of the form was blank on the front and the back. Nurse's notes dated 01/11/13 through 01/13/13 reflected, nurses on all three shifts (day shift, evening shift, and night shift) documented the left lower extremity had a cast with and ace wrap. The nurses documented checking capillary refills to the toes. Resident #1's Treatment Record for January 2013 reflected to elevate her left foot/ankle at all times, in bed, every shift. The left leg cast was to be monitored every shift for C[DIAGNOSES REDACTED] (Cast Complicatio[DIAGNOSES REDACTED]). Nurse's notes dated 01/17/13 reflected Resident #1 had returned from her orthopedic appointment at 11:00 a.m., and she had a boot on her left lower leg. It was further documented Resident #1's family told staff the boot should remain on at all times and not be removed. The note was signed by LVN C. During an interview on 02/09/13 at 3:15 p.m. with LVN C, she said she had been involved with the nursing care for Resident #1's incision during the time she was her nurse. LVN C said the treatment nurse was out, and she was helping with the wound care. The surveyor queried what that involved, and LVN C replied, it was making sure Resident #1 had her foot elevated and she got to the orthopedic appointment, which the LVn did. LVN C said on 01/17/13, Resident #1 went to her orthopedic appointment, and the family came back with the resident with no orders "in hand." LVN C said the family said the boot should stay on, and she was to go to therapy with the boot on. The surveyor queried if LVN C had called and verified the physician orders, which the family had told her. LVN C replied, "No. It was the end of my shift." LVN C said the next day (01/18/13), somebody called from the orthopedic surgeon's office. LVN C said she called them back, left a message and never heard back from them. The surveyor queried whether LVN C followed-up on the phone call or told anyone else to follow-up. LVN C replied, "No. I did not. I used to work with these boots before, and I know all about them, You are not supposed to take them off." LVN C said she did inform the primary care physician about Resident #1's visit to the orthoped's office, the resident returning with a boot on the left foot, and the boot was supposed to stay on all the time. LVN C said the physician said, "OK." LVN C said she continued to follow physician orders, and on Monday (02/04/13), when she returned to work, the Physician Assistant (PA) was there to evaluate Resident #1, and the resident was sent to the emergency room . The surveyor queried what LVN C saw when she removed the dressing to let the PA look at the ankle. LVN C said she saw the hardware in the ankle. Review of nurses note dated 01/17/13 reflected documentation from LVN B concerning Resident #1's boot. LVN B documented she was informed by the previous nurse on duty the boot on Resident #1's leg should not be taken off. LVN B also documented the Occupational Therapist opened the boot and upon assessment, resident's skin was noted as being clean, dry and intact, no swelling, and no redness noted. Interview on 02/09/13 at 3:40 p.m. with LVN B revealed Resident #1 came back from the orthopedic surgeon's office with a left leg boot. LVN B stated LVN C was there when Resident #1 told her the surgical wound was healing very well and the resident had on a boot. LVN B said she asked LVN C what they were supposed to do with the boot. LVN B said LVN C told her there was no order, but the family said not to remove the boot for any reason. LVN B said she asked ask LVN C if she was sure, and she said, "Yes," that was what Resident #1's family member said. The first time LVN B went into Resident #1's room, she said the Occupational Therapist (OT) came into the room and opened the boot. They could see the resident's skin was "ok." LVN B said she told the OT she should not open the boot up, but she did any way. LVN B said she kept watching Resident #1's leg to make sure nothing was wrong. LVN B said Resident #1 always told her (the LVN) everything was fine and she did not need anything. The surveyor queried about the documentation in the nurses notes concerning Resident #1 not wanting LVN B to touch her leg. LVN B said, "I was told not to touch it (the boot). The other nurse told me the physician orders [REDACTED]." The surveyor queried, "Did you ever tell anyone (Resident #1) would not let you touch her leg?" LVN B said, "I never told anyone." The surveyor queried, "Did you ever check to see if there were any physician orders?" LVN B said, no she did not, and when the surveyor queried did LVN B ever see the wound on Resident #1 ' s ankle, LVN B said, "No." The surveyor queried what "C[DIAGNOSES REDACTED]" meant as LVN B was the only nurse to use the term. LVN B said it was to assess Resident #1 for pulses, circulation in her foot and capillary refill. Resident #1's nurse's notes reflected: 01/20/13 - Resident #1 has refused to let LVN A dress her left lower ankle. 01/21/13 - LVN B was unable to assess Resident #1's leg with the boot due to the resident's refusal. 01/22/13 - LVN B was unable to assess Resident #1's leg with boot due to resident's refusal. 01/23/13 - LVN B was unable to assess Resident #1's left leg due to refusal. 01/29/13 - Resident #1 refused assessment of the left leg with boot Says "I am fine." Further review of Resident #1's nurse's notes dated from 01/20/13 through 01/29/13 revealed documentation on other shifts reflected nurses documented the boot was on the foot "as physician ordered." There were no skin assessments for Resident #1 and/or removal of the boot toassess the resident's skin below the boot. Resident #1's Physician Consolidated Orders for February 2013 reflected there were no treatments or orders for monitoring the skin/cast on the left ankle. Resident #1's Treatment Record for February 2013 reflected nothing concerning the left ankle. Resident #1's nurse's notes reflected on 02/02/13, day shift, LVN A documented Resident #1's "...complaint of severe pain to left lateral ankle, greenish drainage to left ankle. Severe pain when palpated " LVN A documented she had notified the PA and had followed the PA's orders. Further review reflected on 02/02/13, night shift, Resident #1 did not allow the nurse to check the leg. Interview on 02/09/13 at 3:30 p.m. with the Physical Therapist (PT) revealed Resident #1 was non-weight bearing on the left foot because of her ankle fracture. The PT said he had gone in the morning of 02/02/13 to get Resident #1 up to take her to therapy. "When I tried to get her up, (Resident #1) was "screaming" in pain and she told me not to touch her at all." The PT said, "I thought maybe the boot was too tight, so I started removing the boot. That is when I saw this drainage, so I went and got the nurse. The nurse came and I helped remove the ace bandage. There was no dressing on the wound, it was very raw, red, lots of serous drainage and a very foul odor. The nurse left to call the physician. I stayed and helped to clean the boot up, because it was very dirty with all the dried, hard cracked drainage and blood and the very foul odor. These boots are washable." The surveyor queried what type of boot was it? The PT said it was a "Cam-Walker Boot," that was used so the resident could walk, and the reason the physician had probably put this type of boot on Resident #1 was because she kept trying to put pressure on the foot and stand." The surveyor asked if one could you remove these types of boots to assess the skin. The PT said, "Yes, you should, because the area around the ankle is very firm (like vinyl) and can get tight. There are metal straps to hold the boot on and the top part of the boot is mesh." Interview on 02/09/13 at 1:00 p.m. with LVN A revealed she had never seen anything on the 24 hour report concerning Resident #1's boot. LVN A said she just took the boot off because of the pain Resident #1 was feeling; the pain was more than usual, which was when she saw her foot and called the PA, the ADON, and the family. LVN A stated, "I got all the orders and took care of them and I made sure to tell the staff the Monday nurse really needed to have the PA see (Resident #1's) ankle, because the PA comes on Monday." The surveyor queried whether LVN A thought the pressure ulcer was bad enough for Resident #1 to go the hospital? LVN A said, "I just did what the PA told me to do." Interview on 02/09/13 at 1:40 p.m. with the ADON revealed the ADON had evaluated Resident #1 one time on 01/31/13 concerning the staff giving Resident #1 [MEDICATION NAME] (antianxiety med) for anxiety, shakiness, and giddy behavior. The ADON stated, "I did a neurological assessment, because the staff thought she was acting different from the medication and did not seem as alert. (Resident #1) did fine, she answered all the appropriate questions. No staff ever told me anything about an assessment of the wound or lack of. I heard about the wound (pressure ulcer) when they called me over the weekend. I never saw the wound (pressure ulcer). On 02/03/13, LVN A charted in the nurse's notes, "left ankle incision site has moderate amount of bloody greenish drainage ...area also very painful to touch, and foul smelling." LVN A documented she had notified the PA and the ADON, no new orders received, just to continue to monitor and wait on the results from the lab. Further review of nurse's notes reflected on other shifts on 02/03/13, the brace continued to be left on, was taken off one time, when the family requested, but later, the brace was back on. Interview on 02/09/13 at 4:00 p.m. with LVN D revealed she was helping out at the facility as treatment nurse, because the current treatment nurse was out on leave. The surveyor queried how the treatment nurse's position worked. LVN D said she saw all the pressure wounds in the facility with the wound care physician, and if there was a problem with a new area or something else, the nurses told her to look at the area. LVN D said she had not seen the pressure ulcer until right before Resident #1 was going to the hospital. LVN D said Resident #1 definitely needed to go the hospital, because the pressure ulcer was very "bad." Resident #1's SBAR form (document for new symptoms, signs, and other changes in condition) dated 02/04/13 reflected LVN C documented, "...symptoms started on 02/02/13 possible osteo[DIAGNOSES REDACTED] to left ankle, (Resident #1) was wearing boot ...as ordered, boot caused pressure area to ankle, hardware from surgery is exposed." Further review of the SBAR form reflected LVN C documented, "...wound red and painful, hardware is exposed... in more pain, wound appears infected." Resident #1's final nurse's note prior to discharge to the hospital on [DATE] was documented by LVN C, "PA in the room to assess left ankle. Old dressing removed. Pressure wound noted to outer side of the left ankle. Hardware placed from surgery visible at site." On 02/09/13 at 9:18 a.m., during initial tour of the facility, RN A told the surveyor each nurse was responsible on the weekends for the care of the residents, and if the resident had a wound, they were supposed to do the treatment and assess the wound. RN A said during the week, the facility had a treatment nurse, who took care of the wounds. RN A informed the surveyor she had four residents, who had surgical wounds, and Resident #1, who had a surgical wound for an ankle fracture, was in the hospital. When the surveyor queried as to why Resident #1 was in the hospital, RN A said she was unclear. RN A stated she worked on the weekends and when she came back she (Resident #1) was gone to the hospital. Interview on 02/09/13 at 7:45 a.m. with a family member revealed, to the family member's knowledge, they had only removed the boot on Resident #1's foot one time, and that was by a therapist. The family member said he/she came in when the therapist was removing the boot from Resident#1's left leg. The family member said the area on the ankle looked terrible, it smelled really bad and the hardware (used to repair the fracture) was visible in the the resident's ankle. He/She stated the nurse called the doctor and got a treatment order for the ankle and ordered x-rays, blood work and antibiotics. He/She said after the weekend, they sent Resident #1 to the hospital, because she would not take her antibiotic, and the PA said to call the surgeon. The doctor at the hospital told the family member Resident #1 would have to have more surgery. The doctor told the family member he (the doctor) had to remove the hardware, which was placed to repair the fracture. The physician also told the family member he hoped the infection cleared and, if not, the doctor said he might have to amputate her foot. The family member stated they put a Wound Vac (Wound Care Treatment Machine) on Resident #1's ankle at the hospital and transferred the resident to another specialty place for treatment for [REDACTED]. Interview on 02/09/13 at 11:05 a.m. with LVN F revealed each nurse had to do their own treatments and skin assessments on the weekend. If the nurse found a problem, they must call the physician and get a treatment for [REDACTED]. Interview on 02/09/13 at 4:10 p.m. with LVN E revealed each nurse had skin assessment assignments they were supposed to do according to the shift they worked. The skin assessments were divided up between two shifts and by rooms. LVN E said if there wasf a problem with a resident's skin, we tell the treatment nurse. Interview on 02/09/13 at 4:23 p.m. with the Administrator and the ADON revealed they had plenty of nurses to come to work. The Administrator said the nurses were required to come into the focus meeting daily during the week, read from the 24 hour reports and then we discuss the areas. The ADON agreed this was what happened. The Administrator and the ADON said they thought there were still problems with the staff communicating to each other the residents' problems and maybe some of the newer nurses took the older staff nurses at their word. Interview on 02/13/13 at 2:05 p.m. with the PA revealed he had seen Resident #1 when she first entered the facility. The PA said he saw Resident #1 on the Monday (02/04/13) after they had found the area on Resident #1's ankle. The PA said, "I asked the nurse if she had seen this before," referring to LVN C, and the nurse said, "No." "The nurse and I cleaned up the area with normal saline and placed Kerlix around the wound, and I told the nurse to call the surgeon immediately." The PA said he could see "the metal inside the wound." Interview on 02/18/13 at 11:14 a.m. with the surgeon reveaeld he had performed surgery on Resident #1 earlier in January 2013. He said Resident #1 went to the facility for rehabilitation. She was a compromised resident with complications from other medical problems and normally surgery would not have been performed, but with Resdient #1 walking before the surgery, "I felt it weas necessary to take the risk. Resident #1 did very nicely with her surgery and at the two weeks checkup, the surgical incision was healing well, and I removed the sutures. My office sent back orders concerning the boot. I have a copy of them here. I do not know if the facility lost them or the family lost them, but no one contacted our office for any oders, so I preusmed they were following my orders. The orders were for the boot to stay on, but could be removed for assessing of the area, showering, dressing, and range of motion. I did not see Resident #1 again until she returned to the hospital (on 02/04/13). I had to readmit Resident #1 to the hospital and remove the hardware I had placed in the ankle." The surgeon said ususally, "...when you have to remove the hardware, the patient has already devopled osteomylitis (bone infection) and (Resident #1) was no different, so I began to treat that and told the family that if we can clear up the infection, we would be able to work toward rehabilitation and walking. With (Resident #1's) mutiple medical problems, it may be difficult to do this, so I did tell the family we would have to take it slow, and as a last resort, the foot might have to amputated." 2) The facility's current policy entitled Skin Reviews/Checks dated December 2008, reflected the following policy: "To promote interpretive guidelines related to skin assessment scores to assure the proper evaluation of all residents' skin and potential skin breakdown. Also to ensure timely identification and notification of newly identified skin problems." Procedure Residents must be checked at time of admission and weekly thereafter by a licensed nurse. The anatomical figure will be marked to identify any skin condition with each area labeled in alphabetical order in the event more than one area is present. Each identified skin area should be labeled as to its causal origin if non-pressure related; e.g., surgical incision... This information will be documented in the site section." 3) The CMS 672, Resident Census and Conditions of Residents, dated 02/09/13, reflected three residents were identified with pressure ulcers. The facility census was 102.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the plan of care for two (Residents #17 and # 25) of 13 residents reviewed, who were administered [MEDICATION NAME] (anti-coagulant/blood thinner). 1) Resident #17, admitted on [DATE] and who received 5 mg of [MEDICATION NAME] daily, did not have the physician-ordered monthly PT/INR levels drawn in August and September 2010. Facility staff had not followed up to monitor and ensure the PT/INRs were completed and were unaware the resident's labs were not done. The resident developed pain in her right hip on 10/01/10. On 10/02/10, the resident continued to complain of pain and had bruising and swelling of her right hip and upper thigh area. X-rays were done without evidence of a fracture. Facility staff assessments did not result in recognition of the bruising as a side effect of the [MEDICATION NAME]. Resident #17 was sent to the hospital on [DATE] for the bruising and to rule out a fracture. At the hospital, the resident's PT was critically high at 49.8 seconds, and her INR was critically high at 16.3. The resident was admitted to the Telemetry unit and was transfused with four units of packed red blood cells and four units of plasma. 2) Newly-admitted Resident #25 received [MEDICATION NAME] 2.5 mg daily. Physician-ordered labs for PT/INRs were scheduled for 10/18/10 and 10/21/10. The PT/INR for 10/18/10 was a day late and done on 10/19/10. Facility staff were not aware the resident's PT/INR for 10/21/10 had not been done. Following surveyor intervention, the resident had a PT/INR done at 11:30 PM on 10/22/10, almost two days late. An IJ was identified on 10/22/10. While the IJ was removed on 10/25/10, 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 implementation of thier plan of removal. These failures could affect the facility's 12 residents receiving [MEDICATION NAME], including Residents #17 and #25, and placed them at risk for bleeding, hemorrhaging, kidney failure, stroke and even death. Findings included: 1) Resident #17 was an [AGE] year-old female, who was (re)admitted to the facility on [DATE], according to the admit record dated 09/13/10. Her diagnoses, according to the admit record, included the following: Senile Dementia, Dysphagia, Debility, [MEDICAL CONDITION], Diabetes Mellitus, Hypertension and Atypical [MEDICAL CONDITION]. Resident #17's MDS assessment dated [DATE] reflected her short and long-term memory were impaired and her decision-making skills were severely impaired. She needed extensive assistance with transfers, dressing and personal hygiene. She needed limited assistance with eating, and she was dependent on staff for bathing. Resident #17 was incontinent of bowel and bladder. A review of Resident #17's Physician order [REDACTED]. The orders also reflected, "MONITOR FOR MEDICATION SIDE EFFECTS R/T (related to) ANTICOAGULATION TX ...BRUISING, NOSE BLEED, HEMATURIA (blood in urine), BLOOD IN STOOL, MOUTH ULCERS, NECROSIS, RASH, BLEEDING GUMS EVERY SHIFT." An interview with ADON K on 10/25/10 at 10:03 AM revealed Resident #17 was on [MEDICATION NAME] for history of a stroke and [MEDICAL CONDITION] Fibrillation. Review of Resident #17's care plans dated 01/18/10 and updated on 04/15/10, 07/09/10 and 09/30/10 revealed there was no care plan regarding the use of [MEDICATION NAME] or an anti-coagulant medication. Resident #17's Anticoagulant Flow Sheet for October 2010 reflected, "MONITOR FOR MEDICATION SIDE EFFECTS R/T (related to) ANTICOAGULATION TX ...BRUISING, NOSE BLEED, HEMATURIA, BLOOD IN STOOL, MOUTH ULCERS, NECROSIS, RASH, BLEEDING GUMS EVERY SHIFT." The Flow Sheet indicated Resident #17 was checked on 10/01/10 on the first shift, all three shifts on 10/02/10 and all three shifts on 10/03/10. The Flow Sheet further reflected Resident #17 received [MEDICATION NAME] 5 mg on 10/01/10, 10/02/10 and 10/03/10. An observation on 10/21/10 at 1:00 PM revealed Resident #17 lying in bed with her eyes closed. An observation on 10/22/10 at 8:32 AM revealed Resident #17 was sitting up in bed for her breakfast and she was sleepy. There was no obvious bruising noted. 2) Nurse's Notes dated 10/01/10 reflected Resident #17 complained of pain in her right hip. Nurse's Notes dated 10/02/10 reflected Resident #17 complained of pain in her right hip and there was bruising, redness and swelling. The Notes reflected the physician's NP was contacted, and the NP gave an order for [REDACTED]. Resident #17's Nurse's Notes dated 10/03/10 reflected the resident had bruising on the back of her right leg with some swelling. The Notes reflected the physician's NP was notified, and he ordered an x-ray of her leg. Then he gave an order to send Resident #17 to the ER for evaluation. An interview with the facility charge nurse, LVN J, who sent Resident #17 to the hospital, was conducted via telephone on 10/21/10 at 2:40 PM revealed Resident #17 had some bruising, and it was painful to the touch. She stated the bruising behind Resident #17's knee was also painful to touch. She stated the x-rays were inconclusive, and Resident #17 was sent to the ER to rule out fractures. LVN J stated she did not know what caused the bruising. LVN J indicated Resident #17 was on [MEDICATION NAME]. An Incident/Accident Report dated 10/03/10 at 5:00 PM (two days after the resident complained of pain and one day after bruising was found) reflected a CNA found a "purplish red in color" bruise on Resident #17's right hip and a bruise on her leg. There were no measurements of the bruises on the report. The Investigation Follow-Up dated 10/03/10 reflected the incident occurred on 10/02/10 and "Unsure of exact reason for bruise-possible medication related ie: [MEDICATION NAME]." A Hospice Nursing Visit Note dated 10/03/10 reflected the "dark purple" bruise on Resident #17's right hip was 12.5 cm x 7.0 cm, and the "dark purple" bruise on her right leg was 12.0 cm x 10.0 cm. Resident #17's MD on 10/22/10 at 2:09 PM was interviewed via telephone regarding the resident and what had occurred. The MD stated he received a call from the hospice nurse, who told him Resident #17 had bruising, and they were going to get a PT/INR. He stated there was a question about what happened to Resident #17 because of the hematoma and the large bruise. Resident #17's MD stated he wanted the PT/INRs done on Resident #17. He stated the last PT/INR was done in July 2010, and at the time of the resident's bruising, there were no current PT/INR results. Resident #17's MD stated the hospice nurse informed his NP there were no current PT/INR results. He stated he wanted the lab done, but Resident #17 was already sent to the hospital. 3) The hospital ER notes dated 10/03/10 reflected: "Right hip: mild tenderness and large ecchymosis (bruise) located in the lateral aspect of the hip. Limited ROM (range of motion) secondary to pain (diminished abduction, adduction, flexion and extension) ...Right thigh: mild tenderness and large ecchymosis located in the lateral aspect of upper, mid and lower thigh." The notes also reflected Resident #17 was type and cross-matched for four units of packed red blood cells and four units of fresh frozen plasma, and she was given 5 mg Vitamin K (for clotting) intramuscularly. The ER notes reflected Resident #17 was admitted to the Telemetry unit. (The Telemetry unit monitors, with the assistance of [MEDICATION NAME] attached to the resident, their heart rate and rhythm, blood pressure and vitals closely to ensure the resident's condition remains stable.) The lab results from the hospital dated 10/03/10 reflected Resident #17's Hgb was critically low at 5.6 g/dL (reference range of 12.0 - 16.0 g/dl), her RBC count was low at 2.05 million/ul (reference range of 4.0 - 5.2 million/ul), her Hct was critically low at 16.8% (reference range of 36 - 46%), her PT was critically high at 49.8 seconds (reference range of 12.0 - 14.5 seconds), and her INR was critically high at 16.30 (reference range of 2.0 - 3.0). The hospital progress notes dated 10/05/10 reflected, "She seems to have stopped bleeding after the 4 units of blood and FFP (fresh frozen plasma) ...Coagulopathy (defect in blood-clotting mechanism). It is not clear why the patient takes [MEDICATION NAME] but the risk of bleeding is too high to continue it. Will give Vitamin K today and leave off the [MEDICATION NAME] permanently...." The hospital History and Physical dated 10/04/10 reflected, "What is noted is that patient was more disoriented than her baseline and so she was brought in by ambulance ...She does tell me that she has no pain but nursing noted that when they moved her she did have quite a bit of pain...." The hospital Discharge Summary dated 10/06/10 reflected: "Discharge Diagnoses: [REDACTED]. 1. Acute blood loss [MEDICAL CONDITION] secondary to hematoma of the hip and right buttock. 2. Acute [MEDICAL CONDITION] secondary to intravascular volume depletion with acute tubular necrosis... ...4. Stage III [MEDICAL CONDITION]. 5. Coagulopathy on [MEDICATION NAME] She was given 4 units of FFP and 4 units of packed red blood cells. Coagulopathy was reversed with Vitamin K as well. Her hemoglobin remained stable and was increasing at the time of discharge and was over 10. She had no further bleeding symptoms. Her hip pain was controlled." 4) Resident #17's pharmacist Consultant Report dated 01/27/10 through 01/28/10 reflected, "Please consider more frequent INR monitoring, perhaps checking an INR value on the next convenient lab day and then weekly thereafter. Rationale for Recommendation - The manufacturer's prescribing information includes a BOXED warning describing an increased potential for serious bleeding events, and more specifically, it has been reported in the literature that individuals with stage 4 or 5 [MEDICAL CONDITION] (CKD) generally require lower doses of [MEDICATION NAME] ([MEDICATION NAME]), have poorer control of anticoagulation and are at higher risk for major hemorrhage as compared to individuals with stage 1, 2, or 3 CKD." The pharmacist Consultant Reports for April, May, June, July, August and September 2010 did not reflect any recommendations regarding Resident #17's [MEDICATION NAME] use and the related lab work. 5) An undated form idenfied by the facility as a "NURSE MAR" reflected an entry dated 07/19/10 reflected Resident #17 was currently receiving 5 mg of [MEDICATION NAME] and current INR results were 4.7. The orders were changed to hold the [MEDICATION NAME] and to do a daily PT/INR and to notify the MD when the resident's INR was less than 4.0. Lab Report dated 07/19/10 reflected Resident #17's PT was high at 56.4 seconds with a reference range of 11.8 - 14.2 seconds and her INR was high at 4.7 with a reference range of 2.0 - 3.5. A telephone order dated 07/19/10 reflected to hold [MEDICATION NAME], check the PT/INR every day and when the INR was less than four, then call the MD for new orders. A telephone order dated 07/20/10 reflected to discontinue the PT/INR every day and to have a PT/INR done on 07/25/10. The "NURSE MAR" reflected there were two entries for 07/25/10 when PT/INR results were 17.0 seconds/1.2. When the NP was notified of the PT/INR results, no new orders were given and the ADONs were to continue to monitor the resident. The second entry dated 07/25/10 reflected Resident #17 was on 5 mg of [MEDICATION NAME] a day and "continue current order" was documented. However, the "NURSE MAR" did not have the above 07/20/10 order. The lab report dated 07/25/10 reflected Resident #17's PT was high at 17.0 seconds (Reference Range 12.4 - 15.4) and her INR was low at 1.2 (Reference Range 2.0 - 3.5). Resident #17's Nurse's Notes dated 07/25/10 reflected the resident's PT/INR results were 17.0 seconds/1.2 and the NP was informed of the results. The NP gave no new order and "stated the ADONs are monitoring (the resident)." LVN J was "uncomfortable due to last order, States Hold Until INR < 4.0 and to call MD for new orders (resident) was recently on [MEDICATION NAME] 5 mg. Nurse (LVN J) spoke (with) supervisor and explained. Supervisor called PA (sic) back n/o (new order) to resume current dose (of [MEDICATION NAME] 5 mg)." A telephone order for Resident #17 dated 07/25/10 reflected to administer [MEDICATION NAME] 5 mg, one tab daily. A telephone order dated 08/10/10 for Resident #17 reflected a clarification order for lab work. A PT/INR was to be done every month related to the resident's [MEDICATION NAME] therapy. Resident #17's Anticoagulant Flow Sheet for September 2010 reflected, "MONITOR FOR MEDICATION SIDE EFFECTS R/T (related to) ANTICOAGULATION TX ...BRUISING, NOSE BLEED, HEMATURIA, BLOOD IN STOOL, MOUTH ULCERS, NECROSIS, RASH, BLEEDING GUMS EVERY SHIFT TX." The Flow Sheet indicated the resident was checked every shift except the second shift on 09/08/10. The Flow Sheet also reflected Resident #17 received [MEDICATION NAME] 5 mg every day, and she received the medication every day except 09/19/10. Resident #17's physician's admitting orders for readmission to the facility dated 10/06/10 reflected [DIAGNOSES REDACTED]. Resident #17's facility Admission/Readmission Data Summary dated 10/06/10 reflected the resident was diagnosed with [REDACTED]. The Summary reflected the resident's [MEDICATION NAME] had been discontinued in the hospital. Resident #17's "NURSE MAR" reflected an entry dated 10/06/10 to discontinue the [MEDICATION NAME]. According to the October 2010 Medication Record, which was effective from 10/06/10, the resident was not taking [MEDICATION NAME] or any other anticoagulant. 6) During an interview with the DON on 10/22/10 at 8:35 AM, she was questioned about the incident, which sent Resident #17 to the hospital. The DON revealed Resident #17 did not have a fall. She stated Resident #17 developed the bruising, because she was bleeding due to [MEDICATION NAME]. The DON stated Resident #17's blood pressure was dropping, and Resident #17 was having difficulty breathing. The DON stated the physician at the hospital told Resident #17's family the bruising was typical of someone who had been on [MEDICATION NAME]. During an interview with ADON K on 10/22/10 at 8:46 AM, the ADON was asked about the incident, which resulted in Resident #17 being sent to the hospital. ADON K stated Resident #17 had bruising on her hip, because she was taking [MEDICATION NAME]. On 10/22/10 at 3:59 PM, the DON stated she had only just realized there was a problem with [MEDICATION NAME] when Resident #17 returned from the hospital on [DATE]. The DON stated they were focused on the issue of Resident #17 falling, which they thought had caused the resident's bruising. She stated when the hospital MD discontinued the resident's [MEDICATION NAME], she thought the problem was resolved. The DON stated she did not know there was a problem with Resident #17's PT/INRs not being done as ordered by the physician until "today" (10/22/10). The DON further stated it was determined the nurses were not always writing the MD orders on telephone orders, but on the actual report with lab results. The DON stated she was in-servicing the nurses on that at this time. She stated the current process to prevent labs from being missed involved the charge nurses. The charge nurses attended the focus meetings in the mornings, and the nurses reviewed the new MD orders. The DON stated the orders were written on the large flip chart during the focus meeting if follow up needed to be done. The DON stated they discussed items on the flip chart every day, and a red line was drawn through the items, which were completed. The DON stated they were not having focus meetings during the time period when Resident #17's August and September 2010 PT/INRs were not done. The DON further stated she was not aware of the incomplete phlebotomy slip. She stated she did not know why the lab was not done. The DON stated she had to find the lab information from September and see if the PT/INR was ordered. She stated corrective measures were in place now. The DON stated focus meetings had been conducted for the last 30 days, which included reviewing new physician orders [REDACTED]. 7) A review of Resident #17's entire clinical record revealed no evidence of PT/INR results for August and September 2010. The surveyor requested all PT/INR results since July 2010 for Resident #17 at approximately 11:00 AM on 10/22/10. The request was made to ADON K. All of Resident #17's lab results from July 2010 to the present were provided to the surveyor by the DON at approximately 11:20 AM on 10/22/10. Review of the lab reports revealed there were no PT/INR results for August or September 2010. One lab report dated 08/11/10 reflected it was notification of an incomplete phlebotomy attempt. The notification did not indicate why the blood was not drawn for the PT/INR. An interview with ADON K and ADON L on 10/22/10 at 11:40 AM revealed a PT/INR was not done in August or September 2010. They stated one should have been drawn in August 2010 and one drawn in September 2010. ADON K provided the surveyor with an Incomplete Phlebotomy Notification (computer generated) dated 08/11/10, which reflected no specimen had been collected. ADON K stated the facility-contracted laboratory should have had a phlebotomist attempt another blood draw for the PT/INR on 08/12/10. An interview with the DON on 10/24/10 at approximately 2:00 PM revealed the facility-contracted lab phlebotomist was not able to "stick" Resident #17 the first time (August 2010) for the PT/INR. The DON stated the phlebotomist did not tell the nurse on duty, and the phlebotomist cancelled the order for September 2010. An interview with LVN G (Resident #17's present charge nurse) was conducted on 10/22/10 at 11:53 AM. The LVN was asked about residents, who were being administered [MEDICATION NAME], and if anything special should be done for them. LVN G stated when a resident was on [MEDICATION NAME], the resident should be watched for bruising and bleeding. She stated if a PT/INR was done weekly, she would let the MD know the results. LVN G stated there was a list of residents who needed lab work done in the lab book. She stated if she did not see the lab results, she would contact the lab and contact the MD to get an order for [REDACTED].#17's PT/INRs were not done in August and September 2010. LVN G had no response. 8) Resident #25, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The interdisciplinary initial care plans dated 10/15/10 reflected Resident #25 was care planned for receiving [MEDICATION NAME] therapy. The care plan reflected the nursing staff was to "...Monitor for S.S. (signs/symptoms) bleeding ...Protect from injury ...Labs/Meds as ordered ...Pro-times as ordered...." Review of Resident #25's admission orders [REDACTED]. The orders reflected the resident was to have a PT/INR drawn every Monday and Thursday. The admission orders reflected: "...labs 10/18/10: CBC, CMP, Mg, TSH, pre [MEDICATION NAME], HgbA1C, PT/INR Q Mon & Thur...." (Note: PT/INRs were next due on 10/18/10 and 10/21/10.) Review of Resident #25's entire clinical record on 10/22/10 revealed no PT/INR results for 10/18/10 or 10/21/10. The lab results reflected a PT/INR was completed on 10/19/10 at 4:25 PM, which was Tuesday and not on Monday as ordered. The 10/21/10 PT/INR was not done until 10/22/10 at 11:30 PM, following surveyor intervention. On 10/22/10 at 3:45 PM, the surveyor requested Resident #25's PT/INR results from 10/18/10 and 10/21/10 from the DON. An interview with the DON on 10/22/10 at 3:55 PM revealed the lab did not draw the PT/INR on 10/18/10 and 10/21/10. She provided the lab requisition form, which reflected the lab work was to start on 10/25/10. She stated she did not know why the lab did not do the physician-ordered lab tests for Resident #25. She stated she was going to call them to determine what happened. Review of Resident #25's laboratory requisition form dated 10/19/10 revealed, "Other Tests: PT/INR Q Monday & Q Thursday...." The laboratory requisition form further reflected "Start Monday 10/25/10" was written across the form. On 10/24/10 at approximately 1:30 PM, the surveyor was provided lab results for Resident #25's PT/INR, which were dated 10/19/10 and 10/22/10 (at 11:30 PM). The DON said the facility had caught the failure the lab had not been done as ordered on [DATE] and got it done 10/19/10. (Note: The 10/22/10 lab was done after the surveyor had questioned the DON about it.) Review of Resident #25's MAR for October 2010 revealed Resident #25 received [MEDICATION NAME] 2.5 mg daily on 10/16/10, 10/18/10, 10/19/10, 10/20/10, 10/21/10, 10/22/10, 10/23/10 and 10/24/10. 9) At approximately 2:05 PM on 10/22/10 the surveyors requested the facility's policy and procedures on labs from the DON. The DON provided an undated policy and procedure at approximately 3:05 PM on 10/22/10 regarding labs, but it was from the facility-contracted lab company and not the facility. The surveyor requested the facility's policy and procedure. The DON stated at that time she did not think there was a facility policy and procedure. The DON provided the surveyors with another policy and procedure revised May 2007 entitled "Laboratory Results." This policy and procedure was in regard to the actual results received from the lab draws and what to with the lab results. The policy and procedure did not address ordering labs, ensuring the labs were conducted as ordered by the physician and ensuring results of the lab work were received from the facility-contracted laboratory. 10) On 10/22/10 at 4:45 PM, the DON provided the surveyors with a copy of the facility's undated "Lab Values Action Plan" in response to the information provided by the survey team regarding the missed lab work. The plan reflected: I. Obtain a correct List of Residents who are to have date specific lab draws i.e. weekly. Corrective Action Taken - All Residents on Anti-Coagulants have been identified and the list is correct. Responsible Person - ADON K and ADON L Date initiated 10/22/10 Date Completed 10/22/10. Other Comments: Updated information will be given during Morning Focus Meeting. II. All Residents who have weekly or bi-weekly lab will be identified and the appropriate "Focus Room" activity will occur. Corrective Action Taken - DON/ADONs will in-service lab ordering and follow-up process to include all license nursing staff. Responsible Person - DON and ADON Date initiated 10/22/10 Other Comments: DON/Designee will review all residents who have date or periodic specific lab draws and assure the process is followed in Focus Meeting (PT/INR) III. Communication of Needed Lab Values or Orders to be done will be made available to all parties involved through Focus Meeting Corrective Action Taken - All care staff have been inserviced on who is on fluid restriction. Families of residents on fluid restriction will be informed. Responsible Person - DON/ADONs Date Initiated 10/22/10 IV. Orders in response to lab will be "Written as Telephone Orders" Corrective Action Taken - DON/ADONs will in-service licensed staff regarding writing a telephone order as it relates to response of abnormal lab values Responsible Person - DON/ADONs Date Initiated 10/22/10 Other Comments - DON/Designee will review all residents who have date or periodic specific lab draws and assure the process is followed in Focus Meeting (PT/INR). 11) An IJ was identified on 10/22/10 at 4:58 PM in the area of Quality of Care with Substandard Quality of Care (SQC) for the facility's 12 residents plus Resident #17. The ADM and the DON were notified at that time of the IJ situation. A Plan of Removal for the IJ was requested. 12) The facility's Plan of Removal originally dated 10/23/10 and updated on 10/23/10, 10/24/10 and 10/25/10 was accepted on 10/25/10. It reflected the following: 1. Resident #17's chart was audited for any missed lab test orders. On 10/23/10, Resident #17 showed no signs or symptoms of bleeding. 2. Resident #17 was re-assessed and there had been no bruising noted since her return from the hospital on [DATE]. 3. All CNAs and MAs were in-serviced on 10/25/10 and provided a post-test. The in-service included the following reminders: On shower days CNAs and/or MAs will complete a shower sheet on each resident showered and note any skin abnormality including bruising. Shower sheets are then handed to the charge nurse, and the CNA will verbally inform the charge nurse of any new skin abnormality. The charge nurse will then physically observe any new skin issues and follow up per the facility skin protocol. Appropriate incident reports on newly identified skin abnormalities will be completed by the charge nurse per facility policy. Incident reports are to be reviewed and additional intervention discussed by administrative nursing staff at least daily and will be included in the morning "Focus meeting." CNAs and MAs are to report any unusual bruising or skin areas in between shower days. The charge nurse will follow up per facility skin protocol. Each CNA and MA who attended the in-service will be provided a post test. Reporting procedures for skin abnormalities will be included in the new employee orientation for CNAs and MAs. 4. A STAT lab for PT/INR was ordered for Resident #25. 5. The facility used a current resident roster, effective 10/22/10, and reviewed each current resident's clinical record to identify those residents, who were at risk for abnormal diagnostic lab values. 6. The Administrator/Designee will monitor and refine the facility "Focus Room Process" to assure all lab values are followed through on a daily basis. 7. The facility will conduct in-services with licensed staff and staff involved in the lab process to include the following: lab ordering and process/request book, new admission and re-admission ordering, tracking for draws and results, documentation of results being reported to the ordering provider and any follow-up orders/directions will be transcribed on a telephone order. 8. Each licensed staff attending the training will be given a post test. 9. The facility's contracted lab company was requested on 10/22/10 to complete an audit of PT/INRs drawn for the facility for the last 90 days. This information will be compared with the facility's audit. Any errors or omissions found in this audit will be reported by the licensed nurses to the MD with subsequent family notification. The "Focus Room" protocol will be followed for all ordered labs discovered through this process, and the ADONs will be responsible for ensuring all steps are followed by licensed nurses. 10. An outside provider was contracted to complete an additional external validation audit to be conducted on 10/25/10. 11. The pharmacy consultant was requested to specifically review residents who were on anti-coagulant therapy and those residents, who need lab results to support medication use during his monthly consultant visits beginning November 2010. 12. The Administrator/Designee will audit the "Focus Room" process beginning on 10/25/10 as it related to physician-ordered lab work using the "Focus Room Audit Tool" weekly until full compliance was attained, and then the Administrator will audit the process at least monthly. The results of the audits will be presented to the Quality Indicators committee on 10/25/10, and each month thereafter for review and recommendations. 13. The QA and A Committee will review lab issues and the initiated lab protocol on a monthly basis beginning on 10/25/10. 13) Interviews with ADON L and RN Y on 10/23/10 at 10:25 AM revealed they were in-serviced on lab procedures and given the post-test. An interview with GVN Z on 10/23/10 at 10:30 AM revealed she was in-serviced on the policy and procedures on labs and given a post-test. An interview with LVN X on 10/23/10 at 10:40 AM revealed she had been in-serviced the night before on the phone regarding lab procedures and when she arrived for work was given the true/false test. An interview with LVN W on 10/23/10 at 10:45 AM revealed she was in-serviced on lab procedures and given a true/false test. An interview with LVN T on 10/23/10 at 10:55 AM revealed she had been in-serviced the night before on the lab procedures, what to do with lab orders, telephone orders, writing on the 24-hour report, filling out the lab requisition and the follow up with the labs to be sure they were completed. LVN T stated she was then given a post-test. An interview with LVN U on 10/23/10 at 11:13 AM revealed she was in-serviced via the phone, and then when she arrived at the facility on 10/23/10, she was given the post-test. An interview with RN V on 10/23/10 at 11:55 AM revealed he was in-serviced the night before on 10/23/10 on the above information, and he was given a true/false test. Interviews with RN H, LVN G, RN A and RN I, on 10/25/10 at 9:57 AM, 10:27 AM, 10:40 AM and 10:56 AM respectively, revealed they had received an in-service and a post test. They stated the in-service taught them to follow up on lab work ordered to make sure the lab work was completed and on lab protocols to follow. They stated if the lab work was not done, it would be ordered STAT. The doctor would be notified of all normal and abnormal lab results. The family would also be notified. The results would be documented in the nurse's notes and 24 hr report. The documentation in the nurse's notes would include when the doctor was notified of the lab results, if new orders were received and when the family was notified. When asked what they assessed a resident on anticoagulants for, they stated for signs and symptoms of bleeding in the stool and urine, for nose bleeds, bruising and reviewing the PT/INR lab results. They added the nurses checked PT/INR results before [MEDICATION NAME] was administered. They stated Vitamin K was the antidote for [MEDICATION NAME] toxicity, and residents being administered anticoagulants were care-planned for it. Interviews with CNA M, CNA N, CNA O and CNA P on 10/25/10 at 1:26 PM, 1:31 PM, 1:37 PM and 1:43 PM respectively, revealed they were last in-serviced on 10/25/10. They stated the in-service included to document resident skin issues on the "Shower Sheets" and to notify the Charge Nurse of any skin issues or concerns. Interviews on 10/25/10 with CNA D at 1:20 PM and CNA Q at 1:28 PM revealed they had been in-serviced regarding residents' skin conditions, marking the information on the shower sheets and telling the charge nurse. Interviews with CNA R and CNA S on 10/25/10 at 2:45 PM revealed they had been in-serviced regarding circling any skin problems on the shower sheets and giving the shower sheets to their charge nurse. They stated they also took a post test. 14) While the IJ was removed on 10/25/10 at 4:31 PM, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" as the facility continued to monitor the implementation of their plan of removal. The ADM and the DON were informed at that time. 15) physician's orders [REDACTED].