Every finding on record at West Houston Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse for 1 of 5 residents (Resident #1) reviewed for abuse by CNA C. The facility failed to prevent CNA C from grabbing Resident #1's right arm, dragging her on the mattress, and transferring her roughly to the wheelchair on 06/24/26. Skin assessment dated [DATE] indicated Resident #1 had a purple bruise on her right thumb and wrist. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. The non-compliance was identified as Past Non-Compliance. The facility corrected the non-compliance prior to entrance.Findings included: Record review of Resident #1's face sheet, dated 08/04/2026, revealed a [AGE] year-old female was admitted on [DATE] from the hospital. Resident #1 had diagnoses which included: dementia (a decline in mental abilities), hypertension (when the pressure in the blood vessels is too high) and diabetes mellitus (body cannot properly control sugar levels in the blood). Record review of Resident #1's quarterly MDS assessment, dated 06/19/26, under section C700 revealed the resident had memory problems. Further review of the MDS revealed Resident #1 was dependent on staff for all ADL care with one staff assistant. Record review of Resident #1's care plan, revised 07/02/26, revealed the resident had a diagnosis of dementia. Intervention: involved resident and FM in care plan. Explained all procedures using terms and gestures the resident could understand. Record review of Resident #1's care plan, revised 06/29/26, revealed functional ability in self care and mobility as evidence by poor quality in functional range of motion other neurological conditions, metabolic encephalopathy. Intervention: chair/bed to chair transfer: dependent x2 staff. Record review of Resident #1's skin assessment dated [DATE] revealed Resident #1 had a purple bruise on her right thumb and wrist. During review of the video obtained from FM from camera located in Resident #1's room on 07/04/26 at 2:15 p.m., it was revealed CNA C entered Resident #1's room and the resident was lying on the mattress on the floor next to the bed. CNA C removed the footrest from the wheelchair and threw it on the resident's bed and removed the indwelling catheter bag, which was hanging on the bed frame, and threw it on the mattress where Resident #1 lay. CNA C grabbed Resident #1's right hand in different areas of her hand while she dragged her from the head of the mattress to the foot of the mattress and turned the resident so her back was facing her, and she placed her hand around Resident #1's waist and transferred her roughly. CNA C was singing through the transfer and did not talk to or tell Resident #1 what she was about to do. During an interview on 08/04/26 at 8:47 a.m., the Treatment Nurse said during the care plan meeting Resident #1's FM said she observed a purple bruise on Resident #1's right hand and she reviewed the video and saw what CNA C did to the resident on 06/24/26. She said Resident #1's FM showed the IDT (Interdisciplinary Team)the video, which revealed CNA C dragged Resident #1 by her hand from the head of the mattress to the foot of the mattress and placed her arms around the resident's waist and lifted the resident from the mattress and placed her roughly in the wheelchair. She said she was shocked and it gave her anxiety when she watched the video because she could not believe what she saw on the video. The Treatment Nurse said Resident #1 could have sustained some type of major injury, but she had a purple bruise at the base of the right thumb around her right wrist. She said she went right away after she observed the video and did a head-to-toe assessment, which revealed purple bruise on Resident #1's right thumb and wrist. During observation on 08/04/26 at 10:00 a.m., Resident #1 was sitting in the living area and did not respond to her name or greeting. The DON told her she was going to take her to the room to be transferred to bed and do a head-to-tee assessment. When the DON was about to move Resident # 1, held onto the table and would not let go of the table. During an interview on 08/04/26 at 12:15 p.m., the FM said when they saw a purple bruise on Resident #1's right wrist, they went back and reviewed the videos, and it had happened two days earlier. The FM said on 06/24/26 they saw CNA C grab Resident #1 on the right wrist, drag Resident #1 from one end of the mattress to the other end, and transferred her roughly to the wheelchair. The FM said they showed the video during the care plan meeting. The FM said if Resident #1 had been able to remember, because she had memory problems, she would have said she was treated without respect and she would have felt ashamed and hurt. The FM said they felt horrible for Resident #1 because she did not believe a resident would be treated in that manner in a nursing facility. During a telephone interview on 08/04/26 at 2:10 p.m., CNA C said she was the aide who transferred Resident #1 improperly. CNA C said she did what the video showed, that she was abusing Resident #1, but she was just pulling her close to herself by her hand, and it was not her intention to abuse her. CNA C said she could have caused serious harm to Resident #1 when she dragged her by the hand, but she did not drag her hard. CNA C said she was given in-services on abuse/neglect and transfers before and after the incident. She said she was suspended on 06/26/26 during the investigation, and after the investigation the facility let her go(terminated on 06/30/26). She said she already knew that the facility would let her go because the video looked like she was pulling the resident hard, and it was physical abuse. During an interview on 08/04/26 at 2:37 p.m., the Administrator said during the care plan meeting on 06/26/26 Resident #1's FM brought up that Resident #1 had a bruise on her wrist. The Administrator said the resident's family member showed them the video, which revealed CNA C pulled Resident #1's arm while she dragged her to the foot of the mattress and placed her arm around the resident's waist and transferred Resident #1 to a wheelchair, and it was an improper transfer. The Administrator said CNA C was suspended right away. The Administrator said management reported to the physician and investigated the incident and terminated CNA C on 06/30/26. He said management provided in-service on abuse/neglect, transfer, resident rights, and burn out. He said they notified the Ombudsman, police, and medical director, and they did QAPI(Quality assurance and performance improvement). He said Resident #1 had a bruise on her thumb close to her wrist and she could have sustained a major injury such as a separated shoulder, broken bone, and skin tear. The Administrator said it could have caused mental anguish for Resident #1, and the social worker did a mental evaluation for three days and it was negative. During an interview on 08/04/26 at 2:47 p.m., the DON said she became aware of the incident when they had a care plan meeting for Resident #1. The DON said Resident #1's family member told the management that Resident #1 had a bruise on her arm or hand, then showed them a video. The DON said she saw CNA C pull and drag Resident #1 by her hand from one end of the mattress on the floor close to the wheelchair and place her hands around Resident #1's waist and transfer her roughly to the wheelchair. She said CNA C improperly transferred Resident #1. She said Resident #1 had a bruise on her thumb when the treatment nurse did a head-to-toe assessment after watching the video. The DON said Resident #1 could have sustained some injuries such as bruising, a broken bone, and a pulled muscle. The DON said Resident #1 would have felt embarrassed and she would have told somebody about it so she could get the appropriate help needed if she had remembered because she had impaired cognition. Record review of the facility policy on abuse, neglect and exploitation, dated 1/2022, reviewed 4/2026, read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Abuse means the willful infliction of injury , intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Record review on 08/05/26 at 4:55 p.m., of the facility timeline for the incident revealed: TimelineName of facility:Date: 6/26/26F- 600 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.Problem: The staff member inappropriately handled the resident during resident functional activities.Resident #1 had a physical assessment completed.Resident #1's care plan for functional activities were reviewed and updated.Other resident care plan functional activities were reviewed and updated.Safe surveys were conducted with residents who were able to participate and answer questions. A skin assessment audit was initiated with residents who were nonverbal, and any issues identified were immediately corrected by the DON/Designee. 6/26/26The CNA was suspended immediately and employment was terminated by the facility.InterventionsThe facility administrator reported the alleged abuse to HHSC, the Local authorities, the Ombudsman, the medical director, and the resident FM. On 6/26/26, DON or Designee immediately implemented CNA Skills check off on functional activities.On 6/26/26, The Administrator/designee immediately initiated an in-service with all facility staff regarding Resident Rights, Abuse and Neglect, Care profile/electronic documentation system location, and change in condition. Administrator/Abuse Coordinator was to provide ongoing oversight, in-services, and supervision of staff in order to assure that policies were implemented and followed as written. Completed 7/3/26 On 6/26/26, The Administrator and DON or designee provided a training presentation to the facility staff on abuse and neglect to include the Definition of abuse, understanding abuse, signs and symptoms of abuse, resident to resident abuse, and facility and staff responsibility on reporting. This presentation included a facility specific procedure on reporting and included examples of various types of abuse. Completed 7/3/26 On 6/26/26, The DON/Designee re-in-serviced on EBP(Enhanced Barrier Precaution)/infection control to include wearing adequate PPE(Personal Proactive Equipment) with any residents who had indwelling devices before they initiated resident contact. On going. On 6/26/26, The ADON initiated EBP compliance observations throughout the facility with staff from all departments. Any opportunities were to be immediately corrected and reported to the DON/Adm. On going. On 6/26/26, The Administrator and DON provided a training presentation to the facility staff on Resident rights. Completed 7/3/26The Administrator or Designee reviewed the last 90 days of incident and accident reports.The Administrator or Designee reviewed the last 90 days of Grievance reports. Monitoring 6/26/26 The DON/ADM and designee began a questionnaire to validate the effectiveness of the training. The questionnaire was conducted with all facility staff. Immediate re-education was to be completed by the DON/ADM/designee if any staff were unable to answer appropriately the questions on the questionnaire. 7/3/26 Staff were not to be allowed to work until after completion of the questionnaire. 6/26/26 The facility management staff were to conduct resident rounds in person to ensure residents had proper oversight, make resident observations/presentations and/or document any grievances. Any concerns noted during daily rounds were to be addressed during the morning meeting and followed up during stand down(end of the day meeting). The IDON/IADM/IDT were to review incident and accidents and grievances during the morning meeting to ensure these were properly investigated and had appropriate interventions in place. Any issues noted were to be immediately addressed by the DON/ADM or designee. 6/26/26 6/26/26, An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Record review of the facility incident binder: QAPI on 6/26/26, Emotional screening on Resident #1 06/26, 06/27/26 and 06/28/26, reported to HCSO ([NAME] County Sheriff's Office) ON 06/26/26: HCSO CASE # 2606-10690 (INJURY TO Elderly). In-service was provided for all staff: burn out, Resident rights, Abuse/neglect also included (never pull a resident by their extremities) 06/26/26, EBP, Fall protocol, electronic document system/care plan, Transfer training using gait belt, Transfer using Hoyer, Notification of change in condition, Skin assessment for nonverbal residents (purple bruise on right wrist at the base of the thumb for Resident #1), and safe survey for intervenable residents check off on abuse/neglect and transfer. The review of the binder also showed the residents care plan was reviewed and there was no issues. Record review of CNA C employment file did not reveal any disciplinary action before the incident and the background search was done upon hire. She was suspended on 06/26/26 and terminated on 06/30/36. During an interview on 08/04/26 between 9:40 a.m. through 2:20 p.m., CNA A, CNA B, CNA D, RA O, LVN A, and LVN B were able to verbalize what they were in serviced on regarding abuse/neglect, resident right, burn out, transfer, fall protocol, care plan/point of care. They were able to verbalize four types of abuse, and the administrator was the abuse coordinator, and abuse was reported immediately. They said during transfer no resident would be transferred by holding the resident extremities (hands and legs); they said residents should be transferred with gait bed or Hoyer lift. They said they also did return demonstration after the transfer in service and skills check off. The staff was able to verbalize that residents observed on the floor had to be assisted off the floor with two or more staff, and they could find how many staff were needed to transfer residents from the POC and care plan. During an interview on 08/05/26 between 9:51 a.m. through 3:36 p.m., SW, Director of Therapy, CNA E, CNA F, CNA G, LVN E, LVN F, RN G, and The Unit manager were able to verbalize what they were in serviced on regarding abuse/neglect, resident right, burn out, transfer, fall protocol, care plan/point of care. They were able to verbalize four types of abuse, and the administrator was the abuse coordinator, and abuse was reported immediately. They said during transfer no resident would be transferred by holding the resident extremities (hands and legs); they said residents should be transferred with gait bed or Hoyer lift. They said they also did return demonstration after the transfer in service and skills check off. The staff was able to verbalize that residents observed on the floor had to be assisted off the floor with two or more staff, and they could find how many staff were needed to transfer residents from the POC and care plan. During an interview on 08/04/26 between 10:14 a.m. through 10:40 a.m., Resident #2, Resident #4, and Resident #5 said the staff assisted them with transfer, and they felt safe in the facility. They said they could not remember when SW talked to them, but he would come around and ask them how they were doing and if the staff assisted with care. He also asked if they felt safe in the facility. The residents said they felt safe in the facility. During an interview on 08/05/26 between 2:30 a.m. and 2:35 p.m., Resident #6 and Resident #7 said the staff assisted them with transfer, and they felt safe in the facility. They said they could not remember when SW talked to them, but he would come around and ask them how they were doing and if the staff assisted with care. He also asked if they felt safe in the facility. The residents said they felt safe in the facility. During an interview on 08/05/26 at 4:05 p.m. with the DON and the Administrator, the DON said the staff were provided in service on resident rights, burn out, resident rights, abuse/neglect, transfer, and care/POC. She said the in service and skill check off was initiated on 06/26/26, and the staff in service was completed on 07/03/26, and they also observed staff during transfer. The Administrator said they reviewed the grievances, and there were no complaints of abuse or rough transfer. They said no staff would work until they received in services.

Based on observation, interview, and record review, the facility failed to ensure that residents who were continent of bladder and bowel on admission received services and assistance to maintain continence and that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and during incontinent care for 2 of 5 residents (Residents #3 and Resident #2) reviewed for incontinent care. The facility failed to ensure CNA A did not wore the same gloves she wore when she checked the wet brief and took off the wet incontinent brief from Resident #3 throughout the care, wiped multiple times with the same wipeand did not separate Resident #3's labia. The facility failed to ensure CNA B donned a pair of gloves and did not provide a protective barrier on Resident #2's bedside table, CNA B did not separate Resident's labia, and she only wiped once between the labia. She applied the incontinent brief with the same gloves she used to provide incontinent care. This failure could place residents at risk of infection, pain, injury, hygiene issues, and hospitalization. Findings included: Record review of Resident #3's face sheet, dated 08/04/2026, revealed a [AGE] year-old female was admitted on [DATE] from the hospital. Resident #3 had diagnoses which included: dementia (a decline in mental abilities), hypertension (when the pressure in the blood vessels was too high), and legal blindness (set standard, not total darkness). Record review of Resident #3's quarterly MDS assessment, dated 05/9/26, revealed the BIMS score was 13, which indicated intact cognition. Further review of the MDS revealed Resident #3 needed moderate assistance with ADLs with one staff assist. Record review of Resident #3's care plan, revised 01/30/26, revealed the resident was frequently incontinent with urine elimination and had frequent incontinent episodes with bowel. Intervention: Assisted during the toilet process. Ensured the resident was kept clean and dry every shift. Observation on 08/04/26 at 9:35 a.m. revealed that, while providing incontinent care, CNA A took off Resident #3's incontinent brief and said the incontinent brief was wet and she was going to change the resident's incontinent brief. CNA A positioned Resident #3 on her side, and CNA A wore the same gloves she wore when she checked the wet brief and took off the wet incontinent brief from Resident #3 throughout the care. She went into the resident's drawer and removed a wipe packet, opened it, and took wipes to clean the resident's buttocks and rectum(the opening where feces exit the body). She then turned the resident onto her back, took three wipes at the same time, and crumpled them together while still wearing the same gloves. CNA A then wiped the resident's left and right pubic area, did not separate Resident #3's labia, and wiped once with the same wipe. During an interview on 08/04/26 at 9:40 a.m., LVN C said CNA A should have separated Resident #3's labia and wiped the left, right, and then middle to ensure the resident's labia (the outside of female genitals [body parts used for sex and peeing]) was clean. She said if Resident #3 was not cleaned properly, the resident could have gotten an infection. LVN C said the aide should have changed her gloves before going into the wipe packet after she washed or sanitized her hands and donned clean gloves to prevent cross contamination. She said CNA A should have used one wipe for each area she wiped because the wipe was dirty after she used it the first time, even though she had three wipes, but she crumpled them together. During an interview on 08/04/26 at 9:48 a.m., CNA A said she used the same gloves she wore when she checked Resident #3's incontinent brief, took off the dirty brief, went into the resident's dresser, and took out a packet of wipes. She said she provided incontinent care for Resident #3 with the same dirty gloves and took three wipes from the wipe packet, held them together, and used them to clean the left and right of the pubic area (area located below the stomach and above the sex organ) and labia. She said because she used the same gloves throughout the incontinent care and the same wipes when she cleaned Resident #3's private area, it was an infection control issue. She said she did not separate the resident's labia, but she should have to ensure the resident was cleaned properly. CNA A said if Resident #3 was not cleaned properly, the resident could have gotten an infection or rashes. During an interview on 08/08/05/26 at 2:05 p.m., the Unit Manager said CNA A should have separated Resident #3's labia on each side: left, right, and then the middle. She said the wipes should have been used once and discarded because once CNA A wiped Resident #3 with a wipe, it had become dirty, and she had to use another wipe to clean a different part of the area. She said using one wipe to clean each area made sure the area was cleaned properly. Unit Manager said if Resident #3 was not cleaned properly, the resident could have had odor and skin irritation in the labia. Unit Manager said CNA A should have changed her gloves when she went from dirty to clean, and she should not have used the dirty gloves to take wipes or go into Resident #3's drawer because of cross contamination. During an interview on 08/05/26 at 4:31 p.m., the DON said CNA A could have used one disposable wipe as many times as possible as long as she used different parts of the disposable wipe or towel to clean Resident #3 during incontinent care. She said Resident #3 would still have been dirty if Resident #3 was not cleaned properly. The DON said CNA A should have changed gloves when she was going from dirty to clean. She said CNA A should have separated Resident #3's labia and cleaned one side, then the other side, and the middle. She said the labia was cleaned in that manner to ensure the resident was clean. She said the resident could have been dirty if not cleaned properly. Resident #2 Record review of Resident #2's face sheet, dated 08/04/2026, revealed an [AGE] year-old female was initially admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #2 had diagnoses which included: dementia (a decline in mental abilities), hypertension (when the pressure in the blood vessels was too high), and diabetes mellitus (the body could not properly control sugar levels in the blood). Record review of Resident #2's quarterly MDS assessment, dated 05/31/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #2 was dependent on staff for toilet use. Record review of Resident #2's care plan, revised 04/17/26, revealed the resident was incontinent of bowel and bladder and required assistance related to decreased mobility. Intervention: Ensured the resident was kept clean and dry every shift. Checked for incontinence during the shift and as needed. During an observation on 08/04/26 at 10:30 a.m., Resident #2 was provided incontinent care by CNA B. CNA B donned a pair of gloves and did not provide a protective barrier on Resident #2's bedside table. The table had the resident's personal items on it, which included an open plastic cup that had water and an open straw. CNA B placed the clean incontinent brief on the bedside table and the wipes on the clean brief, which she used to provide incontinent care for Resident #2. When she ran out of the wipes on the bedside table, she went to the top of the resident's drawer, took wipes out of the packet, and continued to provide care for Resident #2. CNA B did not separate the resident's labia (the folds of skin on the outside of female genitals, such as the urethral opening [for urine] and vaginal opening), and she only wiped once between the labia, which was when the resident said, Ouch. CNA B did not separate the labia area, assess if there were any issues with the skin in the area, or ask the resident why she made that sound. She applied the incontinent brief with the same gloves she used to provide incontinent care. During an interview on 08/04/26 at 10:40 a.m., Resident #2 said she said, Ouch, when CNA B cleaned her private area because she felt pain. During an interview on 08/04/26 at 11:08 a.m., LVN C said CNA B was supposed to separate Resident #2's labia and clean the left side, right side, and middle to make sure the labia area was cleaned properly to prevent infection and skin irritation. She said CNA B was not supposed to place the incontinent supplies on the table with Resident #2's personal items because of cross contamination. LVN C said CNA B should not have used the same gloves she used to provide incontinent care to apply a clean incontinent brief to Resident #2 because it was cross contamination. LVN C said CNA B did not tell her Resident #2 said, Ouch, when CNA B cleaned her labia, which could have meant the resident had irritation, and she was going to assess the resident. During an interview on 08/05/26 at 1:41 p.m., the Unit Manager said if CNA B was about to provide incontinent care, then CNA B should have had a clean bedside table and set up all the supplies needed for incontinent care. She said the aide was not supposed to use the same gloves to go into a clean wipe packet because of cross contamination. Unit Manager said she was supposed to separate the labia and clean three different times with three different wipes; she should have cleaned the left side, right side, and then middle of the separated labia. Unit Manager said if the labia area was not properly cleaned, Resident #2 could have had rashes, skin irritation, and infection. She said when Resident #2 said, Ouch, CNA B should have checked if the labia area was red or had any opening and then told LVN C, who would have gone to assess Resident #2 and follow up with the physician. During an interview on 08/04/26 at 1:45 p.m., CNA B said she did not separate Resident #2's labia and she should have separated and cleaned either side and then the middle to ensure the resident's labia was clean. She said Resident #2 could have had irritation or breakdown on Resident #2's private area. She said the resident said, Ouch, when she cleaned her private area, and she did not check why she made that sound or tell the nurse. CNA B did not respond when she was asked what that sound meant. CNA B said she should have cleaned the bedside table and provided a barrier, then set up all the supplies. She said she should have changed her gloves before she took more wipes from the wipe container or applied a clean incontinent brief after she provided incontinent care for Resident #2, and it was an infection control issue. During an interview on 08/05/26 at 4:11 p.m., the DON said CNA B should not have placed the incontinent supplies on Resident #2's bedside table that had any resident personal items because the aide could have knocked over resident personal items during incontinent care. She said CNA B should have separated Resident #2's labia and cleaned the left side, the right side, and then down the middle. The DON said Resident #2 would still have been dirty if the resident was not cleaned properly. She said CNA B should have changed gloves when she was going from dirty to clean. She said when Resident #2 said, Ouch, CNA B should have checked why she said, Ouch, and notified the nurse so the nurse would have assessed Resident #2 further. Record review of the facility policy on perineal care dated 5/2023, reviewed 1/2024, read in part, . It was the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Females:Assisted resident in bending her knees slightly and spreading her legs.Wet washcloth and applied perineal cleanser. If using prepackaged product, opened package and obtained the wet cloth.Separated the resident's labia with one hand, and cleansed perineum with the other hand by wiping in direction from front to back (from pubic area toward anus).Repeated on opposite side using separate section of washcloth or new disposable wipe.Cleaned urethral meatus and vaginal orifice using clean portion of washcloth or new disposable wipe with each stroke.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to privacy during personal care for 2 of 5 residents (Resident #3 and Resident #2) reviewed for privacy. -The facility failed to ensure CNA A provided privacy during incontinent care for Resident #3 on 08/04/26 at 9:35 a.m. -The facility failed to ensure CNA B provided privacy during incontinent care for Resident #2 on 08/04/26 at 10:30a.m. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem, self-worth, and dignity.Record review of Resident #3's face sheet, dated 08/04/2026, revealed a [AGE] year-old female was admitted on [DATE] from the hospital. Resident #3 had diagnoses which included: dementia (a decline in mental abilities), hypertension (when the pressure in the blood vessels is too high), and legal blindness (set standard not [NAME] darkness). Record review of Resident #3's quarterly MDS assessment, dated 05/9/26, revealed the BIMS score was 13, which indicated intact cognition. Further review of the MDS revealed Resident #3 needed moderate assistance with ADLs with one staff assist. Record review of Resident #3's care plan, revised 01/30/26, revealed the resident was frequently incontinent with urine elimination and had frequent incontinent episodes with bowel. Intervention: Assisted during the toilet process. Ensured the resident was kept clean and dry every shift. During an observation on 08/04/26 at 9:35 a.m., CNA A did not provide privacy when she provided incontinent care for Resident #3. CNA A did not pull the privacy curtain to cover the foot of the bed, close to the entrance door to the resident's room, and left Resident #3 exposed from the waist down while she was waiting for LVN C to bring an incontinent brief. During an interview on 08/04/26 at 9:40 a.m., LVN C said CNA A was supposed to cover Resident #3 while she waited for her to bring the incontinent brief. She said the door and the privacy curtain were supposed to be pulled to cover the foot of the bed, which would have prevented exposing Resident #3 to anybody that may have walked into the room. LVN C said it was a privacy and dignity issue. During an interview on 08/04/26 at 9:43 a.m., CNA A said the door was open when she provided incontinent care for Resident #3, but it was supposed to be closed to provide privacy and to prevent anybody who walked into the room from seeing the resident's exposed area. She said the family members wanted to watch during care because she was very strict; that was why she did not cover the foot of the bed with the privacy curtain. CNA A said the DON was aware the family member wanted the privacy curtain open, and the DON said she had educated the family member about privacy and dignity and did not know what the family member said, but the DON would know. CNA A said it was a privacy and dignity issue because she did not cover Resident #3 up while she was waiting for LVN C to bring an incontinent brief.During an interview on 08/04/26 at 9:51 a.m., attempted to interview Resident #3, but she said go away. During an interview on 08/05/26 at 1:57 p.m., the Unit Manager said CNA A should have closed the entrance door to Resident #3's room and pulled the privacy curtain to provide privacy. She also said CNA A was supposed to cover Resident #3's exposed body while she waited for the nurse to bring an incontinent brief because it was a privacy and dignity issue and would have prevented anybody who entered the room from seeing the resident's exposed body. During an interview on 08/05/26 at 4:07 p.m., the DON said she educated Resident #3's family member that the privacy curtain should have been pulled during care, and she said she would check if she documented the education and see if the family member agreed to it. She said CNA A should have closed Resident #3's room door to prevent anybody who entered the room from seeing the resident's exposed body because the privacy curtain did not cover the foot of the bed. The DON said CNA A should have covered the resident while she waited for LVN C to bring an incontinent brief to provide privacy and dignity for Resident #3. Resident #2 Record review of Resident #2's face sheet, dated 08/04/2026, revealed an [AGE] year-old female was initially admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #2 had diagnoses which included: dementia (a decline in mental abilities), hypertension (when the pressure in the blood vessels is too high), and diabetes mellitus (body cannot properly control sugar levels in the blood). Record review of Resident #2's quarterly MDS assessment, dated 05/31/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #2 was dependent on staff for toilet use. Record review of Resident #2's care plan, revised 04/17/26, revealed the resident was incontinent of bowel and bladder and required assistance related to decreased mobility. Intervention: Ensured the resident was kept clean and dry every shift. Checked incontinence during the shift and as needed. During an observation on 08/04/26 at 10:30 a.m., CNA B did not pull the privacy curtain to cover the foot of the bed while she provided incontinent care for Resident #2. During an interview on 08/04/26 at 10:40 a.m., Resident #2 said did not tell the aide not to pull the privacy curtain, and she would not like to be exposed to staff or anybody who was not providing care for her. During an interview on 08/04/26 at 11:01 a.m., LVN D said CNA B should have pulled the privacy curtain around the bed to cover the foot of the bed while she provided incontinent care for Resident #2. LVN D said if anybody walked into the room, they would have seen Resident #2's exposed body. She said it was a dignity issue. During an interview on 08/04/26 at 1:45 p.m., CNA B said she did not pull the privacy curtain around the foot of the bed when she provided incontinent care for Resident #2 because the resident refused to have the curtain pulled, and the DON was aware and educated Resident #2 about it. CNA B said if anybody entered Resident #2's room, they could see the resident's exposed body, and it was a dignity issue. During an interview on 08/05/26 at 1:51 p.m., the Unit Manager said she had not heard that Resident #2 refused to have the privacy curtain pulled during incontinent care. She said to provide privacy during care, CNA B had to close the door and blind and pull the privacy curtain around the bed. She said if anybody entered Resident #2's room, they would have seen the resident exposed. She said the resident could have been uncomfortable if anybody who was not supposed to see her exposed body saw it, and it was a dignity issue. During an interview on 08/05/26 at 4:28 p.m., the DON said she was not told Resident #2 was refusing CNA B to close the privacy curtain around the bed while she provided incontinent care for her. The DON said Resident #2 could have been exposed if anybody walked into the room, and it was a dignity issue. Record review of the undated facility policy on resident right read in part, . Residents of nursing homes had rights that were guaranteed to them under Federal and State laws. The laws required nursing homes to treat each resident with dignity and respect and care for each resident in an environment that promoted and protected their rights.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one resident (Resident #2) out of five residents reviewed for ADLs. The facility failed to provide timely incontinent care for Resident #2, which resulted in the resident's incontinent brief being saturated with urine and the wet indicator being mashed and faded on 08/04/2026 at 10:30 a.m. This failure could place residents at risk of skin breakdown and reduced feelings of self-worth. Findings included: Record review of Resident #2's face sheet, dated 08/04/2026, revealed an [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses which included: dementia (a decline in mental abilities), hypertension (when the pressure in the blood vessels is too high), and diabetes mellitus (body cannot properly control sugar levels in the blood). Record review of Resident #2's quarterly MDS assessment, dated 05/31/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #2 was dependent on staff for toilet use. Record review of Resident #2's care plan, revised 04/17/26, revealed the resident was incontinent of bowel and bladder and required assistance related to decreased mobility. Intervention: be sure resident was kept clean and dry every shift. Check incontinence during the shift and as needed. During an interview on 08/04/26 at 10:28 a.m., CNA B said she was Resident #2's aide and she clocked in for work on 08/04/2026 at 6:00 a.m. CNA B said she had not checked or changed Resident #2 since she arrived to work because she had to get up and dress other residents who went to the dining room for breakfast. CNA B said she came to assist Resident #2 after she transferred and provided incontinent care to other residents after breakfast. She said aides made rounds every two hours and as needed. Observation on 08/04/26 at 10:30 a.m. of incontinent care provided for Resident #2 by CNA B revealed Resident #2's incontinent brief was saturated with urine, and the wet indicator(showed the incontinent brief was wet with urine) was mashed and faded. During an interview on 08/04/26 at 10:40 a.m., Resident #2 said she was last changed at 5:00 a.m. by the night shift aide. She said the morning aides did not change her whenever she asked to be changed before breakfast; they would tell her that they were busy getting residents up who would be going to the dining for breakfast. She said she would like to be changed, and she did not send staff away or refuse to be changed. She said her incontinent brief was always saturated, and the earliest the morning aides had changed her was 10:00 a.m. During an interview on 08/04/26 at 11:00 a.m., LVN D said staff made rounds every two hours and PRN(as needed) to provide incontinent care for residents. She said Resident #2 would put on the call light and say she wanted to be changed, and if you went to change her without the call light, she would send the staff away. She said she did not document that the resident chased the aides away when they went to change her. She said if a resident was not changed timely, the resident could develop rashes, infections, and skin maceration(skin becomes too soft or soggy). She said the nurses mentored the aide during rounds and the aides had skills check off and in service on ADLs, which included incontinent care. During an interview on 08/04/26 at 1:45 p.m., CNA B said Resident #2's incontinent brief was saturated with urine, and the wet indication was mashed. CNA B said this was the first time she provided incontinent care for the resident that day. CNA B said Resident #2's skin could break down, develop rashes, or develop infection. She said Resident #2 had not refused her from providing incontinent care whenever she went to change her, even if she did not put on the call light. During an interview on 08/05/26 at 1:33 p.m., the Unit Manager said the nurses and the aides made rounds every 2 hours and as needed for incontinent care. She said none of the aides or nurses told her Resident #2 refused to be provided with incontinent care. The Unit Manager said a brief was saturated by looking at the brief wet indication, which had changed color, was mashed and faded, and was saturated with urine. She said if Resident #2 was left in a saturated incontinent brief for an extended period, it could cause incontinent dermatitis (severe painful diaper rash for adults). During an interview on 08/05/26 at 4:41 p.m., the DON said the staff made rounds every two hours and as needed to provide incontinent care for the residents. She said a lot of things could happen to the resident's skin if the resident was not changed timely, such as rash and skin breakdown. She said Resident #2 did not like to be changed when the breakfast tray was out in the hallway, and she liked to be changed when she put on the call light. Record review of the facility policy on activity of daily living, dated 10/2022, reviewed 1/2026, read in part, .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living: #3. Toileting.Policy Explanation and Compliance Guidelines: #3. A resident who is unable to carryout activity of daily living will receive the necessary services to maintain .grooming and personal hygiene.

Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 6 of 10 residents (Residents #1, #2, #3, #5, #9, and #10) reviewed for resident rights. The facility failed to ensure Residents #1, #2, #3, #5, #9, and #10 had privacy curtains that were free of stains and other build-up. These failures could place residents at risk of injuries, cross-contamination, avoidable infections and a decrease in quality of life.Residents #2 and #9 Record review of Resident #2's face sheet dated 05/20/2026, he was a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (weakness and paralysis following a stroke), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life) and cognitive communication deficit (difficulty expressing and communicating with others). Record review of Resident #2's Quarterly MDS dated [DATE], he had a BIMS of 03 out of 15, indicating severe cognitive impairment. Resident #2 was totally dependent on staff for all ADLs, including eating, oral and personal hygiene, dressing, showering and toileting.Record review of Resident #9's face sheet dated 05/20/2026, he was a [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses including injury of nerve root of cervical spine (damage to spine), functional quadriplegia (paralysis), polyneuropathy (damage to peripheral nerves which can cause pain, numbness and weakness in the hands and feet) and vascular dementia (decline in cognitive function due to reduced blood flow to the brain).Record review of Resident #9's Quarterly MDS dated [DATE], Resident #9 had a BIMS score of 15 out of 15, indicating total cognitive intactness. He was totally dependent on staff for all ADLs, including eating, oral and personal hygiene, dressing, showering and toileting.Observation and interview with Residents #2 and #9 on 05/20/2026, the curtain near Resident #9's bed had black stains near the netting at the top of the curtain and one-inch-long brown stain in the middle of the curtain. Resident #2's curtain was observed with gray markings along the length. When asked how often curtains were changed, Resident #9 said that the last time the facility washed their curtains was seven months ago during the holidays. Resident #9 said they told aides about the curtains needing to be washed in recent times, but they did not think aides told who they needed to tell. Resident #9 said he did not remember which aides he talked to about the soiled curtains. Resident #9 said it was his home and he wanted his room to be clean.Observation and interview with the HKS on 05/20/2025 at 12:50 p.m., she checked Resident #9's curtain and said they needed to be washed. The HKS said that Resident #2's curtain also needed to be washed because it also had brown stains along the bottom. Resident #10 Record review of Resident #10's face sheet dated 05/20/2026, she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted [DATE] with medical diagnoses including dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), generalized anxiety disorder (excessive worry and anxiousness), history of falling and abnormalities of gait and mobility.Record review of Resident #10's Quarterly MDS dated [DATE], indicated Resident #10 had a BIMS score of 09 out of 15, indicating moderate cognitive impairment related to thinking and memory. Resident #10 required moderate assistance with dressing and oral hygiene, maximal assistance with showering and toileting, and was totally dependent on staff for personal hygiene.Interview and observation with Resident #10 on 05/20/2026 at 9:06a.m., Resident #10 was in their room and appeared to be comfortable and without distress. Resident #10's middle privacy curtain had brown spots all along the right side. Resident #10 said they did not see anyone come to change and clean their curtains. Resident #10 said they would do it if they asked but that staff should clean it when there were stains. In a later observation on 05/20/2026 at 12:41p.m., the curtain with reddish-brown spots were still in the room.Observation and interview with the HKS on 05/20/2025 at 12:50 p.m., she inspected curtains in Resident #10's room and found the stains along with additional black stains along the bottom of the curtain and said the curtains needed to be removed and washed. Resident #10 was then observed walking down the hall and did not respond to questions. Resident #3 Record review of Resident #3's face sheet dated 05/20/2026, he was a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), chronic kidney disease and muscle weakness.Record review of Resident #3's Quarterly MDS dated [DATE], indicated Resident #3 had a BIMS score of 03 out of 15, indicating severe cognitive impairment related to thinking and memory. Resident #3 required moderate assistance with all ADLs including oral and personal hygiene and showering and toileting.Observation of Resident #3's room on 05/20/2026 at 9:13 a.m., Resident #3 was not in the room. The middle curtain had reddish spots along the top facing Resident #3's side.Interview with CNA C on 05/20/2026 at 12:08 p.m., she said she did not see any soiled curtains and that it was Housekeeping staff responsibilities to take care of curtains. CNA C said she did not know how often housekeeping staff checked on the curtains. If she saw soiled curtains, CNA C said she would tell her charge nurse so they could take care of it. CNA C said soiled curtains could be considered negligent and that they could cause infections.Interview with CNA M on 05/20/2026 at 12:21 p.m., she said she did not see any soiled curtains and that laundry and housekeeping departments were in charge of ensuring clean curtains. CNA M said if she saw soiled curtains she would report it to her nurse. CNA M said soiled curtains could affect residents because soiled items in the room could cause infection control issues and they also would not make residents feel good seeing them.Observation and interview with the HKS on 05/20/2025 at 12:50 p.m., the HKS inspected the middle curtain and observed brown stains at the bottom of the curtain facing Resident #3's side. The HKS thensaid the curtain needed to be taken down for washing. Residents #1 and #8 Record review of Resident #1's face sheet dated 05/20/2026, she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses including dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), chronic kidney disease, major depressive disorder (prolonged periods of sadness, hopelessness and feelings of worthlessness), and dysarthria and anarthria (motor speech condition where there is muscle weakness and slurred speech).Record review of Resident #1's Quarterly MDS dated [DATE], indicated Resident #1 had a BIMS score of 05 out of 15, indicating severe cognitive impairment related to thinking and memory. Resident #1 required maximal assistance with dressing and showering and required moderate assistance with oral and personal hygiene.Record review of Resident #8's face sheet dated 05/20/2026, she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses including dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), muscle weakness and tremors.Record review of Resident #8's Quarterly MDS dated [DATE], indicated Resident #8 had a BIMS of 09 out of 15, indicating moderate cognitive impairment related to thinking and memory. Resident #8 required maximal assistance with oral and personal hygiene and total assistance with toileting, showering and taking off or putting on footwear.Observation and interview with Resident #1 on 05/20/2025 at 9:15 a.m., there was a black stain at the end of Resident #1's privacy curtain, with several dark spots along the curtain. Resident #1 said that curtains did not get cleaned often. When asked the last time the curtain was removed and washed, Resident #1 said she did not know. Resident #1 said she would like the curtains cleaned. When asked how it made her feel, Resident #1 whispered something and did not repeat herself when asked.Observation and interview with the HKS on 05/20/2025 at 12:50 p.m., the HKS inspected Resident #1 and Resident #8's curtains and found stains along the sides and bottom and said that they both needed to be removed for wash.Interview with CNA B on 05/20/2025 at 2:38 p.m., she said she did not notice any soiled curtains in Resident #1 and Resident #8's hall. She said if she saw soiled curtains, CNA B would report it right away to the housekeeping department and that privacy curtains were the responsibility of Housekeeping and Maintenance. CNA B said it was not okay to leave soiled curtains up because that was a form of neglect and that residents could feel they were living in an unsanitary environment.Interview with the HKS on 05/20/2025 at 1:05 p.m., she said that housekeeping staff should be inspecting resident curtains every time staff went into rooms and should report to the HKS when they were unclean so the HKS could tell Maintenance to take them down and bring them to the laundry room to be washed. The HKS said she would also conduct rounds and take curtains to the wash when she sees that they were soiled. The HKS said residents had a right to live in a clean home and that dirty curtains could cause infections. The HKS said she expected rooms to be clean and that she trained staff on monitoring for room cleanliness.Attempted interview with HK N on 05/20/2025 at 2:23 p.m., a voicemail was left and there was no returned response as of exit.Interview with the Administrator and DON on 05/20/2026 at 4:37 p.m., the DON said soiled privacy curtains should be cleaned, and it was part of deep cleaning before new residents arrived at the facility and was conducted once a month for whoever needed it. The DON and Administrator did not hear of complaints of soiled curtains. The DON said they expected soiled curtains to be reported to Housekeeping, Maintenance and Nursing departments. The Administrator said that it could make residents feel like their environment was not clean.Record review of the facility's policy titled Safe and Homelike Environment last reviewed or revised January 2023, it read in part, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 16 residents (Residents #51, #73 and #91) reviewed for comprehensive care plans.1. The facility failed to care plan Resident #51, Resident #73 and Resident #91 for leg straps.2. The facility failed to care plan Resident #51's penile slit and any related interventions. This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health.Resident #51Record review of Resident #51's face sheet dated 4/8/26 reflected a [AGE] year-old male originally admitted on [DATE] and was re-admitted on [DATE] with medical diagnoses of obstructive and reflux uropathy (obstructive uropathy is a condition where urine flow is blocked, causing a damming effect that can damage the kidneys, while reflux uropathy is a condition where urine flows backward (the wrong way) in the urinary tract), indwelling urethral catheter (a common type of thin, flexible tube that a doctor or nurse puts into the bladder to continuously drain and collect urine), schizophrenia (is a serious, long-term brain disorder that causes people to interpret reality in an abnormal way, making it difficult to distinguish between what is real and what is imaginary), type 2 diabetes mellitus and morbid (severe) obesity due to excess calories.Record review of Resident #51's significant change MDS dated [DATE], revealed his BIMS score was 15, indicating no cognitive impairment. He required total assistance with toileting. He was continent for bladder and incontinent of bowel. He had an indwelling catheter. Record review of Resident #51's care plan dated 03/26/2026, reflected interventions were to follow physician orders for catheter insertion, changes, and maintenance. Monitor site for signs and symptoms of infection or skin breakdown - report any noted to MD. Notify the Physician of any adverse findings/changes. The care plan did not address Resident #51's penile slit or the use of straps to secure his catheter.Record review of Resident #51's order summary dated 1/7/26 revealed he had orders for: use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate site of securement daily. (order date 10/10/25). Monitor for potential complications of indwelling urinary catheter use such as redness, irritation, s/s of infection, obstruction, urethral erosion. (start date 12/8/2025). There were no orders for straps.Record review of nurse's notes dated 12/22/25 and 3/28/26 reflected Resident #51 complained of penis pain due to the catheter and was medicated.Record review of MD's notes on 10/21/2025, reflected Resident #51 was sent to the ER for bleeding from a chronic penile wound; returned the same day with a prescription for cefpodoxime (antibiotic) for UTI. Ongoing mild oozing at the wound site. There were no documents reflecting penile slit.Observation and interview during Resident #51's incontinent and foley catheter care on 04/08/2026 at 10:03 am with CNA DD and CNA BB, revealed there was no leg strap or Statlock (stabilization device for a foley catheter) to secure the catheter. There was a slit to the penis. Resident #51 did not verbalize that he was in pain or display any facial grimacing while staff cleaned the indwelling catheter. C NA DD and C NA BB were asked why the Resident did not have a strap to secure his indwelling catheter. CNAs said the nurses secured the indwelling catheter. CNA DD and CNA BB said they had not seen the slit on the resident's penis before. Resident #51 said he the urologist placed a tape on his right thigh which Resident #51 removed when he changed his catheter about 5 days ago because the tape partially came off during shower and it was sticking to his left thigh and it always pulled his skin. When asked if he had tried any other different securing strap, he said no one had offered him any other strap. He said he had pain to the catheter site and sometimes was very uncomfortable. He always requested for pain medication, and it helped. Resident #51 did not remember the exact time when the penile slit started but believed it was around October or September 2025. He said he would love to try another securing strap that would not stick to his skin.Observation on 4/8/2026 at 4:11 PM of the penile slit, revealed LVN treatment nurse measured Resident #51's slit which was 3.00 cm in length and 1.5cm in width. Resident #73Record review of Resident #73's face sheet dated 04/08/2026 reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included dementia (memory loss), type 2 diabetes mellitus (high blood sugar), and neuromuscular dysfunction of the bladder (nerve damage affecting bladder control).Record review of Resident #73's Comprehensive MDS dated [DATE], she had a BIMS score of 00 indicating severe cognitive impairment. Resident #73 was coded for an indwelling catheter. She was coded for having a neurogenic bladder (the nervous system affecting bladder function).Record review of Resident #73's care plan last captured 04/08/2026, she had a focus area of unwanted behavior for removing her foley catheter on 04/01/2026. There were no focus areas specifically for her catheter and no interventions documented for catheter care to be provided. Resident #91Record review of Resident #91's face sheet dated 04/08/2026, he was a [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. He had diagnoses of dementia (memory loss), chronic kidney disease (stage 4, severe) and obstructive and reflux uropathy (a blockage in someone's urinary system). Record review of Resident #91's most current Quarterly MDS dated [DATE], he had a BIMS score of 13, indicating high cognitive intactness. He was care-planned for indwelling catheter and was coded for having renal insufficiency/renal failure or End Stage Renal Disease and having obstructive uropathy.Record review of Resident #91's care plan last captured 04/08/2026, he had a focus area of having an indwelling catheter dated 11/26/2025 with interventions positioning the catheter bag and tubing below the bladder and in a privacy bag, checking the tubing for kinks and monitoring for signs and symptoms of discomfort on urination and frequency and urinary output. There were no interventions for leg straps or means of securing the catheter. Observation of catheter secured straps reflected the facility had 2 kinds:1: Foley cath-secure plus-water Resistant multi-purpose tube holder Resident #51 did not like this one2: Foley catheter holder - with dual-locking tab non-sterile, Resident #51 was okay for it use. Interview with the DON on 04/08/2026 at 4:32pm, she said Resident #51 had a care plan for his in-dwelling catheter and refusal to use a strap.Interview with the MDS Coordinator on 04/08/2026 at 5:25pm, she said residents who had a catheter would have it care planned and have interventions in place including the diagnosis related to the presence of the catheter, the goals and interventions for the catheter like copying down physician orders, checking for a stat lock to keep the catheter in place and prevent pulling or trauma. It was the MDS Coordinator's job to document and sometimes nursing management will document. The MDS Coordinator found that Resident #73 had a catheter due to obstructive uropathy and found that there were no interventions for leg straps. Resident #91 had a care plan for catheter due to neuromuscular dysfunction and had a behavior of removing her catheter which required re-insertion. Interview with the Medical Director on 04/08/2026 at 5:41pm, she was aware of Resident #51's condition and his penile split and said she did not remember the exact date but it had been a year. The Medical Director expected his condition of penile split and how the facility should care for it to be in his care plan. Interview with the Administrator and DON on 04/08/2026 at 6:41pm, the Administrator said he expected staff to provide proper treatment. The DON said she was not aware staff had attempted to provide a leg strap for Resident #51 5 days ago. The DON said she did not know exactly when Resident #51's penile slit began and said Resident #51's catheter should have been secured. Staff should have measured it when he was admitted . The DON's expectations for staff would be for staff to document any injury in Resident #51's records. Record review of the facility's policy on baseline care plans last revised on 01/2026, it read in part, .2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable.Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives.Interventions shall be initiated that address the resident's current needs including:Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk.Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living.Any special needs such as for IV therapy, dialysis, or wound care.Once established, goals and interventions shall be documented in the designated format .8. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. This will be provided by the MDS nurse/designee by the completion date of the comprehensive care plan.

Based on observations, interviews, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care and in making appointments with 1 of 10 residents (Resident #35) reviewed for dental care. -The facility failed to assist the resident in making a follow-up dental appointment.-The facility failed to provide documentation of the extenuating circumstances that led to the delay in Resident #35 not having routine and follow-up dental appointments.-The facility failed to notify Resident #35's guardian of the dental recommendations. These failures could place residents at risk of oral complications, dental pain, and diminished quality of life.Record review of Resident #35's face sheet dated 04/08/2026 reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included unspecified dementia (moderate with psychotic disturbance), heart failure (unspecified, morbid (severe) obesity, anemia, respiratory failure, hypertension, and muscle weakness.Record review of Resident #35's Quarterly MDS dated [DATE], reflected a BIMS score of 11, indicating moderate cognitive impairment. She required total assistance with personal hygiene, shower/bath, toileting, footwear, and bed mobility. She required substantial assistance with oral hygiene and upper body dressing, and supervision with eating. Resident #35's Section L (Oral/Dental Status) of the MDS was not completed.Record Review of Resident #35's Annual MDS Section L (Oral/Dental Status) dated 09/25/2025, indicated that no dental conditions were present.Record review of Resident #35's last progress note regarding dental care, on 01/28/2025 at 8:40am documented Resident has been referred to dentist for eval/treat.Record review of Resident #35's weights, revealed she did not have weight loss for the last 6 months. Resident #35 had weight gain. Resident #35 was put on a pureed diet due to swallowing and respiratory concerns, not because of her teeth. Tooth/oral pain had not been documented.Record review of Resident #35 x-ray and dental recommendations from dental visit dated 02/06/2025 indicated severe calculus (hard layer of plaque under gum line) and plaque build-up, poor oral hygiene, poor gum health, gross decay, bone loss, non-restorable, loose-all teeth. The recommendations suggested extraction of tooth # 3,5,6,7,8,9,10,11,12,13,20,21,22,23,24,25,26,27,28,29.Interview and observation on 04/05/2026 at 3:45pm with Resident #35 she reported she has been at the facility for a long time and is ready to get out. Resident #35 stated she does not know why she is on a pureed diet and does not eat her food because she does not like eating pureed food. Resident #35's teeth were brownish color, some teeth were broken, chipped, and rotten. A strong oral odor was observed. Resident #35 said she has not been to the dentist in a long time and reported she wants to go to the dentist. Resident #35 reported sometimes she has tooth/oral pain. She said she did not remember how often she had tooth pain, but said it was not every day. She said she told the Social Worker that she wanted to go to the dentist about a month ago but had not heard back. She stated her nurse is aware of her oral pain and she is given Tylenol to help ease the pain. She said the pain was not unbearable and the Tylenol was effective with easing the pain. Resident #35 said her CNA helped her brush her teeth in the mornings. Resident #35 said her teeth did not stop her from eating whatever she wanted. Resident # 35 was observed in the common area and dining room of the facility interacting and socializing with other residents and staff.Interview on 4/7/26 at 10am with Social Worker, when asked if Resident #35 ever told him that she needed to go to the dentist, the SW reported the resident has never asked him to schedule any appointments for her. The SW reported that the resident was not seen by the dentist last time because she refused services. SW stated the resident last saw the dentist on 2/6/25 for x-rays. When asked if there was any follow-up after that visit the SW reported no because Resident #35 refused dental services. In a later interview at 10:20am, when relayed to the SW that Resident #35 reported not remembering she ever refused dental services, the SW said he was just on the phone trying to get the dental appointment scheduled for Resident #35.Interview and observation on 4/7/26 at 10:10am of Resident #35, revealed she was in her wheelchair in the hallway attempting to maneuver to the common area to watch TV. Resident #35 said she was feeling okay. Surveyor informed Resident #35 that she spoke with the social worker about her interest in dental appointments. Surveyor asked the Resident #35 if she had refused dental services in the past. Resident #35 said no.In a telephone Interview on 4/8/26 at 12:32pm with Resident #35's RP, when asked if she was aware of Resident #35 refusing dental care, the RP said, No, and reported that she had just heard about the dental recommendations that day. She reported that the SW and DON called her about 2 hours prior on 04/08/2026 asking her if she received an email from the dentist's office. The RP said she told them no because she never received anything from the dental office. She reported coming to the facility regularly and was never asked about an email from the dental office prior to 4/8/26. The RP said she never refused dental treatment for Resident #35. The RP reported the Social Worker forwarded her dental information via email that day (4/8/26). The RP reported she asked the DON why they were just telling her about dental recommendations from over a year ago, she stated the DON told her the dental treatment was going to cost over $1400 out of pocket and did not think the RP wanted to pay that much for the treatment. The RP reported she did not know why the DON would think that. The RP said she really wanted Resident #35 to get her teeth fixed. The RP said Resident #35 had complained of oral pain before but was told the pain was managed with medication.Interview on 4/8/26 at 12:53pm with Social Worker. He said he called Resident #35's RP today to ask if she received the dental recommendations from the visit dated 2/6/25. He said the RP said she never got it, and she confirmed her email and address with Social Worker. The Social Worker acknowledged it would have been best to follow up with the RP sooner but said he was busy with a lot of residents. He said he expected the dentist to follow-up. He said he usually would document when he receives correspondence from the dentist, but he did not. The Social Worker admitted that if he did not hear from the dentist or RP, dental care could go unnoticed. Surveyor asked was the refusal of dental service documented. The Social Worker said that Resident #35 did not refuse dental services. He said initially he had Resident #35 confused with another resident that did refuse. The Social Worker acknowledged that if dental care and recommendations are not followed up, it could cause disease and other health risks.Interview on 4/8/26 at 2:23pm with DON, she said the Social Worker called the dental company on 04/08/2026 regarding Resident #35's last dental appointment dated 02/06/2025 and was told Resident #35's RP never responded by email. The DON said she called Resident #35's RP on 04/08/2026 and verified her email, address, and telephone number and all of those were correct. The DON said Resident #35 was considered a full vendor, and the RP would have to pay for those services. She said the dental company sent a payment plan and the Social Worker got a letter from the dental company saying the family never responded. DON said if the RP wanted Resident #35 to be seen by the dentist, the guardian is responsible and should have been keeping up. DON said the Social Worker helps set up dental services. She said the RP knew Resident #35 was going for the examination. The DON said the dentist communicated with the facility what they are going to do and she said she assumed the dental company called the RP about the dental service. The DON acknowledged that the facility should have followed up with the RP to confirm whether the dental company followed up or not. The DON said she will find out when the dental company informed the RP.Dental policy requested from Administrator on 4/8/26 at 5:14pm. The DON said they did not have a specific dental policy.

Based on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the status of 3 of 24 residents (Resident #3, Resident #35 and Resident #51) whose assessments were reviewed, in that: -Resident #3's stage 4 pressure ulcer was not documented on his latest Quarterly MDS dated [DATE].- Resident #35's dental condition and any related concerns were not documented in the most recent annual (dated 09/25/2025) and quarterly (03/18/2026) MDS assessments.- Resident #51's significant change MDS assessment did not reflect penile slit on 03/25/2026. This failure could place residents at risk because of their health conditions not reflected in their documentation and potentially not receiving the care and services deemed necessary due to inaccurate assessments.Resident #3Record review of Resident #3's face sheet last captured 04/08/2026 reflected a [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. He had medical diagnoses including cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery (stroke due to blockage or narrowing of the artery in the brain), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness after a stroke affecting the right side of the body), cognitive communication deficit, type 2 diabetes mellitus (high blood sugar), and muscle weakness.Record review of Resident #3's care plan last captured 04/08/2026, reflected Resident #3 had a focus care area initiated on 08/05/2025 of a stage 4 pressure injury to the right hip, with interventions including perform treatment per order and report to MD if no improvement within two weeks.Record review of Resident #3's Quarterly MDS dated [DATE], reflected a BIMS was not conducted as he was rarely or never understood. Resident #3 was coded as having short and long-term memory problems. He was totally dependent on staff for all ADLs including eating, oral, personal and toileting hygiene and dressing along with total dependence on staff for bed mobility. In Resident #3's Skin Conditions Section M, he was coded as having a clinical assessment which determined he was at risk for developing pressure ulcers or injuries and had documented that Resident #3 no unhealed pressure ulcers or injuries, including no unstaged pressure ulcers.Record review of Resident #3's Order Summary dated 04/08/2026, reflected the following orders:-Stage 4 wound (an ulcer where there is full-thickness skin damage and loss down to the muscle, bone or tendons) right hip, irrigate or cleanse wound bed with normal saline, pat dry and apply or pack with a start date of 02/19/2026. Record review of Resident #3's skin assessments reflected the following:-On 02/26/2026, Resident #3 had a right hip pressure ulcer, stage 4, measuring 2.6 cm (length), 1.6 cm (width), and 0.1 cm (depth).-On 03/24/2026, Resident #3 had a right hip pressure ulcer, stage 4, measuring 1.2 cm (length), 0.9 cm (width), and 0.1 cm (depth). Record review of Resident #3's wound doctor visit notes, reflected the following:-On 03/05/2026, Resident #3 had a pressure wound on his right hip. It measured 2.6 cm (length), 1.6 cm (width), and 0.1 cm (depth). Healing potential was fair.-On 03/12/2026, Resident #3 had a pressure wound on his right hip. It measured 2.4 cm (length), 1.6 cm (width), and 0.1 cm (depth). Healing potential was fair. Interview with the MDS Coordinator on 04/08/2026 at 12:30pm, she reviewed Resident #3's skin documentation, including admission documentation, weekly skin assessments and the wound doctor visits. She said that Resident #3 had a stage 4 pressure ulcer documented on 03/05/2026 by the wound doctor and it should have been reflected in Resident #3's Quarterly MDS on 03/07/2026. The MDS Coordinator said she did not do wound observations unless she happened to be there and that she reviewed resident documentation to ensure MDS accuracy. She said there were no risks to residents, and it affected MDS coding. Staff used resident's plan of care to provide information on interventions such as nutrition and positioning in Resident #3's case. The MDS Coordinator said whenever a mistake was found on a resident's MDS she would complete a modification and assessment MDS and get approval for it from her MDS Consultant.Interview with the DON on 04/08/2026 at 2:23pm, she said the MDS Coordinator did MDS assessments and care plans, and she had a consultant that she reported to. Since the MDS Coordinator was in-house, she could see residents, look at physician orders, progress notes, and resident charts. The DON said the MDS Coordinator knew that she could do visual assessments on residents to complete her work. Resident # 35Record review of Resident #35's face sheet dated 04/08/2026 reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included unspecified dementia (moderate with psychotic disturbance), heart failure (unspecified), morbid (severe) obesity, anemia, respiratory failure, and hypertensionRecord review of Resident #35's Quarterly MDS dated [DATE], reflected a BIMS score of 11, indicating moderate cognitive impairment. She required total assistance with personal hygiene, shower/bath, toileting, footwear, and bed mobility. She required substantial assistance with oral hygiene and upper body dressing, and supervision with eating. Resident #35's Section L (Oral/Dental Status) of the MDS was not completed.Record Review of Resident #35's Annual MDS Section L (Oral/Dental Status) dated 09/25/2025, indicated that none of the listed conditions were present. The options provided but not selected included: (A)Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose); (B) No natural teeth or tooth fragment(s) (edentulous); (C) Abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn); (D) Obvious or likely cavity or broken natural teeth; (E) Inflamed or bleeding gums or loose natural teeth; (F) Mouth or facial pain, discomfort or difficulty with chewing; and (G) Unable to examineRecord review of Resident #35's last progress note regarding dental care, on 01/28/2025 at 8:40am documented Resident has been referred to dentist for eval/treat.Record review of Resident #35's x-ray and dental recommendations from dental visit dated 02/06/2025 reflected findings indicated severe calculus (also known as tartar which is a hardened form on dental plaque/buildup on the teeth and gum on which bacteria can develop into more serious issues of infection and damage) and plaque build-up, poor oral hygiene, poor gum health, gross decay, bone loss, non-restorable, loose-all teeth. The recommendations suggested extraction of tooth # 3,5,6,7,8,9,10,11,12,13,20,21,22,23,24,25,26,27,28,29.Interview on 04/07/2026 at 3:36pm with MDS Nurse, she said if a resident is admitted , she usually inputs allergies, admitting diagnosis, sometimes diet, fall risk, pressure ulcer, nutrition, and psychotropic meds. She said she will care plan what she sees. She reported that the baseline care plan is done by another team member. The MDS nurse said she would document refusals, and nurses and the Social Worker can document refusals as well. The MDS nurse was asked about Resident #35 and stated the resident can propel the wheelchair, has not complained about anything recently, and has a pureed diet. The MDS nurse did not know why Resident #35 was on a pureed diet at the time of the interview. The MDS Nurse said Resident #35 never complained about her teeth. When shown a picture of Resident #35's teeth and x-ray from dental visit dated 02/06/2025, the MDS nurse acknowledged that someone did not do a good job on the MDS assessment but stated she was not the MDS Nurse at the facility at the time.Interview and observation on 04/05/2026 at 3:45pm with Resident #35, revealed her teeth were brownish, and some teeth were broken and chipped. A strong oral odor was observed. Resident #35 said she has not been to the dentist in a long time and reported she wants to go. Resident #35 reported sometimes she has tooth/oral pain. She said she told the Social Worker that she wanted to go to the dentist about a month ago but has not heard back. She stated her nurse is aware of her oral pain and is given Tylenol to help ease the pain. Resident #51Record review of Resident #51's face sheet dated 4/8/26 reflected a [AGE] year-old male originally admitted on [DATE] and was re-admitted on [DATE] with medical diagnoses of obstructive and reflux uropathy (obstructive uropathy is a condition where urine flow is blocked, causing a damming effect that can damage the kidneys, while reflux uropathy is a condition where urine flows backward (the wrong way) in the urinary tract), indwelling urethral catheter (a common type of thin, flexible tube that a doctor or nurse puts into the bladder to continuously drain and collect urine), schizophrenia (is a serious, long-term brain disorder that causes people to interpret reality in an abnormal way, making it difficult to distinguish between what is real and what is imaginary), type 2 diabetes mellitus and morbid (severe) obesity due to excess calories.Record review of Resident #51's significant change MDS dated [DATE], revealed his BIMS score was 15, indicating no cognitive impairment. He required total assistance with toileting. He was continent for bladder and incontinent of bowel. He had an indwelling catheter. The MDS did not contain any concerns related to skin conditions, including no documentation that Resident #51 had a penile slit.Record review of Resident #51's care plan dated 03/26/2026, reflected interventions were to follow physician orders for catheter insertion, changes, and maintenance, monitor site for signs and symptoms of infection or skin breakdown - report any noted to MD, notify the physician of any adverse findings/changes. Resident #51's care plan did not address Resident #51's penile slit and the use of straps to secure his catheter.Record review of Resident #51's order summary dated 1/7/26 revealed he had orders for: use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate site of securement daily. (order date 10/10/25). Monitor for potential complications of indwelling urinary catheter use such as redness, irritation, s/s of infection, obstruction, urethral erosion (tissue damage to the duct where urine leaves the body and the surrounding penile tissue due to catheter use). (start date 12/8/2025).Record review of nurse's notes dated 3/28/26 reflected Resident #51 complained of penis pain due to the catheter and was medicated.Observation of Resident #51's incontinent and foley catheter care on 04/08/2026 at 10:03 am with CNA DD and CNA BB, revealed there was no leg strap or Statlock (stabilization device for a foley catheter) to secure the catheter. There was a slit to the penis.Observation on 4/8/26 at 4:11 PM revealed the penile slit was measured by the LVN treatment nurse and it was 3.00 cm in length and 1.5cm in width.In an interview with MDS Coordinator on 4/8/26 at 4:40PM, she looked at Resident#51's MDS and said his penile slit being omitted from the MDS and care plan was an oversight on her part. She would do a modification on Resident #51's MDS and care plan.In an interview with DON on 4/8/26 at 4:32 PM regarding Resident #51's indwelling catheter, DON said the expectation would be that the MDS assessments and care plans would be accurate to ensure continuity of resident care.Record review of the facility's policy on MDS Assessments titled Assessment Frequency and Timeliness last revised on 04/2024, it read in part, The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual.9. A significant correction assessment will be completed no later than the 14th calendar day after determination that a significant error in a prior OBRA assessment occurred.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 4 residents (Residents #27 and #48) reviewed for respiratory care.-The facility failed to ensure Resident #27's and Resident #48's oxygen humidifier bottle on the oxygen concentrator had enough water in the bottle to function properly.These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health.Resident #27Record review of Resident #27's undated face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included hypertension (high blood pressure), atrial fibrillation (irregular or rapid heartbeat), congestive heart failure (when the heart does not pump blood effectively), chronic obstructive pulmonary disease (difficulty breathing) and chronic respiratory heart failure with hypoxia (a condition where the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).Record review of Resident #27's admission MDS dated [DATE] Section CO500 revealed a BIMS of 15 indicating the resident was cognitively intact. Section: O 0110 reflected the resident was coded as having oxygen therapy. Record review of Resident #27's care plan dated 2/06/2026 revealed:Focus: Resident #27 requires the use of O2 via nasal canula.Goal: Resident #27 will maintain optimal breathing and evidence s\s of respiratory distress through the next review.Intervention: Allow rest periods during all tasks-do not rush. Apply O2 via nasal canula as ordered. Monitor O2 sats as needed, notify MD of any abnormalities.Observation on 4/05/2026 at 4:00pm revealed Resident #27 was in bed and her O2 was infusing at 4 Lper minute. The humidifier bottle was dated 3/30/2026 and the bottle was empty.In an interview on 4/5/2026 at 4:00pm with Resident #27 revealed that staff normally do not check the water bottle on the humidifier. She said she always had to tell them the humidifier bottle had no water and they took a long time to change the bottle whenever it was empty. Further interview with Resident #27 regarding how she was feeling she said she was okay, but her nostril was a little dry.In an interview on 4/5/2026 at 4:03pm LVN D said she checked the water at the beginning of her shift and there was a small amount of water in the bottle but had not checked it since. She said she was going to look at it and change it. Further interview with LVN D revealed the water on the humidifier was changed weekly and as needed. She said whenever the bottle was empty it should be changed. She said the water should be checked at the beginning of each shift to ensure everything was working properly. She said if there was no water in the bottle it could cause dryness in the resident nose and nosebleed. She said she should check the humidifier, but it was overlooked. Resident #48Record Review of the undated face sheet for Resident #48 revealed she was a [AGE] year-old, female who was admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included hypertension (high blood pressure), atrial fibrillation (rapid heart rate that causes poor blood flow), chronic obstructive pulmonary disease (difficulty breathing) and chronic respiratory heart failure with hypoxia (a condition where the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).Record review of Resident #48's quarterly MDS dated [DATE] Section CO500 revealed a BIMS score of 15 indicating the resident was cognitively intact. Section O: Special treatment revealed the resident was coded as receiving respiratory treatment and oxygen therapy.Record Review of the care plan dated 6/23/23 revealed Resident #48 was care-planned for oxygen therapy at 2-5LPM continuously for sats below 92%.Record review of the physician's orders dated 2/20/23 revealed Resident #48 was to receive 02 at 2L/m via NC Continuously every shift. Additional order dated 6/4/24 revealed Oxygen at 2-4 LPM via nasal cannula continuously. Monitor 02 sat. every shift.Observation on 4/5/26 at 4:50pm revealed Resident #48 lying in bed with the canula in her nostrils and O2 infusing at 4.5 liters per minute. Observed the oxygen tank humidifier water bottle was dated 3/29/2026 with no water in the bottle.During an interview on 4/5/26 at 4:50pm with Resident #48 she said water on the humidifier was supposed to be changed once a week. She said they never usually come to change the water on the humidifier as they should. She said she will tell them, but sometimes they take a long time. She said that morning the nurse checked the nebulizer, but she did not check the humidifier. In an interview on 4/5/2026 at 4:55pm with LVN B revealed she was the nurse assigned to Resident #48. She said she went to the resident's room and checked the water bottle. She said the water was low, but she had not checked it since. She said she was going to change the water bottle. LVN B stated having no water in the bottle could cause shortness of breath, may cause sinus problems and could cause residents to have mental confusion.In an interview on 4/5/2026 at 5:45pm with the DON, she said the responsibility of the nurses was to make rounds and check the humidifier. She said the nurses should check the water, or the entire oxygen tank during their rounds. When the water bottles were empty, they were required to replace them. The DON stated the oxygen flow without water could lead to resident nose bleeding, oxygen issues and cause nose dryness.Record review of the undated Policy for Oxygen Administration implemented 10/2022 and revised 1/2026, revealed: Policy:Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive centered care plans, and the resident's goal and practices.Definition:Oxygen therapy is the administration of oxygen at concentration greater than in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestation of hypoxia. Policy Explanation and Compliance Guidance5. Staff shall perform hand hygiene when administering oxygen or when in contact with oxygen equipment.c. Change humidifier bottle when empty, or per facility policy, or as recommended by the manufacturer. Use only sterile water for humification.Types of delivery systema. Nasal Canula- Oxygen is administered through plastic cannulas in the nose. Effective for low oxygen concentration less than 40%. Requires humidification at flow rate greater than 4 liters/minutes.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #51) reviewed for incontinent care. 1.The facility failed to ensure Resident #51's indwelling catheter was secured and penile slit documented. Resident #51 had a slit on his penis measuring 3 cm length by 1.5 cm width on 04/08/2026. These failures could place residents at risk for pain, infection, injury, and hospitalization.Findings included: Record review of Resident #51's face sheet dated 4/8/26 reflected a [AGE] year-old male originally admitted on [DATE] and was re-admitted on [DATE] with medical diagnoses of obstructive and reflux uropathy (obstructive uropathy is a condition where urine flow is blocked, causing a damming effect that can damage the kidneys, while reflux uropathy is a condition where urine flows backward (the wrong way) in the urinary tract), indwelling urethral catheter (a common type of thin, flexible tube that a doctor or nurse puts into the bladder to continuously drain and collect urine), schizophrenia (is a serious, long-term brain disorder that causes people to interpret reality in an abnormal way, making it difficult to distinguish between what is real and what is imaginary), type 2 diabetes mellitus and morbid (severe) obesity due to excess calories. Record review of Resident #51's significant change MDS dated [DATE], revealed his BIMS score was 15, indicating no cognitive impairment. He required total assistance with toileting. He was continent for bladder and incontinent of bowel. He had an indwelling catheter. Record review of Resident #51's care plan dated 03/26/2026, reflected interventions were to follow physician orders for catheter insertion, changes, and maintenance. Monitor site for signs and symptoms of infection or skin breakdown - report any noted to MD. Notify the Physician of any adverse findings/changes. The care plan did not address Resident #51's penile slit and the use of straps to secure his catheter. Record review of Resident #51's order summary dated 1/7/26 revealed he had orders for: use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate site of securement daily. (order date 10/10/25). Monitor for potential complications of indwelling urinary catheter use such as redness, irritation, s/s of infection, obstruction, urethral erosion ( the wearing away, tearing, or damage of the tissue lining the urethra start date 12/8/2025). Record review of Resident #51's skin assessment on admission on [DATE] reflected no penile slit. Further skin assessments dated 4/2/26, 3/17/26, 2/24/26, and 1/24/26 did not address the slit on the penis. The skin assessments documented that Resident #51's skin was intact. Record review of MD's notes on 10/21/2025, reflected Resident #51 was sent to the ER for bleeding from a chronic penile wound; returned the same day with a prescription for cefpodoxime (antibiotic) for UTI. Ongoing mild oozing at the wound site. There were no documents reflecting penile slit. Record review of nurse's notes dated 12/22/25 and 3/28/26 reflected Resident #51 complained of penis pain due to the catheter and was medicated. Record review of Resident #51's nurses' notes dated 12/22/2025, reflected the nurse documented Resident #51 was Sent to ER ( Emergency) after catheter-related pain with subsequent hematuria (blood in the urine) heart rate was 102, and low O2 saturation. Resident #51 returned on 12/26/2025 on cefdinir (antibiotic) for 7 days. Observation and interview during Resident #51's incontinent and foley catheter care on 04/08/2026 at 10:03 am with CNA DD and CNA BB, revealed there was no leg strap or Statlock (stabilization device for a foley catheter) to secure the catheter. There was a slit to the penis. Resident #51 did not verbalize that he was in pain or display any facial grimacing while staff cleaned the indwelling catheter. C NA DD and C NA BB were asked why the Resident did not have a strap to secure his indwelling catheter. CNAs said the nurses secured the indwelling catheter. CNA DD and CNA BB said they had not seen the slit on the resident's penis before. Resident #51 said he took off the tape the urologist placed on his right thigh when he changed his catheter about 5 days ago because the tape was coming after shower and it was sticking to his left thigh and it always pulled his skin. When asked if he had tried another securing strap, he said no one had offered him any other strap. He said he had pain to the catheter site and sometimes was very uncomfortable. Resident #51 said he always requested for pain medication and it helped. Resident #51 did not remember the exact time when the penile slit started but he was thinking around October or September 2025. He said he would love to try another securing strap that would not stick to his skin . Observation on 4/8/2026 at 4:11 PM of the penile slit, revealed LVN treatment nurse measured the slit which was 3.00 cm in length and 1.5cm in width. Observation on 4/8/26 at 4:15 PM of catheter secured straps reflected the facility had 2 kinds:1: Foley cath-secure plus-water Resistant multi-purpose tube holder Resident #51 was shown both straps, he did not Foley cath-secure plus-water Resistant multi-purpose one. 2: Foley catheter holder - with dual-locking tab non-sterile, Resident #51 was fine with it use. Interview with LVN OO on 4/8/2026 at 3:37 PM she said Resident #51's skin was intact when he came back from the hospital, and he did not want the strap to his right thigh, because it irritates him. LVN OO said she made sure he was not in any pain and penile site was not irritated. The facility uses Foley cath-secure plus-water Resistant multi-purpose strap with tape and that irritates him. She knew not putting the strap to secure the catheter would cause pulling and tension. She will now talk to DON and scheduler to find an alternative strap. She saw the penis; there were no signs of infection. Interview with Treatment Nurse LVN on 4/8/26 at 3:45 PM, She said she worked in the facility for a year. She does treatment for all residents and head to toe assessment. She said she did an assessment when Resident #51 came back from the hospital on 3/17/26. He did not come back with pressure ulcer and the penile slit looks old. Telephone interview with the MD on 4/8/26 at 4:00 PM regarding Resident #51's penile slit, she said she was aware of it and he was referred to urologist for consult for possible supra pubic catheter. Resident #51 wanted a laser surgery, and his insurance did not approve it. MD said the facility should have measurements of the penile slit and documented it in his care plan. Interview with DON on 4/8/26 at 4:32 PM regarding Resident #51's indwelling catheter, DON said Nurses should check to make sure straps are in place. They should check every shift and as needed. They are checking to make sure the catheter is in place and so it does not come out. If residents do not want to use secure straps, the facility should have care plans for secure strap refusal, and it was the resident's right to refuse treatment and that the facility educated him. DON said she knew not securing the catheter could result in trauma. The DON's expectation is all nurse aides would notify the nurse to place the securing strap in the right position. Record review of the facility's policy for Catheter Care revised 04/2026: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.6. Leg bags will be attached to the resident's thigh or calf, making sure to have slack on the on the tubing to minimize pressure and tension. Ensure straps are snug but not tight.Kinks: Ensure the catheter tubing remains free from any kinks that might obstruct urine flo

Based on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 1 of 5 residents (Resident #56) reviewed for call lights. The facility failed to ensure Resident #56's call light was within reach. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life. Findings included: Record review of Resident #56's face sheet dated 01/29/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: cerebral infarction (blood flow to the brain is blocked), hypertension (pressure in the blood vessels is always higher than normal), and diabetes mellitus (when body cannot control blood sugar level). Record review of Resident #56's annual MDS assessment dated [DATE] revealed a BIMS score of 09 of 15 which indicated moderately impaired cognition. Further review revealed the resident was dependent on the staff for ADL care and the was incontinent for bowel and bladder. Record review of Resident #56's undated care plan revealed Resident #56 was at risk for falls related to gait imbalance and incontinence. Intervention: be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During an interview on 01/28/25 at 10:16 a.m., Resident #56 said she needed her incontinent brief changed and could not reach the call light. Resident #56 said she asked her roommate to use her call light to call for assistance. During an observation on 01/28/25 at 10:17 a.m., Resident #56's call light was on the floor by the insertion site to the wall. During observation and interview on 01/28/25 at 10:19 a.m., CNA B said Resident #56's call light was on the floor close to the wall. CNA B said Resident #56's call light should always be within reach. CNA B said Resident #56 could fall if she tried to reach for the call light because it was not within reach and could delay care if the resident had an emergency. CNA B said she had in-service and skill check-off on the call light, and during training, she was educated to ensure the call light was within reach for safety and to prevent health emergencies. During an interview on 01/28/25 at 10:27 a.m., CNA C said she was Resident #56's aide and did not know the call light was on the floor, out of Resident #56's reach. CNA C said the call light should always be within reach for Resident #56 to prevent the resident from falling and delayed care during emergencies such as choking. CNA C said she had in-service and skills check off on the call light, and they were educated to make sure the call light was within reach for assistance and safety. During an Interview on 01/28/25 at 1:24 p.m., LVN B said he was the nurse for Resident #56 and did not observe the call light was on the floor. LVN B said Resident #56's call light should be placed in close range so Resident #56 could use it when she needed it. LVN B said Resident # 56 could have a fall if the resident tried to reach the call light, which was out of reach. LVN B said Resident #56 could have had an emergency, and the resident could not reach the call light, which could be detrimental for Resident #56. LVN B said the nurses monitored the aides during rounding, and the nurse managers monitored the nurses when they made random rounds. LVN B said he had in-service, and skills checks in October on call lights. During an interview on 01/29/25 at 3:44 p.m., the DON said CNA C should have placed the call light within reach of Resident #56. The DON said the aides should place the call light within reach for safety (assistance and fall), and if Resident #56 needed help and could not reach the call light, then the need for Resident #56 would not be met. The DON said the charge nurses monitor the aides to ensure the call lights are within reach, and the managers monitor the nurses when they make random rounds and ensure the call light is in place. During an interview on 01/29/25 at 5:24 p.m., the Administrator said CNA C should have placed Resident #56's call light within reach. The Administrator said Resident # 56 would not promptly receive the care she needed. The Administrator said the nurses monitor the aides to ensure they provide care for the resident, and the nurse manager monitors the nurses. During an interview on 01/29/25 at 5:58 p.m., the ADON said the call light should always be within reach of Resident #56. The ADON said, if the call light was not within reach, Resident #56 would wait an extended period before care would be provided for the resident. The ADON said Resident #56 could fall if she tried to reach for the call light, and the facility would not want the resident to fall. The ADON said the nurse monitors the aides while the nurse manager monitors the nurse during rounding and ensures the call light is within reach. The ADON said the nurse had been in-serviced on the call light, and they were told to make sure the call light was within reach to prevent delay in care or any other issues. Record review of the facility call light policy dated 02/23 read in part . the purpose of this policy is to assure the facility is adequately equipped with a call light at each resident bed . policy explanation and compliance guideline #5 . staff will ensure the call light is within reach of resident while in bed .

Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #2) of 6 residents reviewed for activities of daily living. -The facility failed to groom Resident #2's face that was observed with long facial hairs on her chin. This failure placed resident at risk for embarrassment, depression, and decrease in quality of life. Findings: Record review of Resident #2's face sheet dated 01/30/25 revealed a [AGE] year-old female admitted to the NF on 04/05/23 with the diagnoses that included the following: hypotension (low blood pressure), muscle weakness, need assistance with personal care, glaucoma (nerve damage of the eye that is usually due to high pressure in the eye that could lead to loss of vision), osteoarthritis (type of arthritis when the flexible, tissue at the end of the bones wears away causing a decrease in movement), and cerebral infarction (blood flow to the brain is interrupted). Record review of Resident #2's MDS significant change dated 12/22/24 reflected a BIMS score of 11 indicating resident had moderate impairment of cognition. Further review revealed of section GG (Functional Abilities) was not coded but in section V-Care Area Assessment (CAA) Summary, resident was triggered for ADLs related to personal care. Record review of Resident #2's Care Plan dated 01/02/25 reflected that resident was being care planned for assistance to perform functional abilities in self-care and mobility AEB by weakness in functional range of motion r/t stroke. The interventions included provide hygiene: partial/moderate assistance. Observation on 01/28/25 at 9:47AM of Resident #2 resting in bed. Observation was made of resident having a moderate amount of thick coarse facial hair growing out of resident's chin covering approximately 80 percent of chin. Interview on 01/28/25 at 9:47AM with Resident #2 said she did not like the hair on her face and wanted it removed. Resident said the staff had not removed the hair off her chin in a while. Interview on 01/30/25 at 2:02PM with CNA A said Resident #2 required extensive assistance with grooming. CNA A said it was important to keep the residents groomed because it was a part of the resident's daily living. CNA A said when residents were not groomed, it placed the resident at risk of not feeling good about themselves. CNA A said just like she and other members of the staff like to look presentable, so did the residents. Interview on 01/30/25 at 2:20PM with the DON said it was the charge nurses that were responsible for ensuring that the residents were being groomed and presentable and that their needs were being met daily. Interview on 01/30/25 at 2:50PM LVN B said he was Resident #2's nurse. LVN B said he worked the 6AM-6PM shift full time. LVN B said he had been working at the NF all week. LVN B said the charge nurse was responsible in making sure that the residents were being provided care that included grooming that consisted of making sure the residents' hair and clothing were clean, nails trimmed, and resident was free of any offensive odors. LVN B said it was important to keep the residents groomed for their personal pride and overall to allow the resident to feel good about themselves. LVN B said if the resident was not groomed, it placed the resident at risk for health issues one being psychosocial issues which placed the resident at risk for becoming depressed. Record review of the NF policy on Activities of Daily Living revised January 2025 reflected in part: .The facility will .ensure .care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care .The facility will provide care to assist the resident in achieving and maintaining the highest practicable outcome .resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Record review of the NF policy on Resident Rights revised January 2025 reflected in part: .The resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside of the facility .

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (Halls 300 medication carts ) of 3 medication carts reviewed for medication storage. - The facility failed to ensure the 300 hall medication carts did not contain nasal spray, topical gels and ointment that were opened labeled with the resident's name and not dated . This failure could place residents at risk of adverse medication reactions and infections . Findings Include: During observation on 01/29/25 at 09:11 AM, the following medications were found in the medication carts for 300 hall with LVN C. There were stickers on the medications to document open date: DilofenacDiclofenac Sodium Topical Gel 1% open not dated Triamcinolone Acetonide USP 0.1% open not dated Nystatin Ointment USP (100,000 usp) open not dated Clobetasol Propionate USP 0.005% 960 gm) x 2 open not dated Voltaren Arthritis pain gel 1 % open not dated Tacrolimus ointment 0.1% open not dated Fluticasone Propionate nasal spray USP -50 mcg open not dated During an interview with LVN C on 1/29/25 at 09:11 AM, he was not aware the gel were not dated when opened and the reason was to track the opening date and normally it is good for 30 days. LVN C said if used more than 30 days the effect of the medication may not be potent. During an interview with DON on 1/29/25 at 10:20 AM DON said the facility did not have any policy regarding labeling medication, when asked why the medication had open date sticker on them, she said the pharmacist place the open date sticker on them and it was just the pharmacy requirement . Interview via telephone on 1/30/25 at 11:30AM, with the facility Pharmacist he said they always place open date on the gels, ointments to help the nurses to know the open date and when to discard the topical gel and ointment.

Based on observations, interviews, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 7 % based on 3 errors out of 40 opportunities, which involved 3 of 9 residents (Resident # 13, #43 and Resident #18) reviewed for medication administration. 1. MA A failed to administer Cyanocobalamin (a form of vitamin B12= used to treat and prevent a lack of vitamin B12- may cause anemia ( condition in which the red blood cells do not bring enough oxygen to the organs ) to Resident # 13 according to physician orders. 2. MA A failed to administer Vitamin D (Cholecalciferol = used for vitamin D deficiency = also used with calcium to maintain bone strength ) to Resident #43, according to physician orders. 3. MA A failed to administer Cetirizine Hydrochloride tab ( drug use to prevents and treats allergy symptoms, such as red, itchy, eyes, sneezing, a runny or stuffy nose or hives) to Resident #18, according to physician orders. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. Record review of Resident #13's face sheet dated 1/30/25 revealed a [AGE] year-old female with an admitted [DATE]. Resident #13 had diagnoses which included: intraductal carcinoma ( non-invasive early stage breast cancer ) in situ of left breast, multiple sclerosis (a chronic disease that affects the central nervous system), type 2 diabetes mellitus ( too much glucose then stays in your blood) without complications, acute embolism and thrombosis (Blood clot) of unspecified deep veins of lower extremity, bilateral, other specified peripheral vascular diseases, other vitamin b12 deficiency anemias, malignant neoplasm ( most breast cancers are carcinomas, which are tumors that start in the epithelial cells that line organs and tissues throughout the body) of unspecified site of left female breast. Record review of Resident #13's Admission MDS dated [DATE] revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #13's current physicians orders revealed an order with a start date of 08/14/24, for B12 1000mg, 1 tablet by mouth one time per day for anemia at 08:00 AM. Record review of Resident #13's medication administration record (MAR) dated 1/1/25 reflected B12 1000mg, 1 tablet by mouth one time per day for anemia at 08:00 AM. MA A initialed as given on 01/29/25. During a medication administration observation on 1/29/25 at 8:27 AM for Resident #13, MA A dispensed one B12 500mg 1 tablet into a medication cup and administered the medication to Resident #13 by mouth. 2. Record review of Resident #43's face sheet dated 1/30/25 revealed an [AGE] year-old female with an original admitted [DATE] and re-admission 6/10/22. Resident #43 had diagnoses which included: unspecified severe protein-calorie malnutrition, other idiopathic peripheral autonomic neuropathy (occurs when there is damage to the nerves that control automatic body functions), anemia ( chronic disease causes inflammation, which prevents the body from producing enough red blood cells) in other chronic diseases classified elsewhere, major depressive disorder, ( a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #43's Annual MDS dated [DATE] revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #43's current physicians orders revealed an order with a start date of 02/15/23, for Vitamin D 50 mcg 1 tablet po (Cholecalciferol tablet 50 mg (2000unit) one time a day. During a medication administration observation on 1/29/25 at 8:53 AM for Resident #43, MA A dispensed one Vitamin D 25 mcg1 tablet into a medication cup and administered the medication to Resident #43 by mouth. 3. Record review of Resident #18's face sheet dated 1/30/25 revealed an [AGE] year-old female with an original admitted [DATE] and re-admission 1/9/25 . Resident #18 had diagnoses which included acute respiratory failure with hypoxia ( low oxygen in the blood), type 2 diabetes mellitus without complications , other seasonal allergic rhinitis ( allergies you experience at certain times of the year due to pollen from glassgrass, weeds and trees) bipolar disorder ( a mood disorder that causes extreme mood swings, including periods of mania and depression). Record review of Resident #18's Annual MDS dated [DATE] revealed a BIMS of 13, which indicated the resident was cognitively intact. Record review of Resident #18's current physicians orders revealed an order with a start date of 01/18/23, for Cetirizine Hydrochloride 5mg 1 tablet po one time a day for allergy. During a medication administration observation on 1/29/25 at 10:00 AM for Resident #18, MA A dispensed one Cetirizine Hydrochloride 10 mg 1 tablet into a medication cup and administered the medication to Resident #18 by mouth. Interview with Medication Aide (MA A) on 1/30/25 at 9:58 AM regarding Cetirizine 10mg given to Resident #18 ( cetirizine 5mg was ordered), Vitamin D 25 mcg given to Resident #43, ( instead of 50 mcg ordered= 20000unit ), and Vitamin B12 500mg given to Resident #13 ( instead of 50 mcg ordered=1000mg), she said she was nervous and she discussed with the ADON about Cetirizine 10 mg needed to be change to 5mg this morning. MA A said she had training about 2 months ago with the ADON who no longer work for the facility. MA A said she had been working in the facility for over 3 years and she knew not giving residents the correct medication dosage would not be effective and could cause harm to the resident. Interview with ( unit manager) LVN ADON on 1/30/25 at 10:06 AM, she said she had been working with the facility for 3 years and she was not aware of any change with Cetirizine HCL, said andthe MA A should talk to the floor nurse for medication changes. Interview with the DON on 1/30/25 at 10:15 AM regarding her expectation with medication administration, she said the nurses were to follow right medication, check expiration date, removing discharged med , and follow medication rights . DON was asked what would happen when rights dose of medication not given , DON said if the right dose of medication was not given, Residents would not receive the right strength of the medication for its effectiveness. She said she would have to re-educate and discipline the staff and watch nurses pass medications once or twice a month and as needed, for eye drops it should be drop in the conjunctiva sac for absorbed . Interview with the Administrator on 1/30/25 at 2:10 pm, he said his expectation was 100% of medication error free., He said depending on the medication it could have an adverse effect on the resident. Interview with the cooperateCorporate nurse on 1/30/25 at 2:13 PM, she said she would have to conduct more in-services . Record review of the facility-provided training document for Skilled Services and Medication Pass Competency dated 9/01/24 reflected it andwas marked satisfactory and was signed by MA A and the ADON. Record review of facility-provided policy titled Administering Medications, Revised dated 2025, revealed: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame. . 10. The individual administering the medications checks 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 provide pharmaceutical services including procedures that assure accurate acquiring, receiving, dispensing and administering of all drugs to meet the needs of each resident for 1 resident (Resident #43) of 9 residents reviewed for pharmacy services, in that, MA A did not administer Dorzolamide Hydrochloride Ophthalmic solution (eyedrops used to lower pressure inside the eye in people with open angle glaucoma or ocular hypertension) to Resident #43's lower eyelid for it to be absorbed for effectiveness. These failures affected residents and placed them at risk of decline in health status. Findings include: . Record review of Resident #43's face sheet dated 1/30/25 revealed an [AGE] year-old female with an original admitted [DATE] and re-admission 6/10/22. Resident #43 had diagnoses which included: unspecified severe protein-calorie malnutrition, other idiopathic peripheral autonomic neuropathy (occurs when there is damage to the nerves that control automatic body functions), anemia of chronic disease( causes inflammation, which prevents the body from producing enough red blood cells) in other chronic diseases classified elsewhere, major depressive disorder, ( a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #43's Annual MDS dated [DATE] revealed a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #43's current physicians orders revealed an order with a start date of 02/15/23, for Dorzolamide Hydrochloride Ophthalmic solution 2% 1 drop to each eye one time a day. During a medication administration observation on 1/29/25 at 8:53 AM for Resident #43, Resident was lying down on her bed with eye open looking up and instructed MA A not to touch her eyes. MA A instilled Dorzolamide Hydrochloride Ophthalmic solution 2% 1 drop to each eye eye directly Resident #43's eyeball . MA A did not administered eyedrop to Resident #43's lower eyelid Interview with MA A on 1/30/25 at 9:38 AM regarding administering Dorzolamide Hydrochloride Ophthalmic solution 2%, MA A said she always instilled eye drops to Resident #43's eyeball because the resident does not want her to touch her eyes. MA A said she would let the nurse know Resident #43 did not allow her to touch her eyes. MA A said she had training for medication administration about 2 months ago with the ADON who no longer work for the facility. MA A said she had been working in the facility for over 3 years and she knew not administering the resident's eye drop correctly would not be effective and could cause harm to the resident. During an interview on 1/30/25 at 11:29 AM, with the ADM and DON, the DON stated eye drops should be instilled in the lower eyelid for it absorption and it effectiveness., She said she would have to in-service staff on proper medication administration. She stated the system for monitoring accuracy of medication administration observations was conducted with nursing staff several times per year by the Pharmacy Consultant. DON did not have the log of the Pharmacy Consultant for monitoring staffs. The ADM stated his expectation of staff for accurate medication administration was that guidelines were always followed. He stated a potential negative outcome for failure to properly administer medications, according to physicians' orders would be adverse effects on the resident. Record review of the facility-provided training document for Skilled Services and Medication Pass Competency dated 9/01/24 andreflected it was marked satisfactory and was signed by MA A and the ADON. Record review of the facility policy Administration of Eye Drops or Ointments, Date Implemented: 1/2022 and Reviewed/ Revised:1/2025 reflected. 5. Administration: a. Remove medication cap and place on clean, dry surface (i.e. tissue or paper towel) to prevent contamination. b. Steady hand holding the medication, as needed, on resident's forehead. c. With other hand, pull down lower eyelid to form a pouch of the conjunctival sac, instructing resident to look up. d. For eye drops: squeeze the prescribed number of drops into the conjunctival sac, avoiding placement of the drops directly on the eyeball. e. For eye ointment: squeeze a ribbon of ointment on the edge of the conjunctival sac from the inner to outer canthus.

Based on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal pharyngeal ulcers for 1 (Resident #66) of six residents reviewed for gastrostomy feedings in that: -The facility failed to administer Resident #66 gastrostomy feedings at the rate ordered, 50 ml/hr. This failure placed resident at risk for not receiving their required daily nutritional intake placing the resident at risk for weight loss. Findings: Record review of Resident #66's face sheet dated 01/30/25 revealed an [AGE] year-old- female admitted to the NF on 05/23/24. Resident diagnoses included the following: cerebral infarction (decreased blood flow to the brain), dysphagia (difficulty in swallowing), gastrostomy (surgical procedure that creates an opening in the abdominal wall and into the stomach), adult failure to thrive, paraplegia (paralysis that affects all or part of the body), anorexia (eating disorder), and gastro-esophageal reflux disease (stomach contents flow back up into the food pipe; symptoms include heartburn, chest pain, difficulty swallowing, burping, and sore throat) . Record review of Resident #66's quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating resident cognition was severely impaired. Record review of section K (Swallowing/Nutritional Status) reflected that resident had a feeding tube (e.g., nasogastric or abdominal (PEG {surgical procedure that places a feeding tube inside of the stomach}). Record review of Resident #66's care plan dated 12/09/24 revealed that resident was being care planned for a nutritional problem r/t being NPO/enteral feeding with intervention to evaluate and make diet change recommendations PRN. Record review of Resident #66's physician order for the month of January 2025 reflected the following orders: -Dated 12/13/24 NPO -Dated 01/13/25 Every Shift for GT feeding Isosource 1.5 at 50cc/hr. Record review of the NF TF Formula Equivalents Chart reflected the following: -Isosource 1.5 equivalent to Jevity 1.5 cal. Record review of Resident #66's MAR for the month of January 2025 reflected the NF was administering resident Isosource 1.5 at 50cc/hr. Record review of Resident #66's weights for the past 6 months did not reflect any significant weight loss. Observation on 01/28/25 at 9:37AM revealed Resident #66 resting in bed receiving gastrostomy feedings Jevity 1.5 cal at 45ml/hr along with water flush at 30ml/hr. Observation on 01/29/25 at 10:07AM revealed Resident # 66 resting in bed receiving gastrostomy feedings Jevity 1.5 cal at 45ml/hr along with water flush at 30ml/hr. Interview on 01/29/25 at 10:30AM with LVN C said the order for Resident #66's gastrostomy feeding Isosource was at 50ml/hr but she could have Jevity 1.5 because it was interchangeable. LVN C said the feeding Isosource was ordered on 01/13/25 at 50ml/hr. LVN C said the night nurse RN D was the nurse that hung Resident #66's gastrostomy feeding. LVN C said if a resident was not receiving their gastrostomy feedings as ordered, it could make the resident sick. Interview on 01/29/25 at 10:57AM with the DON said after review of Resident #66's physician orders said the resident's gastrostomy feedings should be infusing at 50ml/hr instead of 45ml/hr. The DON said not receiving the correct dosage as ordered, placed the resident at risk of not meeting the resident's nutrition goals. Interview on 01/29/25 at 12:04PM with the Dietician said the last time she assessed Resident # 66 was on 01/24/25. The Dietician said Jevity 1.5 was equivalent to Isosource and that resident feedings were ordered at 50ml/hr. Observation on 01/29/25 at 3:45PM revealed Resident #66's gastrostomy feedings had been changed from 45ml/hr to 50 ml/hr by LVN C. Interview on 01/29/25 at 3:50PM with RN D said she worked at the NF on a PRN basis on the morning shift and sometimes on the night shift. RN D said she was Resident #66's nurse on the night shift on 01/28/25. RN D said on the facility 24-hour report sheet, it showed that Resident #66 was receiving gastrostomy feedings Isosource at 45ml/hr. RN D said because the facility did not have Isososurce, the interchangeable feeding was Jevity 1.5cal. RN D said there were 6 rights when administering medications or providing care for a resident that consisted of the following: (1) Right resident, (2) Right time, (3) Right dose, (4) Right route, (5) Right medication, and (6) Right documentation. RN D said if she had followed these rights, she would have set Resident #66's feedings at 50ml/hr instead of 45 ml/hr. RN D said she went by what was on the 24-hour report sheet instead of looking at Resident #66's physician orders. RN D said she had a busy shift and did not check the physician orders. The facility DON was asked for policy on Gastrostomy feedings on 01/30/25 at 4:30PM. The facility provided a policy on Nutritional and Dietary Supplements revised April 2023 that read in part: .It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain nutritional status and the resident's highest practicable level of well-being .

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #62) of 6 residents observed for oxygen management. -The NF failed to dispose of an undated oxygen humidifier bottle from Resident #62's room that was at the bedside. This failure placed resident at risk for cross contamination, infections, and decrease in quality of life. Findings: Record review of Resident #62's face sheet dated 01/30/25 revealed a [AGE] year-old male admitted to the NF originally on 01/10/23. Resident #62's diagnoses included the following: dementia (impairment of at least two brain functions, such as memory and judgement), Tourette's disorder (a nervous system disorder involving repetitive movements or unwanted sounds), adult failure to thrive, and sepsis (infection in the blood). Record review of Resident #62's quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating that resident cognition was moderately impaired. Further review section O (Special Treatments, Procedures, and Programs) reflected resident not being coded for oxygen therapy. Record review of Resident #62's Physician Order Summary Report for the month of January 2025 did not reflect an order for oxygen. Record review of Resident #62's Care Plan dated 01/22/2025 reflected that resident was being care planned for SOB and respiratory infection with interventions that did not mention oxygen therapy. Observation on 01/28/25 at 10:28AM revealed Resident #62 resting in bed quietly. Further observation was made of an oxygen machine on the left side of resident bed with a humidifier bottle connected to the machine. The humidifier bottle was not dated. Interview on 01/30/25 at 2:25PM with the DON said respiratory equipment such as oxygen tubing and humidifiers were supposed to have a date to show when the last time the equipment had been changed. The DON said the equipment had to be changed out every week for infection control. The DON said the Unit Managers were assigned to halls to make sure this was being done. The DON said LVN E was the unit manager assigned to the hall that Resident #62 was residing on (hall 200). Interview on 01/30/25 at 2:45PM with LVN E said she was the unit manager for Halls 200 &300. LVN E said she was responsible in making sure that respiratory equipment such as oxygen tubing and humidifier bottles were being changed out every week and as needed. LVN E said the equipment was supposed to be dated to signify when the last time the equipment was changed. LVN E said this was done for infection control. LVN E said she monitored the respiratory equipment daily when in use but at no specific time. LVN E said she tried to make rounds on the residents in the morning. The surveyor asked facility DON, Administrator, and Corporate Nurse for their policy on Infection Control 01/29/25 and 01/30/25, policy was not received.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1was provided personal grooming (dry patches and flaky skin) by facility staff. This failure could place residents at risk for not receiving care and services for ADL. Findings included: Resident #1 Record review of Resident #1's face sheet dated 12/31/24 revealed a [AGE] year-old male was admitted to the facility initially on 09/23/24 and readmitted on [DATE]. Resident #1 had diagnoses that included: anoxic brain damage, (when brain cells are deprived of oxygen which caused brain cell to die) pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) diabetes mellites (body does not manage blood sugar properly), and hypertension (blood is pumping with more than normal through your arteries). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had BIMS of 13 out of 15 which indicated intact cognition. Further review revealed Resident #1 was dependent on staff with ADLs with one to two staff assistance. Record review of Resident #1's undated care plan revealed Resident #1 had ADL self-care performance deficit related to muscle weakness. Intervention: personal hygiene, total dependence on staff with one to two staff assistance. During an observation on 12/15/24 at 2:20 p.m. revealed Resident #1 skin from below the knee on the left leg to the foot had dry, patchy skin, the foot was ashy, and the toes had dry, flaky skin which had fallen off on the linen when the Wound care nurse removed Resident #1's boot. During an interview on 12/15/24 at 4:47 p.m., the Wound care nurse said Resident #1 left leg from below the knee to the foot had patches of dry skin, the toes were also ashy, and the skin on the toes was flaky and flaked off on the linen. The wound care nurse said residents were showered three times a week, and the aides were responsible for showering the residents. The wound care nurse said the aides should apply lotion on Resident #1 after showering and as needed. The wound care nurse said if Resident #1's skin continued to be patchy and dry, then Resident #1 skin could open up. The wound care nurse said the floor nurse was responsible for weekly skin assessment and monitored the aides during rounding, and the nurse managers monitored the nurses during random rounding. The wound care nurse said she only came to the facility maybe every other weekend and was unaware that Resident #1 refused to shower or lotion his skin. During an interview on 12/31/24 at 10:20 a.m., The DON said she expected the aides to provide and offer ADL to every resident to prevent the resident skin from being dry. The DON said the aides were responsible for providing ADL care for residents. The DON said the residents should get showers or bed baths three times a week and may require a bath before their shower day (PRN). The DON said the aides should apply lotion on shower days and as needed. The DON said aides should tell the nurse if Resident #1 had refused shower or lotion, and the nurse would go and assess Resident #1 and offer and apply lotion to Resident #1. The DON said she was not aware that Resident 1's skin on his left foot and toes was dry and flakey. The DON stated the nurse on the floor monitored the aides, and the nurse manager monitored the nurses during random rounds. During an interview on 12/31/24 at 10:25 a.m. Resident #1 said the aides applied moisturizer on him sometimes on shower days but not often. Resident #1 stated his skin sometimes itched, and he would ask the nurse to apply lotion. During an observation and interview on 12/31/24 at 10:34 a.m., the DON revealed Resident #1 skin still had patches of dry skin from above the knee to his left foot and toes. The DON said she could see the resident skin had dry patches, and she said they must do better. The DON said Resident #1 skin assessment should be done once a week by the wound car nurse or charge nurse if the wound care nurse. During an interview on 12/31/24 at 12:35 p.m., LVN B said aides are responsible for showering and applying lotion on residents' skin on shower days and as needed. LVN B said the charge nurse monitors the aides when she made rounds. LVN B said none of the staff had told her Resident #1 refused to be showered or applied lotion. LVN B said she did a skin assessment on Resident #1, and she noted his skin was dry and had patches of dry skin. LVN B said she noted Resident #1 lotion the staff applied to Resident #1 was absolved very quickly, and the skin remained dry with patches of dry skin. LVN B said she should have notified Resident #1's physician that the lotion used on the resident was not the best for the resident, but she did not inform Resident #1 physician. LVN B said Resident #1's skin had patches of dry skin, which could cause his skin to break down. LVN B said she had an LVN skills check-off, which included a skin assessment. During an interview on 12/31/24 at 1:02 p.m., the ADON said the nurses monitored the aides and made sure the aides were providing skin care to the residents. The ADON said she was not aware Resident #1 refused ADL care. The ADON said if Resident #1 had dry skin, the facility had in-house moisturizer , which the aides should have applied to Resident #1 skin because it was the facility slandered protocol for skin care. The ADON said if Resident #1's skin continued to dry, the nurse should have contacted the physician about Resident #1's dry skin and see if there was any prescription cream for Resident #1. The ADON said she had not notified the physician about Resident #1's patchy, dry skin because she was not aware of the dry skin. The ADON said if Resident #1 skin continued to be dry, Resident #1 skin could start to peel off, and we do not want that to happen because the skin could open, and if the skin is dry and Resident #1 scratched his skin, then he could break his skin. During an interview on 12/31/24 p.m., at 1:51 p.m., CNA A said Resident #1's shower days were TTHS. CNA A said Resident #1 did not refuse showers, and Resident #1 had dry, patched, and flaky skin. CNA A said she applied lotion on Resident #1 skin on his shower days when she worked but was unsure if other aides applied moisturizer and when the resident asked for the lotion to be applied on his skin. CNA A said Resident #1's skin was dry and flaky, and he could easily tear. CNA A said she told a nurse that the resident skin was still dry, but she could not remember the nurse's name. CNA A said she had a skills check-off, which included skin care. She stated the nurse monitored the aides when the nurse made random rounds. During an interview on 12/31/24 at 2:22 p.m., the DON said if Resident #1's skin was dry, it could cause Resident #1's skin to break down. Record review of the facility policy on skin integrity - foot care dated 02/2023 read in part . it is the policy of this facility to ensure residents receive proper treatment and care . to maintain good foot care . Record review of the facility policy on resident showers policy dated 01/01/23 and revised 04/17/23 read in part it is the practice of this facility to assist resident with bathing to maintain proper hygiene, stimulate circulate and help prevent skin issues .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 2 staff (The Wound care nurse) reviewed for infection control. 1. The facility failed to ensure The Wound care nurse followed proper infection control and PPE procedure during wound care treatment for Resident #1. This failure could place the residents at risk for infection. Findings included: Record review of Resident #1's face sheet dated 12/31/24 revealed a [AGE] year-old male was admitted to the facility initially on 09/23/24 and readmitted on [DATE]. Resident #1 had diagnoses included: anoxic brain damage, (when brain cells are deprived of oxygen which caused brain cell to die) pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) diabetes mellites (body does not manage blood sugar properly), and hypertension (blood is pumping with more than normal through your arteries). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had BIMS of 13 out of 15 which indicated intact cognition. Further review revealed Resident #1had two stage pressure ulcer and he was dependent on staff with ADLs. Record review of Resident #1's undated care plan revealed Resident #1 had ADL self-care performance deficit related to muscle weakness. Intervention: personal hygiene, total dependence on staff. Further review revealed Resident #1 had a stage 4 pressure ulcer to the sacrum(most serve type of bedsore, skin damage goes deep to muscle, tendon, or bone ): Interventions: perform treatment per order, treatment/wound care per md orders. Record review of Resident #1's order summary report dated December 2024 start date: `read Type of wound: pressure Location of wound: sacrum Irrigate, or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): collagen cover with bordered gauze dressing. Record review of Resident #1's order summary report dated December 2024 start date:11/20/24 read Bactrim DS give one tablet by mouth two times a day to promote wound healing for 10 days. Record review of Resident #1's order summary report dated December 2024 start date:12/04/24 read Bactrim DS give one tablet by mouth two times a day to promote wound healing for 10 days. Record review of Resident #1's TAR dated December 2024 revealed of wound: Stage 4 Pressure Injury location of wound: Sacrum: Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): Calcium alginate with silver cover with ABO pad Secure dressing with: Tape. rRecord review of Resident #1's dated December 2024 revealed Type of wound: pressure location of wound: sacrum Irrigate, or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): calcium alginate cover with: ABO Secure dressing with: tape. During an observation and interview on 12/15/24 from 1:40 p.m. through 2:24 p.m., the Wound Care Nurse provided wound care treatment for Resident #1, and it revealed the dressing was saturated with blood and dark yellow and green drainage. When the wound care nurse removed the dressing, the drainage from the wound bed was dripping down to the peri-wound. The Wound Care Nurse took one wet gauze, padded one section of the wound bed three times with the same gauze, then folded the same gauze and padded the wound bed thrice again. The wound care nurse repeated the same method on the other three sections of the wound bed. The wound was large, and it affected both the right and left sacrum. The Wound Care Nurse changed her gloves three times over the clean filed during the wound care treatment. The Wound Care Nurse did not clean the peri-wound and was about to place silver calcium alginate on the wound bed when the Surveyor asked the Wound care Nurse if she had finished cleaning the wound. The Wound care nurse said yes, and she was going to apply the silver alginate and cover the wound, and the peri-wound would be covered with the dressing. The Wound Care Nurse said she forgot to clean the wound bed. During an interview on 12/15/24 at 3:44 p.m., the Wound Care Nurse said she should have cleaned the wound bed with a gauze and wiped once at 360 degrees, and each gauze is used once. The Wound Care Nurse said she did not realize she dabbed on the wound bed when she cleaned the wound bed. The Wound Care Nurse said dabbing the wound bed would cause injury to the wound, and if the germs are not cleaned off, the wound could be infected. The Wound Care Nurse said she forgot to clean the peri-wound, and that could also infect the wound. The Wound Care Nurse said the dressing was saturated with yellow and green drainage, draining on the peri-wound when she removed the dressing. The wound care nurse said the floor nurse told her Resident #1 had just completed ABT Bactrim DS for the wound infection yesterday. The Wound Care Nurse said she did not have wound certification and did not remember if she had wound care skills check-off or any training on wound care because all nurses do wound care if the wound care nurse does not come to work. The Wound Care Nurse said she did not know who monitored the nurse because she comes here on weekends to do wound care. During an interview on 12/15/24 at 4:47 p.m., the Wound Care Nurse returned and said the Corporate Nurse provided a wound care skills check-off. Record review of the facility skilled services treatment revealed Wound care nurse signed the training on 08/06/2019. Record review of the facility treatment nursing competency read in part . dressing, dry/clean. #15 cleanse the wound with ordered cleanser, if using gauze, use clean gauze for each cleaning stroke .#16 use dry gauze to pat the wound dry . During an interview on 12/31/24 at 9:55 a.m., The DON said the Wound care nurse should have wiped Resident #1's wound bed the first time, which would have cleaned the debris from the wound bed. The DON said the Wound Care Nurse could wipe Resident #1 wound bed multiple times but with a different gauze each, then pad dry the wound after she cleaned the wound. The DON said the wound care nurse should have wiped the peri-wound which would had cleaned of drainage and germs to prevent wound infection. The DON said gloves are not removed on the clean field because of cross-contamination which meant the microbes from the dirty gloves contaminate the clean supplies. The DON said she monitored the wound care nurse when she made rounds with wound care once a month. The DON said the wound care nurse had skills - check off on wound care treatment. During an interview on 12/31/24 at 10:02 a.m., ADON said it depends on the type of the wound; if the wound did not have any drainage, the wound care nurse would not clean the peri-wound. ADON said that the peri-wound should be cleaned if Resident #1's wound had drainage. ADON said the Wound Care Nurse should have removed dirty gloves on the dirty side, not the clean side, to prevent cross-contamination of the clean field. ADON said if the Wound care nurse did not correctly clean Resident #1's wound, it could slow the healing process. During an interview on 12/31/24 at 11:50 a.m., the Unit manager said the Wound Care Nurse should have cleaned Resident #1's wound bed with gauze once, threw it away, and repeated the process until the wound bed was cleaned for Resident #1. The unit manager said the wound care nurse should have cleaned Resident #1's peri-wound and pat it dry with dry gauze. The unit manager said the wound care nurse should have wiped Resident #1's wound bed, which she padded, so the microbes and the drainage would be wiped off. The unit manager said if the wound care nurse did not clean Resident #1's wound well, then the bacteria would still be in the wound bed, which could lead to more bacteria and delay in Resident #1's wound healing. The unit manager said the DON monitors the wound care nurse during rounding. Record review of the facility policy on infection control dated 05/20/23 and Revised 1/20/24 read in part . this facility has established and maintained an infection prevention and control program designed to provide safe, sanitary . to help prevent the development and transmission . infection . Record review of the facility policy on wound treatment management dated 01/20/23 read in part to promote wound healing of various types of wounds .policy explanation and compliance guidelines #1. Wound treatment will be provided in accordance with physician order, including the cleansing method, type of dressing .

Based on observation, interview and record review , the facility to ensure a resident with pressure ulcers received nesessary treatment and services consistant with professional standards of practice, to promote healing, pevent infection a for 1 out of (Resident #1) of 2 residents reviewed for pressure ulcers. -The facility failed to ensure Wound Care Nurse followed proper wound care procedure during Resident #1's wound dressing change. This failure could place residents at risk for worsening existing pressure injuries, infection, pain, and decreased quality of life. Findings included: Resident #1 Record review of Resident #1's face sheet dated 12/31/24 revealed a [AGE] year-old male was admitted to the facility initially on 09/23/24 and readmitted on [DATE]. Resident #1 had diagnoses included: anoxic brain damage, (when brain cells are deprived of oxygen which caused brain cell to die) pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) diabetes mellites (body does not manage blood sugar properly), and hypertension (blood is pumping with more than normal through your arteries). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had BIMS of 13 out of 15 which indicated intact cognition. Further review revealed Resident #1had two stage pressure ulcer and he was dependent on staff with ADLs. Record review of Resident #1's undated care plan revealed Resident #1 had ADL self-care performance deficit related to muscle weakness. Intervention: personal hygiene, total dependence on staff. Further review revealed Resident #1 had a stage 4 pressure ulcer to the sacrum(most serve type of bedsore, skin damage goes deep to muscle, tendon, or bone ): Interventions: perform treatment per order, treatment/wound care per md orders. Record review of Resident #1's order summary report dated December 2024 start date: `read Type of wound: pressure Location of wound: sacrum Irrigate, or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): collagen cover with bordered gauze dressing. Record review of Resident #1's order summary report dated December 2024 start date:11/20/24 read Bactrim DS give one tablet by mouth two times a day to promote wound healing for 10 days. Record review of Resident #1's order summary report dated December 2024 start date:12/04/24 read Bactrim DS give one tablet by mouth two times a day to promote wound healing for 10 days. Record review of Resident #1's TAR dated December 2024 revealed of wound: Stage 4 Pressure Injury location of wound: Sacrum: Irrigate or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): Calcium alginate with silver cover with ABO pad Secure dressing with: Tape. rRecord review of Resident #1's dated December 2024 revealed Type of wound: pressure location of wound: sacrum Irrigate, or cleanse wound bed with Normal saline, Nexodyn solution or wound cleanser, pat dry and apply or pack (if applicable): calcium alginate cover with: ABO Secure dressing with: tape. During an observation and interview on 12/15/24 from 1:40 p.m. through 2:24 p.m., the Wound Care Nurse provided wound care treatment for Resident #1, and it revealed the dressing was saturated with blood and dark yellow and green drainage. When the wound care nurse removed the dressing, the drainage from the wound bed was dripping down to the peri-wound. The Wound Care Nurse took one wet gauze, padded one section of the wound bed three times with the same gauze, then folded the same gauze and padded the wound bed thrice again. The wound care nurse repeated the same method on the other three sections of the wound bed. The wound was large, and it affected both the right and left sacrum. The Wound Care Nurse changed her gloves three times over the clean filed during the wound care treatment. The Wound Care Nurse did not clean the peri-wound and was about to place silver calcium alginate on the wound bed when the Surveyor asked the Wound care Nurse if she had finished cleaning the wound. The Wound care nurse said yes, and she was going to apply the silver alginate and cover the wound, and the peri-wound would be covered with the dressing. Then Wound Care Nurse said she forgot to clean the wound bed. During an interview on 12/15/24 at 3:44 p.m., the Wound Care Nurse said she should have cleaned the wound bed with a gauze and wiped once at 360 degrees, and each gauze is used once. The Wound Care Nurse said she did not realize she dabbed on the wound bed when she cleaned the wound bed. The Wound Care Nurse said dabbing the wound bed would cause injury to the wound, and if the germs are not cleaned off, the wound could be infected. The Wound Care Nurse said she forgot to clean the peri-wound, and that could also infect the wound. The Wound Care Nurse said the dressing was saturated with yellow and green drainage, draining on the peri-wound when she removed the dressing. The wound care nurse said the floor nurse told her Resident #1 had just completed ABT Bactrim DS for the wound infection yesterday. The Wound Care Nurse said she did not have wound certification and did not remember if she had wound care skills check-off or any training on wound care because all nurses do wound care if the wound care nurse does not come to work. The Wound Care Nurse said she did not know who monitored the nurse because she comes here on weekends to do wound care. During an interview on 12/15/24 at 4:47 p.m., the Wound Care Nurse returned and said the Corporate Nurse provided a wound care skills check-off. Record review of the facility skilled services treatment revealed Wound care nurse signed the training on 08/06/2019. Record review of the facility treatment nursing competency read in part . dressing, dry/clean. #15 cleanse the wound with ordered cleanser, if using gauze, use clean gauze for each cleaning stroke .#16 use dry gauze to pat the wound dry . During an interview on 12/31/24 at 9:55 a.m., The DON said the Wound care nurse should have wiped Resident #1's wound bed the first time, which would have cleaned the debris from the wound bed. The DON said the Wound Care Nurse could wipe Resident #1 wound bed multiple times but with a different gauze each, then pad dry the wound after she cleaned the wound. The DON said the wound care nurse should have wiped the peri-wound which would had cleaned of drainage and germs to prevent wound infection. The DON said gloves are not removed on the clean field because of cross-contamination which meant the microbes from the dirty gloves contaminate the clean supplies. The DON said she monitored the wound care nurse when she made rounds with wound care once a month. The DON said the wound care nurse had skills - check off on wound care treatment. During an interview on 12/31/24 at 10:02 a.m., ADON said it depends on the type of the wound; if the wound did not have any drainage, the wound care nurse would not clean the peri-wound. ADON said that the peri-wound should be cleaned if Resident #1's wound had drainage. ADON said the Wound Care Nurse should have removed dirty gloves on the dirty side, not the clean side, to prevent cross-contamination of the clean field. ADON said if the Wound care nurse did not correctly clean Resident #1's wound, it could slow the healing process. During an interview on 12/31/24 at 11:50 a.m., the Unit manager said the Wound Care Nurse should have cleaned Resident #1's wound bed with gauze once, threw it away, and repeated the process until the wound bed was cleaned for Resident #1. The unit manager said the wound care nurse should have cleaned Resident #1's peri-wound and pat it dry with dry gauze. The unit manager said the wound care nurse should have wiped Resident #1's wound bed, which she padded, so the microbes and the drainage would be wiped off. The unit manager said if the wound care nurse did not clean Resident #1's wound well, then the bacteria would still be in the wound bed, which could lead to more bacteria and delay in Resident #1's wound healing. The unit manager said the DON monitors the wound care nurse during rounding. Record review of the facility policy on wound treatment management dated 01/20/23 read in part to promote wound healing of various types of wounds .policy explanation and compliance guidelines #1. Wound treatment will be provided in accordance with physician order, including the cleansing method, type of dressing .

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (CR#1) out of 21 residents reviewed for reporting. 1. CNA A, RN B, and IDON failed to report to the facilities Abuse Coordinator when CR#1 was assessed with unexplained vaginal bleeding a sign and symptom(s/s) of sexual abuse on 09/14/2024. 2. CNA C, RN B, and IDON failed to report to the facilities Abuse Coordinator when CR#1 was assessed with unexplained vaginal bleeding s/s of sexual abuse on 09/24/2024. CR#1 was transferred to a local hospital on 9/24/2024 and semen was present in her urine sample. 3. LVN D failed to report to the facilities Abuse Coordinator when CR#1 was assessed with unexplained vaginal bleeding on 09/24/2024, refused perineal care (washing the genital and anal areas), requested not to be touched, and feared of being touched all s/s of sexual abuse on 09/25/2024. CR#1 was transferred to a local hospital on 9/24/2024 and semen was present in her urine sample. An Immediate Jeopardy (IJ) was identified on 9/27/2024. The IJ template was provided to the facility on [DATE] at 5:20pm. While the IJ was removed on 10/1/2024 at 5:12pm, the facility remained out of compliance of pattern with no actual harm and potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems This deficient practices could place residents at risk for abuse, neglect, exploitation, and or mistreatment. Findings included: CR#1 Record review of CR#1's facesheet dated 09/26/2024, reflected that she was an [AGE] year-old female, who admitted to the facility on [DATE] with a primary diagnosis of cerebral infraction due to embolism of left middle cerebral artery (stroke ). Record review of CR#1's quarterly MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) was not available as the resident rarely /never understood with, a staff assessment for mental status as with cognitive skills for daily decision making severely impaired. Record review of CR#1's undated comprehensive care reflected: Focus: CR#1 has impaired cognitive function and impaired thought processes AEB (as evidenced by): Rarely/never makes decisions Goal: CR#1's needs will be met, and dignity will be maintained through the next review. Intervention: Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of CR#1's Late Entry SBAR (Situation, Background, Assessment, and Recommendation) completed by RN B with effective date of 09/15/2024 at 6:09am reflected, this started on 09/14/2024. Since this started has stayed the same. Spotted [NAME] red blood per vagina noted on the diaper. NP AK (Nurse Practitioner), RP (Responsible Party) and ADON notified. Report endorsed to day shift nurse for follow up. Reported to NP AK on 09/14/2024 10:20 PM. Pending response from NP AK. Record review of CR#1's progress note dated 09/14/2024 at 11:23pm completed by RN B reflected, monitor resident for abnormal bruising and/or bleeding form nose gums, blood in urine or stool every shift every shift. Record review of CR#1's progress note dated 09/15/2024 at 10:05am completed by LVN D reflected, Noted no new orders from NP AK regarding vaginal bleeding, nurse reassessed resident at this time, CNA came along with nurse, no apparent blood noted in resident's diaper or vaginal area, resident denies any pain or discomfort to perineal area, denies any apparent discomfort with urination, fluids encouraged to help resident keep hydrated, resident verbalizes understanding, no apparent distress noted, will continue to monitor. Record review of CR#1's SBAR completed by RN B with effective date of 09/24/2024 05:58 am reflected, Resident noted bleeding per vaginal; thick red blood, 01 brief soaked with blood. Resident noted sitting on the floor but refused fall. Resident is AO (alert and oriented)X (times) 3, skin intact, Vital as follows, BP(blood pressure) 89/55, HR(heart rate) 122, temp(temperature) 97.8, Resp(respiration) 18, bs(blood sugar) 121. DON, NP AND RP Notified. Sending resident to hospital for follow up. EMS notified for transportation to the hospital. Pending transportation and this time, report endorsed to day shift nurse for patient follow up. Record review of CR#1's progress note dated 09/24/2024 06:15am completed by LVN D reflected, received report from off-going nurse that resident is going to hospital ER (emergency room ) due to vaginal bleeding and that ambulance on the way to pick up resident as she's going to hospital for further evaluation. BP at this time=127/74, HR (Heart rare) =114,T(temperature)=97.6, RR(Respiration Rate)=18, spo2(Oxygen saturation)=97% on room air, resident laying in bed, denies any pain, headache or discomfort at this time. Record review of CR#1's progress note dated 09/24/2024 07:00am completed by LVN D reflected, Resident left facility at this time via (by way of) stretcher accompanied by 2 EMS (Emergency Medical Service) personnel, alert, denies any pain or discomfort, resident going to hospital for further evaluation of vaginal bleeding. Record review of CR#1's progress note dated 09/25/2024 08:40 pm completed by Regional QA (Quality Assurance) nurse reflected, Called resident RP an informed her of hospital urine specimen findings as reported to facility acting DON and Administrator today by SSA(State Survey Agency). RP was aware and will come to facility to meet with Administrator. Record review of CR#1's progress note dated 09/25/2024 08:50 pm completed by Regional QA (Quality Assurance) nurse reflected, Physician AL called and notified of hospital urine specimen foundlings and resident remains at the hospital. Record Review of Incident and Accident Reports found no report on CR#1 for the time frame of 09/14/2024-09/25/2024. Record review of CR#1's medical records from a local hospital, emergency room Summary reflected, admitted [DATE] with chief complaint for vaginal bleeding. Urine specimen confirmed positive for UTI (Urinary Tract Infection) and Sperm present. There was no present or active bleeding. Unable to assess if any assault had occurred. No signs of external trauma to genitalia evaluated. Recommend O/B Gyn (Obstetrician-Gynecologist) consult and SANE (Sexual Assault Nurse Examiner) Exam if concern for sexual assault. Record review of CR#1's SANE Exam dated 09/25/2024 completed by Forensic Nurse, reflected hospital requested medical forensic exam for an 83 y/o (year old) female with concerns for acute sexual assault. Genital Exam Findings with acute injury visualized and Hymenal remnants (tissue left behind after the hymen breaks). In an interview on 09/25/2024 at 8:15am with Hospital Nurse, she said that CR#1came to the emergency room [DATE], and during an examination was assessed to be bleeding in the vaginal area. She said CR#1's urine sample was found to be positive for an UTI there was a small amount of semen in the vaginal area. She said that CR#1 had a small laceration on the vaginal area indicative of abuse. She said that she did not know how long the semen had been there, but the resident was examined by an OB/GYN doctor. She said that CR#1 appeared to be afraid of male nurses. She states that the resident was in pain when touched or examined, and sometimes she refused to be cleaned in that area. In an interview and observation on 09/25/2024 at 8:50am with CR#1 at local hospital, interpreter used for Vietnamese translation. She said that she had not been touched inappropriate by a male nurse. She said that she was afraid to return to the facility. She said that staff were nice to her, and she would not continue the conversation with the interpreter. The interpreter indicated that CR#1 rambled and appeared to have a speech problem, during conversation was incoherent, an only answered yes or no questions. CR#1 was observed laying in the bed, wearing hospital gown, and her face, hands, and legs did not show any marks or bruises. In an interview on 9/25/2024 at 4:36pm with the Forensic Nurse, she said that an interview was conducted with CR#1 using Vietnamese translation, she was unable to say how the semen got in the urine, she said the blood was from having a period, she was too old, and no one would want her. She said that during the examination she observed a small abrasion around the anal area. In an interview in 9/25/2024 at 6:45pm with IDON, and she has worked at the facility since August 2024. She said that on 9/14/2024 it was reported that resident had blood in her brief, and the NP gave orders to monitor for further bleeding. She said that on 09/24/2024 she made decision to send the resident to the hospital. She said that the resident did not exhibit pain, or altered mental status. She said that she was unaware how CR#1 got semen in her. In an interview on 09/25/2024 at 7:40pm with the Administrator, he said that he has worked at the facility for three years and he was the abuse coordinator. He said that he did not know anything about semen, there were no complaints, he had heard sexual abuse happened about 6-7 years ago, but not since he started at the facility. During an entrance conference on 09/26/2024 at 1:00pm with the Administrator, IDON, and Regional QA Nurse, they stated CR#1 had not returned from the local hospital, the abuse coordinator was the Administrator, and the facility uses PL(Provider Letter) 18-20 for reporting guidelines on facility incidents. They all stated that after they were made aware that it was suspected that CR#1 was sexually abused on 09/25/2024, notification to police, ombudsman, responsible party, physician, medical director, safety surveys, skin assessments, an initiated staff interview and in-services. In an interview on 09/26/2024 at 3:50pm with CNA A, she had not seen or had to report since working at the facility. She said that if she saw any resident on the floor, bleeding from genitals she would report to the nurse immediately to assessed, and it should be reported to the Administrator. She said prior to 9/14/2024 CR#1 had no history of vaginal bleeding. She said that on 09/14/2024 on 2pm-10pm, she went to check brief of CR#1 at the end of her shift, she saw blood in the brief, reported to RN B who assessed, RN B said that there was vaginal bleeding, and RN#B completed notifications. She said that she did not think to report CR#1's vaginal bleeding on 09/14/2024, , she did not know if RN B had reported, and maybe she should have reported. In an interview on 09/26/2024 at 4:29pm with LVN D, said she had not seen or had to report since working at the facility. She said that if she saw any resident on the floor, bleeding from genitals she would assess, report to the physician, RP, DON, and Administrator immediately. She said that during report the morning of 09/15/2024, RN B told her that CR#1 was assessed with vaginal bleeding with no injuries. She said that the morning of 09/24/2024, RN B said that CR#1 was assessed with vaginal bleeding with no injures, and contact was made with NP AK, resident was to transfer to local hospital. She said that she attempted to assess CR#1 before she left out, CR#1 said no, placed her hand over the brief, and was afraid to let her look. She said she did not know the outcome of CR#1 going to the hospital. She said that she did not know if RN B had reported to Administrator that vaginal bleeding was assessed, but she had not reported. She said that vaginal bleeding would only be reported to the Administrator if there was concern for abuse, no one told her that the bleeding was a concern for abuse, or that she had injuries. She did not answer when asked if vaginal bleeding was s/s of sexual abuse or not wanting to be touched was s/s of sexual abuse. She did not answer when asked if all s/s of sexual abuse should be reported when assessed the Administrator. In a phone interview on 09/26/2024 at 4:29pm with RN B, she said that she works PRN, assignment varied, and usually worked 6p-6am. She said that if she saw any resident on the floor, bleeding from genitals, refusing care, and with fear of being touched, she would assess, report to the physician, RP, DON, and Administrator immediately. She said on 09/14/2024 CNA A reported to her toward the end of the aides (CNA A) shift 2p-10pm, that there was blood in the residents brief, and she assessed determine bleeding was vaginal. She said that she made notifications to the primary physician, IDON, and RP. She said that there was no more bleeding or spotting until the morning of 9/25/2024 at the end of her shift, and CNA E saw blood in the brief of CR#1. She said that she went to assess CR#1, the brief was soaked with blood, and determined it was coming from her vagina. She called NP AK, IDON, and RP. She said that she never assessed CR#1 to have injury with either incident. She said that she did not report to the Administrator that CR#1 had vaginal bleeding because she thought the bleeding was medical and not abuse. She said that she did report to IDON both times. She said that she did not think of abuse, because there were no injuries, CR#1 did not say there was abuse, and CR#1 was not afraid when she assessed. In an interview on 09/26/2024 at 5:12pm with the IDON she said that she worked for the facilities corporate office as a QA Nurse, she was sent to facilities when the DON position was vacant, she had been at the facility as the IDON since 08/07/2024, and her oversight was the [NAME] QA Nurse. She said that all abuse should be reported to the Administrator/Abuse Coordinator immediately. She said that if a nurse saw/received information that any resident on the floor, bleeding from genitals, afraid to be touched, and refusing care, the nurse should assess, contact the physician RP, DON, and Administrator. She said that the Administrator should follow policy for reporting and investigating. She said that the risk of not reporting or investigating was residents could be unsafe or abuse could continue. She said that CR#1 started to have Vaginal Bleeding on 9/14/2024 with spotting in the in brief, RN B notified the NP, RP, and her. She said that on 9/24/2024 RN B notified her that CR#1 was assessed bleeding enough to be concerned, an was transferred to the hospital. She did not learn of the outcome of CR#1's hospital transfer until notified by the SSA on 09/25/2024 around 6pm that CR#1 had UTI and semen in urine. She said that she was not aware of injury to genitals found, and there was a concern for sexual abuse. She said that she notified the Administrator after speaking to SSA. She said that she did not report or ensure RN B reported either incident to Administrator that CR#1, she did not think of abuse after either incident, and thought it was a medical concern In an interview on 09/26/2024 at 5:48pm with the Administrator, he said that he had been trained on Abuse and Neglect, he was able to list types, provide s/s of sexual abuse, vaginal/anal bleeding, bruising or injury to the genitals in both male/female, could refuse care, be afraid to be touched or not want care from opposite sex staff. He said that the risk of not reporting or investigating abuse is that it could continue. He said that CR#1 was sent to hospital for vaginal bleeding on 9/25/2024 for vaginal bleeding. He was made aware due to SSA investigation, that semen was found in the urine of CR#1, he was not made aware of any injuries, or her to have had vaginal bleeding before. He did not answer when asked if staff to include IDON should have notified him as the abuse coordinator when bleeding was observed for both incidents. In an interview on 09/26/2024 at 7:23pm with DON AN, she started orientation on 09/23/2024, did not finish onboarding, and 09/26/2024 was her official first day. She said that she had worked in skilled nursing facilities for [AGE] years, and she had been trained on abuse and neglect. She said that un explained vaginal bleeding with no history of bleeding would be a concern, should be reported immediately, and should be investigated by the facility to rule out abuse. She said that the risk of not reporting or investigating was the abuse could continue, and without a thorough investigation residents are left unprotected an involve more residents. She said that she was not made aware of the on going investigation when she arrived to the facility on [DATE]. She said that that nursing staff and IDON should have notified the Administrator who is the abuse coordinator immediately after CR#1 was observed with vaginal bleeding on 09/14/2024 and 09/25/2024. She said that the facility had not taken the necessary steps to rule out immediacy. In an interview on 09/27/2024 at 8:40am with CNA E, she said that she worked on 09/24/2024 on the 300 hall, and she worked 10pm-6am. She said that she had been trained on abuse and neglect, she listed types, and said s/s of sexual abuse could be vaginal/anal bleeding, injury to the genitals in both male/female, fear, refusing care especially from the sex of who may hurt them, or not wanting to be touched at all. She said that abuse should be reported immediately to the administrator who is the abuse coordinator, and she had not seen/or had to report abuse. She said that the risk of not reporting was the abuse could continue. She said toward the end of shift right before shift change, she entered the room, CR#1 was sitting on the bed with clothing and brief on, and CR#1 pointed to brief toward the vagina. She said that blood was on pajama bottoms towards the back, that was bright red. She said that she immediately got RN B, she came into the room, saw the blood, and she left and went to the nurse station. She said that the when the RN B returned she said that an ambulance was called, and she wanted her to help clean her up. She said that the brief was soaked with blood, but there was no blood anywhere else. She said that the RN B assessed CR#1 head to toe with no bruising or injuries, and she said that the blood was vaginal. She said that she threw out the brief, and clothing was placed in the linen for wash. She said that CR#1 did not have history of bleeding and was her first time seeing the resident with vaginal bleeding. She said that she did not report because she thought RN B did, and she did not think it was abuse because the resident did not say anything happened, she did not seem like she was in pain, or injuries. Record Review of facility policy titled Abuse, Neglect, and Exploitation Dated January 2023 read in part, Its is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriate of resident property .V. Policy Interpretation and Implementation 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . Policy Explanation ad Compliance Guidelines 2. The facility administrator is the Abuse Prevention Coordinator in the facility and is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Record review of Long-Term Care Regulatory Provider Letter (PL) 2024-14 Replaces, PL 2019-17, Date Issued: August 29, 2024, Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) reflected in part, 2.1 Incidents that a NF Must Report to HHSC A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect, Exploitation, Death due to unusual circumstances, A missing resident, Misappropriation, Drug theft, and Suspicious injuries of unknown source, Fire, Emergency situations that pose a threat to resident health and safety, and Communicable disease situations that are an unusual or abnormal event that poses a threat to resident health and safety. 2.4 Reportable Incidents and Timeframe . Do Report: abuse (with or without serious bodily injury ), an incident that results in serious bodily injury and that involves any of the following: neglect, exploitation, mistreatment, injuries of unknown source, Misappropriation of resident property .When to Report Immediately, but not later than two hours after the incident occurs or is suspected Attachment 1: Definitions and Examples of ANE (Abuse and Neglect)and other Reportable Incidents . Abuse: HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Centers for Medicare & Medicaid Services (CMS) defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . This was determined to be an Immediate Jeopardy (IJ) on 9/27/2024, with notification made to the Administrator, with the IDON and Regional QA Nurse present. The IJ template was provided to the Administrator on 09/27/2024 at 5:20pm. The following Plan of Removal(POR) submitted by the facility was accepted on 09/28/2024 3:34 PM The plan of removal reflected the following: PLAN OF REMOVAL Name of facility: Date: F 609 - The facility will report Abuse immediately but not later than 2 hours to the Administrator, State Survey Agency, and Law Enforcement. Problem: Facility staff failed to report to the Administrator immediately when CR #1 showed signs of a possible sexual assault after vaginal bleeding. Immediate action: 1. The facility administrator immediately completed a self-report incident to HHSC d/t allegation of sexual abuse on 9/25/24. 2. On 9/25/24 A Police report was made, they arrived to the facility to collected resident demographics HCSO Case#: [number], Deputy: [name and number]. 3. On 9/25/24 The facility nursing management staff immediately initiated skin assessment focusing on peri-area to ensure no trauma of s/s of physical injuries were present in all residents- no issues noted. Completed 9/26/24 4. On 9/25/24 The facility DON/Designee also assessed male residents who can Ambulate, self-transfer and who wonder in the facility and other residents' rooms. One resident was immediately place on 1:1 supervision due to wondering. Discharge process initiated. 5. On 9/25/24 The facility Adm/DON/SW or designee initiated 1:1 Interviews with facility staff and resident focusing on observation prior to the resident transfer to the hospital. Questionary revealed no unusual circumstances noted by staff or residents. Projected completion 9/28/24 6. On 9/25/24 The facility Social Worker/Designee conducted Life safety interviews with all interviewable residents. Interviews revealed no new negative events. Completed 9/2/24 Interventions: 7. The [NAME] President of Operation conducted and in-service with the facility Administrator: Review of State Reportable guidelines Provider Letter 2024-14 to ensure understanding of reportable incidents including timeline, i.e.: Abuse is to be reported immediately but no later than 2 hours. Completed 9/27/24 The Abuse prevention coordinator contact information is posted throughout the facility and or on employee's name badges to facilitate prompt reporting of suspicion and or any allegation of abuse and neglect. The abuse prevention coordinator will investigate, rule out, or report any allegation of abuse and neglect within the allowed time frame. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow up takes place. Any issues identify with this process will be address through further education and or disciplinary action. 8. On 9/25/24 the IDON/Designee initiated an in-service with the facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect and sexual abuse and symptoms. Projected completion 9/28/24 9. On 9/27/24 the IDON/Designee initiated an in-service with the facility staff on Possible Signs and Symptoms of Sexual Abuse including indicators, how to detect sexual abuse. Projected completion on 9/28/24 10. On 9/25/24 the IDON/Designee initiated and in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting, and documentation. Projected completion 9/28 11. On 9/27/24 the IDON/Designee initiated an in-service with facility staff on: Who is the facility abuse prevention coordinator, notifications of suspected abuse and neglect including sexual abuse signs and symptoms are to be reported to the administrator immediately. 9/28/24 12. On 9/27/23 The DON/Designee initiated an in-service with staff on immediately reporting any new residents' unusual behaviors, fear, crying, guarding, complaint of pain in pelvic area, isolation, etc. Projected completion 9/28/24 Ongoing Projected completion 9/28/24. Any staff member not present or in service on 9/25/24- 9/28/24, will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 1. On 9/27/23 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 9/28/24. 2. An impromptu QAPI meeting was conducted with the facility's Medical Director, Dr. [NAME] on 9/27/24 to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 9/27/24. The Plan of Removal was confirmed for the IJ by monitoring from 09/28/2024 through 10/01/2024 as follows: Record review of evidence provided by the facility reflected, that the facility completed self report to HHSC. Record review of evidence provided by the facility reflected, that the facility notified the law enforcement agency with jurisdiction to the facility. Record review of evidence provided by the facility reflected, that the facility did not immediately initiate skin assessments on 09/25/2024, and the skin assessments were initiated on 09/26/2024 after 1:00pm and completed on 09/26/2024. Record review of evidence provided by the facility reflected, that the facility did not immediately assess male residents who could ambulate, the assessments started after entrance on 09/26/2024, and CR#4 was placed on 1:1 supervision until 09/26/2024 8:15pm. Record review of evidence provided by the facility reflected, that the facility, initiated life safety interviews with on 9/26/2024 with English speaking females on the 300 hall, and the remaining residential population was initiated and completed on 09/27/2024 with no new issues identified. Record review of evidence provided by the facility reflected, that facility staff completed questionnaires that they had not noticed anything suspicious in the facility, had not seen CR#1 out of her room or male staff or residents near the room of CR#1. Record review of evidence provided by the facility reflected, that the facility did not have witness statements or interviews with direct care staff that provided care to CR#1 on the incident dates of 09/14/2024 and 09/24/2024. In an interview on 09/29/2024 from 7:45pm to 8:15pm with 2:00pm -10:00pm shift aides (CNA A , CNA AO , CNA AP, and CNA AQ, who were acknowledge being trained on Abuse Neglect Policy to include typed of abuse highlighting sexual abuse, sign and symptoms of sexual abuse that included vaginal bleeding, refusing care, and fear of being touched, all abuse must reported to the administrator who was the abuse coordinator, and reported immediately. In a telephone interview on 09/30/2024 at 6:10am with CNA AR and with LVN AS at 6:20am, LVN AS could be heard providing the answers to CNA AR in effort determined if their training on abuse and neglect was satisfactory. In an interview on 09/30/2024 at 12pm with HR Director, she said that DON AN did not report to work on 09/27/2024 and was terminated. She said that she had been trained on Abuse Neglect Policy, she was not able to provide the type of abuse, or the sign and symptoms of sexual abuse. In an interview on 09/30/2024 from 12:45p.m. to 6:32p.m. with staff on all shifts (Laundry Aide AU, Housekeeper AV, Floor Technician AW, Housekeeper AX, CNA H, Restorative Aide, CNA L, CNA K , CNA, CNA N, PTA, Cook, Dietary Aide, Dietary Aide, LVN T, LVN V, CNA A , Staffing Coordinator, CNA AZ, LVN AJ, CNA, and MA R ) who acknowledged being trained on Abuse Neglect Policy to include typed of abuse highlighting sexual abuse, sign and symptoms of sexual abuse that included vaginal bleeding, refusing care, and fear of being touched, all abuse must reported to the administrator who was the abuse coordinator, and reported immediately. All acknowledged being trained on Residents Rights Policy to include the right to be free of abuse and neglect, and Redirection of Residents with Wandering Behaviors immediately to nurse, MD, DON, and Administrator. In an interview on 10/01/2024 at 12pm with the HR Director, who acknowledged being trained on Abuse Neglect Policy to include typed of abuse highlighting sexual abuse, sign and symptoms of sexual abuse that included vaginal bleeding, refusing care, and fear of being touched, all abuse must reported to the administrator who was the abuse coordinator, and reported immediately. She acknowledged being trained on Residents Rights Policy to include the right to be free of abuse and neglect, and Redir [TRUNCATED]

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated and prevent further potential abuse or mistreatment while the investigation was in progress for 1 of 21 residents (CR#1) reviewed for abuse. 1. The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed to thoroughly investigate and report when CR#1 was assessed with unexplained vaginal bleeding on 09/14/2024, refused perineal care (washing the genital and anal areas), requested not to be touched, and feared being touched all signs and symptoms (s/s) of sexual abuse on 09/24/2024. CR#1 was transferred to a local hospital on 9/24/2024 and semen was present in her urine sample. 2. The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed thoroughly investigate and accurately report an allegation of abuse, when allegations were made that CR #3's was abused by the Hired Sitter on 07/13/2024. An Immediate Jeopardy (IJ) was identified on 9/27/2024. The IJ template was provided to the facility on [DATE] at 5:20pm. While the IJ was removed on 10/8/2024 at 3:43pm, the facility remained out of compliance of pattern with no actual harm and potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems These failures could place residents involved in abuse incidents at risk of continued abuse, further injury, pain, and physical and emotional distress. Findings included: CR#1 Record review of CR#1's facesheet dated 09/26/2024, reflected that she was an [AGE] year-old female, who admitted to the facility on [DATE] with a primary diagnosis of cerebral infraction due to embolism of left middle cerebral artery (stroke ). Record review of CR#1's quarterly MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) was not available as the resident rarely /never understood with, a staff assessment for mental status as with cognitive skills for daily decision making severely impaired. Record review of CR#1's undated comprehensive care reflected: Focus: CR#1 has impaired cognitive function and impaired thought processes AEB (as evidenced by): Rarely/never makes decisions Goal: CR#1's needs will be met, and dignity will be maintained through the next review. Intervention: Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of CR#1's Late Entry SBAR (Situation, Background, Assessment, and Recommendation) completed by RN B with effective date of 09/15/2024 at 6:09am reflected, this started on 09/14/2024. Since this started has stayed the same. Spotted [NAME] red blood per vagina noted on the diaper. NP AK (Nurse Practitioner), RP (Responsible Party) and ADON notified. Report endorsed to day shift nurse for follow up. Reported to NP AK on 09/14/2024 10:20 PM. Pending response from NP AK. Record review of CR#1's progress note dated 09/14/2024 at 11:23pm completed by RN B reflected, monitor resident for abnormal bruising and/or bleeding form nose gums, blood in urine or stool every shift every shift. Record review of CR#1's progress note dated 09/15/2024 at 10:05am completed by LVN D reflected, Noted no new orders from NP AK regarding vaginal bleeding, nurse reassessed resident at this time, CNA came along with nurse, no apparent blood noted in resident's diaper or vaginal area, resident denies any pain or discomfort to perineal area, denies any apparent discomfort with urination, fluids encouraged to help resident keep hydrated, resident verbalizes understanding, no apparent distress noted, will continue to monitor. Record review of CR#1's SBAR completed by RN B with effective date of 09/24/2024 05:58 am reflected, Resident noted bleeding per vaginal; thick red blood, 01 brief soaked with blood. Resident noted sitting on the floor but refused fall. Resident is AO (alert and oriented)X (times) 3, skin intact, Vital as follows, BP(blood pressure) 89/55, HR(heart rate) 122, temp(temperature) 97.8, Resp(respiration) 18, bs(blood sugar) 121. DON, NP AND RP Notified. Sending resident to hospital for follow up. EMS notified for transportation to the hospital. Pending transportation and this time, report endorsed to day shift nurse for patient follow up. Record review of CR#1's progress note dated 09/24/2024 06:15am completed by LVN D reflected, received report from off-going nurse that resident is going to hospital ER (emergency room ) due to vaginal bleeding and that ambulance on the way to pick up resident as she's going to hospital for further evaluation. BP at this time=127/74, HR (Heart rare) =114,T(temperature)=97.6, RR(Respiration Rate)=18, spo2(Oxygen saturation)=97% on room air, resident laying in bed, denies any pain, headache or discomfort at this time. Record review of CR#1's progress note dated 09/24/2024 07:00am completed by LVN D reflected, Resident left facility at this time via (by way of) stretcher accompanied by 2 EMS (Emergency Medical Service) personnel, alert, denies any pain or discomfort, resident going to hospital for further evaluation of vaginal bleeding. Record review of CR#1's progress note dated 09/25/2024 08:40 pm completed by Regional QA (Quality Assurance) nurse reflected, Called resident RP an informed her of hospital urine specimen findings as reported to facility acting DON and Administrator today by SSA(State Survey Agency). RP was aware and will come to facility to meet with Administrator. Record review of CR#1's progress note dated 09/25/2024 08:50 pm completed by Regional QA (Quality Assurance) nurse reflected, Physician AL called and notified of hospital urine specimen foundlings and resident remains at the hospital. Record Review of Incident and Accident Reports found no report on CR#1 for the time frame of 09/14/2024-09/25/2024. Record review of CR#1's medical records from a local hospital, emergency room Summary reflected, admitted [DATE] with chief complaint for vaginal bleeding. Urine specimen confirmed positive for UTI (Urinary Tract Infection) and Sperm present. There was no present or active bleeding. Unable to assess if any assault had occurred. No signs of external trauma to genitalia evaluated. Recommend O/B Gyn (Obstetrician-Gynecologist) consult and SANE (Sexual Assault Nurse Examiner) Exam if concern for sexual assault. Record review of CR#1's SANE Exam dated 09/25/2024 completed by Forensic Nurse, reflected hospital requested medical forensic exam for an 83 y/o (year old) female with concerns for acute sexual assault. Genital Exam Findings with acute injury visualized and Hymenal remnants (tissue left behind after the hymen breaks). In an interview on 09/25/2024 at 8:15am with Hospital Nurse, she said that CR#1 came to the emergency room [DATE], and during an examination was assessed to be bleeding in the vaginal area. She said CR#1's urine sample was found to be positive for an UTI there was a small amount of semen in the vaginal area. She said that CR#1 had a small laceration on the vaginal area indicative of abuse. She said that she did not know how long the semen had been there, but the resident was examined by an OB/GYN doctor. She said that CR#2 appeared to be afraid of male nurses. She states that the resident is in pain when touched or examined, and sometimes she refuses to be cleaned in that area. In an interview and observation on 09/25/2024 at 8:50am with CR#1 at local hospital, interpreter used for Vietnamese translation. She said that she had not been touched inappropriate by a male nurse. She said that she was afraid to return to the facility. She said that staff were nice to her, and she would not continue the conversation with the interpreter. The interpreter indicated that CR#1 rambled and appeared to have a speech problem, during conversation was incoherent, an only answered yes or no questions. CR#1 was observed laying in the bed, wearing hospital gown, and her face, hands, and legs did not show any marks or bruises. In an interview on 9/25/2024 at 4:36pm with the Forensic Nurse, she said that an interview was conducted with CR#1 using Vietnamese translation, she was unable to say how the semen got in the urine, and said the blood was from having a period, she was too old, and no one would want her. She said that during the examination she observed a small abrasion around the anal area. In an interview in 9/25/2024 at 6:45pm with IDON, and she has worked at the facility since August 2024. She said that on 9/14/2024 it was reported that resident had blood in her brief, and the NP gave orders to monitor for further bleeding. She said that on 09/24/2024 she made decision to send the resident to the hospital. She said that the resident did not exhibit pain, altered mental status so they did not check for a UTI. She said that she was unaware how the CR#1 got semen in her. She said that the night crew were all females. She said that the facility had a large Vietnamese population and visitors come in droves. In an interview on 09/25/2024 at 7:40pm with the Administrator, he said that he has worked at the facility for three years and he was the abuse coordinator. He said that he does not know anything about semen, there were no complaints, he had heard sexual abuse happened about 6-7 years ago, but not since he started at the facility. He said that the receptionist was supposed to monitor visitors and ensure they sign in, but since COVID (coronavirus disease) it had been an open-door policy. During an entrance conference on 09/26/2024 at 1:00pm with the Administrator, IDON, and Regional QA Nurse, information was provided that that CR#1 had not returned from the local hospital, the abuse coordinator was the Administrator. They all stated that after they were made aware that it was suspected that CR#1 was sexually abused on 09/25/2024, notification to police, ombudsman, responsible party, physician, medical director, safety surveys, skin assessments, an initiated staff interview and in-services. Observation in 09/26/2024 at 2:00pm of the room [ROOM NUMBER] of CR#1 and Resident #5 with sign posted at the door for electronic monitoring. In an interview an observation on 09/26/2024 at 3:25pm with CNA J on the 300 hall, he said he had worked at the facility PRN for 23 months, he works shifts 6am-2pm or 2pm-10pm, and today he was working the back of 300 hall until 10pm. He said that both CR#1 and Resident#5 are roommates, speak Vietnamese, do not talk much, and Resident#5 had electronic monitoring in the room, and she does not self-ambulate. He said that CR#1 had behavior of walking from room to nurse stations to dining hall, and back to her room, does not try to leave building do to wander guard placement, or try to enter other residents' rooms. He said he not seen any male staff, residents/visitor going into the room of CR#1. He said that CR#4 in room [ROOM NUMBER] also had behavior of walking down the 300 hall, but he does not have behavior of going into other residents room, and he was easily redirected. He said he worked the following dates 9/13/2024 400 hall 6am-2pm, 9/16/2024 200 hall 6am-2pm, 9/19/2024 back of 300 hall 2pm-10pm, and 9/24/2024 back of 300 hall 2-10pm. He said that no one had interviewed him or asked him to write a witness statement as part of investigation involving CR#1. In an interview on 09/26/2024 at 3:50pm with CNA A, she said that she worked on the front of 300 hall, and she works 2pm-10pm. She said that both CR#1 and CR#4 have behavior of walking the 300 hall but do not go into other residents room, and both are easily redirected. She said that CR#1 had a wander guard and Resident #5 had electronic monitoring. She said that CR#1 was transferred to the hospital for vaginal bleeding, while she was not at work. She said that prior to 9/14/2024 she had no HX (history) of vaginal bleeding. She said that on 09/14/2024 on 2pm-10pm, she went to check brief of CR#1 end of shift, she saw blood in the brief, reported to RN B who assessed, RN B said that there was vaginal bleeding, and completed notifications. She said that she worked 9/24/2024 2p-10pm. She said that she had seen CR#1 with bleeding since 09/14/2024. She said that she did not think to report CR#1 vaginal bleeding on 09/14/2024, she did not know if RN B had reported, and maybe she should have reported. She said that she had not been interview by anyone as part of investigation involving CR#1 or asked to write statement. In an interview on 09/26/2024 at 4:11pm with LVN T, she said that she worked the 6am-6pm shift, and she is assigned 300 hall. She said that CR#1 and CR#4 have behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 has electronic monitoring in place, and she said that not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that during report on 09/16/2024 she was told to monitor CR#1 for vaginal bleeding. She said that she had not history of bleeding, and she had not assessed her to have bleeding. She said that CR#1 was transferred to the hospital for vaginal bleeding on 09/24/2024, she did not know the outcome, and she had not assessed her to have any injuries to the vaginal area. She said that she did not know what steps facility took to determine if assessed bleeding was abuse, but she would have thought nurse that original assessed would have reported, and she would have reported. She said that she had not been interviewed or asked to a write statement. In an interview on 09/26/2024 at 4:29pm with LVN D, she said she worked the 6am-6pm shift and she was usually assigned 300 hall but working 400 hall on 09/26/2024. She said that CR#1 and CR#4 have behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 has electronic monitoring in place, and she said that not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that during report the morning of 09/15/2024, RN B told her that CR#1 was assessed with vaginal bleeding with no injuries, contact made with on-call NP, told to monitor, and follow up with primary. She said that she monitored with no new bleeding assessed, she did not see injury, and she contacted NP AK with no new orders. She said that the morning of 09/24/2024, RN B said that CR#1 was assessed with vaginal bleeding with no injures, and contact was made with NP AK, resident was to transfer to local hospital. She said she attempted to assess and perform peri care on CR#1 before she left out, CR#1 said no, placed her hand over the brief, and was afraid to let her look. She did not know the outcome of CR#1 going to the hospital. She said that the vaginal bleeding would only be reported to the Administrator if there was concern for abuse, and no one told her that the bleeding was a concern for abuse. She did not answer when asked if vaginal bleeding was s/s of sexual abuse or not wanting to be touched was s/s of sexual abuse. She did not answer when asked if all s/s of sexual abuse should be reported when assessed the Administrator. She said she had not been interviewed or asked to write a witness statement after either incident. In an effort to complete a telephone interview on 09/26/2024 at 4:47pm with the RP BH; a message was left. In an effort to complete phone interview on 09/26/2024 at 4:48pm with RP P; a message was left. In a phone interview on 09/26/2024 at 4:29pm with RN B, she said that she worked PRN, assignment varied, and usually worked 6p-6am. She said that CR#1 and CR#4 had behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 had electronic monitoring in place, and she said that she had not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that on 09/14/2024 CNA A reported to her toward the end of the aide (CNA A) shift 2p-10pm, that there was blood in the resident's brief, and she assessed determine bleeding was vaginal. She said she made notifications to the primary physician on-call number, IDON, and RP. She said that there initially was no response from the physician on-call number but successful on second attempt, told to monitor, and follow up with primary physician during regular hours. She said that there was no more bleeding or spotting until the morning of 9/25/2024 at the end of her shift, and CNA E saw blood in the brief of CR#1. She said she went to assess CR#1, the brief was soaked with blood, and determined it was coming from her vagina. She called NP AK with orders to monitor. She said that she contacted the IDON who said that CR#1 need to go to the hospital because it was the second time, to call NP AK back, if no order for transfer, contact RP to see if in agreement for transfer. She said she called RP BH, who agreed to transfer, scheduled transport, and then Call NP AK with agreement. She said she never assessed CR#1 to have injury either incident. She said that she did not remember CNA E telling her CR#1 was on the floor, and she could not remember how CNA E found CR#1. She said that she did not report to the Administrator that CR#1 had vaginal bleeding because she thought the bleeding was medical and not abuse. She said that she did report to IDON both times., NP AK was aware both times, but there was not a concern for abuse. She said that she did not think of abuse, because there were no injuries, CR#1 did not say there was abuse, and CR#1 was not afraid when she assessed. She said she did not know what steps the facility took to ensure there was no abuse when bleeding started on 9/14/2024 until the transfer to hospital. She said she did not complete an incident report. She said she had not been interviewed or asked to write statement. In an interview on 09/26/2024 at 5:12pm with the IDON she said that she worked for the facility's corporate office as a QA Nurse, she was assigned to facilities when the DON position was vacant, she had been at the facility as the IDON since 08/07/2024, and her oversight was the [NAME] QA Nurse. She said that she had been trained, all staff trained upon and ongoing for abuse and neglect. She said that the s/s of sexual abuse could be vaginal/anal bleeding, bruising or injury to the genitals in both male/female, refusal of peri care, afraid to be touched, not want care from opposite sex staff, or s/s of STD to include discharge. She said that all abuse should be reported to the Administrator/Abuse Coordinator immediately. She said that if a nurse saw/received information that any resident on the floor, bleeding from genitals, afraid to be touched, and refusing care, the nurse should assess, contact the physician RP, DON, and Administrator. She said that the Administrator should follow policy for reporting and investigating. She said that the risk of not reporting or investigating was residents could be unsafe or abuse could continue. She said that CR#1 started to have Vaginal Bleeding on 9/14/2024 with spotting in the in brief, RN B notified the NP, RP, and her. She said that on 9/24/2024 RN B notified her that CR#1 was assessed bleeding enough to be concerns, and NP said to monitor when notified. She said that she wanted CR#1 to transfer to the hospital, and she gave RN B guidance to facilitate the transfer in which she followed. She said she did not learn of the outcome of CR#1's hospital transfer until notified by the SSA on 09/25/2024 around 6pm that CR#1 had UTI and semen in urine. She said that she was not aware of injury to genitals found. She said that there was a concern for sexual abuse, and she was confused as to how the urine would test positive for semen. She said she notified the Administrator after speaking to SSA. She said that the Administrator has taken step to ensure safety by reporting to SSA, Law Enforcement, RP, Primary Physician, and Medical Director. In an interview on 09/26/2024 at 5:37pm with the Social Worker, he said that he works Monday-Friday from 8am-5pm. He said that there was an on going investigation involving CR#1, who assessed with vaginal bleeding, transferred to the hospital, and semen was found in her urine. He had not been interviewed as part of the investigation or asked to write a witness statement. He said that he had been asked to complete safety survey's on the 300 Hall, he complete interviews with English speaking female residents on the hall, with no abuse/neglect disclosed, and CNA A went with him. In an interview on 09/26/2024 at 5:48pm with the Administrator, he said that he had been trained on Abuse and Neglect, he was able to list types, provide s/s of sexual abuse, vaginal/anal bleeding, bruising or injury to the genitals in both male/female, could refuse care, be afraid to be touched or not want care from opposite sex staff. He said that the risk of not reporting or investigating abuse is that it could continue. He said that CR#1 was sent to hospital for vaginal bleeding on 9/25/2024 for vaginal bleeding. He said he was made aware due to SSA investigation, that semen was found in the urine of CR#1, he was not made aware of any injuries, or CR#1 to have vaginal bleeding before. He said that he had completed the following tasks as part of his investigation, self report completed, notification to the police, RP, physician, and Medical Director notified, increased monitoring in place, inservice for abuse and neglect initiated, resident interviews completed of all females on 300 hall, reviewed nursing department staff schedules with no male staff that worked during the time of the incident, hallway cameras for 300 hall being viewed by corporate IT was ongoing from 9/24/2024 until resident was transferred. He said that skins assessments were started on 09/26/2024 on 300 hall with female residents. He said he did not know why the assessments delayed, or did not include all residents. He said that staff interviews were ongoing, but did not answer when asked if they had already been started. He said that he did not have direct care staff complete witness statements, or had he reviewed the visitor log. He said no male staff had been suspended or suspected. He did not answer when asked if he thoroughly reviewed the schedules for all clinical male staff working during the time resident was observed with vaginal bleeding. He said that he was not notified that vaginal bleeding starting on 9/14/2024, and did not answer if he would have initiated investigation if he were aware. He did not answer when asked if staff to include IDON should have notified him as the abuse coordinator when bleeding was observed for both incidents. He said that he was not aware that CNA J worked the day prior to the initial bleeding being assessed, and multiple shifts since CR#1 transferred to the hospital to include assessment on the 300 hall. He was made aware of concern that facility self-report evidence was requested at entrance, there had been no evidence provided, and he provided no answer as to why. In an effort to complete phone interview on 09/26/2024 at 6:05pm with NP AK; a message was left. In an interview on 09/26/2024 with CNA A and LVN T, they stated they were not asked to increased monitoring on the hall, and they round every two hours as normal. In an interview on 09/26/2024 at 7:00pm during the end of day meeting with the Administrator, Regional QA Nurse, IDON, and DON AN with a list of concerns provided. The concerns provided were self-reported investigation evidence was requested at entrance not received, multiple interviews with direct staff that had not been interviewed or provide witness statements, Social Worker only interview English speaking residents for safety surveyors, multiple staff to include IDON were aware of vaginal bleeding on 09/14/2024 and 09/24/2024, and had not reported to the Administrator, CNA J who worked 9/13/2024, and multiple dates between 9/14/2024 and 9/24/2024 scheduled to work all though he had not been interview or asked to provide statement, no efforts to exclude male residents, visitors, or staff as perpetrators, no efforts to request electronic monitor of Resident#5 RP P, skin assessment were not initiated until after SSA entrance on 09/26/2024, with the skin assessments completed to include female residents on 300 hall, and staff denial that they were asked to increase monitoring. DON AN asked whose license would be referred if there was an IJ called. In an interview on 09/26/2024 at 7:23pm DON AN stated she started orientation on 09/23/2024, did not finish the onboarding, and 09/26/2024 was her official first day. She said she had worked in skilled nursing facilities for [AGE] years, and she had training on abuse and neglect. She said that unexplained vaginal bleeding with no history of bleeding would be a concern, should be reported immediately, and should be investigated by the facility to rule out abuse. She said that the risk of not reporting or investigating was the abuse could continue, and without a thorough investigation residents are left unprotected an involve more residents. She said that she was not made aware of the ongoing investigation when she arrived to the facility on [DATE]. She said that that nursing staff and IDON should have notified the Administrator who is the abuse coordinator immediately after CR#1 was observed with vaginal bleeding on 09/14/2024 and 09/25/2024. She said that had not taken the necessary steps to rule out immediacy. In an effort to complete phone interview on 09/27/2024 at 8:40am with NP AK; a message was left. In an interview on 09/27/2024 at 8:40am with CNA E, she said that she worked on 09/24/2024 on the 300 hall, and she worked 10pm-6am. She said that she did an initial change of brief after the shift start, could not recall time and CR#1 was not bleeding. She said toward the end of shift right before shift change, she entered the room, CR#1 was sitting on the bed with clothing and brief on, and CR#1 pointed to brief toward the vagina. She said that blood was on pajama bottoms towards the back, that was bright red. She said that she immediately got the RN B, she came into the room, saw the blood, and she left and went to the nurse station. She said that the when the RN B returned, she said that an ambulance was called, and she wanted her to help clean her up. She said that the brief was soaked with blood, but there was no blood anywhere else. She said that the RN B assessed CR#1 head to toe with no bruising or injuries, and she said that the blood was vaginal. She said that she threw out the brief, and clothing was placed in the linen for wash. She said that completed round every two hours, she did not see anyone male staff, residents, or visitors to go in the room. She said that she did not see CR#1 leave room during her shift. She said that CR#1 did not have history of bleeding and was her first time seeing the resident with vaginal bleeding. She said did not think it was abuse because the resident did not say anything happened, she did not seem like she was in pain, or had injuries. She said that she did not see CR#1 on the floor, and she did not tell anyone she was on the floor when she found her. She said that she had not been interviewed or asked to write a witness statement. She said that she had not been asked to increase rounds. In an effort to complete a telephone interview on 09/27/2024 at 8:45am with the RP BH; a message was left. In a phone interview on 09/27/2024 at 9:22am with Physician AL, he said that he is the primary physician for CR#1, nursing staffed notified NP AK that CR#1 was assessed with vaginal bleeding on both 9/14/2024 and 9/25/2024, and staff were to monitor but CR#1 transferred after the second incident. He said that the [NAME] QA nurse contacted him on 09/25/2024 to inform that semen was found in the urine of the CR#1. He said that CR#1 did not have history of vaginal bleeding. He said that based on information provided sexual abuse would be highly unlikely as an initial concern without more information like trauma or injuries with the bleeding. He said that the facility should always follow their polices for abuse and neglect prevention and investigation. In a phone interview on 09/27/2024 at 9:51am with the Medical Director, she said that she was notified about CR#1, the alleged sexual abuse, and that semen was found in urine specimen while at the hospital. She said that she would not initially have concern for sexual abuse with only vaginal bleeding without any injures present for physical abuse. She said that if there were other concerns that physical or sexual abuse occurred, a resident would need to be sent for further work up and testing at the hospital. Record Review of facility policy titled Abuse, Neglect, and Exploitation Dated January 2023 read in part, Its is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriate of resident property. Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies ( as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. VI. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or repo1ts of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 2. Exercising caution in handling evidence that could be used in a criminal investigation ( e.g., not tampering or destroying evidence); 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. 7. All allegations are thoroughly investigated. The administrator initiates investigations . 9. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. 13. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; e. interviews any witnesses to the incident . h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i.interviews the resident's roommate, family members, and visitors . reviews all events leading up to the alleged incident; and . 14. The following guidelines are used when conducting interviews: Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement VII. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: C. Increased supervision of alleged victim and residents; . This was determined to be an Immediate Jeopardy (IJ) on 9/27/2024, with notification made to the Administrator, with the IDON and Regional QA Nurse present. The IJ template was provided to the Administrator on 09/27/2024 at 5:20pm. In an int [TRUNCATED]

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 2 (CR #2 and CR#3) out of 21 residents reviewed for quality of care in that: 1. LVN F failed to notify the hospice nurse, Non-Emergency Medical Service (EMS), and local hospital that CR#2 required assessment for sexual abuse after being observed with vaginal bleeding a sign and symptom of sexual abuse. CR#2 arrived at the hospital on [DATE] at 7:52am and had not been assessed for the concern for sexual abuse at 11:19am. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE]at 10:26am. While the IJ was removed on [DATE] at 3pm, the facility remained out of compliance at a pattern with no actual harm and potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. 2. The facility failed to arrange emergency transportation to a local hospital when CR#3 was in respiratory distress on [DATE] at 10:30am, CR#3 arrived at the local hospital at 3:12pm by means of non-emergency contracted transportation. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:48pm. While the IJ was removed on [DATE] 4:25 pm at , the facility remained out of compliance at a pattern with no actual harm and potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could expose residents to delayed treatment, worsening of condition, low quality of care, hospitalization , and death. Findings included: Record review of CR#2's face sheet dated [DATE], reflected she was an [AGE] year-old female, who admitted to the facility on [DATE] on hospice with a primary diagnosis of traumatic subdural hemorrhage (brain bleed after a head injury). Record review of CR#2's undated comprehensive care reflected: Focus: CR#2 is on hospice services. DX (diagnosis): Acute Respiratory Failure. Call hospice first for any change in condition. Goal: Dignity will be maintained and the resident will be kept comfortable and pain free with in one hour of intervention through the next review. Intervention: Assist with ADL's (Activities of Daily Living) and provide comfort measures as needed. Ensure Advanced Directives are in place per resident and responsible party request. Monitor for decreased appetite, weight loss, skin break down, n\v(nausea and vomiting), etc(et cetera-report to Hospice. Monitor for s\s(sign and symptom) of increased pain, discomfort-give meds(medication)\tx's(treatment) monitor for relief. Focus: CR#2 has a pressure ulcer (Stage 4) to (Sacrum) d/t(do to): Poor Nutritional Status, Moisture/Incontinence and Immobility and is at risk for further skin breakdown. Goal: The wound(s) will show improvement during the review period with therapeutic interventions. Interventions: Air Mattress as indicated and ordered. Assess for pain and treat as indicated especially if pain is noticed before treatment. Assess wound for improvement during each treatment and report to the MD if the wound is declining. Notify MD(Medical Doctor) and RP(Responsible Party) of changes in condition as appropriate. Practice good hygiene. Treatment as ordered. Weekly skin assessment. Record review of CR#2's admission MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS(Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making. Record review of CR#2's progress note completed on [DATE] at 8:00am by LVN F read in part, During routine peri care, writer with CNA E assigned to resident, noted vaginal bleeding, noted also some clots. No signs and symptoms of distress at this time. No visible swelling, bruising, redness noted. Soiled brief and other beddings gathered and preserved. Vitals taken : BP(blood pressure) ,d+[DATE], P(pulse) 101, R(Respiration) 20, TEMP(temperature) 97.5, 89% on collar trach(tracheostomy) of 28% SPO2(Oxygen saturation). DON(IDON), Hospice Nurse, Physician, and NP(nurse practitioner) called. CR#2 and 2 EMS personnel exit the facility at 0726hrs. Record review of CR#'2 SBAR(Situation, Background, Assessment, and Recommendation) dated [DATE] completed by LVN F reflected notification to the RP completed 5:40am of being transferred to the hospital. Record review of CR#2's transfer/discharge report dated [DATE] did not list a chief complaint o reason for transfer. Record review of CR#2's contracted EMS run report dated [DATE] reflected a reason for transport for vaginal bleeding evaluation with no information that the bleeding could be related to sexual abuse. The transport started at 7:39am, and CR#2 arrived to the hospital at 7:49am. Record review of CR#2's hospital medical records dated [DATE] with admission time at 7:54am reflected a chief complaint for vaginal bleeding with no information that the bleeding could be related to sexual abuse. Re-evaluation Progress Note read in part, .update; I was notified that the state was visiting the ER, because of this patient's presentation, and they were concerned about possible sexual assault .Afterwards, I spoke with representative from the state, who asked me several questions regarding the patients presentation, and whether or not we suspect that this is a sexual assault or not. I am unsure whether or not there is any sexual assault component to this case, as the patient's bleeding could be from their sacral ulcer, rather than the vagina, but it is unclear. A pelvic ultrasound, shows no adnexal masses, no peritoneal free fluid, and no visualized uterus and ovaries. Upon our examination, there was no signs of any obvious vaginal trauma such as vaginal laceration. Time of re-eval 11:15am.Records reflected a discharge date of [DATE]. Record review of CR#2'sprogress note dated [DATE] an completed by Regional QA(Quality Assurance) Nurse reflected notification was made to the hospice service and RP to inform of a suspicion of sexual abuse suspected with vaginal bleeding. In an interview on [DATE] at 9:45am with the Administrator, he said that an investigation had been indicated and report made to State Survey Agency (SSA) after a resident (CR#2) was observed that morning between 4:00 am-5:00am with vaginal bleeding. He said that the resident(CR#2)was sent to the hospital for exam, treatment, and to confirm if the bleeding was due to a sexual assault. In an interview on [DATE] at 10:45am with RN AA at a local hospital, she confirmed that CR#2 was in the emergency room (ER) for vaginal bleeding, with no information about a concern for sexual assault. She said that the Emergency Department (ED) should have notified her upon arrival, no one had, and she should no to ensure resident safety while in the hospital. She said that she had to ensure her management was aware, notification for law enforcement, and if a SANE exam was needed. In an interview on [DATE] at 11:17am with RN AB at a local hospital, she said that CR#2 arrived at the hospital with a chief complaint of vaginal bleeding, was assessed, and will be discharged . She said that the bleeding was most likely due to pressure ulcer stage 3 on the sacrum, CR#2 was not actively bleeding, and would not be admitted . She said that CR#2 arrived at the hospital by means of contracted Emergency Medical Service (EMS). She said that Emergency Medical Technician (EMT) or the facility did not provide information that there was concern for abuse, neglect, or sexual abuse. She said that there were no concerns on labs completed for the presence of semen in the urine, but there were no labs completed for sexual transmitted disease (STD). She said that she did not see signs of sexual assault upon the initial physical exam. She said that facility should have informed, if EMT was aware they should have informed, information was needed upon arrival to make an accurate assessment determine if sexual abuse was the cause of the vaginal bleeding, or the presence of STD. Observation on [DATE] at 11:17am while completing interview with RN AB, a Physician (Physician AC)could be seen in the room of CR#2 speaking with the facilities Marketing Director. Observation of the Marketing Director with her cellular phone on speaker with someone from facility speaking too. Observation of the Physician AC providing details that CR#2 would be discharged , and the Marketing Director left the hospital. In an interview on [DATE] at 11:19am with Physician AC at a local hospital, he said that EMT or facility provided details that there was a concern that CR#2 bleeding could be due to sexual assault upon arrival. He said that he should have been provided with the information when CR#2 arrived, for him take the appropriate steps to conclude if there was a concern sexual assault. He said that he was just learning of this concern from the hospitals Quality Assurance Department. He said that CR#2's urine sample did not have semen present, there were no concern on the pelvic exam or ultrasound for concern of assault. He said that there were no labs for STD screening, and if he had known upon arrival would have ordered. He said that he was unsure if CR#2 would be admitted , that would depend on additional labs, and contact was needed with the family of CR#2. He said that the person from the facility (Marketing Director) came to check status of CR#2, determine if she was being admitted or discharging back to the facility, and she did not provide details that there was a concern for sexual assault. Observation on [DATE] at 11:20am of CR#2 at the local hospital revealed CR#2 was not interviewable and was sleeping. In an effort to complete a phone interview on [DATE] at 1:12pm with LVN F a message was left. In a phone interview on [DATE]:14pm with CNA E, she that she worked from 10pm -6am starting the night of [DATE]. She said that at 4:50am LVN F, and her went to change the brief on CR#2, and she saw blood clots in her brief. LVN F assessed to see where the blood was coming from, blood started pouring out, but she (CNA E) could not tell where the blood was coming from, and LVN F never said where it was coming from. She said that she thought LVN F reported the information to the family, physician, IDON, and Administrator. She said that the nurse tried to contact hospice. She said that CR#2 was transferred to the hospital to see why she was bleeding and determine if it had to do with abuse. She said that she thought everyone knew there could be abuse, and the hospital had to know to determine if abuse happened or not. In an interview on [DATE] at 1:27pm with the IDON, she said that she was contacted by LVN F at 4:57am on [DATE]. She said that LVN F informed that CNA E and RN F performed perineal care(the practice of cleaning the genital and anal areas), and saw blood in the brief for of CR#2 with clots. She said that that it was coming from the vagina from RN F's best guess. She instructed LVN F to secure everything that could be evidence, call MD, RP, Hospice nurse, send resident out non-emergency to the hospital to ensure bleeding was not related to sexual abuse, and she would call the Administrator. She said that she was contacted by Hospice Nurse AD, the morning of [DATE], she questioned why CR#2 was sent to the hospital, and expressed concern that CR#2 could be dropped from the hospice for being transferred. She said that she told Hospice Nurse AD the facility would have to worry about that later, CR#2 was sent out to see if she was okay, she did not tell Hospice Nurse AD the concern was to rule out sexual abuse, and it was not her initial concern to do so. She said that the hospital and EMS should be told that CR#2's vaginal bleeding could be due to sexual abuse. She said that LVN F should have called to give report to the hospital and tell them of the concern for sexual abuse, and the nurses should do that with any change of condition. She said LVN F should have told Hospice Nurse AD about a concern for sexual abuse. She declined to answer why she did not tell Hospice Nurse AD that there was concern for sexual abuse when the transfer was questioned if her expectation was that LVN F should have provided the information initially She said that the Marketing Director was sent to the hospital by the Administrator to follow up on CR#2's condition. She said that CR#2 was assessed with no concern for sexual abuse and would return to the facility. She said that hospital should know upon arrival about any concern for abuse or neglect to include sexual abuse so that it is known assess and determine if sexual abuse is valid or not. She said that a hospice nurse was privileged to know all information with a resident as part of care team, and notified with any change in condition. In an effort to complete a phone interview on [DATE] at 1:41pm with RN F a message was left. In a phone interview on [DATE] at 2:06pm with Hospice QA(Quality Assurance) Nurse, she said that Hospice Nurse AD was only told that CR#2 was transferred to the hospital for vaginal bleeding, and she have been told that there was suspicion of sexual abuse. She said that they would have notified law enforcement, family, and completed in person assessment. In an effort to complete a phone interview on [DATE] at 2:23pm with LVN F a message was left. In a phone interview on [DATE] at 2:46pm with NP AE, she said that she was the nurse practitioner (NP) for the Medical Director, the primary physician for CR#2. She said that she was notified the morning of [DATE] that CR#2 was transferred to the hospital after being assessed with vaginal bleeding to rule out the possibility of abuse, neglect, or sexual assault. She said that hospice and the hospital should be notified of a concern for abuse, neglect, or sexual assault. She said that the hospital should know to make a proper assessment to treat and rule out the abuse. She said that she would not say it was delay in treatment, but the hospital should have been told upon arrival. In an interview on [DATE] at 3:36pm with the Marketing Director, she said that she was sent to the hospital by the Administrator to check status of CR#2 and request medical records. She said that she could only assume that CR#2 was sent to the hospital to rule out a concern for sexual assault. She said that while at the hospital she was on the phone with the Administrator while speaking to the ER physician. She said that the ER nurse told her that the bleeding came from her sacral wound. She said that she was not clinical, she had no clue if the hospital should know to rule out sexual assault upon arrival, or who else should know. In an interview on [DATE] at 3:42pm with the Administrator, he said that he was contacted on [DATE] by the IDON between 5:15am-5:25am to inform that CR#2 was assessed with vaginal bleeding. He said that CR#2 was sent to the hospital for medical treatment, to determine the source of bleeding, and rule out abuse/neglect to include sexual assault. He said that he was unsure if EMS, hospice, or the hospital were made aware there was concerns for abuse, neglect, or sexual assault. He said that he was unsure who held the responsibility to ensure the notifications were made, and he would have to speak with corporate office. In an interview on [DATE] at 4:04pm with the Administrator, he said that he did not know if EMS, hospice, or the hospital should be made aware there was concerns sexual assault. He said that hi expectations for staff as abuse coordinator he thought it would have helped for the information to be provided to the hospital, hospice, and EMS to rule out the suspicion of sexual assault. In a phone interview on [DATE] 6:48pm with Hospice Nurse AD, she said that she worked on call last night, and she was contacted by a nurse (LVN F) at the facility that CR#2 was assessed with vaginal bleeding with blood clots, and was being transferred to the hospital. She said that she spoke to both LVN F and IDON, and she was not told that there was a concern for sexual abuse. She said CR#2 could have been dropped from the hospice due to the hospital transfer, but if she had known the transfer was due to a concern for sexual abuse, she would have not questioned the transfer. She said that the hospital should have known for a proper assessment upon arrival to diagnose, treat the bleeding, and determine if the bleeding was due to abuse or neglect. She said it wasis very important to have that information as soon as the CR#2 got to the hospital. She said hospice should be informed with any change of condition, provide all details that the physician would receive. In an interview on [DATE] at 4:08pm with LVN F, she said that CNA E, and she went to the room of CR#2 on [DATE] at 4:50am to change her brief, and she saw blood that she thought was coming from the vagina. She said that she made notifications with the IDON, RP, and Medical Director. She said that she was instructed by the IDON to transfer CR#2 to the hospital for evaluation as it was unclear if the bleeding was due to sexual abuse. She said that she scheduled transport to the hospital, she did not tell them the bleeding could be due to sexual abuse, and at the time she did think she was supposed to say that. In a phone interview on [DATE] at 9:48am with LVN F, she said that she did not tell hospice, EMS, or hospital staff that there was a concern for sexual assault. She said that she felt she provided enough details by reporting vaginal bleeding, and she did not know she needed to include any more information. She said that she did not believe there was a delay in treatment because she went to the hospital, and CR#2 was discharged from the hospital without a concern for sexual assault. In an interview on [DATE] at 9:45pm with the Administrator, IDON, and Regional QA Nurse. The Regional QA Nurse said that there was not a policy for notifying hospice, and hospice is to be notified with the same guidelines as the physician. Record Review of facility policy titled Notification of Changes Dated [DATE] read in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistently with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. life-threatening conditions, .4. A transfer or discharge of the resident from the facility . Record Review of facility policy titled Transfer and Discharge(including AMA Dated [DATE] read in part, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility except in limited circumstances .10. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: d. All other information necessary to meet the resident's needs, which includes, but may not be limited to: i. resident status, including baseline and current mental, behavioral, and functional status, reason for transfer. Record Review of facility policy titled Provision of Quality Care Dated February 2023 read in part, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Policy Explanation and Compliance Guidelines: 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The IJ template was provided to the facility on [DATE] at 10:26am. The following Plan of Removal(POR) submitted by the facility was accepted on [DATE] 8:11am. The plan of removal reflected the following: PLAN OF REMOVAL Name of facility: Date: [DATE] F 684 - The facility will ensure that residents receive treatment and care in accordance with professional standards of practice. Problem: The facility failed to notify the hospice nurse, EMS, and hospital staff that Resident#2 needed to be assessed for sexual abuse after she was observed with suspected vaginal bleeding. On [DATE] Resident #2, was assessed and transferred out to the hospital for further evaluation and returned to the facility with a new order for vibramycin x10 days for wound infection. The residents' care was resumed under hospice and the expired due to end of life complications on [DATE] at 0742am. Immediate action: 1. The facility administrator immediately completed a self-report incident to HHSC due to suspected sexual abuse case on [DATE]. 2. A Police report was made to the HCSO Case#:535847, Deputy: [name of Deputy] 3. On [DATE] the facility nursing management staff immediately initiated assessments focusing on peri-area to ensure no trauma of s/s of physical injuries were present in all residents- no issues noted. Completed [DATE] 4. On [DATE] the Admin/Don/Designee immediately collected statements from staff who had worked with the resident indicating observation of resident status and any other unusual events. No unusual events were reported. Completed [DATE]. 5. On [DATE] the facility Social Worker/Designee initiated Life safety interviews with all interviewable residents. Interviews revealed no new negative events. Completed [DATE] 6. On [DATE] The Adm/Don conducted a 1:1 in-service with the licensed nurse assigned to Resident #2 to ensure understanding of facility expectation to call and give report to the hospital/EMS/responsible party and hospice is provided prior to the transfer. Report should include status of the resident and reason for transfer. 7. On [DATE] at 07:05 the administrator established communication with the resident attending physician and the facility medical director to inform her about the vaginal bleeding with suspected sexual abuse. 8. On [DATE] at 15:47pm the administrator and DON met with resident #2 responsible party to ensure understanding of reason for transfer and the vaginal bleeding with suspected sexual abuse. 9. On [DATE] at 07:30 am the facility DON verbally inform resident #2 hospice nurse of the reason for transfer, vaginal bleeding with suspicion of sexual abuse. 10. On [DATE] at 10:55 The facility marketing director went to the hospital to follow up on resident #2 status. Interventions 11. On [DATE] the facility DON/Designee immediately initiate a 1:1 in-service with the licensed nurses to ensure understanding on facility expectations to call report the hospital on reference to the resident status and reason for the transfer. This in-service included reporting and disclosing suspicion of sexual abuse to the hospital, EMS, MD/NP, Responsible Party and Hospice. Completed on [DATE]. 12. On [DATE] the DON/Designee initiated 1:1 in-service with each license nurse on the steps to follow when a resident is suspected to be the victim of sexual abuse, report required prior transferring residents to the hospital, and who to disclose that information. Completion [DATE]. 13. On [DATE] the DON/Designee initiated in-service with the facility licensed nurses on Transfer/discharged Report. This report is printed out by the nurse/designee, the nurse then writes the reason for transfer at the bottom of the page and turns it into EMS who is to submit to the hospital. Ongoing Projected completion [DATE]. Any staff member not present or in service on [DATE] and [DATE] will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 14. On [DATE] The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility licensed nurses. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion [DATE]. 15. An impromptu QAPI meeting was conducted with the facility's Medical Director on [DATE] to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on [DATE]. The Plan of Removal was confirmed for the IJ by monitoring from [DATE] through [DATE] as follows: Record review of the in-services provided as supporting evidence did not outline steps the nursing staff should take when a resident was transferred to the hospital for suspicion of abuse to ensure that all notification were made and the hospital received information upon arrival to the hospital. In an interview on [DATE] at 1:36pm with the IDON, she recanted her original statements that she did tell Hospice Nurse AD that there was a concern for sexual abuse. She said that skin assessment were completed by the ADON, Wound Care Nurse, and Unit Manager, and there were no issues identified. She said that all nursing staff were trained by either the Administrator, IDON, and Regional QA Nurse with a steps to when transferring a resident to the hospital when there is a suspicion of abuse, neglect, to include sexual abuse, along with who should be notified. She said that the nurse should complete the following steps; If a resident is assessed with any of the s/s of abuse to include sexual abuse. 1. Secure the area that resident was found and room until law enforcement arrives. 2. Secure items that can be used as evidence, secure in bio hazard bag and in the DON office. 3. Notify the Primary MD/NP/On call service, RP, and hospice if appropriate to disclose the change condition and that there was s/s of sexual abuse, and requesting order to send to the ER for treatment and rule out sexual abuse. 4. Notify the RP and hospice if appropriate to disclose the change of condition was a s/s of sexual abuse, and transfer to ER was for treatment and to rule out sexual abuse 5. Notify both the Abuse Coordinator/designee or compliance hotline posted throughout facility there is concern for abuse, neglect, or sexual abuse. Follow guidance provided. 6. Notify DON so that confirmation is made that all previous steps were completed. 7. Notify emergency or non emergency transportation dispatcher, and EMT upon arrival that there was suspension that the s/s could be abuse or sexual abuse o confirm/unconfirm sexual assault or abuse. 8. Complete three transfer/discharge summary ensure that the s/s was listed under chief complaint and there was suspension of abuse or sexual abuse. There should be two provided to the EMT upon arrival, one for EMT, one for the hospital, and one for the facility. 9. Notify the hospital triage/charge nurse prior to residents arrival of suspension that s/s could be abuse or sexual abuse if non emergency transportation is utilized. 10. Document in progress note and complete SBAR. In an interview on [DATE] at 2:34pm with the Administrator, he said that he was trained by the IDON and Regional QA Nurse on the steps the nursing staff should complete when there was suspicion of abuse to include sexual abuse and transferring to the hospital. He said that he assisted with training staff once his training was completed. He said that the step-by-step training was not provided with evidence to support the POR, and he was not able to recall the step trained own. He said that he did not know how he trained the nursing staff on the process if he did not know the steps. In an interview on [DATE] at 2:53pm with the Unit Manager, she said that she assisted with completing skin assessments of the residents with no new issues identified. She said that she was trained since the IJ was called but she could not remember the topic. In an interview on [DATE] at 3:00pm with the ADON, she said that she assisted with completing skin assessments of the residents with no new issues identified. She said that she was trained since the IJ was called but she could not remember the topic. In an interview on [DATE] at 3:10pm with the Regional QA Nurse, with the Administrator and IDON present. She said that the POR was accepted without a step-by-step process, and she was not aware of what the step by step process the IDON would have trained the staff on. She agreed to provide the step-by-step process as outlined by the IDON, 1:1 training would be completed with the Administrator, ADON, and Unit Manager by the IDON, and any nursing staff that could not successfully account the steps would be re-trained. In an interview on [DATE] at 3:34pm with the Wound Care Nurse, she said that she assisted with completing skin assessments of the residents with no new issues identified. She said that she was trained since the IJ was called but she could not remember the topic. In an interview on [DATE] with nursing staff on the 6:00am-6:00pm, LVN U at 3:48pm, LVN T at 4:05pm; at LVN V at 4:23pm, and MDS Coordinator at 4:32pm who were all knowledgeable on the Step by Step process that should be taken when there was suspicion of abuse to include sexual abuse and the resident was transferred to the hospital as detailed by the IDON. In an interview on [DATE] at 10:28am with the Administrator, he said that he received a 1:1 training with the Regional QA Nurse on [DATE], and he was knowledgeable on the Step by Step process that should be taken when there was suspicion of abuse to include sexual abuse and the resident was transferred to the hospital as detailed by the IDON. He said that the risk of not completing the steps was prevent future abuse from happening, CR#2 could have been discharged from the hospital without proper assessment if the abuse did or did not occur, and hospice was a part of the care team and privilege to information the same as the physician. He said that LVN F did not ensure that hospice was aware or that hospital was aware upon arrival, when she should have. In an interview on [DATE] at 11:00an with the ADON, she said that she received a 1:1 training with the Regional QA Nurse on [DATE], and she was knowledgeable on the Step by Step process that should be taken when there was suspicion of abuse to include sexual abuse and the resident was transferred to the hospital as detailed by the IDON. She said that the risk of not completing the steps was prevent future abuse from happening, CR#2 could have been discharged from the hospital without proper assessment if the abuse did or did not occur, and hospice was a part of the care team and privilege to information the same as the physician. She said that LVN F did not ensure that hospice was aware or that hospital was aware upon arrival, when she should have. In a phone interview on [DATE] at 11:23am with Hospice AH, she said that she was the primary hospice nurse for CR#2, and CR#2 started to transition on [DATE], and she expired on [DATE]. She said that Hospice Nurse AD was contacted when CR#2 was assessed with vaginal bleeding, and she was not told there was concern f [TRUNCATED]

Based on observation, interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (CR #1) of 21 residents reviewed for abuse and neglect. -The facility failed to ensure that CR #1 was free from sexual abuse after facility staff assessed the resident to have unexplained vaginal bleeding, a sign and symptom of sexual abuse on 09/14/2024 and 09/24/2024 that resulted in CR#1 being transferred to a local hospital on 09/24/2024 with semen being found in her urine culture and acute injury found during genital exam. An Immediate Jeopardy (IJ) was identified on 9/27/2024. The IJ template was provided to the facility on [DATE] at 5:20pm. While the IJ was removed on 10/10/2024 at 3pm, the facility remained out of compliance of pattern with no actual harm and potential for more than minimal that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems This failure could place residents at risk of serious harm from possible abuse and neglect. Findings included: CR#1 Record review of CR#1's facesheet dated 09/26/2024, reflected that she was an [AGE] year-old female, who admitted to the facility on [DATE] with a primary diagnosis of cerebral infraction due to embolism of left middle cerebral artery (stroke ). Record review of CR#1's quarterly MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) was not available as the resident rarely /never understood with, a staff assessment for mental status as with cognitive skills for daily decision making severely impaired. Record review of CR#1's undated comprehensive care reflected: Focus: CR#1 has impaired cognitive function and impaired thought processes AEB (as evidenced by): Rarely/never makes decisions Goal: CR#1's needs will be met, and dignity will be maintained through the next review. Intervention: Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of CR#1's Late Entry SBAR (Situation, Background, Assessment, and Recommendation) completed by RN B with effective date of 09/15/2024 at 6:09am reflected, this started on 09/14/2024. Since this started has stayed the same. Spotted [NAME] red blood per vagina noted on the diaper. NP AK (Nurse Practitioner), RP (Responsible Party) and ADON notified. Report endorsed to day shift nurse for follow up. Reported to NP AK on 09/14/2024 10:20 PM. Pending response from NP AK. Record review of CR#1's progress note dated 09/14/2024 at 11:23pm completed by RN B reflected, monitor resident for abnormal bruising and/or bleeding form nose gums, blood in urine or stool every shift every shift. Record review of CR#1's progress note dated 09/15/2024 at 10:05am completed by LVN D reflected, Noted no new orders from NP AK regarding vaginal bleeding, nurse reassessed resident at this time, CNA came along with nurse, no apparent blood noted in resident's diaper or vaginal area, resident denies any pain or discomfort to perineal area, denies any apparent discomfort with urination, fluids encouraged to help resident keep hydrated, resident verbalizes understanding, no apparent distress noted, will continue to monitor. Record review of CR#1's SBAR completed by RN B with effective date of 09/24/2024 05:58 am reflected, Resident noted bleeding per vaginal; thick red blood, 01 brief soaked with blood. Resident noted sitting on the floor but refused fall. Resident is AO (alert and oriented)X (times) 3, skin intact, Vital as follows, BP(blood pressure) 89/55, HR(heart rate) 122, temp(temperature) 97.8, Resp(respiration) 18, bs(blood sugar) 121. DON, NP AND RP Notified. Sending resident to hospital for follow up. EMS notified for transportation to the hospital. Pending transportation and this time, report endorsed to day shift nurse for patient follow up. Record review of CR#1's progress note dated 09/24/2024 06:15am completed by LVN D reflected, received report from off-going nurse that resident is going to hospital ER (emergency room ) due to vaginal bleeding and that ambulance on the way to pick up resident as she's going to hospital for further evaluation. BP at this time=127/74, HR (Heart rare) =114,T(temperature)=97.6, RR(Respiration Rate)=18, spo2(Oxygen saturation)=97% on room air, resident laying in bed, denies any pain, headache or discomfort at this time. Record review of CR#1's progress note dated 09/24/2024 07:00am completed by LVN D reflected, Resident left facility at this time via (by way of) stretcher accompanied by 2 EMS (Emergency Medical Service) personnel, alert, denies any pain or discomfort, resident going to hospital for further evaluation of vaginal bleeding. Record review of CR#1's progress note dated 09/25/2024 08:40 pm completed by Regional QA (Quality Assurance) nurse reflected, Called resident RP an informed her of hospital urine specimen findings as reported to facility acting DON and Administrator today by SSA(State Survey Agency). RP was aware and will come to facility to meet with Administrator. Record review of CR#1's progress note dated 09/25/2024 08:50 pm completed by Regional QA (Quality Assurance) nurse reflected, Physician AL called and notified of hospital urine specimen foundlings and resident remains at the hospital. Record Review of Incident and Accident Reports found no report on CR#1 for the time frame of 09/14/2024-09/25/2024. Record review of CR#1's medical records from a local hospital, emergency room Summary reflected, admitted [DATE] with chief complaint for vaginal bleeding. Urine specimen confirmed positive for UTI (Urinary Tract Infection) and Sperm present. There was no present or active bleeding. Unable to assess if any assault had occurred. No signs of external trauma to genitalia evaluated. Recommend O/B Gyn (Obstetrician-Gynecologist) consult and SANE (Sexual Assault Nurse Examiner) Exam if concern for sexual assault. Record review of CR#1's SANE Exam dated 09/25/2024 completed by Forensic Nurse, reflected hospital requested medical forensic exam for an 83 y/o (year old) female with concerns for acute sexual assault. Genital Exam Findings with acute injury visualized and Hymenal remnants (tissue left behind after the hymen breaks). In an interview on 09/25/2024 at 8:15am with Hospital Nurse, she said that CR#1came to the emergency room [DATE], and during an examination was assessed to be bleeding in the vaginal area. She said CR#1's urine sample was found to be positive for an UTI there was a small amount of semen in the vaginal area. She said that CR#1 had a small laceration on the vaginal area indicative of abuse. She said that she did not know how long the semen had been there, but the resident was examined by an OB/GYN doctor. She said that CR#1 appeared to be afraid of male nurses. She states that the resident was in pain when touched or examined, and sometimes she refused to be cleaned in that area. In an interview and observation on 09/25/2024 at 8:50am with CR#1 at local hospital, interpreter used for Vietnamese translation. She said that she had not been touched inappropriate by a male nurse. She said that she was afraid to return to the facility. She said that staff were nice to her, and she would not continue the conversation with the interpreter. The interpreter indicated that CR#1 rambled and appeared to have a speech problem, during conversation was incoherent, an only answered yes or no questions. CR#1 was observed laying in the bed, wearing hospital gown, and her face, hands, and legs did not show any marks or bruises. In a telephone interview on 9/25/2024 at 2:44pm with RN B, she said she worked the 6pm - 6am shift PRN (as needed), and she got to work at 6:00pm on 09/14/2024. She said CR#1 was being changed, and the CNA (CNA A) told her that she noticed spotting in CR#1's brief. She said she completed a head-to-toe assessment. She said she texted the NP, called RP and ADON prior to leaving. She said when she returned the next day, the day shift nurse (LVN C) told her that there was no more blood in resident diaper. She stated on 9/24/24 the CNA (CNA E) noticed blood again in CR#1's brief. She said she completed an assessment and immediately called the IDON and was instructed to send resident to the hospital immediately then call and inform the NP. She said that there were no male staff working during her shifts. She said CR#1 walked by herself, and she has never seen her wander in other residents' room. In an Interview on 9/25/2024 at 4:00pm, with CNA A, she said on 9/14/2024 around 8:45pm, there was some blood coming from CR#1's vagina, and she alerted RN B. She said that RN B completed a head-to-toe assessment, then she text NP but never got a response. She said that the next day 9/15/2024 at 2pm, LVN D and her checked and there was no blood or discharge observed. She said there were no male nurses on the shift. In an interview on 9/25/2024 at 4:36pm with the Forensic Nurse, she said an interview was conducted with CR#1 using Vietnamese translation, she was unable to say how the semen got in the urine, and said the blood was from having a period, she was too old, and no one would want her. She said that during the examination she observed a small abrasion around the anal area. In an interview in 9/25/2024 at 6:45pm the IDON said she has worked at the facility since August 2024. She said that on 9/14/2024 it was reported that resident had blood in her brief, and the NP gave orders to monitor for further bleeding. She said on 09/24/2024 she made decision to send the resident to the hospital. She said the resident did not exhibit pain, altered mental status so they did not check for a UTI. She said she was unaware how the CR#1 got semen in her. She said the night crew were all females. She said the facility had a large Vietnamese population and visitors come in droves. In an interview on 09/25/2024 at 7:40pm with the Administrator, he said he has worked at the facility for three years and he was the abuse coordinator. He said he does not know anything about semen, there were no complaints, he had heard sexual abuse happened about 6-7 years ago, but not since he started at the facility. He said the receptionist was supposed to monitor visitors and ensure they sign in, but since COVID (coronavirus disease) it had been an open-door policy. During an entrance conference on 09/26/2024 at 1:00pm with the Administrator, IDON, and Regional QA Nurse, information was provided that CR#1 had not returned from the local hospital, the abuse coordinator was the Administrator, and the facility used the PL(Provider Letter) 18-20 for reporting guidelines on facility incidents. They said the following task were completed, notification to police, ombudsman, responsible party, physician, medical director, safety surveys, skin assessments, an initiated staff interview and in-services. Observation in 09/26/2024 at 2:00pm of CNA A entering the room [ROOM NUMBER] of CR#1 and Resident #5 for resident care, and sign posted at the door for electronic monitoring. In an effort to complete an interview on 09/26/2024 at 3:12pm with Resident #5, she was not interviewable. In an interview an observation on 09/26/2024 at 3:25pm with CNA J on the 300 hall, he said he had worked at the facility PRN for 23 months, he works shifts 6am-2pm or 2pm-10pm, and today he was working the back of 300 hall until 10pm. He said that both CR#1 and Resident#5 are roommates, speak Vietnamese, do not talk much, and Resident#5 had electronic monitoring in the room, and she does not self-ambulate. He said that CR#1 had behavior of walking from room to nurse stations to dining hall, and back to her room, does not try to leave building do to wander guard placement, or try to enter other residents' rooms. He said he not seen any male staff, residents/visitor going into the room of CR#1. He said that CR#4 in room [ROOM NUMBER] also had behavior of walking down the 300 hall, but he does not have behavior of going into other residents room, and he was easily redirected. He said he worked the following dates 9/13/2024 400 hall 6am-2pm, 9/16/2024 200 hall 6am-2pm, 9/19/2024 back of 300 hall 2pm-10pm, and 9/24/2024 back of 300 hall 2-10pm. In an effort on 09/26/2024 at 1:05pm with CR#4, he did not appear to be interviewable and did not answer questions. In an interview on 09/26/2024 at 3:50pm with CNA A, she said that she worked on the front of 300 hall, and she works 2pm-10pm. She said that both CR#1 and CR#4 have behavior of walking the 300 hall but do not go into other residents room, and both are easily redirected. She said that CR#1 had a wander guard and Resident #5 had electronic monitoring. She said that CR#1 was transferred to the hospital for vaginal bleeding, while she was not at work. She said that prior to 9/14/2024 she had no HX (history) of vaginal bleeding. She said that on 09/14/2024 on 2pm-10pm, she went to check brief of CR#1 end of shift, she saw blood in the brief, reported to RN B who assessed, RN B said that there was vaginal bleeding, and completed notifications. She said that she worked 9/24/2024 2p-10pm. She said that she had seen CR#1 with bleeding since 09/14/2024. In an interview on 09/26/2024 at 4:11pm with LVN T, she said that she worked the 6am-6pm shift, and she is assigned 300 hall. She said that CR#1 and CR#4 have behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 has electronic monitoring in place, and she said that not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that during report on 09/16/2024 she was told to monitor CR#1 for vaginal bleeding. She said that she had not history of bleeding, and she had not assessed her to have bleeding. She said that CR#1 was transferred to the hospital for vaginal bleeding on 09/24/2024, she did not know the outcome, and she had not assessed her to have any injuries to the vaginal area. She said that she did not know what steps facility took to determine if assessed bleeding was abuse, but she would have thought nurse that original assessed would have reported, and she would have reported. She said that she reports everything and leave it up to management to determine if there is a concern for abuse. In an interview on 09/26/2024 at 4:29pm with LVN D, she said she worked the 6am-6pm shift and she was usually assigned 300 hall but working 400 hall on 09/26/2024. She said that CR#1 and CR#4 have behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 has electronic monitoring in place, and she said that not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that during report the morning of 09/15/2024, RN B told her that CR#1 was assessed with vaginal bleeding with no injuries, contact made with on-call NP, told to monitor, and follow up with primary. She said that she monitored with no new bleeding assessed, she did not see injury, and she contacted NP AK with no new orders. She said that the morning of 09/24/2024, RN B said that CR#1 was assessed with vaginal bleeding with no injures, and contact was made with NP AK, resident was to transfer to local hospital. She said she attempted to assess and perform peri care on CR#1 before she left out, CR#1 said no, placed her hand over the brief, and was afraid to let her look. She did not know the outcome of CR#1 going to the hospital. She said that the vaginal bleeding would only be reported to the Administrator if there was concern for abuse, and no one told her that the bleeding was a concern for abuse. She did not answer when asked if vaginal bleeding was s/s of sexual abuse or not wanting to be touched was s/s of sexual abuse. She did not answer when asked if all s/s of sexual abuse should be reported when assessed the Administrator. In an effort to complete a telephone interview on 09/26/2024 at 4:47pm with the RP BH; a message was left. In an effort to complete phone interview on 09/26/2024 at 4:48pm with RP P; a message was left. In a phone interview on 09/26/2024 at 4:29pm with RN B, she said that she worked PRN, assignment varied, and usually worked 6p-6am. She said that CR#1 and CR#4 had behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 had electronic monitoring in place, and she said that she had not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that on 09/14/2024 CNA A reported to her toward the end of the aide (CNA A) shift 2p-10pm, that there was blood in the resident's brief, and she assessed determine bleeding was vaginal. She said she made notifications to the primary physician on-call number, IDON, and RP. She said that there initially was no response from the physician on-call number but successful on second attempt, told to monitor, and follow up with primary physician during regular hours. She said that she gave the information in report to LVN D, who contacted NP AK, with no new orders given. She said that there was no more bleeding or spotting until the morning of 9/25/2024 at the end of her shift, and CNA E saw blood in the brief of CR#1. She said she went to assess CR#1, the brief was soaked with blood, and determined it was coming from her vagina. She called NP AK with orders to monitor. She said that she contacted the IDON who said that CR#1 need to go to the hospital because it was the second time, to call NP AK back, if no order for transfer, contact RP to see if in agreement for transfer. She said she called RP BH, who agreed to transfer, scheduled transport, and then Call NP AK with agreement. She said she never assessed CR#1 to have injury either incident. She said that she did not remember CNA E telling her CR#1 was on the floor, and she could not remember how CNA E found CR#1. She said that she did not report to the Administrator that CR#1 had vaginal bleeding because she thought the bleeding was medical and not abuse. She said that she did report to IDON both times., NP AK was aware both times, but there was not a concern for abuse. She said that she did not think of abuse, because there were no injuries, CR#1 did not say there was abuse, and CR#1 was not afraid when she assessed. She said she did not know what steps the facility took to ensure there was no abuse when bleeding started on 9/14/2024 until the transfer to hospital. She said she did not complete an incident report. In an interview on 09/26/2024 at 5:12pm with the IDON she said that she worked for the facility's corporate office as a QA Nurse, she was assigned to facilities when the DON position was vacant, she had been at the facility as the IDON since 08/07/2024, and her oversight was the [NAME] QA Nurse. She said that she had been trained, all staff trained upon and ongoing for abuse and neglect. She said that the s/s of sexual abuse could be vaginal/anal bleeding, bruising or injury to the genitals in both male/female, refusal of peri care, afraid to be touched, not want care from opposite sex staff, or s/s of STD to include discharge. She said that if a nurse saw/received information that any resident on the floor, bleeding from genitals, afraid to be touched, and refusing care, the nurse should assess, contact the physician RP, DON, and Administrator. She said that the nurse should complete progress, SBAR, and incident report. She said that the Administrator should follow policy for reporting and investigating. She said that CR#1 started to have Vaginal Bleeding on 9/14/2024 with spotting in the in brief, RN B notified the NP, RP, and her. She said that on 9/24/2024 RN B notified her that CR#1 was assessed bleeding enough to be concerns, and NP said to monitor when notified. She said that she wanted CR#1 to transfer to the hospital, and she gave RN B guidance to facilitate the transfer in which she followed. She did not learn of the outcome of CR#1's hospital transfer until notified by the SSA on 09/25/2024 around 6pm that CR#1 had UTI and semen in urine. She said that she was not aware of injury to genitals found. She said that there was a concern for sexual abuse, and she was confused as to how the urine would test positive for semen. She said she notified the Administrator after speaking to SSA. She said that none of the resident are showing behaviors of going into other rooms. She said that the Administrator has taken step to ensure safety by reporting to SSA, Law Enforcement, RP, Primary Physician, and Medical Director. In an interview on 09/26/2024 at 5:48pm with the Administrator, he said CR#1 was sent to hospital for vaginal bleeding on 9/25/2024 for vaginal bleeding. He was made aware due to SSA investigation, that semen was found in the urine of CR#1, he was not made aware of any injuries, or CR#1 to have vaginal bleeding before. He said that he was not notified that vaginal bleeding starting on 9/14/2024. In an effort to complete phone interview on 09/26/2024 at 6:05pm with NP AK; a message was left. In an interview on 09/26/2024 at 7:23pm DON AN stated she started orientation on 09/23/2024, did not finish the onboarding, and 09/26/2024 was her official first day. She said she had worked in skilled nursing facilities for [AGE] years, and she had training on abuse and neglect. She said that unexplained vaginal bleeding with no history of bleeding would be a concern, should be reported immediately, and should be investigated by the facility to rule out abuse. She said that the risk of not reporting or investigating was the abuse could continue, and without a thorough investigation residents are left unprotected an involve more residents. She said that she was not made aware of the ongoing investigation when she arrived to the facility on [DATE]. She said that that nursing staff and IDON should have notified the Administrator who is the abuse coordinator immediately after CR#1 was observed with vaginal bleeding on 09/14/2024 and 09/25/2024. She said that had not taken the necessary steps to rule out immediacy. In an effort to complete phone interview on 09/27/2024 at 8:40am with NP AK; a message was left. In an interview on 09/27/2024 at 8:40am with CNA E, she said that she worked on 09/24/2024 on the 300 hall, and she worked 10pm-6am. She said that she did an initial change of brief after the shift start, could not recall time and CR#1 was not bleeding. She said toward the end of shift right before shift change, she entered the room, CR#1 was sitting on the bed with clothing and brief on, and CR#1 pointed to brief toward the vagina. She said that blood was on pajama bottoms towards the back, that was bright red. She said that she immediately got the RN B, she came into the room, saw the blood, and she left and went to the nurse station. She said that the when the RN B returned, she said that an ambulance was called, and she wanted her to help clean her up. She said that the brief was soaked with blood, but there was no blood anywhere else. She said that the RN B assessed CR#1 head to toe with no bruising or injuries, and she said that the blood was vaginal. She said that she threw out the brief, and clothing was placed in the linen for wash. She said that completed round every two hours, she did not see anyone male staff, residents, or visitors to go in the room. She said that she did not see CR#1 leave room during her shift. She said that CR#1 did not have history of bleeding and was her first time seeing the resident with vaginal bleeding. She said did not think it was abuse because the resident did not say anything happened, she did not seem like she was in pain, or had injuries. She said that she did not see CR#1 on the floor, and she did not tell anyone she was on the floor when she found her. In an effort to complete a telephone interview on 09/27/2024 at 8:45am with the RP BH; a message was left. In a phone interview on 09/27/2024 at 9:22am with Physician AL, he said that he is the primary physician for CR#1, nursing staffed notified NP AK that CR#1 was assessed with vaginal bleeding on both 9/14/2024 and 9/25/2024, and staff were to monitor but CR#1 transferred after the second incident. He said that the [NAME] QA nurse contacted him on 09/25/2024 to inform that semen was found in the urine of the CR#1. He said that CR#1 did not have history of vaginal bleeding. He said that based on information provided sexual abuse would be highly unlikely as an initial concern without more information like trauma or injuries with the bleeding. He said that the facility should always follow their polices for abuse and neglect prevention and investigation. In a phone interview on 09/27/2024 at 9:51am with the Medical Director, she said that she was notified about CR#1, the alleged sexual abuse, and that semen was found in urine specimen while at the hospital. She said that she would not initially have concern for sexual abuse with only vaginal bleeding without any injures present for physical abuse. She said that if there were other concerns that physical or sexual abuse occurred, a resident would need to be sent for further work up and testing at the hospital. Record Review of facility policy titled Abuse, Neglect, and Exploitation Dated January 2023 read in part, Its is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse Definitions: Sexual Abuse is non-consensual sexual contact of any type with a resident .VII. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm . This was determined to be an Immediate Jeopardy (IJ) on 9/27/2024, with notification made to the Administrator, with the IDON and Regional QA Nurse present. The IJ template was provided to the Administrator on 09/27/2024 at 5:20pm. In an interview on 9/27/2024 at 5:20pm the Administrator, IDON, and Regional QA Nurse were notified of the IJ(Immediate Jeopardy), during the IJ Meeting the Regional QA Nurse said that she did not understand why the IJ was called, and there had been steps taken to keep residents safe. The IDON said that video of the 300 Hall, had provided a culprit or perpetrator identified, with CR#4 seen walking the 300 hall, corporate were unable to see if he went into to the room of CR#1, but he would be placed on 1:1 observation. In an interview on 9/28/2024 at 4:40pm with the Administrator and IDON, requested to view the video of the 300 hall. The Administrator said that the video was viewed by the corporate Compliance Officer, provided details from the video, and he did not have physical copy of the video. Observation on 10/01/2024 at 9:30am , there were 10 visitors that entered the facility and were not asked to sign in by the Receptionist. In a telephone interview on 10/02/2024 at 10:08am with RP P, she was unable to provide footage from the electronic monitor of Resident#5, system does not save footage to recall. She had not observed CR#1 to into others room, and she had no concerns for other residents to come into the room of CR#1 and Resident #5. In a phone interview on 10/01/2024 at 11:23am with NP AK, she said that notification was made 9/14/2024 and 9/24/2024 that CR#1 was assessed with vaginal bleeding. She said that she would not had an initial concern for sexual abuse with out trauma related injures like tearing or defensive injures. She said that she was not aware that semen was found in the urine culture while CR#1 was at the hospital. She said that would expect that the facility would follow their policy for reporting and investigating abuse, starting when bleeding was first assessed. In an interview on 10/02/2024 at 1:27pm with Local Police Sergeant who said that there would be no investigation as CR#1 never said that she was sexually assaulted when interviewed by the officers. In an interview on 10/02/2024 at 3:50pm at local hospital with CR#1, she responded to yes/no question only. She said nothing happened to her, she did not want to talk about, and she did not answer anymore questions. In an interview on 10/01/2024 at 3:59pm with Receptionist, she said that all visitors should sign in, she said that she did not have group volunteers sign in that morning, she should have, and it was an oversight. She said that all non staff should sign in for resident safety. In an interview on 10/02/2024 at 4:00pm with RP, who said that CR#1 will not talk about what happened, she did not have male visitors, she did not see males enter the room, or took her out on pass. She did point to a male resident seen outside of the room she said had Parkinson b/c he was shaking, but she never said he did anything to her. She said that she has decided to take CR#1 home once discharged . The following Plan of Removal(POR) submitted by the facility was accepted on 9/28/2024 at 9:14pm The plan of removal reflected the following: PLAN OF REMOVAL Name of facility: Date: F 600 - The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Problem: The facility failed to ensure that CR#1 was free from sexual abuse when presented with vaginal bleeding. CCR[sic] mains[sic] at the hospital in stable condition. The resident responsible party was immediately notified of the transfer to the hospital and the urinalysis results. The facility immediately contacted the residents attending Physician and the facility medical director of the incident and resident status. Immediate action: 1. The facility administrator immediately completed a self-report incident to HHSC d/t allegation of sexual abuse on 9/25/24. 2. On 9/25/24 A Police report was made, they arrived to the facility to collected resident demographics HCSO Case#: [number], Deputy: [name and number]. 3. On 9/25/24 The facility nursing management staff immediately initiated skin assessment focusing on peri-area to ensure no trauma of s/s of physical injuries were present in all residents- no issues noted. Completed 9/26/24 4. On 9/25/24 The facility DON/Designee also assessed male residents who can Ambulate, self-transfer and who wonder in the facility and other residents' rooms. One resident was immediately place on 1:1 supervision due to wondering. Discharge process-initiated due to wondering behaviors. 5. On 9/25/24 The facility Adm/DON/SW or designee initiated 1:1 Interviews with facility staff and resident focusing on observation prior to the resident transfer to the hospital. Questionary revealed no unusual circumstances noted by staff or residents. Projected completion 9/28/24 6. On 9/25/24 The facility Social Worker/Designee conducted Life safety interviews with all interviewable residents. Interviews revealed no new negative events. Completed 9/26/24 Interventions: 7. On 9/25/24 the IDON/Designee initiated an in-service with the facility staff on Abuse and Neglect Facility Expectations based on policy. This included an explanation of the definition of Abuse, Neglect and sexual abuse and symptoms. Projected completion 9/28/24 8. On 9/27/24 the IDON/Designee initiated an in-service with the facility staff on Possible Signs and Symptoms of Sexual Abuse including indicators, how to detect sexual abuse. Projected completion on 9/28/24 9. On 9/25/24 the IDON/Designee initiated and in-service with the facility staff on Resident Rights to include Correspondence to possible/suspected abuse occurrences, interventions, what to do, reporting, and documentation. Projected completion 9/28/24 10. On 9/27/24 the IDON/Designee initiat [TRUNCATED]

Based on interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse for 1 (CR#1) of 21residents reviewed for reporting abuse. -The facility failed to implement their written policy of Abuse, when facility staff failed to report to the Administrator and investigate when CR #1 was assessed with vaginal bleeding on 09/14/2024 and refused perineal care (washing the genital and anal areas), requested not to be touched, and feared being touched all signs and symptoms(s/s) of sexual abuse on 09/24/2024. CR#1 was transferred to a local hospital on 9/24/2024 and semen was present in her urine sample. An Immediate Jeopardy (IJ) was identified on 9/27/2024. The IJ template was provided to the facility on [DATE] at 5:20pm. While the IJ was removed on 10/1/2024 at 5:12pm, the facility remained out of compliance pattern with no actual harm and potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems This deficient practices could place residents at risk for abuse, neglect, exploitation, and or mistreatment. Findings included: CR#1 Record review of CR#1's facesheet dated 09/26/2024, reflected that she was an [AGE] year-old female, who admitted to the facility on [DATE] with a primary diagnosis of cerebral infraction due to embolism of left middle cerebral artery (stroke ). Record review of CR#1's quarterly MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) was not available as the resident rarely /never understood with, a staff assessment for mental status as with cognitive skills for daily decision making severely impaired. Record review of CR#1's undated comprehensive care reflected: Focus: CR#1 has impaired cognitive function and impaired thought processes AEB (as evidenced by): Rarely/never makes decisions Goal: CR#1's needs will be met, and dignity will be maintained through the next review. Intervention: Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of CR#1's Late Entry SBAR (Situation, Background, Assessment, and Recommendation) completed by RN B with effective date of 09/15/2024 at 6:09am reflected, this started on 09/14/2024. Since this started has stayed the same. Spotted [NAME] red blood per vagina noted on the diaper. NP AK (Nurse Practitioner), RP (Responsible Party) and ADON notified. Report endorsed to day shift nurse for follow up. Reported to NP AK on 09/14/2024 10:20 PM. Pending response from NP AK. Record review of CR#1's progress note dated 09/14/2024 at 11:23pm completed by RN B reflected, monitor resident for abnormal bruising and/or bleeding form nose gums, blood in urine or stool every shift every shift. Record review of CR#1's progress note dated 09/15/2024 at 10:05am completed by LVN D reflected, Noted no new orders from NP AK regarding vaginal bleeding, nurse reassessed resident at this time, CNA came along with nurse, no apparent blood noted in resident's diaper or vaginal area, resident denies any pain or discomfort to perineal area, denies any apparent discomfort with urination, fluids encouraged to help resident keep hydrated, resident verbalizes understanding, no apparent distress noted, will continue to monitor. Record review of CR#1's SBAR completed by RN B with effective date of 09/24/2024 05:58 am reflected, Resident noted bleeding per vaginal; thick red blood, 01 brief soaked with blood. Resident noted sitting on the floor but refused fall. Resident is AO (alert and oriented)X (times) 3, skin intact, Vital as follows, BP(blood pressure) 89/55, HR(heart rate) 122, temp(temperature) 97.8, Resp(respiration) 18, bs(blood sugar) 121. DON, NP AND RP Notified. Sending resident to hospital for follow up. EMS notified for transportation to the hospital. Pending transportation and this time, report endorsed to day shift nurse for patient follow up. Record review of CR#1's progress note dated 09/24/2024 06:15am completed by LVN D reflected, received report from off-going nurse that resident is going to hospital ER (emergency room ) due to vaginal bleeding and that ambulance on the way to pick up resident as she's going to hospital for further evaluation. BP at this time=127/74, HR (Heart rare) =114,T(temperature)=97.6, RR(Respiration Rate)=18, spo2(Oxygen saturation)=97% on room air, resident laying in bed, denies any pain, headache or discomfort at this time. Record review of CR#1's progress note dated 09/24/2024 07:00am completed by LVN D reflected, Resident left facility at this time via (by way of) stretcher accompanied by 2 EMS (Emergency Medical Service) personnel, alert, denies any pain or discomfort, resident going to hospital for further evaluation of vaginal bleeding. Record review of CR#1's progress note dated 09/25/2024 08:40 pm completed by Regional QA (Quality Assurance) nurse reflected, Called resident RP an informed her of hospital urine specimen findings as reported to facility acting DON and Administrator today by SSA(State Survey Agency). RP was aware and will come to facility to meet with Administrator. Record review of CR#1's progress note dated 09/25/2024 08:50 pm completed by Regional QA (Quality Assurance) nurse reflected, Physician AL called and notified of hospital urine specimen foundlings and resident remains at the hospital. Record Review of Incident and Accident Reports found no report on CR#1 for the time frame of 09/14/2024-09/25/2024. Record review of CR#1's medical records from a local hospital, emergency room Summary reflected, admitted [DATE] with chief complaint for vaginal bleeding. Urine specimen confirmed positive for UTI (Urinary Tract Infection) and Sperm present. There was no present or active bleeding. Unable to assess if any assault had occurred. No signs of external trauma to genitalia evaluated. Recommend O/B Gyn (Obstetrician-Gynecologist) consult and SANE (Sexual Assault Nurse Examiner) Exam if concern for sexual assault. Record review of CR#1's SANE Exam dated 09/25/2024 completed by Forensic Nurse, reflected hospital requested medical forensic exam for an 83 y/o (year old) female with concerns for acute sexual assault. Genital Exam Findings with acute injury visualized and Hymenal remnants (tissue left behind after the hymen breaks). In an interview on 09/25/2024 at 8:15am with Hospital Nurse, she said that CR#1came to the emergency room [DATE], and during an examination was assessed to be bleeding in the vaginal area. She said CR#1's urine sample was found to be positive for an UTI there was a small amount of semen in the vaginal area. She said that CR#1 had a small laceration on the vaginal area indicative of abuse. She said that she did not know how long the semen had been there, but the resident was examined by an OB/GYN doctor. She said that CR#1 appeared to be afraid of male nurses. She states that the resident was in pain when touched or examined, and sometimes she refused to be cleaned in that area. In an interview and observation on 09/25/2024 at 8:50am with CR#1 at local hospital, interpreter used for Vietnamese translation. She said that she had not been touched inappropriate by a male nurse. She said that she was afraid to return to the facility. She said that staff were nice to her, and she would not continue the conversation with the interpreter. The interpreter indicated that CR#1 rambled and appeared to have a speech problem, during conversation was incoherent, an only answered yes or no questions. CR#1 was observed laying in the bed, wearing hospital gown, and her face, hands, and legs did not show any marks or bruises. In a telephone interview on 9/25/2024 at 2:44pm with RN B, she said she worked the 6pm - 6am shift PRN (as needed), and she got to work at 6:00pm on 09/14/2024. She said CR#1 was being changed, and the CNA (CNA A) told her that she noticed spotting in CR#1's brief. She said she completed a head-to-toe assessment. She said she texted the NP, called RP and ADON prior to leaving. She said when she returned the next day, the day shift nurse (LVN C) told her that there was no more blood in resident diaper. She stated on 9/24/24 the CNA (CNA E) noticed blood again in CR#1's brief. She said she completed an assessment and immediately called the IDON and was instructed to send resident to the hospital immediately then call and inform the NP. She said that there were no male staff working during her shifts. She said CR#1 walked by herself, and she has never seen her wander in other residents' room. In an Interview on 9/25/2024 at 4:00pm, with CNA A, she said on 9/14/2024 around 8:45pm, there was some blood coming from CR#1's vagina, and she alerted RN B. She said that RN B completed a head-to-toe assessment, then she text NP but never got a response. She said that the next day 9/15/2024 at 2pm, LVN D and her checked and there was no blood or discharge observed. She said there were no male nurses on the shift. In an interview on 9/25/2024 at 4:36pm with the Forensic Nurse, she said an interview was conducted with CR#1 using Vietnamese translation, she was unable to say how the semen got in the urine, and said the blood was from having a period, she was too old, and no one would want her. She said that during the examination she observed a small abrasion around the anal area. In an interview in 9/25/2024 at 6:45pm the IDON said she has worked at the facility since August 2024. She said that on 9/14/2024 it was reported that resident had blood in her brief, and the NP gave orders to monitor for further bleeding. She said on 09/24/2024 she made decision to send the resident to the hospital. She said the resident did not exhibit pain, altered mental status so they did not check for a UTI. She said she was unaware how the CR#1 got semen in her. She said the night crew were all females. She said the facility had a large Vietnamese population and visitors come in droves. In an interview on 09/25/2024 at 7:40pm with the Administrator, he said he has worked at the facility for three years and he was the abuse coordinator. He said he does not know anything about semen, there were no complaints, he had heard sexual abuse happened about 6-7 years ago, but not since he started at the facility. He said the receptionist was supposed to monitor visitors and ensure they sign in, but since COVID (coronavirus disease) it had been an open-door policy. During an entrance conference on 09/26/2024 at 1:00pm with the Administrator, IDON, and Regional QA Nurse, information was provided that CR#1 had not returned from the local hospital, the abuse coordinator was the Administrator, and the facility used the PL(Provider Letter) 18-20 for reporting guidelines on facility incidents. They said the following task were completed, notification to police, ombudsman, responsible party, physician, medical director, safety surveys, skin assessments, an initiated staff interview and in-services. Observation in 09/26/2024 at 2:00pm of CNA A entering the room [ROOM NUMBER] of CR#1 and Resident #5 for resident care, and sign posted at the door for electronic monitoring. In an effort to complete an interview on 09/26/2024 at 3:12pm with Resident #5, she was not interviewable. In an interview an observation on 09/26/2024 at 3:25pm with CNA J on the 300 hall, he said he had worked at the facility PRN for 23 months, he works shifts 6am-2pm or 2pm-10pm, and today he was working the back of 300 hall until 10pm. He said that both CR#1 and Resident#5 are roommates, speak Vietnamese, do not talk much, and Resident#5 had electronic monitoring in the room, and she does not self-ambulate. He said that CR#1 had behavior of walking from room to nurse stations to dining hall, and back to her room, does not try to leave building do to wander guard placement, or try to enter other residents' rooms. He said he not seen any male staff, residents/visitor going into the room of CR#1. He said that CR#4 in room [ROOM NUMBER] also had behavior of walking down the 300 hall, but he does not have behavior of going into other residents room, and he was easily redirected. He said he worked the following dates 9/13/2024 400 hall 6am-2pm, 9/16/2024 200 hall 6am-2pm, 9/19/2024 back of 300 hall 2pm-10pm, and 9/24/2024 back of 300 hall 2-10pm. He said that no one had interviewed him or asked him to write a witness statement as part of investigation involving CR#1. In an effort on 09/26/2024 at 1:05pm with CR#4, he did not appear to be interviewable and did not answer questions. In an interview on 09/26/2024 at 3:50pm with CNA A, she said that she worked on the front of 300 hall, and she works 2pm-10pm. She said that both CR#1 and CR#4 have behavior of walking the 300 hall but do not go into other residents room, and both are easily redirected. She said that CR#1 had a wander guard and Resident #5 had electronic monitoring. She said that CR#1 was transferred to the hospital for vaginal bleeding, while she was not at work. She said that prior to 9/14/2024 she had no HX (history) of vaginal bleeding. She said that on 09/14/2024 on 2pm-10pm, she went to check brief of CR#1 end of shift, she saw blood in the brief, reported to RN B who assessed, RN B said that there was vaginal bleeding, and completed notifications. She said that she worked 9/24/2024 2p-10pm. She said that she had seen CR#1 with bleeding since 09/14/2024. She said that she had not been interview by anyone as part of investigation involving CR#1 or asked to write statement. She said that she did not think to report CR#1 vaginal bleeding on 09/14/2024, she did not know if RN B had reported, and maybe she should have reported In an interview on 09/26/2024 at 4:11pm with LVN T, she said that she worked the 6am-6pm shift, and she is assigned 300 hall. She said that CR#1 and CR#4 have behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 has electronic monitoring in place, and she said that not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that during report on 09/16/2024 she was told to monitor CR#1 for vaginal bleeding. She said that she had not history of bleeding, and she had not assessed her to have bleeding. She said that CR#1 was transferred to the hospital for vaginal bleeding on 09/24/2024, she did not know the outcome, and she had not assessed her to have any injuries to the vaginal area. She said that she did not know what steps facility took to determine if assessed bleeding was abuse, but she would have thought nurse that original assessed would have reported, and she would have reported. She said that she reports everything and leave it up to management to determine if there is a concern for abuse. She said that she had not been interviewed or asked to a write statement. In an interview on 09/26/2024 at 4:29pm with LVN D, she said she worked the 6am-6pm shift and she was usually assigned 300 hall but working 400 hall on 09/26/2024. She said that CR#1 and CR#4 have behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 has electronic monitoring in place, and she said that not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that during report the morning of 09/15/2024, RN B told her that CR#1 was assessed with vaginal bleeding with no injuries, contact made with on-call NP, told to monitor, and follow up with primary. She said that she monitored with no new bleeding assessed, she did not see injury, and she contacted NP AK with no new orders. She said that the morning of 09/24/2024, RN B said that CR#1 was assessed with vaginal bleeding with no injures, and contact was made with NP AK, resident was to transfer to local hospital. She said she attempted to assess and perform peri care on CR#1 before she left out, CR#1 said no, placed her hand over the brief, and was afraid to let her look. She did not know the outcome of CR#1 going to the hospital. She said that the vaginal bleeding would only be reported to the Administrator if there was concern for abuse, and no one told her that the bleeding was a concern for abuse. She did not answer when asked if vaginal bleeding was s/s of sexual abuse or not wanting to be touched was s/s of sexual abuse. She did not answer when asked if all s/s of sexual abuse should be reported when assessed the Administrator. She said she had not been interviewed or asked to write a witness statement after either incident. In an effort to complete a telephone interview on 09/26/2024 at 4:47pm with the RP BH; a message was left. In an effort to complete phone interview on 09/26/2024 at 4:48pm with RP P; a message was left. In a phone interview on 09/26/2024 at 4:29pm with RN B, she said that she worked PRN, assignment varied, and usually worked 6p-6am. She said that CR#1 and CR#4 had behavior of walking down 300 hall, but neither resident goes into rooms of other residents. She said that Resident#5 had electronic monitoring in place, and she said that she had not seen male staff, residents, or visitors to enter the room of CR#1 and Resident#5. She said that on 09/14/2024 CNA A reported to her toward the end of the aide (CNA A) shift 2p-10pm, that there was blood in the resident's brief, and she assessed determine bleeding was vaginal. She said she made notifications to the primary physician on-call number, IDON, and RP. She said that there initially was no response from the physician on-call number but successful on second attempt, told to monitor, and follow up with primary physician during regular hours. She said that she gave the information in report to LVN D, who contacted NP AK, with no new orders given. She said that there was no more bleeding or spotting until the morning of 9/25/2024 at the end of her shift, and CNA E saw blood in the brief of CR#1. She said she went to assess CR#1, the brief was soaked with blood, and determined it was coming from her vagina. She called NP AK with orders to monitor. She said that she contacted the IDON who said that CR#1 need to go to the hospital because it was the second time, to call NP AK back, if no order for transfer, contact RP to see if in agreement for transfer. She said she called RP BH, who agreed to transfer, scheduled transport, and then Call NP AK with agreement. She said she never assessed CR#1 to have injury either incident. She said that she did not remember CNA E telling her CR#1 was on the floor, and she could not remember how CNA E found CR#1. She said that she did not report to the Administrator that CR#1 had vaginal bleeding because she thought the bleeding was medical and not abuse. She said that she did report to IDON both times., NP AK was aware both times, but there was not a concern for abuse. She said that she did not think of abuse, because there were no injuries, CR#1 did not say there was abuse, and CR#1 was not afraid when she assessed. She said she did not know what steps the facility took to ensure there was no abuse when bleeding started on 9/14/2024 until the transfer to hospital. She said she did not complete an incident report. She said she had not been interviewed or asked to write statement. In an interview on 09/26/2024 at 5:12pm with the IDON she said that she worked for the facility's corporate office as a QA Nurse, she was assigned to facilities when the DON position was vacant, she had been at the facility as the IDON since 08/07/2024, and her oversight was the [NAME] QA Nurse. She said that she had been trained, all staff trained upon and ongoing for abuse and neglect. She said that the s/s of sexual abuse could be vaginal/anal bleeding, bruising or injury to the genitals in both male/female, refusal of peri care, afraid to be touched, not want care from opposite sex staff, or s/s of STD to include discharge. She said that all abuse should be reported to the Administrator/Abuse Coordinator immediately. She said that if a nurse saw/received information that any resident on the floor, bleeding from genitals, afraid to be touched, and refusing care, the nurse should assess, contact the physician RP, DON, and Administrator. She said that the nurse should complete progress, SBAR, and incident report. She said that the Administrator should follow policy for reporting and investigating. She said that the risk of not reporting or investigating is residents could be unsafe or abuse could continue. She said that CR#1 started to have Vaginal Bleeding on 9/14/2024 with spotting in the in brief, RN B notified the NP, RP, and her. She said that on 9/24/2024 RN B notified her that CR#1 was assessed bleeding enough to be concerns, and NP said to monitor when notified. She said that she wanted CR#1 to transfer to the hospital, and she gave RN B guidance to facilitate the transfer in which she followed. She did not learn of the outcome of CR#1's hospital transfer until notified by the SSA on 09/25/2024 around 6pm that CR#1 had UTI and semen in urine. She said that she was not aware of injury to genitals found. She said that there was a concern for sexual abuse, and she was confused as to how the urine would test positive for semen. She said she notified the Administrator after speaking to SSA. She said that none of the resident are showing behaviors of going into other rooms. She said that the Administrator has taken step to ensure safety by reporting to SSA, Law Enforcement, RP, Primary Physician, and Medical Director. In an interview on 09/26/2024 at 5:37pm with the Social Worker, he said that he works Monday-Friday from 8am-5pm. He said that there was an on going investigation involving CR#1, who assessed with vaginal bleeding, transferred to the hospital, and semen was found in her urine. He had not been interviewed as part of the investigation or asked to write a witness statement. He said that he had been asked to complete safety survey's on the 300 Hall, he complete interviews with English speaking female residents on the hall, with no abuse/neglect disclosed, and CNA A went with him. In an interview on 09/26/2024 at 5:48pm with the Administrator, he said that he had been trained on Abuse and Neglect, he was able to list types, provide s/s of sexual abuse, vaginal/anal bleeding, bruising or injury to the genitals in both male/female, could refuse care, be afraid to be touched or not want care from opposite sex staff. He said that the risk of not reporting or investigating abuse is that it could continue. He said that CR#1 was sent to hospital for vaginal bleeding on 9/25/2024 for vaginal bleeding. He was made aware due to SSA investigation, that semen was found in the urine of CR#1, he was not made aware of any injuries, or CR#1 to have vaginal bleeding before. He said that he had completed the following tasks as part of his investigation, self report completed, notification to the police, RP, physician, and Medical Director notified, increased monitoring in place, inservice for abuse and neglect initiated, resident interviews completed of all females on 300 hall, reviewed nursing department staff schedules with no male staff that worked during the time of the incident, hallway cameras for 300 hall being viewed by corporate IT was ongoing from 9/24/2024 until resident was transferred. He said that skins assessments were started on 09/26/2024 on 300 hall with female residents. He said he did not know why the assessments delayed, did not include all residents. He said that staff interviews were ongoing, but did not answer when asked if they had already been started. He said that he did not have direct care staff complete witness statements, he had not reviewed visitor log. He said no male staff had been suspended or suspected. He did not answer when asked if he thoroughly reviewed the schedules for all clinical male staff working during the time resident was observed with vaginal bleeding. He said that he was not notified that vaginal bleeding starting on 9/14/2024, and did not answer if he would have initiated investigation if he were aware. He did not answer when asked if staff to include IDON should have notified him as the abuse coordinator when bleeding was observed for both incidents. He said that he was not aware that CNA J worked the day prior to the initial bleeding being assessed, and multiple shifts since CR#1 transferred to the hospital to include assessment on the 300 hall. He was made aware of concern that facility self-report evidence was requested at entrance, there had been no evidence provided, and he provided no answer as to why. In an effort to complete phone interview on 09/26/2024 at 6:05pm with NP AK; a message was left. In an interview on 09/26/2024 with CNA A and LVN T, they stated they were not asked to increased monitoring on the hall, and they round every two hours as normal. In an interview on 09/26/2024 at 7:00pm during the end of day meeting with the Administrator, Regional QA Nurse, IDON, and DON AN with a list of concerns provided. The concerns provided were self-reported investigation evidence was requested at entrance not received, multiple interviews with direct staff that had not been interviewed or provide witness statements, Social Worker only interview English speaking residents for safety surveyors, multiple staff to include IDON were aware of vaginal bleeding on 09/14/2024 and 09/24/2024, and had not reported to the Administrator, CNA J who worked 9/13/2024, and multiple dates between 9/14/2024 and 9/24/2024 scheduled to work all though he had not been interview or asked to provide statement, no efforts to exclude male residents, visitors, or staff as perpetrators, no efforts to request electronic monitor of Resident#5 RP P, skin assessment were not initiated until after SSA entrance on 09/26/2024, with the skin assessments completed to include female residents on 300 hall, and staff denial that they were asked to increase monitoring. DON AN asked whose license would be referred if there was an IJ called. In an interview on 09/26/2024 at 7:23pm DON AN stated she started orientation on 09/23/2024, did not finish the onboarding, and 09/26/2024 was her official first day. She said she had worked in skilled nursing facilities for [AGE] years, and she had training on abuse and neglect. She said that unexplained vaginal bleeding with no history of bleeding would be a concern, should be reported immediately, and should be investigated by the facility to rule out abuse. She said that the risk of not reporting or investigating was the abuse could continue, and without a thorough investigation residents are left unprotected an involve more residents. She said that she was not made aware of the ongoing investigation when she arrived to the facility on [DATE]. She said that that nursing staff and IDON should have notified the Administrator who is the abuse coordinator immediately after CR#1 was observed with vaginal bleeding on 09/14/2024 and 09/25/2024. She said that had not taken the necessary steps to rule out immediacy. In an effort to complete phone interview on 09/27/2024 at 8:40am with NP AK; a message was left. In an interview on 09/27/2024 at 8:40am with CNA E, she said that she worked on 09/24/2024 on the 300 hall, and she worked 10pm-6am. She said that she did an initial change of brief after the shift start, could not recall time and CR#1 was not bleeding. She said toward the end of shift right before shift change, she entered the room, CR#1 was sitting on the bed with clothing and brief on, and CR#1 pointed to brief toward the vagina. She said that blood was on pajama bottoms towards the back, that was bright red. She said that she immediately got the RN B, she came into the room, saw the blood, and she left and went to the nurse station. She said that the when the RN B returned, she said that an ambulance was called, and she wanted her to help clean her up. She said that the brief was soaked with blood, but there was no blood anywhere else. She said that the RN B assessed CR#1 head to toe with no bruising or injuries, and she said that the blood was vaginal. She said that she threw out the brief, and clothing was placed in the linen for wash. She said that completed round every two hours, she did not see anyone male staff, residents, or visitors to go in the room. She said that she did not see CR#1 leave room during her shift. She said that CR#1 did not have history of bleeding and was her first time seeing the resident with vaginal bleeding. She said did not think it was abuse because the resident did not say anything happened, she did not seem like she was in pain, or had injuries. She said that she did not see CR#1 on the floor, and she did not tell anyone she was on the floor when she found her. She said that she had not been interviewed or asked to write a witness statement. She said that she had not been asked to increase rounds. In an effort to complete a telephone interview on 09/27/2024 at 8:45am with the RP BH; a message was left. In a phone interview on 09/27/2024 at 9:22am with Physician AL, he said that he is the primary physician for CR#1, nursing staffed notified NP AK that CR#1 was assessed with vaginal bleeding on both 9/14/2024 and 9/25/2024, and staff were to monitor but CR#1 transferred after the second incident. He said that the [NAME] QA nurse contacted him on 09/25/2024 to inform that semen was found in the urine of the CR#1. He said that CR#1 did not have history of vaginal bleeding. He said that based on information provided sexual abuse would be highly unlikely as an initial concern without more information like trauma or injuries with the bleeding. He said that the facility should always follow their polices for abuse and neglect prevention and investigation. In a phone interview on 09/27/2024 at 9:51am with the Medical Director, she said that she was notified about CR#1, the alleged sexual abuse, and that semen was found in urine specimen while at the hospital. She said that she would not initially have concern for sexual abuse with only vaginal bleeding without any injures present for physical abuse. She said that if there were other concerns that physical or sexual abuse occurred, a resident would need to be sent for further work up and testing at the hospital. Record review of Long-Term Care Regulatory Provider Letter (PL) 2024-14 Replaces, PL 2019-17, Date Issued: August 29, 2024, Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) reflected in part, 2.1 Incidents that a NF Must Report to HHSC A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect, Exploitation, Death due to unusual circumstances, A missing resident, Misappropriation, Drug theft, and Suspicious injuries of unknown source, Fire, Emergency situations that pose a threat to resident health and safety, and Communicable disease situations that are an unusual or abnormal event that poses a threat to resident health and safety. 2.4 Reportable Incidents and Timeframe . Do Report: abuse (with or without serious bodily injury ), an incident that results in serious bodily injury and that involves any of the following: neglect, exploitation, mistreatment, injuries of unknown source, Misappropriation of resident property .When to Report Immediately, but not later than two hours after the incident occurs or is suspected Attachment 1: Definitions and Examples of ANE (Abuse and Neglect)and other Reportable Incidents . Abuse: HHSC rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resu [TRUNCATED]

Based on observation, interview, and record review, the facility failed to consult with the resident's physician; and notify the resident representative for 2 of 21 residents (CR#2 and CR#3) reviewed for change of condition, in that, 1. LVN G failed to notify CR#3's Primary Care Physician that the resident was observed having difficulty breathing on [DATE] when transporting resident via non-ermergency which resulted in delay of emergency medical care. 2. LVN G failed to notify CR#3's Responsible Party that the resident had difficulty breathing and signs of a seizure [DATE]. 3. LVN F failed to notify the Responsible Party that CR#2's hospital transfer on [DATE] required assessment for a concern of sexual abuse after being observed with vaginal bleeding. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:48pm. While the IJ was removed on [DATE] at 4:25 pm, the facility remained out of compliance scoped at isolated with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could expose residents to delay in treatment, worsening of condition, hospitalization , and death. Findings included: CR#3 Record review of CR#3's facesheet dated [DATE], reflected she was a [AGE] year-old female, who admitted to the facility on [DATE] with a primary diagnosis of mild unspecified dementia with secondary diagnosis of down syndrome(genetic condition effecting brain development), hypothyroidism(underactive thyroid), generalized anxiety disorder, and unspecified convulsions(uncontrolled shaking). CR#3 was transfer to a local hospital at the family's request on [DATE] due to convulsions in the hand. CR#3 presented to the hospital on [DATE] with a chief complaint of altered mental state and shortness of breath. CR#3 expired on [DATE] at a local hospital with discharge diagnosis of massive intracerebral hemorrhage(brain bleed), acute hypoxic respiratory failure (lungs are unable to deliver enough oxygen to the body's tissues), pneumonia (lung infection), hypothyroidism, and down syndrome. Record review of CR#3's undated comprehensive care plan reflected: Focus: CR#3 has history of Seizures and is at risk for Injury. Goal: Resident will be free from Seizure Activity until the next review Intervention: Call MD and family for s/s of antiseizure medication toxicity. Document/notify family and MD to notify of any seizures. Ensure direct care staff are aware of residents history of Seizure Activity. Give medications per order, monitor labs--report abnormals to M.D. If a seizure occurs, protect from injury-do not restrain, turn to side, loosen tight clothing, etc, take vital signs-inform M.D. and R.P. Labs per MD order. Make resident comfortable after seizure activity. Monitor for efficacy and adverse consequences, abdominal pain, anorexia nausea, dermatologic reactions, blood dyscrasias. Monitor for warning signs-prior to seizure activity. Record review of CR#3's quarterly MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS(Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making. Record review of progress note completed [DATE] at 1:00pm completed by LVN G read in part, Family member at bedside notified nurse that resident was having a seizure. Upon assessment resident noted to have jerking movements to bilateral hands. Resident noted with eyes open. Vital signs obtained and as follows BP ,d+[DATE] P 84 R 17 T 97.6 O2 96% room air. Resident currently taking Keppra per MD orders. Clarified with medication aide that resident had received dose for morning. Notified NP of findings. Family then requested that resident be transferred to emergency room for further evaluation. Notified MD. DON notified. Rp notified per alternate contact whom was still present at bedside .notified for need of transport and en route. Resident lying in bed alert and jerking movement subsided. Record review of progress note completed [DATE] at 2:50pm completed by LVN G read in part, Family member requested writer reassess resident's o2 sats. Upon assessment resident's o2 noted at 90% room air with no apparent distress noted. At this time, EMS arrived to transport resident and were notified of resident's desaturation and EMTs(Emergency Medical Technician) placed resident on oxygen prior to exiting facility. Resident exited the facility stable per stretcher via (by way of) . family to follow to hospital. Record review of CR#'3 SBAR dated [DATE] completed by LVN G reflected that CR#3 was assessed for signs, symptoms: Increased shaking that started on [DATE] and given hydroxyzine. O2 96 % on [DATE] at 1:32pm Method: Room Air. There was no mention of oxygen provide to the resident. Recommendation to monitor vitals signs and transfer to the hospital. Notification made with family at bed side at 1pm and NP at 1pm. SBAR reflected under the section for RP notification as the family member at the beside and not the RP as identified on the facesheet of CR#3. Record review of CR#3's contracted EMS run report dated [DATE] reflected LVN G contacted the transportation company at 1:18pm, transport arrived at the facility at 2:23pm, transported departed the facility at 2:43pm, and transport arrived to the hospital at 3:12pm. The note read in part .EMS made patient contact, finding the patient at 2:33pm in emergent (yellow) condition. EMS decided the patient required transport for respiratory distress not available at origin. On scene pt was O2 stat 88 on NC (Nasal cannula) placed patient on a non rebreather pt O2 rose to 96. Record review of CR#3's hospital medical records dated [DATE] with admission time at 3:22pm reflected a chief complaint for altered mental state and stated complaint of shortness of breather. History of present illness notes read in part XXX[AGE] year old female with history of Down syndrome, prior CVA( cerebrovascular accident/stroke) presenting for altered mental status and hypoxia. Patient was found slumped over and minimally responsive earlier today, was noted to be hypoxic to 60% on room air per EMS, was started on non-rebreather with improvement to 85 .CT (computed tomography ) imaging was significant for large intracranial bleed with midline shift .Patient family wishes to proceed with comfort measures and hospice care. No indications for ICU (intensive care unit) intervention at this time due to DNR (do-not-resuscitate) status. Date of expiration [DATE]. Cause of death large left intracranial hemorrhage, acute hypoxic respiratory failure, pneumonia, down syndrome, and hypothyroidism. In an interview on [DATE] at 9:30am with a Registered Nurse at a local hospital, she said that CR#3 admitted on [DATE] with a chief complaint of altered mental state and shortness of breath. She said that CR#3 was DNR, the family did not want further treatment, so she was not transferred to ICU, placed on hospice for comfort care [DATE], and she expired on [DATE] with cause of death listed as massive intracerebral hemorrhage, acute hypoxic respiratory failure, pneumonia, hypothyroidism, and down syndrome. She said that transportation was contracted, EMT report noted CR#3 with O2 sat at facility at 60 and placed on non rebreather mask that increased to O2 stat to 85%. She said that contracted transportation should not have been used and EMS should have been used via 911. In a phone interview on [DATE] at 12:20pm with RP, who said that a relative visited CR#3 the morning of [DATE] at 10:00am. She said that the relative contacted her at 11:00am on [DATE], and said that CR#3 did not look well, was having a seizure when she arrived, she felt like something happened to the resident, and the residents breathing was not good. She said that she could her that CR#3's breathing was not normal over phone, and the relative sent her a video of her breathing. She said that she was told by the relative that she asked for CR#3 to be sent to the hospital. She arrived to the facility around 1:00pm when found out CR#3 was still at the facility and not at hospital. She said that no one from the facility contacted her about the condition of CR#3 and she received the information from the relative at the beside. Observation of video on [DATE] at 1:48pm provided by the Relative which showed that CR#3 was struggling to breath with date and time of [DATE] at 11:38am. In an interview on [DATE] at 3:00pm with CNA A. She said that she worked the 200 Hall from 2:00pm-0:00pm on [DATE]. She worked the 200 Hall from 10:30am-2:00pm on [DATE], and the 300 hall from 2:00pm-10:00pm. She said that CR#3 was on the 200 hall. She said at the start of her shift on [DATE] she was immediately alerted by a relative at the beside that CR#3 that something was wrong with CR#3. She said that when she entered the room CR#3's she found her breathing was labored, she was flush, she alerted LVN G who came to check vitals (results unknown), LVN G left the room, and she thought it was to contact the doctor. She said that when LVN G returned to the room she told the relative that CR#3 had received medication (Name unknown), she would monitor, would check on CR#3 in 1 hour, and the relative was not happy. She said that 11:30am she returned to check on CR#3, and resident breathing was still labored. She said that she alerted LVN G and they returned to the room, the relative said she no longer wanted to wait, she wanted CR#3 to got the hospital. She said that she did not know if the relative at the beside was the RP, and she would have assumed that LVN G would have confirmed. She said that CR#3 left the facility with scheduled non-emergency transport after 2:00pm. She said that it's the families right to request 911 for a resident. She said that if resident is having trouble breathing that's a change in condition, and the RP and are to be notified. She said that a resident and RP have the right to asked to be transferred and be notified. She said that if the relative at the beside was not the RP she would have thought LVN G would have confirmed. In a phone interview on [DATE] at 3:38pm with LVN G, she said that she worked on [DATE] from 6:00am-6:00pm. She said at 9:00am she was alerted that someone at the beside of CR#3 thought the resident was having a seizure. She said that she assessed the resident to have increased hand tremors which was her baseline, she checked vitals that were in normal range, and she gave PRN (as needed) Hydroxyzine for anxiety. She said she returned to the room in 30 minutes to check on CR#3, the tremors had subsided, the family was not happy, she told the relative she could have CR#3 go to the hospital, the relative wanted to wait a little longer, did not request that CR#3 go to the hospital until 11:00am, and never requested transportation by 911. She said that she notified NP I that the family was requesting CR#3 be sent to the hospital for concerns of hand shaking, and she scheduled non emergency transportation. She said that she did could not remember exact time, it could have been around 1:00pm, and it took the transport 45minutes to1 hour to arrive. She said that CR#3's breathing was normal when she assessed the resident, and she never received information from anyone that CR#3 was having trouble breathing. She said a physician should notified with change in condition, CR#3 did not have change in condition until right before transportation arrived, and she did not need to notify because CR#3 had left the building. She said that there was no risk because CR#3 did not have any respiratory issues prior to the transport arriving. She said that if a resident is in respiratory distress that would be a change in condition, the physician should be notified, and non emergency transportation would not be appropriate. She said that a risk of delay in treatment for respiratory issues could be the condition could worsen, require longer hospitalization , or death. She said that the relative at the beside was the RP, she did not confirm, and another staff (name unknown ) told her that it was the RP. She did not answer when asked if that was a delay in treatment. She did not answer when asked should she have confirmed that family at beside was the RP and able to make decisions. She did not answer when asked if it was the RP/Resident had the right to be informed about a change in condition. She said that she resigned on today and ended the call. In an interview on [DATE] at 4:00pm with Unit Manager, she said that she worked on [DATE], and she arrived between 9:30am-10:00am. She said that LVN G asked her to help assess CR#3 between 12:45pm-1:00 pm because the family at the beside though she was a having seizure, and LVN G assessed the resident with hand shakes that was her baseline, the nurse had given PRN medication for the hand shakes, and CR#3 had received daily medication Keppra for seizures. She said that CR#3 was not seizing when they got to the room, was responsive, her breathing was normal, and she did not have tremors in the hands. She said that the family at the beside was not the RP. She said that the family at the beside came to the nurse station , said she felt something was wrong, and she asked that CR#3 go to the hospital. She said that she told LVN G to contact the RP and Physician. She said that LVN G setup scheduled non emergency transport because the resident was not in distress. She said that if CR#3 was assessed with respiratory issues that morning and notification to NP and transport was not scheduled until 1:00pm, that would be delay in treatment. She said that if resident is in respiratory distress would contact call 911 immediately and she would call the physician and RP after, and the risk of delay in treatment when there is respiratory issues could be death. She said that a RP have the right to be notified with a change of condition. She said that if a relative request transfer, the RP should still be contacted and you must go by what the RP said. She said that nurses use a facility cell phone to contact physicians and their NP's, and if nurse made notification by texted, the thread would be there and they do not delete. Record Review on [DATE] at 5:18pm of facility cell phone used by LVN G to notified NP I on [DATE] at 1:12pm red in part . CR#3 is having increased shaking . All medications were given. PRN hydralazine was given. Family requesting, she be sent to ER (emergency room ). Sending to local hospital per family's request. Phone interview on [DATE] at 6:02pm with NP I, she said that she was contacted by the facility after 1:00pm on [DATE] in regard to CR#3 as the family wanted to send her to hospital after she was observed with handshakes. She said that CR#3 hand tremors were her baseline. She called the nurse who sent the message (LVN G), the nurse said the resident did not have a seizure only the hand tremor, the medication given was effective, the facility had to honor the request of the family, and she said okay after she spoke to the IDON to confirm. She said that if any resident was observed to be in respiratory distress know matter what the oxygen saturation range was, notification to the physician or NP should be done immediately when it was first identified, and the resident should have been sent to the hospital with EMS by calling 911. She said that the believed the facility policy was to notify the physician, RP, and DON with any change of condition. She said that if the resident was seen at 10:30am with trouble breathing she should have been notified, she was not, if the resident did not leave the facility until after 2:00pm it was a delay in treatment, if CR#3 was in respiratory distress it could cause death. In an interview on [DATE] at 6:46pm with IDON, she said that notification should be made the MD, NP, RP, and DON immediately when there is a change of condition. She said that if notification was not immediate it could be delay in treatment depending on the issue. She said that staff should still notify the RP even if family was at the beside and it was their right to be notified. She said that if family request a hospital transfer staff should call RP to confirm they approve. She said that the physician should be notified of all clinical details immediately after a change of condition. She expressed concern that the family at the beside, RP, CNA and EMT observed CR#3 with difficulty breathing, there was video footage of CR#3 seen with difficulty breathing, and that nurses that entered the room denied knowing the resident had difficulty breathing. She said that if CR#3 had a change in condition at 10:30am and the physician was not notified, and transportation was not scheduled until 1pm it would be a delay in treatment with harm to the resident. She said that LVN G resigned. In an interview on [DATE] at 7:33pm with Administrator, he said that notification should be made the MD, NP, RP, and DON immediately when there is a change of condition. He said that the physician should be notified of all clinical details immediately after a change of condition. He said that staff should still notify the RP even if family was at the beside and it was their right to be notified. He said that if family request a hospital transfer staff should call RP to confirm they approve. He expressed concern that family at the beside, RP, CNA and EMT observed CR#3 with difficulty breathing, there was video footage of CR#3 seen with difficulty breathing, and the nurses that entered the room denied knowing the resident had difficulty breathing. He said that if CR#3 had a change in condition at 10:30am and the physician was not notified, and transportation was not scheduled until 1pm it would be a delay in treatment with harm to the resident. He said that the nurse resigned but he was unsure why. Record Review of facility policy titled Notification of Changes Dated [DATE] read in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistently with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. life-threatening conditions, .4. A transfer or discharge of the resident from the facility . Record Review of facility policy titled Resident Rights Dated February 2023 read in part, Resident Rights. The resident has the right o a dignified existence, self -determination, and communication with and access to persons and services inside and outside the facility. 1. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United State. d. The resident representative has the right to exercise the resident rights to the extent those rights are delegated to the resident representative. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:48pm The following Plan of Removal (POR) submitted by the facility was accepted on [DATE] 2:14pm. The plan of removal reflected the following PLAN OF REMOVAL Name of facility: Date: [DATE] F -580 Notification of Changes. Problem: -The facility failed to notify CR#3's Primary Care Physician that the resident was observed having difficulty breathing -The facility failed to notify CR#3's Responsible Party that the resident had difficulty breathing and signs of a seizure CR#3 no longer resides at the facility. Immediate action: 35. On [DATE] the facility nursing management staff immediately initiated assessments of current residents focusing on changes in conditions to include shortness of breath and signs of seizure activity. no issues noted. Completed [DATE] 36. On [DATE] the Admin/Don/Designee initiated an investigation of events statements from staff who had worked with the resident indicating observation of resident were collected. Completed [DATE]. 37. On [DATE] LVN G is no longer employed by the facility. 38. On [DATE] the facility initiated an audit of resident's changes in conditions/SBARs within the last 4 weeks to ensure appropriate assessments and notification to the MD/NP and responsible party took place. Any issues identified will be addressed immediately. Completed [DATE] 1. [DATE] The facility Notification of Changes Policy was reviewed by the facility Administrator, DON and Regional nurse. No changes made. Interventions 2. On [DATE] the facility DON/Designee immediately initiated a 1:1 in-service with the licensed nurses to review and overview the facility Notification of Changes Policy to include circumstances requiring notification of changes to the MD/NP. Completed [DATE]. 3. On [DATE] the [NAME] /designee initiated an in-service with the licensed nurses regarding timely notification to the MD/NP, this includes confirming who is RP when notifications are made at bedside. Completed [DATE] 4. On [DATE] the DON/Designee initiated an in-service with the licensed nurses on when situations that required 911 services vs when to schedule emergency transportation services. Completed [DATE]. 5. On [DATE] the DON/Designee initiated in-service with the facility licensed nurses on the interact tools: Resident Changes in condition, when to report to the MD/NP, this includes Immediate notification and Non-immediate notifications. Completed [DATE] 6. On [DATE] the DON/Designee initiated in-service with the facility licensed nurses on the Care Pathway Assessment tool: Shortness of Breath (SOB). This exhibit shows the licensed nurse steps to take with SOB symptoms, Assessment, Further nursing evaluation, consideration of order to obtain, Evaluation, etc. Completed [DATE] 7. The DON or administrator is notified of resident changes in condition, emergencies, and resident transfers to provide guidance and ensure proper assessment, interventions and transfers are done appropriately. Issues identified will be immediately addressed through further education, disciplinary action and or termination of employmentXXX[DATE] Ongoing Projected completion [DATE]. Any staff member not present or in service on [DATE]- [DATE] will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 8. On [DATE] The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion [DATE]. 9. An impromptu QAPI meeting was conducted with the facility's Medical Director on [DATE] to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on [DATE]. The Plan of Removal was confirmed for the IJ by monitoring from [DATE] through [DATE] as follows: In an interview on [DATE] at 10:20am with Physician Y, he is the primary physician for CR#3. He said that the MD/NP and RP should be notified with any change of condition. He said that NP I or he were notified about a respiratory issue on [DATE], and NP I was contacted about hand tremors. He viewed the video dated [DATE] at 11:12am, and he indicated that the resident in the video was CR#3. He viewed the text threat to show that the notification to NP I was made on [DATE] at 1:12pm by LVN G. He said that the breathing of CR#3 was unstable in the video and she was in clear respiratory distress. He said that anyone that went into the room should have been able to see that CR#3 was in respiratory distress, and it was even more concerning if nursing staff could not see what he saw on the video. He said that notification should have been made to MD/NP. He said that if CR#3 had a respiratory change that morning at 10:30am, the video was taken at 11:12 am, the notification should have been immediate and not at 1:12pm, and EMS should have been contact immediately. He said that if CR#3 arrived at the hospital at 3:12pm that was delay in treatment, and the risk was death. In an interview on [DATE] at 11:34am with Unit Manager, at 11:56am with ADON, 2:30pm with Wound Care Nurse, and 3:39pm with RN B who acknowledged that training was received on the topics of topics of change in condition, notifications, and resident rights. All said that a change in condition is a change outside of the resident's baseline, and a life-threatening change like respiratory distress should be reported immediately to MD or NP, RP, DON, and now administrator. All said it was never appropriate to schedule non-emergency transportation for a life-threatening change in condition, and EMS by means of 911 should be contacted immediately. All said that all none nurse nursing staff have been trained to use the stop and watch tool to report a change of condition to the nurse, the form is completed, signed by the nurse, with a copy is given to the nurse and DON. All said that a change in condition should be documented in PCC, with SBAR completed with all details, observation, assessments, notifications, transfer location, and method of transportation documented. All said the RP must be verified when at the beside, if family at beside is requesting transportation for a resident it must be confirmed by the RP, and transportation was scheduled by method provide by RP. All said that the RP/Resident have right to request transfer to hospital by which every means requested emergency or non emergency transport, and right to be notified of a change in condition. In an interview on [DATE] at 1:14pm with LVN T, she said that she received training on Changing in Condition. She said that a change in condition is a sudden onset, seizures, bleeding and any respiratory. She said that 911 is notified along with the physician, hospice, families, DON and Administrator. In an interview on [DATE] at 1:31pm with LVN U, she said that she received training on Changing in Condition. She said that change in condition that is an emergency would be cardiac issues, respiratory issue, unresponsive, shortness of breath, or seizures She said that 911 is notified along with the physician, hospice, RP, DON and Administrator. In an interview on [DATE] at 2:30pm with LVN V, she said that she received training on Changing in Condition. She said that change in condition that is an emergency would be shortness of breath. She said that 911 is notified along with the physician, RP, DON and Administrator. In an interview on [DATE] at 3:02pm with MDS Nurse, she said that she had been trained on the stop and watch tool used to notify nurses of a change in condition. She said that any change in condition should be reported to the floor nurse, DON and Administrator if necessary. She said stop and watch is being used as a tool for the staff to complete and give to the nurse to ensure they are aware of the change in condition. She said as a nurse, she would assess the resident, call physician, DON and Administrator about her findings. She said a change in condition would be updated as well in EMR(electronic medical record) and MDS. In an interview on [DATE] at 3:48pm with LVN W, she said that she received training on Changing in Condition. She said that change in condition that is an emergency would respiratory distress, shortness of breath, cardiac arrest, active or bleeding. She said that 911 is notified along with the physician, RP, DON and Administrator. In an interview on [DATE] at 12:05pm with the Regional QA Nurse, she said that all nursing staff have been trained on the topics as outlined in the POR. She viewed the of CR#3 dated [DATE] recorded at 11:12am. She said the person in the video was CR#3, and her breathing was in distress, she was gasping for air, and she was not aware of the video. She said that her breathing would start as shown in the video, subside, and return. She said that she was now concerned with statements provided by LVN G and the Unit Manager as to the condition of CR#3 when she transferred to the hospital. She said that if she had gone into the room and saw CR#3 breathing as shown in the video, she would have been transferred out by means of 911, MD and RP notified, and she now feels that was the reason LVN G resigned. She said that she thought that LVN did everything correctly she did not. She said that if LVN G had not resigned she would have been terminated. She said that she would need to speak with upper management about the Unit Manager to determine what disciplinary action would be taken, and she was not aware that she went to the room of CR#3. She said that the negative impact to CR#3 was death due to respiratory distress, those are things you can not play with, and CR#3 died . In an interview on [DATE] at 3:56pm with DON Z, she said that she started at the facility on [DATE], and she was being trained by the IDON and Regional QA Nurse on the facilities policy, procedures, and duties. She has worked in skilled nursing facilities since she became a nurse over eight years ago. She was made aware of IJ for Change in Condition for an alleged delay in treatment. She has received all the training identified in the POR. She said that a change in condition is a change outside of the resident's baseline, and a life-threatening change like respiratory distress should be reported immediately to MD or NP, RP, DON, and now administrator. She said it was never appropriate to schedule non-emergency transportation for a life-threatening change in condition, and EMS by means of 911 should be contacted immediately. She said that all none nurse nursing staff should have been trained to use the stop and watch tool to report a change of condition to the nurse, the form is completed, signed by the nurse, with a copy is given to the nurse and DON. She said that a change in condition should be documented in PCC, with SBAR completed with all details, observation, assessments, notifications, transfer location, and method of transportation documented. She said that RP must be verified when at the beside, if family at beside is requesting transportation for a resident it must be confirmed by the RP, and transportation was scheduled by method provide by RP. All said that the RP/Resident have right to request transfer to hospital by which every means requested emergency or non emergency transport, and right to be notified of a change in condition. She viewed the video dated [DATE] at 11:12am of CR#3. She said that although she was not familiar with the resident she could see that her breathing was labored and she was in respiratory distress. She said that if anyone went in the room around the time of the video until she would have left the facility weather it was a visitor or nursing staff, would be able to identify she was in distress. She said that if the time of the video was 11:12am, the physician was never contacted, the resident did not arrive at the hospital until 3:12pm by non-emergency transport, it was a delay in treatment. The risk to the resident would be death. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:48pm [TRUNCATED]

Based on observations, interview and record review, the facility failed to ensure that personnel provide basic life support including CPR, to a resident requiring such emergency care prior to the arrival of medical personnel and subject to related physician orders and the resident advance directive for 1 resident (CR #1) of 13 residents reviewed for quality of life. The facility failed to immediately initiate CPR at 3:41 p.m. on [DATE] when CR#1 was found unresponsive, causing a 3-minute delay. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:49p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective. This failure could place residents that are a full code at risk of not being provided CPR in a timely manner at risk for death. Findings include: Record review of CR#1's face sheet on [DATE] at 10:30 a.m., revealed she was an [AGE] year-old female that was originally admitted on [DATE]. She had diagnoses of Dementia-loss of cognitive functioning, Psychotic Disturbance-loss of contact with reality, Paroxysmal Atrial Fibrillation-a rapid erratic heart rate, Aphasia-a language disorder that affects a person ability to communicate, Contracture-abnormal thickening of the skin. Record review of CR#1's hospital record dated [DATE] revealed that CR#1 was examined in the emergency room and was found to have been in cardiac arrest, PEA, ACLS measures implemented, definitive airway established, patient with PEA and one episode of V-fib status post defibrillation, subsequently with ROSC though patient became bradycardic again and became pulseless, ACLS measures were implemented again, PEA rhythms again encountered. Given period of pulselessness, recurrent PEA, patient with poor prognosis, resuscitative efforts terminated, patient expired at 5:08 p.m. Record review of MDS dated [DATE] revealed, CR #1's BIMS score was not scored because cognitive skills were severely impaired. CR #1's functional status revealed she required supervision in the following areas: bed mobility, ambulation, eating, and extensive assistance with dressing, toilet use, and personal hygiene. Record review of CR #1's Care Plan dated [DATE] indicated CR # 1 was care planned for advance directive having a guardianship and full code. Further review revealed that CR #1 was care planned for impaired communication evidence by no speech, rarely/never understood. Record review of CR #1's Physician Orders dated [DATE] revealed CR #1 code status: FULL CODE. Observation of video surveillance from Cr #1's on [DATE] revealed the following on [DATE]: -3:41 p.m. CNA B had a wipe and wiped the side of her face and neck. CNA B left the room in a hurried walking pace, no rise or fall of chest noticeable; -3:42 p.m. LVN B returned, calls CR #1's name and pushed on the side of her head, there was no rise and fall of chest noticeable. LVN B left and said we got a code and told CNA B to stay right there. No one initiated CPR, -3:43 p.m. heard 911 from the hallway, and staff members LVN-C came and wiped resident face with her gown, did not initiate CPR, -3:43 p.m. crash cart and LVN B, ADON, LVN C, can B, and CNA D enter the room, -3:44p.m. staff was getting resident placed on floor, and -3:44 p.m. CPR was initiated. Interview with CNA B on [DATE] at 1:22pm revealed that she was preparing to provide care for CR#1 and she noticed that the resident was having difficulty breathing. She said she told LVN B two or three times that CR#1 was having difficulty breathing and LVN-B finally came into the room and saw CR#1 was having difficulty breathing and LVN B called a Code blue. Interview with LVN B 0n [DATE] at 11:37 a.m., revealed she said CNA B did not tell her several times that CR#1 was having difficulty breathing. LVN B said that CNA B came to her once and said that CR#1 seemed to have difficulty breathing and that is when she went to the room and saw that CR#1 chest was not rising and she immediately called Code blue and ran to get help and she told CNA B to stay with the resident. Interview with the DON on [DATE] at 12:54 p.m., revealed she prefers that in the event of a Code Blue that the Nurse goes and get the crash cart and whatever else may be needed, because the Nurse has access to know if a resident is a full code or DNR. Interview with LVN C on [DATE] at 2:15pm revealed that she entered CR#1's room and did not initiate CPR. Instead, she stood by CR#1's bed and wiped her mouth with a towel. LVN C was asked why she did not initiate CPR. Her answer was that the resident was on an air mattress, and she could not initiate CPR because she could not place CR#1 on the floor. Record review of https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600120/ on [DATE] For every minute without CPR, survival from witnessed VF cardiac arrest decreases by ,d+[DATE]%.1 When bystander CPR is provided, the decrease in survival is more gradual and averages ,d+[DATE]% per minute from collapse to defibrillation. Bystander CPR has been shown to double or triple the chances of survival from witnessed cardiac arrest at many different intervals to defibrillation. Record review of the NF Policy on Cardiopulmonary Resuscitation revealed in part: The facility will follow current American Heart Association guidelines regarding CPR. If a resident experiences a cardiac arrest , facility staff will provide basic life support , including CPR prior to the arrival of emergency medical services. The Administrator and the DON were informed the Immediate Jeopardy was removed on [DATE] at 2:43 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The Plan of Removal was accepted on [DATE] at 10:47am and indicated the following: Facility Plan to ensure compliance: Plan of Removal Date: [DATE] F- 678 Problem: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. -The facility failed to immediately initiate CPR at 3:41 p.m. when CR#1 was found unresponsive, causing a 3-minute delay CR#1 Was transferred out to the hospital via EMS on [DATE] @ 1616. LVN# B and C were suspended pending investigation on [DATE]. C.N.A.'s B and D were suspended pending investigation on [DATE]. Interventions: 1. On [DATE] The facility conducted a Mock code blue by the DON/Designee and re-reviewed the process to ensure staff have a sense of urgency and are knowledgeable of the appropriate steps to take in an emergency. The facility will conduct the mock code blue with all employees and all departments. This includes but is not limited to employees performing a Code response return demonstration, acknowledgment of training. The training also includes placing residents on a hard surface before CPR is initiated regardless of whether they are on an air mattress, Wheelchair or Geri-chair. During the mock code the response and understanding of the role is being evaluated along with the skill and acknowledgement that the response and the skill will be performed timely and appropriately during a code. The trainer utilizes a check list to ensure the course of events takes place appropriately and provides feedback. Any nurse not present or in serviced on [DATE] and [DATE], will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Completion projected [DATE]. 2. On [DATE] the DON/Designee immediately initiated an in-service with the facility staff on the importance of immediately initiating CPR, including but not limited to the consequences of delaying emergency care. Projected completion [DATE]. Monitoring notes Record review of 'In-service Training Report dated [DATE] revealed all facility staff were educated by the facilities DON/Designee. Staff were educated on the importance of initiating CPR as soon as possible and the consequences of what can happened when CPR is delayed. 3. On [DATE] The facility immediately initiated an in-service regarding the CPR process. When a resident is noted to have a life-threatening change in condition, such as gasping for air, without a pulse, or unresponsive, the employee will immediately shout for code blue. They will get the crash cart, AED and check the residents advance directive status. If the resident wishes to be a full code the staff will immediately initiate CPR. Projected completion [DATE]. 4. On [DATE] A study on recent advances and controversies in adult cardiopulmonary resuscitation, by Wanis H [NAME], was reviewed with facility managers, C.N.A's, Med Aides, and licensed nurses. The study will be reviewed via in-service with the staff to give them perspective about CPR and how important it is to perform it and why is it important to initiate promptly. Projected completion [DATE]. 5. On [DATE] the DON/Designee initiated an in-service with the facility nursing staff on Changes of condition/Code Status/CPR Process, focusing on the sequence of events of a code. [DATE]. 6. On [DATE] the DON/Designee did in-service with all staff on the location of the residents' code status binder and or where in the electronic medication record that is information is also located. [DATE] 7. On [DATE] The Social Worker/designee completed the audit to verify all code status were correct and in place for staff to identify. No issues noted. 8. On [DATE] the DON/Designee educated on practicing within the scope of their license/certification during a code. Staff were educated during a mock code with return demonstration and acknowledgement. Monitoring notes 9. On [DATE] The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with nursing staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion [DATE]. Record review of the facility's training questionnaire dated [DATE] revealed that all facility staff were able to answer the questions listed on the questionnaire in a satisfactory manner. 10. An impromptu QAPI meeting was conducted with the facility's Medical Director, on [DATE] to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on [DATE]. Monitoring Notes Interviews were conducted on [DATE] from 3:00 p.m. until 3:30 p.m. with staff on 2pm to 10pm shift LVN-F, LVN G, and CNA E to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. Interviews were conducted on [DATE] from 12:00 a.m. until 12:30 a.m. with staff on 10 pm to 6 am shift RN-M, LVN-O, LVN-P, CNA-Q, CNA-R, and CNA-S to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. Interviews were conducted on [DATE] from 1:00 p.m. until 1:30 p.m. with staff on 6am to 2pm shift CNA-F, House Keeper, Physical Therapy Assistant to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. Record review of in-service revealed Any nurse not present or in serviced on [DATE] and [DATE], will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Completion projected [DATE]. Record review of 'In-service Training Report dated [DATE] revealed that staff had been trained on their roles regarding mock code. Record review of check list sheet used during this mock code revealed that staff were able to answer questions in a satisfactory manner. Record review of 'In-service Training Report dated [DATE] revealed all facility staff were educated on the CPR process. Staff were educated on resident change in condition, call code blue, they were educated on the location of the crash cart, and were the residents advance directive book is located. Record review of 'In-service Training Report dated [DATE] revealed all facility managers, C.N.A's, Med Aides, and licensed nurses were educated on the components of CPR. Components discussed were emergency services, chest compressions, rescue breaths, and associated components discussed were Heimlich maneuver, and Automatic external defibrillators. Record review of 'In-service Training Report dated [DATE] revealed that the DON/Designee in serviced nursing staff on changes of condition/Code status/and CPR process. Record review of 'In-service Training Report dated [DATE] revealed that the facility's DON/Designee did in-service with all staff on the location of the residents' code status binder and or where in the electronic medication. Record review of facility's audit sheets dated [DATE] revealed that all code status were correct and in place for staff to identify. Record review of 'In-service Training Report dated [DATE] revealed that staff were educated during a mock code on what their roles are. Record review of the sign in sheet dated [DATE] for the QAPI meeting revealed that all department managers, the administrator, the director of nursing, and medical director attended the meeting. The IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolation. as the facility continued to monitor the implementation and effectiveness of their plan of removal.

Based on interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for pressure ulcers. -The facility failed to ensure CR#1, who was identified at high risk of developing a pressure ulcer, was not provided appropriate interventions and treatment to prevent excoriation on left sacrum that deteriorated to 12.5 x 7.5 cm necrotic infected wound with a second wound on the right medial buttock that measured 1.2 x 1.0 x 0.1 cm. These failures could place residents at risk for new development or worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: CR #1 Record review of CR #1's face sheet revealed a [AGE] year - old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS of 07 out of 15, indicating severe cognitive impairment. CR #1 required total care with one-person assistance with all ADLs. The resident was incontinent of bowel and bladder and was at risk for pressure ulcers. CR #1 did not have any pressure ulcers at admission. Record review of CR #1's Braden scale dated 05/22/21 revealed CR #1 was at risk because her score was 17. Record review of CR#1's skin assessment for 07/19/21 and 07/26/21, read in part . excoriation to the sacrum improving, barrier cream daily . Record review of CR #1's order summary active as of September 2021 read in part . apply barrier cream daily . order date 07/26/ . . clean left sacrum wound with NS (normal saline) pat dry apply Santyl then ¼ strength Dakin's moistened gauze to wound bed and cover with dry dressing daily and as needed . Record review of CR #1's skin assessment for 08/02/21 and 08/09/21 revealed resident had wound on left sacrum unstageable, and buttock with shearing 1.2 x 1.0 x 0.1 cm. Record review of CR #1's [NAME] wound physicians wound evaluation dated 08/02/21 revealed wound on buttock measured 1.2 x 1.0 x 0.1 cm. Record review of CR #1's [NAME] Wound Physicians wound evaluation dated 08/02/21 revealed left sacrum wound measured 12.5 X 7.5 cm. it had 86 % thick adherent back necrotic tissue(eschar), 10 % slough, and 5% granulation tissue. The wound was unstageable due to Necrosis. It also read clean surgical technique curette was used to surgically excise 89.06 cm of devitalized tissue and necrotic muscle and surrounding fascial fibers along with slough and biofilm were removed at a depth of 0.9 cm and healthy bleeding tissue was observed. Record review of CR #1's [NAME] Wound Physicians wound evaluation dated 08/09/21 revealed left sacrum wound stage 4 measured 10.5 X 9.5 x 0.5 cm. It also read clean surgical technique curette was used to surgically excise 85.05 cm of devitalized tissue and necrotic muscle and surrounding fascial fibers along with slough and biofilm were removed at a depth of 1.5 cm and healthy bleeding tissue was observed. Deep wound culture performed on stage 4 pressure wound of the left sacrum. Interview on 08/13/21 at 8:54 a.m. with the Wound Care Nurse she said CR #1 went to the hospital from [CONDITION(S)] and she did not change the dressing on her wound before she left for [CONDITION(S)]. Interview on 09/02/21 at 11:21 a.m., with Wound Care Nurse. She said the facility protocol was to do head-to-toe skin assessment once a week for all residents, even the resident at risk for pressure ulcer or resident had wound previously. She said they were doing barrier cream at first, and the protocol is for all residents after performing incontinent care. She said she thought that CR #1 had excoriation on the left sacrum, and it was a small area, and she did not measure the size because the facility does not measure excoriation. She said CR # 1 excoriation happened when the resident was sliding and shifting in bed and when she went to [CONDITION(S)] for long hours, about 4 to 5 hours three times a week. She said if the resident was not cleaned and changed on time, it would cause excoriation, CR #1 was not changed before she went to [CONDITION(S)]. She said they were applying barrier cream on the excoriation until the Wound Care Doctor saw CR #1 on 08/02/21. He debrided the wound and wrote a new order. The Wound Care Nurse said the excoriation did not open until 08/02/21. The Wound Care Nurse said she would have to look at the facility protocol for wound assessment and staging. The Wound Care Nurse said she told CR #1 she could not sit for long hours after CR #1 had developed the wound. She said she assessed the excoriated site on the left sacrum on 07/26/21, and it was still the same color or a little darker than the surrounding skin, it was improving, and size was still small. The Wound Care Nurse said she did not assess the site again until the wound doctor saw the resident on 08/02/21. She said the wound had a foul odor before 08/09/21. When asked what should have been done about the foul odor, she did not respond. She said the facility protocol was to turn and reposition the resident every two hours, and the resident had an air mattress. Interview on 08/02/21 at 1:31 p.m. with DON, she said the excoriated area on CR #1's sacrum was monitored during the weekly skin assessment, reposition, and Cr # 1 had an air mattress. She said the doctor was notified because the excoriation worsened on 08/02/21, and the Wound Care Doctor was told when he came to the facility on Monday (08/02/21). She said the Wound Care Nurse should have called the CR #1's doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said they didn't measure the excoriation, and the facility did not have any protocol for excoriation. She said she was aware CR#1's excoriation and could not tell how it went from excoriation to unstageable wound without being noticed. She said she did not observe the wound and didn't know if the area was blanchable or not. She said she became aware of the wound on the buttocks on 08/02/21 when the Wound Care Doctor saw CR #1. Interview on 09/02/21 at 2:15 p.m. with Wound Care Nurse, she said she had not assessed the resident wound area until the aide told her on Monday (08/02/21). She said CR #1's wound looked worse, and she called resident's doctor. CR #1's doctor said the wound doctor should see the resident. She said she talked to the resident's doctor previously about the excoriation, and he was ok with the barrier cream. She said she did not document when she spoke to the doctor about the barrier cream. She said she was the person that should be monitoring residents' wounds but did not monitor the site because CR #1 had a closed stage four in May in the same area. She said she reported to the DON about the excoriation and could not remember if she observed the site. She said she could not remember if she checked the affected area was blanchable or not. If she did, she said she would have documented it on the weekly skin assessment. The Wound Care Nurse said she found out about the wound on the buttocks on 08/2/21. She said she was not a certified wound care nurse but was trained during the floor orientation. Interview on 09/02/21 at 2:31 p.m. with CNA B, she said she was off Saturday and Sunday, and when she was changing the resident on Monday, the wound area's color had changed, and it looked very different and darker. She said CR #1 had another site on her buttock that was open. She said before 08/02/2, the area of the excoriation was big, and the color was darker than other areas around the excoriation but could not describe the color, and there was some tiny openened areas on it. CNA B called the Wound Care Nurse to see the area because it was very bad. Record review of the facility pressure ulcer dated 2001 MED - PASS, Inc. (Revised July 2017) read in part . the purpose procedure is to provide information regarding clinical identification of pressure ulcer/injuries and associated risk factors . unstageable pressure ulcer appears as full - thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound be is obscured by slough or eschar .

Based on observation, interview, and record review, the facility failed to ensure 9 (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #10) of 10 residents reviewed for weight loss maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible of resident preferences indicated otherwise. In addition, the facility failed to offer a therapeutic diet when there is a nutritional problem and the health care provider orders to 5 (Residents #2, #3, #4, #5, and #6) of 10 residents reviewed for therapeutic diets. -Resident #1 developed critical BUN levels and was sent to the hospital with suspected [MEDICAL CONDITION]. -The facility did not notify the physician of significant weight loss prior to surveyor intervention for Residents #1, #2, #3, #4, #5, #6, #7, #8, and #10. -The facility failed to provide physician ordered therapeutic diets and nutritional supplements in a timely manner or at all for Residents #1, #2, #3, #4, #5, #6, #7, #8, and #10. -Residents #1, #2, #3, #4, #5, #6, #7, #8, and #10 all exhibited severe weight loss. An Immediate Jeopardy (IJ) situation was identified on 01/15/2021. While the IJ was removed on 01/21/2021 at 12:30 p.m. the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy and a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of severe weight loss, delayed interventions, hospitalization , and worsening health condition. Findings Include: 1 Record review of the Admission Record for Resident #1, dated 01/15/2021, revealed he was [AGE] years old, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].#1 did have a [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed Resident #1 scored 13 out of 15 on the BIMS, indicative of intact cognition. Resident #1 did not exhibit behavioral issues. Resident #1 required extensive assist of one person for eating. Resident #1 weighed 143 pounds at the time of the assessment. Resident #1 received a therapeutic diet and received 25% or less of the total calories via enteral nutrition. The MDS reflected Resident #1 was receiving a therapeutic diet and was not on a physician prescribed weight loss program. Record review of the Care Plan dated 08/31/2020 revealed the resident required total assistance of one staff for eating (initiated 08/31/2020). Resident #1 was at risk for nutritional problems. Record review revealed staff was to monitor, record, and report signs and symptoms of malnutrition to the physician. The criteria for significant weight loss were greater than 5% in one month, greater than 7.5% in three months, and 10% in six months. The Registered Dietician was to evaluate and make diet changes as needed (initiated 08/31/2020). Record review on 01/14/2021 at noon of the electronic weight record for Resident #1 revealed the following weights: 08/13/2020 143.2 pounds 09/02/2020 142.8 pounds 10/07/2020 141.2 pounds 11/07/2020 132.8 pounds 12/07/2020 129.6 pounds 01/07/2020 116.4 pounds Calculations of the weights revealed weight losses of 10.2% in one month, 17.6% in three months, and 18.7% in six months. Record review of a Nutrition/Dietary Note for Resident #1, dated 12/29/20, revealed Resident #1 exhibited a 9.0% weight loss in three months (12.9#). The Dietician recommended whole milk and pudding three times daily, with meals. The Dietician recommended starting liquid protein 30 cc three times daily, Med Plus 2.0 supplement, 120 cc four times daily. Record review of the NP Progress Note dated 01/08/2021 for Resident #1, revealed the NP referenced the 12/07/2020 weight of 129 pounds, not the most recent weight of 116.4 pounds from 01/07/2021. Under the Diagnosis, Assessment, and Plan section, the NP wrote the resident was to continue with PEG feeding. However, there were no orders for PEG feeding at that time. Record review of the Order Summary Report printed on 01/14/2021 at 12:36 p.m. revealed Resident #1 was not receiving nutrition via the PEG tube on 01/08/2021. The resident's diet order was for a fortified diet with whole milk three times daily. He was to receive Med Plus 2.0 supplement, 120 cc four times daily for COVID-19. The order was initiated on 01/06/2021, eight days after it was recommended by the Dietician. The resident was to receive liquid protein three times daily for thirty days for COVID-19. The order was not implimented until 01/06/2021, eight days after it was recommended by the Dietician. Interview on 01/14/2021 at 3:08 p.m. with the DON revealed she said the Dietician reviewed a majority of the residents monthly, via the electronic clinical record. She said she was responsible to forward the Dietician's recommendations to the physician. If the physician agreed, the DON was to write the order, then notify the family. She said the facility had some residents with significant weight loss. She said the facility kept a weekly weight book. She said if there was a significant weight loss, the policy was to notify the physician, dietician, and family. Interventions were then initiated. She said normally an increase in Med Plus 2.0 was the initial intervention. She said the acceptable time frame for interventions was three days or less. She said she spoke with Physician B,and was told to re-weigh some residents. She said the NP ordered IV fluids for Resident #1 on 01/13/2021. Interview on 01/14/2021 at 3:43 p.m. with Corporate Nurse C revealed she said the facility initiated interventions when the weight loss was identified for Resident #1. She said the weight loss was initially identified on 11/12/2020. She said the physician was contacted at that time. She said usually a resident with significant weight loss would be placed on weekly weights. If the weight loss continued, there would need to be additional interventions. She said Resident #1 was ordered Med Plus 2.0 on 01/06/2021. Record review of the Care Plan updated for Nutrition on 11/19/2020 revealed no interventions were initiated. Observation on 01/14/2021 at 4:57 p.m. revealed Corporate Nurse C called Dietician E. Corporate Nurse C said the Dietician just sent new recommendations. Record review of the Communication Between the Dietitian and the Attending Physician form, dated 01/14/2021, revealed Dietician E recommended starting Resident #1 on [MEDICATION NAME] 1.5 at 45 cc/hr for 12 hours per day. The enteral feeding was to start at 7:00 p.m. and stop at 7:00 a.m. Dietician E recommended flushing the PEG tube with 150 cc of water every six hours. The Dietician recommended discontinuing the Med Plus 2.0. When he awakened briefly, he did not respond to a verbal greeting. Observation and interview on 01/14/2021 at 5:40 p.m. revealed Resident #1 was lying in bed. The head of the bed was elevated to approximately 30 degrees. The resident appeared to be asleep. He exhibited severe contractures of all extremities. There was an IV of NS infusing. There was approximately 0.5 liters of the 1.0 liter bag remaining. There was a bag of [MEDICATION NAME] 1.5 connected to the resident's PEG tube via tubing. The pump warning alarm was sounding. The label on the bag was marked as being started on 01/14/2021, but no time was scribed. 925 cc of the 1000 cc remained. RN F entered the room and re-set the pump, but there was no flow observed. The DON entered the room and said she was going to re-weigh the resident. The resident did not respond to her verbal greeting. She said she would ask the nurse to administer pain medication, since the resident could experience pain during the weighing. RN F provided one crushed tablet of [MEDICATION NAME] via the Resident's feeding tube. Continued observation at 6:07 p.m. revealed the DON again attempted to weigh the Resident #1. He complained of pain. At 6:25 p.m., LVN G entered the room and said she would be the evening shift nurse. LVN G administered one crushed tablet of [MEDICATION NAME] via the feeding tube at 7:05 p.m. Continued observation revealed Resident #1 was successfully weighed at 7:36 p.m., using a mechanical lift. His weight was 113.4 pounds. The weight was verified by the DON. Record review and calculation at that time revealed Resident #1 had lost 3 pounds between 01/07/2021 (116.4 pounds) and 01/14/2021 (113.4 pounds). Interview on 01/15/2021 at 9:00 a.m. with the DON revealed she said when Resident #1 went to the COVID-19 unit the weight loss was identified. When asked why the weight loss was not addressed, she verbalized the interventions prior to 01/07/21. There were no interventions after 01/07/2021. Record review of the Order Sunmary Report for Resident #1, dated 01/14/2021, revealed the resident was receiving a FMP diet, and no nutrition via the PEG tube. Record review of the Order Recap for Resident #1, dated 01/15/2021, revealed he was to continue to receive Med Plus 2.0 supplement, 120 cc four times daily for COVID-19. The resident was to continue to receive liquid protein three times daily for thirty days for COVID-19. There was no order for any PO diet. There was an order for [REDACTED]. The enteral nutrition was to be given via the PEG tube from 7:00 p.m. to 7:00 a.m. Record review of the January 2021 meal intake report for Resident #1 revealed no entries for 2 meals on 01/06/2021, all 3 meals on 01/07/2021, 1 meal on 01/08/2021, all 3 meals on 01/09/2021, 1 meal on 01/10/2021, 1 meal on 01/11/2021, all three meals on 01/12/2021, and 2 meals on 01/13/2021. Record review of the January 2021 meal intake documentation (Documentation Survey Report v2) dated 01/15/2021 for Resident #1 revealed the following meal percentages: 01/01/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 76%-100% 01/02/2021 8:00 a.m. 76%-100% 12:00 p.m. 51%-75% 6:00 p.m. 51%-75% 01/03/2021 8:00 a.m. 76%-100% 12:00 p.m. 51%-75% 6:00 p.m. 51%-75% 01/04/2021 8:00 a.m. 75%-100% 12:00 p.m. 51%-75% 6:00 p.m. 75%-100% 01/05/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 51%-75% 01/06/2021 8:00 a.m. 26%-50% 12:00 p.m. blank 6:00 p.m. blank 07/07/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 07/08/2021 8:00 a.m 76%-100% 12:00 p.m. refused 6:00 p.m. blank 07/09/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 07/10/2021 8:00 a.m. 0%-25% 12:00 p.m. refused 6:00 p.m. blank 07/11/2021 8:00 a.m. 76%-100% 12:00 p.m. blank 6:00 p.m. 51%-75% 07/12/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 07/13/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. -95 (unknown) 07/14/2021 8:00 a.m. 0%-25% 12:00 p.m. 0%-25% 6:00 p.m. blank Record review of the January 2021 Progress Notes for Resident #1 from 01/01/2021 to 01/14/2021 did not reveal the physician was notified of the missed meals prior to surveyor inquiry on 01/14/2021. Record review and interview on 01/15/2021 at 1:10 p.m. revealed the DON said enteral nutrition was re-started for Resident #1 on 01/14/2021. She was asked if there were any new interventions for the resident implemented after 01/07/2021. The DON spoke about the Med Plus 2.0, liquid protein and weekly weights initiated in November 2020, but no interventions after 01/07/2021. Record review of the electronic clinical record for Resident #1 revealed no weekly weights in November or December of 2020. The DON said the weekly weights were not kept in the electronic record, and that they were kept in a notebook. The DON said Resident #1 was being sent to the hospital for suspected acute [MEDICAL CONDITION]. Record review of the lab report (drawn on 01/14/2021) revealed Resident #1 had a BUN level of 125 mg/dl, with the reference (normal) range of 8.4 - 25.7 mg/dl. The level was reported as critical high. Record review of the weekly weight notebook on 01/15/2021 at 2:10 p.m. revealed no weekly weights for Resident #1. The resident's name was not in the weekly weight notebook at all. Interview on 01/15/2021 at 2:15 p.m. with RA A revealed she said the weekly weights were not completed. Record review of the Nutritional Assessments for Resident #1 revealed an initial assessment dated [DATE]. There were no quarterly assessments. There was no Nutritional Assessment for Resident #1 following the identified weight loss in November 2020 2. Record review of the Admission Record for Resident #2, dated 01/15/2021, revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed Resident #2 scored 3 out of 12 on the BIMS, indicative of severe cognitive impairment. He required extensive assist from one person for eating. He weighed 86 pounds at the time of the assessment. Resident #1 was receiving a therapeutic diet. Resident #2 was not on a physician prescribed weight loss program. Record review of the Care Plan dated 11/04/2020 revealed Resident #2 was at risk for weight loss and malnutrition. The staff was to notify the physician if the resident lost 3 pounds in one week, greater than 5% in one month, greater than 7.5% in three months, or greater than 10% in six months (initiated on 11/04/2020). Record review of the Order Recap Report dated 01/15/2021 revealed Resident #2 was to receive a FMP diet. A Med Plus 2.0 supplement 120 cc twice daily order was discontinued on 12/07/20. Record review on 01/14/2021 at noon of the electronic weight record for Resident #2 revealed the following weights 10/28/2020 86.4 pounds 11/ 0 82.6 pounds 12/07/2020 81.6 pounds 01/09/2021 75.6 pounds Calculations of the weights revealed weight losses of 7.4% in one month and 12.5% in three months. Record review of the January 2021 meal intake documentation (Documentation Survey Report v2) dated 01/15/2021 for Resident #2 revealed the following meal percentages: 01/01/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. 26%-50% 01/02/2021 8:00 a.m. 26%-50% 12:00 p.m. 0%-25% 6:00 p.m. 0%-25% 01/03/2021 8:00 a.m. 0%-25% 12:00 p.m. 0%-25% 6:00 p.m. 25%-50% 01/04/2021 8:00 a.m. 51%-75% 12:00 p.m. refused 6:00 p.m. 0%-25% 01/05/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. 26%-50% 01/06/2021 8:00 a.m. 51%-75% 12:00 p.m. 76-100% 6:00 p.m. 0%-25% 07/07/2021 8:00 a.m. 51%-75% 12:00 p.m. 76%-100% 6:00 p.m. 26%-50% 07/08/2021 8:00 a.m 26%-50% 12:00 p.m. 51%-75% 6:00 p.m. 26%-50% 07/09/2021 8:00 a.m. 26%-50% 12:00 p.m. 51%-75% 6:00 p.m. 51%-75% 07/10/2021 8:00 a.m. 26%-50% 12:00 p.m. 76%-100% 6:00 p.m. 0%-25% 07/11/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 0%-25% 07/12/2021 8:00 a.m. 51%-75% 12:00 p.m. 26%-50% 6:00 p.m. 0%-25% 07/13/2021 8:00 a.m. 76%-100% 12:00 p.m. 26%-50% 6:00 p.m. 26%-50% 07/14/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 26%-50% Record review revealed Resident #2 had a Nutritional Assessment on 10/27/2020. Review of the Progress Notes from 11/01/2020 to 01/14/2021 for Resident #2, did not reveal any additional nutritional assessments. 3. Record review of the Admission Record for Resident #3, dated 01/15/2021, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed Resident #3 scored a 15 of 15 on the BIMS, indicative of intact cognition. Resident #3 required supervision for eating and weighed 141 pounds at the time of the assessment. Resident #3 was receiving a therapeutic diet. Resident #3 was not on a physician prescribed weight loss program. Record review of the Care Plan dated 01/01/2019 revealed Resident #3 had a regular, no added salt diet. The staff was to monitor meal intake. Resident #3 was care planned for unplanned weight loss on 01/14/2021. The staff was to serve the diet as ordered (initiated 01/14/2021 after surveyor inquiry). Record review on 01/14/2021 at 12:55 p.m. of the electronic weight record for Resident #3 revealed the following weights: 07/06/2020 153.2 pounds 08/04/2020 148.8 pounds 09/02/2020 146.6 pounds 10/07/2020 136.7 pounds 11/07/2020 139.6 pounds 12/07/2020 140.6 pounds 01/09/2021 128.0 pounds Calculations of the weights revealed a weight loss of 8.9% in one month. Record review of a Nutrition/Dietary Note dated 12/22/2020 revealed Resident #3 was readmitted from the hospital with orders for Fortified NAS diet, health shakes three times daily, and ice cream with dinner. There was no documented weight for the resident upon re-admission, and review of the Progress Notes from 12/01/20 to 12/22/20 revealed no documentation of the resident going to the hospital. Record review of the Order Recap Report dated 01/15/2021 at 3:36 p.m. revealed Resident #3 was to have a no added salt diet, of regular consistency. There were no orders for the health shakes or ice cream. Resident #3 had been receiving [MEDICATION NAME], an antidepressant that has a side effect of increased appetite, but it had been discontinued on 12/17/2020. Record review of the January 2021 meal intake documentation (Documentation Survey Report v2) dated 01/15/2021 for Resident #3 revealed the following meal percentages: 01/01/2021 8:00 a.m. 0%-25% 12:00 p.m. 26%-50% 6:00 p.m. 26%-50% 01/02/2021 8:00 a.m. refused 12:00 p.m. 76%-100% 6:00 p.m. 0%-25% 01/03/2021 8:00 a.m. 51%-75% 12:00 p.m. refused 6:00 p.m. refused 01/04/2021 8:00 a.m. 26%-50% 12:00 p.m. refused 6:00 p.m. 0%-25% 01/05/2021 8:00 a.m. refused 12:00 p.m. refused 6:00 p.m. 76%-100% 01/06/2021 8:00 a.m. refused 12:00 p.m. 26%-50% 6:00 p.m. 51%-75% 07/07/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. 0%-25% 07/08/2021 8:00 a.m refused 12:00 p.m. 26%-50% 6:00 p.m. 26%-50% 07/09/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. 26%-50% 07/10/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. 76%-100% 07/11/2021 8:00 a.m. refused 12:00 p.m. 51%-75% 6:00 p.m. blank 07/12/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. blank 07/13/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. 51%-75% 07/14/2021 8:00 a.m. 26%-50% 12:00 p.m. 76%-100% 6:00 p.m. 26%-50% 4. Record review of the Admission Record for Resident #4, dated 01/15/2021, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed Resident #4 scored 13 of 15 on the BIMS, indicative of intact cognition. The resident required extensive assist from one person for eating. She weighed 146 pounds at the time of the assessment. Resident #4 was not on a therapeutic diet or physician prescribed weight loss program. Record review of the Care Plan dated 11/30/2020 revealed Resident #4 was care planned for unplanned weight loss on 01/14/2021. The interventions included serving the diet as ordered (initiated 01/14/2021). Review revealed the resident was not care planned for desired weight loss. Resident #4 had no swallowing disorder or special diet. Record review on 01/14/2021 at 12:55 p.m. of the electronic weight record for Resident #4 revealed the following weights: 11/16/2020 145.6 pounds 12/09/2020 135.6 pounds 01/09/1010 121.6 pounds Calculations of the weights revealed weight losses of 10.7% in one month and 16.8% in three months. Interview on 01/15/2021 at 2:28 p.m. with the DON revealed she said she spoke with Resident #4 and she was ok with the weight loss. When asked why she was still receiving Med Plus 2.0 as a supplement, the DON answered, She's happy with her weight loss, but they don't want her to lose too much. When asked if the resident wanted to lose weight, should it be care planned, the DON answered, Yes. Record review of the Order Recap Report printed on 01/15/2021 at 3:36 p.m. revealed Resident #4 was receiving a regular diet. She was receiving Med Plus 2.0 as a supplement after meals twice daily (initiated 12/01/2020). The FMP diet was not on the orders. The Med Plus 2.0 was not increased as recommended by the Dietician. The whole milk to be given three times daily was not added. Record review of the January 2021 meal intake documentation (Documentation Survey Report v2) dated 01/15/2021 for Resident #4 revealed the following meal percentages: 01/01/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 51%-75% 01/02/2021 8:00 a.m. 76%-100% 12:00 p.m. 76%-100% 6:00 p.m. 76%-100% 01/03/2021 8:00 a.m. 76%-100% 12:00 p.m. 51%-75% 6:00 p.m. 76%-100% 01/04/2021 8:00 a.m. 76%-100% 12:00 p.m. 76%-100% 6:00 p.m. 76%-100% 01/05/2021 8:00 a.m. 76%-100% 12:00 p.m. 76%-100% 6:00 p.m. 76%-100% 01/06/2021 8:00 a.m. 76%-100% 12:00 p.m. 76%-100% 6:00 p.m. 51%-75% 07/07/2021 8:00 a.m. 76%-100% 12:00 p.m. 76%-100% 6:00 p.m. 76%-100% 07/08/2021 8:00 a.m 76%-100% 12:00 p.m. 76%-100% 6:00 p.m. 76%-100% 07/09/2021 8:00 a.m. 76%-100% 12:00 p.m. 76%-100% 6:00 p.m. 76%-100% 07/10/2021 8:00 a.m. 76%-100% 12:00 p.m. 51%-75% 6:00 p.m. 76%-100% 07/11/2021 8:00 a.m. 76%-100% 12:00 p.m. 76%-100% 6:00 p.m. blank 07/12/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 76%-100% 07/13/2021 8:00 a.m. 51%-75% 12:00 p.m. 76%-100% 6:00 p.m. 76%-100% 07/14/2021 8:00 a.m. 51%-75% 12:00 p.m. res not there 6:00 p.m. 76%-100% 5. Record review of the Admission Record for Resident #5, dated 01/15/2021, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed Resident #5 scored 3 out of 15 on the BIMS, indicative of severely impaired cognition. Resident #5 required supervision with setup only for eating. Resident #5 weighed 189 pounds at the time of the assessment. Resident #5 was not on a therapeutic diet or physician prescribed weight loss program. Record review of the Care Plan dated 11/30/2020 revealed Resident #5 had potential for nutritional problems. Staff was to monitor, record, and report significant weight loss of 3 pounds in one week, greater than 5% in one month, greater than 7.5% in three months, or greater than 10% in six months (initiated 11/30/2020). Resident #5 was at risk for unplanned weight loss. Interventions included the facility was to serve diet as ordered and offer the resident foods rich in calories (initiated 01/14/2021 after surveyor inquiry). Record review on 01/14/2021 at 1:00 p.m. of the electronic weight record for Resident #5 revealed the following weights: 11/16/2020 184.0 pounds 12/07/2020 188.7 pounds 01/08/2020 171.0 pounds Calculations revealed a 9.3% weight loss in one month. Record review of a Nutrition/Dietary Note dated 01/15/2021 at 1:39 p.m. revealed the Dietician I recommended FMP diet and whole milk three times daily with meals. Record review of the Order Recap Report dated 01/15/2021 at 3:37 p.m. revealed Resident #5 was to receive a NAS diet. Resident #5 was to receive Med Plus 2.0 supplement, 90cc, two times daily for 30 days. The order date was 01/14/2021. Record review of the January 2021 meal intake documentation (Documentation Survey Report v2) dated 01/15/2021 for Resident #5 revealed the following meal percentages: 01/01/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. 51%-75% 01/02/2021 8:00 a.m. 51%-75% 12:00 p.m. 76%-100% 6:00 p.m. 51%-75% 01/03/2021 8:00 a.m. 76%-100% 12:00 p.m. 51%-75% 6:00 p.m. 76%-100% 01/04/2021 8:00 a.m. 76%-100% 12:00 p.m. 51%-75% 6:00 p.m. 76%-100% 01/05/2021 8:00 a.m. 76%-100% 12:00 p.m. 51%-75% 6:00 p.m. 26%-50% 01/06/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 07/07/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. 26%-50% 07/08/2021 8:00 a.m 0%-25% 12:00 p.m. 0%-25% 6:00 p.m. blank 07/09/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 07/10/2021 8:00 a.m. 76%-100% 12:00 p.m. 51%-75% 6:00 p.m. blank 07/11/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. 51%-75% 07/12/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 07/13/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. 26%-50% 07/14/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. 26%-50% 6. Record review of the Admission Record for Resident #6, dated 01/15/2021, revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed Resident #6 scored 3 out of 15 on the BIMS, indicative of severely impaired cognition. The resident required supervision with setup for meals. The resident weighed 137 pounds at the time of the assessment. Resident #6 was not on a physician prescribed weight loss program. He was receiving a mechanically altered diet. Record review of the Care Plan dated 02/25/2019 revealed Resident #6 had potential for nutritional problems. Staff was to monitor, record, and report significant weight loss of 3 pounds in one week, greater than 5% in one month, greater than 7.5% in three months, or greater than 10% in six months (initiated 02/25/2019). Resident #6 was at risk for unplanned weight loss. Interventions included the facility was to serve diet as ordered (revised 01/14/2021 after surveyor inquiry). Record review on 01/14/2021 at 1:01 p.m. of the electronic weight record for Resident #6 revealed the following weights: 06/12/2020 141.2 pounds 07/06/2020 142.2 pounds 08/11/2020 149.6 pounds 09/02/2020 148.2 pounds 10/07/2020 144.4 pounds 11/07/2020 137.8 pounds 12/07/2020 143.6 pounds 01/08/2021 134.8 pounds Calculation of the weights revealed a weight loss of 6.1% in one month. Record review of a Nutrition/Dietary Note dated 01/15/2021 at 1:50 p.m. for Resident #6 revealed Dietician I recommended FMP diet with large portions, health shakes with all meals, and ice cream with the evening meal. Record review of the Order Recap Report dated 01/15/2021 at 3:37 p.m. revealed Resident #6 was receiving Med Plus 2.0, 120 cc, three times daily from 11/13/2020 to 12/13/2020. A new order dated 01/14/2021 reflected the resident was to receive Med Plus 2.0 twice daily for 30 days due to weight loss. No diet order type was on the Order Recap Report. Record review of the January 2021 meal intake documentation (Documentation Survey Report v2) dated 01/15/2021 for Resident #6 revealed the following meal percentages: 01/01/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 01/02/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. 26%-50% 01/03/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50% 6:00 p.m. 26%-50% 01/04/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 01/05/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. 51%-75% 01/06/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 07/07/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. 25%-50% 07/08/2021 8:00 a.m blank 12:00 p.m. blank 6:00 p.m. blank 07/09/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 51%-75% 07/10/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. blank 07/11/2021 8:00 a.m. blank 12:00 p.m. blank 6:00 p.m. 51%-75% 07/12/2021 8:00 a.m. 26%-50% 12:00 p.m. 26%-50 6:00 p.m. refused 07/13/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 75%-100% 07/14/2021 8:00 a.m. 51%-75% 12:00 p.m. 51%-75% 6:00 p.m. 51%-75% 7. Record review of the Admission Record for Resident #7, dated 01/15/2021, revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS assessment dated [DATE] revealed Resident #7 scored 7 out of 15 on the BIMS, indicative of severely impaired cognition. Resident #7 required extensive assist from one person for eating. Resident #7 weighed 156 pounds at the time of the assessment. Resident #7 was not on a physician prescribed weight loss regimen. Record review of the Care Plan dated 01/14/2021 revealed Resident #7 was receiving a regular diet. The Care Plan reflected Resident #7 had unplanned weight loss. Staff was to serve diet as ordered and offer substitutions if the resident ate less than 75% (initiated on 01/14/2021 after surveyor inquiry). Record review on 01/14/2021 at 1:03 p.m. of the electronic weight record for Resident #7 revealed the following weights: 06/12/2020 147.6 pounds 07/06/2020 149.4 pounds 08/04/2020 149.8 pounds 09/02/2020 152.2 pounds 10/07/2020 153.0 pounds 11/07/2020 156.6 pounds 12/07/2020 155.8 pounds 01/09/2021 145.0 pounds Calculations revealed a 6.9% weight loss in one month. Record review of the Nutrition/Dietary Note dated 01/15/2021 at 3:28 p.m., for Resident # 7 revealed Dietician I recommended health shakes three times daily with meals, ice cream with the evening meals, and Med Plus 2.0, 60 cc, twice daily for thirty days. Record review of the Order Recap Report dated 01/15/2021 at 3:38 p.m. revealed Resident #7 was receiving a regular diet until 01/15/2021, when it was changed to a fortified diet. No dietary supplements other than chocolate milk with all meals was on the orders. Observation and interview on 01/14/2021 at 6:07 p.m. revealed Resident #7 was in bed, with the head of the bed elevated to approximately 45 degrees. CNA J was assisting the resident with eating. Resident #7 did not eat any of the facility food. He had another meal brought from outside of the facility. CNA J assisted him with the meal, and the resident ate 100%. Resident #7 said he did not care for the food at the facility. Record review of the January 2021 meal intake documentation

Based on observation, interview and record review the facility failed to ensure that based on the comprehensive assessment residents received care, consistent with professional standards of practice to receive the necessary treatment and services, to promote healing, and prevent infection for 4 of 6 residents (Resident #1, #5, #58 and #3) reviewed for pressure ulcer in that: -Resident #1 was not provided with an air mattress, pressure wounds were not treated and the resident was not repositioned as ordered by the physician. The facility also did not routinely and accurately assess wounds resulting in Resident #1's pressure ulcer deteriorated to a Stage IV that needed multiple debridement and the resident developed an ESBL infection. - RN [NAME] did not use proper technique in order to prevent infections during wound care of Resident #1. - Resident # 5 had a hospital staty related [MEDICAL CONDITION] (infection) in pressure sore. Resident #5 wound care was not provided according to physician orders [REDACTED]. - Resident #58's Weekly 'PUSH' score (facility tool to measure wound improvement) was not completed for the month of (MONTH) 2019. - Resident # 58's wound care was not provided according to physician's orders [REDACTED]. - Resident #3's Weekly 'PUSH' score was not completed for the month of (MONTH) 2019. These failures resulted in an IJ on 10/25/19. While the IJ was lowered on 10/29/19, the facility remained out of compliance at a scope of pattern and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected four residents and placed them at risk of a decline in their quality of life,[MEDICAL CONDITION], hospitalization and worsening of their pressure sores. Findings included: Resident #1: Record review of the admission sheet for Resident # 1 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #1's Comprehensive MDS assessment dated [DATE] revealed a BIMS of 00 indicating severely impaired cognition. Resident # 1 had short term memory problem, long term memory problem, and cognitive skills for daily decision making was severely impaired and she never/rarely made decision. Further review of the MDS revealed that she required total dependence from staff for dressing, toilet use and personal hygiene and total dependence of two people for transfers and bed mobility. Resident #1 was always incontinent of bowel and had indwelling catheter. Section M Unhealed Pressure Ulcers indicated Resident #1 had one stage III pressure ulcer and one stage IV pressure ulcer that were present upon admission. Record Review of Resident #1's Care Plan initiated 5/23/2018 revealed Resident #1 was admitted with multiple pressure injuries related to immobility, health condition, right sacrum (stage 3), right ischium (stage 4) (re-opened 4/4/19) and right hip (stage 4 with abscess) now classified as infection (1/31/19). Goal: Resident will be free of complications related to wound by review date. Resident's wounds will show signs of improvement by review date. interventions: air mattress , dietician consult as required, heel protector to ble (bilateral) every day while in bed, pain medication as needed for pain, treatment/wound care per md orders, turn and reposition resident often and as needed, use padding between pressure areas and positioning devices for proper body alignment, weekly skin assessment and wound treatment per current order. A Braden scale (tool to predict pressure ulcer risk) was requested multiple times from the DON during the survey but not provided before exit. Record review and interview of Resident #1's laboratory report dated 12/1/18 read in part: .Right hip collected on 11/28/18 at 5:55pm. The laboratory result indicated moderate growth of [NAME]ella [NAME]ii isolated . The laboratory result was presented by the interim DON on 10/25/19 at 2:31pm. She said she looked in Resident #1's records and was able to retrieve the latest wound culture that was dated 11/28/18. Record review of the physician's orders [REDACTED]. Nurse to check/monitor q shift. Every shift for wound healing ensure mattress is on and correct setting. Record review of Resident #1's nurses notes dated 4/5/2019 read in part: . Treatment nurse spoke with family member regarding deterioration to right hip (Abscess)wound, resident was on [MEDICATION NAME] (ABT) 500mg po tid x10 days and Bactrim (ABT) DS PO BID X10 days . Record review of Resident #1's nurses notes dated 4/19/2019 read in part: .right ischium (hip bone): cleanse with ns, pat dry, apply collagen powder and calcium alginate and dry dressing qday daily for reopened pressure injury for 30 days- 5/19/19 . Record review of Resident #1's nurses notes dated 5/9/19 read in part: .right hip wound deteriorated related to observed undermining with heavy purulent drainage pocketed, undermining 6 cm . Record review of Resident #1's hospital discharge summary dated 5/13/19 read in part: .Impression: draining and infected right lateral thigh wound. Query underlying osteo[DIAGNOSES REDACTED]. Plan: The patient on [MEDICATION NAME]. ID consultation: Air mattress. Wound Care consult: Assessment: Right hip wound infection. Plan: for sharp excisional debridement of right hip wound infection . Record review of Resident #1's hospital discharge summary dated 5/13/19 reviewed 5/16/19 read in part: .problem list: abscess of right hip resolved 12/13/18. Presents on 5/13/19 with abscess of right hip, hypotensive episode and skin infection . Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Daily related to abscess of bursa, right hip discontinued on 10/23/19. Record review of the physician's orders [REDACTED]. Record review of Resident #1's wound evaluation and management summary dated 9/23/19, 10/01/19, 10/9/19 and 10/22/19 revealed Surgical excisional debridement procedure was performed on Sacrum and right Hip pressure wounds. Record review of Resident #1's weekly 'PUSH' score (facility tool to track wound improvement) revealed they were not completed on 10/4/19 and 10/17/19. No measurements recorded for Resident #1's Right hip wound and Stage IV Sacrum pressure wound on 10/4/19. No measurement recorded for Stage IV Sacrum and wound of the right hip on 10/17/19. Record review of Resident#1's MAR for the month of (MONTH) 2019 revealed nurses were signing off on MAR indicated [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of Resident#1's Wound care evaluation and management summary dated 10/22/19 revealed an order for [REDACTED]. Record review of Resident #1's wound evaluation and management summary dated 10/22/19 revealed read in part: .Stage 4 pressure wound sacrum wound size: length: 2.2cm, width: 7.7cm, depth: 0.4cm. Surgical excisional debridement procedure: curette was used to surgically excise 16.94 cm of devitalized tissue and necrotic muscle and surrounding fascial fibers along with slough and biofilm were removed at a depth of 0.6cm and healthy bleeding tissue was observed. Wound of the Right Hip measuring length: 2.8cm, width: 0.8cm, depth: 0.7cm. Surgical excisional debridement procedure: curette was used to surgically excise 2.24 cm of devitalized tissue and necrotic muscle and surrounding fascial fibers along with slough and biofilm were removed at a depth of 0.9cm and healthy bleeding tissue was observed. Stage 4 pressure wound of the right ischium measuring length: 0.6cm, width: 0.6cm and depth: 0.3cm . Observation and Interview on 10/22/19 at 10:06 am with Resident #1 revealed resident resting in bed facing the door. She was alert and well groomed. She did not answer to questions asked about her pressure sore/injuries. There was no air mattress in the bed. Observation and Interview on 10/22/19 at 1:31 pm Resident #1 revealed resident resting in bed facing the door. She had not yet been repositioned. Observation on 10/22/19 at 10:31 am revealed the interim DON that was on wound evaluation rounds, performed wound care on Resident # 1 assisted by CNA QQ. Prior to initiation of the treatment, Resident #1 was assisted on to her left side. Observation revealed the dressing that was adhered to the resident's back was dated 10/21/19. When the pressure sore wound dressing was removed from the sacrum area, observation revealed a stage 4 pressure ulcer to the sacrum area approximately 2 cm in diameter, pressure injury was very deep reaching into muscle and bone with moderate drainage. A wound of the right hip approximately 2 cm in diameter and a stage 4 ulcer to the right ischium approximately 0.4 cm in diameter with moderate drainage. In an interview on 10/22/19 at 10:55 am LPN Z said she worked full time during 6-2pm shift at this facility. When surveyors asked if she was aware that the Resident#1 had wounds, the nurse replied, she would have to check in the system. She said she did not know what wounds Resident #1 had and said it was the Wound Care Nurse that did the dressing changes in the evenings. She said she worked mornings, so she did not know who the wound care nurse was. She said if the dressing on the resident's wound needed to be changed or was soiled then she would look to see if any PRN dressing changes were ordered. She said if none were ordered then she would call the doctor to get a new order to cover the wound. She said wound care nurses were responsible to complete weekly wound measurements. She said the wound care nurse rounds with the wound care doctor. She said the wound care doctor came to the facility weekly. She said since the wound care nurse left she said she did not know who rounded with the wound care doctor. She confirmed Resident #1 was on contact isolation for ESBL to her wound. In an interview on 10/22/19 at 1:45 pm with the Resident #1's family member, she said Resident #1 arrived at the facility with one nearly healed wound to the buttocks and she now had three additional wounds to the buttocks, including a gaping hole on the right side because she was not being turned and repositioned. She said the resident was currently on isolation because of an infection that was not responsive to antibiotics. She said the resident had been hospitalized three times since admission. She said Resident #1 was hospitalized for [REDACTED]. The family member said this had been an ongoing issue, regarding lack of assitance with re-positioning and feeding the resident. The family member said they have had several meetings with the facility about their concerns with the wounds. Observation on 10/22/19 at 2:54 pm revealed resident resting in bed and was still facing the door. There was no air mattress in the bed. Observation on 10/23/19 at 9:10 am revealed resident resting in bed facing the door. There was no air mattress on the bed. Observation on 10/23/19 at 11:34 am revealed the Environmental Service Director and the Housekeeping laundry supervisor setting up the air mattress in Resident #1's room. In an interview on 10/23/19 at 12:40 pm with LPN Z, She said yesterday she noticed Resident #1 had an order for [REDACTED]. Record review of Nurse's note for Resident #1 dated 10/23/2019 read in part: .this nurse with call regarding air mattress, answering service answered and stated that they would let agency know. She stated she is unsure why agency isn't answering at the moment . In an interview on 10/23/19 at 1:03 pm with the Environmental Service Director, he said he was told by nursing to place the air mattress for Resident #1. He said the facility had 4 air loss mattresses kept on Hall 100 that could be used for residents in need of an air mattress. Observation on 10/23/19 at 1:34 pm revealed resident resting in bed facing the door. Record review of the physician's orders [REDACTED]. Record review of Resident #1's Nutrition/Dietary notes dated 9/5/19 revealed read in part: .CBW: 121#, Ht: 60, BMI: 23.6, IBW: 1003, %IBW: 121% Resident on hospice, wt loss may be unavoidable. Noted wt loss of 10.43 (7.9%) x 3 months and 22.4# (15.7%) x 6 months. Diet: Regular, mech-soft w/ thin liquids. Intake: Fair to good PO continues. Has feeding assistance in room. Per CNA, resident eats well and has h/o requesting more food. Supplement: Health shake @ breakfast. Ice cream q lunch & dinner. Meds: Fe, Zinc, Senna, Insulin Skin: Stg 3 PI to sacrum. Stg 4 PI to R ischium No lab updates. Diet medication for elevated Glu may not be appropriate at this time d/t weight loss & hospice. Increased needs r/t place for wounds & weight loss. Recommendations: -Rec MVI/min and 500mg Vit C BID. -Rec large egg/meat Goals: Wound healing & comfort care . Record review of Resident #1's Nutrition/Dietary notes dated 10/23/19 read in part: .Resident has ongoing pressure injury to sacrum and R ischium. On MVI/min & Zn. Increased needs due to skin breakdown. Noted current labs suggest [MEDICAL CONDITION]. Recommendations: Clarify MVI/min to renal MVI/min. Recommend 30cc liquid pro BID x 30 days. Put stop date for Zinc (rec x 14 days). Goals: Stable wt of 120.8# +/-4%, wound healing . Record review of Resident #1's physician's orders [REDACTED]. In an interview on 10/29/19 at 9:31 am with the interim DON and the Vice President of Clinical Services, VP said Nurse practitioner visits the facility once a month, but nurses can call and receive an order at any time. She further said as per facility's policy facility has 7 days to respond to dietician's recommendations. She said the recommendation was written on 10/23/19. Observation on 10/24/19 at 10:45 am and 3:21 pm revealed resident resting on an air mattress facing the door. Observation on 10/24/19 at 10:45 am revealed RN [NAME] performed wound care for Resident #1, while CNA QQ and CNA RR assisted with positioning the resident. Resident #1 was assisted onto her left side. RN [NAME] placed a clear trash bag near resident's leg. RN [NAME] removed resident's soiled right hip wound dressing and placed it in the trash bag on the bed. She then removed her dirty gloves. RN [NAME] was about to place clean gloves on, CNA QQ intervened and asked RN [NAME] to sanitize her hands. RN [NAME] donned double gloves on her right hand. She cleansed the wound with normal saline, pat dried and applied Calcium Alginate with silver with a dry dressing. RN [NAME] did not use skin prep as ordered. RN [NAME] removed her gloves and washed her hands. She donned new gloves and removed the soiled dressing from the right ischium wound. The resident then had a small bowel movement. RN [NAME] provided incontinent care and then completed the right ischium wound care with the same soiled gloves. RN [NAME] removed her gloves, performed hand hygiene and without gloves looked for a clean brief in the resident's room. CNA RR pointed to the clean briefs sitting on the side table. RN [NAME] returned with a clean brief. RN [NAME] donned clean gloves without hand sanitizing or washing her hands and placed a clean brief on the resident. RN [NAME] picked up a trash bag off the resident's bed, placed it on the resident's bedside table. With the same soiled gloves she touched the resident's clean gown and brief. In an interview on 10/24/19 at 11:50 am with RN E, she said she started working full time last month at this facility. She said she had little to no experience with wound care. She said she was asked yesterday if she could provide wound care for the next two days (Thursday and Friday). She said she did not feel comfortable but agreed to do the wound care as long as she had assistance. She said when she came to work today she was told that they were short a nurse and that she had to work the hall. She said she does whatever the facility assigns her to do. She said this was the first time she had performed wound care on a resident at this facility. She said the wound care nurse performed all the wound care in evenings. She said the unit manager prepared the supplies for the wound care, so she did not know what was on the table. She said she looked at the order but did not check to see if all the supplies were available to provide wound care. She said she should have washed her hands or used hand sanitizer after changing gloves since the resident had a bowel movement. She said it placed the resident at risk for cross contamination. She said she had not been in serviced on hand washing/ infection control upon hire. In an interview on 10/24/19 at 2:16 pm with the interim DON, surveyor asked the difference between Calcium Alginate and Calcium Alginate with silver. She said Calcium Alginate with silver has antimicrobial which prevents infection and bacteria growth. She said if the wound does not have an infection Calcium alginate was sufficient. In an interview on 10/25/19 at 10:14 am with the Administrator and the interim DON, the interim DON said while preforming wound evaluation rounds with the wound care doctor and the surveyor she noticed Resident #1 did not have an air mattress, so she asked the maintenance to provide a facility's air mattress. The Interim DON said she in serviced the floor nurses yesterday on wound care technique/infection control. She said she had to check with the educator to see what additional wound training had been completed for nurses. In an interview on 10/25/19 at 10:36 am with RN B, she said she was the interim DON, and the Educator/Infection Control Nurse. She said upon hire, nurses go through general orientation for all skills. She said there was no skills check off specifically on wounds. She said nurses were trained to apply/reinforce dressing, but no direct wound care as the facility had a certified wound care nurse. She said the facility currently does not have a wound care nurse. She said the previous DON took the wound care nurse that she had hired along with her when she left. She said she did not know the wound care nurse's credential/experience with wound care as the previous DON had interviewed her for the position. When asked who was providing wound care to the residents at this time, she said the weekend wound care nurse dose the wound care in the evenings. She said if a dressing was needed to be changed a floor nurse would do the dressing change. She said she performed monthly in services on infection control/hand hygiene. She said she expects staff to follow facility's policy and procedures. Observation on 10/25/19 at 1:16 pm revealed Resident # 1 resting on an air mattress facing the door. In an interview on 10/25/19 at 1:23 pm with CNA RR, she said she was assigned to Resident #1. She said interventions included putting a pillow under her knee and boots on both of her feet. She said residents that were bed bound were supposed to be repositioned every 2 hours. She said repositioning depends on resident's comfort level. She said if the resident says he/she was comfortable on their left side then CNAs would turn/reposition them either on their left side or on their back. When asked when was the last time that Resident #1 was repositioned, she said may be an hour ago. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. In an interview on 10/29/19 at 9:05 am with the LPN C, she said she collected the wound cultures herself. She said lab picked up wound cultures on 10/26/19 and the facility was contacted on 10/27/19 stating the lab sent the cultures to the secondary lab. She said there was no follow up/preliminary results for the cultures as of today. Record review of Resident #1's culture requisition for Right hip sacrum and Right ischium revealed cultures were collected on 10/25/19. The Requisition was presented by vice president of clinical and interim DON on 10/29/19 at 10:15am. Resident #5: Record review of Resident # 5's face sheet, revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the admission MDS, dated [DATE], revealed Resident #5 had a BIMS of 3 /15 indicating severe cognitive impairment. The MDS reflected Resident #5 required extensive assistance with ADLs, had an indwelling catheter and was always incontinent of bowel. Review of section M0150 and M0300 of the admission MDS reflected Resident #5 had 2 stage 4 pressure ulcers on admission. Record review of the comprehensive care plan for Resident #5, date initiated 10/22/19, revealed, in part: .Focus: .pressure ulcer injuries related to history, health condition and immobility (date initiated 7/15/19 revised 10/23/19). Interventions: .perform treatment per order, if not improvement within two weeks, report to physician . treatment/wound care per physician orders. Further review if the care plan revealed, Focus: .at risk for wound infection (date initiated 8/07/19). Interventions: .assist and arrange Resident #5's wound care schedules as needed . treatment per physician order [REDACTED]. weekly skin assessments. Record review of the physician's orders [REDACTED].#5's sacrum: cleanse with normal saline, pat dry, apply sorbact dressing and top with dry dressing qday. Record review of nursing progress notes dated 9/17/19 at 9:07 p.m. reflected the facility received an order to transfer Resident #5 to the hospital due to critical high WBC 39.1, BUN 97 and creatinine 4.88 lab values. The resident was transported via EMS. Record review of the of hospital discharge report dated 9/28/19 identified medical [DIAGNOSES REDACTED]. Further review of the hospital consultation reports from the infectious disease physician read, in part: .the patient was hospitalized .in (MONTH) 2019 for treatment of [REDACTED]. She also had negative bacteremia with Proteus mirabilis and staph epidermidis . blood culture obtained from 9/17/19 is positive for gram-negative bacilli . Record review of the nursing progress notes reflected one progress noted dated 9/29/19 at 2:51 p.m. reflecting wound care was completed on 9/29/19. Further record review of the progress notes listed in the EMR for Resident #5 did not reflect wound care was completed on 9/6/19 or 9/30/19. Record review of physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Record review of the TAR dated 10/1/2019 - 10/31/19 revealed no documentation to reflect wound care for Resident #5 was completed on 10/16/19, 10/17/19, and 10/18/19. Record review of the nursing progress notes reflected no progress notes to reflect wound care was completed on 10/16/19, 10/17/19, 10/18/19. Additional documentation was not available to reflect treatment was provided on the above dates. Observation of Resident #5 on 10/23/19 at 10:55 a.m. revealed the Resident was in bed with eyes open. Her lower extremities reflected bilateral knees, feet, and extremities with callus severely dry skin. Resident #5 was observed peeling/picking a small portion of her epidermis on the left ankle. Interview with LPN C on 10/23/19 at 10:58 a.m. she said the treatment nurse would be at the facility at approximately 7:00 p.m. She said the interim DON completed wound evaluation rounds with the wound care physician on 10/22/19. Observation of Resident #5' s sacral dressing on 10/23/19 at 11:04 a.m. revealed it was dated 10/22/19. The Dressing was attached with a light-yellow stain. Observation o f the wounds revealed a golf ball sized ulcered area. No muscle or bone visible. The area was reddened and a small amount of slough was noted. No drainage and no overt malodor was noted. Observation of the right ischium revealed the area was reddened with scar tissue noted. The area was unopened. Observation of the right posterior upper thigh revealed an open area approximately 3/4th of an inch. The area revealed a scant amount of blood. No drainage was noted in the area. Record review of Resident #5's most recent wound evaluation dated 10/22/19 identified: site 1 stage 4 pressure wound sacrum . dressing treatment plan alginate calcium apply once daily for 9 days. Interview with the Interim DON on 10/23/19 at 11:15 a.m. she said she completed wound evaluation rounds with the wound physician on 10/22/19. She denied new wound treatment orders for Resident #5. She reviewed the TAR during the interview and confirmed no documentation was available to support wound care had been completed for Resident #5 on 10/16/19, 10/17/19, and 10/18/19. She said the DON and treatment nurse resigned last week. She said the nurses assigned to the floor told her they completed the wound care for Resident #5. She said we identified issues with wound care and treatment completion documentation. She said the facility created a PIP (performance improvement plan). She said last week the DON left the position abruptly and the facility was still in the process of implementing the PIP. During a later interview with the Interim DON on 10/23/19 at 11:56 a.m. she said the wound physician evaluates Residents identified with pressure ulcers weekly. She said the completed wound evaluations were available to the facility within 24 hours and were uploaded the following day. She said wound measurements were completed weekly. She said the floor nurse completed rounds with the wound physician. She said the pressure ulcer scale for healing ('PUSH' tool) assessment was completed by nurses. Record review of the PUSH tool revealed a form for staff to document the site and description of skin issues. Record review with the Interim DON during the interview revealed the last PUSH tool assessment for Resident #5 was completed on 10/4/19. She said the facility still have issues with completing the facility assessment tools including but not limited to, skin observation tool and the PUSH tool, used to monitor wounds in the facility. She said since the issues have been identified, floor nurses round with the wound physician and weekly assessments were completed by the treatment nurse. She said the wound care evaluations were not available for the nurses in the facility because she did not have access to the portal to receive the wound evaluations. She informed the survey team she had to contact the physician's portal support team to receive access, so the wound evaluations would be available to the facility staff nurses completing wound care. During interview with LPN C on 10/25/19 at 9:24 a.m. she said nurses were trained to document after treatment or care was completed. She said she was not aware of the documentation not completed for treatment on 9/6/19, 9/30/19, 10/16/19, 10/17/19, and 10/18/19. She was unable to verify if treatment had been completed on those dates. Interview with the Interim DON on 10/25/19 at 9:26 a.m. she said the same nurse was scheduled to work on 10/16/19, 10/17/19, and 10/18/19. She said the nurse told her she forgot to document the treatment. She said nurses were trained to document all care or treatment had been provided. She was unable to determine if treatment was provided on 9/6/19 and 9/30/19. Resident # 58: Record review of the admission sheet for Resident #58 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record Review of Resident #58's Quarterly MDS assessment dated [DATE] revealed a BIMS 03 indicating severely impaired cognition. Resident #58 had short term memory problem, long term memory problem, and cognitive

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 6 residents (Resident #1) reviewed for pain management in that: -Resident #1's pain was not effectively managed while receiving wound care treatment resulting in her yelling in pain. -Resident #1's pain level assessment was inaccurately documented during wound care treatment. -Facility Staff failed to use appropriate pain scale and follow up method to adequately assess and monitor Resident #1's pain. These failures affected one resident placing her at risk for continued unnecessary pain and at risk of not receiving necessary wound care treatment. Findings included: Record review of the admission sheet for Resident # 1 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #1's Comprehensive MDS assessment dated [DATE] revealed a BIMS of 00 indicating severely impaired cognition. Resident # 1 had short term memory problem, long term memory problem, and cognitive skills for daily decision making was severely impaired and she never/rarely made decision. Further review of the MDS revealed that she required total dependence from staff for dressing, toilet use and personal hygiene and total dependence of two people for transfers and bed mobility. Resident #1 was always incontinent of bowel and had indwelling catheter. Further review of Section J revealed Resident #1 did not receive scheduled pain medication regimen, should assessed for pain and was unbale to answer staff assessment questions for pain. MDS indicated staff assessment for was not conducted and pain indicators were not present. Record review of Resident #1's care plan initiated on 5/23/18 revealed the following care plan: Problem: Resident #1 is at risk for pain and discomfort R/T wounds, limited self-mobility, [MEDICAL CONDITION] and arthritis. Interventions: Administer pain medications as ordered. (MONTH) use pain Ad scale d/t cognitive loss. Will maintain adequate level of comfort as evidence by: no signs or symptoms of unrelieved pain or distress, verbalizing satisfaction with level of comfort. Record Review of Resident #1's Care Plan initiated 5/23/2018 revealed Resident #1 was admitted with multiple pressure injuries related to immobility, health condition, right sacrum (stage 3), right ischium (stage 4) (re-opened 4/4/19) and right hip (stage 4 with abscess) now classified as infection (1/31/19). Goal: Resident will be free of complications related to wound by review date. Record review of Resident #1's physician' order dated 1/23/19 revealed to perform pain assessment prior to and after wound care daily for multiple wounds. Record review of Resident #1's physician' order dated 6/13/19 revealed monitor for pain every shift use 1-10 scale(a)for alert residents use pain ad(b) for confused residents document which pain scale used to assess residents pain rating. Record review of Resident #1's physician' order dated 7/23/19 revealed to administer Tylenol Tablet 325 MG ([MEDICATION NAME]) Give 650 mg by mouth every 6 hours as needed for pain related to PAIN. Not to exceed 3 gm in 24 hours. Record review of Resident #1's physician' order dated 8/23/2019 revealed to administer [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 0.5 ml by mouth every 2 hours as needed for for moderate pain 5-7 or SOB. Record review of Resident #1's physician' order dated 8/23/2019 revealed to administer [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 1 ml by mouth every 2 hours as needed for SEVERE PAIN 8-10 OR SOB. Observation on 10/22/19 at 10:31am revealed the interim DON on wound evaluation rounds performed wound care on Resident # 1 assisted by CNA QQ. Prior to initiation of the treatment. Resident #1 was assisted onto her left side. Observation revealed the dressing that was adhered to the resident's right ischium was dated 10/21/19. Interim DON removed the soiled dressing, cleaned the perimeter of the wound, Resident#1 yelled in pain. Wound care doctor stated he had a numbing spray that also worked as a room fresher and sprayed it on the right ischium wound. Interim DON continued the wound care. When the pressure sore wound soiled dressing was removed from the sacrum area, observation revealed a stage 4 pressure ulcer to the sacrum area approximately 2 cm in diameter. Interim DON cleaned the perimeter of the wound Resident #1 yelled in pain again. Wound care doctor sprayed on the wound and the interim DON continued with the wound care treatment. Observation on 10/24/19 at 10:45 am revealed RN [NAME] performed wound care for Resident #1, assisted by CNA QQ and CNA RR. Prior to initiation of the treatment, Resident #1 denied having pain. Resident #1 was assisted onto her left side. When the pressure sore wound dressing was removed from the sacrum, observation revealed a stage 4 open area of approximately two centimeters in diameter. RN [NAME] cleaned the perimeter of the wound, and the Resident yelled Ow! The nurse continued with the treatment. When RN [NAME] dried the area with a dry 4 x 4-inch gauze, the Resident yelled out in pain again. RN [NAME] said, I need to hurry up. RN [NAME] completed the wound care for the resident. Before leaving the room, RN [NAME] asked if she was in pain. Resident said, yes. Surveyor asked RN [NAME] what the resident's pain level was. RN [NAME] asked Resident #1 her pain level on a scale was from 0-10. Resident did not respond. Record review of Resident #1's MAR for (MONTH) 2019 documented on 10/22/19 and 10/24/19 '0' pain for the shift, even though Resident #1 yelled in pain when the interim DON and the RN [NAME] performed wound care on those shifts. Record review of Resident #1's (MONTH) 2019 MAR indicated [REDACTED]. Record review of Resident #1's (MONTH) 2019 MAR indicated [REDACTED]. Record review of Resident#1's nurses notes for (MONTH) 2019 revealed there was no documentation that the resident was receiving medication or non-pharmacological intervention for pain prior to wound care daily or that the physician was contacted to address pain management for the resident. Record review of Resident #1's nurses notes dated 10/24/19 at 12:03pm revealed read in part: .c/o pain during wound, unable to specify pain level from 0-10. Flat affect, ouches upon touch at the coccyx wound. Her charge nurse notified, she said she will give the pain med . In an interview on 10/22/19 at 1:23pm with CNA RR, she said she worked full time at this facility. She said Resident #1 was able to tell if she was in pain. In an interview on 10/24/19 at 11:50am with RN E, she said she did not ask floor nurse if she gave her pain medication prior to starting wound care. She said Resident #1 was not her resident. She said if she would have known how big her wound was she would have medicated the resident before starting the wound care. She said she should have stopped the wound care when the resident yelled in pain. She said at that time she thought to herself that she needed to hurry up and complete the wound care, so she could reposition the resident and make her comfortable. She said she would go ask the floor nurse to give her something for pain as the resident was grimacing. In an interview on 10/24/19 at 1:54pm CNA OO, said she worked full time at this facility. She said Resident #1 was alert and verbal when you asked her where the pain was located. In an interview on 10/24/19 at 2:16pm with the interim DON, she said the nurse should have assessed for pain prior to starting wound care. In an interview on 10/25/19 at 11:10am am LPN Z, she said she worked full time during 6-2pm at this facility. She said Resident #1 was able to express pain to some extent. If the resident was in pain she would verbalize or have facial grimacing. Record review of Pain Assessment and Management policy (revised (MONTH) (YEAR)) read in part: .the purposes of this procedures are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goal and needs and that address the underlying causes of pain. 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: a. assessing the potential for pain; b. effectively recognizing the presence of pain; c. identifying the characteristics of pain; d. addressing the underlying causes of pain; e. developing and implementing approaches of pain management; f. identifying and using specific strategies for different levels and sources of pain; g. monitoring for the effectiveness of interventions; and h. modifying approaches as necessary. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Recognizing pain 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) sign of pain. 2. Possible Behavioral signs of pain: a. verbal expressions such as groaning, crying, screaming; b. facial expressions such as grimacing, frowning, clenching of the jaw. 4. Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling. 5. Review the Medication Administration Record [REDACTED]. Assessing Pain: 1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative): a. history of pain and its treatment, including pharmacological and non-pharmacological interventions; b. characteristics of pain: (1) intensity of pain (as measured on a standardized pain scale); (2) descriptors of pain; (3) Pattern of pain (e.g., constant or intermittent); (4) location and [MEDICAL CONDITION] of pain; and (5) frequency, timing and duration of pain. C. impact of pain on quality of life. 2. Assesses pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 3. Review the resident's treatment record or recent nurses' notes to identify any situations or interventions where an increase in the resident's pain may be anticipated, for example b. treatment such as wound care or dressing changes. Implementing Pain Management strategies: 1. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: a environment -providing a pressure-reducing mattress, repositioning, etc.; 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Monitoring and Modifying Approaches: 1. Re-assesses the resident's pain and consequences of pain at least each shift for acute pain or significate changes in levels of chronic pain and at least weekly in stable chronic pain. Documentation: 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program .

Based on observation, interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 1 of 10 residents reviewed for neglect and timely assessments. (CR #2) The Administrator failed to: -- implement the facility Abuse, Neglect, and Exploitation prohibition policy to prevent neglect. --supervise the DON to ensure she was monitoring and training the nursing staff on completing accurate and timely nursing and pain assessments after falls -supervise the DON to ensure staff was consulting with physicians in a timely manner of radiology results and residents ' complaints of pain. The DON failed to: - supervise the nursing staff to ensure they were completing accurate and timely nursing and pain assessments after falls. - supervise and train the nursing staff in consulting with physicians regarding resident's change of conditions, uncontrolled pain and to provide prompt care to the residents. - supervise the nursing staff to ensure they completed timely and accurate clinical documentation. An IJ was identified on 09/15/16. While the IJ was lowered on 09/17/16, 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 was continuing to monitor the implementation and effectiveness of their plan of removal. This failure affected 1 discharged resident that required surgical intervention for her injuries and could place 23 residents identified by the facility as having falls during the month of August 2016 at risk of not receiving adequate medical care, pain, and decline in their health condition well-being. Findings include: CR #2: Record review of CR #2 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. CR #1 was discharged to the hospital on [DATE]. Record review of CR #1 ' s initial care plan dated 07/26/16 and revised on 09/01/16 read in part, Resident is at risk for falls and is at risk for increased falls and injury. Confusion .Actual fall- 08/12/16- observed on floor Interventions read in part, X-ray lower extremity . Record review CR #2 ' s facility Incident Report dated 08/12/16 at 1520 read in part, Res found on floor laying at foot of bed. Res complained of pain to LE extremities. Further interventions included- initial interventions to prevent future falls: X-ray of left lower extremities. Further review of the form revealed IDT met to review resident ' s fall on 08/12/16. Resident attempted to transfer self-unassisted. Res c/o pain to LE, X-ray done, no fracture identified. MD in building N.O (new order) for [MEDICATION NAME] for pain management. Additional care plan/Nurse Aide Assignment Updates: 1) scoop mat in place (initiated), 2) x-ray negative, 3) falling star program initiated. Record review of CR#2 ' s X-rays revealed the following X-rays: 08/12/16-Left tibia and fibula Impressions: no evidence of fracture 08/12/16- Left Ankle Impressions: no definite radiographic evidence of acute fracture or dislocation 08/13/16-Left Hand Impressions: Significant [MEDICAL CONDITION] changes with no evidence of acute displaced fracture. Record review of the Physician ' s note dated 08/12/16 read in part, Labs Ordered: Noted .X-Ray the L Hip and X-Ray of the L knee There was no evidence that X-rays were done for the left hip. Record review of the Nurses notes dated 08/12/16 read as follows: .At 10:17 am-Resident was observed on floor at foot of bed lying on lt (left) side. Resident is in pain upon movement of it . (lower extremity). But can move it slightly, V/S ' s taken and stable, resident assisted up off of floor, and into W/C, and then back to bed, resident now lying on the rt (right) side. (X ray company) here in facility, and charge nurse called to place order for X-ray to be done to the left lower ext .procedure done, results pending, NP notified of fall, and stated that the doctor would be in the facility today and to have him assess the resident . later resident started guarding lt (left) hip/thigh area, and X-Ray company was called to do a X-Ray of Lt. hip and femur . There was no documentation that pain medication was administer at this time. Completed by LVN A. At 3:00 pm- Addendum order received for X ray of left lower extremities d/t swelling and resident guarding left knee and foot .completed by LVN A At 3:15 pm- resident c/o of upper left leg hurting, and guarding thigh area, (company) called for stat X-Ray to the left hip and femur .There was no documentation that the resident was medicated at this time. Completed by LVN A At 10:39 pm- Medicated resident with [MEDICATION NAME] at this time for pain level of 3 to left leg . Record review of Nurse note dated 08/14/16 at 1:46 pm revealed in part that X-ray result of left hand was received and showed no fracture. Resi9dent medicated for pain with [MEDICATION NAME], assessed after an hour and no pain noted. Record review of the Nurses notes for CR#2 revealed that there was no mention of the hip X-ray results or documentation of pain issues from 08/14/16 until 08/31/16. Record review of the Nurses notes dated 08/31/16 read as follows: At 02:13 am- Res was noted with her head out of the pillow and slightly hanging out of her bed. She stated she was trying to get comfortable in bed and that she was fine. Assessed, no bruises or injuries were noted. C/O pain to left hip . At 3:00 am- note revealed prn medication administered and effective .signed by LVN B At 1:24 pm- Charge nurse received (new order) for X-Ray to the right Hip stat, and a Arterial/Venous Doppler to the left leg R/T pain from a previous fall, order called in and X-Ray will be out today to perform procedure completed by LVN A At 7:20 pm- Resident ' s stat X-ray of left hip results received with impression: Acute fracture. Called this results to NP, order given to send resident to . At 8:28 pm- Resident left facility via stretcher . Record review of physician telephone order dated 08/31/16 revealed left hip X ray stat for pain status [REDACTED].sign by LVN A and time noted was 2:00 pm Record review of the Physical Therapy plan of Care notes for CR#2 dated 08/30/16 revealed the following: Treatment Diagnosis: [REDACTED].The patient reports a pain scale rating of 10 out of 10 for L knee pain, R knee pain and L hip 7/10. There was no documentation on the note to indicate that the nurses were informed of pain level for the resident. Record review of hospital progress note dated 09/01/16 revealed the following notes: Physical Examination: shows her left leg to be flexed and externally rotated. She has pain with range of motion .Left hip externally rotated .The patient appears to be in mild distress with the pain .fracture of left hip . In an interview with Resident #4 on 09/15/16 at 10:15 am, she said that she was the roommate of CR#2. She said that she was in the hospital and returned to the facility on [DATE]th. She said that when she came back from the hospital, CR#2 seemed like a different person. The resident said: They told me that she had a fall while I was gone. Every time someone tried to reposition her she would scream bloody murder and she would say things like, I can ' t take it anymore. Resident #4 said that on the night of 8/30 around 11:30pm: I saw CR #2 lying on her left side and she kept moaning. The CNA came in and he repositioned her to the other side and he left the room. Then I fell asleep and I woke up to something around 1:30 am. I looked over and all I could see was her legs in the air, I could not see her body. She was not on the bed. I pressed the call light right away and waited. No one came. I waited until almost 2 am and still there was no one coming. I wanted to help her but I could not move on my own, I was helpless. I did not know what else to do. My cell phone was away from me charging otherwise I could have used that to call the nurses ' station. Then I picked up the small container of lotion from my bedside table and tried to throw it out the room so that someone would see it and it would catch their attention. I threw the bottle but it hit the wall and did not make it outside the room. I wanted to scream and yell for help but with [MEDICAL CONDITION] made it difficult. I decided to try anyway and screamed with everything I got. No one came in. I screamed again and this time CNA D came running in. By this time, I was out of breath and could barely talk. CNA D, rushed over to me and I pointed to bed A, he quickly went over and assisted CR#2. CNA D then went and got the nurse and the nurse came in. CR#2 was moaning all this time and the nurse came and gave her medication. I kept telling the nurse since I came back from the hospital that something was wrong with CR#2 and that I think she broke something because of the way she was screaming during care. She said that CR#2 was not like that before she had that fall (08/12/16). In a phone interview with LVN A on 09/15/16 at 12:15pm, she said that she was the nurse that did the assessment on CR#2 after her fall on 08/12/16. She explained that after the fall, she assisted the resident back to her wheelchair. She said the resident complained of pain to her knee and left hip. She said she called the NP to notify, the NP told her that the doctor will be in and that he will assess the patient. The doctor came in shortly after and he did rounds with the DON. She said the doctor went to see CR#2 with the DON. After the rounds, the DON gave me order for [MEDICATION NAME] 50mg. LVN A said that there was so much going on that day so she does not remember the details and exactly what she documented. She said that she did order for hip X-ray but it was never done. She said that when she came back to work the next day and asked staff about it, no one knew anything about it. She said that after this fall, time to time when we touched her or moved her, she will scream in pain. Every time she complained of pain, I would medicate her with the [MEDICATION NAME]. She said that she spoke with the DON about CR #2 being in pain but does not know what was done about it. She explained that CR#2 never complained of pain prior to this fall so she knew something was going on. I was the only one trying to figure out why she was in pain. The other nurses didn ' t do anything. LVN A said that her documentation was true and that she had not falsified anything. After the fall, CR#2 was holding her hip. LVN A said that during morning meetings, she would bring up CR#2 ' s pain but no one seemed to care. In an interview with the Physical Therapist on 09/15/16 at 1:02 pm, he said that he saw CR#2 on 08/30/16 because of knee pain. During the initial assessment, I asked her if she was in pain and she said that she was. She said she had pain to both knees and hip. I tried to stand her up on the parallel bar and there was a loud thud to her knee, so I sat her back down. She was in pain. She verbalized pain and she was also moaning. It was very hard for her to move physically. He said that after the assessment he brought the resident back to the T.V. room. The physical therapist said that he did not tell nursing about her pain issues because they brought her to me because she had pain so therefore I didn't feel the need to tell them. In an interview with Physical therapy assistant on 09/15/16 at 1:10 pm, she said that she saw CR#2 on 08/31/16 in the afternoon. She said: CR#2 was in her room, in the bed and I could tell she was in a lot of pain. I asked her if she was hurting and she was not able to verbalize. I asked her where it was hurting her and she pointed to her hip. She was moaning and seemed very confused. I repositioned her and propelled her legs and told the nurse that CR#2 was in pain. She said she does not remember exactly when this was but it was after lunch. In an interview with the DON on 09/15/16 at 1:15pm, she said that she was not aware of CR#2 having hip pain. She said that she thought the pain was only in the knee. She said that LVN A told her that CR#2 was complaining of pain to the lower leg and that she was guarding her foot and knee. She claimed that LVN A falsified her documentation and that CR#2 never had pain to her hip and that an X-Ray was not ordered for her hip on August 12th. The surveyor asked the DON how she knew LVN A falsified documentation as she was the nurse that did the initial assessment. The DON replied: about an hour after LVN A assessed CR#2, I went into the room an assess her and she did not complain of pain to her hip. She said that she did rounds with the physician on August 12th and he wrote on his notes that she needed a hip X-ray but he did not verbalized that to her or wrote an order for [REDACTED]. She said that she did everything she could because every time CR#2 complained of pain, she was medicated with [MEDICATION NAME]. In an interview with the DON on 09/16/16 at 12:53pm, when asked how the IJ came about she said that it was poor communication. She said that they would not have had the IJ if CR#2 did not have pain. She said that the resident ' s hip pain was not communicated to her and even the physician that did rounds with her did not tell her about an order for [REDACTED].>In an interview with the Administrator on 09/16/16 at 1:05 pm, when asked how the IJ came about, he said that it was lack of communication between the departments. He said CR#2 ' s pain issues was not communicated effectively between departments. He said that they could have done a better job of monitoring the pain for example monitoring the pain daily instead of weekly. He said that now when the X-Ray comes back positive the nurses can send the patient out via 911 verses before waiting for the doctor ' s order which delays the process. He said I became aware of the [MEDICAL CONDITION] on August 31st. Before that, I only knew of the hand and knee pain. The Administrator and DON were informed on 09/17/16 at 10:10 am that the IJ was lowered; however the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy at an isolated level due to facility needing more time to monitor the plan of removal for effectiveness. The Administrator and the DON were informed that an IJ was identified on 09/15/16 at 3:55 pm and a plan of removal (POR) was requested. A Plan of Removal was received on 09/16/16 at 8:25am. After several revisions were made the Plan of Removal was accepted on 09/16/16 at 4:15pm. The Plan of Removal included in part, .In services on new policy were initiated on 09/15/16 and were completed on 09/16/16. DON, ADON, Staffing coordinator, MDS nurses, and Dept. Heads were in-serviced on new procedure . DON/ADON or Nurse Manager on Duty will run report twice daily (AM/PM) to review Pain scales on all residents. Manager on duty will verify that any pain level 6 and higher have been called into the physician and any needed assessments were conducted .Any new orders for pain medication will also be reviewed in the morning meeting for effectiveness and frequency Reports will be placed in a Pain Monitoring binder and will reviewed weekly by the IDT team to ensure compliance .Nurse managers were all in-serviced on new policy on 09/16/16 . Nurse protocol for pain level 6 and higher was changed to require Physician/NP notification after administration of pain med. Any change in a resident pain profile will require that they nurse fill out a Stop and Watch form to be given to Nurse Manager for review. Nurse will then initiate a Comprehensive pain assessment .Residents with new or worsening complaint of pain should be reported to doctor and X-Ray of affected area should be requested. Any complaints of pain to lower extremities should include hip X-ray. In-Services with Nurses completed on 09/16/16 The Stop and Watch form was amended to include the requirement for a nurse ' s signature and managerial review. The managerial review includes verification that the doctor and resident family member were notified. All departments were in-serviced that a copy must be given to nurse manager after obtaining the nurse ' s signature so the manger can review interventions . X-Ray Company was informed that any positive findings on tests performed must be called into the facility. They will also call the DON or Administrator Any positive fractures will be sent to ER immediately via 911 as a nursing intervention. Doctor will be informed of transfer Rehab Department Communication Process changes They were instructed that notification of the nurse is mandatory. A copy must also be given to the DON, ADON or Staffing Coordinator. They were also directed to report any pain or concerns to the Rehab Director .The Rehab Director will do an end of day report with the Director of Nurses or designated agent to review concerns. The resident that triggered the IJ is currently still in the hospital. Her plan of care has been reviewed and updated as much as possible. Clinical notes from the hospital will be reviewed prior to her readmission to ensure pain management and care needs will be met . All resident that had a falls in September were reviewed for recurrent pain, that a new fall assessment was completed at the time of the incident, doctor was informed of any issues and that care plan was updated. The facility was monitored on 09/16/16 and 09/17/16. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff representing all three shifts had been in-serviced from 09/15/16-09/16/16. The topics included in part: Signs and symptoms of pain, Reporting pain to charge nurse, Stop & Watch protocol, Pain Scale ( verbal and non-verbal), Stop & Watch and change of behavior, Stop & Watch and change in conditions of Resident and reporting, and Nursing Communication. Further review of documentation provided revealed that all residents that had falls in September were assessed for pain on 09/16/16 and Physician or NP were notified if pain level was 6 or higher. Observations were made from 09/16/16-09/17/16 to ensure adequate supervision was provided and pain issues were being addressed by staff. Interviews were conducted from 09/16/16-09/17/16 with CNAs, Nurses, administration, Therapy and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services. The Administrator and DON were informed on 09/17/16 at 10:10 am that the IJ was lowered; however the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy at an pattern level due to facility needing more time to monitor the plan of removal for effectiveness. The facility Incident and Accident report identified 24 residents who fell during August 2016.

Based on observations, interviews and record reviews the facility failed to implement their written policy and procedures that prohibit neglect for 1 of 10 residents (CR #2) - CR #2 sustained a fall on 08/12/16 and had complaints of pain to the left hip. The facility failed to provide adequate pain management to CR #2 when she had signs and complaints of pain on her left hip/tight area for 18 days. - On 08/30/16 the PT failed to report to the nursing staff that CR #1 was experiencing severe pain. - On 08/31/16 CR #2 was found with her head hanging from the bed and her lower body still in bed and she was complaining of pain. - An X-ray was done on 08/31/16 revealed an acute interochanteric [MEDICAL CONDITION] hip. CR #2 was sent to the hospital on [DATE] 18 hours after she was found in bed with complains of hip pain. CR #2 remains in the hospital. An IJ was identified on 09/15/16. While the IJ was lowered on 09/17/16, 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 was continuing to monitor the implementation and effectiveness of their plan of removal. This failure affected 1 discharged resident that required surgical intervention for her injuries and could place 23 residents identified by the facility as having falls during the month of August 2016 at risk of not receiving adequate medical care, pain, and decline in their health condition well-being. Findings Include: CR #2: Record review of CR #2 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. CR #2 was discharged to the hospital on [DATE]. Record review of the Minimum Data Set (MDS) assessment, dated 07/28/16 revealed CR #2 had severely impaired cognitive skills for daily living. She was totally dependent on one staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. She was occasionally incontinent of bowel and bladder. Record review of CR #2 ' s initial care plan dated 07/26/16 and revised on 09/01/16 read in part, Resident is at risk for falls and is at risk for increased falls and injury. Confusion .Actual fall- 08/12/16- observed on floor Interventions read in part, X-ray lower extremity . Record review CR #2 ' s facility Incident Report dated 08/12/16 at 3:20 pm read in part, Res found on floor laying at foot of bed. Res complained of pain to LE extremities. Further interventions included- initial interventions to prevent future falls: X-ray of left lower extremities. Further review of the form revealed IDT met to review resident ' s fall on 08/12/16. Resident attempted to transfer self-unassisted. Res c/o pain to LE, X-ray done, no fracture identified. MD in building N.O (new order) for [MEDICATION NAME] for pain management. Additional care plan/Nurse Aide Assignment Updates: 1) scoop mat in place (initiated), 2) x-ray negative, 3) falling star program initiated. Record review of the Physician ' s note dated 08/12/16 read in part, Labs Ordered: Noted .X-Ray the L Hip and X-Ray of the L knee There was no evidence that X-rays were done for the left hip. Record review of CR#2 ' s X-rays revealed the following X-rays results: 08/12/16-Left tibia and fibula Impressions: no evidence of fracture 08/12/16- Left Ankle Impressions: no definite radiographic evidence of acute fracture or dislocation 08/13/16-Left Hand Impressions: Significant [MEDICAL CONDITION] changes with no evidence of acute displaced fracture. Record review of the Nurses notes dated 08/12/16 read as follows: .At 10:17 am-Resident was observed on floor at foot of bed lying on lt (left) side. Resident is in pain upon movement of it . (lower extremity). But can move it slightly, V/S ' s taken and stable, resident assisted up off of floor, and into W/C, and then back to bed, resident now lying on the rt (right) side. (X ray company) here in facility, and charge nurse called to place order for X-ray to be done to the left lower ext .procedure done, results pending, NP notified of fall, and stated that the doctor would be in the facility today and to have him assess the resident . later resident started guarding lt (left) hip/thigh area, and X-Ray company was called to do a X-Ray of Lt. hip and femur . There was no documentation that pain medication was administer at this time. Completed by LVN A. At 3:00 pm- Addendum order received for X ray of left lower extremities d/t swelling and resident guarding left knee and foot .completed by LVN A At 3:15 pm- resident c/o of upper left leg hurting, and guarding thigh area, (company) called for stat X-Ray to the left hip and femur .There was no documentation that the resident was medicated at this time. Completed by LVN A At 10:39 pm- Medicated resident with [MEDICATION NAME] at this time for pain level of 3 to left leg . Record review of Nurse note dated 08/14/16 at 1:46 pm revealed in part that X-ray result of left hand was received and showed no fracture. Resi9dent medicated for pain with [MEDICATION NAME], assessed after an hour and no pain noted. Record review of the Nurses notes for CR#2 revealed that there was no mention of the hip X-ray results or documentation of pain issues from 08/14/16 until 08/31/16. Record review of pain assessment records for the month of August 2016 revealed that CR # had complaints of pain on the following days: 08/12/16- level 3 in the afternoon 08/13/16- level 5 in the morning and level 3 in the afternoon. 08/14/16- level 5 in the morning. 08/18/16- level 4 in the morning. 08/14/16- level 4 in the morning. 08/19/16-level 4 in the morning. 08/24/16- level 5 in the morning. 08/29/16- level 5 in the morning. 08/31/16- level 3 in the afternoon. Record review or the MAR for CR#2 dated 08/01/16-08/31/16 revealed the following: [MEDICATION NAME] HCL tablet 50mg give 1 tablet by mouth every 4 hours as needed for pain, ordered 08/12/16. The form indicated that the resident only received pain medication on: 08/12/16- pain level 3, medication administered at 1854-Effective 08/13/16-pain level 5, medication administered at 1402-Ineffective 08/13/16- pain level 2, medication administered at 2228-Effective 08/25/16-pain level 5, medication administered at 0850-Effective 08/31/16- pain level 5, medication administered at 0213 -Effective Record review of Nurse ' s note dated 08/19/16 and signed by LVN A revealed that the residents ' family member inquired about fall .family member suggested that PT see resident for strengthening and ambulation . Record review of physician telephone orders dated 08/30/16 revealed an order for [REDACTED].>Further review revealed another order dated 08/30/16 for PT to evaluate and treat for three weeks for therapeutic exercise, mobility and gait for pain in knees, left hip and joint abnormalities. Record review of the Physical Therapy plan of Care notes for CR#2 dated 08/30/16 revealed the following: Treatment Diagnosis: [REDACTED].The patient reports a pain scale rating of 10 out of 10 for L knee pain, R knee pain and L hip 7/10. There was no documentation on the note to indicate that the nurses were informed of pain level for the resident. In an interview with the Physical Therapist on 09/15/16 at 1:02 pm, he said that he saw CR#2 on 08/30/16 because of knee pain. During the initial assessment, I asked her if she was in pain and she said that she was. She said she had pain to both knees and hip. I tried to stand her up on the parallel bar and there was a loud thud to her knee, so I sat her back down. She was in pain. She verbalized pain and she was also moaning. It was very hard for her to move physically. He said that after the assessment he brought the resident back to the T.V. room. The physical therapist said that he did not tell nursing about her pain issues because they brought her to me because she had pain so therefore I didn't feel the need to tell them. Record review of the Nurses notes dated 08/31/16 read as follows: At 02:13 am- Res was noted with her head out of the pillow and slightly hanging out of her bed. She stated she was trying to get comfortable in bed and that she was fine. Assessed, no bruises or injuries were noted. C/O pain to left hip . At 3:00 am- note revealed prn medication administered and effective .signed by LVN B At 1:24 pm- Charge nurse received (new order) for X-Ray to the right Hip stat, and a Arterial/Venous Doppler to the left leg R/T pain from a previous fall, order called in and X-Ray will be out today to perform procedure completed by LVN A At 7:20 pm- Resident ' s stat X-ray of left hip results received with impression: Acute fracture. Called this results to NP, order given to send resident to . At 8:28 pm- Resident left facility via stretcher . Record review of physician telephone order dated 08/31/16 revealed left hip X ray stat for pain status [REDACTED].sign by LVN A and time noted was 2:00 pm Record review of X ray result dated 08/31/16- revealed Left Hip, Impressions: Acute [MEDICAL CONDITION] femur, intertrochanteric. Record review of hospital progress note dated 09/01/16 revealed the following notes: Physical Examination: shows her left leg to be flexed and externally rotated. She has pain with range of motion .Left hip externally rotated .The patient appears to be in mild distress with the pain .fracture of left hip . Record review of Resident #4 ' s MDS assessment dated [DATE] revealed that she had moderately impaired decision making skills and was able to understand others and be understood. In an interview with Resident #4 on 09/15/16 at 10:15 am, she said that she was the roommate of CR#2. She said that she was in the hospital and returned to the facility on [DATE]th. She said that when she came back from the hospital, CR#2 seemed like a different person. The resident said: They told me that she had a fall while I was gone. Every time someone tried to reposition her she would scream bloody murder and she would say things like, I can ' t take it anymore. Resident #4 said that on the night of 8/30 around 11:30pm: I saw CR #2 lying on her left side and she kept moaning. The CNA came in and he repositioned her to the other side and he left the room. Then I fell asleep and I woke up to something around 1:30 am. I looked over and all I could see was her legs in the air, I could not see her body. She was not on the bed. I pressed the call light right away and waited. No one came. I waited until almost 2 am and still there was no one coming. I wanted to help her but I could not move on my own, I was helpless. I did not know what else to do. My cell phone was away from me charging otherwise I could have used that to call the nurses ' station. Then I picked up the small container of lotion from my bedside table and tried to throw it out the room so that someone would see it and it would catch their attention. I threw the bottle but it hit the wall and did not make it outside the room. I wanted to scream and yell for help but with [MEDICAL CONDITION] made it difficult. I decided to try anyway and screamed with everything I got. No one came in. I screamed again and this time CNA D came running in. By this time, I was out of breath and could barely talk. CNA D, rushed over to me and I pointed to bed A, he quickly went over and assisted CR#2. CNA D then went and got the nurse and the nurse came in. CR#2 was moaning all this time and the nurse came and gave her medication. I kept telling the nurse since I came back from the hospital that something was wrong with CR#2 and that I think she broke something because of the way she was screaming during care. She said that CR#2 was not like that before she had that fall (08/12/16). Observation on 09/16/16 at 11:50 am revealed that CR #2 was in the hospital. She was in the Intensive Care Unit. She was lying down on the bed on her back. A staff member was next to her, assisting her with her lunch. CR #2 was confused and was unable to answer questions. In an interview on 09/16/16 at 11:55 am with hospital staff, she stated that resident had a ORIF to the left hip and that she was doing better now. She said the resident still required total assistance for everything. In a phone interview with LVN A on 09/15/16 at 12:15pm, she said that she was the nurse that did the assessment on CR#2 after her fall on 08/12/16. She explained that after the fall, she assisted the resident back to her wheelchair. She said the resident complained of pain to her knee and left hip. She said she called the NP to notify, the NP told her that the doctor will be in and that he will assess the patient. The doctor came in shortly after and he did rounds with the DON. She said the doctor went to see CR#2 with the DON. After the rounds, the DON gave me order for [MEDICATION NAME] 50mg. LVN A said that there was so much going on that day so she does not remember the details and exactly what she documented. She said that she did order for hip X-ray but it was never done. She said that when she came back to work the next day and asked staff about it, no one knew anything about it. She said that after this fall, time to time when we touched her or moved her, she will scream in pain. Every time she complained of pain, I would medicate her with the [MEDICATION NAME]. She said that she spoke with the DON about CR #2 being in pain but she does not know what was done about it. She explained that CR#2 never complained of pain prior to this fall so she knew something was going on. I was the only one trying to figure out why she was in pain. The other nurses didn ' t do anything. LVN A said that her documentation was true and that she had not falsified anything. After the fall, CR#2 was holding her hip. LVN A said that during morning meetings, she would bring up CR#2 ' s pain but no one seemed to care. In an interview with CNA A on 09/15/16 at 11:40 am, she said that she had worked with CR#2 after the fall incident. She said she does not remember the exact date but it was somewhere around 08/12/16 when she was doing incontinent care and CR#2 was screamed in pain. I asked her if she was in pain and she said that she was. She said that her legs were hurting. At this time I did not notice any bruising or swelling anywhere. I immediately went and told LVN A about this and she said that she would medicate the resident for pain. In an interview with Physical therapy assistant (PTA) on 09/15/16 at 1:10 pm, she said that she saw CR#2 on 08/31/16 in the afternoon. She said: CR#2 was in her room, in the bed and I could tell she was in a lot of pain. I asked her if she was hurting and she was not able to verbalize. I asked her where it was hurting her and she pointed to her hip. She was moaning and seemed very confused. I repositioned her and propelled her legs and told the nurse that CR#2 was in pain. She said she does not remember exactly when this was but it was after lunch. Record review of note completed by PTA and dated 08/31/16 revealed in part that on her arrival the resident was complaining of pain. extensive time taken in figuring out where pain was located .patient said everywhere .asked in hips and knees, pt said yes .communicated with pt nurse regarding pt current condition .roommate states at 2 am she found pt hanging out of bed with head towards floor and feet half in the air and half in bed . In an interview with the DON on 09/15/16 at 1:15pm, she said that she was not aware of CR#2 having hip pain. She said that she thought the pain was only in the knee. She said that LVN A told her that CR#2 was complaining of pain to the lower leg and that she was guarding her foot and knee. She claimed that LVN A falsified her documentation and that CR#2 never had pain to her hip and that an X-Ray was not ordered for her hip on August 12th. The surveyor asked the DON how she knew LVN A falsified documentation as she was the nurse that did the initial assessment. The DON replied: about an hour after LVN A assessed CR#2, I went into the room an assess her and she did not complain of pain to her hip. She said that she did rounds with the physician on August 12th and he wrote on his notes that she needed a hip X-ray but he did not verbalized that to her or wrote an order for [REDACTED]. She said that she did everything she could because every time CR#2 complained of pain, she was medicated with [MEDICATION NAME]. Record review of the facility's Abuse and Neglect Policy revised 04/2007 read in part, - The nurse will assess the individual and document related findings. Assessment data will include: Injury assessment (bleeding, bruising deformity, swelling, etc.), signs of fall, pain assessment . - The nurse will report findings to the physician . The Administrator and the DON were informed that an IJ was identified on 09/15/16 at 3:55 pm and a plan of removal (POR) was requested. A Plan of Removal was received on 09/16/16 at 8:25am. After several revisions were made the Plan of Removal was accepted on 09/16/16 at 4:15pm. The Plan of Removal included in part, .In services on new policy were initiated on 09/15/16 and were completed on 09/16/16. DON, ADON, Staffing coordinator, MDS nurses, and Dept. Heads were in-serviced on new procedure . DON/ADON or Nurse Manager on Duty will run report twice daily (AM/PM) to review Pain scales on all residents. Manager on duty will verify that any pain level 6 and higher have been called into the physician and any needed assessments were conducted .Any new orders for pain medication will also be reviewed in the morning meeting for effectiveness and frequency Reports will be placed in a Pain Monitoring binder and will reviewed weekly by the IDT team to ensure compliance .Nurse managers were all in-serviced on new policy on 09/16/16 . Nurse protocol for pain level 6 and higher was changed to require Physician/NP notification after administration of pain med. Any change in a resident pain profile will require that they nurse fill out a Stop and Watch form to be given to Nurse Manager for review. Nurse will then initiate a Comprehensive pain assessment .Residents with new or worsening complaint of pain should be reported to doctor and X-Ray of affected area should be requested. Any complaints of pain to lower extremities should include hip X-ray. In-Services with Nurses completed on 09/16/16 The Stop and Watch form was amended to include the requirement for a nurse ' s signature and managerial review. The managerial review includes verification that the doctor and resident family member were notified. All departments were in-serviced that a copy must be given to nurse manager after obtaining the nurse ' s signature so the manger can review interventions . X-Ray Company was informed that any positive findings on tests performed must be called into the facility. They will also call the DON or Administrator Any positive fractures will be sent to ER immediately via 911 as a nursing intervention. Doctor will be informed of transfer Rehab Department Communication Process changes They were instructed that notification of the nurse is mandatory. A copy must also be given to the DON, ADON or Staffing Coordinator. They were also directed to report any pain or concerns to the Rehab Director .The Rehab Director will do an end of day report with the Director of Nurses or designated agent to review concerns. The resident that triggered the IJ is currently still in the hospital. Her plan of care has been reviewed and updated as much as possible. Clinical notes from the hospital will be reviewed prior to her readmission to ensure pain management and care needs will be met . All resident that had a falls in September were reviewed for recurrent pain, that a new fall assessment was completed at the time of the incident, doctor was informed of any issues and that care plan was updated. An additional interview with facility Staff after IJ was called: In an interview with CNA B on 09/16/16 at 8:50 am, she said that she worked with CR#2 several times in August. She said that CR#2 had complained of pain several times to I believe the left leg and knee. She said that she had noticed that the left side of her leg was different than the right side because it was more swollen. The CNA said: She would moan in pain anytime I tried to change her or reposition her. She normally was not like that. I can't recall her being like that prior to her fall. Every time she complained of pain, I would tell the nurse and the nurse would give her pain medicine. In an interview with CNA C on 09/16/16 at 3:00 pm, she said, I remember CR#2 grabbing onto her leg and screaming whenever I was changing her. When I reposition her, she would scream in pain. I cannot remember which leg it was but I do remember her being in pain every time I repositioned her. In a phone interview with CNA D on 09/16/16 at 3:30pm, he said that early morning on August 31st, he was coming out of another resident ' s room when he heard screaming coming from the end of the hall. He ran over and found that it was coming out of CR #2 and Resident #4's bedroom. He rushed over and saw that it was Resident #4 that was screaming, he ran over and asked what she needed. She pointed to her roommate which was CR#2. CR#2 ' s head was facing down, almost hanging off the bed but was still on the bed. She was lying in a weird way. I asked CR#2 what she was doing, and she said that she does not know. I went to get the nurse, and we both repositioned her together to the center of the bed. She didn't want to lie on her left side, she was guarding it. She preferred being on her right side. Every time I have tried to change her and move to the left side, she would refuse to move to that side. In an interview with LVN B on 09/16/16 at 3:15pm, she said that she was working early morning on 08/31/16 she went in and assessed CR#2 because the CNA came and told her that she was needed in that room. The nurse said: When I went in, I assessed the patient and took her vitals. I asked her if she was in pain and she pointed to her hip. I medicated her with [MEDICATION NAME]. I went to reassess her after about an hour and she was sleeping. I did not notify the NP or Physician because after I gave her the medication she was fine. She slept through my shift. The facility was monitored on 09/16/16 and 09/17/16. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff representing all three shifts had been in-serviced from 09/15/16-09/16/16. The topics included in part: Signs and symptoms of pain, Reporting pain to charge nurse, Stop & Watch protocol, Pain Scale ( verbal and non-verbal), Stop & Watch and change of behavior, Stop & Watch and change in conditions of Resident and reporting, and Nursing Communication. Further review of documentation provided revealed that all residents that had falls in September were assessed for pain on 09/16/16 and Physician or NP were notified if pain level was 6 or higher. Observations were made from 09/16/16-09/17/16 to ensure adequate supervision was provided and pain issues were being addressed by staff. Interviews were conducted from 09/16/16-09/17/16 with CNAs, Nurses, administration, Therapy and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services. In an interview with the DON on 09/16/16 at 12:53pm, when asked how the IJ came about she said that it was poor communication. She said that they would not have had the IJ if CR#2 did not have pain. She said that the resident ' s hip pain was not communicated to her and even the physician that did rounds with her did not tell her about an order for [REDACTED].>In an interview with the Administrator on 09/16/16 at 1:05 pm, when asked how the IJ came about, he said that it was lack of communication between the departments. He said CR#2 ' s pain issues was not communicated effectively between departments. He said that they could have done a better job of monitoring the pain for example monitoring the pain daily instead of weekly. He said that now when the X-Ray comes back positive the nurses can send the patient out via 911 verses before waiting for the doctor ' s order which delays the process. He said I became aware of the [MEDICAL CONDITION] on August 31st. Before that, I only knew of the hand and knee pain. In an interview with the ADON on 09/17/16 at 9:30am, she said that since they started implementing the pain monitoring daily, she has already been seeing a great improvement. She said that she reviewed all pain assessments and ensured that the nurses had documented that that they notified physician or NP for pain level 6 and higher. The Administrator and DON were informed on 09/17/16 at 10:10 am that the IJ was lowered; however the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy at an pattern level due to facility needing more time to monitor the plan of removal for effectiveness. The facility Incident and Accident report identified 24 residents who fell during August 2016.

Based on observation, interview and record review the facility failed to ensure 1 of 10 residents (CR #2) reviewed for quality of care were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. - CR #2 sustained a fall on 08/12/16 and had complaints of pain to the left hip. The facility failed to provide adequate pain management to CR #2 when she had signs and complaints of pain on her left hip/tight area for 18 days. - On 08/30/16 the PT failed to report to the nursing staff that CR #1 was experiencing severe pain. - On 08/31/16 CR #2 was found with her head hanging from the bed and her lower body still in bed and she was complaining of pain. - An X-ray was done on 08/31/16 revealed an acute interochanteric [MEDICAL CONDITION] hip. CR #2 was sent to the hospital on [DATE] 18 hours after she was found in bed with complains of hip pain. CR #2 remains in the hospital. An IJ was identified on 09/15/16. While the IJ was lowered on 09/17/16, 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 was continuing to monitor the implementation and effectiveness of their plan of removal. This failure affected 1 discharged resident that required surgical intervention for her injuries and could place 23 residents identified by the facility as having falls during the month of August 2016 at risk of not receiving adequate medical care, pain, and decline in their health condition well-being. Findings Include: CR #2: Record review of CR #2 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. CR #2 was discharged to the hospital on [DATE]. Record review of the Minimum Data Set (MDS) assessment, dated 07/28/16 revealed CR #2 had severely impaired cognitive skills for daily living. She was totally dependent on one staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. She was occasionally incontinent of bowel and bladder. Record review of CR #2 ' s initial care plan dated 07/26/16 and revised on 09/01/16 read in part, Resident is at risk for falls and is at risk for increased falls and injury. Confusion .Actual fall- 08/12/16- observed on floor Interventions read in part, X-ray lower extremity . Record review CR #2 ' s facility Incident Report dated 08/12/16 at 3:20 pm read in part, Res found on floor laying at foot of bed. Res complained of pain to LE extremities. Further interventions included- initial interventions to prevent future falls: X-ray of left lower extremities. Further review of the form revealed IDT met to review resident ' s fall on 08/12/16. Resident attempted to transfer self-unassisted. Res c/o pain to LE, X-ray done, no fracture identified. MD in building N.O (new order) for [MEDICATION NAME] for pain management. Additional care plan/Nurse Aide Assignment Updates: 1) scoop mat in place (initiated), 2) x-ray negative, 3) falling star program initiated. Record review of the Physician ' s note dated 08/12/16 read in part, Labs Ordered: Noted .X-Ray the L Hip and X-Ray of the L knee There was no evidence that X-rays were done for the left hip. Record review of CR#2 ' s X-rays revealed the following X-rays results: 08/12/16-Left tibia and fibula Impressions: no evidence of fracture 08/12/16- Left Ankle Impressions: no definite radiographic evidence of acute fracture or dislocation 08/13/16-Left Hand Impressions: Significant [MEDICAL CONDITION] changes with no evidence of acute displaced fracture. Record review of the Nurses notes dated 08/12/16 read as follows: .At 10:17 am-Resident was observed on floor at foot of bed lying on lt (left) side. Resident is in pain upon movement of it . (lower extremity). But can move it slightly, V/S ' s taken and stable, resident assisted up off of floor, and into W/C, and then back to bed, resident now lying on the rt (right) side. (X ray company) here in facility, and charge nurse called to place order for X-ray to be done to the left lower ext .procedure done, results pending, NP notified of fall, and stated that the doctor would be in the facility today and to have him assess the resident . later resident started guarding lt (left) hip/thigh area, and X-Ray company was called to do a X-Ray of Lt. hip and femur . There was no documentation that pain medication was administer at this time. Completed by LVN A. At 3:00 pm- Addendum order received for X ray of left lower extremities d/t swelling and resident guarding left knee and foot .completed by LVN A At 3:15 pm- resident c/o of upper left leg hurting, and guarding thigh area, (company) called for stat X-Ray to the left hip and femur .There was no documentation that the resident was medicated at this time. Completed by LVN A At 10:39 pm- Medicated resident with [MEDICATION NAME] at this time for pain level of 3 to left leg . Record review of Nurse note dated 08/14/16 at 1:46 pm revealed in part that X-ray result of left hand was received and showed no fracture. Resi9dent medicated for pain with [MEDICATION NAME], assessed after an hour and no pain noted. Record review of the Nurses notes for CR#2 revealed that there was no mention of the hip X-ray results or documentation of pain issues from 08/14/16 until 08/31/16. Record review of pain assessment records for the month of August 2016 revealed that CR # had complaints of pain on the following days: 08/12/16- level 3 in the afternoon 08/13/16- level 5 in the morning and level 3 in the afternoon. 08/14/16- level 5 in the morning. 08/18/16- level 4 in the morning. 08/14/16- level 4 in the morning. 08/19/16-level 4 in the morning. 08/24/16- level 5 in the morning. 08/29/16- level 5 in the morning. 08/31/16- level 3 in the afternoon. Record review or the MAR for CR#2 dated 08/01/16-08/31/16 revealed the following: [MEDICATION NAME] HCL tablet 50mg give 1 tablet by mouth every 4 hours as needed for pain, ordered 08/12/16. The form indicated that the resident only received pain medication on: 08/12/16- pain level 3, medication administered at 1854-Effective 08/13/16-pain level 5, medication administered at 1402-Ineffective 08/13/16- pain level 2, medication administered at 2228-Effective 08/25/16-pain level 5, medication administered at 0850-Effective 08/31/16- pain level 5, medication administered at 0213 -Effective Record review of Nurse ' s note dated 08/19/16 and signed by LVN A revealed that the residents ' family member inquired about fall .family member suggested that PT see resident for strengthening and ambulation . Record review of physician telephone orders dated 08/30/16 revealed an order for [REDACTED].>Further review revealed another order dated 08/30/16 for PT to evaluate and treat for three weeks for therapeutic exercise, mobility and gait for pain in knees, left hip and joint abnormalities. Record review of the Physical Therapy plan of Care notes for CR#2 dated 08/30/16 revealed the following: Treatment Diagnosis: [REDACTED].The patient reports a pain scale rating of 10 out of 10 for L knee pain, R knee pain and L hip 7/10. There was no documentation on the note to indicate that the nurses were informed of pain level for the resident. In an interview with the Physical Therapist on 09/15/16 at 1:02 pm, he said that he saw CR#2 on 08/30/16 because of knee pain. During the initial assessment, I asked her if she was in pain and she said that she was. She said she had pain to both knees and hip. I tried to stand her up on the parallel bar and there was a loud thud to her knee, so I sat her back down. She was in pain. She verbalized pain and she was also moaning. It was very hard for her to move physically. He said that after the assessment he brought the resident back to the T.V. room. The physical therapist said that he did not tell nursing about her pain issues because they brought her to me because she had pain so therefore I didn't feel the need to tell them. Record review of the Nurses notes dated 08/31/16 read as follows: At 02:13 am- Res was noted with her head out of the pillow and slightly hanging out of her bed. She stated she was trying to get comfortable in bed and that she was fine. Assessed, no bruises or injuries were noted. C/O pain to left hip . At 3:00 am- note revealed prn medication administered and effective .signed by LVN B At 1:24 pm- Charge nurse received (new order) for X-Ray to the right Hip stat, and a Arterial/Venous Doppler to the left leg R/T pain from a previous fall, order called in and X-Ray will be out today to perform procedure completed by LVN A At 7:20 pm- Resident ' s stat X-ray of left hip results received with impression: Acute fracture. Called this results to NP, order given to send resident to . At 8:28 pm- Resident left facility via stretcher . Record review of physician telephone order dated 08/31/16 revealed left hip X ray stat for pain status [REDACTED].sign by LVN A and time noted was 2:00 pm Record review of X ray result dated 08/31/16- revealed Left Hip, Impressions: Acute [MEDICAL CONDITION] femur, intertrochanteric. Record review of hospital progress note dated 09/01/16 revealed the following notes: Physical Examination: shows her left leg to be flexed and externally rotated. She has pain with range of motion .Left hip externally rotated .The patient appears to be in mild distress with the pain .fracture of left hip . Record review of Resident #4 ' s MDS assessment dated [DATE] revealed that she had moderately impaired decision making skills and was able to understand others and be understood. In an interview with Resident #4 on 09/15/16 at 10:15 am, she said that she was the roommate of CR#2. She said that she was in the hospital and returned to the facility on [DATE]th. She said that when she came back from the hospital, CR#2 seemed like a different person. The resident said: They told me that she had a fall while I was gone. Every time someone tried to reposition her she would scream bloody murder and she would say things like, I can ' t take it anymore. Resident #4 said that on the night of 8/30 around 11:30pm: I saw CR #2 lying on her left side and she kept moaning. The CNA came in and he repositioned her to the other side and he left the room. Then I fell asleep and I woke up to something around 1:30 am. I looked over and all I could see was her legs in the air, I could not see her body. She was not on the bed. I pressed the call light right away and waited. No one came. I waited until almost 2 am and still there was no one coming. I wanted to help her but I could not move on my own, I was helpless. I did not know what else to do. My cell phone was away from me charging otherwise I could have used that to call the nurses ' station. Then I picked up the small container of lotion from my bedside table and tried to throw it out the room so that someone would see it and it would catch their attention. I threw the bottle but it hit the wall and did not make it outside the room. I wanted to scream and yell for help but with [MEDICAL CONDITION] made it difficult. I decided to try anyway and screamed with everything I got. No one came in. I screamed again and this time CNA D came running in. By this time, I was out of breath and could barely talk. CNA D, rushed over to me and I pointed to bed A, he quickly went over and assisted CR#2. CNA D then went and got the nurse and the nurse came in. CR#2 was moaning all this time and the nurse came and gave her medication. I kept telling the nurse since I came back from the hospital that something was wrong with CR#2 and that I think she broke something because of the way she was screaming during care. She said that CR#2 was not like that before she had that fall (08/12/16). Observation on 09/16/16 at 11:50 am revealed that CR #2 was in the hospital. She was in the Intensive Care Unit. She was lying down on the bed on her back. A staff member was next to her, assisting her with her lunch. CR #2 was confused and was unable to answer questions. In an interview on 09/16/16 at 11:55 am with hospital staff, she stated that resident had a ORIF to the left hip and that she was doing better now. She said the resident still required total assistance for everything. In a phone interview with LVN A on 09/15/16 at 12:15pm, she said that she was the nurse that did the assessment on CR#2 after her fall on 08/12/16. She explained that after the fall, she assisted the resident back to her wheelchair. She said the resident complained of pain to her knee and left hip. She said she called the NP to notify, the NP told her that the doctor will be in and that he will assess the patient. The doctor came in shortly after and he did rounds with the DON. She said the doctor went to see CR#2 with the DON. After the rounds, the DON gave me order for [MEDICATION NAME] 50mg. LVN A said that there was so much going on that day so she does not remember the details and exactly what she documented. She said that she did order for hip X-ray but it was never done. She said that when she came back to work the next day and asked staff about it, no one knew anything about it. She said that after this fall, time to time when we touched her or moved her, she will scream in pain. Every time she complained of pain, I would medicate her with the [MEDICATION NAME]. She said that she spoke with the DON about CR #2 being in pain but she does not know what was done about it. She explained that CR#2 never complained of pain prior to this fall so she knew something was going on. I was the only one trying to figure out why she was in pain. The other nurses didn ' t do anything. LVN A said that her documentation was true and that she had not falsified anything. After the fall, CR#2 was holding her hip. LVN A said that during morning meetings, she would bring up CR#2 ' s pain but no one seemed to care. In an interview with CNA A on 09/15/16 at 11:40 am, she said that she had worked with CR#2 after the fall incident. She said she does not remember the exact date but it was somewhere around 08/12/16 when she was doing incontinent care and CR#2 was screamed in pain. I asked her if she was in pain and she said that she was. She said that her legs were hurting. At this time I did not notice any bruising or swelling anywhere. I immediately went and told LVN A about this and she said that she would medicate the resident for pain. In an interview with Physical therapy assistant (PTA) on 09/15/16 at 1:10 pm, she said that she saw CR#2 on 08/31/16 in the afternoon. She said: CR#2 was in her room, in the bed and I could tell she was in a lot of pain. I asked her if she was hurting and she was not able to verbalize. I asked her where it was hurting her and she pointed to her hip. She was moaning and seemed very confused. I repositioned her and propelled her legs and told the nurse that CR#2 was in pain. She said she does not remember exactly when this was but it was after lunch. Record review of note completed by PTA and dated 08/31/16 revealed in part that on her arrival the resident was complaining of pain. extensive time taken in figuring out where pain was located .patient said everywhere .asked in hips and knees, pt said yes .communicated with pt nurse regarding pt current condition .roommate states at 2 am she found pt hanging out of bed with head towards floor and feet half in the air and half in bed . In an interview with the DON on 09/15/16 at 1:15pm, she said that she was not aware of CR#2 having hip pain. She said that she thought the pain was only in the knee. She said that LVN A told her that CR#2 was complaining of pain to the lower leg and that she was guarding her foot and knee. She claimed that LVN A falsified her documentation and that CR#2 never had pain to her hip and that an X-Ray was not ordered for her hip on August 12th. The surveyor asked the DON how she knew LVN A falsified documentation as she was the nurse that did the initial assessment. The DON replied: about an hour after LVN A assessed CR#2, I went into the room an assess her and she did not complain of pain to her hip. She said that she did rounds with the physician on August 12th and he wrote on his notes that she needed a hip X-ray but he did not verbalized that to her or wrote an order for [REDACTED]. She said that she did everything she could because every time CR#2 complained of pain, she was medicated with [MEDICATION NAME]. Record review of the facility ' s Pain Assessment and Management policy revised 10/2010 read in part: - Assess the resident ' s pain and consequences of pain at lease each shift for acute pain - Recognizing Pain- Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. - Possible Behavioral Signs of Pain- Verbal expressions such as groaning, crying, screaming . facial expressions such as grimacing Limitations in his or her level of activity due to the presence of pain . Guarding, rubbing or favoring a particular part of the body - Review the resident ' s clinical record to identify conditions or situations that my predispose the resident to pain including Fractures following information to the physician or practitioner Significant changes in the level of the resident ' s pain . The Administrator and the DON were informed that an IJ was identified on 09/15/16 at 3:55 pm and a plan of removal (POR) was requested. A Plan of Removal was received on 09/16/16 at 8:25am. After several revisions were made the Plan of Removal was accepted on 09/16/16 at 4:15pm. The Plan of Removal included in part, .In services on new policy were initiated on 09/15/16 and were completed on 09/16/16. DON, ADON, Staffing coordinator, MDS nurses, and Dept. Heads were in-serviced on new procedure . DON/ADON or Nurse Manager on Duty will run report twice daily (AM/PM) to review Pain scales on all residents. Manager on duty will verify that any pain level 6 and higher have been called into the physician and any needed assessments were conducted .Any new orders for pain medication will also be reviewed in the morning meeting for effectiveness and frequency Reports will be placed in a Pain Monitoring binder and will reviewed weekly by the IDT team to ensure compliance .Nurse managers were all in-serviced on new policy on 09/16/16 . Nurse protocol for pain level 6 and higher was changed to require Physician/NP notification after administration of pain med. Any change in a resident pain profile will require that they nurse fill out a Stop and Watch form to be given to Nurse Manager for review. Nurse will then initiate a Comprehensive pain assessment .Residents with new or worsening complaint of pain should be reported to doctor and X-Ray of affected area should be requested. Any complaints of pain to lower extremities should include hip X-ray. In-Services with Nurses completed on 09/16/16 The Stop and Watch form was amended to include the requirement for a nurse ' s signature and managerial review. The managerial review includes verification that the doctor and resident family member were notified. All departments were in-serviced that a copy must be given to nurse manager after obtaining the nurse ' s signature so the manger can review interventions . X-Ray Company was informed that any positive findings on tests performed must be called into the facility. They will also call the DON or Administrator Any positive fractures will be sent to ER immediately via 911 as a nursing intervention. Doctor will be informed of transfer Rehab Department Communication Process changes They were instructed that notification of the nurse is mandatory. A copy must also be given to the DON, ADON or Staffing Coordinator. They were also directed to report any pain or concerns to the Rehab Director .The Rehab Director will do an end of day report with the Director of Nurses or designated agent to review concerns. The resident that triggered the IJ is currently still in the hospital. Her plan of care has been reviewed and updated as much as possible. Clinical notes from the hospital will be reviewed prior to her readmission to ensure pain management and care needs will be met . All resident that had a falls in September were reviewed for recurrent pain, that a new fall assessment was completed at the time of the incident, doctor was informed of any issues and that care plan was updated. An additional interview with facility Staff after IJ was called: In an interview with CNA B on 09/16/16 at 8:50 am, she said that she worked with CR#2 several times in August. She said that CR#2 had complained of pain several times to I believe the left leg and knee. She said that she had noticed that the left side of her leg was different than the right side because it was more swollen. The CNA said: She would moan in pain anytime I tried to change her or reposition her. She normally was not like that. I can't recall her being like that prior to her fall. Every time she complained of pain, I would tell the nurse and the nurse would give her pain medicine. In an interview with CNA C on 09/16/16 at 3:00 pm, she said, I remember CR#2 grabbing onto her leg and screaming whenever I was changing her. When I reposition her, she would scream in pain. I cannot remember which leg it was but I do remember her being in pain every time I repositioned her. In a phone interview with CNA D on 09/16/16 at 3:30pm, he said that early morning on August 31st, he was coming out of another resident ' s room when he heard screaming coming from the end of the hall. He ran over and found that it was coming out of CR #2 and Resident #4's bedroom. He rushed over and saw that it was Resident #4 that was screaming, he ran over and asked what she needed. She pointed to her roommate which was CR#2. CR#2 ' s head was facing down, almost hanging off the bed but was still on the bed. She was lying in a weird way. I asked CR#2 what she was doing, and she said that she does not know. I went to get the nurse, and we both repositioned her together to the center of the bed. She didn't want to lie on her left side, she was guarding it. She preferred being on her right side. Every time I have tried to change her and move to the left side, she would refuse to move to that side. In an interview with LVN B on 09/16/16 at 3:15pm, she said that she was working early morning on 08/31/16 she went in and assessed CR#2 because the CNA came and told her that she was needed in that room. The nurse said: When I went in, I assessed the patient and took her vitals. I asked her if she was in pain and she pointed to her hip. I medicated her with [MEDICATION NAME]. I went to reassess her after about an hour and she was sleeping. I did not notify the NP or Physician because after I gave her the medication she was fine. She slept through my shift. The facility was monitored on 09/16/16 and 09/17/16. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff representing all three shifts had been in-serviced from 09/15/16-09/16/16. The topics included in part: Signs and symptoms of pain, Reporting pain to charge nurse, Stop & Watch protocol, Pain Scale ( verbal and non-verbal), Stop & Watch and change of behavior, Stop & Watch and change in conditions of Resident and reporting, and Nursing Communication. Further review of documentation provided revealed that all residents that had falls in September were assessed for pain on 09/16/16 and Physician or NP were notified if pain level was 6 or higher. Observations were made from 09/16/16-09/17/16 to ensure adequate supervision was provided and pain issues were being addressed by staff. Interviews were conducted from 09/16/16-09/17/16 with CNAs, Nurses, administration, Therapy and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services. In an interview with the DON on 09/16/16 at 12:53pm, when asked how the IJ came about she said that it was poor communication. She said that they would not have had the IJ if CR#2 did not have pain. She said that the resident ' s hip pain was not communicated to her and even the physician that did rounds with her did not tell her about an order for [REDACTED].>In an interview with the Administrator on 09/16/16 at 1:05 pm, when asked how the IJ came about, he said that it was lack of communication between the departments. He said CR#2 ' s pain issues was not communicated effectively between departments. He said that they could have done a better job of monitoring the pain for example monitoring the pain daily instead of weekly. He said that now when the X-Ray comes back positive the nurses can send the patient out via 911 verses before waiting for the doctor ' s order which delays the process. He said I became aware of the [MEDICAL CONDITION] on August 31st. Before that, I only knew of the hand and knee pain. In an interview with the ADON on 09/17/16 at 9:30am, she said that since they started implementing the pain monitoring daily, she has already been seeing a great improvement. She said that she reviewed all pain assessments and ensured that the nurses had documented that that they notified physician or NP for pain level 6 and higher. The Administrator and DON were informed on 09/17/16 at 10:10 am that the IJ was lowered; however the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy at an pattern level due to facility needing more time to monitor the plan of removal for effectiveness. The facility Incident and Accident report identified 24 residents who fell during August 2016.

Based on interview and record review the facility failed to ensure that the resident's environment remained free of accident/hazards and received assistance devices during transfers for 1 of 10 residents reviewed for prevention of avoidable accidents and injuries. (CR #1). -- CNA A transferred CR #1 from the shower bed to the bed without the assistance of another staff member as required by the MDS and care plan. CR #1 slid out of the hoyer lift sling and the resident fell to the floor sustaining a laceration to the left side of his head that required hospitalization . This failure affected one discharged resident and placed 9 other residents in Hall 100 Unit requiring assistance with full body transfers at risk for injury and unnecessary pain. Findings include: CR #1: Record review of the face sheet for CR #1 revealed that he was [AGE] years old. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was transferred to the hospital on [DATE]. Record review of CR #1's Initial Minimum Data Set assessment completed on 05/27/16 revealed he required total assistance of two staff for transfers and had limitation of movement on one side of his upper and lower extremities. Record review of CR #1's care plan dated 5/27/16 for activities of daily living (ADLs) revealed he required total assistance with transfers using a Full-Body lift with a sling and assistance of 2 CNA's for transfers. His care plan for transfer deficit due to limitation to the upper and lower extremities revealed he required two CNA's to transfer using a Hoyer lift. Review of the facility incident report dated 8/03/16, revealed the CR #1 required total assistance with transfers and was interviewable. The description of the incident was While CNA A was transferring CR #1 from the shower. She utilized a Hoyer Lift but perform the transfer alone in the violation of the plan of care and standard mechanical lift procedures. CR #1 fell and had a laceration to the left side of his head. He was sent to the emergency room . LVN A provided first Aid to Resident to stop bleeding. 911 was called. They arrived at 9:15 p.m. and assumed care of CR #1. Interview on 08/09/16 at 2:00 p.m. with CNA A said CR #1 wanted a shower so she asked MA B to assist her in transferring him to the shower bed. She said she knew the resident was a two person transfer so that was why she got the MA to help her. She said she took him to the shower room and when she came back she looked around for help but could not find any one to assist her. She said that the resident started complaining that he was cold. She said that she told him she had to wait for help but the resident got upset and started yelling that he was cold. She said at that point she decided to transfer him by herself. She said she hooked him up to the Hoyer lift and was about to put him in bed and he slid up of the sling and fell to the floor. She said she called for help and the nurse came and assessed him as he was bleeding from the head. She said the nurse try to stop the bleeding and 911 was called and CR #1 was sent to the hospital. Further interview at that time CNA A said after the fall one CNA told he she was using the wrong sling she should have used the mesh sling. During an interview on 08/09/16 at 9:30 a.m. the DON said the facility had in-serviced staff after CR #1's fall on 08/04/16 . She said they had met with the staff again that morning and re-trained the night staff regarding lift transfers and using 1-2 staff for each transfer as stated in their care plans. She said the facility developed a new system and now required the nurse to indicate on the wall behind the resident's bed how many people needed for Hoyer lift or any other method of transfer for resident who needed staff to transfer them. She said when the resident care plans required 1-2 staff as needed, the number of staff that would be used for a transfer was determined by the CNA's and nursing according to each resident's condition or change in condition. She said the nursing staff would notify their supervisor if a resident became anxious or combative or if any other changes in condition occurred. In an interview 08/09/16 at 9:40 p.m. with the Staff Coordinator she said they would in-service nursing staff regarding resident transfers and the use of the Hoyer lift. She said they in-serviced nursing staff after CR #1's fall about the change in transferring technique. She said after the in-serviced the nursing staffs did return demonstration of Hoyer lift transfer. She said she concentrated on the safety of the transfer. Record review of the facility policies revealed policies in place for: - Fall Intervention program undated. Any fall (observed or non-observed will be reported Record review of the facility policies revealed policies in place for falls: A fall is defined as a sudden, uncontrolled, unintentional downward displacement of the to the ground or other object, excluding falls resulting from violent blows or other purposeful actions Resident should be evaluated for their fall risk. On admission, monthly and any change of status. The facility report revealed 10 residents required the use of Hoyer lifts for transfers.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there was a change in condition in one of 11 residents (CR#1) reviewed for consulting with the physician. - CR #1 sustained a fall on 12/13/15 at 11:45 pm. RN A and LVN A did not consult with a physician of x-ray results showing a probable fracture to the right hip and actual fracture to the right wrist. This resulted in a delay of 18 hours in sending CR #1 to receive treatment in the hospital. CR #1 remains in the hospital after two surgical interventions. An IJ was identified on 12/29/2015. While the IJ was removed on 12/31/2015, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 discharged resident that required surgical intervention for her injuries and could place 13 residents identified by the facility as having falls during the month of December 2015 at risk of not receiving adequate medical care, pain, decline in their health condition well-being. Intake ID # 4 Findings Include: CR #1: Record review of CR #1 ' s face sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. CR #1 was discharged to the hospital on [DATE]. Record review of CR #1 ' s initial care plan dated 12/3/2015 read in part, Resident is at fall risk related to fall risk score, new admission, impaired balance, ambulatory and placed on falling star program. Actual fall- 12/13/2015- found on floor in another resident room. Interventions read in part, X-ray right arm, hip . All staff to observe resident when passing and inform nursing if found to have any problems with . pain . Record review CR #1 ' s facility Incident Report dated 12/13/2015 at 11:45 pm read in part, that the resident was found laying on her back in another resident ' s room near the bathroom door . Language barrier- but resident was holding right hand and grimacing .Immediate action taken: Assessed for pain .No bruises noted . ROM to bilateral arm and left leg, could not lift the right leg. Head placed on pillow and doctor called .No injuries observed . Level of pain 4 (0-4 is considered mild pain in a scale of 1 to 10) . Injuries report post incident, right trochanter (anatomical part of the femur connecting to the hip bone), right hand . Attending Physician notified 12/13/2015 at 11:45pm. Record review of CR #1 ' chart revealed an incomplete SBAR note dated 12/13/2015 and timed 11:45 pm read in part, The change in condition, symptoms or signs I am calling about is: fall- pain Things that make the condition or symptom worse: movement . Record review of the Provider Investigation Report submitted 12/17/2015 detailing CR #1 ' s un witnessed fall on 12/13/2015 read in part, Resident speaks Chinese only with broken English . Description of the Allegation- Resident had a fall on 12/13/2015 with fracture . Provider Response- Assessment by nurse, neuro check initiated, POA notified, MD notified, orders received for x-ray, care plan updated . Investigation Summary- On 12/13/2015 while nurse was doing rounds she noted resident was on floor . resident was holding her right hand and grimacing. Call placed to resident ' s MD and received order for hip and hand x-ray stat . MD called to follow up with recommendation of the radiologist. Resident was sent to emergency room for MRI on 12/14/2015 . Prior to fall on 12/13/2015 Resident required minimal to moderate assistance with ambulation. Observation on 12/30/15 at noon revealed that CR #1 was in the hospital. She was sitting in a wheelchair waiting for her lunch tray. A family member was with her. Further observation revealed she had a cast on her right arm, extending from her wrist to above her elbow. Her upper hand and fingers were bruised. CR #1 was confused and was unable to answer questions. In an interview on 12/30/15 at 12:05 pm, the family member stated that CR #1 was still not able to walk and was tired all the time. He said the resident was in therapy and would be discharged back to a facility on 1/8/16. In an interview on 12/30/15 at 12:18 pm the hospital RN said that CR#1 had surgeries on her right hip and right wrist and is now receiving therapy. She said the resident now needed to be fed by staff and required total assistance of three or more staff for transfers. CR #1 is non-weight bearing. Record review of hospital progress note dated 12/15/15 revealed that the resident was admitted after right femoral fracture on 12/13/15. Further review revealed that CR #1 was in a skilled facility waiting for an X-ray. When the family came and found her in great pain and brought her to the hospital complaining of right hip and leg pain .movement exacerbated the pain. The hospital found CR #1 had a right Colles (lower end of the radius in the wrist) fracture. The resident required surgery on 12/15/15 of an open reduction and internal fixation of the right femur and a close reduction of her right arm. Record review of CR #1 ' s chart revealed the following radiology reports dated 12/14/2015: - Fax server date 12/14/2015 and time 2:19 am read in part, Preliminary Radiology Interpretation . Date of exam- 12/14/2015 at 1:21 am . 2 views of the right hand . Impression: Age-indeterminate distal radial fracture . Single view of right hip . Impression: Probable non-displaced intertrochanteric fracture. There was no hand written notes on the report from facility staff. - Fax server date 12/14/2015 and time 8:24 am read in part, Preliminary Report Exam date 12/14/2015 . Right hip . Impression: Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. There was no hand written notes on the report from facility staff. - Fax server date 12/14/2015 and time 8:57 am read in part, Final report . Exam date 12/14/2015 . Right hip. Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. Hand written note on the report read, Noted. Called in to Dr ' s office, faxed also. 12/14/2015 . There was no time or name/initial of the person who hand wrote the note and called the physician. - Fax server date 12/14/2015 and time 8:57 am revealed another copy of the same final reports read in part, . Exam date 12/14/2015 . Right hip. Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. Hand written note on the report read: Send to (local hospital). MRI of the Hip. [MEDICATION NAME] 50mg x1. There was no date, time or name/initial noted on the hand written note. - Fax server date and time illegible report read in part, Final report . exam date 12/14/2015 Right hip. Possible non-displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding . further review of the document revealed a note from the radiology company stating that report had been called in to: LVN A on 12/14/2015 at 2:40 pm. In an interview with the facility DON on 12/29/2015 at 10:25 am, she stated the fax server date and time listed at the top of the radiology reports reflects the date and time the fax arrived to the facility ' s fax machine. When asked what time CR #1 ' s physician was notified of the radiology results she stated she would check. Record review of CR #1 ' s chart revealed Neurological (Neuro) Checks dated 12/14/2015 and timed 12:00 am read in part, Most recent pain level: 4 Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 and timed 12:15 am read in part, Most recent pain level: 4 . Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 at 12:45 am read in part, Most recent pain level: 5 . Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 at 5:45 am read in part, Pain level: 4 . Hand grasps- left grasp greater than right . Unable to move right leg. There was no documentation that the physician was informed of the pain issues or that pain medication was administered. Record review of CR #1 ' s December pain assessment flow sheet revealed the following: -12/13/2015 Night shift- Pain level 3/10 (mild pain) -12/14/2015 Day shift- Pain level 10/10 (worst possible pain level) -12/14/2015 Evening shift- Pain level 10/10 Record review of CR #1 ' s December 2015 MAR indicated [REDACTED] -[MEDICATION NAME] Tablet 50mg, give 1 tablet by mouth one time only for pain. - Order date 12/14/2015 at 3:48pm. Pain level- 10/10. Administration date/time- 12/14/2015 at 6:14 pm. Further review of the December 2015 MAR indicated [REDACTED]. Further review revealed that the resident had no orders for pain medication on record. Record review of CR #1 ' s December 2015 physicians ' orders revealed the following orders: -X-ray to right hip and right hand due to pain/fall. Order date 12/14/2015, order time: 12:30am. -Send to West Houston hospital dx [MEDICAL CONDITION]. Order date 12/14/2015, order time: 3:47 pm. -[MEDICATION NAME] tablet 50 mg, give one tablet one time only for pain for 1 day. Order date 12/14/2015, order time: 3:48 pm. -There were no orders for scheduled or PRN pain medications other than the above order for [MEDICATION NAME] 50mg. Record review of CR #1 ' s progress notes revealed the following nurse ' s notes: - 12/14/2015 at 5:24 am- Found this resident in room [ROOM NUMBER] . Resident was laying on the floor. Walker was on the side . Resident holding right hand and grimacing. Grimaced more and yelling when assessing the right side of her body. No bruising noted. Left on the floor with pillow under head. Doctor called who gave orders for right hand and right hip x-ray . X-ray results back and called placed to the doctor . Awaiting call back . Neuro checks started . - 12/14/2015 at 6:31 am- No call back from the doctor yet. Report given to nurse on floor. Resident resting at this time, no sign of distress. - 12/14/2015 at 12:13 pm- Patient complained of right leg pain. status [REDACTED]. Pain arising from fall. Will continue to monitor and notify physician. - 12/14/2015 at 4:40 pm- Patient is status [REDACTED]. Report called to PCP and faxed also. Family member aware and been present with patient all day during shift. Noted redness on right wrist and right leg swollen. Patient will be transported to (local)hospital . - 12/14/2015 at 5:45 pm- Resident left the facility to the (local hospital ER) related to recent fracture . In an interview with RN A on 12/29/2015 at 11:22 am, she stated she was working the 11pm to 7am shift on 12/13-14/2015 and CR #1 was one of her assigned residents. She stated on the night of 12/13/2015, a CNA C reported CR #1 was found on the floor in another resident ' s room. Upon assessment, RN A stated the resident complained of pain saying Ow,ow,ow , however she stated the resident did not speak English and was unable to describe the location or level of her pain. When CR #1 was moved from the floor to her bed, RN A stated the resident yelled out in pain when her right leg was moved. She stated she notified CR #1 ' s physician who gave orders for x-ray of the right hip and right hand. The x-rays were done and RN A stated she received a phone call from the radiology company that night reporting CR #1 had a fracture to the right wrist and right hip. She stated she did not remember the time of the phone call or if she received a fax of the radiology report. RN A stated she called the resident ' s physician to report the x-ray results, however, she stated she did not receive a return call before her shift ended. She said she did not remember the date and time of the phone call to the physician or how many times she attempted calling. RN A stated CR #1 was in pain saying, Ow, ow, ow throughout the night and touching her right hand and wrist. When asked why she did not have the resident sent to the hospital for further evaluation, she stated it was Up to the physician to determine if patient should be sent to the hospital and I cannot write an order to send the resident to the hospital . She stated she did not provide any pain medication to CR #1 because she thought the resident would be sent to the hospital, but the physician never called back with orders. RN A further stated she could not explain why she did not provide CR #1 with pain medication. She said that around the same time that night, another resident reported falling and hitting her head. Since CR #1 was unable to state if she hit her head (due to language barrier) and no bumps were found on CR #1's head on assessment, RN A stated she felt the other resident's injury warranted more medical attention than CR #1's. RN A also stated the information in the nurses ' note she wrote dated 12/14/2015 at 5:45 am did not accurately reflect the actual timeline of events regarding the resident ' s fall. In an interview with LVN A on 12/29/2015 at 11:54 am, she stated she was the nurse assigned to CR #1 during the 7 am to 3 pm shift. She stated at the beginning of her shift, she got report that CR #1 fell during the night. She denied receiving report from the previous nurse that the resident had pain, the x-ray results or physician notification from the prior shift. LVN A stated she noted redness and pain to CR #1 ' s right wrist and hip during her morning assessment and assessed the resident as being in 10/10 pain due to the residents moaning and yelling , however she did not remember the time of the assessment. She said that at that point, she noticed an x-ray order in the residents chart, however, she had not seen the results. LVN A stated during her shift, she received a phone call from radiology reporting CR #1 ' s x-ray results but stated she did not remember the time of the phone call or what the results were stating It must have been bad since they called with the results . After receiving the x-ray results, she left a message for CR #1 ' s physician via phone and fax, however she was unsure of the time of the notification. LVN A stated she gave CR #1 pain medication but could not remember when she gave the medication or what medication she gave. She added CR #1 did not speak English, however family members were at the bedside who could speak English. She stated she did not receive report from the family regarding the resident being in pain during her shift. LVN A stated the information in the nurse ' s notes she wrote on 12/14/2015 at 12:13 pm and 4:40 pm did not reflect the actual timeline of events during her shift. When asked why she did not call 911 or seek further medical attention for CR #1 she stated that 12/14/2015 was her first day and that, It depends on the severity. I didn't know the patient well and she fell on the night shift. When asked if she received training on physician notification she stated, I 'm sure I did. She did not elaborated on what the training was about. In a phone interview with a family member of CR #1 on 12/29/15 at 1:45pm, she said that facility left her a voicemail the night of the fall informing her of the fall. When the family member came into the facility the next day CR #1 was laying down. She had a bruise on her right wrist. The family member said that when she asked the nurse what had happened to the resident, no one knew exactly what happened just that she had a fall. No one knew any details as to what occurred. She said that CR #1 was laying still but when they tried to move her she was in pain. The family member said that around noon on 12/14/15, the resident seemed to be in more pain so the family member told the nurse to give her pain medication. The nurse told them that they were trying to get a hold of the doctor. She said that staff end up giving her something for pain at around 2 or 3pm, right before the ambulance came to get her. The family member said that the nurse that was working during the day did not know what was going on, because she said that the night nurse did not leave her much information about the patient. The family member said the resident has been in the hospital for 8 days and currently she was at the hospital rehabilitation center for therapy. In an interview with the DON on 12/29/2015 at 1:00 pm, she stated she saw CR #1 during her morning rounds and the resident did not appear to be in distress. She stated she observed the resident and but did not do a physical assessments of the resident. The DON stated that when radiology called at around 2:00 pm with the results of CR #1 ' s x-ray, the attending physician was notified and orders for pain medication and transfer to the hospital were given. The DON then added that nothing could have been done differently. She stated a physician's orders [REDACTED].#1 to the hospital for a MRI. Since the radiology report stated there was a probable facture and CR #1 did not have any signs of obvious fracture, the DON stated ER transfer was not indicated. She also stated sending the resident to the ER with results of a probable fracture could contribute to recidivism and the hospital may send her back to the facility due to lack of physician's order [REDACTED]. She stated the resident was medicated that afternoon but was unsure of the time. When shown documentation on CR #1 ' s MAR indicated [REDACTED]. She stated the resident should have been medicated for pain sooner and was unsure why treatment was delayed. The DON added she was also unsure when CR #1 ' s x-ray results were initially received or when attempts to notify CR #1 ' s physician of the x-ray results were initially made. She stated the resident's attending physician was difficult to contact and that the medical director could have been notified to receive orders for treatment. The DON said this was the policy for the facility. A policy was requested but was not provided before the exit. In further interview with the DON on 12/29/2015 at 1:48 pm, she stated nurses were to document the time lab results are received, the time of physician notification, and the time medications are administered to residents and that she recognized the problem with documentation during the incident investigation. However, she stated she did not do any formal in-servicing regarding physician notification or documentation. The DON further stated that if a resident 's attending physian cannot be reached, the policy to call the medical director for orders. She added that she did not know why CR #1 was not medicated in a timely manner or why the medical director was not notified when the attending physician could not be contacted. CR #1 ' s physician was called on 12/29/2015 at 2:50 pm, however his office stated he was unavailable until 1/4/2016. Interview with CNA A on 12/30/15 at 10:00 am, she said that she worked with CR #1 on 12/14/15 during the day shift. She explained that when she was doing her usual morning rounds with CR #1, she kept pointing to her right hand and wrist. She said I then stepped out to bring her breakfast tray. Normally, I just have to set up her tray in front of her and she will feed herself but on that day she was unable to pick up her fork even. Her wrist and hand was bruised, it was reddish purple. She kept pointing to that hand. I went and told the nurse that the resident had a bruise and is pointing to it. The nurse told me that the resident had a fall during the night and went to look at the resident. I walked out the room when the nurse was doing the assessment so I am not sure what happened after that. CNA A was unable to recall who was the nurse that she had talked to. CNA A explained that the resident had a family in the room all day so she did not see her too much that day. The resident had a pull up on and she checked her pull up throughout the day but she was not wet so she did not have to do incontinent care on the resident. CNA A said When I checked on her throughout the day she seemed like she was in pain because she kept pointing to it. Basically the whole day, she was holding her wrist and pointing to it until she was sent to the hospital. CNA A explained that she always notifies her nurse when a resident complains of pain. If the nurse is unavailable then she would go to the next chain up. In an interview on 12/30/15 at 8:49 am the DON said that CR #1 ' s fall was discussed in the morning meeting but that at that time they were not aware the resident was in pain or that an X-ray had been done. She said that she went in CR #1 ' s room that morning and the resident appeared calm and was in bed under the covers. When asked, she said that she did not do a physical assessment of the resident. She said that later that day she received the X-ray report showing the resident had a fracture and she did assessed CR #1 then. She said the resident was in pain. She called the physician who order pain medication and to send the resident to the hospital. Record review of facility policy dated 4/2013 and titled Attending Physician Responsibilities read in part: .ensure adequate ongoing coverage .15. The attending physician will designate and alternate physician or another appropriate license practitioner to respond in an appropriate, timely manner in case the attending physician is unavailable .24. The physician will respond in an appropriate time frame to emergencies and routine notification from staff . Record review of the facility ' s Pain Assessment and Management policy revised 10/2010 read in part: - Assess the resident ' s pain and consequences of pain at lease each shift for acute pain - Report the following information to the physician or practitioner Significant changes in the level of the resident ' s pain . Record review of the facility ' s Abuse and Neglect Policy revised 04/2007 read in part, - The nurse will assess the individual and document related findings. Assessment data will include: Injury assessment (bleeding, bruising deformity, swelling, etc), signs of fall, pain assessment . - The nurse will report findings to the physician . An IJ was identified on 12/29/2015 at 3:30 pm. A Plan of Removal was received on 12/29/15 at 7:38 pm. After several revisions were made the Plan of Removal was accepted on 12/30/2015 at 12:00 pm. The Plan of Removal included in part, . 12/29/15- An in- service on nursing assessment and pain management was done with all the nurses. The in-service was started on 12-29-15 that included at review of pain scales, fall protocols and changes in reporting requirements. The in-services also included documentation requirements. Contact numbers were posted at each nurse ' s station for the DON, Administrator, and Medical Director. An in-service was started with the C.N.As on 12-30-15 and will be complete on 12-30-15. They were in-serviced on the stop and watch program including post fall monitoring and reporting change in condition to the nurses or administration. No nursing staff will be allowed to work with patients until they have received the in-services described above. In-services were completed on 12-30-15 . 12/30/15- ROM and Pain Assessment audit was initiated and completed on all dependent residents to insure that there needs are being met. The ROM assessments were done by the rehab staff and the pain assessments were completed by the nursing staff. Updated Incident Protocol Step 1: Immediate Assessment of the resident to include ROM, pain assessment and signs of change in condition and or injury. If life threating condition exists call 911 for immediate transfer. Step 2: Notification of Primary Physician or on-call of the incident. a. In the case of a suspected injury or pain; If the PCP or on-call fails to return the phone call within one hour, The facility must call the medical director . For orders or use nursing judgment to send the ER for assessment and treatment. b. If no apparent injury exists, continue to monitor for any changes in condition and follow normal protocols. Step 3: Notification of the DON or administrator must happen immediately after making the initial attempt of the physician notification for instructions. Step 4: Notification of responsible party. Step 5: Timely documentation to include incident report, progress note and medications given. Progress note must include time line of events: Who was notified and when? When x-ray or lab was received and communicated to physician or nurse practitioner. What orders were received and implement and at what time. Notification of responsible party including time and the name of the person notified. This information can be entered into incident report and copied to progress note. Medications given must be entered into the MAR indicated [REDACTED] Step 6: Follow up by administration in the morning clinical meeting to ensure that protocols were followed . The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff representing all three shifts had been in-serviced from 12/29/15 to 12/31/15.The topics included in part: Stop and Watch reporting pain tool, pain assessment, reporting changes in a resident, updated incident reporting protocol, physician notification, and documentation. Further review of documentation provided revealed that all residents were assessed for pain on 12/30/15 and dependent residents were assessed by therapy on 12/30/15 to ensure their needs were met. Observations were made from 12/30/15 to 12/31/15 to ensure adequate supervision was provided and pain issues were being addressed by staff. Interviews were conducted from 12/30/15 to 12/31/15 with CNAs, Nurses, administration, and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services. In a phone interview on 12/30/15 at 4:30 pm the Medical Director said that he was not aware of the specifics on the incident with CR #1 but that the staff should know that if an attending physician does not answer their calls in a timely manner they can reach him or any of the other two medical directors. He said that he thought each face sheet for the residents in the facility had two physician contacts, the primary doctor and a Medical Director. The Medical Director said that he was going to talk to the DON to implement a procedure on this if one is not already in place. He said he participated in the monthly Quality Assurance meetings. In further interview at the time, the Medical Director said that this was the first time he was aware of any issues with physicians not calling back the nursing staff in this facility. Record review of CR #1 ' s face sheet revealed no documentation of an alternate physician. In an interview with the VP of Operations on 12/31/2015 at 9:20 am, he stated every morning the IDT would meet with facility clinical team, incidents and accidents will be reviewed, falls will be investigated, care plans updated and assessments will be reviewed for completeness. CNA's were also empowered to call the Administrator or DON if they felt a resident needs further assessment. He added that he will personally review the 24 hour report, Incident and Accident log and nurses notes to ensure correct documentation. The VP of Operations also stated he will be completing, reviewing and investigating all reportable incidents in conjunction with the nursing department. To ensure staff proficiency and effectiveness, staff will be observed and evaluated, in-serviced, re-evaluated for learning, and counseled if protocol was not followed. Training will also be made a part of new employee orientation. Effectiveness will be evaluated during weekly IDT meetings with monthly monitoring by the medical director. He stated the IJ occurred due to a systems failure. He added although systems were in place they were not implemented effectively. He stated the IJ happened under the direction of the facility Administrator who was out on vacation at the moment and that his employment with this company did not start until 12/28/2015. He added that the facility Administrator will be terminated and he will be taking over as the Administrator. In an interview with the DON on 12/31/2015 at 9:35 am, when asked how the IJ came about she said I honestly don ' t know what happened. She said no one called her about CR #1 ' s fall. She stated staff members usually called her if something happened during night shift. The DON further stated she did not find out about CR #1 ' s fall until the IDT morning meeting on 12/14/2015. She stated they reviewed the incident report completed by RN A and talked about the fall during the meeting. However she stated she did not do any assessment for injury and did not know about CR #1 ' s injuries until notified of the x-ray results done during the night shift. The DON stated the incident report completed by RN A reported CR #1 did not sustain injuries, so she did not think an assessment was necessary. The DON added had she, the Administrator or other member of the facility management team been notified of the fall and subsequent x-ray, We would have acted quickly and taken care of the situation. The VP of Operations and DON were informed on 12/31/2015 at 10:50 am that the IJ was lowered; however the facility remained out of compliance at an isolated level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The facility Incident and Accident report identified 19 residents who fell during December 2015.

Based on observation, interview and record review the facility failed to ensure 1 of 11 residents (CR #1) reviewed for care provided, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. - CR #1 sustained a fall on 12/13/15 at 11:45 pm. RN A and LVN A did not consult with a physician of x-ray results showing a probable fracture to the right hip and actual fracture to the right wrist. This resulted in a delay of 18 hours in sending CR #1 to receive treatment in the hospital. CR #1 remains in the hospital after two surgical interventions. - CR #1 was assessed as being in pain and did not receive pain medication or other intervention for her complaints of pain after the fall for 17 hours. An IJ was identified on 12/29/2015. While the IJ was removed on 12/31/2015, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 discharged resident that required surgical intervention for her injuries and could place 13 residents identified by the facility as having falls during the month of December 2015 at risk of not receiving adequate medical care, pain, decline in their health condition well-being. Intake ID # 4 Findings Include: CR #1: Record review of CR #1 ' s face sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. CR #1 was discharged to the hospital on [DATE]. Record review of CR #1 ' s initial care plan dated 12/3/2015 read in part, Resident is at fall risk related to fall risk score, new admission, impaired balance, ambulatory and placed on falling star program. Actual fall- 12/13/2015- found on floor in another resident room. Interventions read in part, X-ray right arm, hip . All staff to observe resident when passing and inform nursing if found to have any problems with . pain . Record review of CR #1 ' s admission MDS assessment dated [DATE] revealed she had a BIMS score of 06 which indicated moderate cognitive impairment. She was assessed as requiring one person limited assistance for walking in corridor, one person extensive assistance for walking in room, two person extensive assistance for transfer, and two person limited assistance for locomotion on unit and locomotion off unit. She was also coded as not steady only able to stabilize with staff assistance for walking, turning around and facing the opposite direction while walking, moving on and off toilet, moving from seated to standing position and surface to surface transfer. Record review CR #1 ' s facility Incident Report dated 12/13/2015 at 11:45 pm read in part, that the resident was found laying on her back in another resident ' s room near the bathroom door . Language barrier- but resident was holding right hand and grimacing .Immediate action taken: Assessed for pain .No bruises noted . ROM to bilateral arm and left leg, could not lift the right leg. Head placed on pillow and doctor called .No injuries observed . Level of pain 4 (0-4 is considered mild pain in a scale of 1 to 10) . Injuries report post incident, right trochanter (anatomical part of the femur connecting to the hip bone), right hand . Attending Physician notified 12/13/2015 at 11:45pm. Record review of CR #1 ' chart revealed an incomplete SBAR note dated 12/13/2015 and timed 11:45 pm read in part, The change in condition, symptoms or signs I am calling about is: fall- pain Things that make the condition or symptom worse: movement . Record review of the Provider Investigation Report submitted 12/17/2015 detailing CR #1 ' s un witnessed fall on 12/13/2015 read in part, Resident speaks Chinese only with broken English . Description of the Allegation- Resident had a fall on 12/13/2015 with fracture . Provider Response- Assessment by nurse, neuro check initiated, POA notified, MD notified, orders received for x-ray, care plan updated . Investigation Summary- On 12/13/2015 while nurse was doing rounds she noted resident was on floor . resident was holding her right hand and grimacing. Call placed to resident ' s MD and received order for hip and hand x-ray stat . MD called to follow up with recommendation of the radiologist. Resident was sent to emergency room for MRI on 12/14/2015 . Prior to fall on 12/13/2015 Resident required minimal to moderate assistance with ambulation. Observation on 12/30/15 at noon revealed that CR #1 was in the hospital. She was sitting in a wheelchair waiting for her lunch tray. A family member was with her. Further observation revealed she had a cast on her right arm, extending from her wrist to above her elbow. Her upper hand and fingers were bruised. CR #1 was confused and was unable to answer questions. In an interview on 12/30/15 at 12:05 pm, the family member stated that CR #1 was still not able to walk and was tired all the time. He said the resident was in therapy and would be discharged back to a facility on 1/8/16. In an interview on 12/30/15 at 12:18 pm the hospital RN said that CR#1 had surgeries on her right hip and right wrist and is now receiving therapy. She said the resident now needed to be fed by staff and required total assistance of three or more staff for transfers. CR #1 is non-weight bearing. Record review of hospital progress note dated 12/15/15 revealed that the resident was admitted after right femoral fracture on 12/13/15. Further review revealed that CR #1 was in a skilled facility waiting for an X-ray. When the family came and found her in great pain and brought her to the hospital complaining of right hip and leg pain .movement exacerbated the pain. The hospital found CR #1 had a right Colles (lower end of the radius in the wrist) fracture. The resident required surgery on 12/15/15 of an open reduction and internal fixation of the right femur and a close reduction of her right arm. Record review of CR #1 ' s chart revealed the following radiology reports dated 12/14/2015: - Fax server date 12/14/2015 and time 2:19 am read in part, Preliminary Radiology Interpretation . Date of exam- 12/14/2015 at 1:21 am . 2 views of the right hand . Impression: Age-indeterminate distal radial fracture . Single view of right hip . Impression: Probable non-displaced intertrochanteric fracture. There was no hand written notes on the report from facility staff. - Fax server date 12/14/2015 and time 8:24 am read in part, Preliminary Report Exam date 12/14/2015 . Right hip . Impression: Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. There was no hand written notes on the report from facility staff. - Fax server date 12/14/2015 and time 8:57 am read in part, Final report . Exam date 12/14/2015 . Right hip. Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. Hand written note on the report read, Noted. Called in to Dr ' s office, faxed also. 12/14/2015 . There was no time or name/initial of the person who hand wrote the note and called the physician. - Fax server date 12/14/2015 and time 8:57 am revealed another copy of the same final reports read in part, . Exam date 12/14/2015 . Right hip. Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. Hand written note on the report read: Send to (local hospital). MRI of the Hip. [MEDICATION NAME] 50mg x1. There was no date, time or name/initial noted on the hand written note. - Fax server date and time illegible report read in part, Final report . exam date 12/14/2015 Right hip. Possible non-displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding . further review of the document revealed a note from the radiology company stating that report had been called in to: LVN A on 12/14/2015 at 2:40 pm. In an interview with the facility DON on 12/29/2015 at 10:25 am, she stated the fax server date and time listed at the top of the radiology reports reflects the date and time the fax arrived to the facility ' s fax machine. When asked what time CR #1 ' s physician was notified of the radiology results she stated she would check. Record review of CR #1 ' s chart revealed Neurological (Neuro) Checks dated 12/14/2015 and timed 12:00 am read in part, Most recent pain level: 4 Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 and timed 12:15 am read in part, Most recent pain level: 4 . Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 at 12:45 am read in part, Most recent pain level: 5 . Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 at 5:45 am read in part, Pain level: 4 . Hand grasps- left grasp greater than right . Unable to move right leg. There was no documentation that the physician was informed of the pain issues or that pain medication was administered. Record review of CR #1 ' s December pain assessment flow sheet revealed the following: -12/13/2015 Night shift- Pain level 3/10 (mild pain) -12/14/2015 Day shift- Pain level 10/10 (worst possible pain level) -12/14/2015 Evening shift- Pain level 10/10 Record review of CR #1 ' s December 2015 MAR indicated [REDACTED] -[MEDICATION NAME] Tablet 50mg, give 1 tablet by mouth one time only for pain. - Order date 12/14/2015 at 3:48pm. Pain level- 10/10. Administration date/time- 12/14/2015 at 6:14 pm. Further review of the December 2015 MAR indicated [REDACTED]. Further review revealed that the resident had no orders for pain medication on record. Record review of CR #1 ' s December 2015 physicians ' orders revealed the following orders: -X-ray to right hip and right hand due to pain/fall. Order date 12/14/2015, order time: 12:30am. -Send to West Houston hospital dx [MEDICAL CONDITION]. Order date 12/14/2015, order time: 3:47 pm. -[MEDICATION NAME] tablet 50 mg, give one tablet one time only for pain for 1 day. Order date 12/14/2015, order time: 3:48 pm. -There were no orders for scheduled or PRN pain medications other than the above order for [MEDICATION NAME] 50mg. Record review of CR #1 ' s progress notes revealed the following nurse ' s notes: - 12/14/2015 at 5:24 am- Found this resident in room [ROOM NUMBER] . Resident was laying on the floor. Walker was on the side . Resident holding right hand and grimacing. Grimaced more and yelling when assessing the right side of her body. No bruising noted. Left on the floor with pillow under head. Doctor called who gave orders for right hand and right hip x-ray . X-ray results back and called placed to the doctor . Awaiting call back . Neuro checks started . - 12/14/2015 at 6:31 am- No call back from the doctor yet. Report given to nurse on floor. Resident resting at this time, no sign of distress. - 12/14/2015 at 12:13 pm- Patient complained of right leg pain. status [REDACTED]. Pain arising from fall. Will continue to monitor and notify physician. - 12/14/2015 at 4:40 pm- Patient is status [REDACTED]. Report called to PCP and faxed also. Family member aware and been present with patient all day during shift. Noted redness on right wrist and right leg swollen. Patient will be transported to (local)hospital . - 12/14/2015 at 5:45 pm- Resident left the facility to the (local hospital ER) related to recent fracture . In an interview with RN A on 12/29/2015 at 11:22 am, she stated she was working the 11pm to 7am shift on 12/13-14/2015 and CR #1 was one of her assigned residents. She stated on the night of 12/13/2015, a CNA C reported CR #1 was found on the floor in another resident ' s room. Upon assessment, RN A stated the resident complained of pain saying Ow,ow,ow , however she stated the resident did not speak English and was unable to describe the location or level of her pain. When CR #1 was moved from the floor to her bed, RN A stated the resident yelled out in pain when her right leg was moved. She stated she notified CR #1 ' s physician who gave orders for x-ray of the right hip and right hand. The x-rays were done and RN A stated she received a phone call from the radiology company that night reporting CR #1 had a fracture to the right wrist and right hip. She stated she did not remember the time of the phone call or if she received a fax of the radiology report. RN A stated she called the resident ' s physician to report the x-ray results, however, she stated she did not receive a return call before her shift ended. She said she did not remember the date and time of the phone call to the physician or how many times she attempted calling. RN A stated CR #1 was in pain saying, Ow, ow, ow throughout the night and touching her right hand and wrist. When asked why she did not have the resident sent to the hospital for further evaluation, she stated it was Up to the physician to determine if patient should be sent to the hospital and I cannot write an order to send the resident to the hospital . She stated she did not provide any pain medication to CR #1 because she thought the resident would be sent to the hospital, but the physician never called back with orders. RN A further stated she could not explain why she did not provide CR #1 with pain medication. She said that around the same time that night, another resident reported falling and hitting her head. Since CR #1 was unable to state if she hit her head (due to language barrier) and no bumps were found on CR #1's head on assessment, RN A stated she felt the other resident's injury warranted more medical attention than CR #1's. RN A also stated the information in the nurses ' note she wrote dated 12/14/2015 at 5:45 am did not accurately reflect the actual timeline of events regarding the resident ' s fall. In an interview with LVN A on 12/29/2015 at 11:54 am, she stated she was the nurse assigned to CR #1 during the 7 am to 3 pm shift. She stated at the beginning of her shift, she got report that CR #1 fell during the night. She denied receiving report from the previous nurse that the resident had pain, the x-ray results or physician notification from the prior shift. LVN A stated she noted redness and pain to CR #1 ' s right wrist and hip during her morning assessment and assessed the resident as being in 10/10 pain due to the residents moaning and yelling , however she did not remember the time of the assessment. She said that at that point, she noticed an x-ray order in the residents chart, however, she had not seen the results. LVN A stated during her shift, she received a phone call from radiology reporting CR #1 ' s x-ray results but stated she did not remember the time of the phone call or what the results were stating It must have been bad since they called with the results . After receiving the x-ray results, she left a message for CR #1 ' s physician via phone and fax, however she was unsure of the time of the notification. LVN A stated she gave CR #1 pain medication but could not remember when she gave the medication or what medication she gave. She added CR #1 did not speak English, however family members were at the bedside who could speak English. She stated she did not receive report from the family regarding the resident being in pain during her shift. LVN A stated the information in the nurse ' s notes she wrote on 12/14/2015 at 12:13 pm and 4:40 pm did not reflect the actual timeline of events during her shift. When asked why she did not call 911 or seek further medical attention for CR #1 she stated that 12/14/2015 was her first day and that, It depends on the severity. I didn't know the patient well and she fell on the night shift. When asked if she received training on physician notification she stated, I 'm sure I did. She did not elaborated on what the training was about. In a phone interview with a family member of CR #1 on 12/29/15 at 1:45pm, she said that facility left her a voicemail the night of the fall informing her of the fall. When the family member came into the facility the next day CR #1 was laying down. She had a bruise on her right wrist. The family member said that when she asked the nurse what had happened to the resident, no one knew exactly what happened just that she had a fall. No one knew any details as to what occurred. She said that CR #1 was laying still but when they tried to move her she was in pain. The family member said that around noon on 12/14/15, the resident seemed to be in more pain so the family member told the nurse to give her pain medication. The nurse told them that they were trying to get a hold of the doctor. She said that staff end up giving her something for pain at around 2 or 3pm, right before the ambulance came to get her. The family member said that the nurse that was working during the day did not know what was going on, because she said that the night nurse did not leave her much information about the patient. The family member said the resident has been in the hospital for 8 days and currently she was at the hospital rehabilitation center for therapy. In an interview with the DON on 12/29/2015 at 1:00 pm, she stated she saw CR #1 during her morning rounds and the resident did not appear to be in distress. She stated she observed the resident and but did not do a physical assessments of the resident. The DON stated that when radiology called at around 2:00 pm with the results of CR #1 ' s x-ray, the attending physician was notified and orders for pain medication and transfer to the hospital were given. The DON then added that nothing could have been done differently. She stated a physician's orders [REDACTED].#1 to the hospital for a MRI. Since the radiology report stated there was a probable facture and CR #1 did not have any signs of obvious fracture, the DON stated ER transfer was not indicated. She also stated sending the resident to the ER with results of a probable fracture could contribute to recidivism and the hospital may send her back to the facility due to lack of physician's order [REDACTED]. She stated the resident was medicated that afternoon but was unsure of the time. When shown documentation on CR #1 ' s MAR indicated [REDACTED]. She stated the resident should have been medicated for pain sooner and was unsure why treatment was delayed. The DON added she was also unsure when CR #1 ' s x-ray results were initially received or when attempts to notify CR #1 ' s physician of the x-ray results were initially made. She stated the resident's attending physician was difficult to contact and that the medical director could have been notified to receive orders for treatment. In further interview with the DON on 12/29/2015 at 1:48 pm, she stated nurses were to document the time lab results are received, the time of physician notification, and the time medications are administered to residents and that she recognized the problem with documentation during the incident investigation. However, she stated she did not do any formal in-servicing regarding physician notification or documentation. The DON further stated that if a resident 's attending physian cannot be reached, the policy to call the medical director for orders. She added that she did not know why CR #1 was not medicated in a timely manner or why the medical director was not notified when the attending physician could not be contacted. CR #1 ' s physician was called on 12/29/2015 at 2:50 pm, however his office stated he was unavailable until 1/4/2016. In an interview on 12/30/15 at 9:48 am the DON said that the staff discussed CR#1 ' s fall in the morning meeting on 12/14/15. She said that at that point she was only aware that the resident had a fall and believed that the X-rays were still pending. When asked if she was aware that preliminary X-ray results had been faxed to the facility at least three times that morning she said she did not know because nobody told her. The DON said that she was not aware that the resident had any injuries. When asked if she saw CR #1 the morning of 12/14/15, she said that she went in the room and the resident was sleeping. She said that she did not assess the resident or look at her skin. In further interview at the time, the DON said that nurses usually call her in the middle of the night to inform her of any incidents. She said she did not receive any phone calls regarding CR #1 ' s fall. Interview with CNA A on 12/30/15 at 10:00 am, she said that she worked with CR #1 on 12/14/15 during the day shift. She explained that when she was doing her usual morning rounds with CR #1, she kept pointing to her right hand and wrist. She said I then stepped out to bring her breakfast tray. Normally, I just have to set up her tray in front of her and she will feed herself but on that day she was unable to pick up her fork even. Her wrist and hand was bruised, it was reddish purple. She kept pointing to that hand. I went and told the nurse that the resident had a bruise and is pointing to it. The nurse told me that the resident had a fall during the night and went to look at the resident. I walked out the room when the nurse was doing the assessment so I am not sure what happened after that. CNA A was unable to recall who was the nurse that she had talked to. CNA A explained that the resident had a family in the room all day so she did not see her too much that day. The resident had a pull up on and she checked her pull up throughout the day but she was not wet so she did not have to do incontinent care on the resident. CNA A said When I checked on her throughout the day she seemed like she was in pain because she kept pointing to it. Basically the whole day, she was holding her wrist and pointing to it until she was sent to the hospital. CNA A explained that she always notifies her nurse when a resident complains of pain. If the nurse is unavailable then she would go to the next chain up. In an interview on 12/30/15 at 8:49 am ADON 1 said that she was also the Charge Nurse for the 300 and 200 halls. She said that one of her duties was to print the electronic 24 report and a copy of the hand written 24 report and review it in the morning meeting. She said that the morning of 12/14/15, there only documentation regarding CR #1 ' s fall was a note on the hand written 24 hr. report stating the resident had a fall. There were no notes on the electronic 24 hr. report. Record review of the electronic 24 hr. records for 12/13/15 and 12/14/15 revealed no notes for CR #1. In further interview with ADON 1at the time she said that CR #1 ' s fall was discussed in the morning meeting but that at that time they were not aware the resident was in pain or that an X-ray had been done. She said that she went in CR #1 ' s room that morning and the resident appeared calm and was in bed under the covers. When asked, she said that she did not do a physical assessment of the resident. She said that later that day she received the X-ray report showing the resident had a fracture and she did assessed CR #1 then. She said the resident was in pain. She called the physician who order pain medication and to send the resident to the hospital. In an interview with CNA C on 12/30/15 at 3:25pm, she said that she was the CNA on hall 300 on 12/13 /15 from 3-11pm. She explained that she found CR #1 on the floor by another resident's room while doing rounds. She said, When I found her she was laying on her back, she wasn't saying anything, she just seemed confused. I asked her if she was okay and she just said ya , I told her to hold on while I get the nurse. I got the nurse and she came to assess. I did not see any bruising on the resident. She didn ' t seem like she was in pain or anything. Record review of the facility ' s Pain Assessment and Management policy revised 10/2010 read in part: - Assess the resident ' s pain and consequences of pain at lease each shift for acute pain - Recognizing Pain- Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. - Possible Behavioral Signs of Pain- Verbal expressions such as groaning, crying, screaming . facial expressions such as grimacing Limitations in his or her level of activity due to the presence of pain . Guarding, rubbing or favoring a particular part of the body - Review the resident ' s clinical record to identify conditions or situations that my predispose the resident to pain including Fractures - Non-pharmacological interventions may be appropriate alone or in conjunction with medications - Report the following information to the physician or practitioner Significant changes in the level of the resident ' s pain . Record review of the facility ' s Assessing Falls and Their Causes policy revised 10/2010 read in part: - If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will Evaluate for possible injuries to the head, neck, spine and extremities . - Nursing staff will notify the resident ' s Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone . Record review of the facility ' s Abuse and Neglect Policy revised 04/2007 read in part, - The nurse will assess the individual and document related findings. Assessment data will include: Injury assessment (bleeding, bruising deformity, swelling, etc), signs of fall, pain assessment . - The nurse will report findings to the physician . Record review of the facility ' s Charting and Documentation Policy revised 08/2008 read in part, - All observations, medications administered, services performed, etc., must be documented in the resident ' s clinical record - All incidents, accidents, or changes in the resident ' s condition must be recorded. - Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: The date and time the procedure/treatment was provided . name and title of the individuals who provided the care . notification of the family, physician or other staff Record review of the facility ' s Test Results Policy revised 04/2007 read in part, - The resident ' s Attending Physician will be notified of the results of the diagnostic tests - Should the test results be provided to the facility, the Attending Physician shall be promptly notified of the results - The DON or charge nurse receiving the test results, shall be responsible for notifying the Attending Physician of such test results. An IJ was identified on 12/29/2015 at 3:30 pm. A Plan of Removal was received on 12/29/15 at 7:38 pm. After several revisions were made the Plan of Removal was accepted on 12/30/2015 at 12:00 pm. The Plan of Removal included in part, . (Administrator) was suspended . (RN A) and (LVN A) . have been terminated from employment . 12/29/15- An in- service on nursing assessment and pain management was done with all the nurses. The in-service was started on 12-29-15 that included at review of pain scales, fall protocols and changes in reporting requirements. The in-services also included documentation requirements. Contact numbers were posted at each nurse ' s station for the DON, Administrator, and Medical Director. An in-service was started with the C.N.As on 12-30-15 and will be complete on 12-30-15. They were in-serviced on the stop and watch program including post fall monitoring and reporting change in condition to the nurses or administration. No nursing staff will be allowed to work with patients until they have received the in-services described above. In-services were completed on 12-30-15 . 12/30/15- ROM and Pain Assessment audit was initiated and completed on all dependent residents to insure that there needs are being met. The ROM assessments were done by the rehab staff and the pain assessments were completed by the nursing staff. Updated Incident Protocol Step 1: Immediate Assessment of the resident to include ROM, pain assessment and signs of change in condition and or injury. If life threating condition exists call 911 for immediate transfer. Step 2: Notification of Primary Physician or on-call of the incident. a. In the case of a suspected injury or pain; If the PCP or on-call fails to return the phone call within one hour, The facility must call the medical director . For orders or use nursing judgment to send the ER for assessment and treatment. b. If no apparent injury exists, continue to monitor for any changes in condition and follow normal protocols. Step 3: Notification of the DON or administrator must happen immediately after making the initial attempt of the physician notification for instructions. Step 4: Notification of responsible party. Step 5: Timely documentation to include incident report, progress note and medications given. Progress note must include time line of events: Who was notified and when? When x-ray or lab was received and communicated to physician or nurse practitioner. What orders were received and implement and at what time. Notification of responsible party including time and the name of the person notified. This information can be entered into incident report and copied to progress note. Medications given must be entered into the MAR indicated [REDACTED] Step 6: Follow up by administration in the morning clinical meeting to ensure that protocols were followed . The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff representing all three shifts had been in-serviced from 12/29/15 to 12/31/15.The topics included in part: Stop and Watch reporting pain tool, pain assessment, reporting changes in a resident, updated incident reporting protocol, physician notification, and documentation. Further review of documentation provided revealed that all residents were assessed for pain on 12/30/15 and dependent residents were assessed by therapy on 12/30/15 to ensure their needs were met. Observations were made from 12/30/15 to 12/31/15 to ensure adequate supervision was provided and pain issues were being addressed by staff. Interviews were conducted from 12/30/15 to 12/31/15 with CNAs, Nurses, administration, and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services. In a phone interview on 12/30/15 at 4:30 pm the Medical Director said that he was not aware of the specific

Based on observation, interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 1 of 11 residents reviewed for neglect and timely assessments. (CR #1) The Administrator failed to: -- implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent neglect. --supervise the DON to ensure nursing staff completed accurate and timely nursing and pain assessments after falls -supervise the DON to ensure staff was consulting with physicians in a timely manner of radiology results and complaints of pain. The DON failed to: - assess CR #1 after she sustained a fall. - supervise the nursing staff to ensure they were completing accurate and timely nursing and pain assessments after falls - supervise and train the nursing staff in consulting with physicians regarding resident's change of conditions to provide prompt care to the residents. - supervise the nursing staff in timely, accurate clinical documentation. An IJ was identified on 12/29/2015. While the IJ was removed on 12/31/2015, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 discharged resident that required surgical intervention for her injuries and could place 13 residents identified by the facility as having falls during the month of December 2015 at risk of not receiving adequate medical care, pain, and decline in their health condition well-being. Intake ID # 4 Findings Include: In an interview with the DON on 12/29/2015 at 1:00 pm, she stated she saw CR #1 during her morning rounds and the resident did not appear to be in distress. She stated she observed the resident and but did not do a physical assessments of the resident. The DON stated that when radiology called at around 2:00 pm with the results of CR #1 ' s x-ray, the attending physician was notified and orders for pain medication and transfer to the hospital were given. The DON then added that nothing could have been done differently. She stated a physician's orders [REDACTED].#1 to the hospital for a MRI. Since the radiology report stated there was a probable facture and CR #1 did not have any signs of obvious fracture, the DON stated ER transfer was not indicated. She also stated sending the resident to the ER with results of a probable fracture could contribute to recidivism and the hospital may send her back to the facility due to lack of physician's order [REDACTED]. She stated the resident was medicated that afternoon but was unsure of the time. When shown documentation on CR #1 ' s MAR indicated [REDACTED]. She stated the resident should have been medicated for pain sooner and was unsure why treatment was delayed. The DON added she was also unsure when CR #1 ' s x-ray results were initially received or when attempts to notify CR #1 ' s physician of the x-ray results were initially made. She stated the resident's attending physician was difficult to contact and that the medical director could have been notified to receive orders for treatment. In further interview with the DON on 12/29/2015 at 1:48 pm, she stated nurses were to document the time lab results are received, the time of physician notification, and the time medications are administered to residents and that she recognized the problem with documentation during the incident investigation. However, she stated she did not do any formal in-servicing regarding physician notification or documentation. The DON further stated that if a resident 's attending physian cannot be reached, the policy to call the medical director for orders. She added that she did not know why CR #1 was not medicated in a timely manner or why the medical director was not notified when the attending physician could not be contacted. In an interview on 12/30/15 at 9:48 am the DON said that the staff discussed CR#1 ' s fall in the morning meeting on 12/14/15. She said that at that point she was only aware that the resident had a fall and believed that the X-rays were still pending. When asked if she was aware that preliminary X-ray results had been faxed to the facility at least three times that morning she said she did not know because nobody told her. The DON said that she was not aware that the resident had any injuries. When asked if she saw CR #1 the morning of 12/14/15, she said that she went in the room and the resident was sleeping. She said that she did not assess the resident or look at her skin. In further interview at the time, the DON said that nurses usually call her in the middle of the night to inform her of any incidents. She said she did not receive any phone calls regarding CR #1 ' s fall. In an interview with the VP of Operations on 12/31/2015 at 9:20 am, he stated every morning the IDT would meet with facility clinical team, incidents and accidents will be reviewed, falls will be investigated, care plans updated and assessments will be reviewed for completeness. CNA's were also empowered to call the Administrator or DON if they felt a resident needs further assessment. He added that he will personally review the 24 hour report, Incident and Accident log and nurses notes to ensure correct documentation. The VP of Operations also stated he will be completing, reviewing and investigating all reportable incidents in conjunction with the nursing department. To ensure staff proficiency and effectiveness, staff will be observed and evaluated, in-serviced, re-evaluated for learning, and counseled if protocol was not followed. Training will also be made a part of new employee orientation. Effectiveness will be evaluated during weekly IDT meetings with monthly monitoring by the medical director. He stated the IJ occurred due to a systems failure. He added although systems were in place they were not implemented effectively. He stated the IJ happened under the direction of the facility Administrator who was out on vacation at the moment and that his employment with this company did not start until 12/28/2015. He added that the facility Administrator will be terminated and he will be taking over as the Administrator. In an interview with the DON on 12/31/2015 at 9:35 am, when asked how the IJ came about she said I honestly don ' t know what happened. She said no one called her about CR #1 ' s fall. She stated staff members usually called her if something happened during night shift. The DON further stated she did not find out about CR #1 ' s fall until the IDT morning meeting on 12/14/2015. She stated they reviewed the incident report completed by RN A and talked about the fall during the meeting. However she stated she did not do any assessment for injury and did not know about CR #1 ' s injuries until notified of the x-ray results done during the night shift. The DON stated the incident report completed by RN A reported CR #1 did not sustain injuries, so she did not think an assessment was necessary. The DON added had she, the Administrator or other member of the facility management team been notified of the fall and subsequent x-ray, We would have acted quickly and taken care of the situation. In an interview with RN A on 12/29/2015 at 11:22 am, she stated she was working the 11pm to 7am shift on 12/13-14/2015 and CR #1 was one of her assigned residents. She stated on the night of 12/13/2015, a CNA C reported CR #1 was found on the floor in another resident ' s room. Upon assessment, RN A stated the resident complained of pain saying Ow,ow,ow , however she stated the resident did not speak English and was unable to describe the location or level of her pain. When CR #1 was moved from the floor to her bed, RN A stated the resident yelled out in pain when her right leg was moved. She stated she notified CR #1 ' s physician who gave orders for x-ray of the right hip and right hand. The x-rays were done and RN A stated she received a phone call from the radiology company that night reporting CR #1 had a fracture to the right wrist and right hip. She stated she did not remember the time of the phone call or if she received a fax of the radiology report. RN A stated she called the resident ' s physician to report the x-ray results, however, she stated she did not receive a return call before her shift ended. She said she did not remember the date and time of the phone call to the physician or how many times she attempted calling. RN A stated CR #1 was in pain saying, Ow, ow, ow throughout the night and touching her right hand and wrist. When asked why she did not have the resident sent to the hospital for further evaluation, she stated it was Up to the physician to determine if patient should be sent to the hospital and I cannot write an order to send the resident to the hospital . She stated she did not provide any pain medication to CR #1 because she thought the resident would be sent to the hospital, but the physician never called back with orders. RN A further stated she could not explain why she did not provide CR #1 with pain medication. She said that around the same time that night, another resident reported falling and hitting her head. Since CR #1 was unable to state if she hit her head (due to language barrier) and no bumps were found on CR #1's head on assessment, RN A stated she felt the other resident's injury warranted more medical attention than CR #1's. RN A also stated the information in the nurses ' note she wrote dated 12/14/2015 at 5:45 am did not accurately reflect the actual timeline of events regarding the resident ' s fall. In an interview with LVN A on 12/29/2015 at 11:54 am, she stated she was the nurse assigned to CR #1 during the 7 am to 3 pm shift. She stated at the beginning of her shift, she got report that CR #1 fell during the night. She denied receiving report from the previous nurse that the resident had pain, the x-ray results or physician notification from the prior shift. LVN A stated she noted redness and pain to CR #1 ' s right wrist and hip during her morning assessment and assessed the resident as being in 10/10 pain due to the residents moaning and yelling , however she did not remember the time of the assessment. She said that at that point, she noticed an x-ray order in the residents chart, however, she had not seen the results. LVN A stated during her shift, she received a phone call from radiology reporting CR #1 ' s x-ray results but stated she did not remember the time of the phone call or what the results were stating It must have been bad since they called with the results . After receiving the x-ray results, she left a message for CR #1 ' s physician via phone and fax, however she was unsure of the time of the notification. LVN A stated she gave CR #1 pain medication but could not remember when she gave the medication or what medication she gave. She added CR #1 did not speak English, however family members were at the bedside who could speak English. She stated she did not receive report from the family regarding the resident being in pain during her shift. LVN A stated the information in the nurse ' s notes she wrote on 12/14/2015 at 12:13 pm and 4:40 pm did not reflect the actual timeline of events during her shift. When asked why she did not call 911 or seek further medical attention for CR #1 she stated that 12/14/2015 was her first day and that, It depends on the severity. I didn't know the patient well and she fell on the night shift. When asked if she received training on physician notification she stated, I 'm sure I did. She did not elaborated on what the training was about. In a phone interview with a family member of CR #1 on 12/29/15 at 1:45pm, she said that facility left her a voicemail the night of the fall informing her of the fall. When the family member came into the facility the next day CR #1 was laying down. She had a bruise on her right wrist. The family member said that when she asked the nurse what had happened to the resident, no one knew exactly what happened just that she had a fall. No one knew any details as to what occurred. She said that CR #1 was laying still but when they tried to move her she was in pain. The family member said that around noon on 12/14/15, the resident seemed to be in more pain so the family member told the nurse to give her pain medication. The nurse told them that they were trying to get a hold of the doctor. She said that staff end up giving her something for pain at around 2 or 3pm, right before the ambulance came to get her. The family member said that the nurse that was working during the day did not know what was going on, because she said that the night nurse did not leave her much information about the patient. The family member said the resident has been in the hospital for 8 days and currently she was at the hospital rehabilitation center for therapy. Record review of CR #1 ' s face sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. CR #1 was discharged to the hospital on [DATE]. Record review CR #1 ' s facility Incident Report dated 12/13/2015 at 11:45 pm read in part, that the resident was found laying on her back in another resident ' s room near the bathroom door . Language barrier- but resident was holding right hand and grimacing .Immediate action taken: Assessed for pain .No bruises noted . ROM to bilateral arm and left leg, could not lift the right leg. Head placed on pillow and doctor called .No injuries observed . Level of pain 4 (0-4 is considered mild pain in a scale of 1 to 10) . Injuries report post incident, right trochanter (anatomical part of the femur connecting to the hip bone), right hand . Attending Physician notified 12/13/2015 at 11:45pm. Record review of CR #1 ' chart revealed an incomplete SBAR note dated 12/13/2015 and timed 11:45 pm read in part, The change in condition, symptoms or signs I am calling about is: fall- pain Things that make the condition or symptom worse: movement . Record review of the Provider Investigation Report submitted 12/17/2015 detailing CR #1 ' s un witnessed fall on 12/13/2015 read in part, Resident speaks Chinese only with broken English . Description of the Allegation- Resident had a fall on 12/13/2015 with fracture . Provider Response- Assessment by nurse, neuro check initiated, POA notified, MD notified, orders received for x-ray, care plan updated . Investigation Summary- On 12/13/2015 while nurse was doing rounds she noted resident was on floor . resident was holding her right hand and grimacing. Call placed to resident ' s MD and received order for hip and hand x-ray stat . MD called to follow up with recommendation of the radiologist. Resident was sent to emergency room for MRI on 12/14/2015 . Prior to fall on 12/13/2015 Resident required minimal to moderate assistance with ambulation. Record review of CR #1 ' s chart revealed the following radiology reports dated 12/14/2015: - Fax server date 12/14/2015 and time 2:19 am read in part, Preliminary Radiology Interpretation . Date of exam- 12/14/2015 at 1:21 am . 2 views of the right hand . Impression: Age-indeterminate distal radial fracture . Single view of right hip . Impression: Probable non-displaced intertrochanteric fracture. There was no hand written notes on the report from facility staff. - Fax server date 12/14/2015 and time 8:24 am read in part, Preliminary Report Exam date 12/14/2015 . Right hip . Impression: Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. There was no hand written notes on the report from facility staff. - Fax server date 12/14/2015 and time 8:57 am read in part, Final report . Exam date 12/14/2015 . Right hip. Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. Hand written note on the report read, Noted. Called in to Dr ' s office, faxed also. 12/14/2015 . There was no time or name/initial of the person who hand wrote the note and called the physician. - Fax server date 12/14/2015 and time 8:57 am revealed another copy of the same final reports read in part, . Exam date 12/14/2015 . Right hip. Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. Hand written note on the report read: Send to (local hospital). MRI of the Hip. [MEDICATION NAME] 50mg x1. There was no date, time or name/initial noted on the hand written note. - Fax server date and time illegible report read in part, Final report . exam date 12/14/2015 Right hip. Possible non-displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding . further review of the document revealed a note from the radiology company stating that report had been called in to: LVN A on 12/14/2015 at 2:40 pm. Record review of CR #1 ' s December pain assessment flow sheet revealed the following: -12/13/2015 Night shift- Pain level 3/10 (mild pain) -12/14/2015 Day shift- Pain level 10/10 (worst possible pain level) -12/14/2015 Evening shift- Pain level 10/10 Record review of CR #1 ' s December 2015 MAR indicated [REDACTED] -[MEDICATION NAME] Tablet 50mg, give 1 tablet by mouth one time only for pain. - Order date 12/14/2015 at 3:48pm. Pain level- 10/10. Administration date/time- 12/14/2015 at 6:14 pm. Further review of the December 2015 MAR indicated [REDACTED]. Further review revealed that the resident had no orders for pain medication on record. An IJ was identified on 12/29/2015 at 3:30 pm. A Plan of Removal was received on 12/29/15 at 7:38 pm. After several revisions were made the Plan of Removal was accepted on 12/30/2015 at 12:00 pm. The Plan of Removal included in part, .12/29/15- An in- service on nursing assessment and pain management was done with all the nurses. The in-service was started on 12-29-15 that included at review of pain scales, fall protocols and changes in reporting requirements. The in-services also included documentation requirements. Contact numbers were posted at each nurse ' s station for the DON, Administrator, and Medical Director. An in-service was started with the C.N.As on 12-30-15 and will be complete on 12-30-15. They were in-serviced on the stop and watch program including post fall monitoring and reporting change in condition to the nurses or administration. No nursing staff will be allowed to work with patients until they have received the in-services described above. In-services were completed on 12-30-15 . 12/30/15- ROM and Pain Assessment audit was initiated and completed on all dependent residents to insure that there needs are being met. The ROM assessments were done by the rehab staff and the pain assessments were completed by the nursing staff. Updated Incident Protocol Step 1: Immediate Assessment of the resident to include ROM, pain assessment and signs of change in condition and or injury. If life threating condition exists call 911 for immediate transfer. Step 2: Notification of Primary Physician or on-call of the incident. a. In the case of a suspected injury or pain; If the PCP or on-call fails to return the phone call within one hour, The facility must call the medical director . For orders or use nursing judgment to send the ER for assessment and treatment. b. If no apparent injury exists, continue to monitor for any changes in condition and follow normal protocols. Step 3: Notification of the DON or administrator must happen immediately after making the initial attempt of the physician notification for instructions. Step 4: Notification of responsible party. Step 5: Timely documentation to include incident report, progress note and medications given. Progress note must include time line of events: Who was notified and when? When x-ray or lab was received and communicated to physician or nurse practitioner. What orders were received and implement and at what time. Notification of responsible party including time and the name of the person notified. This information can be entered into incident report and copied to progress note. Medications given must be entered into the MAR indicated [REDACTED] Step 6: Follow up by administration in the morning clinical meeting to ensure that protocols were followed . The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff representing all three shifts had been in-serviced from 12/29/15 to 12/31/15.The topics included in part: Stop and Watch reporting pain tool, pain assessment, reporting changes in a resident, updated incident reporting protocol, physician notification, and documentation. Further review of documentation provided revealed that all residents were assessed for pain on 12/30/15 and dependent residents were assessed by therapy on 12/30/15 to ensure their needs were met. Observations were made from 12/30/15 to 12/31/15 to ensure adequate supervision was provided and pain issues were being addressed by staff. Interviews were conducted from 12/30/15 to 12/31/15 with CNAs, Nurses, administration, and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services. The VP of Operations and DON were informed on 12/31/2015 at 10:50 am that the IJ was lowered; however the facility remained out of compliance at an isolated level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The facility Incident and Accident report identified 19 residents who fell during December 2015.

Based on observations, interviews and record reviews the facility failed to implement their written policy and procedures that prohibit neglect for 1 of 11 residents (CR #1) - CR #1 sustained a fall on 12/13/15 at 11:45 pm. RN A and LVN A did not consult with a physician of x-ray results showing a probable fracture to the right hip and actual fracture to the right wrist. This resulted in a delay of 18 hours in sending CR #1 to receive treatment in the hospital. CR #1 remains in the hospital after two surgical interventions. - CR #1 was assessed as being in pain and did not receive pain medication or other intervention for her complaints of pain after the fall for 17 hours. An IJ was identified on 12/29/2015. While the IJ was removed on 12/31/2015, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 discharged resident that required surgical intervention for her injuries and could place 13 residents identified by the facility as having falls during the month of December 2015 at risk of not receiving adequate medical care, pain, decline in their health condition well-being. Intake ID # 4 Findings Include: CR #1: Record review of CR #1 ' s face sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. CR #1 was discharged to the hospital on [DATE]. Record review of CR #1 ' s initial care plan dated 12/3/2015 read in part, Resident is at fall risk related to fall risk score, new admission, impaired balance, ambulatory and placed on falling star program. Actual fall- 12/13/2015- found on floor in another resident room. Interventions read in part, X-ray right arm, hip . All staff to observe resident when passing and inform nursing if found to have any problems with . pain . Record review of CR #1 ' s admission MDS assessment dated [DATE] revealed she had a BIMS score of 06 which indicated moderate cognitive impairment. She was assessed as requiring one person limited assistance for walking in corridor, one person extensive assistance for walking in room, two person extensive assistance for transfer, and two person limited assistance for locomotion on unit and locomotion off unit. She was also coded as not steady only able to stabilize with staff assistance for walking, turning around and facing the opposite direction while walking, moving on and off toilet, moving from seated to standing position and surface to surface transfer. Record review CR #1 ' s facility Incident Report dated 12/13/2015 at 11:45 pm read in part, that the resident was found laying on her back in another resident ' s room near the bathroom door . Language barrier- but resident was holding right hand and grimacing .Immediate action taken: Assessed for pain .No bruises noted . ROM to bilateral arm and left leg, could not lift the right leg. Head placed on pillow and doctor called .No injuries observed . Level of pain 4 (0-4 is considered mild pain in a scale of 1 to 10) . Injuries report post incident, right trochanter (anatomical part of the femur connecting to the hip bone), right hand . Attending Physician notified 12/13/2015 at 11:45pm. Record review of CR #1 ' chart revealed an incomplete SBAR note dated 12/13/2015 and timed 11:45 pm read in part, The change in condition, symptoms or signs I am calling about is: fall- pain Things that make the condition or symptom worse: movement . Record review of the Provider Investigation Report submitted 12/17/2015 detailing CR #1 ' s un witnessed fall on 12/13/2015 read in part, Resident speaks Chinese only with broken English . Description of the Allegation- Resident had a fall on 12/13/2015 with fracture . Provider Response- Assessment by nurse, neuro check initiated, POA notified, MD notified, orders received for x-ray, care plan updated . Investigation Summary- On 12/13/2015 while nurse was doing rounds she noted resident was on floor . resident was holding her right hand and grimacing. Call placed to resident ' s MD and received order for hip and hand x-ray stat . MD called to follow up with recommendation of the radiologist. Resident was sent to emergency room for MRI on 12/14/2015 . Prior to fall on 12/13/2015 Resident required minimal to moderate assistance with ambulation. Observation on 12/30/15 at noon revealed that CR #1 was in the hospital. She was sitting in a wheelchair waiting for her lunch tray. A family member was with her. Further observation revealed she had a cast on her right arm, extending from her wrist to above her elbow. Her upper hand and fingers were bruised. CR #1 was confused and was unable to answer questions. In an interview on 12/30/15 at 12:05 pm, the family member stated that CR #1 was still not able to walk and was tired all the time. He said the resident was in therapy and would be discharged back to a facility on 1/8/16. In an interview on 12/30/15 at 12:18 pm the hospital RN said that CR#1 had surgeries on her right hip and right wrist and is now receiving therapy. She said the resident now needed to be fed by staff and required total assistance of three or more staff for transfers. CR #1 is non-weight bearing. Record review of hospital progress note dated 12/15/15 revealed that the resident was admitted after right femoral fracture on 12/13/15. Further review revealed that CR #1 was in a skilled facility waiting for an X-ray. When the family came and found her in great pain and brought her to the hospital complaining of right hip and leg pain .movement exacerbated the pain. The hospital found CR #1 had a right Colles (lower end of the radius in the wrist) fracture. The resident required surgery on 12/15/15 of an open reduction and internal fixation of the right femur and a close reduction of her right arm. Record review of CR #1 ' s chart revealed the following radiology reports dated 12/14/2015: - Fax server date 12/14/2015 and time 2:19 am read in part, Preliminary Radiology Interpretation . Date of exam- 12/14/2015 at 1:21 am . 2 views of the right hand . Impression: Age-indeterminate distal radial fracture . Single view of right hip . Impression: Probable non-displaced intertrochanteric fracture. There was no hand written notes on the report from facility staff. - Fax server date 12/14/2015 and time 8:24 am read in part, Preliminary Report Exam date 12/14/2015 . Right hip . Impression: Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. There was no hand written notes on the report from facility staff. - Fax server date 12/14/2015 and time 8:57 am read in part, Final report . Exam date 12/14/2015 . Right hip. Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. Hand written note on the report read, Noted. Called in to Dr ' s office, faxed also. 12/14/2015 . There was no time or name/initial of the person who hand wrote the note and called the physician. - Fax server date 12/14/2015 and time 8:57 am revealed another copy of the same final reports read in part, . Exam date 12/14/2015 . Right hip. Possible non displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist . Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding. Hand written note on the report read: Send to (local hospital). MRI of the Hip. [MEDICATION NAME] 50mg x1. There was no date, time or name/initial noted on the hand written note. - Fax server date and time illegible report read in part, Final report . exam date 12/14/2015 Right hip. Possible non-displaced [MEDICAL CONDITION] region of the right hip. Recommend CT scan for further evaluation . Right wrist Impression: Fracture involving the distal radius which is of indeterminate age. MRI is recommended to age this finding . further review of the document revealed a note from the radiology company stating that report had been called in to: LVN A on 12/14/2015 at 2:40 pm. In an interview with the facility DON on 12/29/2015 at 10:25 am, she stated the fax server date and time listed at the top of the radiology reports reflects the date and time the fax arrived to the facility ' s fax machine. When asked what time CR #1 ' s physician was notified of the radiology results she stated she would check. Record review of CR #1 ' s chart revealed Neurological (Neuro) Checks dated 12/14/2015 and timed 12:00 am read in part, Most recent pain level: 4 Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 and timed 12:15 am read in part, Most recent pain level: 4 . Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 at 12:45 am read in part, Most recent pain level: 5 . Hand grasps- left grasp greater than right . Unable to move right leg. The next Neuro Check dated 12/14/2015 at 5:45 am read in part, Pain level: 4 . Hand grasps- left grasp greater than right . Unable to move right leg. There was no documentation that the physician was informed of the pain issues or that pain medication was administered. Record review of CR #1 ' s December pain assessment flow sheet revealed the following: -12/13/2015 Night shift- Pain level 3/10 (mild pain) -12/14/2015 Day shift- Pain level 10/10 (worst possible pain level) -12/14/2015 Evening shift- Pain level 10/10 Record review of CR #1 ' s December 2015 MAR indicated [REDACTED] -[MEDICATION NAME] Tablet 50mg, give 1 tablet by mouth one time only for pain. - Order date 12/14/2015 at 3:48pm. Pain level- 10/10. Administration date/time- 12/14/2015 at 6:14 pm. Further review of the December 2015 MAR indicated [REDACTED]. Further review revealed that the resident had no orders for pain medication on record. Record review of CR #1 ' s December 2015 physicians ' orders revealed the following orders: -X-ray to right hip and right hand due to pain/fall. Order date 12/14/2015, order time: 12:30am. -Send to West Houston hospital dx [MEDICAL CONDITION]. Order date 12/14/2015, order time: 3:47 pm. -[MEDICATION NAME] tablet 50 mg, give one tablet one time only for pain for 1 day. Order date 12/14/2015, order time: 3:48 pm. -There were no orders for scheduled or PRN pain medications other than the above order for [MEDICATION NAME] 50mg. Record review of CR #1 ' s progress notes revealed the following nurse ' s notes: - 12/14/2015 at 5:24 am- Found this resident in room [ROOM NUMBER] . Resident was laying on the floor. Walker was on the side . Resident holding right hand and grimacing. Grimaced more and yelling when assessing the right side of her body. No bruising noted. Left on the floor with pillow under head. Doctor called who gave orders for right hand and right hip x-ray . X-ray results back and called placed to the doctor . Awaiting call back . Neuro checks started . - 12/14/2015 at 6:31 am- No call back from the doctor yet. Report given to nurse on floor. Resident resting at this time, no sign of distress. - 12/14/2015 at 12:13 pm- Patient complained of right leg pain. status [REDACTED]. Pain arising from fall. Will continue to monitor and notify physician. - 12/14/2015 at 4:40 pm- Patient is status [REDACTED]. Report called to PCP and faxed also. Family member aware and been present with patient all day during shift. Noted redness on right wrist and right leg swollen. Patient will be transported to (local)hospital . - 12/14/2015 at 5:45 pm- Resident left the facility to the (local hospital ER) related to recent fracture . In an interview with RN A on 12/29/2015 at 11:22 am, she stated she was working the 11pm to 7am shift on 12/13-14/2015 and CR #1 was one of her assigned residents. She stated on the night of 12/13/2015, a CNA C reported CR #1 was found on the floor in another resident ' s room. Upon assessment, RN A stated the resident complained of pain saying Ow,ow,ow , however she stated the resident did not speak English and was unable to describe the location or level of her pain. When CR #1 was moved from the floor to her bed, RN A stated the resident yelled out in pain when her right leg was moved. She stated she notified CR #1 ' s physician who gave orders for x-ray of the right hip and right hand. The x-rays were done and RN A stated she received a phone call from the radiology company that night reporting CR #1 had a fracture to the right wrist and right hip. She stated she did not remember the time of the phone call or if she received a fax of the radiology report. RN A stated she called the resident ' s physician to report the x-ray results, however, she stated she did not receive a return call before her shift ended. She said she did not remember the date and time of the phone call to the physician or how many times she attempted calling. RN A stated CR #1 was in pain saying, Ow, ow, ow throughout the night and touching her right hand and wrist. When asked why she did not have the resident sent to the hospital for further evaluation, she stated it was Up to the physician to determine if patient should be sent to the hospital and I cannot write an order to send the resident to the hospital . She stated she did not provide any pain medication to CR #1 because she thought the resident would be sent to the hospital, but the physician never called back with orders. RN A further stated she could not explain why she did not provide CR #1 with pain medication. She said that around the same time that night, another resident reported falling and hitting her head. Since CR #1 was unable to state if she hit her head (due to language barrier) and no bumps were found on CR #1's head on assessment, RN A stated she felt the other resident's injury warranted more medical attention than CR #1's. RN A also stated the information in the nurses ' note she wrote dated 12/14/2015 at 5:45 am did not accurately reflect the actual timeline of events regarding the resident ' s fall. In an interview with LVN A on 12/29/2015 at 11:54 am, she stated she was the nurse assigned to CR #1 during the 7 am to 3 pm shift. She stated at the beginning of her shift, she got report that CR #1 fell during the night. She denied receiving report from the previous nurse that the resident had pain, the x-ray results or physician notification from the prior shift. LVN A stated she noted redness and pain to CR #1 ' s right wrist and hip during her morning assessment and assessed the resident as being in 10/10 pain due to the residents moaning and yelling , however she did not remember the time of the assessment. She said that at that point, she noticed an x-ray order in the residents chart, however, she had not seen the results. LVN A stated during her shift, she received a phone call from radiology reporting CR #1 ' s x-ray results but stated she did not remember the time of the phone call or what the results were stating It must have been bad since they called with the results . After receiving the x-ray results, she left a message for CR #1 ' s physician via phone and fax, however she was unsure of the time of the notification. LVN A stated she gave CR #1 pain medication but could not remember when she gave the medication or what medication she gave. She added CR #1 did not speak English, however family members were at the bedside who could speak English. She stated she did not receive report from the family regarding the resident being in pain during her shift. LVN A stated the information in the nurse ' s notes she wrote on 12/14/2015 at 12:13 pm and 4:40 pm did not reflect the actual timeline of events during her shift. When asked why she did not call 911 or seek further medical attention for CR #1 she stated that 12/14/2015 was her first day and that, It depends on the severity. I didn't know the patient well and she fell on the night shift. When asked if she received training on physician notification she stated, I 'm sure I did. She did not elaborated on what the training was about. In a phone interview with a family member of CR #1 on 12/29/15 at 1:45pm, she said that facility left her a voicemail the night of the fall informing her of the fall. When the family member came into the facility the next day CR #1 was laying down. She had a bruise on her right wrist. The family member said that when she asked the nurse what had happened to the resident, no one knew exactly what happened just that she had a fall. No one knew any details as to what occurred. She said that CR #1 was laying still but when they tried to move her she was in pain. The family member said that around noon on 12/14/15, the resident seemed to be in more pain so the family member told the nurse to give her pain medication. The nurse told them that they were trying to get a hold of the doctor. She said that staff end up giving her something for pain at around 2 or 3pm, right before the ambulance came to get her. The family member said that the nurse that was working during the day did not know what was going on, because she said that the night nurse did not leave her much information about the patient. The family member said the resident has been in the hospital for 8 days and currently she was at the hospital rehabilitation center for therapy. In an interview with the DON on 12/29/2015 at 1:00 pm, she stated she saw CR #1 during her morning rounds and the resident did not appear to be in distress. She stated she observed the resident and but did not do a physical assessments of the resident. The DON stated that when radiology called at around 2:00 pm with the results of CR #1 ' s x-ray, the attending physician was notified and orders for pain medication and transfer to the hospital were given. The DON then added that nothing could have been done differently. She stated a physician's orders [REDACTED].#1 to the hospital for a MRI. Since the radiology report stated there was a probable facture and CR #1 did not have any signs of obvious fracture, the DON stated ER transfer was not indicated. She also stated sending the resident to the ER with results of a probable fracture could contribute to recidivism and the hospital may send her back to the facility due to lack of physician's order [REDACTED]. She stated the resident was medicated that afternoon but was unsure of the time. When shown documentation on CR #1 ' s MAR indicated [REDACTED]. She stated the resident should have been medicated for pain sooner and was unsure why treatment was delayed. The DON added she was also unsure when CR #1 ' s x-ray results were initially received or when attempts to notify CR #1 ' s physician of the x-ray results were initially made. She stated the resident's attending physician was difficult to contact and that the medical director could have been notified to receive orders for treatment. In further interview with the DON on 12/29/2015 at 1:48 pm, she stated nurses were to document the time lab results are received, the time of physician notification, and the time medications are administered to residents and that she recognized the problem with documentation during the incident investigation. However, she stated she did not do any formal in-servicing regarding physician notification or documentation. The DON further stated that if a resident 's attending physian cannot be reached, the policy to call the medical director for orders. She added that she did not know why CR #1 was not medicated in a timely manner or why the medical director was not notified when the attending physician could not be contacted. CR #1 ' s physician was called on 12/29/2015 at 2:50 pm, however his office stated he was unavailable until 1/4/2016. In an interview on 12/30/15 at 9:48 am the DON said that the staff discussed CR#1 ' s fall in the morning meeting on 12/14/15. She said that at that point she was only aware that the resident had a fall and believed that the X-rays were still pending. When asked if she was aware that preliminary X-ray results had been faxed to the facility at least three times that morning she said she did not know because nobody told her. The DON said that she was not aware that the resident had any injuries. When asked if she saw CR #1 the morning of 12/14/15, she said that she went in the room and the resident was sleeping. She said that she did not assess the resident or look at her skin. In further interview at the time, the DON said that nurses usually call her in the middle of the night to inform her of any incidents. She said she did not receive any phone calls regarding CR #1 ' s fall. Interview with CNA A on 12/30/15 at 10:00 am, she said that she worked with CR #1 on 12/14/15 during the day shift. She explained that when she was doing her usual morning rounds with CR #1, she kept pointing to her right hand and wrist. She said I then stepped out to bring her breakfast tray. Normally, I just have to set up her tray in front of her and she will feed herself but on that day she was unable to pick up her fork even. Her wrist and hand was bruised, it was reddish purple. She kept pointing to that hand. I went and told the nurse that the resident had a bruise and is pointing to it. The nurse told me that the resident had a fall during the night and went to look at the resident. I walked out the room when the nurse was doing the assessment so I am not sure what happened after that. CNA A was unable to recall who was the nurse that she had talked to. CNA A explained that the resident had a family in the room all day so she did not see her too much that day. The resident had a pull up on and she checked her pull up throughout the day but she was not wet so she did not have to do incontinent care on the resident. CNA A said When I checked on her throughout the day she seemed like she was in pain because she kept pointing to it. Basically the whole day, she was holding her wrist and pointing to it until she was sent to the hospital. CNA A explained that she always notifies her nurse when a resident complains of pain. If the nurse is unavailable then she would go to the next chain up. In an interview on 12/30/15 at 8:49 am ADON 1 said that she was also the Charge Nurse for the 300 and 200 halls. She said that one of her duties was to print the electronic 24 report and a copy of the hand written 24 report and review it in the morning meeting. She said that the morning of 12/14/15, there only documentation regarding CR #1 ' s fall was a note on the hand written 24 hr. report stating the resident had a fall. There were no notes on the electronic 24 hr. report. Record review of the electronic 24 hr. records for 12/13/15 and 12/14/15 revealed no notes for CR #1. In further interview with ADON 1at the time she said that CR #1 ' s fall was discussed in the morning meeting but that at that time they were not aware the resident was in pain or that an X-ray had been done. She said that she went in CR #1 ' s room that morning and the resident appeared calm and was in bed under the covers. When asked, she said that she did not do a physical assessment of the resident. She said that later that day she received the X-ray report showing the resident had a fracture and she did assessed CR #1 then. She said the resident was in pain. She called the physician who order pain medication and to send the resident to the hospital. In an interview with CNA C on 12/30/15 at 3:25pm, she said that she was the CNA on hall 300 on 12/13 /15 from 3-11pm. She explained that she found CR #1 on the floor by another resident's room while doing rounds. She said, When I found her she was laying on her back, she wasn't saying anything, she just seemed confused. I asked her if she was okay and she just said ya , I told her to hold on while I get the nurse. I got the nurse and she came to assess. I did not see any bruising on the resident. She didn ' t seem like she was in pain or anything. Record review of the facility's Abuse and Neglect Policy revised 04/2007 read in part, - The nurse will assess the individual and document related findings. Assessment data will include: Injury assessment (bleeding, bruising deformity, swelling, etc.), signs of fall, pain assessment . - The nurse will report findings to the physician . An IJ was identified on 12/29/2015 at 3:30 pm. A Plan of Removal was received on 12/29/15 at 7:38 pm. After several revisions were made the Plan of Removal was accepted on 12/30/2015 at 12:00 pm. The Plan of Removal included in part, .12/29/15- An in- service on nursing assessment and pain management was done with all the nurses. The in-service was started on 12-29-15 that included at review of pain scales, fall protocols and changes in reporting requirements. The in-services also included documentation requirements. Contact numbers were posted at each nurse's station for the DON, Administrator, and Medical Director. An in-service was started with the C.N.As on 12-30-15 and will be complete on 12-30-15. They were in-serviced on the stop and watch program including post fall monitoring and reporting change in condition to the nurses or administration. No nursing staff will be allowed to work with patients until they have received the in-services described above. In-services were completed on 12-30-15 . 12/30/15- ROM and Pain Assessment audit was initiated and completed on all dependent residents to insure that there needs are being met. The ROM assessments were done by the rehab staff and the pain assessments were completed by the nursing staff. Updated Incident Protocol Step 1: Immediate Assessment of the resident to include ROM, pain assessment and signs of change in condition and or injury. If life threating condition exists call 911 for immediate transfer. Step 2: Notification of Primary Physician or on-call of the incident. a. In the case of a suspected injury or pain; If the PCP or on-call fails to return the phone call within one hour, The facility must call the medical director . For orders or use nursing judgment to send the ER for assessment and treatment. b. If no apparent injury exists, continue to monitor for any changes in condition and follow normal protocols. Step 3: Notification of the DON or administrator must happen immediately after making the initial attempt of the physician notification for instructions. Step 4: Notification of responsible party. Step 5: Timely documentation to include incident report, progress note and medications given. Progress note must include time line of events: Who was notified and when? When x-ray or lab was received and communicated to physician or nurse practitioner. What orders were received and implement and at what time. Notification of responsible party including time and the name of the person notified. This information can be entered into incident report and copied to progress note. Medications given must be entered into the MAR indicated [REDACTED] Step 6: Follow up by administration in the morning clinical meeting to ensure that protocols were followed . The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff representing all three shifts had been in-serviced from 12/29/15 to 12/31/15.The topics included in part: Stop and Watch reporting pain tool, pain assessment, reporting changes in a resident, updated incident reporting protocol, physician notification, and documentation. Further review of documentation provided revealed that all residents were assessed for pain on 12/30/15 and dependent residents were assessed by therapy on 12/30/15 to ensure their needs were met. Observations were made from 12/30/15 to 12/31/15 to ensure adequate supervision was provided and pain issues were being addressed by staff. Interviews were conducted from 12/30/15 to 12/31/15 with CNAs, Nurses, administration, and other staff members from all three shifts. Interviews revealed staff was able to verbalize understanding of the information from the recent in-services. In a phone interview on 12/30/15 at 4:30 pm the Medical Director said that he was not aware of the specifics on the incident with CR #1 but that the staff should know that if an attending physician does not answer their calls in a timely manner they can reach him or any of the other two medical directors. He said that he thought each face sheet for the residents in the facility had two physician contacts, the primary doctor and a Medical Director. The Medical Director said that he was going to talk to the DON to implement a procedure on this if one is not already in place. He said he participated in the monthly Quality Assurance meetings. In further interview at the time, the Medical Director said that this was the first time he was aware of any issues with physicians not calling back the nursing staff in this facility. Record review of CR #1 ' s face sheet revealed no documentation of an alternate physician. In an interview with the VP of Operations on 12/31/2015 at 9:20 am, he stated every morning the IDT would meet with facility clinical team, incidents and accidents will be reviewed, falls will be investigated, care plans updated and assessments will be reviewed for completeness. CNA ' s were also empowered to call the Administrator or DON if they felt a resident needs further assessment. He added that he will personally review the 24 hour report, Incident and Accident log and nurses notes to ensure correct documentation. The VP of Operations also stated he will be completing, reviewing and investigating all reportable incidents in conjunction with the nursing department. To ensure staff proficiency and effectiveness, staff will be observed and evaluated, in-serviced, re-evaluated for learning, and counseled if protocol was not followed. Training will also be made a part of new employee orientation. Effectiveness will be evaluated during weekly IDT meetings with monthly monitoring by the medical director. He stated the IJ occurred due to a systems failure. He added although systems were in place they were not implemented effectively. He stated the IJ happened under the direction of the facility Administrator who was out on vacation at the moment and that his employment with this company did not start until 12/28/2015. He added that the facility Administrator will be terminated and he will be taking over as the Administrator. In an interview with the DON on 12/31/2015 at 9:35 am, when asked how the IJ came about she said I honestly don ' t know what happened. She said no one called her about CR #1 ' s fall. She stated staff members usually called her if something happened during night shift. The DON further stated she did not find out about CR #1's fall until the IDT morning meeting on 12/14/2015. She stated they reviewed the incident report completed by RN A and talked about the fall during the meeting. However she stated she did not do any assessment for injury and did not know about CR #1's injuries until notified o

Based on observation, interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 5 of 10 residents reviewed for accidents and supervision. ( CR #8, Resident #4, #1, #10 and #5) The Administrator failed to: -- implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent neglect. --implement the facility fall policies and protocols to prevent residents from falling. --supervise the DON to ensure nursing staff completed accurate care plans to address resident's with falls. -supervise the DON to ensure medication regimen was reviewed as part of the fall prevention program for residents with multiple falls. --supervise the DON to ensure that nursing staff put into place effective interventions for fall prevention for Residents with frequent falls and at risk for falls. The DON failed to: -Monitor and supervise the development of resident care plans for falls. - ensure medication regimen was reviewed as part of the fall prevention program for residents with multiple falls. -Train and monitor the staff on Fall Prevention and Fall Management Program -Train and monitor the nursing staff on revising care plans with effective interventions for residents at risk for falls or had actually fallen. An IJ was identified on 11/16/2015. While the IJ was removed on 11/19/2015, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 5 residents and could place 4 other residents identified by the facility as being at risk for falls at risk of increased accidents, falls and injuries. Intake # 1, 1, 2, 6 Findings Include: In an Interview with the DON on 11/4/2015 at 1:10 p.m. regarding plan of care of residents with high risk falls, the DON said: when a resident is admitted to facility we will do a fall risk assessment and pending on their score, we will place a sign at the head of resident bed. If the resident actually falls or continue to fall we will place a sign outside their door and alert CNA ' s on paper. We also place them on a low bed and place mats on the floor by their bed. In an interview with the Administrator on 11/16/2015 at 10:21 am, in response to the visit on 11/5/2015, she stated the entire resident census has been placed on the Falling Star Program. She added every resident now has yellow tape on their wheelchairs and walker and a yellow star at their door and over their bed. In order to identify those at risk for falls, the IDT team will perform a weekly evaluation of each resident during their meetings. If the resident has had no falls for 30 days, they will be removed from the Falling Star Program. She stated all newly admitted residents and those with a recent fall or change of condition will be considered a fall risk and placed on the Falling Star Program for at least 30 days for monitoring. She added that Fall Risk Assessments are also considered when evaluating for fall risk. The Administrator also stated every resident ' s care plan has been updated to address fall risk. In an interview done on 11/16/2015 at 2:25 p.m. with DON regarding fall program: DON states I am in charge of the fall program. I look at risk management and go over it and discuss in the morning meetings. I look at circumstances and see if it is care planned for physical therapy. The medications are viewed by the pharmacist. We have a psychiatrist that come in every other week. In an interview with the Administrator on 11/16/2015 at 6:03 pm, she stated she did not understand why an IJ has been called. She stated the facility has been putting a plan of correction in place in response to the visit on 11/5/2015 regarding falls and care plans. She added that she felt that the facility was being penalized for previous non-compliance that they were still working to complete. In an interview the Administrator on 11/17/2015 at 8:57 am, she stated the facility will continue the Falling Star program and the evaluation of residents to identify those at risk for falls. Lastly, the Administrator stated she did not see the Immediate Jeopardy. She stated she saw the deficient practice but did not see the failure in the facility ' s systems. She said the facility was implementing a plan of correction in response to the deficiencies identified on 11/5/2015 and that the situation was a past performance non-compliance issue because CR #8 was no longer in the facility. In an interview with the DON on 11/17/2015 at 9:56 am, she stated staff members were in-serviced on the components of the Falling Star Program and which residents should be in the program. She stated the facility formed a Falls Committee to specifically evaluate and investigate recent falls. The DON added that the facility was previously using the Falling Star Program, fall risk assessments and CNA assignment sheets to identify residents at risk for falls but there was a lack in care planning for falls. When asked regarding the IJ she stated, I can ' t see were there would be an IJ. She stated although CR #8 sustained injuries, interventions were put in place to help prevent further falls and that her fall on 11/3/2015 was probably preventable. The DON added, I think we did our due diligence. CR #8: Record review of CR #8 ' s initial care plan dated 09/23/15 revealed in part : at risk for falls, approaches-reinforce call light for assistance, evaluate for safety devises, provide wheelchair as needed, keep floors free of spills . general goals included: resident will not have any injuries related to falls over the next 90 days .resident will not experience any side effects related to the use of [MEDICAL CONDITION] drugs . Record review of Resident #8 ' s nurse ' s notes revealed the resident had 6 falls from 10/13/2015 to 11/3/2015 with the last two falls resulting in intraventricular hemorrhage and two hospital stays. CR #8 remains in the hospital. Record review of CR #8 ' s Care Plans revealed that a fall care plan was not completed until 10/24/2015 (after 4 falls) and revised on 10/30/2015. Record review of a psychiatric consult completed in the hospital dated 10/30/2015 read in part: .The patient had been taking a huge amount of [MEDICAL CONDITION] with duplication in several of the drug categories . The list of [MEDICAL CONDITION] at present-Trazadone 50 mg at night, [MEDICATION NAME] 2 mg IV prn, [MEDICATION NAME] Sprinkles 125 mg TID, [MEDICATION NAME] 20 mg bid, [MEDICATION NAME] SR150 tid, Klonopin .5 mg tid, [MEDICATION NAME] 750 mg every six hours (muscle relaxer) and [MEDICATION NAME] 12.5 mg prn . Recommendations- The patient is taking a large number of lubricated [MEDICAL CONDITION], recommend a gradual decrease in them to permit increasing alertness and decreasing lowering extremity weakness leading to falls . Record review of CR #8 ' s nurses note dated 10/31/2015 at 11:06 pm read in part, Resident is a readmit . Has a hematoma to right forehead . Orders given to do neuro (checks) . Multiple bruises old bruises to bilateral upper extremities and scabs to bilateral upper extremities . Stable with no signs of pain or discomfort . Further review of CR #8 ' s clinical file revealed no documentation indicating [MEDICAL CONDITION] medication was reviewed by the facility for possible reduction after this readmission. In an interview with the DON on 11/4/2015 at 3:50 pm, she stated CR #8 has had several falls since her admission and was in the hospital after falling and hitting her head on 11/3/2015. She further stated the resident was on the Falling Star program and that her care plan was initiated on 10/24/2015 and revised on 10/30/15 to address the resident ' s unwitnessed falls. The DON stated she did not know why care plans were not revised prior to 10/24/2015 to address the resident ' s risk for falls or history of falls. In an interview with the DON on 11/16/2015 at 3:00 pm, she stated she was in charge of the facility ' s fall program. When investigating a fall, she stated she reviewed the incident report submitted by facility staff and it was discussed with her team during the morning meeting. The DON said that as part of the post fall investigation, they review the circumstances surrounding the fall, checked and updated care plans and interventions, and request a therapy screen for the resident. Furthermore, she said she reviews the resident ' s medications and also has the pharmacy consultant to review. When asked if she had reviewed CR #8 ' s medications when investigating her falls, she stated she had reviewed the resident ' s medications, however, the resident had not been seen by the pharmacy consultant because he only come once monthly. The DON was provided with a copy of CR #8 ' s Psychiatrist Consult note from 10/30/2015 done during CR #8 ' s hospital stay. She stated she had not seen the note and that it was the ADON ' s duty to review residents hospital records upon re-admission from the hospital. She stated the resident was being seen by the facility ' s psychiatrist, who had not recommended any changes to her psychiatric medications. The DON stated she did not know why the resident did not have a care plan or documented monitoring of her use of [MEDICAL CONDITION] and antidepressant medications and their related side effects. She also stated she did not know why there was no care plan addressing the residents risk for fall when she was initially found on the floor on 10/13/2015. In an interview on 11/17/15 at 1:00 pm with the ADON she said she did not see any notes from the hospital psychiatrist consult. She said that the nurse doing the resident ' s admission has to review the medication with the MD and they will tell the facility to continue or not the medication. She said that the resident did not have any significant change of condition that would warrant a change in her medication. Resident #4: Record Review of the Incident Report from 06/2015 to 11/2015 indicated Resident #4 had 9 falls on that period. Record review of the care plans for Resident #4 indicated care plan for falls was not initiated until 09/15/15 and revised 11/15/15. The only actual falls addressed were dated 11/11/15, 11/14/15. The care plan did not mention if resident was safe to shower be herself. -ADL functions care plan initiated 09/15/15, Revision date: 09/15/15. Bathing/Personal hygiene - Limited to extensive assist of one. Staff will bathe the resident as scheduled 3 times a week or per schedule. Interview on 11/4/15 at 3: 45 pm Resident #4 said that the reason why she is falling so much is because staff takes too long to help her so she attempts to do it herself. She said I know I am going to fall because I have Parkinson ' s disease. Resident #4 also said that staff tells her to learn to do it yourself so you will be ready to go home. Observation and interview on 11/16/15 at 10:10 a.m. indicated Resident #4 was not in her room. When the surveyor asked CNA E if the resident was in the bathroom she said she did not know. CNA E then knocked on the door and Resident #4 answered, stating she was in the shower. When CNA E opened the door to the bathroom she said Resident #4 was in the shower by herself. When asked if Resident #4 should be showering unassisted, CNA E said she did not normally work on that hall and she did not know if Resident #4 showered by herself. In an interview on 11/16/15 at 3:00 pm the DON said that she did not know if staff had care planned the fact that the resident was taking showers unsupervised. Resident #1: Record review of the Provider Investigation Report submitted on 10/30/2015 at 3:30 pm detailing Resident #1's fall on 10/26/2015 read, in part, Place resident on the Falling Star Program . Monitor resident for adverse effect from fall . Record review of Resident #1 ' s fall risk assessments revealed the resident was assessed as being at risk for falls on: - 4/20/2015 score of 14 (score of 10 or more indicates risk for falls) - 10/26/2015 score of 16 Record review of Resident #1 ' s Care Plan section revealed that a fall care plan was not initiated until 10/30/15 (after an actual fall) . The care plan did not listed specific, appropriate and individualized approaches to prevent further falls for this resident. Observations made on 11/4/15 at 9:40 am, 10:50 am and 2:10 pm revealed Resident #1 lying in bed on a low air loss mattress. Her bed was not in the lowest position. In an interview with the DON on 11/4/15 at 4:15 pm, she stated after Resident #1's fall, she was placed on the facility's Falling Star falls prevention program. She said this included placing a star above the resident ' s bed and outside their door, placing the bed at the lowest position and placing fall mats when appropriate. When asked why Resident #1 ' s bed was not at the lowest position, she stated the resident ' s personal sitter moves the bed up and will not place it back at the lowest position. She stated the resident was initially on the facility Falling Star program on admission but was taken off after 30 days because she did not have a fall. The DON stated she did not know why a risk for fall care plan was not initiated in April or provide individualized interventions to prevent falls. Resident #10: Record review of Resident #10 ' s fall risk assessments revealed she was assessed as being at risk for falls on: - 4/14/2015 score of 18 - 11/6/2015 score of 16 Record review of Resident #10 ' s care plan section revealed that the care plan for risk for falls was not initiated until 11/06/15, after the resident sustained [REDACTED]. Observation on 11/16/2015 at 10:54 am, Resident #10 was found on the floor by a Surveyor in a common area next to the nurses ' station. A wall was noted separating the nurses ' station and the common area, decreasing the amount of visibility from the nurses ' station. There were no staff members noted in the common area with the residents. In an interview with the DON on 11/4/2015 at 11:15 am, she stated the yellow tape in the wheelchair indicated the resident was on the Falling Star Program. She stated Resident #10 had no history of falls. She stated staff members were to be closely monitoring residents on falls precautions. The DON further stated she did not know the circumstances surrounding Resident #10 ' s fall or why the residents were gathered in the common area because she was not in the area prior to the fall. Resident # 5: Record review of the facility incident reports revealed that the resident had the following falls: -09/19/2015 revealed an un-witnessed fall involving Resident # 5. -10/16/15 revealed that she on the floor holding to the bed side rail. Record review of Resident # 5 care plan for risk for falls initiated on 07/02/2015 and revised on 11/17/15 revealed that she was at risk for falls due to impaired balance, history of falls, [MEDICAL CONDITION] medication use, and short of breath issues. The care plan was not revised with new interventions after falls sustained on 9/19/15 and 10/16/15. In an interview on 11/4/2015 at 11:50 a.m. Resident # 5 said she showered by herself. In an interview on 11/4/2015 at 11:55 a.m. with CNA G she states that if the resident needed to take a shower, she would just get towels for her to use because the resident could take a shower by herself. In an interview on 11/16/15 at 3:00 pm the DON said that staff should be standing right there with Resident #5 when she takes a shower. She said she did not know if the resident was care planned to shower without supervision. Record review of Resident # 5 ' s care plan section revealed there was no care plan addressing resident was safe to shower without supervision. An IJ was identified on 11/16/2015 at 6:03 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 11/16/15 at 9:36 pm . After several revisions were made the POR was accepted on 11/18/2015. The POR included in part: .11/16/15 initiated-11/17/15 completed, In-service completion dates to reflect Fall Prevention and Falling Star Program and Individualized Resident Interventions. Content of Falling Star Program in-service presented to all facility staff. Falling Star Interventions include: Resident who has a fall risk score greater than 10, change in behavior/condition, history of falls prior to admission or experienced a fall will be placed on the falling star list x 4 weeks for follow up. The Falling Star Identification consists of a yellow star outside of resident room on name plate, on over bed sign, CNA assignment sheet and yellow tape placed on all assistive devices. Staff will be in serviced prior to working on the floor regarding these programs. The training will cover how a resident is placed on the Falling Star Program, Potential Interventions that can be initiated when a resident is at Risk for fall, Review of interventions after every fall and updates to Care Plan. Staff who are on leave of absence, prn or weekend only will be called in to receive training prior to working their scheduled shift. 11/6/15-11/17/15 Initial Resident Assessment 100% Audit completed on 11/13/15 for at Risk for fall and updated Care Plan accordingly. 11/15/15 Reevaluation initiated and completion 11/17/15 of Individualized Care Plans for those residents who have had falls and Care Plans will reflect interventions and current plan of care specific to each resident ' s needs .Comprehensive MDS Assessment CAAS, Care Area Assessment Summary, triggered areas will be Care Planned as deemed necessary. 100% audit completed and Fall Risk Care Plans reevaluated and updated with interventions. 11/6/15 initiated Care Plan updates -11/17/15 Completed Care plan updates for falls and or revised with fall interventions in the daily clinical meeting by the MDS Nurse, DON or designee. In this meeting is the IDT members, which include DON, MDS Nurse, ADON, Social Services, Activities, Rehab, and Dietary Manager who can discuss current interventions and reevaluate effectiveness and will include recommendations for review by Pharmacy Consultant, Psychiatry, and or MD. Interventions will be added to Care Plan and is available on Point Click Care which is available to Licensed Nurses ,Direct Care Staff for intervention updates, Additionally Interventions will be added to the CNA Assignment Sheet daily. These are the methods of communication with staff for interventions. Licensed staff have access to Care Plans through Point Click Care, Direct Care Staff including Med Aides have access to the Kardex in Point Click Care. The Kardex, has information about ADL interventions within Point Click Care. This is the information alert which Direct Care Staff have access to. Re in servicing Licensed Staff and Direct Care staff on the access to Care Plan and Kardex , initiated 11/17/15 and completion on 11/18/15. Side Effect/ Behavior Monitoring, if side effects/behavior are observed, report and document in the medical record. Licensed nurses was in serviced by 11/16/15-11/17/15 by DSD, DON or designee. Per EMAR, Electronic Medication Administration Record, [REDACTED]. Specific to residents with actual falls meds will be reviewed for possible reduction by PCP, Psychiatrist and or Pharmacist. Licensed staff who are on leave, prn or weekend staff will be called to come in and receive in service prior to working. 11/17/15 Completed by Nursing Administration Psych Medication Review completed of those residents who have had falls in last 30 days. Further review by Pharmacy Consultant initiated review of those residents who have fallen in last 30 days on 11/5/15 with completion to be 11/18/15, Psychiatrist has reviewed on his visit for those residents on his caseload 11/17/15 additional referrals are being made by Social Worker today 11/18/15 with next visit on 11/20/15 . The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff representing all three shifts had been in-serviced from 11/17/2015 until 11/18/2015.The topics included in part: Fall Assessment; Falling star program; Point Click Care, Kardex and Care Plan; Behavior/side effect monitoring, How to document on Point Click Care. Observations were made from 11/17/2015 until 11/19/2015 to ensure that fall prevention measures were put in place, such as beds in low position, fall mats when appropriate, care plans were updated, and adequate supervision was provided. Interviews were conducted from 11/17/15 until 11/19/15 between 9:00 am to 4:00 pm with CNAs, Nurses, administration, and other staff members not involved in direct resident care on various shifts. Interviews revealed staffs was able to verbalize understanding of the information from the recent in-services. The Administrator and DON were informed on 11/19/2015 at 2:43 pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The facility CMS form 802 dated 11/4/2015 identified 9 residents as being at risk for falls.

Based on observation, interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent falls and accidents for 5 of 10 residents (CR #8 and Residents #4, #1, #10 and #5) reviewed for risk for falls. - CR #8 had 6 falls from 10/13/2015 to 11/3/2015. On 10/29/15 she had a fall where she suffered an intraventricular hemorrhage and subdural hematoma and another fall on 11/3/2015 that resulted in worsening of the subdural hematoma. The facility did not revise her care plan and put in place effective interventions to prevent further falls. CR #8 remains in the hospital. Cr #8 was receiving multiple psychotropic medications since admission. - Resident # 4 ,who was assessed as being at risk for falls and had multiple falls in the facility, was allowed to shower without supervision. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. - Resident #1 had a fall on 10/26/2015 that resulted in minor injuries. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. - Resident #10 was assessed as being at risk for fall on 4/20/2015. No care plan was put in place with effective interventions or supervision to prevent falls until 11/6/2015, when the resident had a fall. - Resident #5 who was assessed as being at risk for falls and had a history of [REDACTED]. Care plan to address ADL needs for showers was not updated until 11/9/15. An IJ was identified on 11/16/2015. While the IJ was removed on 11/19/2015, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 5 residents and could place 3 other residents identified by the facility as being at risk for falls at risk of increased accidents, falls and injuries. Intake # 1, 1, 2, 6 Findings Include: CR #8: Record review of CR #8 ' s face sheet revealed she was admitted to the facility on [DATE], with a re-admission date of [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. CR #8 was discharged to the hospital on [DATE]. Record review of CR #8 ' s admission MDS assessment dated [DATE] revealed she had a BIMS score of 04 which indicated severe cognitive impairment. She was assessed as needing extensive assistance from one staff member for eating, bed mobility, transfer, toilet use and personal hygiene. CR #8 was coded as not steady only able to stabilize with staff assistance for surface to surface transfers. She was also assessed as not having any history of fall within the last 2-6 months prior to admission. Further record review of CAA summary revealed resident was triggered for care plan for falls, psychotropic drug use, psychosocial well-being and behavioral symptoms. Record review of CR #8 ' s initial care plan dated 09/23/15 revealed in part : at risk for falls, approaches-reinforce call light for assistance, evaluate for safety devises, provide wheelchair as needed, keep floors free of spills . general goals included: resident will not have any injuries related to falls over the next 90 days .resident will not experience any side effects related to the use of psychotropic drugs . Record review of CR #8 ' s physician's order [REDACTED]. ·Bupropion HCL ER 150mg, give one tablet by mouth three times a day for depression. Start date 9/23/2015 ·Trazadone 50mg, give one tablet by mouth at bedtime for depression. Give one to two tabs. Start date 9/23/2015 ·Robaxin 750, give one tablet by mouth four times a day for muscle spasm. Start date 9/23/2015 ·Carbidopa-Levodopa 25/100mg, give two tablets by mouth three times a day for Parkinson. Start date 9/30/2015 ·Cymbalta delayed release 20mg, give one capsule by mouth two times a day for dementia with depression. Start date 9/30/2015 ·Depakote sprinkles 125mg, give one capsule by mouth three times a day related to epilepsy and recurrently seizures. Start date 9/30/2015 ·Carbidopa-Levodopa 25/100mg, give 2.5 tablets by mouth one time a day for Parkinson. Start date 10/2/2015 .Clonazepam 0.5mg, give one table by mouth three times a day for anxiety. Start date 10/21/2015. ·Tramadol 50mg, given one tale by mouth every 6 hours as needed for pain. Start date 10/21/2015 Record review of CR #8 ' s fall risk assessments revealed she assessed as being At risk for falls on the following dates: - 9/23/2015, score of 12 (10 or more indicates the resident is at risk for falls) - 10/13/2015, score of 20 (resident assessed as-having falls in the last 90 days, overestimates limits, moderate vision impairment, confined to a chair, not able to balance without help, impaired gait and use of multiple medications with potential for drug reaction) - 10/19/2015, score of 18 - 10/22/2015, score of 12 (falls in the last 90 days, adequate vision, confined to a chair, balance issues was blank, impaired gait and use of multiple medications with potential for drug reaction) - 10/29/2015, score of 18 (falls in the last 90 days, adequate vision, confined to a chair, unable to balance without physical help, impaired gait and use of multiple medications with potential for drug reaction) - 10/31/2015, score of 10 (falls in the last 90 days, adequate vision, confined to a chair, steady balance, medications with potential for drug reaction was marked as none) Record review of CR #8 ' s nurse notes revealed the following : 10/13/2015 at 10: 36 pm- CR #8 found on the floor in her room. Head to toe assessment revealed no injuries. Further review revealed there was no post fall interventions put in place. A Situation, Background, Assessment and Recommendation (SBAR) was attached. The mental status, functional status changes areas were marked N/A. Section for RN/LVN assessment asking : What do you think is going on with the resident? was blank for the RN section and only mentioned confusion under the LVN area. No other information was attached. 10/18/2015 at 10:35 pm- CR #8 found on the floor in her room, lying on her back with clothes in her hands. The resident sustained [REDACTED]. The physician was notified and gave orders to apply steri-strips to the skin tear and x-ray of the left shoulder which revealed no injury. Further review revealed there was no post fall interventions put in place 10/22/2015 at 10:41 pm- CR #8- Resident was witnessed in her room trying to get into her wheelchair when the chair moved and the resident slowly sat on the floor. A head to toe assessment revealed no injuries. Further review revealed there were no post fall interventions or updates made to the care plan addressing the fall or fall risk assessment. Further review revealed there was no post fall interventions put in place. A Situation, Background, Assessment and Recommendation (SBAR) was attached. The mental status, functional status changes areas were marked N/A. Section for RN/LVN assessment asking: What do you think is going on with the resident? only mentioned confusion under the RN section. Under the request section for I suggest or request (check all that apply) the nurse documented: monitor patient closely encourage use of call light. 10/24/2015 at 11:09 pm- Resident was found on the floor in her room and orient to self only. The resident sustained [REDACTED]. Further review revealed there was no post fall interventions put in place. Further review of the nurses ' notes revealed that CR #8 sustained another fall on 10/29/15 that required hospitalization and another fall on 11/3/15 that also required hospitalization . Record review of CR #8 ' s Care Plan section revealed that a fall care plan was not completed until 10/24/2015 and revised on 10/30/2015 and read in part, Focus- Recent Fall . Goal- Will have no further fall during the next 14 days Interventions- Call MD or RP for any changes in condition . Head to toe assessment . Monitor and report to MD and RP for any injury from fall . Neuro- checks as ordered .Pain medication as needed per MD order for any pain or discomfort from fall . Rehab screen and resident to go to dining room for all meals. Further review revealed a care plan initiated on 10/1/2015 that read in part, Focus- Resident has episodes of un-wanted behaviors of frequently crying, tearing/pulling off brief . Goal- Behavior episodes will be reduces to less than daily until the next review target date 12/22/2015 .Interventions-Give 1:1 assistance to try and calm resident down as needed . Monitor and chart behaviors every shift and report to MD . Refer to Mental Health for evaluation and treatment . Seek alternative placement as when needed. Further review of her care plans revealed there was no care plan addressing the resident ' s use of psychotropic medications or addressing the resident ' s risk for fall, being found on the floor or other interventions to prevent further falls. Record review of CR #8 ' s facility Incident Report dated 10/29/2015 at 6:48 pm read in part: . Nurse noted resident on the floor in her room with hematoma to right side of forehead and bleeding . Oriented to person Predisposing Factors- Impaired Memory . Ambulating without Assist . Record review of CR #8 ' s SBAR note dated 10/29/2015 read in part, Mental Status Changes- Increased confusion . Functional Status Changes- Needs more assistance with ADL ' s. Record review of the Provider Investigation Report submitted 11/4/2015 detailing the same unwitnessed fall on 10/29/2015 read in part, Investigation Summary- Resident had an unwitnessed fall while eating supper Resident was taken to room when hall trays came out, she was set up in her usual fashion at the desk in her room CNA left room and resident was feeding herself per her usual routine. Shortly thereafter, resident screamed and was overheard by family member across hallway. Nursing staff immediately entered room and observed resident on the floor . Provider Action Taken Post Investigation- Resident ' s room re-arranged to provide ample room for resident to navigate in room . Resident placed on Falling Star Program . Care plan updated . Monitor resident for adverse effect from fall . CNA assignment sheet updated to include encouraging resident to go to dining room for meals. Record review of CR #8 ' s chart revealed a nurse ' s noted dated 10/29/2015 at 6:47 pm read in part, CNA notified nurse that resident is on the floor, nurse noted resident on the floor with hematoma to right side of forehead and bleeding Skin tear to bilateral lower arm . vital signs blood pressure 156/88 . unable to raise left upper extremity . applied ice to hematoma, cleaned skin tear and sterile dressing applied. Physicians notified and order given to transfer resident to the hospital . picked up by EMS at 6:30 pm. RP notified. Record review of CR #8 ' s hospital record for 10/29/2015 to 10/30/2015 revealed admitting [DIAGNOSES REDACTED]. The Discharge Summary read in part, 73 y/o female with Parkinson ' s and dementia admitted after fall and intracranial hemorrhage. Results of a CT scan done on 10/29/15 results revealed small collections of intraventricular hemorrhage demonstrated in both occipital horns of the right lateral ventricle, small right temporal subdural hematoma and decreased right frontal scalp contusion Underlying skeleton is intact No findings are seen in this patient ' s pelvis or either hip. A neurosurgical consult dated 10/31/2015 read in part, CT head series reviewed with essentially stable findings, hematomas small and non-surgical in nature . Recommend falls precautions to prevent further trauma to head. Record review of a psychiatric consult completed in the hospital dated 10/30/2015 read in part: .The patient had been taking a huge amount of psychotropic with duplication in several of the drug categories . The list of psychotropic at present-Trazadone 50 mg at night, Haldol 2 mg IV prn, Depakote Sprinkles 125 mg TID, Cymbalta 20 mg BID, Wellbutrin SR 150 TID, Klonopin .5 mg TID, Robaxin 750 mg every six hours (muscle relaxer) and Benadryl 12.5 mg prn Recommendations- The patient is taking a large number of lubricated psychotropics, recommend a gradual decrease in them to permit increasing alertness and decreasing lowering extremity weakness leading to falls . Record review of CR #8 ' s nurses note dated 10/31/2015 at 11:06 pm read in part, Resident is a readmit Has a hematoma to right forehead Orders given to do neuro (checks) Multiple bruises old bruises to bilateral upper extremities and scabs to bilateral upper extremities . Stable with no signs of pain or discomfort . Further review of CR #8 ' s clinical file to include the MAR for 11/2015 revealed no evidence that the psychotropic medication was reviewed by the facility for possible reduction after this readmission. CR #8 received the same psychotropic medications and the Robaxin from 11/1/15 until 11/3/15. Record review of Physician telephone order dated 11/2/15 revealed to add floor mats to bedside, bed and chair alarms. Full fall precautions . Record review of CR #8 ' s nurses note dated 11/3/2015 at 6:59 pm read in part, Resident was seen trying to reach for something on the floor from her wheelchair Resident hit her forehead to the ground and had a deep cut on the right side of the head . site cleaned . NP for physician notified . order received to transfer resident to ER for evaluation . RP notified EMS left with resident at 6:40 pm. Record review of CR #8 ' s facility Incident Report detailing her fall dated 11/3/2015 at 5:50 pm read in part, Predisposing Factors- Confused. At the time of the investigation from 11/4/2015 to 11/19/2015, CR #8 remained in the hospital. Record review of CR #8 ' s hospital record with admission date of [DATE] revealed a CT scan done on 11/3/2015 read in part, In comparison to the most recent prior CT head performed 4 days prior, there is slight enlargement and elongation of the right-sided subdural hematoma. A physician ' s note dated 11/3/2015 read in part, This is a [AGE] year old female who is known to our service from her last admission . a repeat CT head showed that there was some worsening of the right sided hematoma . no neurosurgery intervention at this time End of life care issues were also brought up . (family member) also wanted a psych re-evaluation. In an interview with the DON on 11/4/2015 at 3:50 pm, she stated CR #8 has had several falls since her admission and was in the hospital after falling and hitting her head on 11/3/2015. She further stated the resident was on the Falling Star program and that her care plan was initiated on 10/24/2015 and revised on 10/30/15 to address the resident ' s unwitnessed falls. The DON stated she did not know why care plans were not revised prior to 10/24/2015 to address the resident ' s risk for falls or history of falls. Observation was made of CR #8 on 11/5/2015 at 8:07 am in the hospital intensive care unit. She was only oriented to self, very confused and non-interviewable. She was noted to have bruising to the right side of forehead extending down her right jaw and neck, just below the right ear. Bruising was also noted below the right eye. Two lacerations were noted to the forehead just above the right eye. Record review of a the Provider Investigation Report submitted on 11/11/2015 detailing CR #8 ' s witnessed fall on 11/11/2015 read in part, Investigation Summary-On 11/3/2015 around 5:30 pm, resident became restless and agitated . nurse requested CNA to keep resident within eyesight due to fall risk and increased agitation . CNA went to answer call light for another resident, (nurse) was on the hallway dispensing medication when he noted resident bending over . he ran toward resident but it was too late. Resident fell hitting the right side of her head re-opening a previous hematoma. Provider Action Taken Post- Investigation- Resident to continue on Falling Star Program Care plan updated .Self-report to DADS. Record review of CR #8 ' s psychoactive medication evaluation dated 9/23/2015 revealed a review of Clonazepam 0.5 mg TID that read in part, Diagnosis- anxiety. Behavior warranting use of medication- anxiety. N/A was documented in the areas of Number of episodes per week, Interventions attempted that were effective, and Interventions tried that were effective. Adverse reactions- None apparent . physician notified . new orders given. Evaluation- no change noted, appears controlled. Record review of CR #8 ' s medical chart revealed an initial psychiatric progress note dated 9/29/2015 that read in part, Reason for referral: Anxiety; adjustment issues . Summary: Becomes panicky when left alone (illegible) may try to get out of bed (has not succeeded thus far). Further review revealed a psychiatric progress note dated 10/6/2015 that read in part, no acute problems Continue meds as ordered. There were no other psychiatric evaluations noted in the residents chart or provided before exit. Plan of Care- plan of care updated on 9/25/2015. Further review revealed another Psychoactive Medication Evaluation dated 10/31/2015 revealed a review of Wellbutrin (Bupropion) 150 mg three times daily that read in part, Diagnosis- nothing documented. Behavior warranting use of medication- confusion. Number of episodes per week- uncountable. Redirection was documented in the areas of Interventions attempted that were ineffective and Interventions tried that were effective. Adverse reactions- None apparent No documentation of physician notification. Evaluation- No change noted. There was no documentation indicating the plan of care was updated. There were no other psychoactive medication evaluations noted in the chart or provided before exit. Record review of CR #8 ' s chart revealed there was no behavior monitoring associated with CR #8 ' s use of psychoactive and antidepressant medications and their related side effects. There was no documentation provided before exit. In an interview with the DON on 11/16/2015 at 3:00 pm, she stated she was in charge of the facility ' s fall program. When investigating a fall, she stated she reviewed the incident report submitted by facility staff and it was discussed with her team during the morning meeting. The DON said that as part of the post fall investigation, they review the circumstances surrounding the fall, checked and updated care plans and interventions, and request a therapy screen for the resident. Furthermore, she said she reviews the resident ' s medications and also has the pharmacy consultant to review. When asked if she had reviewed CR #8 ' s medications when investigating her falls, she stated she had reviewed the resident ' s medications, however, the resident had not been seen by the pharmacy consultant because he only come once monthly. The DON was provided with a copy of CR #8 ' s Psychiatrist Consult note from 10/30/2015 done during CR #8 ' s hospital stay. She stated she had not seen the note and that it was the ADON ' s duty to review residents hospital records upon re-admission from the hospital. She stated the resident was being seen by the facility ' s psychiatrist, who had not recommended any changes to her psychiatric medications. The DON stated she did not know why the resident did not have a care plan or documented monitoring of her use of psychotropic and antidepressant medications and their related side effects. She also stated she did not know why there was no care plan addressing the residents risk for fall when she was initially found on the floor on 10/13/2015. In an interview on 11/17/15 at 1:00 pm with the ADON she said she did not see any notes from the hospital psychiatrist consult. She said that the nurse doing the resident ' s admission has to review the medication with the MD and they will tell the facility to continue or not the medication. She said that the resident did not have any significant change of condition that would warrant a change in her medication. In an interview with LVN B on 11/18/2015 at 2:45 pm, she stated she was the nurse who assessed CR #8 after she was found on the floor in her room on 10/29/2015. She stated the resident had a history of [REDACTED]. LVN B stated she usually worked the 7:00 am to 3:00 pm shift and the resident usually ate her breakfast and lunch in the dining room but would sometimes choose to eat in her room. If the resident chose to eat in her room, LVN B stated she would ensure the resident was supervised. She stated on the evening of 10/29/2015, she worked the 3:00 pm to 11:00 pm shift, which was not her usual shift. LVN B stated she was not familiar with CR #8 ' s behavior and routine during the evening shifts. She stated the CNAs told her CR #8 usually ate dinner unsupervised in her room, so she allowed CR #8 to eat in her room without supervision. LVN B stated she was summoned by a CNA to assess CR #8 when she was found on the floor in her room. When asked if she felt it was safe for CR #8 to eat in her room without supervision, she stated, Yes and no because the CNA s said the resident was not trying to get up during the evening shift and had not fallen while eating in her room unsupervised. In an interview with RN B on 11/18/2015 on 3:35 pm, he stated he was the nurse who witnessed CR #8 ' s fall on 11/3/2015. RN B stated the he was aware of CR #8 ' s history of fall and that resident was agitated and restless during his shift, so he had CNA U sit with the resident in the hallway next to her room. He stated he went in to a resident ' s room to administer medications and left CNA U sitting with the resident. Upon exiting the room, he stated he saw CR #8 bending over in her wheelchair as if to get something from the floor. RN B stated he ran to catch the resident but she fell from the chair, hitting her head. He stated CNA U was no longer sitting with the resident and did not know where she went, so he called for help. CNA U arrived, stating she was answering a call light in another resident ' s room. RN B stated CR #8 did not have an order for [REDACTED]. In an interview with CNA U on 11/18/2015 at 4:17 pm, she stated she was ordered to sit with CR #8 on the evening of 11/3/2015 to make sure she didn ' t fall . CNA U stated she was aware of the resident ' s history of fall. She said that when leaving to answer a call light, she told RN B where she was going. She said that while in the other resident ' s room, she heard a commotion in the hallway and found RN B holding CR #8. Resident #4: Record review of Resident #4's clinical file revealed she was [AGE] years old. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4 ' s quarterly MDS assessment dated [DATE] revealed that she had moderately severe cognitive skills. She was assessed as requiring extensive assistance of two persons for bed mobility, transfers and of one person for dressing, toilet use and personal hygiene. For bathing, she was assessed as requiring physical help of one person in part of the bathing activity. Further review revealed that she was coded as having falls before admission and having two falls with no injury after admission. Record Review of the Incident Report dated 04/13/15 - 11/04/15 indicated Resident #4 had the following falls with no injuries: 06/14- Resident was trying to reach something on the floor, 08/14- found resident sitting on her bottom on the floor of the bathroom. Resident said she was trying to get to the commode, 08/15- resident was found in a sitting position on the floor besides the commode . 09/15- resident on the floor in the hallway. Resident said she was reaching for something and fell from the chair. 09/18- resident on the floor in her room. Resident said she was reaching for the phone and fell . 09/24- Resident found lying in supine position in the bathroom. 10/19- Resident ambulating by herself in hallway with walker .she fell on her right knee . 11/11- Found in a sitting position in her room. Said she tried to get in bed by herself. 11/14- Observed on the floor sitting in the bathroom. Stated that she was transferring without locking the chair . Record review of Resident #4's fall risk assessment revealed she was assessed as being At risk for falls on 11/11/15 with a score of 22. She had 3 or more falls in the last 90 days, required assistance for elimination, was confined to a wheelchair, had 3 or more health conditions/risk factors, was on 3 or more medications within the last 7 days, and her gait was impaired. Record review of the care plans for Resident #4 indicated: - At risk for further falls due to history of falls and recent fall, gait and balance problems due to Parkinson ' s disease, impulsiveness, noncompliance, DJD and transfer herself to bathroom at times . Date initiated 09/15/15, Revision date: 11/11/15. Approaches included: call light within reach and encourage to use it. The resident needs prompt response to all requests for assistance .educate the resident/family/caregivers about safety reminders and what to do if falls occurs .encourage resident to wait on assistance to the bathroom. Actual falls 11/11/15, 11/14/15. The care plan did not mention if resident was safe to shower be herself. -ADL functions require extensive assist due to Parkinson's, degenerative joint disease. Date initiated 09/15/15, Revision date: 09/15/15. Bathing/Personal hygiene - Limited to extensive assist of one. Staff will bathe the resident as scheduled 3 times a week or per schedule. - Psychotropic medication. Date initiated 06/28/15, Revision date: 11/02/15. Monitor/Document any adverse reactions: unsteady gait, frequent falls, blurred vision, fatigue, behavior symptoms. - Has impaired cognitive function and impaired thought processes. Long/short term memory loss. Date initiated 06/28/15, Revision date: 11/02/15. Observation on 11/4/15 at 3:35 pm Resident #4 was observed in her bathroom with CNA B assisting with dental care. Interview on 11/4/15 at 3:40 pm CNA B said that Resident #4 had a history of [REDACTED]. She said that the staff tells her not to get up without assistance. Interview on 11/4/15 at 3: 45 pm Resident #4 said that the reason why she is falling so much is because staff takes too long to help her so she attempts to do it herself. She said I know I am going to fall because I have Parkinson ' s disease. Resident #4 also said that staff tells her to learn to do it yourself so you will be ready to go home. Observation and interview on 11/16/15 at 10:10 a.m. indicated Resident #4 was not in her room. When the surveyor asked CNA E if the resident was in the bathroom she said she did not know. CNA E then knocked on the door and Resident #4 answered, stating she was in the shower. When CNA E opened the door to the bathroom she said Resident #4 was in the shower by herself. When asked if Resident #4 should be showering unassisted, CNA E said she did not normally work on that hall and she did not know if Resident #4 showered by herself. CNA E said she did not have a CNA assignment sheet for the day. Further interview and record review on 11/16/15 at 10:13 a.m. CNA Y was outside of Resident #4 ' s room. She said she did not know if Resident #4 always showered by herself. When the surveyor asked to see her assignment sheet it was dated 10/26/15 and indicated: - Code Status - Full code; Diet - Regular; Shower & Brief size - 7am to 3pm Tuesday, Thursday, Saturday. - Transfer, Glasses, Assistive devise, Diabetic, Skin risk, fall risk were all blank areas on the CNA Assignment Sheet. Interview and observation on 11/16/15 at 10:13 a.m. Resident #4 said she put on her call light for assistance to transfer to/from her bed/wheelchair. She said she received assistance transferring from/to the shower chair/wheelchair. She said staff also assisted in drying her back when she got out of the shower. Resident #4 said no staff stayed in the bathroom or outside the bathroom door when she showered. She said she has had multiple falls. Resident #4 said she had a fall in the bathroom in the past while transferring from the shower chair to her wheelchair, so she asked for assistance for transferring now. Record review of the Consultant Pharmacy Monthly Report dated 09/2015 indicated: Resident #4: The resident is receiving the following medications which may increase the risk for falls: - Ambien 10 mg at bedtime. Please consider a change to as needed. - Xanax 1 mg three times daily. Please consider a reduction and use as needed. - Cymbalta - May cause drowsiness and fatigue. - Tramadol - May cause orthostatic hypotension .Please monitor and have patient stand slowly. - Robaxin - May increase risk for falls particularly when used with Xanax and other sedating medications the effects could be multiplied. Record review of the Physician order's dated 11/2015 for Resident #4 indicated: - Ambien 10 mg at bedtime, - Bupropion 300 mg daily, - Cymbalta 30 mg daily, - Cymbalta 60 mg daily, - Tramadol 60 mg daily, - Robaxin 760 mg twice daily, - Robaxin 600 mg three times daily, - Xanax 1 mg three times daily. Record review of the Nurse's Notes dated 10/13/15 indicated: IDT met to review Resident #4's multiple falls since admission, all interventions reviewed for appropriateness, and despite interventions resident continues to fall. In an interview on 11/16/15 at 3:00 pm the DON said that she did not know if staff had care planned the fact that the resident was taking showers unsupervised. Resident #1: Record review of Resident #1 ' s face sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1 ' s fall risk assessments revealed the resident was assessed as being at risk for falls (score of 10 or more indicates risk for falls)on: · 4/20/2015 score of 14 (no falls in the last 90 days, knows own limits, confined to a chair, not able to balance without assistance, use of medication with potential drug reactions, impaired gait) · 10/26/2015 score of 16 (no falls in the last 90 days, overestimates limits, confined to a chair, not able to balance without assistance, use of medication with potential drug reactions, impaired gait) Record review of Resident #1 ' s quarterly MDS dated [DATE] revealed a BIMS score of 06 which indicated severe cognitive impairment. She was assessed as being totally dependent with two or more person physical assist for bed mobility, transfer, dressing, eating, and personal hygiene. She was coded as not steady, only able to stabilize with staff assistance for surface-to-surface transfers. Under fall history, she was ass

Based on observation, interview and record review, the facility failed to develop and revise comprehensive care plans for each resident to meet a resident's medical, nursing, mental and psychosocial needs identified in the assessments for 6 of 10 residents (CR #8 and Residents #4, #1, #10 and #5)) reviewed for care plans. - CR #8 had 6 falls from 10/13/2015 to 11/3/2015. On 10/29/15 she had a fall where she suffered an intraventricular hemorrhage and subdural hematoma and another fall on 11/3/2015 that resulted in worsening of the subdural hematoma. The facility did not revise her care plan and put in place effective interventions to prevent further falls. CR #8 remains in the hospital. - Resident # 4, who was assessed as being at risk for falls and had multiple falls in the facility, was allowed to shower without supervision. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. - Resident #1 had a fall on 10/26/2015 that resulted in minor injuries. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. - Resident #10 was assessed as being at risk for fall on 4/20/2015. No care plan was put in place with effective interventions or supervision to prevent falls until 11/6/2015, when the resident had a fall. - Resident #5 who was assessed as being at risk for falls and had a history of [REDACTED]. Care plan to address ADL needs for showers was not updated until 11/9/15. An IJ was identified on 11/16/2015. While the IJ was removed on 11/19/2015, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 5 residents and could place 3 other residents identified by the facility as being at risk for falls at risk of not receiving care based on their assessed needs. Intake # 1, 1, 2, 6 CR #8: Record review of CR #8 ' s face sheet revealed she was admitted to the facility on [DATE], with a re-admission date of [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. CR #8 was discharged to the hospital on [DATE]. Record review of CR #8 ' s admission MDS assessment dated [DATE] revealed she had a BIMS score of 04 which indicated severe cognitive impairment. She was assessed as needing extensive assistance from one staff member for eating, bed mobility, transfer, toilet use and personal hygiene. CR #8 was coded as not steady only able to stabilize with staff assistance for surface to surface transfers. She was also assessed as not having any history of fall within the last 2-6 months prior to admission. Further record review of CAA summary revealed resident was triggered for care plan for falls, [MEDICAL CONDITION] drug use, psychosocial well-being and behavioral symptoms. Record review of CR #8 ' s initial care plan dated 09/23/15 revealed in part: at risk for falls, approaches-reinforce call light for assistance, evaluate for safety devises, provide wheelchair as needed, keep floors free of spills . general goals included: resident will not have any injuries related to falls over the next 90 days .resident will not experience any side effects related to the use of [MEDICAL CONDITION] drugs . Record review of CR #8 ' s fall risk assessments revealed she assessed as being At risk for falls on the following dates: - 9/23/2015, score of 12 (10 or more indicates the resident is at risk for falls) - 10/13/2015, score of 20 (resident assessed as-having falls in the last 90 days, overestimates limits, moderate vision impairment, confined to a chair, not able to balance without help, impaired gait and use of multiple medications with potential for drug reaction) - 10/19/2015, score of 18 - 10/22/2015, score of 12 (falls in the last 90 days, adequate vision, confined to a chair, balance issues was blank, impaired gait and use of multiple medications with potential for drug reaction) - 10/29/2015, score of 18 (falls in the last 90 days, adequate vision, confined to a chair, unable to balance without physical help, impaired gait and use of multiple medications with potential for drug reaction) - 10/31/2015, score of 10 (falls in the last 90 days, adequate vision, confined to a chair, steady balance, medications with potential for drug reaction was marked as none) Record review of CR #8 ' s incident reports revealed the following : 10/13/2015 at 10: 36 pm- CR #8 found on the floor in her room. Head to toe assessment revealed no injuries. Further review revealed there was no post fall interventions put in place. A Situation, Background, Assessment and Recommendation (SBAR) was attached. The mental status, functional status changes areas were marked N/A. Section for RN/LVN assessment asking : What do you think is going on with the resident? was blank for the RN section and only mentioned confusion under the LVN area. No other information was attached. 10/18/2015 at 10:35 pm- CR #8 found on the floor in her room, lying on her back with clothes in her hands. The resident sustained [REDACTED]. The physician was notified and gave orders to apply steri-strips to the skin tear and x-ray of the left shoulder which revealed no injury. Further review revealed there was no post fall interventions put in place 10/22/2015 at 10:41 pm- CR #8- Resident was witnessed in her room trying to get into her wheelchair when the chair moved and the resident slowly sat on the floor. A head to toe assessment revealed no injuries. Further review revealed there were no post fall interventions or updates made to the care plan addressing the fall or fall risk assessment. Further review revealed there was no post fall interventions put in place. A Situation, Background, Assessment and Recommendation (SBAR) was attached. The mental status, functional status changes areas were marked N/A. Section for RN/LVN assessment asking: What do you think is going on with the resident? only mentioned confusion under the RN section. Under the request section for I suggest or request (check all that apply) the nurse documented: monitor patient closely encourage use of call light. 10/24/2015 at 11:09 pm- Resident was found on the floor in her room and orient to self only. The resident sustained [REDACTED]. Further review revealed there was no post fall interventions put in place. Further review of the nurses ' notes revealed that CR #8 sustained another fall on 10/29/15 that required hospitalization and another fall on 11/3/15 that also required hospitalization . Record review of CR #8 ' s Care Plan section revealed that a fall care plan was not completed until 10/24/2015 and revised on 10/30/2015 and read in part, Focus- Recent Fall . Goal- Will have no further fall during the next 14 days Interventions- Call MD or RP for any changes in condition . Head to toe assessment . Monitor and report to MD and RP for any injury from fall . Neuro- checks as ordered .Pain medication as needed per MD order for any pain or discomfort from fall . Rehab screen and resident to go to dining room for all meals. Further review revealed a care plan initiated on 10/1/2015 that read in part, Focus- Resident has episodes of un-wanted behaviors of frequently crying, tearing/pulling off brief . Goal- Behavior episodes will be reduces to less than daily until the next review target date 12/22/2015 .Interventions-Give 1:1 assistance to try and calm resident down as needed . Monitor and chart behaviors every shift and report to MD . Refer to Mental Health for evaluation and treatment . Seek alternative placement as when needed. Further review of her care plans revealed there was no care plan addressing the resident ' s use of [MEDICAL CONDITION] medications or addressing the resident ' s risk for fall, being found on the floor or other interventions to prevent further falls. Record review of CR #8 ' s hospital record for 10/29/2015 to 10/30/2015 revealed admitting [DIAGNOSES REDACTED]. The Discharge Summary read in part, 73 y/o female with Parkinson ' s and dementia admitted after fall and [MEDICAL CONDITION]. Results of a CT scan done on 10/29/15 results revealed small collections of intraventricular hemorrhage demonstrated in both occipital horns of the right lateral ventricle, small right temporal subdural hematoma and decreased right frontal scalp contusion Underlying skeleton is intact No findings are seen in this patient ' s pelvis or either hip. A neurosurgical consult dated 10/31/2015 read in part, CT head series reviewed with essentially stable findings, hematomas small and non-surgical in nature . Recommend falls precautions to prevent further trauma to head. Record review of a psychiatric consult completed in the hospital dated 10/30/2015 read in part: .The patient had been taking a huge amount of [MEDICAL CONDITION] with duplication in several of the drug categories . The list of [MEDICAL CONDITION] at present-Trazadone 50 mg at night, [MEDICATION NAME] 2 mg IV prn, [MEDICATION NAME] Sprinkles 125 mg TID, [MEDICATION NAME] 20 mg bid, [MEDICATION NAME] SR150 tid, Klonopin .5 mg tid, [MEDICATION NAME] 750 mg every six hours (muscle relaxer) and [MEDICATION NAME] 12.5 mg prn Recommendations- The patient is taking a large number of lubricated [MEDICAL CONDITION], recommend a gradual decrease in them to permit increasing alertness and decreasing lowering extremity weakness leading to falls . Record review of CR #8 ' s nurses note dated 10/31/2015 at 11:06 pm read in part, Resident is a readmit Has a hematoma to right forehead Orders given to do neuro (checks) Multiple bruises old bruises to bilateral upper extremities and scabs to bilateral upper extremities . Stable with no signs of pain or discomfort . Further review of CR #8 ' s clinical file revealed no review of the [MEDICAL CONDITION] medication being reviewed by the facility for possible reduction after this readmission. The care plan was not revised upon readmission from the hospital. Record review of CR #8 ' s facility Incident Report detailing her fall dated 11/3/2015 at 5:50 pm read in part, Predisposing Factors- Confused. At the time of the investigation from 11/4/2015 to 11/19/2015, CR #8 remained in the hospital. Record review of CR #8 ' s hospital record with admission date of [DATE] revealed a CT scan done on 11/3/2015 read in part, In comparison to the most recent prior CT head performed 4 days prior, there is slight enlargement and elongation of the right-sided subdural hematoma. A physician ' s note dated 11/3/2015 read in part, This is a [AGE] year old female who is known to our service from her last admission . a repeat CT head showed that there was some worsening of the right sided hematoma . no neurosurgery intervention at this time End of life care issues were also brought up . (family member) also wanted a psych re-evaluation. In an interview with the DON on 11/4/2015 at 3:50 pm, she stated CR #8 has had several falls since her admission and was in the hospital after falling and hitting her head on 11/3/2015. She further stated the resident was on the Falling Star program and that her care plan was initiated on 10/24/2015 and revised on 10/30/15 to address the resident ' s unwitnessed falls. The DON stated she did not know why care plans were not revised prior to 10/24/2015 to address the resident ' s risk for falls or history of falls. Resident #4: Record review of Resident #4's clinical file revealed she was [AGE] years old. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4 ' s quarterly MDS assessment dated [DATE] revealed that she had moderately severe cognitive skills. She was assessed as requiring extensive assistance of two persons for bed mobility, transfers and of one person for dressing, toilet use and personal hygiene. For bathing, she was assessed as requiring physical help of one person in part of the bathing activity. Further review revealed that she was coded as having falls before admission and having two falls with no injury after admission. Record Review of the Incident Report dated 04/13/15 - 11/04/15 indicated Resident #4 had falls with no injuries on: 06/14- Resident was trying to reach something on the floor, 08/14- found resident sitting on her bottom on the floor of the bathroom. Resident said she was trying to get to the commode, 08/15- resident was found in a sitting position on the floor besides the commode . 09/15- resident on the floor in the hallway. Resident said she was reaching for something and fell from the chair. 09/18- resident on the floor in her room. Resident said she was reaching for the phone and fell . 09/24- Resident found lying in supine position in the bathroom. 10/19- Resident ambulating by herself in hallway with walker .she fell on her right knee . 11/11- Found in a sitting position in her room. Said she tried to get in bed by herself. 11/14- Observed on the floor sitting in the bathroom. Stated that she was transferring without locking the chair . Record review of Resident #4's fall risk assessment revealed she was assessed as being At risk for falls on 11/11/15 with a score of 22. She had 3 or more falls in the last 90 days, required assistance for elimination, was confined to a wheelchair, had 3 or more health conditions/risk factors, was on 3 or more medications within the last 7 days, and her gait was impaired. Record review of the care plans for Resident #4 indicated: - At risk for further falls due to history of falls and recent fall, gait and balance problems due to Parkinson ' s disease, impulsiveness, noncompliance, DJD and transfer herself to bathroom at times . Date initiated 09/15/15, Revision date: 11/11/15. Approaches included: call light within reach and encourage to use it. The resident needs prompt response to all requests for assistance .educate the resident/family/caregivers about safety reminders and what to do if falls occurs .encourage resident to wait on assistance to the bathroom. Actual falls-11/11/15, 11/14/15. The care plan did not mention if resident was safe to shower be herself. -ADL functions require extensive assist due to [MEDICAL CONDITIONS] joint disease. Date initiated 09/15/15, Revision date: 09/15/15. Bathing/Personal hygiene - Limited to extensive assist of one. Staff will bathe the resident as scheduled 3 times a week or per schedule. - [MEDICAL CONDITION] medication. Date initiated 06/28/15, Revision date: 11/02/15. Monitor/Document any adverse reactions: unsteady gait, frequent falls, blurred vision, fatigue, behavior symptoms. - Has impaired cognitive function and impaired thought processes. Long/short term memory loss. Date initiated 06/28/15, Revision date: 11/02/15. Observation on 11/4/15 at 3:35 pm Resident #4 was observed in her bathroom with CNA B assisting with dental care. Interview on 11/4/15 at 3:40 pm CNA B said that Resident #4 had a history of [REDACTED]. She said that the staff tells her not to get up without assistance. Interview on 11/4/15 at 3: 45 pm Resident #4 said that the reason why she is falling so much is because staff takes too long to help her so she attempts to do it herself. She said I know I am going to fall because I have Parkinson ' s disease. Resident #4 also said that staff tells her to learn to do it yourself so you will be ready to go home. Further interview and record review on 11/16/15 at 10:13 a.m. CNA Y was outside of Resident #4 ' s room. She said she did not know if Resident #4 always showered by herself. When the surveyor asked to see her assignment sheet it was dated 10/26/15 and indicated: - Code Status - Full code; Diet - Regular; Shower & Brief size - 7am to 3pm Tuesday, Thursday, Saturday. - Transfer, Glasses, Assistive devise, Diabetic, Skin risk, fall risk were all blank areas on the CNA Assignment Sheet. In an interview on 11/16/15 at 3:00 pm the DON said that she did not know if staff had care planned the fact that the resident was taking showers unsupervised. Resident #1: Record review of Resident #1 ' s face sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1 ' s fall risk assessments revealed the resident was assessed as being at risk for falls (score of 10 or more indicates risk for falls)on: · 4/20/2015 score of 14 (no falls in the last 90 days, knows own limits, confined to a chair, not able to balance without assistance, use of medication with potential drug reactions, impaired gait) · 10/26/2015 score of 16 (no falls in the last 90 days, overestimates limits, confined to a chair, not able to balance without assistance, use of medication with potential drug reactions, impaired gait) Record review of Resident #1 ' s quarterly MDS dated [DATE] revealed a BIMS score of 06 which indicated severe cognitive impairment. She was assessed as being totally dependent with two or more person physical assist for bed mobility, transfer, dressing, eating, and personal hygiene. She was coded as not steady, only able to stabilize with staff assistance for surface-to-surface transfers. Under fall history, she was assessed as having one fall without injury since her admission. Falls was listed as a triggered area in the CAA summary. Record review of Resident #1 ' s nurses ' notes and assessments revealed she was found on the floor in her room on 10/26/2015 at 1:03 am with a hematoma noted to back of her head on the right side. A CT done on 10/27/2015 was negative for intracranial bleed. She had no other injuries. There was no other history of falls noted. Record review of Resident #1 ' s Care Plan section revealed that a fall care plan was not initiated until 10/30/15. The care plan read in part: . Focus- Recent Fall: 10/26/15 found on floor Goal- Will have no further fall during the next 14 days Interventions- Call MD and RP for any changes in condition . CT scan 10/27/2015 . D/C this care plan when condition is resolved or complete or discontinued . Monitor and report to MD and RP for any injury from fall . Neuro-checks as ordered . Pain medication as needed . Participate in Falling Star Program. There were no review dates listed. The care plan did not listed specific, appropriate and individualized approaches to prevent further falls for this resident. Observations made on 11/4/15 at 9:40 am, 10:50 am and 2:10 pm revealed Resident #1 lying in bed on a low air loss mattress. Her bed was not in the lowest position. In an interview with the DON on 11/4/15 at 4:15 pm, she stated after Resident #1's fall, she was placed on the facility's Falling Star falls prevention program. She said this included placing a star above the resident ' s bed and outside their door, placing the bed at the lowest position and placing fall mats when appropriate. When asked why Resident #1 ' s bed was not at the lowest position, she stated the resident ' s personal sitter moves the bed up and will not place it back at the lowest position. She stated the resident was initially on the facility Falling Star program on admission but was taken off after 30 days because she did not have a fall. The DON stated she did not know why a risk for fall care plan was not initiated in April or provide individualized interventions to prevent falls. Resident #10: Record review of Resident #10 ' s Face Sheet she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #10 ' s quarterly MDS dated [DATE] revealed BIMS score of 02 which indicates severe cognitive impairment. She was assessed as needing extensive assistance of two or more staff member for bed mobility and toilet use. Transfer was assessed as having only occurred once or twice with two more staff assistance. Locomotion on and off unit was assessed as having only occurred once or twice with one person physical assistance. She was coded as not steady, only able to stabilize with staff assistance. She had no history of falls. Record review of Resident #10 ' s fall risk assessments revealed she was assessed as being at risk for falls on: · 4/14/2015 score of 18 (score of 10 or more indicates risk for falls) · 11/6/2015 score of 16 Record review of Resident #10 ' s care plan section revealed that the care plan for risk for falls was not initiated until 11/06/15, after the resident sustained [REDACTED]. Record review of Resident #10 ' s fall Care Plan dated 11/06/2015 read in part, Focus- Resident is at risk for falls and is a risk for increased falls and injury due to poor safety awareness and poor balance/gait control Actual fall 11/16/2015 . Goal- Will remain free from falls through next review target date 12/28/2015 Interventions- Anticipate needs, provide prompt assessment . bed in lowest position . Encourage resident to ask for assistance from staff . Ensure that call light is in reach and answer promptly . Participate in Falling Star Program and interventions. Observation on 11/16/2015 at 10:54 am, Resident #10 was found on the floor by a Surveyor in a common area next to the nurses ' station. Other residents in wheelchairs were around. A wall was noted separating the nurses ' station and the common area, decreasing the amount of visibility from the nurses ' station. There were no staff members noted in the common area with the residents. Resident #10 was noted to be on her buttocks sitting in front of her wheelchair which was tilted forward. Several staff members were noted at the nurse ' s station including the ADON and Central Supply Clerk with others walking passed the common area. The Surveyor alerted the facility Central Supply Clerk who responded, with the DON, ADON, and CNA Z responding a few seconds later. Resident #10 was assessed, placed back in her wheelchair and taken to her room, where a family member took over her care. A yellow piece of tape was noted on the resident ' s wheelchair and on the wheelchairs of the other residents in the common area. In an interview with the DON on 11/16/2015 at 11:15 am, she stated the yellow tape in the wheelchair indicated the resident was on the Falling Star Program. She stated Resident #10 had no history of falls. She stated staff members were to be closely monitoring residents on falls precautions. The DON further stated she did not know the circumstances surrounding Resident #10 ' s fall or why the residents were gathered in the common area because she was not in the area prior to the fall. Resident # 5: Record review of Resident #5 clinical file revealed she was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 5 ' s admission MDS assessment dated [DATE] revealed that she was assessed as being cognitively intact. For functional status she was assessed as requiring limited assistance of one person for bed mobility, toilet use and personal hygiene. For bathing, she was assessed as requiring physical help of one person to complete the activity. She was assessed as having no history of falls. Record review of Resident # 5 ' s quarterly MDS assessment dated [DATE] revealed she was cognitively intact. She was assessed as requiring required limited assistance one person for bed mobility, toilet use and personal hygiene Bathing was coded as an 8 (Activity itself did not occur or family and /or non-facility staff provided care 100% of the time for that activity over the entire 7-day period). She was assessed as having no history of falls. Record review of Resident # 5 fall risk assessment reads as follows: on 6/17/2015 score 11- at risk, 08/19/2015 score 10 -at risk, 09/19/2015 score 9- at risk, 10/16/2015 score 10-at risk. Record review of the facility incident reports revealed that the resident had the following falls: -09/19/2015 revealed an un-witnessed fall involving Resident # 5. Report revealed CNA G reported to the nurse that resident # 5 was on the floor. When CNA G arrived to residents room, resident observed sitting on the floor. -10/16/15 revealed that she on the floor holding to the bed side rail. She said she bend down to adjust the O2 and got weak. There were no post interventions documented. Record review of Resident # 5 care plan for risk for falls initiated on 07/02/2015 and revised on 11/17/15 revealed that she was at risk for falls due to impaired balance, history of falls, [MEDICAL CONDITION] medication use, and short of breath issues. Interventions included to anticipate needs assess psych medication reduction, encourage resident to ask for assistance. The care plan was not revised with new interventions after falls sustained on 9/19/15 and 10/16/15. In an interview on 11/4/2015 at 11:50 a.m. Resident # 5 said that she was getting ready to go and take a shower (the resident ' s private bathroom has a shower). She was asked if she normally took showers without assistance and the resident replied yes. In an interview on 11/4/2015 at 11:55 a.m. with CNA G she states that she was familiar with the care and assistance required for Resident # 5. CNA G states that if the resident needed to take a shower, she would just get towels for her to use because the resident could take a shower by herself. In an interview on 11/16/15 at 3:00 pm the DON said that staff should be standing right there with Resident #5 when she takes a shower. She said she did not know if the resident was care planned to shower without supervision. In an interview done on 11/16/2015 at 3:10 p.m. with CNA MM she said that when resident # 5 goes to take a shower sometimes we will stay in the bathroom outside of the shower until she is done and sometimes she tell us she is okay so we will just get her towels for her to take her shower. In an interview done on 11/16/2015 at 3:10 p.m. with Resident # 5, she was asked if staff has ever stood outside while she was taking a shower. Resident #5 stated no I would probably feel embarrassed the first few times but then after a few times, I would get used to it. Record review of Resident # 5 ' s care plan section revealed there was no care plan addressing resident was safe to shower without supervision. Record review of care plan initiated on 11/09/15 and revised on 11/16/15 revealed that Resident #5 had a ADL deficit and resident reported shower self unsupervised at times Approaches included bathing-supervision-extensive assistance, showering- provide sponge bath when a full bath is not tolerated .There were no care plan to address the resident showering unsupervised before this date. Further review of the care plan section revealed a care plan dated 09/08/15 indicating the resident was at risk of bleeding due to the use of anticoagulants. Interventions included to attempt to avoid any injury causing bruising, cuts, or abrasions. In an Interview with the DON on 11/4/2015 at 1:10 p.m. regarding plan of care of residents with high risk falls, DON states that when a resident is admitted to facility we will do a fall risk assessment and pending on their score, we will place a sign at the head of resident bed. If the resident actually falls or continue to fall we will place a sign outside their door and alert CNA ' s on paper. We also place them on a low bed and place mats on the floor by their bed. In an interview with the Administrator on 11/16/2015 at 10:21 am, in response to the visit on 11/5/2015, she stated the entire resident census has been placed on the Falling Star Program. She added every resident now has yellow tape on their wheelchairs and walker and a yellow star at their door and over their bed. In order to identify those at risk for falls, the IDT team will perform a weekly evaluation of each resident during their meetings. If the resident has had no falls for 30 days, they will be removed from the Falling Star Program. She stated all newly admitted residents and those with a recent fall or change of condition will be considered a fall risk and placed on the Falling Star Program for at least 30 days for monitoring. She added that Fall Risk Assessments are also considered when evaluating for fall risk. The Administrator also stated every resident ' s care plan has been updated to address fall risk. In an interview done on 11/16/2015 at 2:25 p.m. with the DON regarding fall program the DON said I am in charge of the fall program. I look at risk management and go over it and discuss in the morning meetings. I look at circumstances and see if it is care planned for physical therapy. The medications are viewed by the pharmacist. We have a psychiatrist that comes in every other week. Record review if the facility ' s undated Falling Star Program policy read in part: -The following interventions will be initiated when a resident is identified at risk for falls: . Evaluate medications, underlying disease processes and mobility impairments that may contribute to falls . Interventions must be reviewed with every fall and revised or changed as needed . Record review of the facility ' s undated Falls/Prevention policy read in part: - Following a fall . review the plan of care and update the interventions as appropriate. An IJ was identified on 11/16/2015 at 6:03 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 11/16/15 at 9:36 pm. After several revisions were made the POR was accepted on 11/18/2015. The POR included in part: .11/16/15 initiated-11/17/15 completed, In-service completion dates to reflect Fall Prevention and Falling Star Program and Individualized Resident Interventions. Content of Falling Star Program in-service presented to all facility staff. Falling Star Interventions include: Resident who has a fall risk score greater than 10, change in behavior/condition, history of falls prior to admission or experienced a fall will be placed on the falling star list x 4 weeks for follow up. The Falling Star Identification consists of a yellow star outside of resident room on name plate, on over bed sign, CNA assignment sheet and yellow tape placed on all assistive devices. Staff will be in serviced prior to working on the floor regarding these programs. The training will cover how a resident is placed on the Falling Star Program, Potential Interventions that can be initiated when a resident is at Risk for fall, Review of interventions after every fall and updates to Care Plan. Staff who are on leave of absence, prn or weekend only will be called in to receive training prior to working their scheduled shift. 11/6/15-11/17/15 Initial Resident Assessment 100% Audit completed on 11/13/15 for at Risk for fall and updated Care Plan accordingly. 11/15/15 Reevaluation initiated and completion 11/17/15 of I

Based on observations, interviews and record reviews the facility failed to implement their written policy and procedures that prohibit neglect for 5 of 10 residents (CR #8, Resident #4, #1, #10 and #5) - CR #8 had 6 falls from 10/13/2015 to 11/3/2015. On 10/29/15 she had a fall where she suffered an intraventricular hemorrhage and subdural hematoma and another fall on 11/3/2015 that resulted in worsening of the subdural hematoma. The facility did not revise her care plan and put in place effective interventions to prevent further falls. CR #8 remains in the hospital. Cr #8 was receiving multiple [MEDICAL CONDITION] medications since admission. - Resident # 4 ,who was assessed as being at risk for falls and had multiple falls in the facility, was allowed to shower without supervision. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. - Resident #1 had a fall on 10/26/2015 that resulted in minor injuries. The care plan was not revised to put in place effective interventions or supervision to prevent further falls. - Resident #10 was assessed as being at risk for fall on 4/20/2015. No care plan was put in place with effective interventions or supervision to prevent falls until 11/6/2015, when the resident had a fall. - Resident #5 who was assessed as being at risk for falls and had a history of [REDACTED]. Care plan to address ADL needs for showers was not updated until 11/9/15. An IJ was identified on 11/16/2015. While the IJ was removed on 11/19/2015, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 5 residents and could place 4 other residents identified by the facility as being at risk for falls at risk of increased accidents, falls and injuries. Intake # 1, 1, 2, 6 Findings Include: CR #8: Record review of CR #8 ' s face sheet revealed she was admitted to the facility on [DATE], with a re-admission date of [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. CR #8 was discharged to the hospital on [DATE]. Record review of CR #8 ' s admission MDS assessment dated [DATE] revealed she had a BIMS score of 04 which indicated severe cognitive impairment. She was assessed as needing extensive assistance from one staff member for eating, bed mobility, transfer, toilet use and personal hygiene. CR #8 was coded as not steady only able to stabilize with staff assistance for surface to surface transfers. She was also assessed as not having any history of fall within the last 2-6 months prior to admission. Further record review of CAA summary revealed resident was triggered for care plan for falls, [MEDICAL CONDITION] drug use, psychosocial well-being and behavioral symptoms. Record review of CR #8 ' s initial care plan dated 09/23/15 revealed in part : at risk for falls, approaches-reinforce call light for assistance, evaluate for safety devises, provide wheelchair as needed, keep floors free of spills . general goals included: resident will not have any injuries related to falls over the next 90 days .resident will not experience any side effects related to the use of [MEDICAL CONDITION] drugs . Record review of CR #8 ' s physician's order [REDACTED]. ·[MEDICATION NAME] HCL ER 150mg, give one tablet by mouth three times a day for depression. Start date 9/23/2015 ·Trazadone 50mg, give one tablet by mouth at bedtime for depression. Give one to two tabs. Start date 9/23/2015 ·[MEDICATION NAME] 750, give one tablet by mouth four times a day for muscle spasm. Start date 9/23/2015 ·[MEDICATION NAME]-[MEDICATION NAME] 25/100mg, give two tablets by mouth three times a day for Parkinson. Start date 9/30/2015 ·[MEDICATION NAME] delayed release 20mg, give one capsule by mouth two times a day for dementia with depression. Start date 9/30/2015 ·[MEDICATION NAME] sprinkles 125mg, give one capsule by mouth three times a day related to [MEDICAL CONDITION] and recurrently [MEDICAL CONDITION]. Start date 9/30/2015 ·[MEDICATION NAME]-[MEDICATION NAME] 25/100mg, give 2.5 tablets by mouth one time a day for Parkinson. Start date 10/2/2015 .[MEDICATION NAME] 0.5mg, give one table by mouth three times a day for anxiety. Start date 10/21/2015. ·[MEDICATION NAME] 50mg, given one tale by mouth every 6 hours as needed for pain. Start date 10/21/2015 Record review of CR #8 ' s fall risk assessments revealed she assessed as being At risk for falls on the following dates: - 9/23/2015, score of 12 (10 or more indicates the resident is at risk for falls) - 10/13/2015, score of 20 (resident assessed as-having falls in the last 90 days, overestimates limits, moderate vision impairment, confined to a chair, not able to balance without help, impaired gait and use of multiple medications with potential for drug reaction) - 10/19/2015, score of 18 - 10/22/2015, score of 12 (falls in the last 90 days, adequate vision, confined to a chair, balance issues was blank, impaired gait and use of multiple medications with potential for drug reaction) - 10/29/2015, score of 18 (falls in the last 90 days, adequate vision, confined to a chair, unable to balance without physical help, impaired gait and use of multiple medications with potential for drug reaction) - 10/31/2015, score of 10 (falls in the last 90 days, adequate vision, confined to a chair, steady balance, medications with potential for drug reaction was marked as none) Record review of CR #8 ' s nurse notes revealed the following : 10/13/2015 at 10: 36 pm- CR #8 found on the floor in her room. Head to toe assessment revealed no injuries. Further review revealed there was no post fall interventions put in place. A Situation, Background, Assessment and Recommendation (SBAR) was attached. The mental status, functional status changes areas were marked N/A. Section for RN/LVN assessment asking : What do you think is going on with the resident? was blank for the RN section and only mentioned confusion under the LVN area. No other information was attached. 10/18/2015 at 10:35 pm- CR #8 found on the floor in her room, lying on her back with clothes in her hands. The resident sustained [REDACTED]. The physician was notified and gave orders to apply steri-strips to the skin tear and x-ray of the left shoulder which revealed no injury. Further review revealed there was no post fall interventions put in place 10/22/2015 at 10:41 pm- CR #8- Resident was witnessed in her room trying to get into her wheelchair when the chair moved and the resident slowly sat on the floor. A head to toe assessment revealed no injuries. Further review revealed there were no post fall interventions or updates made to the care plan addressing the fall or fall risk assessment. Further review revealed there was no post fall interventions put in place. A Situation, Background, Assessment and Recommendation (SBAR) was attached. The mental status, functional status changes areas were marked N/A. Section for RN/LVN assessment asking: What do you think is going on with the resident? only mentioned confusion under the RN section. Under the request section for I suggest or request (check all that apply) the nurse documented: monitor patient closely encourage use of call light. 10/24/2015 at 11:09 pm- Resident was found on the floor in her room and orient to self only. The resident sustained [REDACTED]. Further review revealed there was no post fall interventions put in place. Further review of the nurses ' notes revealed that CR #8 sustained another fall on 10/29/15 that required hospitalization and another fall on 11/3/15 that also required hospitalization . Record review of CR #8 ' s Care Plan section revealed that a fall care plan was not completed until 10/24/2015 and revised on 10/30/2015 and read in part, Focus- Recent Fall . Goal- Will have no further fall during the next 14 days Interventions- Call MD or RP for any changes in condition . Head to toe assessment . Monitor and report to MD and RP for any injury from fall . Neuro- checks as ordered .Pain medication as needed per MD order for any pain or discomfort from fall . Rehab screen and resident to go to dining room for all meals. Further review revealed a care plan initiated on 10/1/2015 that read in part, Focus- Resident has episodes of un-wanted behaviors of frequently crying, tearing/pulling off brief . Goal- Behavior episodes will be reduces to less than daily until the next review target date 12/22/2015 .Interventions-Give 1:1 assistance to try and calm resident down as needed . Monitor and chart behaviors every shift and report to MD . Refer to Mental Health for evaluation and treatment . Seek alternative placement as when needed. Further review of her care plans revealed there was no care plan addressing the resident ' s use of [MEDICAL CONDITION] medications or addressing the resident ' s risk for fall, being found on the floor or other interventions to prevent further falls. Record review of CR #8 ' s facility Incident Report dated 10/29/2015 at 6:48 pm read in part: . Nurse noted resident on the floor in her room with hematoma to right side of forehead and bleeding . Oriented to person Predisposing Factors- Impaired Memory . Ambulating without Assist . Record review of CR #8 ' s SBAR note dated 10/29/2015 read in part, Mental Status Changes- Increased confusion . Functional Status Changes- Needs more assistance with ADL ' s. Record review of the Provider Investigation Report submitted 11/4/2015 detailing the same unwitnessed fall on 10/29/2015 read in part, Investigation Summary- Resident had an unwitnessed fall while eating supper Resident was taken to room when hall trays came out, she was set up in her usual fashion at the desk in her room CNA left room and resident was feeding herself per her usual routine. Shortly thereafter, resident screamed and was overheard by family member across hallway. Nursing staff immediately entered room and observed resident on the floor . Provider Action Taken Post Investigation- Resident ' s room re-arranged to provide ample room for resident to navigate in room . Resident placed on Falling Star Program . Care plan updated . Monitor resident for adverse effect from fall . CNA assignment sheet updated to include encouraging resident to go to dining room for meals. Record review of CR #8 ' s chart revealed a nurse ' s noted dated 10/29/2015 at 6:47 pm read in part, CNA notified nurse that resident is on the floor, nurse noted resident on the floor with hematoma to right side of forehead and bleeding Skin tear to bilateral lower arm . vital signs blood pressure 156/88 . unable to raise left upper extremity . applied ice to hematoma, cleaned skin tear and sterile dressing applied. Physicians notified and order given to transfer resident to the hospital . picked up by EMS at 6:30 pm. RP notified. Record review of CR #8 ' s hospital record for 10/29/2015 to 10/30/2015 revealed admitting [DIAGNOSES REDACTED]. The Discharge Summary read in part, 73 y/o female with Parkinson ' s and dementia admitted after fall and [MEDICAL CONDITION]. Results of a CT scan done on 10/29/15 results revealed small collections of intraventricular hemorrhage demonstrated in both occipital horns of the right lateral ventricle, small right temporal subdural hematoma and decreased right frontal scalp contusion Underlying skeleton is intact No findings are seen in this patient ' s pelvis or either hip. A neurosurgical consult dated 10/31/2015 read in part, CT head series reviewed with essentially stable findings, hematomas small and non-surgical in nature . Recommend falls precautions to prevent further trauma to head. Record review of a psychiatric consult completed in the hospital dated 10/30/2015 read in part: .The patient had been taking a huge amount of [MEDICAL CONDITION] with duplication in several of the drug categories . The list of [MEDICAL CONDITION] at present-Trazadone 50 mg at night, [MEDICATION NAME] 2 mg IV prn, [MEDICATION NAME] Sprinkles 125 mg TID, [MEDICATION NAME] 20 mg BID, [MEDICATION NAME] SR 150 TID, Klonopin .5 mg TID, [MEDICATION NAME] 750 mg every six hours (muscle relaxer) and [MEDICATION NAME] 12.5 mg prn Recommendations- The patient is taking a large number of lubricated [MEDICAL CONDITION], recommend a gradual decrease in them to permit increasing alertness and decreasing lowering extremity weakness leading to falls . Record review of CR #8 ' s nurses note dated 10/31/2015 at 11:06 pm read in part, Resident is a readmit Has a hematoma to right forehead Orders given to do neuro (checks) Multiple bruises old bruises to bilateral upper extremities and scabs to bilateral upper extremities . Stable with no signs of pain or discomfort . Further review of CR #8 ' s clinical file to include the MAR for 11/2015 revealed no evidence that the [MEDICAL CONDITION] medication was reviewed by the facility for possible reduction after this readmission. CR #8 received the same [MEDICAL CONDITION] medications and the [MEDICATION NAME] from 11/1/15 until 11/3/15. Record review of Physician telephone order dated 11/2/15 revealed to add floor mats to bedside, bed and chair alarms. Full fall precautions . Record review of CR #8 ' s nurses note dated 11/3/2015 at 6:59 pm read in part, Resident was seen trying to reach for something on the floor from her wheelchair Resident hit her forehead to the ground and had a deep cut on the right side of the head . site cleaned . NP for physician notified . order received to transfer resident to ER for evaluation . RP notified EMS left with resident at 6:40 pm. Record review of CR #8 ' s facility Incident Report detailing her fall dated 11/3/2015 at 5:50 pm read in part, Predisposing Factors- Confused. At the time of the investigation from 11/4/2015 to 11/19/2015, CR #8 remained in the hospital. Record review of CR #8 ' s hospital record with admission date of [DATE] revealed a CT scan done on 11/3/2015 read in part, In comparison to the most recent prior CT head performed 4 days prior, there is slight enlargement and elongation of the right-sided subdural hematoma. A physician ' s note dated 11/3/2015 read in part, This is a [AGE] year old female who is known to our service from her last admission . a repeat CT head showed that there was some worsening of the right sided hematoma . no neurosurgery intervention at this time End of life care issues were also brought up . (family member) also wanted a psych re-evaluation. In an interview with the DON on 11/4/2015 at 3:50 pm, she stated CR #8 has had several falls since her admission and was in the hospital after falling and hitting her head on 11/3/2015. She further stated the resident was on the Falling Star program and that her care plan was initiated on 10/24/2015 and revised on 10/30/15 to address the resident ' s unwitnessed falls. The DON stated she did not know why care plans were not revised prior to 10/24/2015 to address the resident ' s risk for falls or history of falls. Observation was made of CR #8 on 11/5/2015 at 8:07 am in the hospital intensive care unit. She was only oriented to self, very confused and non-interviewable. She was noted to have bruising to the right side of forehead extending down her right jaw and neck, just below the right ear. Bruising was also noted below the right eye. Two lacerations were noted to the forehead just above the right eye. Record review of a the Provider Investigation Report submitted on 11/11/2015 detailing CR #8 ' s witnessed fall on 11/11/2015 read in part, Investigation Summary-On 11/3/2015 around 5:30 pm, resident became restless and agitated . nurse requested CNA to keep resident within eyesight due to fall risk and increased agitation . CNA went to answer call light for another resident, (nurse) was on the hallway dispensing medication when he noted resident bending over . he ran toward resident but it was too late. Resident fell hitting the right side of her head re-opening a previous hematoma. Provider Action Taken Post- Investigation- Resident to continue on Falling Star Program Care plan updated .Self-report to DADS. Record review of CR #8 ' s psychoactive medication evaluation dated 9/23/2015 revealed a review of [MEDICATION NAME] 0.5 mg TID that read in part, Diagnosis- anxiety. Behavior warranting use of medication- anxiety. N/A was documented in the areas of Number of episodes per week, Interventions attempted that were effective, and Interventions tried that were effective. Adverse reactions- None apparent . physician notified . new orders given. Evaluation- no change noted, appears controlled. Record review of CR #8 ' s medical chart revealed an initial psychiatric progress note dated 9/29/2015 that read in part, Reason for referral: Anxiety; adjustment issues . Summary: Becomes panicky when left alone (illegible) may try to get out of bed (has not succeeded thus far). Further review revealed a psychiatric progress note dated 10/6/2015 that read in part, no acute problems Continue meds as ordered. There were no other psychiatric evaluations noted in the residents chart or provided before exit. Plan of Care- plan of care updated on 9/25/2015. Further review revealed another Psychoactive Medication Evaluation dated 10/31/2015 revealed a review of [MEDICATION NAME] ([MEDICATION NAME]) 150 mg three times daily that read in part, Diagnosis- nothing documented. Behavior warranting use of medication- confusion. Number of episodes per week- uncountable. Redirection was documented in the areas of Interventions attempted that were ineffective and Interventions tried that were effective. Adverse reactions- None apparent No documentation of physician notification. Evaluation- No change noted. There was no documentation indicating the plan of care was updated. There were no other psychoactive medication evaluations noted in the chart or provided before exit. Record review of CR #8 ' s chart revealed there was no behavior monitoring associated with CR #8 ' s use of psychoactive and antidepressant medications and their related side effects. There was no documentation provided before exit. In an interview with the DON on 11/16/2015 at 3:00 pm, she stated she was in charge of the facility ' s fall program. When investigating a fall, she stated she reviewed the incident report submitted by facility staff and it was discussed with her team during the morning meeting. The DON said that as part of the post fall investigation, they review the circumstances surrounding the fall, checked and updated care plans and interventions, and request a therapy screen for the resident. Furthermore, she said she reviews the resident ' s medications and also has the pharmacy consultant to review. When asked if she had reviewed CR #8 ' s medications when investigating her falls, she stated she had reviewed the resident ' s medications, however, the resident had not been seen by the pharmacy consultant because he only come once monthly. The DON was provided with a copy of CR #8 ' s Psychiatrist Consult note from 10/30/2015 done during CR #8 ' s hospital stay. She stated she had not seen the note and that it was the ADON ' s duty to review residents hospital records upon re-admission from the hospital. She stated the resident was being seen by the facility ' s psychiatrist, who had not recommended any changes to her psychiatric medications. The DON stated she did not know why the resident did not have a care plan or documented monitoring of her use of [MEDICAL CONDITION] and antidepressant medications and their related side effects. She also stated she did not know why there was no care plan addressing the residents risk for fall when she was initially found on the floor on 10/13/2015. In an interview on 11/17/15 at 1:00 pm with the ADON she said she did not see any notes from the hospital psychiatrist consult. She said that the nurse doing the resident ' s admission has to review the medication with the MD and they will tell the facility to continue or not the medication. She said that the resident did not have any significant change of condition that would warrant a change in her medication. In an interview with LVN B on 11/18/2015 at 2:45 pm, she stated she was the nurse who assessed CR #8 after she was found on the floor in her room on 10/29/2015. She stated the resident had a history of [REDACTED]. LVN B stated she usually worked the 7:00 am to 3:00 pm shift and the resident usually ate her breakfast and lunch in the dining room but would sometimes choose to eat in her room. If the resident chose to eat in her room, LVN B stated she would ensure the resident was supervised. She stated on the evening of 10/29/2015, she worked the 3:00 pm to 11:00 pm shift, which was not her usual shift. LVN B stated she was not familiar with CR #8 ' s behavior and routine during the evening shifts. She stated the CNAs told her CR #8 usually ate dinner unsupervised in her room, so she allowed CR #8 to eat in her room without supervision. LVN B stated she was summoned by a CNA to assess CR #8 when she was found on the floor in her room. When asked if she felt it was safe for CR #8 to eat in her room without supervision, she stated, Yes and no because the CNA s said the resident was not trying to get up during the evening shift and had not fallen while eating in her room unsupervised. In an interview with RN B on 11/18/2015 on 3:35 pm, he stated he was the nurse who witnessed CR #8 ' s fall on 11/3/2015. RN B stated the he was aware of CR #8 ' s history of fall and that resident was agitated and restless during his shift, so he had CNA U sit with the resident in the hallway next to her room. He stated he went in to a resident ' s room to administer medications and left CNA U sitting with the resident. Upon exiting the room, he stated he saw CR #8 bending over in her wheelchair as if to get something from the floor. RN B stated he ran to catch the resident but she fell from the chair, hitting her head. He stated CNA U was no longer sitting with the resident and did not know where she went, so he called for help. CNA U arrived, stating she was answering a call light in another resident ' s room. RN B stated CR #8 did not have an order for [REDACTED]. In an interview with CNA U on 11/18/2015 at 4:17 pm, she stated she was ordered to sit with CR #8 on the evening of 11/3/2015 to make sure she didn ' t fall . CNA U stated she was aware of the resident ' s history of fall. She said that when leaving to answer a call light, she told RN B where she was going. She said that while in the other resident ' s room, she heard a commotion in the hallway and found RN B holding CR #8. Resident #4: Record review of Resident #4's clinical file revealed she was [AGE] years old. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4 ' s quarterly MDS assessment dated [DATE] revealed that she had moderately severe cognitive skills. She was assessed as requiring extensive assistance of two persons for bed mobility, transfers and of one person for dressing, toilet use and personal hygiene. For bathing, she was assessed as requiring physical help of one person in part of the bathing activity. Further review revealed that she was coded as having falls before admission and having two falls with no injury after admission. Record Review of the Incident Report dated 04/13/15 - 11/04/15 indicated Resident #4 had the following falls with no injuries: 06/14- Resident was trying to reach something on the floor, 08/14- found resident sitting on her bottom on the floor of the bathroom. Resident said she was trying to get to the commode, 08/15- resident was found in a sitting position on the floor besides the commode . 09/15- resident on the floor in the hallway. Resident said she was reaching for something and fell from the chair. 09/18- resident on the floor in her room. Resident said she was reaching for the phone and fell . 09/24- Resident found lying in supine position in the bathroom. 10/19- Resident ambulating by herself in hallway with walker .she fell on her right knee . 11/11- Found in a sitting position in her room. Said she tried to get in bed by herself. 11/14- Observed on the floor sitting in the bathroom. Stated that she was transferring without locking the chair . Record review of Resident #4's fall risk assessment revealed she was assessed as being At risk for falls on 11/11/15 with a score of 22. She had 3 or more falls in the last 90 days, required assistance for elimination, was confined to a wheelchair, had 3 or more health conditions/risk factors, was on 3 or more medications within the last 7 days, and her gait was impaired. Record review of the care plans for Resident #4 indicated: - At risk for further falls due to history of falls and recent fall, gait and balance problems due to Parkinson ' s disease, impulsiveness, noncompliance, DJD and transfer herself to bathroom at times . Date initiated 09/15/15, Revision date: 11/11/15. Approaches included: call light within reach and encourage to use it. The resident needs prompt response to all requests for assistance .educate the resident/family/caregivers about safety reminders and what to do if falls occurs .encourage resident to wait on assistance to the bathroom. Actual falls 11/11/15, 11/14/15. The care plan did not mention if resident was safe to shower be herself. -ADL functions require extensive assist due to [MEDICAL CONDITIONS] joint disease. Date initiated 09/15/15, Revision date: 09/15/15. Bathing/Personal hygiene - Limited to extensive assist of one. Staff will bathe the resident as scheduled 3 times a week or per schedule. - [MEDICAL CONDITION] medication. Date initiated 06/28/15, Revision date: 11/02/15. Monitor/Document any adverse reactions: unsteady gait, frequent falls, blurred vision, fatigue, behavior symptoms. - Has impaired cognitive function and impaired thought processes. Long/short term memory loss. Date initiated 06/28/15, Revision date: 11/02/15. Observation on 11/4/15 at 3:35 pm Resident #4 was observed in her bathroom with CNA B assisting with dental care. Interview on 11/4/15 at 3:40 pm CNA B said that Resident #4 had a history of [REDACTED]. She said that the staff tells her not to get up without assistance. Interview on 11/4/15 at 3: 45 pm Resident #4 said that the reason why she is falling so much is because staff takes too long to help her so she attempts to do it herself. She said I know I am going to fall because I have Parkinson ' s disease. Resident #4 also said that staff tells her to learn to do it yourself so you will be ready to go home. Observation and interview on 11/16/15 at 10:10 a.m. indicated Resident #4 was not in her room. When the surveyor asked CNA E if the resident was in the bathroom she said she did not know. CNA E then knocked on the door and Resident #4 answered, stating she was in the shower. When CNA E opened the door to the bathroom she said Resident #4 was in the shower by herself. When asked if Resident #4 should be showering unassisted, CNA E said she did not normally work on that hall and she did not know if Resident #4 showered by herself. CNA E said she did not have a CNA assignment sheet for the day. Further interview and record review on 11/16/15 at 10:13 a.m. CNA Y was outside of Resident #4 ' s room. She said she did not know if Resident #4 always showered by herself. When the surveyor asked to see her assignment sheet it was dated 10/26/15 and indicated: - Code Status - Full code; Diet - Regular; Shower & Brief size - 7am to 3pm Tuesday, Thursday, Saturday. - Transfer, Glasses, Assistive devise, Diabetic, Skin risk, fall risk were all blank areas on the CNA Assignment Sheet. Interview and observation on 11/16/15 at 10:13 a.m. Resident #4 said she put on her call light for assistance to transfer to/from her bed/wheelchair. She said she received assistance transferring from/to the shower chair/wheelchair. She said staff also assisted in drying her back when she got out of the shower. Resident #4 said no staff stayed in the bathroom or outside the bathroom door when she showered. She said she has had multiple falls. Resident #4 said she had a fall in the bathroom in the past while transferring from the shower chair to her wheelchair, so she asked for assistance for transferring now. Record review of the Consultant Pharmacy Monthly Report dated 09/2015 indicated: Resident #4: The resident is receiving the following medications which may increase the risk for falls: -[MEDICATION NAME] mg at bedtime. Please consider a change to as needed. - [MEDICATION NAME] 1 mg three times daily. Please consider a reduction and use as needed. - [MEDICATION NAME] - May cause drowsiness and fatigue. - [MEDICATION NAME] - May cause orthostatic [MEDICAL CONDITION] .Please monitor and have patient stand slowly. - [MEDICATION NAME] - May increase risk for falls particularly when used with [MEDICATION NAME] and other sedating medications the effects could be multiplied. Record review of the Physician order's dated 11/2015 for Resident #4 indicated: -[MEDICATION NAME] mg at bedtime, - [MEDICATION NAME] 300 mg daily, - [MEDICATION NAME] 30 mg daily, - [MEDICATION NAME] 60 mg daily, - [MEDICATION NAME] 60 mg daily, - [MEDICATION NAME] 760 mg twice daily, - [MEDICATION NAME] 600 mg three times daily, - [MEDICATION NAME] 1 mg three times daily. Record review of the Nurse's Notes dated 10/13/15 indicated: IDT met to review Resident #4's multiple falls since admission, all interventions reviewed for appropriateness, and despite interventions resident continues to fall. In an interview on 11/16/15 at 3:00 pm the DON said that she did not know if staff had care planned the fact that the resident was taking showers unsupervised. Resident #1: Record review of Resident #1 ' s face sheet revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #1 ' s fall risk assessments revealed the resident was assessed as being at risk for falls (score of 10 or more indicates risk for falls)on: · 4/20/2015 score of 14 (no falls in the last 90 days, knows own limits, confined to a chair, not able to balance without assistance, use of medication with potential drug reactions, impaired gait) · 10/26/2015 score of 16 (no falls in the last 90 days, overestimates limits, confined to a chair, not able to balance without assistance, use of medication with potential drug reactions, impaired gait) Record review of Resident #1 ' s quarterly MDS dated [DATE] revealed a BIMS score of 06 which indicated severe cognitive impairment. She was assessed as being totally dependent with two or more person physical assist for bed mobility, transfer, dressing, eating, and personal hygiene. She was coded as not steady, only able to stabilize with staff assistance for surface-to-surface transfers. Under fall history, she was assessed as having one fall without injury since her admission. Falls was listed as a triggered area in t

Based on interview and record review the facility Administration failed to administer the facility in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being for 2 of 11 residents CR#2 and Resident #3 ) reviewed for their highest practicable well-being. The Administrator failed: -Implement the facility's Abuse Prevention Program Policies and Procedures to prevent neglect. -Make sure the facility had a protocol to screen potential new admissions, and use the PASRR to ensure facility could provide care to residents with special needs. -to report an incident involving CR #2's death and did not conduct an a thorough investigation in a timely manner; -identify possible circumstances surrounding CR #2's death in order to implement appropriate interventions and safety measures. -to investigate thoroughly and report Resident #3 ' s fall and fracture in a timely manner. -failed to supervise the DON to ensure nursing staff was properly trained to assess changes in condition, monitor residents with special needs. The DON failed to: --Nursing staff was trained to care for residents ' with special needs. --monitor nursing staff to ensure they were properly trained to recognize changes in condition and were able to monitor residents special needs such as risk for aspiration. --ensure that residents' care plans were updated as needed with appropairate interventions. An immediate jeopardy (IJ) was identified on [DATE], While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected 2 residents and placed 84 at risk of a decline in their health and well-being. Intake: Incident # 9 and Complaint #'s 5, 6, 7 and # 6. Findings include: Interview on [DATE] at 4:00 pm the Administrator said she did not understand why the IJ had been called: - For CR#2 she said the facility had monitored CR#2 for his NPO status and he continued to eat. She said they even put a lock on the door to the employee lounge. She said the only thing she could have done differently was to review the admissions more extensively before they took the residents into the facility. - For Resident #3 she said she and the DON had done everything they could have done, once the fracture was identified. She said they had investigated and called the incident into the state agency. She said they had in-serviced the staff. In an interview with the Administrator and the DON on [DATE] at 1:55 p.m. they said the staff had notified the DON of CR#2 ' s death when it occurred and the DON notified the Administrator. They said the family and the physician were notified. The emergency medical services were called and the body was sent to the funeral home. They said they were not aware that the police had been called to the building by the EMS personnel. They said they were not aware of the need to report unusual deaths in the facility to the State Agency or the need to investigate that CR #2 was found unresponsive in his bathroom floor. In an interview with the DON on [DATE] at 11:45 a.m. she said CR#2 had Intellectual disabilities/Mental [MEDICAL CONDITION]. She said he had a [DEVICE] and was NPO upon admission. She said he was quiet at first and he was in isolation. He started to improve and he was always running, trying to eat and yelling ' I ' m hungry ' . She said he used to eat at home previous to being in the hospital. She said the staff would redirect him when they saw him eating or drinking. She said they were in the process of getting the family to sign a waiver for his non-compliance. She said that his code status was changed to an OHDNR (out-of-hospital-Do-Not-Resuscitate) status. During further interview on [DATE] at 12:45 p.m. with the DON when asked if the facility had completed a Report of Incident/Accident form for CR#2 ' s death on [DATE], she said an Incident report would have been done on the computer, she said she did not think they had, but she would check. An Incident Report was not provided by the end of the survey. In an interview with the Administrator and the DON on [DATE] at 9:00 a.m. the Administrator and DON said they had been in-servicing staff yesterday evening and this morning regarding monitoring resident ' s with behaviors, abuse/neglect prevention and reporting, and incident/accident prevention and reporting. The facility Administrator and the DON were notified on [DATE] at 4:00 p.m. that an Immediate Jeopardy situation had been identified due to the above failures; however the IJ started on [DATE]. A Plan of Removal (POR) was requested. CR#2: Further record review of the Case Management Notes from the hospital for CR#2 ' s admission to the facility dated [DATE] indicated: -Current Diagnosis: [REDACTED]. - Precautions: dietary reflux, history of Pica, CR#2 remains upright for at least 1 ½ hours after meals to reduce reflux. - Additional information: ambulatory, can do ADL ' s with some verbal prompting. He is blind in his left eye and has [MEDICAL CONDITION] in right eye. So he is at risk for falls. He needs to be told to slow down when eating. He can toilet independently but needs supervision due to rectal digging and history of Pica. Record Review of CR#2's Care Plans indicated the Care plan for behaviors was not initiated until [DATE] with interventions of supervision needed. Care plan was not updated with exhibited behaviors during the month of [DATE]. Record review of modified [MEDICATION NAME] study (MBSS) competed on [DATE] revealed in part: findings: dysphagia severity is moderate. Aspiration and penetration of thin liquids noted ; Risk for aspiration is high due to decreased oral control, residue in vestibule, residue on vocal folds, residue in airway and pharynx. Significant penetration/aspiration observed. Recommendations included: Small bites- monitor oral intake, monitor oral pocketing, patient to be fed and supervised 1 on 1 feeding. Record review of physician ' s telephone order dated [DATE] completed by the speech therapist revealed: per MBSS and physician recommendation- resident to remain NPO with g tube. Speech pathologist to train staff/family that only resident was supposed to receive purred solids and nectar thick pleasure feeds. Record review of additional nurses ' notes for CR #2 revealed: - Nurse ' s Note: [DATE] at 3:07 p.m. Found in rest room drinking water from the bathroom sink faucet. Taken back to room and made comfortable in chair. - Nurse ' s Note: [DATE] at 2:31 p.m. Quiet most of the morning, at noon resident began to wander looking for food. Was found drinking water off nutrition cart. Assisted back to room . - Nurse ' s Note: [DATE] at 2:15 p.m. Less wandering for food noted today. - Nurse ' s Note: [DATE] at 1:28 p.m. CR#2 is NPO, feeding via [DEVICE], supervision and reminders for toileting, one person assist with bed mobility . is calm and compliant with care and medications this morning, alert and oriented to person, no care plan changes indicated . very dull at this time, not participating as usual this morning, NP notified, order for stat chest x-ray, results received and communicated to NP, no new orders. Patient drooling and spitting a lot. - SBAR Nurse ' s Note: [DATE] at 5:01 p.m. Situation: I am calling about the following condition, signs, symptoms: Patient looks is dull, not participating in activities, drooling and spitting a lot. This started on [DATE]. Since this started has stayed the same . This condition, symptom or sign has not occurred before . Patient remains NPO . Mental status change: Decreased consciousness inability to participate in simple activities, drooling, spitting a lot. Functional status change: Needs more assistance with ADL ' s . Assessment(RN)/Appearance(LPN): RN thinks the problem may be possible aspiration pneumonia. Recommendations: Monitor vital signs, stat chest x-ray. - Nurse ' s Note: [DATE] at 11:01 a.m. Eating with assistance and supervision .Patient observed in wheelchair . Pleasure feeding ordered but pending . - Nurse ' s Note: [DATE] at 1:10 a.m. CR#2 remains in bed sleeping, no distress at this time. - Nurse ' s Note: [DATE] at 3:00 a.m. CR#2 in bed, sleeping. No shortness of breath, no distress noted. - Nurse ' s Note: [DATE] at 6:20 a.m. CR#2 was noted not to be in his bed at 5:50 a.m. during my rounds on the 200 hall. He was noted in his bathroom on the floor, supine, unresponsive on assessment. Code blue was activated and CPR initiated immediately. Nurses remained with the resident performing CPR. 911 was called at 5:52 a.m. Paramedics arrived. The responsible party was called at 6:15 a.m. and spoke with the sister who provided funeral home information. Nurse practitioner for resident ' s doctor was informed and telephone order obtained to transfer body to family ' s funeral home of choice. Interviews with CNA U and D and with LVN H and A revealed that they had recieve no spexial training or information on CR #2s special needs. Resident #3: Resident #3, who required two person for transfers and a sit to stand lift was transferred by an OT staff without assistance on [DATE]. Resident #1 felt she twisted her ankle and was in pain. The incident was not reported to the facility, assessments were not conducted until the resident reported what happened on [DATE]. X-ray was done on [DATE] at 6:00 pm that showed acute fracture to the left malleolus (bone in the ankle) and fracture of left metatarsal (bones in the foot). The resident was sent to theER on [DATE]. Interview with Resident #3 on [DATE] at 1:25 p.m. regarding injury to lower left extremity, she said she could not remember the exact date but it happen one day last week when OTA-B came to her room alone with the standing frame lift. She said that the OT tried to put her in it by sitting her and moving her to the edge of bed to stand her up in the standing frame. She said: My knees were jammed and I could not move them. I told her my knees are hurting and I could not move them and I started crying and hollering. She said that OTA-B said I am trying to get you out. Resident #3 said my knees became more and more tight and my whole left leg down to the ankle area was in so much pain. She said that OTA-B was standing behind her trying to hook something on the machine stating, I am trying I am trying, next thing I know I am on the floor. Resident 33 said that she thinks that OTA-B called for help because two people put her in the wheelchair and from the wheel chair back in my bed. Resident #3 states she asked for something for pain from the nurse and told her what had happen but also asked to speak to the supervisor but could not remember the supervisor ' s name. The facility Administrator and the DON were notified on [DATE] at 4:00 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) was requested. A POR for the IJ was submitted on [DATE] at 6:47 pm. After several revisions, the plan was accepted on [DATE] at 4:02 p.m. The POR included in part: Plan of Removal for Immediate Jeopardy -The Admission Director, DON or Nursing Administration, Administrator or designee and MDS Coordinator will review clinicals prior to admission to determine if the prospective resident is appropriate for the building and needs can be met. -In-service staff as needed on highly specialized care needs or disorders not commonly known for behaviors and interventions. -[DATE] completion date- Interventions added to the Nurse Aide Assignment Sheet on all residents and ongoing updates. -[DATE] completion date- In-service staff on Aspiration Risks by use of the Red Dot System which is clearly marked on an over the bed sheet above each residents bed in their rooms. This is for all staff in all departments. -Abuse and Neglect Reporting to include Death if not expected. A report will be made to DADS by the Administrator and or DON. -Care Plan Process- Updating Change of Condition and Interventions ongoing by the MDS Coordinator, Nursing Administration, Social Worker, Dietician and Activities. -[DATE] completion date- Behaviors have been addressed by way of audit and care plans updated to reflect current interventions. The plan was monitored from [DATE] until [DATE] by the surveyor with the following results: - Nurse Aide Assignment sheets were reviewed on each shift by interviewing and observation of the facility Assignment sheets for 7 CNA ' s on all 4 halls. The assignment sheets were updated to indicate resident ' s that were at risk for falls, transfer assistance, aspiration risk and modified diets. - The surveyor reviewed the facility in-services on Abuse/Neglect prevention and reporting, Over-Bed signs, Dot System for aspiration risk and fall precautions, behavior monitoring and reporting, and the Stop and Watch reporting system for any Changes in Condition were provided to staff on all 3 shifts from [DATE] - [DATE]. - Staff, (including 7 CNA ' s, 4 LVN ' s, 3 Housekeeping staff, Activity staff and Dietary staff) was interviewed between [DATE] - [DATE] to verify training received on Abuse/Neglect prevention and reporting, reporting changes in condition, monitoring behaviors, over-bed signs in resident rooms and the meanings of the Dot system for aspiration and fall prevention/risk. - Care Plans for behaviors were addressed and updated. - Resident ' s meal tickets and meals were observed on [DATE] - [DATE] for modified diets for 10 residents and they were accurate). The facility Administrator was notified on [DATE] at 9:53 a.m. that the Immediate Jeopardy was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. According to the facility's roster, the census was 84.

Based on observation, interview and record review the facility failed to implement their written policies and procedures that prohibit neglect and abuse 2 of 11 residents (Resident #3 and CR#2) reviewed for abuse and neglect. -The facility failed to provide adequate supervision and put proper interventions in place for CR #2 who had [DIAGNOSES REDACTED]. CR #2 ate food from other residents ' rooms, the employee break room, and drank water multiple times from [DATE] - [DATE]. -CR #2 had a decline of condition starting on [DATE]. On [DATE] CR #2 was found unresponsive in the bathroom and was pronounced dead. CR #2's cause of death was aspiration pneumonitis and [MEDICAL CONDITION]. -Resident #3, who required two person for transfers and a sit to stand lift was transferred by an OT staff without assistance on [DATE] and she fell to the floor. The OT and other witnesses did not report the incident to the nurse or Administration. Assessments were not conducted until the resident reported what happened on [DATE]. X-ray was done on [DATE] at 6:00 pm that showed acute fracture to the left malleolus (bone in the ankle) and fracture of left metatarsal (bones in the foot). The resident was sent to theER on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected two residents and placed 83 current residents at risk of neglect, decline in their health, and unnecessary pain. Intake: Incident # 9 and Complaint #'s 5, 6, 7 and # 6. Findings include: Record review of the Preventing Resident Abuse policy dated revised February 2014 indicated: - 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: .j. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; .o. Identifying areas within the facility that may make abuse and/or neglect more likely to occur . and monitoring these areas regularly . Record review of the Reporting Abuse to Facility Management policy dated revised February 2014 indicated: -It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and the theft or misappropriation of resident property to facility management. CR #2: Record Review of the residents' records revealed that CR #2 was a [AGE] year old male admitted to the facility on [DATE] from the hospital. His [DIAGNOSES REDACTED]. Record review of the Nurses ' telephone report called into the facility from the hospital (undated) indicated CR#2 was a [AGE] year old male. Diagnoses: [REDACTED]. Slurred speech, full code, high fall risk, no skin wounds, incontinent of bowel and bladder, NPO . Record review of CR #2 ' s Case Management notes from the hospital admission to the facility dated [DATE] and [DATE] indicated: -Date of Service: [DATE] No acute events overnight. He has still been restless, agitated, and combative, worse during evening and early morning hours. Further record review of the Case Management Notes from the hospital for CR#2 ' s admission to the facility dated [DATE] indicated: -Current Diagnosis: [REDACTED]. - Additional information: ambulatory can do ADL's with some verbal prompting. He is blind in his left eye and has [MEDICAL CONDITION] in right eye. So he is at risk for falls. He needs to be told to slow down when eating. He can toilet independently but needs supervision due to rectal digging and history of Pica. Record Review of CR #2's MDS assessment dated [DATE] revealed CR #2 rarely/never understands and is rarely/never understood. CR #2 had short and long term memory problems and he was severely cognitively impaired. CR #2's behaviors were marked as 0, not exhibited. CR#2's ADL needs revealed he required total assistance for bed mobility, two+ persons physical assist for transfers, total dependence of one person physical assistance for eating and dressing, total dependence and two + persons assist for hygiene, total dependence and one person assist for bathing. CR #2 was noted to have a feeding tube and he was on a therapeutic diet. He received 51% or more through his tube feeding and 501 cc/day or more fluid intake by IV or tube feeding. CR #2 had the following care areas triggered: cognitive loss/dementia, visual function, communication, urinary incontinence, falls, nutritional status, feeding tube, dehydration/fluid maintenance, dental care pressure ulcer and [MEDICAL CONDITION] drug use. Record Review of CR#2's Care Plans indicated the Care plan for behaviors was not initiated until [DATE] with interventions of supervision needed. Care plan was not updated with exhibited behaviors during the month of [DATE]. Care plans included: - ADL Functions-balance, initiated [DATE] requires extensive assist due to cognition and impaired. Eating - NPO - G/T. - Diet: NPO status, initiated [DATE] PEG placed. - Behavior problem due to pulls at G/T . He has [DIAGNOSES REDACTED]. Interventions: Anticipate and meet the resident ' s needs, apply abdominal binder daily, feedings changed to bolus, if resident becomes agitated leave and return when resident appears calmer, observed resident when walking by or redirect when putting things in mouth that are non-eatable and food due to NPO, redirect resident back to room, staff will anticipate needs as needed. Care plan was not updated after [DATE]. - CR#2 requires tube feeding due to swallowing problem - NPO at risk for aspiration due to will drink from bathroom faucet and eat regular food or objects, initiated [DATE]. Interventions: redirect resident from drinking from faucet, speech therapy evaluation and treatment was ordered . Care plan was not updated after [DATE]. There was no care plan to address the residents need to be supervised for toileting. Record review of CR #2's interdisciplinary notes indicated: - Nurse ' s Note: [DATE] at 4:50 a.m. Resident observed to have pulled out his [DEVICE] in spite of abdominal binder that was in place to secure it. (Re-inserted) - Dietician/Dietary Note [DATE]: . Diet - NPO status. Recommendations - 1) D/C current tube feeding order. 2) Start [MEDICATION NAME] 1.2 at 70cc per hour times 22 hours per day continuous plus 150cc water flush via peg . - Nurse ' s Note: [DATE] at 11:45 a.m. Resident pulling out tube - facility requesting bolus feeding. - Nurse ' s Note: [DATE] at 6:05 p.m. Found tube feeding pole knocked down to the floor with feeding tube tubing cut in half, disconnected from the resident . New order for bolus feeding noted and carried out. - Nurse ' s Note: [DATE] at 4:55 p.m. Very loud and pushing staff. Trying to get out of bed, four staff assist to get resident calm. Continues to request coffee. Quieted down a little after taken to rest room and back to bed. - Nurse ' s Note: [DATE] at 3:13 p.m. Resident pulled out PEG while up in chair at bedside. Notified physician. Resident again found wandering into break room eating staff food on table. Return resident to his room and put him back to bed. - Nurse ' s Note: [DATE] at 10:58 p.m. .Resident is a [DEVICE] feeder, incontinent of bladder and bowel and uses diaper, able to move in bed without staff assist, able to transfer self without staff help, able to ambulate by self and needs staff assist for safety, confused, behaviors, no care plan changes . - Nurse ' s Note: [DATE] at 1:40 p.m. Continues to wander looking for food as well as asking everyone for food. - Nurse ' s Note: [DATE] at 9:36 p.m. .Resident feeds via [DEVICE] and requires one staff assist, able to move in bed without staff assist, able to transfer self without staff help, able to ambulate by self and needs staff assist for safety, confused, behaviors, no care plan changes . - Nurse ' s Note: [DATE] at 7:18 a.m. Noncompliance, refused meds through [DEVICE], med given PO. - Nurse ' s Note: [DATE] at 11:18 a.m. Behaviors noted related to PO food intake. - Social Worker Note: [DATE] at 11:23 a.m. Care plan meeting held. The team consisted of nursing, rehabilitation, dietary, activities and social work. Attempted to contact CR #2 ' s family, no answer. The group home owner, of CR#2 ' s previous home participated via phone. Upon termination of care plan meeting owner was given the opportunity to ask questions and or give comments. Agreed to continue current plan of care. There was no mention of CR #2 ' s food intake behavior problem. - Nurse ' s Note: [DATE] at 12:04 p.m. Noncompliance, refused meds feeding via [DEVICE]. Meds and feeding given PO. CR#2 keeps moving aimlessly . - Nurse ' s Note: [DATE] at 4:33 p.m. Continues to wander looking and taking food off nourishment cart. - Nurse ' s Note: [DATE] at 2:33 p.m. CR#2 eats and drinks via [DEVICE], extensive assistance with toileting, no care plan changes, CR#2 noted frequently fast walking out to the hallway looking for food and going into rooms. Redirected several times with no compliance. Will continue to monitor. Record review of modified [MEDICATION NAME] study (MBSS) competed on [DATE] revealed in part: findings: dysphagia severity is moderate. Aspiration and penetration of thin liquids noted ; Risk for aspiration is high due to decreased oral control, residue in vestibule, residue on vocal folds, residue in airway and pharynx. Significant penetration/aspiration observed. Recommendations included: Small bites- monitor oral intake, monitor oral pocketing, patient to be fed and supervised 1 on 1 feeding. Record review of physician ' s telephone order dated [DATE] completed by the speech therapist revealed: per MBSS and physician recommendation- resident to remain NPO with g tube. Speech pathologist to train staff/family that only resident was supposed to receive pureed solids and nectar thick pleasure feeds . Record review of additional nurses ' notes for CR #2 revealed: - Nurse ' s Note: [DATE] at 3:07 p.m. Found in rest room drinking water from the bathroom sink faucet. Taken back to room and made comfortable in chair. - Nurse ' s Note: [DATE] at 2:31 p.m. Quiet most of the morning, at noon resident began to wander looking for food. Was found drinking water off nutrition cart. Assisted back to room . - Nurse ' s Note: [DATE] at 2:15 p.m. Less wandering for food noted today. - Nurse ' s Note: [DATE] at 1:28 p.m. CR#2 is NPO, feeding via [DEVICE], supervision and reminders for toileting, one person assist with bed mobility . is calm and compliant with care and medications this morning, alert and oriented to person, no care plan changes indicated . very dull at this time, not participating as usual this morning, NP notified, order for stat chest x-ray, negative results received and communicated to NP, no new orders. Patient drooling and spitting a lot. - SBAR Nurse ' s Note: [DATE] at 5:01 p.m. Situation: I am calling about the following condition, signs, and symptoms: Patient looks is dull, not participating in activities, drooling and spitting a lot. This started on [DATE]. Since this started has stayed the same . This condition, symptom or sign has not occurred before . Patient remains NPO . Mental status change: Decreased consciousness inability to participate in simple activities, drooling, spitting a lot. Functional status change: Needs more assistance with ADL ' s . Assessment(RN)/Appearance(LPN): RN thinks the problem may be possible aspiration pneumonia. Recommendations: Monitor vital signs, stat chest x-ray. - Nurse ' s Note: [DATE] at 11:01 a.m. eating with assistance and supervision .Patient observed in wheelchair . Pleasure feeding ordered but pending . - Nurse ' s Note: [DATE] at 1:10 a.m. CR#2 remains in bed sleeping, no distress at this time. - Nurse ' s Note: [DATE] at 3:00 a.m. CR#2 in bed, sleeping. No shortness of breath, no distress noted. - Nurse ' s Note: [DATE] at 6:20 a.m. CR#2 was noted not to be in his bed at 5:50 a.m. during my rounds on the 200 hall. He was noted in his bathroom on the floor, supine, unresponsive on assessment. Code blue was activated and CPR initiated immediately. Nurses remained with the resident performing CPR. 911 was called at 5:52 a.m. Paramedics arrived. The responsible party was called at 6:15 a.m. and spoke with the sister who provided funeral home information. Nurse practitioner for resident ' s doctor was informed and telephone order obtained to transfer body to family ' s funeral home of choice. Record review of CR #2's Physician ' s Progress Notes indicated: - [DATE] Initial visit. CR#2 here for rehabilitation, has multiple medical issues inclusive [MEDICAL CONDITION] in sputum, pica, history of severe cognitive impairment, altered mental status, dysphagia, bi-polar,[MEDICAL CONDITIONS]. Sepsis [MEDICAL CONDITION]: Continue antibiotics. Dysphagia: Continue tube feeding. - [DATE] Follow up on behavior, dysphagia, tube feeding. Patient very combative, refusing care per staff. Pulled PEG 2 nights ago. PEG replaced and evaluated for bolus feeding. Dementia with behavior: Aggressive/combative with care. Continue current medications, consult psychiatry. Monitor. - [DATE] Patient continues to pull on lines and tubes. PEG with bolus feeding. Severe cognitive impairment: Continue supportive care, [MEDICATION NAME] as needed, psychiatry consult pending. Chest x-ray for follow up to pneumonia. - [DATE] History and Physical Note: Weakness, confusion for 3 weeks.[MEDICAL CONDITION]-MRSA-Pneumonia-Septic shock resolved. Dysphagia - PEG tube feedings - Replaced [DEVICE]. Continue aspiration precautions. - [DATE] Follow up behavior, [DEVICE] feeding. PEG in place, past re-insertion, patient pulling out over the weekend. Continue tube feeding at recommended rate, monitor for aspiration. - [DATE] per staff patient is walking around and eating food. Will have Speech Therapy evaluate and treat as indicated. Severe cognitive impairment. - [DATE] Modified [MEDICATION NAME] Swallow test done today, result pending. Per staff patient goes to lounge and eats up food in refrigerator. Patient is non conversant when questioned. Severe cognitive impairment. - [DATE] Patient seen on hallway and in staff lounge getting food and eating. MBS done by speech therapy, awaiting safest diet. - [DATE] increased drooling and lowered activity. Chest x-ray negative for aspiration pending. Patient is high risk for aspiration due to lack of oral control and result of MBS recommending pleasure feeding with pureed, small bites with nectar thick liquids with supervision. However, patient is non-compliant, he is seen going into the staff lounge and eating foods unassisted. - [DATE] Staff reports decreased drooling, still less activity. Discontinue pleasure feeds to avoid possible silent aspiration. Continue NPO, continue bolus feeds, monitor. - [DATE] Patient expired. Record review of CR#2 ' s Death certificate dated [DATE] indicated the cause of death was Aspiration pneumonia and [MEDICAL CONDITION]. In an interview with CNA D on [DATE] at 10:45 a.m. she said she had worked with CR#2 when he was in the facility. She said he was calm and he needed assistance with his ADL ' s. She said one time he had vomited on his shoes and he did not want her to remove them. She said he kept repeating ' I want my shoes ' as he rocked back and forth. She said she did not receive any information about his needs before she worked with him. She said she had seen him walking around, getting water and that she did not know about any precautions for him. She said she had not received any training regarding CR#2 ' s care needs related to NPO or his eating disorder. In an interview with CNA U on [DATE] at 11:05 a.m. she said she had seen CR#2 ambulating in the facility. She said he kept busy and would draw on things and was monitored for putting things in his mouth. She said she had not received training specific to CR#2's care needs related to NPO or his eating disorder. In an interview with LVN H on [DATE] at 10:45 a.m. she said she was still an orientee when CR#2 was in the facility. She said she did not work with him, but she knew he received nutrition via tube feedings; he had special needs and was NPO. She said she had not received training specific to CR#2's care needs related to his eating disorder. She was not trained regarding any additional supervision he needed because he would eat food from others. She said he would go into the employee lounge and eat food. In an interview with LVN A on [DATE] at 10:20 a.m. she said Pica was when someone eats things like plastic or things they should not eat. You said she had to watch them a lot and check their room frequently for things they may try to eat and remove it. You have to have one on one to watch them constantly. During interviews on [DATE] from 10:10 - 10:30 a.m. CNA W, CNA I, CNA AA and CNA A said they did not know/remember what Pica was and that the facility had not trained them on what to do with somebody with this disorder. In a phone interview with RN G on [DATE] at 1:05 p.m. she said she worked on the 10:00 p.m. to 6:00 a.m. shift on the morning CR#2 died . She said she monitored CR#2 every 2 hours. She said he was in bed asleep at 11:15 p.m. on [DATE], at 1:10 a.m., 3:00 a.m. and 5:00 a.m. She said she was aware of his NPO/Pica status and they had to watch him for putting things in his mouth. She said she was passing by his room at 5:50 a.m. and noticed he was not in his bed. She walked in the room and checked in the bathroom. She said she saw CR#2 on the floor lying on his back with his mouth open. He was unresponsive. She started yelling for help and initiated CPR. A co-worker brought in the crash cart and EMS was called. She had been preforming CPR for about 10 minutes when the EMS arrived. RN G said that EMS did not continue with CPR stating He is cold and he is dead . She said that the EMS personnel started asking questions about CR#2 and then they called the police. When the police arrived they also asked questions. She said that she informed the DON, physician and the family was notified.CR#2 ' s remains were taken to the funeral home. Record review of the facility training/in-services for June and [DATE] indicated there was no evidence that staff had been in serviced on CR #2 ' s need for supervision and appropriate interventions for his Pica disorder or that he was not supposed to eat by mouth due to dysphagia. In an interview with the DON on [DATE] at 11:45 a.m. she said CR#2 had Intellectual disabilities/Mental [MEDICAL CONDITION]. She said he had a [DEVICE] and was NPO upon admission. She said he was quiet at first and he was in isolation. He started to improve and he was always running, trying to eat and yelling ' I ' m hungry ' . She said he used to eat at home previous to being in the hospital. She said the staff would redirect him when they saw him eating or drinking. She said they were in the process of getting the family to sign a waiver for his non-compliance. She said that his code status was changed to an OHDNR (out-of-hospital-Do-Not-Resuscitate) status. During further interview on [DATE] at 12:45 p.m. with the DON when asked if the facility had completed a Report of Incident/Accident form for CR#2 ' s death on [DATE], she said an Incident report would have been done on the computer, she said she did not think they had, but she would check. An Incident Report was not provided by the end of the survey. In an interview with the Administrator (The Abuse Prevention Coordinator) and the DON on [DATE] at 1:55 p.m. they said the staff had notified the DON of CR#2 ' s death when it occurred and the DON notified the Administrator. They said the family and the physician were notified. The emergency medical services were called and the body was sent to the funeral home. They said they were not aware that the police had been called to the building by the ems personnel. They said they were not aware of the need to report unusual deaths in the facility to the State Agency or the need to investigate that CR #2 was found unresponsive in his bathroom floor. Resident #3: Record Review of Resident #3 ' s clinical records revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #3 ' s MDS assessment dated [DATE] revealed a BIMS score of 15 that indicated cognition skills were intact. Resident behaviors were marked 0 not exhibited. ADL needs revealed she required extensive assistance with two + persons physical assistance with weight bearing support transfer moves to and from bed, chair, wheelchair, and standing position. Resident did not walk. Resident scored 3 with dressing herself putting on and taking off clothing requiring extensive assistance and support. Personal hygiene required extensive assistance. Record Review of Resident #3 ' s clinical file revealed that the only care plans were initial Care Plans dated [DATE]. There were no care plans to address ADL needs. The care plan for falls included: due to unsteady gait, history of falls. Record Review of Incident Report done by DON on Resident #3 dated [DATE] revealed resident complained of both legs swollen and painful. Resident stated that legs were twisted during therapy on [DATE], stat X-Ray requested to bilateral lower extremities. Record Review of Resident # 3 Physical Therapist progress notes dated [DATE] continue to have difficulty with knee extension and has used standing frame for a few minutes at a time. Remaining functional deficits/underlying impairments of bed mobility, transfers, strengthening and safety awareness. Record Review Rehab Addendum note date [DATE] done by OTA-B revealed on [DATE] Resident #3 agreed with OTA-B and PTA-C to stand in standing frame at bedside. Resident #3 tolerated standing in frame approx. ,[DATE] minutes with complaints of knee pain, upon lowering, resident externally rotated feet and began to slouch in sling. [DATE] and [DATE] resident agreed to sit on edge of bed however unwilling to participate in therapy. Interview with Resident #3 on [DATE] at 1:25 p.m. regarding injury to lower left extremity, she said she could not remember the exact date but it happened one day last week when OTA-B came to her room alone with the standing frame lift. She said that the OT tried to put her in it by sitting her and moving her to the edge of bed to stand her up in the standing frame. She said: My knees were jammed and I could not move them. I told her my knees are hurting and I could not move them and I started crying and hollering. She said that OTA-B said I am trying to get you out. Resident #3 said my knees became more and more tight and my whole left leg down to the ankle area was in so much pain. She said that OTA-B was standing behind her trying to hook something on the machine stating, I am trying I am trying, next thing I know I am on the floor. Resident #3 said that she thought OTA-B called for help because two people put her in the wheelchair and from the wheel chair back in her bed. Resident #3 stated she asked for something for pain from the nurse and told her what had happen, but also asked to speak to the supervisor. She could not remember the supervisor ' s name. Record Review of a statement dated [DATE] given by the DON revealed in part that on [DATE] that: . CNA came to my office saying Resident #3 wanted to speak to me around 5:30 p.m. DON met with resident. Resident reported she did not want to do therapy anymore. Resident reported that OTA-B had made her stand up in the standing frame and her leg got twisted, especially when OTA-B let her down. While visiting with resident DON noted both of resident ' s legs were more swollen than usual, reported pain. DON asked RN to medicate resident with pain meds due to resident complaining of pain level ,[DATE]. DON called MD to request X-Ray . Record Review of a statement completed by the DON on Resident #3 dated [DATE] indicated X-Ray results revealed fracture of fibula. MD orders to transfer resident to ER for evaluation, Administrator was notified. Interview with OTA-B on [DATE] at 10.00 a.m. she said that on [DATE] OTA-B and PTA-C were on their way to Resident #3 room when PTA-C was called to go to another resident ' s room. OTA-B stated she went to Resident #3 ' s room to get her out of bed for therapy using the standing frame equipment. OTA-B stated: I began by moving Resident #3 to the edge of bed in a sitting position and placed the slings underneath and on both sides of resident #3 ' s hips and connected the sling to the frame. I used the machine to electronically assist resident into a standing position. Resident #3 was only able to stand for about minute and started to request to stop therapy. I began to let her down using the standing frame. She started to turn her feet out and lost balance and started to slide downward out of the sling strap. I had to ease Resident #3 down to the floor in a sitting position. OTA-B stated that resident #3 was crying but that she always cried when receiving therapy and that she always had swelling in her legs because of arthritis. OTA-B states that CNA-D was standing in the doorway and came to assist with getting resident #3 off the floor into the wheelchair. She said that then PTA-C assisted her in transferring resident back to bed using a sliding board. OTA-B stated she did report to the nurse that Resident #3 needed something for pain, but did not report the incident to the nurse because she did not consider it a fall. In further interview at the time OTA-B stated she did report the incident to the Rehab Director (supervisor) who in return told her to let the nurse know what took place with resident #3 and the standing frame. OTA-B stated did not report what happened to the nurse until [DATE] when the Administrator and DON asked OTA-B about the incident with Resident #3 and asked her to write a statement regarding the incident. Record review of nurses ' notes for Resident #3 revealed: [DATE] at 4:12 pm. - Resident complaint of pain in left leg. No other notes. [DATE] at 8:41 am- patient complaint of pain on both knees, prn [MEDICATION NAME] administered. Will continue to monitor. [DATE] at 4:21 pm- prn pain medication- effective. [DATE] at 6:00 am -patient requested pain medication. No other notes. [DATE] at 7:00 am-prn administration was effective. [DATE] at 11:10 am- patient requested medication on a pain level of 1- on a scale of ,[DATE]. [DATE] at 2:03 pm- pain medication was ineffective. No other notes. [DATE] at 8:20 pm (late entry) on [DATE] patient returned from physical therapy and complained of some discomfort with her legs. Patient medicated for pain and assessed. Pain level minimally reduced. DON visited with resident before leaving for the day .evening supervisor notified of need for a portable chest x-ray on patient .x-ray on both lower extremities order .done around 12 midnight and 1:00 am . [DATE] 7:10 am X-ray result from previous shift revealed acute fracture of distal fibula .affected limb immobilized.pt complaint of mild pain .prn [MEDICATION NAME] administered .NP notified, new order to transfer to ER for evaluation. Record reviews revealed Resident #3 was assessed for pain verbally, but there was no documentation to indicate Resident #3 was assessed physically related to pain complaints between [DATE] - [DATE]. Interview with CNA-D on [DATE] at 10:40 a.m. regarding the incident with Resident #3 on [DATE], CNA-D stated that while she was sitting down at the computer charting on hall 200, she heard loud yelling. She said she approached the resident ' s room and saw resident #3 sitting on floor with her feet turned outwards and OTA-B was standing behind the resident. CNA-D said OTA-B asked for assistance to transfer Resident #3 back into her wheelchair. She then assisted OTA-B with transferring the resident from the floor into the wheelchair by holding the resident lower body and torso and OTA-B holding residents ' upper body torso both lifting and transferring the resident to wheelchair. CNA-D said she then left the resident room because PTA-C had arrived to help. CNA-D states could not remember if she reported the incident to nurse or not. Record Review of Rehab Addendum Note written by the Rehab Director and dated [DATE] revealed that on [DATE] both OTA-B and PTA-C reported that Resident #3 slouched in the standing frame on [DATE] because she wanted down. Resident was lowered and then taken out of standing frame. OTA-B and PTA-C used sliding board to transfer resident from wheelchair to bed. Director of rehab instructed staff to continue to address pain management including coordinating with nursing for pain medication as well as offering modalities (biofreeze, moist heat packs, and e-stim). Further review of the statement revealed: On Friday [DATE] received a phone call from Administrator that Resident #3 had received X-Ray showing a fracture that resident reports she believes occurred while was in standing frame. Director of Rehab contacted OTA-B and PTA-C to gather their documentation reported on [DATE] and spoke with Administrator and DON regarding resident. On [DATE] Director of Rehab stated began in-servicing OTA-B and PTA-C on reporting any incidents to nursing as well as knowing that any change of condition even if assisting patient to floor that they should always inform nurse. Record Review statement from Administrator dated [DATE] states that .on [DATE] she was contacted by the DON that Resident #3 had sustained a fracture after working with rehab on [DATE]. X-ray results on [DATE] in a.m. showed a fracture. DON stated on [DATE] i

Based on observation, interview and record review, the facility failed to report to the Department of Aging and Disability Services (DADS) and injury of unknown source and failed to thoroughly investigate allegations of abuse/neglect for for 2 of 11 residents (Resident #3 and CR#2) reviewed for abuse and neglect. -The facility did not immediately report to DADS and did not immediately investigate when CR #2 had a decline of condition starting on [DATE]. On [DATE] CR #2 was found unresponsive in the bathroom and was pronounced dead. CR #2's cause of death was aspiration pneumonitis and [MEDICAL CONDITION]. -The facility staff failed to immediately report to the Administrator and to thoroughly investigate when Resident #3, who required two person for transfers and a sit to stand lift was transferred by an OT staff without assistance on [DATE] and she fell to the floor. Assessments were not conducted until the resident reported what happened on [DATE]. X-ray was done on [DATE] at 6:00 pm that showed acute fracture to the left malleolus (bone in the ankle) and fracture of left metatarsal (bones in the foot). The resident was sent to theER on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected two residents and placed 83 current residents at risk of neglect, decline in their health, unnecessary pain and even death. Intake: Incident # 9 and Complaint #'s 5, 6, 7 and # 6. Findings include: CR #2: Record Review of the residents' records revealed that CR #2 was a [AGE] year old male admitted to the facility on [DATE] from the hospital. His [DIAGNOSES REDACTED]. Record review of the Nurses ' telephone report called into the facility from the hospital (undated) indicated CR#2 was a [AGE] year old male. Diagnoses: [REDACTED]. Slurred speech, full code, high fall risk, no skin wounds, incontinent of bowel and bladder, NPO . Further record review of the Case Management Notes from the hospital for CR#2 ' s admission to the facility dated [DATE] indicated: -Current Diagnosis: [REDACTED]. - Additional information: ambulatory can do ADL's with some verbal prompting. He is blind in his left eye and has [MEDICAL CONDITION] in right eye. So he is at risk for falls. He needs to be told to slow down when eating. He can toilet independently but needs supervision due to rectal digging and history of Pica. Record Review of CR #2's MDS assessment dated [DATE] revealed CR #2 rarely/never understands and is rarely/never understood. CR #2 had short and long term memory problems and he was severely cognitively impaired. CR #2's behaviors were marked as 0, not exhibited. CR#2's ADL needs revealed he required total assistance for bed mobility, two+ persons physical assist for transfers, total dependence of one person physical assistance for eating and dressing, total dependence and two + persons assist for hygiene, total dependence and one person assist for bathing. CR #2 was noted to have a feeding tube and he was on a therapeutic diet. He received 51% or more through his tube feeding and 501 cc/day or more fluid intake by IV or tube feeding. CR #2 had the following care areas triggered: cognitive loss/dementia, visual function, communication, urinary incontinence, falls, nutritional status, feeding tube, dehydration/fluid maintenance, dental care pressure ulcer and [MEDICAL CONDITION] drug use. Record Review of CR#2's Care Plans indicated the Care plan for behaviors was not initiated until [DATE] with interventions of supervision needed. Care plan was not updated with exhibited behaviors during the month of [DATE]. Care plans included: - ADL Functions-balance, initiated [DATE] requires extensive assist due to cognition and impaired. Eating - NPO - G/T. - Diet: NPO status, initiated [DATE] PEG placed. - Behavior problem due to pulls at G/T . He has [DIAGNOSES REDACTED]. Interventions: Anticipate and meet the resident ' s needs, apply abdominal binder daily, feedings changed to bolus, if resident becomes agitated leave and return when resident appears calmer, observed resident when walking by or redirect when putting things in mouth that are non-eatable and food due to NPO, redirect resident back to room, staff will anticipate needs as needed. Care plan was not updated after [DATE]. - CR#2 requires tube feeding due to swallowing problem - NPO at risk for aspiration due to will drink from bathroom faucet and eat regular food or objects, initiated [DATE]. Interventions: redirect resident from drinking from faucet, speech therapy evaluation and treatment was ordered . Care plan was not updated after [DATE]. There was no care plan to address the residents need to be supervised for toileting. Record review of CR #2's interdisciplinary notes indicated: - Nurse ' s Note: [DATE] at 4:50 a.m. Resident observed to have pulled out his [DEVICE] in spite of abdominal binder that was in place to secure it. (Re-inserted) - Dietician/Dietary Note [DATE]: . Diet - NPO status. Recommendations - 1) D/C current tube feeding order. 2) Start [MEDICATION NAME] 1.2 at 70cc per hour times 22 hours per day continuous plus 150cc water flush via peg . - Nurse ' s Note: [DATE] at 11:45 a.m. Resident pulling out tube - facility requesting bolus feeding. - Nurse ' s Note: [DATE] at 6:05 p.m. Found tube feeding pole knocked down to the floor with feeding tube tubing cut in half, disconnected from the resident . New order for bolus feeding noted and carried out. - Nurse ' s Note: [DATE] at 4:55 p.m. Very loud and pushing staff. Trying to get out of bed, four staff assist to get resident calm. Continues to request coffee. Quieted down a little after taken to rest room and back to bed. - Nurse ' s Note: [DATE] at 3:13 p.m. Resident pulled out PEG while up in chair at bedside. Notified physician. Resident again found wandering into break room eating staff food on table. Return resident to his room and put him back to bed. - Nurse ' s Note: [DATE] at 10:58 p.m. .Resident is a [DEVICE] feeder, incontinent of bladder and bowel and uses diaper, able to move in bed without staff assist, able to transfer self without staff help, able to ambulate by self and needs staff assist for safety, confused, behaviors, no care plan changes . - Nurse ' s Note: [DATE] at 1:40 p.m. Continues to wander looking for food as well as asking everyone for food. - Nurse ' s Note: [DATE] at 9:36 p.m. .Resident feeds via [DEVICE] and requires one staff assist, able to move in bed without staff assist, able to transfer self without staff help, able to ambulate by self and needs staff assist for safety, confused, behaviors, no care plan changes . - Nurse ' s Note: [DATE] at 7:18 a.m. Noncompliance, refused meds through [DEVICE], med given PO. - Nurse ' s Note: [DATE] at 11:18 a.m. Behaviors noted related to PO food intake. - Social Worker Note: [DATE] at 11:23 a.m. Care plan meeting held. The team consisted of nursing, rehabilitation, dietary, activities and social work. Attempted to contact CR #2 ' s family, no answer. The group home owner, of CR#2 ' s previous home participated via phone. Upon termination of care plan meeting owner was given the opportunity to ask questions and or give comments. Agreed to continue current plan of care. There was no mention of CR #2 ' s food intake behavior problem. - Nurse ' s Note: [DATE] at 12:04 p.m. Noncompliance, refused meds feeding via [DEVICE]. Meds and feeding given PO. CR#2 keeps moving aimlessly . - Nurse ' s Note: [DATE] at 4:33 p.m. Continues to wander looking and taking food off nourishment cart. - Nurse ' s Note: [DATE] at 2:33 p.m. CR#2 eats and drinks via [DEVICE], extensive assistance with toileting, no care plan changes, CR#2 noted frequently fast walking out to the hallway looking for food and going into rooms. Redirected several times with no compliance. Will continue to monitor. Record review of modified [MEDICATION NAME] study (MBSS) competed on [DATE] revealed in part: findings: dysphagia severity is moderate. Aspiration and penetration of thin liquids noted ; Risk for aspiration is high due to decreased oral control, residue in vestibule, residue on vocal folds, residue in airway and pharynx. Significant penetration/aspiration observed. Recommendations included: Small bites- monitor oral intake, monitor oral pocketing, patient to be fed and supervised 1 on 1 feeding. Record review of physician ' s telephone order dated [DATE] completed by the speech therapist revealed: per MBSS and physician recommendation- resident to remain NPO with g tube. Speech pathologist to train staff/family that only resident was supposed to receive pureed solids and nectar thick pleasure feeds . Record review of additional nurses ' notes for CR #2 revealed: - Nurse ' s Note: [DATE] at 3:07 p.m. Found in rest room drinking water from the bathroom sink faucet. Taken back to room and made comfortable in chair. - Nurse ' s Note: [DATE] at 2:31 p.m. Quiet most of the morning, at noon resident began to wander looking for food. Was found drinking water off nutrition cart. Assisted back to room . - Nurse ' s Note: [DATE] at 2:15 p.m. Less wandering for food noted today. - Nurse ' s Note: [DATE] at 1:28 p.m. CR#2 is NPO, feeding via [DEVICE], supervision and reminders for toileting, one person assist with bed mobility . is calm and compliant with care and medications this morning, alert and oriented to person, no care plan changes indicated . very dull at this time, not participating as usual this morning, NP notified, order for stat chest x-ray, negative results received and communicated to NP, no new orders. Patient drooling and spitting a lot. - SBAR Nurse ' s Note: [DATE] at 5:01 p.m. Situation: I am calling about the following condition, signs, and symptoms: Patient looks is dull, not participating in activities, drooling and spitting a lot. This started on [DATE]. Since this started has stayed the same . This condition, symptom or sign has not occurred before . Patient remains NPO . Mental status change: Decreased consciousness inability to participate in simple activities, drooling, spitting a lot. Functional status change: Needs more assistance with ADL ' s . Assessment(RN)/Appearance(LPN): RN thinks the problem may be possible aspiration pneumonia. Recommendations: Monitor vital signs, stat chest x-ray. - Nurse ' s Note: [DATE] at 11:01 a.m. eating with assistance and supervision .Patient observed in wheelchair . Pleasure feeding ordered but pending . - Nurse ' s Note: [DATE] at 1:10 a.m. CR#2 remains in bed sleeping, no distress at this time. - Nurse ' s Note: [DATE] at 3:00 a.m. CR#2 in bed, sleeping. No shortness of breath, no distress noted. - Nurse ' s Note: [DATE] at 6:20 a.m. CR#2 was noted not to be in his bed at 5:50 a.m. during my rounds on the 200 hall. He was noted in his bathroom on the floor, supine, unresponsive on assessment. Code blue was activated and CPR initiated immediately. Nurses remained with the resident performing CPR. 911 was called at 5:52 a.m. Paramedics arrived. The responsible party was called at 6:15 a.m. and spoke with the sister who provided funeral home information. Nurse practitioner for resident ' s doctor was informed and telephone order obtained to transfer body to family ' s funeral home of choice. Record review of CR #2's Physician ' s Progress Notes indicated: - [DATE] Initial visit. CR#2 here for rehabilitation, has multiple medical issues inclusive [MEDICAL CONDITION] in sputum, pica, history of severe cognitive impairment, altered mental status, dysphagia, bi-polar,[MEDICAL CONDITIONS]. Sepsis [MEDICAL CONDITION]: Continue antibiotics. Dysphagia: Continue tube feeding. - [DATE] Follow up on behavior, dysphagia, tube feeding. Patient very combative, refusing care per staff. Pulled PEG 2 nights ago. PEG replaced and evaluated for bolus feeding. Dementia with behavior: Aggressive/combative with care. Continue current medications, consult psychiatry. Monitor. - [DATE] Patient continues to pull on lines and tubes. PEG with bolus feeding. Severe cognitive impairment: Continue supportive care, [MEDICATION NAME] as needed, psychiatry consult pending. Chest x-ray for follow up to pneumonia. - [DATE] History and Physical Note: Weakness, confusion for 3 weeks.[MEDICAL CONDITION]-MRSA-Pneumonia-Septic shock resolved. Dysphagia - PEG tube feedings - Replaced [DEVICE]. Continue aspiration precautions. - [DATE] Follow up behavior, [DEVICE] feeding. PEG in place, past re-insertion, patient pulling out over the weekend. Continue tube feeding at recommended rate, monitor for aspiration. - [DATE] per staff patient is walking around and eating food. Will have Speech Therapy evaluate and treat as indicated. Severe cognitive impairment. - [DATE] Modified [MEDICATION NAME] Swallow test done today, result pending. Per staff patient goes to lounge and eats up food in refrigerator. Patient is non conversant when questioned. Severe cognitive impairment. - [DATE] Patient seen on hallway and in staff lounge getting food and eating. MBS done by speech therapy, awaiting safest diet. - [DATE] increased drooling and lowered activity. Chest x-ray negative for aspiration pending. Patient is high risk for aspiration due to lack of oral control and result of MBS recommending pleasure feeding with pureed, small bites with nectar thick liquids with supervision. However, patient is non-compliant, he is seen going into the staff lounge and eating foods unassisted. - [DATE] Staff reports decreased drooling, still less activity. Discontinue pleasure feeds to avoid possible silent aspiration. Continue NPO, continue bolus feeds, monitor. - [DATE] Patient expired. Record review of CR#2 ' s Death certificate dated [DATE] indicated the cause of death was Aspiration pneumonia and [MEDICAL CONDITION]. In an interview with CNA D on [DATE] at 10:45 a.m. she said she had worked with CR#2 when he was in the facility. She said he was calm and he needed assistance with his ADL ' s. She said one time he had vomited on his shoes and he did not want her to remove them. She said he kept repeating ' I want my shoes ' as he rocked back and forth. She said she did not receive any information about his needs before she worked with him. She said she had seen him walking around, getting water and that she did not know about any precautions for him. She said she had not received any training regarding CR#2 ' s care needs related to NPO or his eating disorder. In an interview with CNA U on [DATE] at 11:05 a.m. she said she had seen CR#2 ambulating in the facility. She said he kept busy and would draw on things and was monitored for putting things in his mouth. She said she had not received training specific to CR#2's care needs related to NPO or his eating disorder. In an interview with LVN H on [DATE] at 10:45 a.m. she said she was still an orientee when CR#2 was in the facility. She said she did not work with him, but she knew he received nutrition via tube feedings; he had special needs and was NPO. She said she had not received training specific to CR#2's care needs related to his eating disorder. She was not trained regarding any additional supervision he needed because he would eat food from others. She said he would go into the employee lounge and eat food. In an interview with LVN A on [DATE] at 10:20 a.m. she said Pica was when someone eats things like plastic or things they should not eat. You said she had to watch them a lot and check their room frequently for things they may try to eat and remove it. You have to have one on one to watch them constantly. In a phone interview with RN G on [DATE] at 1:05 p.m. she said she worked on the 10:00 p.m. to 6:00 a.m. shift on the morning CR#2 died . She said she monitored CR#2 every 2 hours. She said he was in bed asleep at 11:15 p.m. on [DATE], at 1:10 a.m., 3:00 a.m. and 5:00 a.m. She said she was aware of his NPO/Pica status and they had to watch him for putting things in his mouth. She said she was passing by his room at 5:50 a.m. and noticed he was not in his bed. She walked in the room and checked in the bathroom. She said she saw CR#2 on the floor lying on his back with his mouth open. He was unresponsive. She started yelling for help and initiated CPR. A co-worker brought in the crash cart and EMS was called. She had been preforming CPR for about 10 minutes when the EMS arrived. RN G said that EMS did not continue with CPR stating He is cold and he is dead . She said that the EMS personnel started asking questions about CR#2 and then they called the police. When the police arrived they also asked questions. She said that she informed the DON, physician and the family was notified.CR#2 ' s remains were taken to the funeral home. Record review of the facility training/in-services for June and [DATE] indicated there was no evidence that staff had been in serviced on CR #2 ' s need for supervision and appropriate interventions for his Pica disorder or that he was not supposed to eat by mouth due to dysphagia. In an interview with the DON on [DATE] at 11:45 a.m. she said CR#2 had Intellectual disabilities/Mental [MEDICAL CONDITION]. She said he had a [DEVICE] and was NPO upon admission. She said he was quiet at first and he was in isolation. He started to improve and he was always running, trying to eat and yelling ' I ' m hungry ' . She said he used to eat at home previous to being in the hospital. She said the staff would redirect him when they saw him eating or drinking. She said they were in the process of getting the family to sign a waiver for his non-compliance. She said that his code status was changed to an OHDNR (out-of-hospital-Do-Not-Resuscitate) status. During further interview on [DATE] at 12:45 p.m. with the DON when asked if the facility had completed a Report of Incident/Accident form for CR#2 ' s death on [DATE], she said an Incident report would have been done on the computer, she said she did not think they had, but she would check. An Incident Report was not provided by the end of the survey. In an interview with the Administrator (The Abuse Prevention Coordinator) and the DON on [DATE] at 1:55 p.m. they said the staff had notified the DON of CR#2 ' s death when it occurred and the DON notified the Administrator. They said the family and the physician were notified. The emergency medical services were called and the body was sent to the funeral home. They said they were not aware that the police had been called to the building by the ems personnel. They said they were not aware of the need to report unusual deaths in the facility to the State Agency or the need to investigate that CR #2 was found unresponsive in his bathroom floor. Resident #3: Record Review of Resident #3 ' s clinical records revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #3 ' s MDS assessment dated [DATE] revealed a BIMS score of 15 that indicated cognition skills were intact. Resident behaviors were marked 0 not exhibited. ADL needs revealed she required extensive assistance with two + persons physical assistance with weight bearing support transfer moves to and from bed, chair, wheelchair, and standing position. Resident did not walk. Resident scored 3 with dressing herself putting on and taking off clothing requiring extensive assistance and support. Personal hygiene required extensive assistance. Record Review of Resident #3 ' s clinical file revealed that the only care plans were initial Care Plans dated [DATE]. There were no care plans to address ADL needs. The care plan for falls included: due to unsteady gait, history of falls. Record Review of Incident Report done by DON on Resident #3 dated [DATE] revealed resident complained of both legs swollen and painful. Resident stated that legs were twisted during therapy on [DATE], stat X-Ray requested to bilateral lower extremities. Record Review of Resident # 3 Physical Therapist progress notes dated [DATE] continue to have difficulty with knee extension and has used standing frame for a few minutes at a time. Remaining functional deficits/underlying impairments of bed mobility, transfers, strengthening and safety awareness. Record Review Rehab Addendum note date [DATE] done by OTA-B revealed on [DATE] Resident #3 agreed with OTA-B and PTA-C to stand in standing frame at bedside. Resident #3 tolerated standing in frame approx. ,[DATE] minutes with complaints of knee pain, upon lowering, resident externally rotated feet and began to slouch in sling. [DATE] and [DATE] resident agreed to sit on edge of bed however unwilling to participate in therapy. Interview with Resident #3 on [DATE] at 1:25 p.m. regarding injury to lower left extremity, she said she could not remember the exact date but it happened one day last week when OTA-B came to her room alone with the standing frame lift. She said that the OT tried to put her in it by sitting her and moving her to the edge of bed to stand her up in the standing frame. She said: My knees were jammed and I could not move them. I told her my knees are hurting and I could not move them and I started crying and hollering. She said that OTA-B said I am trying to get you out. Resident #3 said my knees became more and more tight and my whole left leg down to the ankle area was in so much pain. She said that OTA-B was standing behind her trying to hook something on the machine stating, I am trying I am trying, next thing I know I am on the floor. Resident #3 said that she thought OTA-B called for help because two people put her in the wheelchair and from the wheel chair back in her bed. Resident #3 stated she asked for something for pain from the nurse and told her what had happen, but also asked to speak to the supervisor. She could not remember the supervisor ' s name. Record Review of a statement dated [DATE] given by the DON revealed in part that on [DATE] that: . CNA came to my office saying Resident #3 wanted to speak to me around 5:30 p.m. DON met with resident. Resident reported she did not want to do therapy anymore. Resident reported that OTA-B had made her stand up in the standing frame and her leg got twisted, especially when OTA-B let her down. While visiting with resident DON noted both of resident ' s legs were more swollen than usual, reported pain. DON asked RN to medicate resident with pain meds due to resident complaining of pain level ,[DATE]. DON called MD to request X-Ray . Record Review of a statement completed by the DON on Resident #3 dated [DATE] indicated X-Ray results revealed fracture of fibula. MD orders to transfer resident to ER for evaluation, Administrator was notified. Interview with OTA-B on [DATE] at 10.00 a.m. she said that on [DATE] OTA-B and PTA-C were on their way to Resident #3 room when PTA-C was called to go to another resident ' s room. OTA-B stated she went to Resident #3 ' s room to get her out of bed for therapy using the standing frame equipment. OTA-B stated: I began by moving Resident #3 to the edge of bed in a sitting position and placed the slings underneath and on both sides of resident #3 ' s hips and connected the sling to the frame. I used the machine to electronically assist resident into a standing position. Resident #3 was only able to stand for about minute and started to request to stop therapy. I began to let her down using the standing frame. She started to turn her feet out and lost balance and started to slide downward out of the sling strap. I had to ease Resident #3 down to the floor in a sitting position. OTA-B stated that resident #3 was crying but that she always cried when receiving therapy and that she always had swelling in her legs because of arthritis. OTA-B states that CNA-D was standing in the doorway and came to assist with getting resident #3 off the floor into the wheelchair. She said that then PTA-C assisted her in transferring resident back to bed using a sliding board. OTA-B stated she did report to the nurse that Resident #3 needed something for pain, but did not report the incident to the nurse because she did not consider it a fall. In further interview at the time OTA-B stated she did report the incident to the Rehab Director (supervisor) who in return told her to let the nurse know what took place with resident #3 and the standing frame. OTA-B stated did not report what happened to the nurse until [DATE] when the Administrator and DON asked OTA-B about the incident with Resident #3 and asked her to write a statement regarding the incident. Record review of nurses ' notes for Resident #3 revealed: [DATE] at 4:12 pm. - Resident complaint of pain in left leg. No other notes. [DATE] at 8:41 am- patient complaint of pain on both knees, prn [MEDICATION NAME] administered. Will continue to monitor. [DATE] at 4:21 pm- prn pain medication- effective. [DATE] at 6:00 am -patient requested pain medication. No other notes. [DATE] at 7:00 am-prn administration was effective. [DATE] at 11:10 am- patient requested medication on a pain level of 1- on a scale of ,[DATE]. [DATE] at 2:03 pm- pain medication was ineffective. No other notes. [DATE] at 8:20 pm (late entry) on [DATE] patient returned from physical therapy and complained of some discomfort with her legs. Patient medicated for pain and assessed. Pain level minimally reduced. DON visited with resident before leaving for the day .evening supervisor notified of need for a portable chest x-ray on patient .x-ray on both lower extremities order .done around 12 midnight and 1:00 am . [DATE] 7:10 am X-ray result from previous shift revealed acute fracture of distal fibula .affected limb immobilized.pt complaint of mild pain .prn [MEDICATION NAME] administered .NP notified, new order to transfer to ER for evaluation. Record reviews revealed Resident #3 was assessed for pain verbally, but there was no documentation to indicate Resident #3 was assessed physically related to pain complaints between [DATE] - [DATE]. Interview with CNA-D on [DATE] at 10:40 a.m. regarding the incident with Resident #3 on [DATE], CNA-D stated that while she was sitting down at the computer charting on hall 200, she heard loud yelling. She said she approached the resident ' s room and saw resident #3 sitting on floor with her feet turned outwards and OTA-B was standing behind the resident. CNA-D said OTA-B asked for assistance to transfer Resident #3 back into her wheelchair. She then assisted OTA-B with transferring the resident from the floor into the wheelchair by holding the resident lower body and torso and OTA-B holding residents ' upper body torso both lifting and transferring the resident to wheelchair. CNA-D said she then left the resident room because PTA-C had arrived to help. CNA-D states could not remember if she reported the incident to nurse or not. Record Review of Rehab Addendum Note written by the Rehab Director and dated [DATE] revealed that on [DATE] both OTA-B and PTA-C reported that Resident #3 slouched in the standing frame on [DATE] because she wanted down. Resident was lowered and then taken out of standing frame. OTA-B and PTA-C used sliding board to transfer resident from wheelchair to bed. Director of rehab instructed staff to continue to address pain management including coordinating with nursing for pain medication as well as offering modalities (biofreeze, moist heat packs, and e-stim). Further review of the statement revealed: On Friday [DATE] received a phone call from Administrator that Resident #3 had received X-Ray showing a fracture that resident reports she believes occurred while was in standing frame. Director of Rehab contacted OTA-B and PTA-C to gather their documentation reported on [DATE] and spoke with Administrator and DON regarding resident. On [DATE] Director of Rehab stated began in-servicing OTA-B and PTA-C on reporting any incidents to nursing as well as knowing that any change of condition even if assisting patient to floor that they should always inform nurse. Record Review statement from Administrator dated [DATE] states that .on [DATE] she was contacted by the DON that Resident #3 had sustained a fracture after working with rehab on [DATE]. X-ray results on [DATE] in a.m. showed a fracture. DON stated on [DATE] in the afternoon she was told resident was in pain and did not want to participate in therapy. DON spoke to resident and noted leg swollen and got an order for [REDACTED]. OTA-B states that resident was experiencing pain and discomfort so she lowered resident to the floor then placed her in the wheelchair and that PTA-C was working with her. The DON asked OTA-B who did she tell? Did she tell the charge nurse? OTA-B said she did not. She told the Director of Rehab. Administrator asked Director of Rehab to in-service her department on reporting incidents or falls to the charge nurse for further assessment, incident report and follow up. Administrator states that per company preference, all fractures are reported to DADS, self-report by DON on [DATE]. OTA-B said resident had therapy in room on [DATE] and [DATE]. Resident was sent to ER for evaluation and treatment of [REDACTED]. Record review of Resident #3 ' s MAR for the month of [DATE] revealed that the resident received prn [MEDICATION NAME] on [DATE] for a pain level of 9 out of 10, [DATE] for pain of 5 out of 10, [DATE] for a pain level of 8 out of 10. During an interview on [DATE] at 9:50 a.m. with the Administrator and the DON regarding Resident #3 ' s fall and fracture, they said when they knew about it they intervened. They said they were not informed of the fall until the resident told the DON on [DATE]. At that time the DON notified the charge nurse to assess Residen

Based on observation, interview and record review and interview, the facility failed to implement their policies and procedures that prohibit neglect for 2 of 11 residents (CR#2 and Resident #3) reviewed for abuse and neglect. -The facility failed to provide adequate supervision and put proper interventions in place for CR #2 who had [DIAGNOSES REDACTED]. CR #2 ate food from other residents ' rooms, the employee break room, and drank water multiple times from [DATE] - [DATE]. -CR #2 had a decline of condition starting on [DATE]. On [DATE] CR #2 was found unresponsive in the bathroom and was pronounced dead. CR #2's cause of death was aspiration pneumonitis and [MEDICAL CONDITION]. -Resident #3, who required two person for transfers and a sit to stand lift was transferred by an OT staff without assistance on [DATE] and she fell to the floor. The OT and other witnesses did not report the incident to the nurse or Administration. Assessments were not conducted until the resident reported what happened on [DATE]. X-ray was done on [DATE] at 6:00 pm that showed acute fracture to the left malleolus (bone in the ankle) and fracture of left metatarsal (bones in the foot). The resident was sent to theER on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected two residents and placed 83 current residents at risk of neglect, decline in their health, and unnecessary pain. Intake: Incident # 9 and Complaint #'s 5, 6, 7 and # 6. Findings include: CR #2: Record Review of the residents' records revealed that CR #2 was a [AGE] year old male admitted to the facility on [DATE] from the hospital. His [DIAGNOSES REDACTED]. Record review of the Nurses ' telephone report called into the facility from the hospital (undated) indicated CR#2 was a [AGE] year old male. Diagnoses: [REDACTED]. Slurred speech, full code, high fall risk, no skin wounds, incontinent of bowel and bladder, NPO . Record review of CR #2 ' s Case Management notes from the hospital admission to the facility dated [DATE] and [DATE] indicated: -Date of Service: [DATE] No acute events overnight. He has still been restless, agitated, and combative, worse during evening and early morning hours. Further record review of the Case Management Notes from the hospital for CR#2 ' s admission to the facility dated [DATE] indicated: -Current Diagnosis: [REDACTED]. - Additional information: ambulatory can do ADL's with some verbal prompting. He is blind in his left eye and has [MEDICAL CONDITION] in right eye. So he is at risk for falls. He needs to be told to slow down when eating. He can toilet independently but needs supervision due to rectal digging and history of Pica. Record Review of CR #2's MDS assessment dated [DATE] revealed CR #2 rarely/never understands and is rarely/never understood. CR #2 had short and long term memory problems and he was severely cognitively impaired. CR #2's behaviors were marked as 0, not exhibited. CR#2's ADL needs revealed he required total assistance for bed mobility, two+ persons physical assist for transfers, total dependence of one person physical assistance for eating and dressing, total dependence and two + persons assist for hygiene, total dependence and one person assist for bathing. CR #2 was noted to have a feeding tube and he was on a therapeutic diet. He received 51% or more through his tube feeding and 501 cc/day or more fluid intake by IV or tube feeding. CR #2 had the following care areas triggered: cognitive loss/dementia, visual function, communication, urinary incontinence, falls, nutritional status, feeding tube, dehydration/fluid maintenance, dental care pressure ulcer and [MEDICAL CONDITION] drug use. Record Review of CR#2's Care Plans indicated the Care plan for behaviors was not initiated until [DATE] with interventions of supervision needed. Care plan was not updated with exhibited behaviors during the month of [DATE]. Care plans included: - ADL Functions-balance, initiated [DATE] requires extensive assist due to cognition and impaired. Eating - NPO - G/T. - Diet: NPO status, initiated [DATE] PEG placed. - Behavior problem due to pulls at G/T . He has [DIAGNOSES REDACTED]. Interventions: Anticipate and meet the resident ' s needs, apply abdominal binder daily, feedings changed to bolus, if resident becomes agitated leave and return when resident appears calmer, observed resident when walking by or redirect when putting things in mouth that are non-eatable and food due to NPO, redirect resident back to room, staff will anticipate needs as needed. Care plan was not updated after [DATE]. - CR#2 requires tube feeding due to swallowing problem - NPO at risk for aspiration due to will drink from bathroom faucet and eat regular food or objects, initiated [DATE]. Interventions: redirect resident from drinking from faucet, speech therapy evaluation and treatment was ordered . Care plan was not updated after [DATE]. There was no care plan to address the residents need to be supervised for toileting. Record review of CR #2's interdisciplinary notes indicated: - Nurse ' s Note: [DATE] at 4:50 a.m. Resident observed to have pulled out his [DEVICE] in spite of abdominal binder that was in place to secure it. (Re-inserted) - Dietician/Dietary Note [DATE]: . Diet - NPO status. Recommendations - 1) D/C current tube feeding order. 2) Start [MEDICATION NAME] 1.2 at 70cc per hour times 22 hours per day continuous plus 150cc water flush via peg . - Nurse ' s Note: [DATE] at 11:45 a.m. Resident pulling out tube - facility requesting bolus feeding. - Nurse ' s Note: [DATE] at 6:05 p.m. Found tube feeding pole knocked down to the floor with feeding tube tubing cut in half, disconnected from the resident . New order for bolus feeding noted and carried out. - Nurse ' s Note: [DATE] at 4:55 p.m. Very loud and pushing staff. Trying to get out of bed, four staff assist to get resident calm. Continues to request coffee. Quieted down a little after taken to rest room and back to bed. - Nurse ' s Note: [DATE] at 3:13 p.m. Resident pulled out PEG while up in chair at bedside. Notified physician. Resident again found wandering into break room eating staff food on table. Return resident to his room and put him back to bed. - Nurse ' s Note: [DATE] at 10:58 p.m. .Resident is a [DEVICE] feeder, incontinent of bladder and bowel and uses diaper, able to move in bed without staff assist, able to transfer self without staff help, able to ambulate by self and needs staff assist for safety, confused, behaviors, no care plan changes . - Nurse ' s Note: [DATE] at 1:40 p.m. Continues to wander looking for food as well as asking everyone for food. - Nurse ' s Note: [DATE] at 9:36 p.m. .Resident feeds via [DEVICE] and requires one staff assist, able to move in bed without staff assist, able to transfer self without staff help, able to ambulate by self and needs staff assist for safety, confused, behaviors, no care plan changes . - Nurse ' s Note: [DATE] at 7:18 a.m. Noncompliance, refused meds through [DEVICE], med given PO. - Nurse ' s Note: [DATE] at 11:18 a.m. Behaviors noted related to PO food intake. - Social Worker Note: [DATE] at 11:23 a.m. Care plan meeting held. The team consisted of nursing, rehabilitation, dietary, activities and social work. Attempted to contact CR #2 ' s family, no answer. The group home owner, of CR#2 ' s previous home participated via phone. Upon termination of care plan meeting owner was given the opportunity to ask questions and or give comments. Agreed to continue current plan of care. There was no mention of CR #2 ' s food intake behavior problem. - Nurse ' s Note: [DATE] at 12:04 p.m. Noncompliance, refused meds feeding via [DEVICE]. Meds and feeding given PO. CR#2 keeps moving aimlessly . - Nurse ' s Note: [DATE] at 4:33 p.m. Continues to wander looking and taking food off nourishment cart. - Nurse ' s Note: [DATE] at 2:33 p.m. CR#2 eats and drinks via [DEVICE], extensive assistance with toileting, no care plan changes, CR#2 noted frequently fast walking out to the hallway looking for food and going into rooms. Redirected several times with no compliance. Will continue to monitor. Record review of modified [MEDICATION NAME] study (MBSS) competed on [DATE] revealed in part: findings: dysphagia severity is moderate. Aspiration and penetration of thin liquids noted ; Risk for aspiration is high due to decreased oral control, residue in vestibule, residue on vocal folds, residue in airway and pharynx. Significant penetration/aspiration observed. Recommendations included: Small bites- monitor oral intake, monitor oral pocketing, patient to be fed and supervised 1 on 1 feeding. Record review of physician ' s telephone order dated [DATE] completed by the speech therapist revealed: per MBSS and physician recommendation- resident to remain NPO with g tube. Speech pathologist to train staff/family that only resident was supposed to receive pureed solids and nectar thick pleasure feeds . Record review of additional nurses ' notes for CR #2 revealed: - Nurse ' s Note: [DATE] at 3:07 p.m. Found in rest room drinking water from the bathroom sink faucet. Taken back to room and made comfortable in chair. - Nurse ' s Note: [DATE] at 2:31 p.m. Quiet most of the morning, at noon resident began to wander looking for food. Was found drinking water off nutrition cart. Assisted back to room . - Nurse ' s Note: [DATE] at 2:15 p.m. Less wandering for food noted today. - Nurse ' s Note: [DATE] at 1:28 p.m. CR#2 is NPO, feeding via [DEVICE], supervision and reminders for toileting, one person assist with bed mobility . is calm and compliant with care and medications this morning, alert and oriented to person, no care plan changes indicated . very dull at this time, not participating as usual this morning, NP notified, order for stat chest x-ray, negative results received and communicated to NP, no new orders. Patient drooling and spitting a lot. - SBAR Nurse ' s Note: [DATE] at 5:01 p.m. Situation: I am calling about the following condition, signs, and symptoms: Patient looks is dull, not participating in activities, drooling and spitting a lot. This started on [DATE]. Since this started has stayed the same . This condition, symptom or sign has not occurred before . Patient remains NPO . Mental status change: Decreased consciousness inability to participate in simple activities, drooling, spitting a lot. Functional status change: Needs more assistance with ADL ' s . Assessment(RN)/Appearance(LPN): RN thinks the problem may be possible aspiration pneumonia. Recommendations: Monitor vital signs, stat chest x-ray. - Nurse ' s Note: [DATE] at 11:01 a.m. eating with assistance and supervision .Patient observed in wheelchair . Pleasure feeding ordered but pending . - Nurse ' s Note: [DATE] at 1:10 a.m. CR#2 remains in bed sleeping, no distress at this time. - Nurse ' s Note: [DATE] at 3:00 a.m. CR#2 in bed, sleeping. No shortness of breath, no distress noted. - Nurse ' s Note: [DATE] at 6:20 a.m. CR#2 was noted not to be in his bed at 5:50 a.m. during my rounds on the 200 hall. He was noted in his bathroom on the floor, supine, unresponsive on assessment. Code blue was activated and CPR initiated immediately. Nurses remained with the resident performing CPR. 911 was called at 5:52 a.m. Paramedics arrived. The responsible party was called at 6:15 a.m. and spoke with the sister who provided funeral home information. Nurse practitioner for resident ' s doctor was informed and telephone order obtained to transfer body to family ' s funeral home of choice. Record review of CR #2's Physician ' s Progress Notes indicated: - [DATE] Initial visit. CR#2 here for rehabilitation, has multiple medical issues inclusive [MEDICAL CONDITION] in sputum, pica, history of severe cognitive impairment, altered mental status, dysphagia, bi-polar,[MEDICAL CONDITIONS]. Sepsis [MEDICAL CONDITION]: Continue antibiotics. Dysphagia: Continue tube feeding. - [DATE] Follow up on behavior, dysphagia, tube feeding. Patient very combative, refusing care per staff. Pulled PEG 2 nights ago. PEG replaced and evaluated for bolus feeding. Dementia with behavior: Aggressive/combative with care. Continue current medications, consult psychiatry. Monitor. - [DATE] Patient continues to pull on lines and tubes. PEG with bolus feeding. Severe cognitive impairment: Continue supportive care, [MEDICATION NAME] as needed, psychiatry consult pending. Chest x-ray for follow up to pneumonia. - [DATE] History and Physical Note: Weakness, confusion for 3 weeks.[MEDICAL CONDITION]-MRSA-Pneumonia-Septic shock resolved. Dysphagia - PEG tube feedings - Replaced [DEVICE]. Continue aspiration precautions. - [DATE] Follow up behavior, [DEVICE] feeding. PEG in place, past re-insertion, patient pulling out over the weekend. Continue tube feeding at recommended rate, monitor for aspiration. - [DATE] per staff patient is walking around and eating food. Will have Speech Therapy evaluate and treat as indicated. Severe cognitive impairment. - [DATE] Modified [MEDICATION NAME] Swallow test done today, result pending. Per staff patient goes to lounge and eats up food in refrigerator. Patient is non conversant when questioned. Severe cognitive impairment. - [DATE] Patient seen on hallway and in staff lounge getting food and eating. MBS done by speech therapy, awaiting safest diet. - [DATE] increased drooling and lowered activity. Chest x-ray negative for aspiration pending. Patient is high risk for aspiration due to lack of oral control and result of MBS recommending pleasure feeding with pureed, small bites with nectar thick liquids with supervision. However, patient is non-compliant, he is seen going into the staff lounge and eating foods unassisted. - [DATE] Staff reports decreased drooling, still less activity. Discontinue pleasure feeds to avoid possible silent aspiration. Continue NPO, continue bolus feeds, monitor. - [DATE] Patient expired. Record review of CR#2 ' s Death certificate dated [DATE] indicated the cause of death was Aspiration pneumonia and [MEDICAL CONDITION]. In an interview with CNA D on [DATE] at 10:45 a.m. she said she had worked with CR#2 when he was in the facility. She said he was calm and he needed assistance with his ADL ' s. She said one time he had vomited on his shoes and he did not want her to remove them. She said he kept repeating ' I want my shoes ' as he rocked back and forth. She said she did not receive any information about his needs before she worked with him. She said she had seen him walking around, getting water and that she did not know about any precautions for him. She said she had not received any training regarding CR#2 ' s care needs related to NPO or his eating disorder. In an interview with CNA U on [DATE] at 11:05 a.m. she said she had seen CR#2 ambulating in the facility. She said he kept busy and would draw on things and was monitored for putting things in his mouth. She said she had not received training specific to CR#2's care needs related to NPO or his eating disorder. In an interview with LVN H on [DATE] at 10:45 a.m. she said she was still an orientee when CR#2 was in the facility. She said she did not work with him, but she knew he received nutrition via tube feedings; he had special needs and was NPO. She said she had not received training specific to CR#2's care needs related to his eating disorder. She was not trained regarding any additional supervision he needed because he would eat food from others. She said he would go into the employee lounge and eat food. In an interview with LVN A on [DATE] at 10:20 a.m. she said Pica was when someone eats things like plastic or things they should not eat. You said she had to watch them a lot and check their room frequently for things they may try to eat and remove it. You have to have one on one to watch them constantly. During interviews on [DATE] from 10:10 - 10:30 a.m. CNA W, CNA I, CNA AA and CNA A said they did not know/remember what Pica was and that the facility had not trained them on what to do with somebody with this disorder. In a phone interview with RN G on [DATE] at 1:05 p.m. she said she worked on the 10:00 p.m. to 6:00 a.m. shift on the morning CR#2 died . She said she monitored CR#2 every 2 hours. She said he was in bed asleep at 11:15 p.m. on [DATE], at 1:10 a.m., 3:00 a.m. and 5:00 a.m. She said she was aware of his NPO/Pica status and they had to watch him for putting things in his mouth. She said she was passing by his room at 5:50 a.m. and noticed he was not in his bed. She walked in the room and checked in the bathroom. She said she saw CR#2 on the floor lying on his back with his mouth open. He was unresponsive. She started yelling for help and initiated CPR. A co-worker brought in the crash cart and EMS was called. She had been preforming CPR for about 10 minutes when the EMS arrived. RN G said that EMS did not continue with CPR stating He is cold and he is dead . She said that the EMS personnel started asking questions about CR#2 and then they called the police. When the police arrived they also asked questions. She said that she informed the DON, physician and the family was notified.CR#2 ' s remains were taken to the funeral home. Record review of the facility training/in-services for June and [DATE] indicated there was no evidence that staff had been in serviced on CR #2 ' s need for supervision and appropriate interventions for his Pica disorder or that he was not supposed to eat by mouth due to dysphagia. In an interview with the DON on [DATE] at 11:45 a.m. she said CR#2 had Intellectual disabilities/Mental [MEDICAL CONDITION]. She said he had a [DEVICE] and was NPO upon admission. She said he was quiet at first and he was in isolation. He started to improve and he was always running, trying to eat and yelling ' I ' m hungry ' . She said he used to eat at home previous to being in the hospital. She said the staff would redirect him when they saw him eating or drinking. She said they were in the process of getting the family to sign a waiver for his non-compliance. She said that his code status was changed to an OHDNR (out-of-hospital-Do-Not-Resuscitate) status. During further interview on [DATE] at 12:45 p.m. with the DON when asked if the facility had completed a Report of Incident/Accident form for CR#2 ' s death on [DATE], she said an Incident report would have been done on the computer, she said she did not think they had, but she would check. An Incident Report was not provided by the end of the survey. In an interview with the Administrator (The Abuse Prevention Coordinator) and the DON on [DATE] at 1:55 p.m. they said the staff had notified the DON of CR#2 ' s death when it occurred and the DON notified the Administrator. They said the family and the physician were notified. The emergency medical services were called and the body was sent to the funeral home. They said they were not aware that the police had been called to the building by the ems personnel. They said they were not aware of the need to report unusual deaths in the facility to the State Agency or the need to investigate that CR #2 was found unresponsive in his bathroom floor. Resident #3: Record Review of Resident #3 ' s clinical records revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #3 ' s MDS assessment dated [DATE] revealed a BIMS score of 15 that indicated cognition skills were intact. Resident behaviors were marked 0 not exhibited. ADL needs revealed she required extensive assistance with two + persons physical assistance with weight bearing support transfer moves to and from bed, chair, wheelchair, and standing position. Resident did not walk. Resident scored 3 with dressing herself putting on and taking off clothing requiring extensive assistance and support. Personal hygiene required extensive assistance. Record Review of Resident #3 ' s clinical file revealed that the only care plans were initial Care Plans dated [DATE]. There were no care plans to address ADL needs. The care plan for falls included: due to unsteady gait, history of falls. Record Review of Incident Report done by DON on Resident #3 dated [DATE] revealed resident complained of both legs swollen and painful. Resident stated that legs were twisted during therapy on [DATE], stat X-Ray requested to bilateral lower extremities. Record Review of Resident # 3 Physical Therapist progress notes dated [DATE] continue to have difficulty with knee extension and has used standing frame for a few minutes at a time. Remaining functional deficits/underlying impairments of bed mobility, transfers, strengthening and safety awareness. Record Review Rehab Addendum note date [DATE] done by OTA-B revealed on [DATE] Resident #3 agreed with OTA-B and PTA-C to stand in standing frame at bedside. Resident #3 tolerated standing in frame approx. ,[DATE] minutes with complaints of knee pain, upon lowering, resident externally rotated feet and began to slouch in sling. [DATE] and [DATE] resident agreed to sit on edge of bed however unwilling to participate in therapy. Interview with Resident #3 on [DATE] at 1:25 p.m. regarding injury to lower left extremity, she said she could not remember the exact date but it happened one day last week when OTA-B came to her room alone with the standing frame lift. She said that the OT tried to put her in it by sitting her and moving her to the edge of bed to stand her up in the standing frame. She said: My knees were jammed and I could not move them. I told her my knees are hurting and I could not move them and I started crying and hollering. She said that OTA-B said I am trying to get you out. Resident #3 said my knees became more and more tight and my whole left leg down to the ankle area was in so much pain. She said that OTA-B was standing behind her trying to hook something on the machine stating, I am trying I am trying, next thing I know I am on the floor. Resident #3 said that she thought OTA-B called for help because two people put her in the wheelchair and from the wheel chair back in her bed. Resident #3 stated she asked for something for pain from the nurse and told her what had happen, but also asked to speak to the supervisor. She could not remember the supervisor ' s name. Record Review of a statement dated [DATE] given by the DON revealed in part that on [DATE] that: . CNA came to my office saying Resident #3 wanted to speak to me around 5:30 p.m. DON met with resident. Resident reported she did not want to do therapy anymore. Resident reported that OTA-B had made her stand up in the standing frame and her leg got twisted, especially when OTA-B let her down. While visiting with resident DON noted both of resident ' s legs were more swollen than usual, reported pain. DON asked RN to medicate resident with pain meds due to resident complaining of pain level ,[DATE]. DON called MD to request X-Ray . Record Review of a statement completed by the DON on Resident #3 dated [DATE] indicated X-Ray results revealed fracture of fibula. MD orders to transfer resident to ER for evaluation, Administrator was notified. Interview with OTA-B on [DATE] at 10.00 a.m. she said that on [DATE] OTA-B and PTA-C were on their way to Resident #3 room when PTA-C was called to go to another resident ' s room. OTA-B stated she went to Resident #3 ' s room to get her out of bed for therapy using the standing frame equipment. OTA-B stated: I began by moving Resident #3 to the edge of bed in a sitting position and placed the slings underneath and on both sides of resident #3 ' s hips and connected the sling to the frame. I used the machine to electronically assist resident into a standing position. Resident #3 was only able to stand for about minute and started to request to stop therapy. I began to let her down using the standing frame. She started to turn her feet out and lost balance and started to slide downward out of the sling strap. I had to ease Resident #3 down to the floor in a sitting position. OTA-B stated that resident #3 was crying but that she always cried when receiving therapy and that she always had swelling in her legs because of arthritis. OTA-B states that CNA-D was standing in the doorway and came to assist with getting resident #3 off the floor into the wheelchair. She said that then PTA-C assisted her in transferring resident back to bed using a sliding board. OTA-B stated she did report to the nurse that Resident #3 needed something for pain, but did not report the incident to the nurse because she did not consider it a fall. In further interview at the time OTA-B stated she did report the incident to the Rehab Director (supervisor) who in return told her to let the nurse know what took place with resident #3 and the standing frame. OTA-B stated did not report what happened to the nurse until [DATE] when the Administrator and DON asked OTA-B about the incident with Resident #3 and asked her to write a statement regarding the incident. Record review of nurses ' notes for Resident #3 revealed: [DATE] at 4:12 pm. - Resident complaint of pain in left leg. No other notes. [DATE] at 8:41 am- patient complaint of pain on both knees, prn [MEDICATION NAME] administered. Will continue to monitor. [DATE] at 4:21 pm- prn pain medication- effective. [DATE] at 6:00 am -patient requested pain medication. No other notes. [DATE] at 7:00 am-prn administration was effective. [DATE] at 11:10 am- patient requested medication on a pain level of 1- on a scale of ,[DATE]. [DATE] at 2:03 pm- pain medication was ineffective. No other notes. [DATE] at 8:20 pm (late entry) on [DATE] patient returned from physical therapy and complained of some discomfort with her legs. Patient medicated for pain and assessed. Pain level minimally reduced. DON visited with resident before leaving for the day .evening supervisor notified of need for a portable chest x-ray on patient .x-ray on both lower extremities order .done around 12 midnight and 1:00 am . [DATE] 7:10 am X-ray result from previous shift revealed acute fracture of distal fibula .affected limb immobilized.pt complaint of mild pain .prn [MEDICATION NAME] administered .NP notified, new order to transfer to ER for evaluation. Record reviews revealed Resident #3 was assessed for pain verbally, but there was no documentation to indicate Resident #3 was assessed physically related to pain complaints between [DATE] - [DATE]. Interview with CNA-D on [DATE] at 10:40 a.m. regarding the incident with Resident #3 on [DATE], CNA-D stated that while she was sitting down at the computer charting on hall 200, she heard loud yelling. She said she approached the resident ' s room and saw resident #3 sitting on floor with her feet turned outwards and OTA-B was standing behind the resident. CNA-D said OTA-B asked for assistance to transfer Resident #3 back into her wheelchair. She then assisted OTA-B with transferring the resident from the floor into the wheelchair by holding the resident lower body and torso and OTA-B holding residents ' upper body torso both lifting and transferring the resident to wheelchair. CNA-D said she then left the resident room because PTA-C had arrived to help. CNA-D states could not remember if she reported the incident to nurse or not. Record Review of Rehab Addendum Note written by the Rehab Director and dated [DATE] revealed that on [DATE] both OTA-B and PTA-C reported that Resident #3 slouched in the standing frame on [DATE] because she wanted down. Resident was lowered and then taken out of standing frame. OTA-B and PTA-C used sliding board to transfer resident from wheelchair to bed. Director of rehab instructed staff to continue to address pain management including coordinating with nursing for pain medication as well as offering modalities (biofreeze, moist heat packs, and e-stim). Further review of the statement revealed: On Friday [DATE] received a phone call from Administrator that Resident #3 had received X-Ray showing a fracture that resident reports she believes occurred while was in standing frame. Director of Rehab contacted OTA-B and PTA-C to gather their documentation reported on [DATE] and spoke with Administrator and DON regarding resident. On [DATE] Director of Rehab stated began in-servicing OTA-B and PTA-C on reporting any incidents to nursing as well as knowing that any change of condition even if assisting patient to floor that they should always inform nurse. Record Review statement from Administrator dated [DATE] states that .on [DATE] she was contacted by the DON that Resident #3 had sustained a fracture after working with rehab on [DATE]. X-ray results on [DATE] in a.m. showed a fracture. DON stated on [DATE] in the afternoon she was told resident was in pain and did not want to participate in therapy. DON spoke to resident and noted leg swollen and got an order for [REDACTED]. OTA-B states that resident was experiencing pain and discomfort so she lowered resident to the floor then placed her in the wheelchair and that PTA-C was working with her. The DON asked OTA-B who did she tell? Did she tell the charge nurse? OTA-B said she did not. She told the Director of Rehab. Administrator asked Director of Rehab to in-service her department on reporting incidents or falls to the charge nurse for further assessment, incident report and follow up. Administrator states that per company preference, all fractures are reported to DADS, self-report by DO

Based on interview, observation and record review the facility failed to ensure that that the resident environment remained as free of accident/hazards and received adequate supervision for 2 of 11 residents (CR#2 and Resident #3) reviewed for prevention of avoidable accidents and injuries. -The facility failed to provide adequate supervision and put proper interventions in place for CR #2 who had [DIAGNOSES REDACTED]. CR #2 ate food from other residents ' rooms, the employee break room, and drank water multiple times from [DATE] - [DATE]. -CR #2 had a decline of condition starting on [DATE]. On [DATE] CR #2 was found unresponsive in the bathroom and was pronounced dead. CR #2's cause of death was aspiration pneumonitis and cardiac arrest. -Resident #3, who required two person for transfers and a sit to stand lift was transferred by an OT staff without assistance on [DATE] and she fell to the floor. The OT and other witnesses (PT and CNA) did not report the incident to the nurse or Administration. Assessments were not conducted until the resident reported what happened on [DATE]. X-ray was done on [DATE] at 6:00 pm that showed acute fracture to the left malleolus (bone in the ankle) and fracture of left metatarsal (bones in the foot). The resident was sent to theER on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy as the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected 2 residents and placed 20 residents that were NPO (nothing by mouth) and 15 residents that required a 2-person transfer at risk of injury and unnecessary pain. Intake: Incident # 9 and Complaint #'s 5, 6, 7 and # 6. Findings include: CR #2: Record Review of the residents' records revealed that CR #2 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #2 ' s Case Management records from the hospital admission to the facility dated indicated: -Date of Service: [DATE] No acute events overnight. He has still been restless, agitated, and combative, worse during evening and early morning hours. Further record review of the Case Management Notes from the hospital for CR#2 ' s admission to the facility dated [DATE] indicated: -Current Diagnosis: [REDACTED]. - Precautions: dietary reflux, history of Pica, CR#2 remains upright for at least 1 ½ hours after meals to reduce reflux. - Additional information: ambulatory, can do ADL ' s with some verbal prompting. He is blind in his left eye and has glaucoma in right eye. So he is at risk for falls. He needs to be told to slow down when eating. He can toilet independently but needs supervision due to rectal digging and history of Pica. Record Review of CR #2's MDS assessment dated [DATE] revealed CR #2 rarely/never understands and is rarely/never understood. CR #2 had short and long term memory problems and he was severely cognitively impaired. CR #2 ' s behaviors were marked as 0, not exhibited. CR#2's ADL needs revealed he required total assistance for bed mobility, two+ persons physical assist for transfers, total dependence of one person physical assistance for eating and dressing, total dependence and two + persons assist for hygiene, total dependence and one person assist for bathing. CR #2 was noted to have a feeding tube and he was on a therapeutic diet. He received 51% or more through his tube feeding and 501 cc/day or more fluid intake by IV or tube feeding. CR #2 had the following care areas triggered: cognitive loss/dementia, visual function, communication, urinary incontinence, falls, nutritional status, feeding tube, dehydration/fluid maintenance, dental care pressure ulcer and psychotropic drug use. Record Review of CR#2's Care Plans indicated the Care plan for behaviors was not initiated until [DATE] with interventions of supervision needed. Care plans included: - ADL Functions-balance, initiated [DATE] requires extensive assist due to cognition and impaired. Eating - NPO - G/T. - Diet: NPO status, initiated [DATE] PEG placed. - Behavior problem due to pulls at G/T . He has [DIAGNOSES REDACTED]. Interventions: Anticipate and meet the resident ' s needs, apply abdominal binder daily, feedings changed to bolus, if resident becomes agitated leave and return when resident appears calmer, observed resident when walking by or redirect when putting things in mouth that are non-eatable and food due to NPO, redirect resident back to room, staff will anticipate needs as needed. Care plan was not updated after [DATE]. - CR#2 requires tube feeding due to swallowing problem - NPO at risk for aspiration due to will drink from bathroom faucet and eat regular food or objects, initiated [DATE]. Interventions: redirect resident from drinking from faucet, speech therapy evaluation and treatment as ordered Care plan was not updated after [DATE]. There was no care plan to address the residents need to be supervised for toileting. Record review of CR #2's interdisciplinary notes indicated: - Nurse ' s Note: [DATE] at 4:50 a.m. Resident observed to have pulled out his [DEVICE] in spite of abdominal binder that was in place to secure it. (re-inserted) - Dietician/Dietary Note: .Diet - NPO status. Recommendations - 1) D/C current tube feeding order. 2) Start Jevity 1.2 at 70cc per hour times 22 hours per day plus 150cc water flush via peg. - Nurse ' s Note: [DATE] at 11:45 a.m. Resident pulling out tube - facility requesting bolus feeding. - Nurse ' s Note: [DATE] at 6:05 p.m. Found tube feeding pole knocked down to the floor with feeding tube tubing cut in half, disconnected from the resident . New order for bolus feeding noted and carried out. - Nurse ' s Note: [DATE] at 4:55 p.m. Very loud and pushing staff. Trying to get out of bed, four staff assist to get resident calm. Continues to request coffee. Quieted down a little after taken to rest room and back to bed. - Nurse ' s Note: [DATE] at 3:13 p.m. Resident pulled out PEG while up in chair at bedside. Notified physician. Resident again found wandering into break room eating staff food on table. Return resident to his room and put him back to bed. - Nurse ' s Note: [DATE] at 10:58 p.m. .Resident is a [DEVICE] feeder, incontinent of bladder and bowel and uses diaper, able to move in bed without staff assist, able to transfer self without staff help, able to ambulate by self and needs staff assist for safety, confused, behaviors, no care plan changes . - Nurse ' s Note: [DATE] at 1:40 p.m. Continues to wander looking for food as well as asking everyone for food. - Nurse ' s Note: [DATE] at 9:36 p.m. .Resident feeds via [DEVICE] and requires one staff assist, able to move in bed without staff assist, able to transfer self without staff help, able to ambulate by self and needs staff assist for safety, confused, behaviors, no care plan changes . - Nurse ' s Note: [DATE] at 7:18 a.m. Noncompliance, refused meds through [DEVICE], med given PO. - Nurse ' s Note: [DATE] at 11:18 a.m. Behaviors noted related to PO food intake. - Social Worker Note: [DATE] at 11:23 a.m. Care plan meeting held. The team consisted of nursing, rehabilitation, dietary, activities and social work. Attempted to contact CR #2 ' s family, no answer. Personal Care home owner participated via phone. Upon termination of care plan meeting owner was given the opportunity to ask questions and or give comments. Agreed to continue current plan of care. There was no mention of CR #2 ' s food intake behavior problem. - Nurse ' s Note: [DATE] at 12:04 p.m. Noncompliance, refused meds feeding via [DEVICE]. Meds and feeding given PO. CR#2 keeps moving aimlessly . - Nurse ' s Note: [DATE] at 4:33 p.m. Continues to wander looking and taking food off nourishment cart. - Nurse ' s Note: [DATE] at 2:33 p.m. CR#2 eats and drinks via [DEVICE], extensive assistance with toileting, no care plan changes, CR#2 noted frequently fast walking out to the hallway looking for food and going into rooms. Redirected several times with no compliance. Will continue to monitor. Record review of modified barium study (MBSS) competed on [DATE] revealed in part: findings: dysphagia severity is moderate. Aspiration and penetration of thin liquids noted ; Risk for aspiration is high due to decreased oral control, residue in vestibule, residue on vocal folds, residue in airway and pharynx. Significant penetration/aspiration observed. Recommendations included: Small bites- monitor oral intake, monitor oral pocketing, patient to be fed and supervised 1 on 1 feeding. Record review of physician ' s telephone order dated [DATE] completed by the speech therapist revealed: per MBSS and physician recommendation- resident to remain NPO with g tube. Speech pathologist to train staff/family that only resident was supposed to receive pureed solids and nectar thick pleasure feeds. Record review of the training records and CR #2' clinical file revealed no training conducted by the speech pathologist. Record review of additional nurses ' notes for CR #2 revealed: - Nurse ' s Note: [DATE] at 3:07 p.m. Found in rest room drinking water from the bathroom sink faucet. Taken back to room and made comfortable in chair. - Nurse ' s Note: [DATE] at 2:31 p.m. Quiet most of the morning, at noon resident began to wander looking for food. Was found drinking water off nutrition cart. Assisted back to room . - Nurse ' s Note: [DATE] at 2:15 p.m. Less wandering for food noted today. - Nurse ' s Note: [DATE] at 1:28 p.m. CR#2 is NPO, feeding via [DEVICE], supervision and reminders for toileting, one person assist with bed mobility . is calm and compliant with care and medications this morning, alert and oriented to person, no care plan changes indicated . very dull at this time, not participating as usual this morning, NP notified, order for stat chest x-ray, results received and communicated to NP, no new orders. Patient drooling and spitting a lot. - SBAR Nurse ' s Note: [DATE] at 5:01 p.m. Situation: I am calling about the following condition, signs, symptoms: Patient looks is dull, not participating in activities, drooling and spitting a lot. This started on [DATE]. Since this started has stayed the same . This condition, symptom or sign has not occurred before . Patient remains NPO . Mental status change: Decreased consciousness inability to participate in simple activities, drooling, spitting a lot. Functional status change: Needs more assistance with ADL ' s . Assessment(RN)/Appearance(LPN): RN thinks the problem may be possible aspiration pneumonia. Recommendations: Monitor vital signs, stat chest x-ray. - Nurse ' s Note: [DATE] at 11:01 a.m. Eating with assistance and supervision .Patient observed in wheelchair . Pleasure feeding ordered but pending . - Nurse ' s Note: [DATE] at 1:10 a.m. CR#2 remains in bed sleeping, no distress at this time. - Nurse ' s Note: [DATE] at 3:00 a.m. CR#2 in bed, sleeping. No shortness of breath, no distress noted. - Nurse ' s Note: [DATE] at 6:20 a.m. CR#2 was noted not to be in his bed at 5:50 a.m. during my rounds on the 200 hall. He was noted in his bathroom on the floor, supine, unresponsive on assessment. Code blue was activated and CPR initiated immediately. Nurses remained with the resident performing CPR. 911 was called at 5:52 a.m. Paramedics arrived. The responsible party was called at 6:15 a.m. and spoke with the sister who provided funeral home information. Nurse practitioner for resident ' s doctor was informed and telephone order obtained to transfer body to family ' s funeral home of choice. Record review of CR #2's Physician ' s Progress Notes indicated: - [DATE] Initial visit. CR#2 here for rehabilitation, has multiple medical issues inclusive of MRSA in sputum, pica, history of severe cognitive impairment, altered mental status, dysphagia, bi-polar, gerd and chronic kidney disease. Sepsis with MRSA: Continue antibiotics. Dysphagia: Continue tube feeding. - [DATE] Follow up on behavior, dysphagia, tube feeding. Patient very combative, refusing care per staff. Pulled PEG 2 nights ago. PEG replaced and evaluated for bolus feeding. Dementia with behavior: Aggressive/combative with care. Continue current medications, consult psychiatry. Monitor. - [DATE] Patient continues to pull on lines and tubes. PEG with bolus feeding. Severe cognitive impairment: Continue supportive care, Haldol as needed, psychiatry consult pending. Chest x-ray for follow up to pneumonia. - [DATE] History and Physical Note: Weakness, confusion for 3 weeks. Sepsis-MRSA-Pneumonia-Septic shock resolved. Dysphagia - PEG tube feedings - Replaced [DEVICE]. Continue aspiration precautions. - [DATE] Follow up behavior, [DEVICE] feeding. PEG in place, past re-insertion, patient pulling out over the weekend. Continue tube feeding at recommended rate, monitor for aspiration. - [DATE] Per staff patient is walking around and eating food. Will have Speech Therapy evaluate and treat as indicated. Severe cognitive impairment. - [DATE] Modified Barium Swallow test done today, result pending. Per staff patient goes to lounge and eats up food in refrigerator. Patient is non conversant when questioned. Severe cognitive impairment. - [DATE] Patient seen on hallway and in staff lounge getting food and eating. MBS done by speech therapy, awaiting safest diet. - [DATE] Increased drooling and lowered activity. Chest x-ray negative for aspiration pending. Patient is high risk for aspiration due to lack of oral control and result of MBS recommending pleasure feeding with pureed, small bites with nectar thick liquids with supervision. However, patient is non-compliant, he is seen going into the staff lounge and eating foods unassisted. - [DATE] Staff reports decreased drooling, still less activity. Discontinue pleasure feeds to avoid possible silent aspiration. Continue NPO, continue bolus feeds, monitor. - [DATE] Patient expired. Record review of CR#2 ' s Death certificate indicated the cause of death was Aspiration pneumonia and cardiac arrest. In an interview with CNA D on [DATE] at 10:45 a.m. she said she had worked with CR#2 when he was in the facility. She said he was calm and he needed assistance with his ADL ' s. She said one time he had vomited on his shoes and he did not want her to remove them. She said he kept repeating ' I want my shoes ' as he rocked back and forth. She said she did not receive any information about his needs before she worked with him. She said she had seen him walking around, getting water and that she did not know about any precautions for him. She said she had not received any training regarding CR#2 ' s care needs related to NPO or his eating disorder. In an interview with CNA U on [DATE] at 11:05 a.m. she said she had seen CR#2 ambulating in the facility. She said he kept busy and would draw on things and was monitored for putting things in his mouth. She said she had not received training specific to CR#2's care needs related to NPO or his eating disorder. In an interview with LVN H on [DATE] at 10:45 a.m. she said she was still an orientee when CR#2 was in the facility. She said she did not work with him, but she knew he received nutrition via tube feedings; he had special needs and was NPO. She said she had not received training specific to CR#2's care needs related to his eating disorder. She was not trained regarding any additional supervision he needed because he would eat food from others. She said he would go into the employee lounge and eat food. In an interview with LVN A on [DATE] at 10:20 a.m. she said Pica was when someone eats things like plastic or things they should not eat. You said you had to watch them a lot and check their room frequently for things they may try to eat and remove it. You have to have one on one to watch them constantly. During interviews on [DATE] from 10:10 - 10:30 a.m. CNA W, CNA I, CNA AA and CNA A said they did not know/remember what Pica was and that the facility had not trained them on what to do with somebody with this disorder. They did not recall working with CR#2 when he was in the facility. In a phone interview with RN G on [DATE] at 1:05 p.m. she said she worked on the 10:00 p.m. to 6:00 a.m. shift on the morning CR#2 died . She said she monitored CR#2 every 2 hours. She said he was in bed asleep at 11:15 p.m. on [DATE], at 1:10 a.m., 3:00 a.m. and 5:00 a.m. She said she was aware of his NPO/Pica status and they had to watch him for putting things in his mouth. She said she was passing by his room at 5:50 a.m. and noticed he was not in his bed. She walked in the room and checked in the bathroom. She said she saw CR#2 on the floor lying on his back with his mouth open. He was unresponsive. She started yelling for help and initiated CPR. A co-worker brought in the crash cart and EMS was called. She had been preforming CPR for about 10 minutes when the EMS arrived. RN G said that EMS did not continue with CPR stating He is cold and he is dead . She said that the EMS personnel started asking questions about CR#2 and then they called the police. When the police arrived they also asked questions. She said that she informed the DON, physician and the family was notified.CR#2 ' s remains were taken to the funeral home. Record review of the facility training/in-services for June and [DATE] indicated there was no evidence that staff had been in serviced on CR #2 ' s need for supervision and appropriate interventions for his Pica disorder or that he was not supposed to eat by mouth due to dysphagia. In an interview with the DON on [DATE] at 11:45 a.m. she said CR#2 had Intellectual disabilities/Mental retardation. She said he had a [DEVICE] and was NPO upon admission. She said he was quiet at first and he was in isolation. He started to improve and he was always running, trying to eat and yelling ' I ' m hungry ' . She said he used to eat at home previous to being in the hospital. She said the staff would redirect him when they saw him eating or drinking. She said they were in the process of getting the family to sign a waiver for his non-compliance. She said that his code status was changed to an OHDNR (out-of-hospital-Do-Not-Resuscitate) status. In an interview with CR #2's physician on [DATE] at 11:45 am he said that he believed that the facility did everything they could to address the residents behaviors. During further interview on [DATE] at 12:45 p.m. with the DON when asked if the facility had completed a Report of Incident/Accident form for CR#2 ' s death on [DATE], she said an Incident report would have been done on the computer, she said she did not think they had, but she would check. An Incident Report was not provided by the end of the survey. In an interview with the Administrator and the DON on [DATE] at 1:55 p.m. they said the staff had notified the DON of CR#2 ' s death when it occurred and the DON notified the Administrator. They said the family and the physician were notified. The emergency medical services were called and the body was sent to the funeral home. Resident #3: Record Review of Resident #3 ' s clinical records revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #3 ' s MDS assessment dated [DATE] revealed a BIMS score of 15 that indicated cognition skills were intact. Resident behaviors were marked 0 not exhibited. ADL needs revealed she required extensive assistance with two + persons physical assistance with weight bearing support transfer moves to and from bed, chair, wheelchair, and standing position. Resident did not walk. Resident scored 3 with dressing herself putting on and taking off clothing requiring extensive assistance and support. Resident #3 scored 1 in eating requiring supervision such as encouraging or cueing. Resident #3 required total dependence and 2 person assist. Personal hygiene required extensive assistance. Record Review of Resident #3 ' s clinical file revealed that the only care plans were initial Care Plans dated [DATE], there were no care plans to address ADL needs. Care plan for falls due to unsteady gait, history of falls. Record Review of Incident Report done by DON on Resident #3 dated [DATE] revealed resident complained of both legs swollen and painful. Resident stated that legs were twisted during therapy on [DATE], stat X-Ray requested to bilateral lower extremities. Record Review of Resident # 3 Physical Therapist progress notes dated [DATE] continue to have difficulty with knee extension and has used standing frame for a few minutes at a time. Remaining functional deficits/underlying impairments of bed mobility, transfers, strengthening and safety awareness. Record Review Rehab Addendum note date [DATE] done by OTA-B revealed on [DATE] Resident #3 agreed with OTA-B and PTA-C to stand in standing frame at bedside. Resident #3 tolerated standing in frame approx. ,[DATE] minutes with complaints of knee pain, upon lowering, resident externally rotated feet and began to slouch in sling. [DATE] and [DATE] resident agreed to sit on edge of bed however unwilling to participate in therapy. Interview with Resident #3 on [DATE] at 1:25 p.m. regarding injury to lower left extremity, she said she could not remember the exact date but it happened one day last week when OTA-B came to her room alone with the standing frame lift. She said that the OT tried to put her in it by sitting her and moving her to the edge of bed to stand her up in the standing frame. She said: My knees were jammed and I could not move them. I told her my knees are hurting and I could not move them and I started crying and hollering. She said that OTA-B said I am trying to get you out. Resident #3 said my knees became more and more tight and my whole left leg down to the ankle area was in so much pain. She said that OTA-B was standing behind her trying to hook something on the machine stating, I am trying I am trying, next thing I know I am on the floor. Resident #3 said that she thought OTA-B called for help because two people put her in the wheelchair and from the wheel chair back in her bed. Resident #3 stated she asked for something for pain from the nurse and told her what had happen, but also asked to speak to the supervisor. She could not remember the supervisor ' s name. Record Review of a statement dated [DATE] given by the DON revealed in part that on [DATE] that: . CNA came to my office saying Resident #3 wanted to speak to me around 5:30 p.m. DON met with resident. Resident reported she did not want to do therapy anymore. Resident reported that OTA-B had made her stand up in the standing frame and her leg got twisted, especially when OTA-B let her down. While visiting with resident DON noted both of resident ' s legs were more swollen than usual, reported pain. DON asked RN to medicate resident with pain meds due to resident complaining of pain level ,[DATE]. DON called MD to request X-Ray . Record Review of statement completed by DON on Resident #3 dated [DATE] X-Ray results revealed fracture of fibula. MD orders to transfer resident to ER for evaluation administrator was notified. Interview with OTA-B on [DATE] at 10.00 a.m. she said that on [DATE] OTA-B and PTA-C were on their way to Resident #3 room when PTA-C was called to go to another residents room. OTA-B stated she went to Resident #3 ' s room to get her out of bed for therapy using the standing frame equipment. OTA-B stated: I began by moving Resident #3 to the edge of bed in a sitting position and placed the slings underneath and on both sides of resident #3 ' s hips and connected the sling to the frame. I used the machine to electronically assist resident into a standing position. Resident #3 was only able to stand for about minute and started to request to stop therapy. I began to let her down using the standing frame. She started to turn her feet out and lost balance and started to slide downward out of the sling strap. I had to ease Resident #3 down to the floor in a sitting position. OTA-B stated that resident #3 was crying but that she always cried when receiving therapy and that she always had swelling in her legs because of arthritis. OTA-B states that CNA-D was standing in the doorway and came to assist with getting resident #3 off the floor into the wheelchair. She said that then PTA-C assisted her in transferring resident back to bed using a sliding board. OTA-B stated she did report to the nurse that Resident #3 needed something for pain, but did not report the incident to the nurse because she did not consider it a fall. In further interview at the time OTA-B stated she did report the incident to the Rehab Director (supervisor) who in return told her to let the nurse know what took place with resident #3 and the standing frame. OTA-B stated did not report what happened to the nurse until [DATE] when the Administrator and DON asked OTA-B about the incident with Resident #3 and asked her to write a statement regarding the incident. Interview with CNA-D on [DATE] at 10:40 a.m. regarding the incident with Resident #3 on [DATE], CNA-D stated that while she was sitting down at the computer charting on hall 200, she heard loud yelling. She said she approached the resident ' s room and saw resident #3 sitting on floor with her feet turned outwards and OTA-B was standing behind the resident. CNA-D said OTA-B asked for assistance to transfer Resident #3 back into her wheelchair. She then assisted OTA-B with transferring the resident from the floor into the wheelchair by holding the resident lower body and torso and OTA-B holding residents ' upper body torso both lifting and transferring the resident to wheelchair. CNA-D said she then left the resident room because PTA-C had arrived to help. CNA-D states could not remember if she reported the incident to nurse or not. Record Review of Rehab Addendum Note written by the Rehab Director and dated [DATE] revealed that on [DATE] both OTA-B and PTA-C reported that Resident #3 slouched in the standing frame on [DATE] because she wanted down. Resident was lowered and then taken out of standing frame. OTA-B and PTA-C used sliding board to transfer resident from wheelchair to bed. Director of rehab instructed staff to continue to address pain management including coordinating with nursing for pain medication as well as offering modalities (biofreeze, moist heat packs, and e-stim). Further review of the statement revealed: On Friday [DATE] received a phone call from Administrator that Resident #3 had received X-Ray showing a fracture that resident reports she believes occurred while was in standing frame. Director of Rehab contacted OTA-B and PTA-C to gather their documentation reported on [DATE] and spoke with Administrator and DON regarding resident. On [DATE] Director of Rehab stated began in-servicing OTA-B and PTA-C on reporting any incidents to nursing as well as knowing that any change of condition even if assisting patient to floor that they should always inform nurse. Record Review statement from Administrator dated [DATE] states that .on [DATE] she was contacted by the DON that Resident #3 had sustained a fracture after working with rehab on [DATE]. X-ray results on [DATE] in a.m. showed a fracture. DON stated on [DATE] in the afternoon she was told resident was in pain and did not want to participate in therapy. DON spoke to resident and noted leg swollen and got an order for [REDACTED]. Following morning meeting the DON and Administrator interview OTA-B who states she had been worked with resident on [DATE] on a Tuesday on standing Frame. OTA-B states that resident was experiencing pain and discomfort so she lowered resident to the floor then placed her in the wheelchair and that PTA-C was working with her. The DON asked OTA-B who did she tell? Did she tell the charge nurse? OTA-B said she did not. She told the Director of Rehab. Administrator asked Director of Rehab to inservice her department on reporting incidents or falls to the charge nurse for further assessment, incident report and follow up. Administrator states that per company preference, all fractures are reported to DADS, self report by DON on [DATE]. OTA-B said resident had therapy in room on [DATE] and [DATE]. Resident was sent to ER for evaluation and treatment of [REDACTED]. During an interview on [DATE] at 9:50 a.m. with the Administrator and the DON regarding Resident #3 ' s fall and fracture, they said when they knew about it they intervened. They said they were not informed of the fall until the resident told the DON on [DATE]. At that time the DON notified the charge nurse to assess Resident #3 and to get an x-ray done. Once the facility staff notified her of the x-ray results Resident #3 was transferred to the hospital. She said they interviewed the therapy staff involved regarding the incident and reported it to the state agency. The DON and the Administer were not aware CNA D was involved in the incident and had not reported it to the nursing staff. During an interview on [DATE] at 11:55 a.m. RN A said he worked in the facility on a prn basis. The last day he worked was Thursday, [DATE] from 7:00 a.m. - 11:00 p.m. He said Resident #3 complained of pain to her left knee and ankle and pain to her right knee. She said the pain was ,[DATE] on a scale of 10. He said he medicated her for pain. He did not assess her by ' laying eyes on her legs ' at that time. He said the DON called the facility later in the evening and spoke to RN C. RN C told him to obtain an x-ray of Resident #3 ' s legs. RN A and RN C then went to assess Resident #3 ' s legs. He said he did not observe any signs or symptoms of edema or discoloration at that time. He did not see anything out of normal. The x-rays were taken later in the evening, but the results did not come back while he