Every finding on record at Westward Trails Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 4 of 14 residents reviewed for resident rights. (Resident #19. Resident #37, Resident #73, and Resident #75).1. The facility failed to replace/repair the overbed table with loose trim and chipped edges located in Resident 19's room.2. The facility failed to repair broken and torn drywall at the corner, by the bathroom, of resident living space in Resident #37's room.3. The facility failed to repair broken and missing drywall at the corner at the entrance of resident living space in Resident #73 and Resident #75's room.These failures placed residents at risk of an uncomfortable environment and a diminished quality of life. Findings include:1.Record review of an admission Record dated 8/19/2026, for Resident #19 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a neurodegenerative disease that usually starts slowly and progressively worsens), Diabetes Mellitus (a problem in the way the body regulates and uses sugar as a fuel ), and malnutrition(an imbalance between the nutrients your body needs to function and the nutrients it gets).Record review of a quarterly MDS assessment, dated 7/22/26, indicated Resident #19 had moderately impaired cognition with a BIMS of 10. It indicated Resident #19 required supervision and set-up assistance for all ADLs.During an observation on 8/17/26 at 10:20 AM and 8/18/26 at 9:00 am, a bedside table, located next to Resident #19's bed, had chipped edges and loose trim. The edges of the table were rough to touch.During an interview on 8/18/26 at 9:00 AM with Resident #19, she stated she was not sure how long her table had chipped edges or loose trim. She stated, I haven't had a chance to go to the store and buy a new one. Resident #19 was not aware the facility would replace her bedside table, and stated she had not asked for a new table because she believed she had to purchase a new one.2. Record review of an admission Record dated 8/19/2026 for Resident #37 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease , epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of a quarterly MDS dated [DATE] for Resident #37 indicated he had moderate impaired cognition with a BIMS score of 11. It indicated he requires minimum to moderate assistance with ADL's.During an observation on 8/17/2026 at 9:45 AM, 8/18/2026 at 8:45 am, and 8/19/2026 at 8:30 AM the corner of the wall at entrance of room was noted to have damaged and missing drywall that measured approximately 24 inches in length.An attempt was made to interview Resident #37 on 8/18/2026 and 8/19/2026, but the resident unwilling to speak with surveyor.3. Record review of an admission Record dated 8/19/2026 for Resident #73 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of macular degeneration (a common eye disease that damages the macula, the central part of the retina), depression, and hypertension (high blood pressure).Record review of a quarterly MDS dated [DATE] for Resident #73 indicated he was cognitively intact with a BIMS score of 15. It indicated he was independent with ADL's.4. Review of an admission Record dated 8/19/2026 for Resident #75 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis that included Alzheimer's Disease , bipolar disorder (extreme changes in mood and behavior) and right above the knee amputation (the removal of all or part of a limb or body extremity).Record review of a quarterly MDS dated [DATE] for Resident #75 indicated he had mild cognitive impairment with a BIMS score of 11. It also indicated that he required supervision with his ADL's.During an observation on 8/17/2026 at 10:00 AM, 8/18/2026 at 8:50 AM, and 8/19/2026 at 8:35 AM, the corner of the wall, at the entrance of room, was noted to have damaged and missing drywall that measured approximately 24 inches in length. There was also an area along the wall under Resident #73's television with damaged drywall approximately 2 and a half feet from the floor extending approximately 3-4 feet across the wall. During an interview on 8/19/2026 at 8:15 AM, Resident #73 stated he was not able recall how long the wall in his room had been damaged. He said he reported the damage to the maintenance supervisor on Monday, 8/17/26, and requested it to be repaired. He stated he did not like the look of the damaged drywall and he did not like the drywall dust that was always on the floor. He stated his roommate (Resident #75) often hit the wall with his electric wheelchair and scrapped the wall with the armrest of the electric wheelchair. He said most of the damage is on his side of the room and would like it to look better.During an interview on 8/19/2026 at 8:30 am, Resident #75 stated he was unable to recall how long the wall in his room had been damaged. He stated he bumps into the wall while in his electric wheelchair sometimes and believes it was the cause of the damage to the room. He stated he has not reported the damage to any staff. He stated he believed the maintenance supervisor would repair the wall. During an interview on 8/19/2026 at 9:20 am, the Maintenance Supervisor stated he was responsible for repairs to walls and bedside tables in the facility. He stated he was aware of the repairs needed to the walls in Resident #37, Resident #73 and Resident #75's rooms. He said that he needed to purchase some of the supplies needed for the repair, and because the facility changed ownership at the first of the month, he had[SH2.1] been transitioning his reporting system and other responsibilities to adjust to the new ownership. He stated the staff is responsible for reporting any repairs needed in the resident rooms, and that QR codes are located throughout the facility to utilize the maintenance reporting system. He said the staff scans the QR code and the link will allow any staff member to report repairs needed. He stated the report is sent to him immediately. He stated the damage to resident walls and furniture does not foster a homelike environment. He stated moving forward he would educate staff on reporting any repairs or damage that is observed so he could address the issue.During an interview on 8/19/2026 at 10:00 am, the Administrator stated the Maintenance Supervisor was responsible for repairs to the walls and furniture located in the facility. He stated all staff were responsible for reporting any damage to walls or furniture to the maintenance supervisor by utilizing the QR code (a square two-dimensional barcode that stores website links) system in place. He stated the communication is sent to the maintenance supervisor so that he can assess any damage reported and repair as needed. He stated he expected staff to report any issues that needed to be addressed by maintenance and maintenance was responsible for following up on any reports sent by staff. He said repairs must be maintained to create a homelike environment for the residents. Record review of the facility's document titled Resident Rights, indicated .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 9 residents (Resident's #85, #21, #17, and #30) reviewed for infection control.The facility failed to ensure CNA C wore appropriate PPE for contact precautions while serving meal trays on 8/17/2026 to Resident #85The facility failed to ensure LVN E followed appropriate enhanced barrier precautions while administering a tube feeding to Resident #21 on 8/19/2026.The facility failed to ensure CNA F washed or sanitized her hands or changed gloves while performing incontinent care for Resident #17 on 8/17/2026.The facility failed to ensure the ADON and CNA A washed or sanitized their hands and did not touch clean items with dirty items while performing incontinent care for Resident #30 on 8/17/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: 1.Record review of a facility face sheet dated 8/18/26 for Resident #85 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including Urinary Tract Infection. Record review of a comprehensive MDS assessment dated [DATE] for Resident #85 indicated a BIMS score of 15 indicating she was cognitively intact. She was independent or required supervision/touching assist with most ADLs. Record review of a physician's order summary report dated 8/18/26 for Resident #85 indicated the following physician's order dated 8/18/26: .Currently on transmission-based precautions related to: ESBL in wound .until 08/28/2026 . During an observation on 08/17/2026 at 12:06 pm, a contact precautions sign was observed on the doorway for Resident #85 with a PPE box located outside door for donning (putting on) PPE before entering room. CNA C served a meal tray to Resident #85 without wearing any PPE. She set up the meal tray for Resident #85, adjusted the residents' bed, leaned over the bed with her clothes touching the resident's bedding, exited room, and then sanitized her hands. Record review of a contact precautions sign located on Resident #85's door read: .Doctors and staff must: gown and glove at door . During an interview on 8/18/2026 at 8:37 am, CNA C said she should have put on a gown yesterday (8/16/2026) when she entered Resident #85's room because she adjusted and touched her bedding. She said it was an infection control issue. 2.Record review of a facility face sheet dated 8/19/26 for Resident #21 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including seizures and atrial fibrillation (irregular heartrate). Record review of a quarterly MDS assessment dated [DATE] for Resident #21 indicated a BIMS score of 99, which indicated he was unable to complete interview. Staff assessment for mental status indicated he had severely impaired cognition. He had a feeding tube and received 51% or more of his total calories through tube feeding. Record review of a comprehensive care plan dated 8/5/26 for Resident #21 indicated he was on enhanced barrier precautions due to feeding tube and had an intervention that read: .Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity . During an observation and interview on 8/19/2026 at 10:05 am, an enhanced barrier precautions sign was observed on Resident #21's door. LVN E was observed to enter Resident #21's room, wash hands, put on gloves, and administer a bolus tube feeding to Resident #21. She did not put on a gown for EBP. After verifying placement, she connected syringe to feeding port and administered 30 ml water, then administered 250 ml bolus feeding, then 150 ml water flush. Once completed, she gathered trash and began walking to restroom to wash hands and said, I forgot to put on my gown, I was nervous. After exiting room, she said she was just nervous and she forgot the gown. She said if proper precautions were not followed, staff could potentially spread infections to the resident, or other residents. EBP sign observed on Resident's door. PPE box observed in hallway next to the door. 3.Record review of an electronic face sheet for Resident #17 indicated she was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses that included: Dementia (progressive brain disorder that slowly destroys memory, thinking skills), reduced mobility, and muscle weakness. Record review of Resident #17's Quarterly MDS dated [DATE] indicated Resident #17's BIMS score was a 12 which indicated mild impairment in cognition. Resident #17 was dependent for toileting hygiene. Record review of Resident #17's care plan dated 07/30/2026 indicated Resident #17 had bladder and bowel incontinence and required extensive assistance. During an observation on 08/17/2026 at 9:45 am, Resident #17's incontinent care was provided by CNA F and the MDS Nurse. CNA F provided the majority of the care with the MDS Nurse helping to turn Resident #17. After cleaning Resident #17 from front to back CNA F rolled Resident #17 onto her left side, and CNA F changed gloves, but did not wash or sanitize hands before donning new gloves. CNA F then cleaned bowel movement from Resident #17, changed gloves but did not wash or sanitize hands before donning new gloves. CNA F wiped bowel movement again from Resident #17, and changed gloves but did not wash or sanitize hands before donning new gloves. CNA F then removed the gloves and sanitized hands. During an interview on 08/17/2026 at 10:01 am, CNA F said she had worked at the facility for about a month and had been a CNA for over 6 years at another facility. She said she did not wash or sanitize her hands after each glove change during the incontinent care because the sanitizer was in her pocket. She said she should have sanitized her hands in between each glove change. She said it could cause the residents to get an infection by not sanitizing or washing her hands. 4. Record review of an admission Record for Resident #30 dated 8/18/2026 indicated he was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of major depressive disorder (persistent sadness or loss of interest in doing things), hemiplegia and hemiparesis following cerebral infarction (paralyzed on one side of the body following a stroke), and type 2 diabetes. Record review of an Annual MDS Assessment for Resident #30 dated 7/29/2026 indicated he had moderate impairment in thinking with a BIMS score of 11. He was dependent on staff for toileting hygiene and was always incontinent of urine and bowel. Record review of a care plan for Resident #30 dated 7/18/2024 indicated he had bladder incontinence with interventions for incontinent care at least every 2 hours. During an observation on 8/17/2026 at 3:03 pm, the ADON and CNA A were at the door of Resident #30 gathering supplies to provide incontinent. Both staff donned (put on) gowns in the hallway, and placed supplies in a plastic bag and donned gloves without washing or sanitizing them. Both staff operated a mechanical lift to transfer Resident #30 from his wheelchair to the bed. The ADON pulled down Resident #30's pants and opened his brief and pulled it down between his thighs. CNA A removed wipes from a plastic bag and wiped across Resident #30's lower abdomen and placed the wipe in the trash. CNA A removed another wipe and wiped down both inner thighs and groin area and placed the wipe in the trash. CNA A removed another wipe and cleaned his penis in a circular motion and wiped his scrotum and placed the wipe and gloves in the trash. CNA A donned gloves without washing or sanitizing her hands. The ADON rolled the brief under his buttocks and CNA A removed a wipe and wiped his buttocks and anal area using multiple wipes and placed them in the trash. CNA A removed her gloves and placed them in the trash and applied clean gloves applied to both hands without sanitizing or washing her hands. The ADON applied barrier cream to his buttocks. CNA A placed a clean brief under the resident's buttocks, the resident was rolled onto his left side, and the soiled brief was removed by the ADON and placed in the trash. The ADON removed her gloves and placed them in the trash and applied clean gloves without washing or sanitizing them. Resident #30's brief was secured and his pants were pulled back up. Both ADON and CNA A used a mechanical lift and transferred Resident #30 back to his wheelchair. Both staff removed their gowns and gloves and placed them in the trash and washed their hands in the bathroom and exited the room with the trash. During an interview on 8/17/2026 at 3:26 pm, the ADON said she had been at the facility for 4 years, and helped with training new hire staff. She said she was IP for the facility and was responsible for training staff on infection control. She said during the care provided to Resident #30 she would have sanitized her hands between her glove changes and would have removed the dirty brief before placing the clean brief. She said she did not wash or sanitize her hands before the care was started. She said the staff were in-services on hand washing and proper techniques to not spread germs often. She said she was nervous and forgot to wash or sanitize her hands. She said there was a risk of infections and possible UTI's if staff did not follow infection control protocols. Record review of a Nurse Proficiency Audit for the ADON dated 2/3/26 indicated she was proficient in infection that included hand washing techniques and preventing cross contamination. During an interview on 8/17/2026 at 3:30 pm, CNA A said has been employed at the facility for 6 years and currently worked prn. She said during the care provided to Resident #30, she sould have washed her hands before care started and would have had hand sanitizer in the room. She said she ran out of sanitizer before the care was started on Resident #30. She said she should have sanitized her hands between glove changes, and they should have removed the dirty brief before placing the clean brief. She said her last skills check-off was a while ago. She said there was a risk of infections that could occur to the residents if staff did not wash or sanitize their hands and cross contamination with touching dirty items on clean ones. Record review of a CNA Proficiency Audit for CNA A dated 7/20/2026 indicated she was proficient in hand washing and perineal care of a male resident. During an interview on 8/18/2026 at 9:36 am, the DON said she was responsible for oversight of nursing care. She said staff were trained on infection control quarterly that included hand hygiene. She said hand hygiene should be performed before care, before gloves were applied, after care was completed, and between residents that could include hand washing or use of a sanitizer. She said staff should have as many gloves as possible in the room when care was provided. She said gloves should be changed when changing tasks going from dirty items to clean items. She said residents could be at risk of infections if staff did not follow proper procedures. During an interview on 8/19/26 at 9:45 am, the ADON said she was the Infection Preventionist, and expected staff to perform appropriate hand hygiene when performing incontinent care, when entering rooms, changing gloves, and exiting rooms. She said she expected staff to put on a gown and gloves when entering a room with contact precautions. She said if hand hygiene and contact precautions were not appropriately followed, the staff could spread infections. She said, going forward, they would be performing training and in-services along with completing more frequent checkoffs with return demonstrations. During an interview on 08/19/2026 at 9:50 am, the DON said she expected her staff to follow proper precautions with residents on contact isolation and enhanced barrier precautions. She said they were expected to wash hands appropriately when entering/exiting room and changing gloves. She said she would be doing more training with staff going forward. During an interview on 08/19/2026 at 10:43 am, the Administrator said he expected his staff to follow proper infection control policies and procedures. He said they should be putting a gown and gloves on for contact precautions, and with EBP, to help prevent the spread of infections to residents. He said going forward, they would be educating staff and holding in-services. Record review of a facility policy titled Fundamentals of Infection Control Precautions undated read: .1. Gowns and protective apparel are worn to provide barrier protections and reduce the opportunity for transmission of microorganisms in the LTCF. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. Gowns that are selected for use in the facility will be impermeable to liquids. 2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments; when gowns are worn for this purpose, they are removed before the personnel leave the resident's environment; Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that required hand hygiene: when coming on duty; before and after assisting a Resident with personal care; after handling soiled or used linens; after removing gloves; and after completing duty . Record review of a facility policy titled Enhanced Barrier Precautions dated 4/1/24 read: .EBP are indicated for residents with any of the following: .wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . and .indwelling medical devices examples include central lines, urinary catheters, feeding tubes, and tracheostomies . and also indicated that gown and gloves were required with device care or use .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident., for 1 of 4 medication carts (300 hall Nurse Cart) reviewed for medication storage.The facility failed to ensure a bottle of Lantus insulin was discarded and not used past the expiration date on 8/19/26. This failure could put residents at risk for adverse reactions to medications and decreased quality of life.Findings included:Record review of a facility face sheet dated 8/18/26 for Resident #64 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) and type 2 diabetes (uncontrolled blood sugar). Record review of a quarterly MDS assessment dated [DATE] for Resident #64 indicated a BIMS score of 10, indicating moderately impaired cognition. He received daily insulin injections. Record review of a comprehensive care plan dated 6/16/26 for Resident #64 indicated he had diabetes mellitus (uncontrolled blood sugar) and had an intervention to administer insulin as ordered. Record review of a physician's order summary report dated 8/18/26 for Resident #64 indicated the following order dated 10/31/25: .Lantus SoloStar Subcutaneous Solution .100 UNITS/ML (Insulin Glargine) Inject 10 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . Record review of a medication administration record dated 8/1/26 to 8/31/26 for Resident #64 indicated he received daily Lantus injections during the month of August with last documented injection occurring on 8/17/26, in the evening. During an observation and interview on 08/18/2026 at 1:41 pm of the 300-hall nurse cart, an opened bottle of Lantus 100 Units/ml insulin was dated as opened on 7/15/26. The insulin was for Resident #64, and the prescription label read: .Discard 28 days after initial use . LVN B said all the nurses should check their carts to ensure they were not using medications that were expired. She said if a resident was given old insulin, it might not work. She said Lantus was only good for 28 days after being opened.During an interview on 08/19/2026 at 9:50 am, the DON said she expected that charge nurses check the carts daily and ensure medications were not being used past the expiration date. She said if residents received expired insulin, it may not work as effectively. She said she would be providing more education to the nurses going forward.During an interview on 08/19/2026 at 10:43 am, the Administrator said it was the charge nurse's responsibility to check carts for expired medications. He said residents could be at risk for adverse reactions if they were to receive expired medications. He said going forward, he would educate the nurses to ensure they checked carts appropriately. Record review of a facility policy titled Vials and ampules of injectable medications dated 2025 read: .Vials and ampules of injectable medication are used in accordance with the manufacture recommendations or the Pharmcare USA directions for storage, use, and disposal .

Based on interview and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 (Kitchen 1) of 1 kitchen reviewed for food safety requirements .The facility failed to ensure temperatures of foods were checked as required for food safety on 9/1/25, 9/3/25, 9/4/25, 9/7/25 through 9/10/25, 9/13/25 through 9/24/25, 9/26/25, 9/30/25, 10/3/25 through 10/9/25, and 10/11/25 through 11/4/25.This failure could place residents at risk for food-borne illnesses and decreased quality of life.Findings included:Record review of temperature log forms provided by DM indicated: 9/1/25 - No log was provided. 9/3/25 - No temperatures were documented for Supper. 9/4/25 - No log was provided. 9/7/25 - No log was provided. 9/8/25 - No log was provided. 9/9/25 - No log was provided. 9/10/25 - No temperatures were documented for Supper. 9/13/25 - No temperatures were documented for Supper. 9/14/25 - No temperatures were documented for Lunch or Supper. 9/15/25 - No temperatures were documented for Lunch or Supper. 9/16/25 - No log was provided. 9/17/25 - No log was provided. 9/18/25 - No log was provided. 9/19/25 - No log was provided. 9/20/25 - No temperatures were documented for Supper. 9/21/25 - No temperatures were documented for Breakfast, Lunch, or Supper. 9/22/25 - No log was provided. 9/23/25 - No log was provided. 9/24/25 - No log was provided. 9/25/25 - No log was provided. 9/26/25 - No temperatures were documented for Lunch or Supper. 9/27/25 - No temperatures were documented for Lunch or Supper. 9/28/25 - No log was provided. 9/29/25 - No log was provided. 9/30/25 - No log was provided. 10/3/25 - No temperatures were documented for Lunch or Supper. 10/4/25 - No temperatures were documented for Breakfast, Lunch, or Supper. 10/5/25 - No temperatures were documented for Lunch or Supper. 10/6/25 - No temperatures were documented for Lunch or Supper. 10/7/25 - No log was provided. 10/8/25 - No temperatures were documented for Lunch or Supper. 10/9/25 - No temperatures were documented for Supper. 10/11/25 - No temperatures were documented for Lunch or Supper. 10/12/25 - No temperatures were documented for Supper. 10/13/25 - No temperatures were documented for Lunch or Supper. 10/14/25 through 11/4/25 - No log was provided.Temperature logs did not have any staff names or signatures to indicate who checked the temperatures or who was responsible for checking them.During an interview on 11/4/25 at 12:35 p.m., DM said the cooks were responsible for checking food temperatures before serving. He said he did not know why they had not been doing it, as he provided thermometers for each food there for their use. He said ensuring the cooks checked temperatures appropriately was his responsibility. He said he provided all the temperature logs that he could find. He said the logs that did not have temperatures recorded on them meant the cook did not document any temperatures for that meal. He said the missing days (the days logs were not provided) also indicated there was no documentation for temperatures for that day.During an interview on 11/4/25 at 2:10 p.m., the Administrator said if food was not cooked to required temperatures and served at appropriate temperatures, residents could be at risk for food borne illnesses. He said, going forward, he would ensure they were kept up to date. He said DM and himself would be responsible for ensuring temperatures were checked appropriately.During an interview on 11/4/25 at 2:23 p.m., DM said if food was not cooked to appropriate temperatures, they could make residents sick, or they may have to go to the hospital. He said he would be in-servicing the staff and would have them show the temperature logs before leaving for the day. He said he expected his cooks to check the foods to ensure they were cooked to the appropriate temperatures before serving. He said they had been short staffed recently, but that was no excuse for not checking the temperatures of the foods. He said all residents in the facility, except for two residents who were tube fed, ate from the facility kitchen.Record review of a facility policy titled Daily Food Temperature Control, dated 2012, read, .We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges. and .Temperatures are recorded on the Temperature Log or Production sheet form.

Based on observations, interviews, and records review, the facility failed to ensure the resident environment was free of hazards for 1 of 4 residents reviewed for accidents. (Resident #81). The facility failed to ensure the safety and well-being of Resident #81 by not following procedures for exiting residents from the van using the wheelchair lift. The noncompliance was identified as PNC (past noncompliance). The IJ began on 05/28/2025 and ended on 05/28/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for potential accidents, injuries, harm, or death. Findings included: Record review of a face sheet on 06/23/2025 indicated Resident #81 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included end stage renal disease (final stage of chronic kidney disease and requires kidney dialysis or transplant), diabetes mellitus, heart failure, and mild cognitive impairment. Record review of an admission MDS dated [DATE] indicated Resident #81 had clear speech, usually understood others and was usually understood. She had a BIMS score of 14 indicating her cognition was intact. The MDS indicated she received dialysis treatments and was mobile via wheelchair. Record review of physician orders records dated 06/24/2025 indicated Resident #81 had a physician's order for dialysis treatments every Monday, Wednesday, and Friday at 11:30 AM at a local dialysis center. Record review of a facility reported incident dated 05/28/2025 indicated Resident #81 was transported to the dialysis center on 05/28/2028 via the facility's van. Van Driver A lowered the wheelchair lift to the ground, re-entered the van, and proceeded to back the resident in her wheelchair out the back door of the van. The lift's platform was not flush with the van's floor and both Resident #81 and Van Driver A fell to the ground landing on the lift's platform positioned on the ground. Review of Resident #81's Progress Notes in the electronic record dated 05/28/2025 at 12:22 PM indicated the dialysis center notified the facility that resident had a fall out of the back of the van. Informed them our diver had notified us but we thanked them for the call. They reviewed with us what occurred and stated that Resident #81 did decline to go to the ER. Review of Resident #81's Progress Notes in the electronic record dated 05/28/2025 at 01:34 PM indicated the DON went to the dialysis center to check on the resident and noted a scratch to the left second finger and Resident #81 complained of a headache. The progress notes also indicated the dialysis center gave Resident #81 some Tylenol for the headache and offered to send Resident #81 to the ER for further evaluation and she refused. Review of Progress Notes dated 05/28/2025 at 02:09 PM indicated Resident #81, in an interview with the DON, said I really don't remember much. She got in the van, and we started backwards and I heard a click and we fell. She caught me though. I landed on her. I think my head hit her face. The note further indicated the MD, NP, and Resident #81's responsible party were notified of the incident. Further review of Progress Notes dated 05/28/2025 at 02:09 PM indicated the following: Transporter (Van Driver A) had arrived at dialysis center and parked, and got out of driver's side door and went to the back and opened the back doors and had began letting the lift down when she noticed a bag a resident had left and unknowingly let the lift all the way down to the ground. She grabbed the bag and went through the side door of the van, closed it behind her and unlatched the resident and began walking backwards with the resident in the wheelchair to load onto the lift. She did not know the lift was all the way down and both transporter and resident fell out of the transport van. Record review of Progress Notes dated 05/28/2025 at 02:23 PM indicated the DON offered to send Resident #81 to the hospital upon her return to the facility. The documentation indicated Resident #81 had a fall out of the back of the van, hit her head on Van Driver A's face, and scraped her finger and knee and was at risk for brain bleed, worsening health conditions, fractures, hospitalizations, and/or death. Resident declined to go to the hospital but agreed to having x-rays done at the facility. Record review of Van Driver A's written statement dated 05/28/2025 indicated she was letting the wheelchair lift down when she noticed a bag belonging to another resident on the ground. She said in her statement she reached for the bag and unknowingly let the lift all the way down to ground level. Her statement further indicated she walked to the front of the bus, entered the bus, and proceeded to back Resident #81 out of the bus and onto the lift. She said she did not notice the lift was not positioned flush with the van floor and stepped backwards, falling to the ground and landing on the floor of the lift. The statement further indicated Van Driver A caught Resident #81 as she fell backwards in her wheelchair and both the resident and wheelchair landed on top of the van driver. Record review of the maintenance director's inspection of the vehicle and lift dated 05/28/2025 indicated the van and lift were operating correctly. During observation and interview of Resident #81 on 05/23/2025 at 10:10 AM, she said she fell out of the back of the van about a week ago. She said she was sitting in her wheelchair and the driver was pulling her backwards out of the van. She said she heard something click and the next thing she knew, she and her wheelchair were falling backwards out of the van. She said she landed on top of the driver. She pointed to an area on her left second finger and said she got a scratch. There was no remaining evidence of an injury. She said she was not hurt and was not afraid to go to dialysis on the facility's van. She said the person who currently takes her to dialysis made sure the lift was in place before loading or unloading her. During observations and interviews on 06/23/2025 at 1:15 PM, the current van driver (Van Driver B) demonstrated the use of the van's wheelchair lift to load and unload a resident. Van Driver B opened the doors at the back of the bus, unlocked and lowered the lift floor, secured the safety strap at the front of the lift, and manually lowered the lift to the ground by pushing a button on the lift. The maintenance director, who was present during the demonstration, explained and demonstrated that the lift could not be lowered or raised without physically placing a finger on the button. When asked about the clicking sound Resident #81 heard, the maintenance director pointed to a metal pressure-activated sensor mat and demonstrated how when it was stepped on, a clicking sound was made, an alarm sounded, and a red flashing light was activated signaling that the lift was not flush with the van floor. The maintenance director said the lift could not have been lowered to the ground without Van Driver A manually pressing the button that lowered it. The distance from the floor of the van to the ground was 28 inches. The distance from the floor of the van to the floor of the lift at ground level was 26.5 inches. During an interview with the DON on 06/23/2025 at 10:25 AM, she said Van Driver A called the facility from the dialysis center and notified her of the incident involving the wheelchair lift and Resident #81. The DON said she went to the dialysis center and assessed the resident. She said the dialysis center had offered to send Resident #81 to the ER but she refused. The DON said she assessed Resident #81 and found no evidence of a major injury but encouraged Resident #81 to go to the ER but she refused. She said Resident #81 completed her dialysis treatment and returned to the facility where she was assessed again, neuro checks were initiated, and x-rays of Resident #81's skull, left arm, left hand, left hip, and left leg were done. She said the x-rays were negative for any injury. During an interview with the Administrator on 06/23/2025 at 11:05 AM, he said Van Driver A transported Resident #81 to the dialysis center on 05/28/2025 for the Resident's scheduled dialysis treatment at 11:30 AM. He said on 05/28/2025, Van Driver A was re-trained on neglect and the van's wheelchair lift use, screened for drug use, and suspended and sent home pending the facility's investigation of the incident and the results of the drug screen. The Administrator said the maintenance director performed a vehicle and lift inspection on 05/28/2025 and noted no issues. He said beginning 05/28/2025, the facility used city transportation for residents until they were able to train a new van driver. He said the facility immediately began abuse and neglect training of its employees after the incident. The Administrator said Van Driver A was terminated for failing to use the van's lift in a safe and accurate manner and for a negative drug screen test. He said the incident was reported to the QAPI team. A review of Resident #81's x-ray reports dated 05/28/2025 indicated she had no injuries of the skull, left arm, left hand, left hip, and left leg. A review of neuro checks completed on 05/28/2025 for Resident #81 indicated no abnormal findings. A review of Van Driver A's personnel record indicated the following: *Van Driver A applied for employment on 01/19/2024 and began work on 01/22/2024. *The latest annual nurse aide registry check, misconduct registry check, and criminal history check were completed on 02/08/2025 with no negative findings noted. *Training on abuse and neglect were completed on hire and multiple times throughout the year. *Van Driver A was trained and checked by return demonstration on the operation of the van and lift use on 02/06/25, on 03/25/25 and on again on 05/26/25. *Van Driver A was re-trained on the operation of the van and wheelchair lift on 05/28/2025. *Van Driver A was suspended on 05/28/2025 pending the investigation of the incident and results of the drug screen performed on 05/28/2025. *Van Driver A was terminated 06/05/2025 after the facility received the failed drug screen results. Record review of drug screen results for the van driver collected on 05/28/2025 at 01:35 PM indicated Van Driver A tested positive for THC (tetrahydrocannabinol, primary psychoactive compound in marijuana). A review of the facility's Van Incident Monitoring tool indicated Van Driver B received training and was checked off by return demonstration on the use and operation of the facility van and lift on 06/13/2025. Follow-up checks by return demonstration by Van Driver b were noted completed on 06/16/2025, 06/17/2025, 06/18/2025, 06/19/2025, 06/20/2025, and 06/23/2025 with no issues noted. A review of the facility's policy on the use of the facility van and wheelchair lifts undated and titled Employee Auto Training Handbook indicated the following: Serious violations include but are not limited to: Driving under the influence of alcohol or drugs . Lift Operation Procedures and Checklist: Wheelchair lifts make it possible to load wheelchairs of all weights in and efficient and safe manner. However, lifts are potentially hazardous equipment. They must be maintained and operated properly. Considerable caution and awareness is needed when operating a lift. No one but the vehicle operator should operate the vehicle wheelchair lift. Lifts may differ slightly in structure and function, Therefore, each vehicle operator should be familiar with all the lifts likely to be used Unloading: . 3.Staff will operate lift from to up position to assure the lift is in correct position, flush with van floor and ensure front safety barrier is locked before loading the resident onto the lift . A review of the facility's policy undated policy titled Transportation of a Resident indicated the following: 3. Residents must be physically assisted in and out of the vehicle by a trained employee using appropriate transfer techniques. A review of the facility's undated policy titled Employee Drug Free Workplace Policy indicated the following: It is the policy of this facility to maintain a safe, drug-free working environment through the use of education and for cause drug testing. All staff employee by the company is prohibited, during wok time, from using, distributing or being under the influence of prohibited drugs, alcohol,or abusing prescription drugs, whether on the company's premises or elsewhere. The noncompliance was identified as PNC (past noncompliance). The IJ began on 05/28/2025 and ended on 05/28/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for 2 of 5 residents (Residents #1 and #2) reviewed for ADL care. 1. The facility failed when Resident #1 had long fingernails with a visible black/brown substance underneath them on 5/20/25 and had not received regular or as needed nail care. 2. The facility failed when Resident #2 had long fingernails with a visible black/brown substance underneath them and long toenails on 5/20/25 when the Resident #2 did not receive regular or as needed nail care. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, lack of dignity, and health. Findings included: 1.Review of an Admission Record for Resident #1 dated 5/20/2025 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified sequelae of unspecified cerebrovascular disease (long term effects due to illness or injury related to a stroke) and hemiplegia and hemiparesis following cerebral infarction affecting left side (weakness or paralysis on left side of the body). Record review of a quarterly MDS Assessment for Resident #1 dated 5/11/2025 indicated he had moderately impaired thinking with a BIMS score of 12. He required substantial/maximal assistance for personal hygiene, and he was always incontinent of bowel and bladder. Record review of a care plan for Resident #1 revised on 2/2/2024 indicated he had an ADL self-care performance deficit related to a diagnosis of hemiplegia/hemiparesis affecting his left side and limited physical mobility related to contracture (restricted joint mobility) of left upper extremity. Interventions were in place to assist with all ADLs as needed. During an observation and interview on 5/20/2025 at 2:40 p.m., Resident #1 was lying in his bed awake, his left upper extremity appeared to be contracted and the fingernails on his left and right hands were long and contained a black/brown substance underneath them. He said he was unable to trim his own nails due to his limited mobility and required staff assistance. He said staff were supposed check his nails when he had showers, but they had not been checking. He said his nails were too long for his preference and he wanted them to be cut and cleaned. 2. Review of an Admission Record dated 5/20/2025 for Resident #2 indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of late onset Alzheimer's Disease (progressive brain disorder that destroys memory and thinking skills), Cerebral Infarction (stroke), and hemiplegia of right dominant side. Record review of a Quarterly MDS Assessment for Resident #2 dated 4/14/2025 indicated he had moderately impaired thinking with a BIMS score of 11. He required supervision or moderate assistance with most ADLs. Record review of a care plan for Resident #2 revised 1/30/25 indicated he had an ADL self-care performance deficit, and interventions were in place including check nail length and trim and clean on bath day and as necessary. During an observation and interview on 5/20/2025 at 2:44 p.m., Resident #2 was lying in his bed awake. His right upper right extremity appeared to be contracted and the fingernails on his left and right hands were long and contained a black/brown substance underneath them; the toenails on his left and right toes were long . He said his fingernails and toenails were too long and he wanted to have them trimmed and cleaned. He said he was unable to trim his own nails due to his limited mobility and required staff assistance. He said he could not remember the last time a staff member checked his nails. During an interview on 5/20/2025 at 2:50 p.m., the ADM said he was not aware of any issues with residents not having their nails trimmed and cleaned regularly. He said CNAs were responsible for checking residents' nails as part of routine hygiene and they should be trimmed and cleaned on shower days or as needed. During an interview on 5/20/2025 at 3:00 p.m., the DON said she was not aware of any current concerns with resident nail care. She said in-serviced staff on 3/25/25 regarding resident hygiene and sent a group text to all nursing staff on 5/11/25 reminding them to ensure resident nails were being checked and nail care provided as needed. She said the facility had experienced recent staff turn-over and hired two new CNAs. She said she would ensure new employees received additional training regarding resident hygiene and nail care. During an interview on 5/20/2025 at 3:10 p.m., the ADON said the facility policy reflected nail care would be provided regularly for every resident. She said CNAs were expected to check residents' nails daily and resident nails were to be trimmed and cleaned on shower days or as needed. During an interview on 5/20/2025 at 3:20 p.m., LVN A said CNAs were expected to inspect all residents' nails as part of routine hygiene assistance and when showering residents. She said CNAs were expected to trim and clean resident's nails on shower days or as needed; she said for residents with a diagnosis of diabetes CNAs were expected to report the need for nail care to the charge nurse. During an interview on 5/20/2025 at 3:50 p.m., LVN B said she was not aware of a specific facility policy addressing nail care, but CNAs should be checking residents' nails regularly and trimming and cleaning them on shower days or as needed. During interviews on 5/20/2025 between 6:10 p.m. - 6:20 p.m. CNA C, CNA D, and CNA E all said they inspect, trim, and clean resident nails when assisting them with showers, but not as a daily routine. All CNAs said they were responsible for trimming and cleaning resident nails. All CNAs said if a resident had a diagnosis of diabetes, they were responsible for reporting the concern to the charge nurse. Review of in-service records revealed an in-service dated 3/25/25 which included topics of timely resident assistance, ensuring resident cleanliness, and resident hygiene and showering. The in-service was attended by all direct care staff. Review of facility policy titled Nail Care dated 2003 indicated .Nail care will be performed regularly and safely.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 2 of 6 resident (Resident #1 and Resident #2) reviewed for accidents and hazards. 1.The facility failed to ensure Resident #1 did not wander outside of the facility and down the road while wearing a wander guard. On 1/04/2025 Resident #1 while wearing a wander guard left the facility through the front door and was seen walking down the road by another resident's family member who notified the facility of Resident #1's whereabouts. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 01/04/2025 and ended on 01/08/2025. The facility corrected the non-compliance before surveyor's entrance. 2.The facility failed to ensure Resident #2 was properly strapped down in the van to prevent Resident #2's wheelchair from flipping over backwards during transport. On 2/21/2025 during transport to dialysis by the contract transport service Resident #2's wheelchair flipped over backwards in the van causing Resident #2 to have head and neck pain. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/21/2025 and ended on 02/25/2025. The facility corrected the non-compliance before surveyor's entrance. This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols. Findings included: Record review Resident #1's Face sheet dated 3/25/2025 indicated Resident #1 was admitted to the facility on [DATE] with the most recent admission on 12/04/2023. Resident #1 was a [AGE] year-old female admitted with diagnosis of severe dementia with anxiety (agitation, restlessness, and difficulty concentrating stemming from confusion and disorientation), hypertension (high blood pressure), and muscle weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. The MDS Assessment indicated Resident #1 required supervision or touching assistance with walking 150 feet. Record review of Resident#1's care plan dated 11/04/2021 indicated: Resident #1 was at risk for wandering, Resident #1 had a wander guard in place with interventions that included: .3. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 4. Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. 5. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review of Resident #1's medication administration record dated January 2025 indicated: Monitor for function of wander guard every shift and as needed for preventative and was signed as functioning on 1/3/2025 night shift. Record review of Resident #1's weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin issues. Record review of Resident #1's elopement risk assessment dated [DATE] indicated a score of 9 which indicated low risk for elopement. Record review of incident report dated 01/04/2025 revealed: elopement on 1/04/2025 at 9:10am from the reception/lobby. No injuries were observed at the time of the incident and Resident #1 was not taken to the hospital. Record review of the facility's Provider Investigation report dated 01/09/2025 revealed the following: The resident went out the front door and was observed by another family member about 60 yards away from the facility. They notified the facility, and the resident was returned with no injuries. During an observation on 3/25/2025 at 3:00 PM the Administrator and DON demonstrated Resident #1's wander guard at the front door and the door did not alarm or lock. The Corporate Maintenance Director provided a new wander guard and when approached at the front door the door locked, when the new wander guard approached the front door when the door was open, and alarm sounded. During an interview on 3/25/2025 at 3:00 PM the DON said Resident #1 went out the front door of the facility. She said Resident #1's wander guard did not lock the front door or alarm. The DON said the wander guard had been checked on the night shift prior to the morning of the incident and said it was functioning. She said after the incident and Resident #1 was returned to the facility the malfunctioning wander guard was replaced with a new one and Resident #1 was placed on 1 to 1 supervision. She said Resident #1 was discharged later that day to a facility with a secured unit. During an interview on 3/25/2025 at 3:00 PM the Administrator said the Resident #1's wander guard did not lock the front door or alarm. He said sometime between it being checked on the night shift and the incident the wander guard malfunctioned and did not work. He said another resident's family member took a picture of the resident walking down the road and showed it to the facility and the facility went and retrieved Resident #1 without incident. Resident #1 was returned to the facility and a new wander guard was placed on Resident #1. He said a head-to-toe assessment was completed on Resident #1 with no injuries found. He said later that same day the resident was transferred to another facility with a secured unit. Record review of QAPI notes dated 01/04/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: 1. Self report to HHSC. 2. Interview the resident completed on 1/4/2025. 3. Take statements from everyone involved or with potential knowledge/involvement completed 1/4/2025. 4. Determine if resident will be able to remain in the facility with any new interventions. Resident #1 was transferred to a new facility with a secured unit on 1/4/2025. 5. 1 on 1 monitoring for resident involved until evaluated by the IDT and further instructions are provided. Completed on 1/4/2025. 6. Complete risk management entry for elopement and complete elopement event note and elopement risk assessment for the resident involved. Document conclusion in the risk management entry of PCC (records system). Completed on 1/4/2025. 7. Complete an elopement risk assessment for all other residents. Completed 1/4/2025. 8. Complete the QA tool for elopements. Completed 2/4/2025. 9. Update the care plan for the resident who exited with new interventions. Completed 1/4/2025. 10. Review and update the plan of care as needed of any resident who has been assessed to be a high risk for elopement. Completed 1/4/2025. 11. Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 1/4/2025. 12. If known, in-service staff related to findings and ways to prevent residents exiting. In-services on abuse, neglect, and elopement initiated on 1/4/2025. 13. Notification to families to mindful of residents attempting to exit the facility and not to share the door code with the residents. Completed on 1/10/2025. 14. Place signage at visitor exits to be mindful of residents attempting to exit the facility and not to share a door code with the residents. Completed 1/4/2025. 15. The Medical Director was notified of this plan. Completed 1/4/2025. Record review of Resident #1's electronic medical record indicated Resident #1 discharged from the facility on 1/4/2025. Record review of 1 to 1 monitoring sheets dated 1/4/2025 from 9:30 AM to 3:45 PM. Record review of Missing Resident/Elopement Monitoring tool dated 1/4/2025 through 2/4/2025 indicated: 1. The locking mechanism or alarm functioned properly on all exit doors of the facility. 2. Wander guard bracelets were in place every shift. Record review of Trauma Informed PRN assessment dated [DATE] indicated Resident #1 had no trauma from the incident. Record review of Elopement Risk assessment dated [DATE] indicated a score of 28 which indicated high risk for elopement. Record review of the care plan for Resident #1 indicated revised on 1/4/2025 indicated a new intervention for 1 to 1 monitoring of Resident #1 until alternate placement could be arranged. Record review of in-services dated 1/4/2025-1/5/2025 titled Abuse, Neglect, Elopement, ways to prevent resident exiting, reporting concerns with 135 employee signatures. Record review of elopement drills dated 1/7/2025, 1/9/2025, 1/15/2025, 1/17/2025, 1/21/2025, and 1/23/2025 indicated multiple drills across multiple shifts had been conducted. Observation of signage on the front door of the facility on 3/25/2025 at 3:00 PM notifying families to be mindful of residents attempting to exit the facility and not to share door code with the residents. On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 1/04/2025 and ended on 2/4/2025. The facility had corrected the noncompliance before the investigation began. 2. Record review of the electronic face sheet dated 3/24/2025 for Resident #2 indicated Resident #2 was admitted to the facility on [DATE] with diagnosis that included: end stage renal disease (kidneys do not function properly), hyperkalemia (excessive amount of potassium in the blood), and muscle weakness. Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 had a BIMS score of 11 which indicated mild cognitive impairment. The MDS assessment indicated Resident #2 required supervision or touching assistance for transfers. Record review of Resident #2's care plan dated 9/22/2023 and revised on 2/5/2024 indicated Resident #2 had end stage renal disease and was on dialysis on Mondays, Wednesdays, and Fridays with interventions that included: 1. Encourage resident to do for the scheduled dialysis appointments, resident received dialysis on Mondays, Wednesdays, and Fridays. The resident had an ADL self-care performance deficit with interventions that included: 1. the resident uses a wheelchair. The resident was at risk for falls gait/balance problems with interventions that included: 1. Skin assessment, new pain medication, xrays ordered, neuros started, 3rd party transportation on hold for in-servicing their staff on van safety/buckling and monitoring in place. Record review of nursing progress note dated 2/21/2025 at 6:00 AM written by LVN C indicated Notified by transport driver, while on the way to drop off resident at dialysis, residents wheelchair tilted backwards resulting in resident falling backwards in chair. Driver states resident stated he was ok to continue to dialysis appointment. Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by LVN C indicated Resident returned from dialysis and is complaining of neck pain post fall from this morning. New order received for xray of neck due to neck pain. Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by the DON indicated Resident denied any pain medication at this time and stated he would let us know if he needed anything. Record review of nursing progress note dated 2/21/2025 at 11:40 AM written by the DON indicated Down to check on resident at this time to see how he is doing; resident is stating that his head/neck is bothering him and asked if he could get something for pain at this time. MD was notified and new order for Tylenol 325mg every 4 hours as needed for pain. (medication was administered at this time to resident) Attempted to notify [family] but no answer at this time. Record review of nursing progress note dated 2/21/2025 at 12:03 PM written by the DON indicated Down to follow up with resident and he does state that the Tylenol was effective. Record review of nursing progress note dated 2/21/2025 at 1:46 PM written by the DON indicated Went down to check on resident at this time and he stated that he was feeling ok. Inquired again if resident was wanting to go to ER (resident had been asked when incident initially occurred if he would like to go be he did not feel he needed to go at that time and wanted to proceed going to dialysis) to get checked out and he stated well I feel like I guess I should. Explained that xrays had been taken and results were pending when I last looked however if felt he needed to be checked out we could certainly send him. He thought for a minute and stated he felt like he ought to go ahead and go just to be safe. MD notified of request and new orders given to transport to ER for evaluation and treatment. Record review of nursing progress noted dated 2/21/2025 at 5:42 PM written by ADON B indicated Resident returned via wheelchair with [facility] van transport from [hospital] ER related to fall, resident cleared from ER and sent back to facility with no changes in medications or orders. Record review of facility incident report dated 2/21/2025 at 6:00 AM indicated Resident #2 had a fall with no other information. Record review of hospital paperwork dated 2/21/2025 indicated no acute findings and Resident #2 was discharged back to the facility with no new orders. During an interview on 3/24/2025 at 10:33 AM Resident #2 said on the day he fell in the van the Contract Van Driver did not strap him down in the van. He said the Contract Van Driver was trying to go up the hill in the driveway and his wheelchair flipped backwards. He said the Contract Van Driver stopped and picked him back up in the van. He said he told the Contract Van Driver he was having pain but the Contract Van Driver continued on to dialysis. He said he told them at dialysis he was in pain also. He said when he got back to the facility the nurse checked him over and he complained of head and neck pain. He said the facility sent him out to the ER to get checked out. He said he no longer is having any pain to his head and neck. During an interview on 3/24/2025 at 11:10 AM the Contract Van Driver said on 2/21/2025 at approximately 5:00 AM he got to the facility and put the resident on the van. He said he placed Resident #2 on the ramp and raised the ramp. He said he then pushed Resident #2 forward, he said he usually used 2 front straps, and 2 back straps when securing a resident in the van. He said when he drove off and going up the incline in the facility parking lot Resident #2 flipped back in his wheelchair. He said he stopped the van and got out to check if Resident #2 was ok, and said Resident #2 told him that he was fine and to continue on to dialysis. He said he picked Resident #2 upright in his wheelchair and continued on to dialysis. He said he did not notify anyone of the fall until later on that day. He said he had no idea how the incident happened. During an interview on 3/24/2025 at 11:30 AM the Facility Van Driver said she picked up Resident #2 from dialysis on the day he fell on the Contract Van. She said when she picked him up about 10:30am the Dialysis Tech pushed him out to the van that day and said Resident #2 was complaining of severe head and neck pain because he fell backwards in the Contract Van that morning. She said she brought Resident #2 straight back to the facility and said when she got there the Contract Van Driver was at the facility to report the fall that happened that morning. Said she reported to the nurse that Resident #2 was complaining of head and neck pain. She said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, she said then there is a seatbelt that goes across the resident to hold the resident in the chair. She said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards. During an interview on 3/24/2025 at 12:26 PM the Dialysis Tech said on 2/21/2025 Resident #2 never complained of pain until the end of his treatment and then he told her that he had fallen in the van on his way to dialysis that morning. She said she did not administer anything for pain while he was at dialysis that day. She said the Contract Van Driver did not notify anyone at dialysis that Resident #2 had fallen that morning. During an Observation and interview on 3/24/2025 at 12:43 PM the Contract Van Driver demonstrated how to correctly strap down a wheelchair in the van. At the end of the demonstration the surveyor asked the Contract Van Driver if it was plausible that on the day Resident #2 fell in the van that Resident #2 was not secured properly in the van and the Contract Van Driver said yes. During an interview on 3/25/2025 at 10:25 AM the Corporate Maintenance Director said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, he said then there is a seatbelt that goes across the resident to hold the resident in the wheelchair. He said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards and the wheelchair should not move in the van. During an interview on 3/25/2025 at 10:40 AM the DON said on 2/21/2025 at approximately 10:30 AM the Contract Van Driver came to the facility to report to her that Resident #2 had fallen in the van that morning. She said the Contract Van Driver did not report it to the facility that morning when it happened but waited until later in the day. She said the Contract Van Driver told her he asked Resident #2 if he was ok and Resident #2 said he was, so he continued with transporting Resident #2 to dialysis. She said the Contract Van driver said he had not reported the incident to dialysis. During an interview on 3/25/2025 at 11:04 AM the Administrator said on 2/21/2025 he received a call from the Contract Van Drivers supervisor stating the Contract Van Driver was going to the facility to let them know about and incident that had happened that morning. He said at approximately 10:30 AM he overheard the Contract Van Driver telling the DON that Resident #2 had fallen in the van that morning. He said the Contract Van Driver said he loaded Resident #2 on the van and when leaving the facility parking lot incline Resident #2 flipped backwards in his wheelchair. He said the Contract Van Driver immediately stopped the vehicle and asked Resident #2 if he was ok and Resident #2 said lets just go on to dialysis. He said Resident #2 denied any pain, so he continued transport to dialysis. Record review of Contract Van Drivers successful completion of the Passenger Assistance Safety and Sensitivity 7.0 Two-day Driver Certification Program including sensitivity training, left operating procedures, wheelchair and occupant securement valid January 09, 2025, through January 09, 2027. Observation of training video titled Retractable wheelchair tie-downs to secure wheelchair superior van and mobility. Video was accessed at https://youtu.be/mY_GThwGdbI?si=zQH-3ntbRIcPyck0 which indicated there should be 2 tie down straps in the front of the wheel chair and 2 tie down straps at the back of the wheelchair and the seatbelt that goes across the resident. Surveyor requested the facility policy and procedure regarding wheelchair tie down procedure and none was provided. Record review of QAPI notes dated 02/21/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: 1. Self report to HHSC. Completed 2/21/2025. 2. The Contract van services was removed from service for resident transport on 2/21/2025. 3. The Contract Van Services were to educate drivers before services to be reinstated. Completed on 2/25/2025. 4. The Contract Van Driver was not allowed to transport for the facility pending investigation. Completed 2/21/2025. 5. Take statements from everyone involved or with potential knowledge/involvement. Completed 2/21/2025. 6. Begin abuse/neglect in-service for all staff who transport or assist with transporting residents in the van. Started on 2/21/2025. 7. In-service staff who transport or assist with transporting residents in the van on the following (with return demonstration): How to safely load and unload residents in the van using the lift, properly securing a resident in the van, ambulatory resident -securing with a seatbelt, Non-ambulatory resident-securing the wheel chair and the resident. Started 2/21/2025. 8. Maintain a list of staff who have completed training and provided return demonstration regarding transporting a resident in the van. Staff not listed will not transport residents. Completed on 2/24/2025. 9. Complete risk management entry as other in PCC. Attempt to determine the root cause of the incident. Document conclusion in this risk management entry of PCC. Fall Note completed 2/21/2025. 10. Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 2/21/2025. 11. The medical director was notified of this plan. Completed on 2/21/2025. Record review of in-service titled Van Training/Proper Tie Down Procedures Dated 2/24/2025 provided by the Corporate Maintenance Director and signed by the Facility Van Driver. Record review of Education Sign in Sheet with the topic Wheelchair securement during Transport dated 2/25/2025 signed by the Contract Van Service 6 employees. Record review on plan of correction submitted to the facility by the Contract Van Services indicated: 1. All transporters will receive reinforcement education of reasons for following all safety precautions, with visual confirmation. Education for log implementation will be provided also with the date to be completed of 2/26/2025. 2. Log to be implemented to record daily checks that all belts are to be checked daily prior to vehicle use to confirm safe and correct functioning to be completed daily with implementation by 2/26/2025. Supervisor will check logs of all vehicles used weekly to ensure compliance. If a vehicle is not used on a given day, it should be marked as not used on the log for that day. 3. [Contract Van Driver] will show correct use of all safety belts and sign acknowledgement of importance for checking safe functioning and ensuring correct use every time. He will also acknowledge who and how to reach out for support if he is unsure of a procedure or safe functioning completed 2/26/2025. Supervisor will monitor patients for safe travel and follow up with [Contract Van Driver] weekly for 2 months, then as needed, to ensure compliance and provide support for [Contract Van Driver] to be successful in safely transporting patients. Record review of Follow up Training Completion Sheet 2025 for the Contract Van Driver indicated his supervisor had signed completion for 4 weeks dated 2/21/2025 through 3/21/2025. Record review of Daily Checklist for Securement Device(s) Functionality dated March 2025 for multiple transport vehicles dated 3/3/2025 through 3/23/2025. Record review of facility in-services titled Abuse, Neglect, Resident Rights dated 2/21/2025 with 130 facility employee signatures. Record review of Trauma informed PRN assessment dated [DATE] at 12:40 PM indicated Resident #2 did not experience any trauma from the incident. Record review of employee questionnaires on abuse/neglect completed on 2/21/2025 with no concerns noted. Record review of resident safe surveys on abuse/neglect completed on 2/21/2025 with no concerns noted. Record review of monitoring of the Facility Van Driver completed 2/21/2025 through 2/27/2025 with no concerns noted. On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 2/21/2025 and ended on 2/25/2025. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as based on the comprehensive assessment of the residents; in that: 4 out of 5 residents reviewed incontinence (Resident #5, #6, #7, #8) The facility failed to ensure Residents #5, #6, #7, and #8 were not wearing two briefs after incontinent care was provided. Residents #5, #6, #7, and #8 were observed wearing two briefs at the same time. These deficient practices could place residents at-risk for infections and skin break downs due to improper care practices. The findings included: Record review of a facility face sheet dated 3/26/25 for Resident #6 indicated she was a [AGE] year-old female admitted to the facility 4/6/2022 with diagnoses including Seizures, Morbid Obesity, and Pressure Ulcer. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #6 revealed a BIMS score of 11, indicating moderate cognitive impairment. She required maximal assistance with all ADLs, and she was incontinent to bowel and bladder. Record review of a care plan dated 3/26/25 for Resident #6 indicated potential/actual impairment to skin integrity related to immobility and Obesity. Record review of a comprehensive care plan dated 3/26/25 for Resident #6 indicated impaired cognitive function/dementia or impaired thought processes related to diagnosis of Alzheimer's. Record review of a facility face sheet dated 1/01/2024 for Resident #5 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (stroke), pneumonia, pressure ulcer to the head and urinary tract infection. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #5 revealing a BIMS score of 13, indicating intact cognitive functioning. She required maximal assistance with all ADLs, and incontinent to bowel and bladder. Record review of a comprehensive care plan dated 1/01/2024 for Resident #5 indicated he was dependent on staff for immobility, physical limitations, and social interactions. Record review of a facility face sheet dated 3/26/25 for Resident #8 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type-2 Diabetes mellitus, foot ulcer, hypertension, cerebral infraction (Stroke). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #8 revealed a BIMS score of 10, indicating moderate cognitive impairment. She required maximal assistance with all ADLs and was incontinent to bowel and bladder. Record review of a comprehensive care plan dated 3/26/25 for Resident #8 indicated potential/actual impairment to skin integrity. Record review of a comprehensive care plan dated 3/26/25 for Resident #8 indicated had impaired cognitive function/dementia or impaired thought processes neurological symptoms with cardiovascular accident. Record review of a facility face sheet dated 3/27/25 for Resident #7 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type-2 Diabetes mellitus, foot ulcer, hypertension, cerebral infraction. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #7 revealed a BIMS score of 10, indicating moderate cognitive impairment. He required maximal assistance with all ADLs, and he was incontinent to bowel and bladder. Record review of a comprehensive care plan dated 3/27/25 for Resident #7 indicated the potential for further pressure ulcer development and worsening of current pressure ulcer with cognitive deficits, physical limitations, and fragile skin. Record review of a comprehensive care plan dated 3/27/25 for Resident #7 indicated he had impaired cognitive function/dementia or impaired thought processes dementia. During an interview and observation on 3/25/2025 10:50am with Resident #6 she said she had on two briefs and wears 2 brief every day. She said she did not ask to be doubled briefed but had not complained about it because she felt it helped her not soil her bed. She said she did not get changed every two hours and sometimes it was more than 3 hours Resident #6 was observed with two briefs at that time. During an interview and observation on 3/25/2025 11:10am with Resident #8 he said he wears 2 briefs at one time every day and night. He said he did not ask for the briefs and not remember staff asking him if he wants the briefs or not. Resident #8 was observed with two briefs at that time. During an interview and observation on 3/25/2025 11:30am with Resident #7 he said he wear briefs and do not know how many they put on but thinks they put on two briefs each time they change him. Resident #7 was observed with two briefs at that time. During an interview and observation on 3/25/2025 11:45am with Resident #5 he said he know he wears briefs but do not know how many briefs he has on and never asked anyone. Resident #5 was observed with two briefs at that time. During an interview on 3/25/2025 at 1:11pm CNA K she said she do not know about any resident being double briefed and she as well as other CNA's use single briefs daily on several of the incontinent residents. She said she was not sure of the number of residents that use briefs in the facility. She said that's the way it was done when she started work at the facility, and she just continued with the resident's normal daily care. She said they have frequent in-services on abuse/neglect, incontinent care, residents' rights, and other direct care trainings. During an interview on 3/24/2025 at 3:25pm CNA I she said she uses briefs on some residents but do not use two at one time. She said she have witnessed double briefing a couple of times in the past but not lately and do not know who applied the double briefs. She said she know that double briefing is wrong and not sure of the negative effects but knows to only use one brief at a time. During an interview on 3/24/2025 at 2:14pm with CNA J she said she have witness aides doubled briefing residents. She said she reported to the charge nurses when she found double briefing. She said double briefing or leaving briefs on too long could cause skin break downs and irritation to residents. During an interview on 3/24/2025 at 2:45pm with LVN L she said she have not witnessed any residents wearing double briefs. She said she normally observes her residents very close. She said she knows they wear briefs but do not know if they are care planned to wear briefs. She said wearing briefs increase the chance of residents having skin issues and urinary tract infections. During an interview on 3/25/2025 at 2:20pm with the RN G, she said she's aware of aides double briefing some residents. She said she never reported the inappropriate practice due to it becoming a normal thing in the facility. She said she's aware that she should have reported the neglectful practice. She said double briefing the residents and leaving them up in one position too long may increase the chance of skin break downs and urinary tract infections. During an interview on 3/25/2025 at 3:00pm with the DON she said she was not aware of staff double briefing residents. She said double briefing residents was a big no, no. She said a brief can increase chances of urinary tract infections and ulcers/sores. Double briefing will hold the moister, warmth and bacteria more and cause a greater chance for the resident to have negative effects from using briefs. During an interview on 3/25/2025 at 3:20pm with the administrator he said he did not know the staff were double briefing residents. He said double briefing is not proper practice and could cause negative effects to the residents by irritating their skin and increase chances of infections. Record review on 3/25/2025 of a facility policy titled Abuse/Neglect revised on March 29, 2018, read . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse to any resident in the facility. Record review on 3/25/2025 of a facility policy titled Residents Rights dated 2003 revised on November 28, 2016, read . Planning and implementing care-The resident has the right to be informed of, and participate in, his or her treatment, including: 1. The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. 2. The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: 3.The right to be informed, in advance, by the physician or other practitioner or professional that will furnish care. 4. The right to be informed in advance, by the physician or other practitioner or professional, of the risk and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. 5.The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Based on interview, and record review the facility failed to ensure residents the right to be free from abuse and neglect for 1 of 6 (Resident #4) residents reviewed for abuse and neglect. The facility failed to ensure Resident #4 was free from verbal abuse from Resident #3 on 10/31/2024 during a resident to resident verbal altercation. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings included: 1.Record review of Resident #4's electronic face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with most recent admission on 2/24/2024. Resident #4's diagnoses included: nontraumatic subarachnoid hemorrhage (bleeding in the brain), seizures (disruption of normal brain function), and muscle weakness. Record review of Resident #4's Quarterly MDS, dated [DATE] indicated a BIMS of 03 indicating a severe cognitive impairment. The MDS indicated Resident #4 was dependent for all bed mobility. Record Review of Resident #4's care plan dated 12/7/2021 and revised on 2/5/2024 indicated: Resident #4 had a communication problem related to cerebrovascular accident causing aphasia, dysphagia and cognitive deficit with interventions that included: Use effective strategies: facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1 to 1, quiet setting for communicating with resident. 2.Record review of facility electronic face sheet indicated Resident #3 was a [AGE] year-old female admitted to facility on 5/01/2024 with the most recent admission on 11/05/2024. Resident #3's diagnosis included: dementia (decline in mental ability), anxiety (excessive worry, fear, and nervousness), and bipolar disorder (extreme shifts in mood, energy, and behavior). Record Review of Resident #3's comprehensive care plan dated 1/08/2025 indicated Resident # 3 refused medications at times with intervention of a negotiated risk assessment signed. Resident #3 had impaired cognitive function dementia or impaired thought processes with an intervention to administer medications as ordered. Resident #3 had verbal behaviors threatening to kill roommate and staff with an intervention of assist resident in avoiding resident that may incite outburst. Resident #3 required antipsychotic medications with an intervention to administer medications as ordered, monitor and document for side effects and effectiveness. Record review of Resident #3's Quarterly MDS dated [DATE] indicated Resident #3 had a BIMS of 15 indicating no cognitive impairment. Record review of nursing progress note dated 10/31/2025 at 4:15 AM written by RN D indicated: I heard resident screaming at nurse aide that if she touches her, she will kill her. I entered the room and resident sitting [Resident #4's] bed and cursing. I called the aide to the side, and she stated that she was trying to get [Resident #3] to get off the bed, as she was threatening her too. I witnessed then [Resident #3] threaten to hit the other resident, and to even kill her if she touched her. I asked [Resident #3] what is wrong, did she need me to send her to the hospital. She said no. Interventions: I talked with [Resident #3] and convinced her to get into her own bed. She started to cry, got up and got into her bed and covered her head . During an interview on 3/25/2025 at 1:05 PM LVN E said Resident #3 had a psychotic episode on 10/31/2025 at 4:15 AM. She said RN D went to Resident #3's room and during the psychotic episode found Resident #3 on top of Resident #4 threatening to kill her. She said RN D was able to de-escalate the situation and moved Resident #4 out of the room. During an interview on 3/25/2025 at 3:00 PM the DON said on 10/31/2024 Resident #3 was found sitting on Resident #4's bed threatening to kill her. She said Resident #4 was removed from the room and did not have any effects from the incident due to Resident #4's cognition. During an interview on 3/26/2025 at 10:49 AM RN D said on 10/31/2025 at about 4:15 AM she went down the hall and heard resident screaming so she went in the room and the aide was in the room and Resident #3 was sitting on Resident #4's bed shaking her fist threatening to kill Resident #4. She said she removed Resident #4 from the room and took her to the dining room. She said she tried to call the DON with no answer, so she notified the on-call nurse of the situation. During an interview on 3/26/2025 at 11:21 AM RN G said she was on call the night of 10/31/2024 and received a call from RN D regarding Resident #3 having a psychotic episode. She said she told RN D to make sure that Resident #4 was out of the room and safe. During an interview on 3/26/2025 at 1:19 PM CNA H said on the night of 10/31/2025 she remembered Resident #3 was not herself that night. She said Resident #3 was getting up and going over to Resident #4's side of the room. She said Resident #4 was bedbound and Resident #3 was sitting on the edge of Resident #4's bed threatening to kill her. She said she told Resident #3 she couldn't be on Resident #4's bed and that's when she became combative to the CNA. She said RN D entered the room and was finally able to calm Resident #3 down enough to get her off Resident #4's bed and back in her own bed. She said Resident #4 was then removed from the room. During an interview on 3/26/2025 at 2:45 PM the DON said the reason it was not reported was because Resident #3 had a psychotic issue but never did anything to Resident #4. She said that Resident #4 did not appear to be upset and she did not feel as though the incident was reportable. She said they did not feel as though it was abuse because it did not harm Resident #4 physically or emotionally. She said she knew they talked about the situation in the morning meeting the next day. So, it was at least by the morning meeting that the Administrator was notified. She said the expectation was that all allegations of alleged abuse be reported to the abuse coordinator immediately. During an interview on 3/26/2025 at 2:55 PM the Administrator said they did not report that incident because Resident #4 did not even know what was going on. He said when they separated Resident #3 and Resident #4 there was no injury to Resident #4. He said his expectation was they will follow their policy and guidelines for reporting alleged abuse. Record review of facility policy titled Abuse/Neglect dated 3/29/18 indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . 3. Verbal Abuse: Any use of oral , written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc. Abuse as defined in 40 TAC 19.101(1) . E. Reporting .3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 .

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included 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 2 of 6 residents (Resident #4 and Resident # 3) reviewed for abuse. The facility failed to keep Resident #4 safe from verbal abuse from Resident #3. On 10/31/2025 at 4:15 AM Resident #4's roommate was found on Resident #3 's bed threatening to kill her. This failure could place residents at risk of further potential abuse. Findings included: 1.Record review of Resident #4's electronic face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with most recent admission on 2/24/2024. Resident #4's diagnoses included: nontraumatic subarachnoid hemorrhage (bleeding in the brain), seizures (disruption of normal brain function), and muscle weakness. Record review of Resident #4's Quarterly MDS, dated [DATE] indicated a BIMS of 03 indicating a severe cognitive impairment. The MDS indicated Resident #4 was dependent for all bed mobility. Record Review of Resident #4's care plan dated 12/7/2021 and revised on 2/5/2024 indicated: Resident #4 had a communication problem related to cerebrovascular accident causing aphasia(affects the ability to communicate), dysphagia (difficulty swallowing) and cognitive deficit with interventions that included: Use effective strategies: facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1 to 1, quiet setting for communicating with resident. 2.Record review of facility electronic face sheet indicated Resident #3 was a [AGE] year-old female admitted to facility on 5/01/2024 with the most recent admission on 11/05/2024. Resident #3's diagnosis included: dementia (decline in mental ability), anxiety (excessive worry, fear, and nervousness), and bipolar disorder (extreme shifts in mood, energy, and behavior). Record Review of Resident #3's comprehensive care plan dated 1/08/2025 indicated Resident # 3 refused medications at times with intervention of a negotiated risk assessment signed. Resident #3 had impaired cognitive function dementia or impaired thought processes with a intervention to administer medications as ordered. Resident #3 had verbal behaviors threatening to kill roommate and staff with an intervention of assist resident in avoiding resident that may incite outburst. Resident #3 required antipsychotic medications with an intervention to administer medications as ordered, monitor and document for side effects and effectiveness. Record review of Resident #3's Quarterly MDS dated [DATE] indicated Resident #3 had a BIMS of 15 indicating no cognitive impairment. Record review of nursing progress note dated 10/31/2025 at 4:15 AM written by RN D indicated: I heard resident screaming at nurse aide that if she touches her she will kill her. I entered the room and resident sitting [Resident #4's] bed and cursing. I called the aide to the side and she stated that she was trying to get [Resident #3] to get off the bed, as she was threatening her too. I witnessed then [Resident #3] threaten to hit the other resident, and to even kill her if she touched her. I asked [Resident #3] what is wrong, did she need me to send her to the hospital. She said no. Interventions: I talked with [Resident #3] and convinced her to get into her own bed. She started to cry, got up and got into her bed and covered her head . During an interview on 3/25/2025 at 11:00 AM Resident #4 was not able to answer questions appropriately due to cognition. During an interview on 3/25/2025 at 1:05 PM LVN E said Resident #3 had a psychotic episode on 10/31/2025 at 4:15 AM. She said RN D went to Resident #3's room and during the psychotic episode found Resident #3 on top of Resident #4 threatening to kill her. She said RN D was able to de-escalate the situation and moved Resident #4 out of the room. During an interview on 3/25/2025 at 3:00 PM the DON said on 10/31/2024 Resident #3 was found sitting on Resident #4's bed threatening to kill her. She said Resident #4 was removed from the room and did not have any effects from the incident due to Resident #4's cognition. Resident #3 was monitored 1 to 1 until she discharged to the hospital. During an interview on 3/26/2025 at 10:49 AM RN D said on 10/31/2025 at about 4:15 AM she went down the hall and heard resident screaming so she went in the room and the aide was in the room and Resident #3 was sitting on Resident #4's bed shaking her fist threatening to kill Resident #4. She said she removed Resident #4 from the room and took her to the dining room. She said she tried to call the DON with no answer, so she notified the on-call nurse of the situation. During an interview on 3/26/2025 at 11:21 AM RN G said she was on call the night of 10/31/2024 and received a call from RN D regarding Resident #3 having a psychotic episode. She said she told RN D to make sure that Resident #4 was out of the room and safe. During an interview on 3/26/2025 at 1:19 PM CNA H said on the night of 10/31/2025 she remembered Resident #3 was not herself that night. She said Resident #3 was getting up and going over to Resident #4's side of the room. She said Resident #4 was bedbound and Resident #3 was sitting on the edge of Resident #4's bed threatening to kill her. She said she told Resident #3 she couldn't be on Resident #4's bed and that's when she became combative to the CNA. She said RN D entered the room and was finally able to calm Resident #3 down enough to get her off Resident #4's bed and back in her own bed. She said Resident #4 was then removed from the room. During an interview on 3/26/2025 at 2:45 PM the DON said the reason it was not reported is because Resident #3 had a psychotic issue but never did anything to Resident #4. She said that Resident #4 did not appear to be upset and she did not feel as though the incident was reportable. She said they did not feel as though it was abuse because it did not harm Resident #4 physically or emotionally. She said she knew they talked about the situation in the morning meeting the next day. So, it was at least by the morning meeting that the Administrator was notified. She said the expectation was that all allegations of alleged abuse be reported to the abuse coordinator immediately. During an interview on 3/26/2025 at 2:55 PM the Administrator said they did not report that incident because Resident #4 did not even know what was going on. He said when they separated Resident #3 and Resident #4 there was no injury to Resident #4. He said his expectation is they will follow their policy and guidelines for reporting alleged abuse. Record review of facility policy titled Abuse/Neglect dated 3/29/18 indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . 3. Verbal Abuse: Any use of oral , written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc. Abuse as defined in 40 TAC 19.101(1) . E. Reporting .3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 .

Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 6 residents (Resident #3) and reviewed for pharmacy services. The facility failed to ensure Resident #3 ingested all medications as prescribed and was not able to stash medications in room. On 10/31/2024 Resident #3 had a psychotic episode, and 40 to 50 pills were found on the floor in Resident #3's room. On 1/29/2024 Resident #3 had a psychotic episode, and 10 to 15 pills were found in Resident #3's room. These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications. Findings included: Record review of facility electronic face sheet indicated Resident #3 was a [AGE] year-old female admitted to facility on 5/01/2024 with the most recent admission on 11/05/2024. Resident #3's diagnosis included: dementia (decline in mental ability), anxiety (excessive worry, fear, and nervousness), and bipolar disorder (extreme shifts in mood, energy, and behavior). Record Review of Resident #3's comprehensive care plan dated 1/08/2025 indicated Resident # 3 refused medications at times with intervention of a negotiated risk assessment signed. Resident #3 had impaired cognitive function dementia or impaired thought processes with an intervention to administer medications as ordered. Resident #3 had verbal behaviors threatening to kill roommate and staff with an intervention of assist resident in avoiding resident that may incite outburst. Resident #3 required antipsychotic medications with an intervention to administer medications as ordered, monitor and document for side effects and effectiveness. Record review of Resident #3's Quarterly MDS dated [DATE] indicated Resident #3 had a BIMS of 15 indicating no cognitive impairment. Record review of physician orders dated as of 1/29/2025 indicated Resident #3 had an order for acetaminiophen-codeine 300-60mg 1 tablet every 6 hours as needed, alprazolam 0.25mg 1 tablet at bedtime, amantadine 100mg 1 tablet twice daily, baclofen 10mg 1 tablet three times daily, ciprofloxacin 500mg 1 tablet twice daily, dicyclomine 20mg 1 tablet every 8 hours as needed, linzess 72mcg 1 tablet once a day, esomeprazole 40mg 1 tablet once a day, omega-3 capsule 1000mg 1 tablet once a day, oxcarbazepine 300mg give 2 tablets twice daily, probiotic capsule 1 capsule daily, rosuvastatin 5mg 1 tablet once daily, Seroquel 300mg 1 tablet twice daily, Seroquel 25mg 1 tablet twice daily, trazodone 50mg 2 tablets at bedtime, and Wellbutrin xl 150mg 1 tablet once daily. Record review of Resident #3's medication administration record dated 10/01/24-10/31/2024 revealed Resident #3 refused to take omega-3 on 10/29/24 and 10/31/24. Record review of Resident #3's medication administration record dated 1/01/25-1/31/2025 revealed Resident #3 refused to take omega-3 on 1/1/24, 1/15/24, 1/16/24, 1/17/24, 1/21/24, and 1/23/24. She refused linzess 72mcg on 1/2/25, 1/10/25, 1/20/25, 1/21/25, 1/23/25, 1/27/25, and 1/28/25. She refused probiotic 1/3/25, 1/11/25, and 1/23/25. She refused Wellbutrin xl 150mg on 1/6/25, 1/9/25, and 1/29/25. She refused amantadine 100mg on 1/1/25, 1/6/25, and 1/7/25. She refused baclofen 10mg on 1/4/25, 1/6/25, 1/13/25, 1/14/25, 1/15/25, 1/17/25, 1/20/25, 1/22/25, 1/23/25, 1/24/25, and 1/26/25. Record review of nursing progress note dated 10/31/2024 at 4:15 AM written by RN D indicated: .I talked with [Resident #3] and convinced her to get into her own bed. She started to cry, got up and got into her bed and covered her head. I saw multiple pills on the floor. I picked them all up. I called [psych doctor] and spoke with NP. She gave orders to go 1 to 1 with [Resident #3] if it were possible. She also stated that resident needs to go to an inpatient psych facility as soon as possible. During an interview on 3/25/2025 at 1:05 PM LVN E said Resident #3 had a psychotic episode on 10/31/2025. She said RN D went to Resident #3's room and during the psychotic episode found approximately 50 pills scattered on the floor. She said RN D picked up the pills and put them in a cup for the DON. She said the next time Resident #3 had a psychotic episode was on 1/29/2025 and said Resident #3's room was searched after she transferred to the inpatient psych hospital and 10 to 15 more pills were found in different places in Resident #3's room. During an interview on 3/25/2025 at 3:00 PM the DON said she could not remember which psychotic episode it was but there were about 12 pills found in Resident #3's room. She said she used the computer pill identifier and said the pills mostly consisted of Resident #3's linzess, probiotic, and omega-3. She said Resident #3 had taken her antipsychotic medications and it was mostly her vitamins that were found not taken. She said she did 1 to 1 education with the weekend medication nurse LVN F that consisted of an in-service about not leaving medications at bedside. The DON said her expectation was for all medications to be administered per facility policy and physicians orders. Record review of in-service dated 11/1/2024 titled Leaving Medications at Bedside signed by LVN F. During an interview on 3/26/2025 at 8:29 AM ADON A said during Resident #3's psychotic episode on 10/31/2025 there were approximately 20 pills found in a basket on Resident #3's bedside table, in Resident #3's purse, and in Resident #3's dresser drawer. She said she recognized some of the pills as a multivitamin and said some of the pills she did not recognize that could have maybe been a stool softener, she said there were not any narcotics and none of the medications were psych medications. She said the episode that happened on 1/29/2025 approximately 5 or 6 pills more pills were found in the basket in Resident #3's beside table. During an interview on 3/26/2025 at 10:49 AM RN D said on 10/31/2025 at about 4:00 AM she entered Resident #3's room due to Resident #3 having a psychotic episode. She said she felt something crunching under her feet and there were pills all over the floor. She said there were approximately 50 pills on the floor. She said she picked up all the pills and gave them to the day shift nurse LVN C the next morning to give to the DON. During an interview on 3/26/2025 at 11:21 AM RN G said she was on call the night of 10/31/2024 and received a call from RN D regarding Resident #3 having a psychotic episode. She said RN D told her she had found a bunch of pills on the floor in Resident #3's room. She said she did not give RN D any instruction on what to do with the pills. She said on 1/29/2025 Resident #3 had a similar psychotic episode and thought there were pills found in Resident #3's room again. During an interview on 3/26/2025 at 1:19 PM CNA H said on the night of 10/31/2025 she remembered Resident #3 having a psychotic episode and remembered seeing approximately 30-50 pills scattered all over the floor and behind her bed. She said RN D picked up all the pills and put them in a cup. She said it looked like Resident #3 had been stashing the pills and had knocked them over scattering them all over the floor. During an interview on 3/26/2025 at 2:55 PM the Administrator said it was his expectation for all medications to be administered per the physicians' orders and facility policy. He said no medications should be left at bedside. During an interview on 3/31/2025 at 11:37 AM LVN F said there was an incident that she did leave medications at bedside for Resident #3. She said Resident #3 requested her to leave her medications on her bedside table. She said one day she forgot to go back and check to make sure Resident #3 took the medications. She said when she left the medications at bedside, she means she went back to computer right outside the door not that she left the hall. She said Resident #3 was never out of her line of vision when taking her medications. She said she did not know where Resident #3 could have gotten the pills that were found. She said Resident #3 never refused medication and always took all her medications after it was explained to her what they were. She said Resident #3 was the only resident she left pills at bedside for. She said she was not aware of the pills that were found after the psychotic incident on 10/31/2024 or 1/29/2025. She said she had been in serviced upon hire regarding medication administration. She said she was aware she was not supposed leave medications at bedside. She said she had been in-serviced 1 on 1 regarding leaving medications at bedside. Record review of facility policy titled Medication Administration Procedures dated 10/25/17 indicated: 5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used. Check marks are not acceptable. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse . 6. If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy .

46436 Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 staff (CNA A and CNA B) and 2 of 4 residents (Resident #13 and Resident #65) reviewed for infection control. CNA A did not change gloves or perform hand hygiene during incontinent care to Resident #13 on 4/22/2024. CNA A and CNA B did not change gloves or perform hand hygiene during incontinent care to Resident #65 on 4/22/2024. These failures could place residents at risk of exposure to communicable diseases and infections. The findings were: 1.Record review of a facility face sheet dated 04/23/2024 indicated Resident #13 was a [AGE] year-old female and admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (inability of the kidneys to filter waste), diabetes (high glucose content in the blood), and morbid obesity. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #13 had a BIMS score of 12 indicating cognition was mildly impaired and was incontinent of urine and bowel requiring total assistance with toileting. Record review of the care plan dated 02/14/2024 indicated Resident #13 had an ADL (activity of daily living) function disorder and to assist with ADLs as needed. During an observation and interview on 04/22/2024 at 9:43 am Resident # 13 was provided incontinent care by CNA H and CNA A. Both CNA's donned (applied) gloves. CNA H positioned Resident # 13 and held her on her right side while CNA A provided incontinent care to Resident # 13's front genitalia using wipes to clean across the peri area. CNA A discarded the wipe with a large amount of feces, changed gloves but did not sanitize. CNA donned gloves, wiped down the right side, discarded the wipe and gloves with a large amount of fecal material. CNA A applied clean gloves but did not sanitize. CNA donned gloves, wiped down the left side, discarded the wipe and gloves with a large amount of fecal material. CNA A applied clean gloves but did not sanitize. CNA A wiped the buttocks of Resident #13 with a wet wipe, discarded the wipe then took her gloved hand and pushed debris off bed linens with same gloves that had removed the BM. CNA A said she should have sanitized after each glove change. She said she failed to use sanitizer because they didn't bring any into the room. CNA A said she had been a CNA for 2.5 years and had received training on incontinent care. 2. Record review of a facility face sheet dated 04/23/2024 indicated Resident # 65 was a [AGE] year-old male that admitted to the facility on [DATE] with the diagnosis of fluid overload. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #65 had a BIMS score of 14 indicating intact cognition, was incontinent of bowel and bladder and was dependent on staff for toileting. Record review of a comprehensive care plan dated 03/28/2024 indicated Resident # 65 had bowel and bladder incontinence and required assistance from staff for personal care. During an observation on 04/22/2024 at 9:13 am Resident # 65 was provided incontinent care by CNA B and CNA A. Both CNA's donned (applied) PPE and entered the room. Resident # 65's brief was opened by CNA B and perineal care was provided to Resident # 65's front genitalia using wipes. CNA A then assisted Resident # 65 to turn onto his left side and provided perineal care to his buttock's region using wipes. CNA A then removed the soiled brief and placed a clean brief under Resident # 65 without changing her gloves or performing hand hygiene. CNA A and CNA B proceeded to provided care wearing soiled gloves by obtaining clean clothing from Resident # 65's dresser, dressed Resident # 65, and then transferred Resident # 65 into his wheelchair. It was not until care was complete that both CNA A and CNA B removed their PPE and performed hand hygiene. During an interview on 04/22/2024 at 9:25 am CNA B said she had been a CNA for 1 year and said during incontinent care she should have changed her gloves from dirty to clean and she had received training on incontinent care. She said by not removing soiled gloves it could cause the spread of infections. During an interview on 04/22/2024 at 9:32 am CNA A said she had been a CNA for 2.5 years and had received training on incontinent care. She said during incontinent care she should have changed her gloves when going from dirty to clean. She said she should have removed her gloves, washed her hands, and put on new gloves before getting Resident # 65 dressed and transferred to prevent spread of infection. During an interview on 04/22/2024 at 12:00 pm the DON said she was very disappointed the CNA's did not follow the proper procedure for hand hygiene and they should have removed their gloves and used hand santizer or soap and water before applying new gloves . She said that not following correct hand hygiene could cause urinary tract infections. She said that she had just completed in-services for hand hygiene and peri care on 03/12/2024. During an interview on 04/23/2024 at 3:20 pm the Administrator stated infection control oversight was the responsibility of the DON. He stated if infection control measures were not followed it could cause infections and expected that infection control measures were followed. During an interview on 04/24/2024 at 8:33 am the ADON said she was responsible for competency checks for the nurses and aides. She said that CNA A and CNA B were both trained on proper incontinent care and hand washing. She said if proper technique was not followed it could cause infections. Record review of CNA proficiency audit dated 6/28/2023 indicated CNA B had been observed in perineal care and was competent in proper incontinent care technique. Record review of competencies for aide's checklist dated 4/05/2024 indicated CNA A had demonstrated competency for perineal care/incontinent care of male resident. Record review of an undated facility policy titled Hand Hygiene indicated, hand hygiene for the following, before and after assisting resident with personal care, after handling soiled material, after removing gloves . Record review of a facility policy titled Perineal Care dated 5/11/2022 indicated, .24) doff gloves and PPE and 25) perform hand hygiene .

Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #32) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #32 had a new level 1 PASSAR completed with a new diagnosis of Post-Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations) and major depressive disorder (persistent feeling of sadness and loss of interest that interferes with daily life). These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life. The findings were: Record review of a face sheet dated 4/23/2024 for Resident #32 indicated she admitted to the facility on [DATE] and was a [AGE] year old female with diagnoses of Huntington's disease (an inherited condition in which the nerve cells in the brain break down over time), post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations), major depressive disorder with psychotic symptoms (persistent feeling of sadness and loss of interest that interferes with daily life), and heart failure. Record review of a Quarterly MDS assessment dated [DATE] for Resident #32 indicated she had moderate impairment in thinking with a BIMS score of 8. She had active diagnoses that included psychiatric/mood disorders of anxiety disorder, depression, and post-traumatic stress disorder (PTSD) during the 7 days look back period. There was no referral made to the local contact agency because the discharge date was more than 3 months away. Record review of a PL1 dated 9/27/2021 for Resident #32 indicated she was positive for mental illness. Record review of a PE dated 9/28/2021 for Resident #32 indicated she did not meet the definition of mental illness. Record review of a care plan dated 7/1/2021 revised on 2/5/2024 for Resident #32 indicated she had depression related to diagnosis of major depressive disorder with interventions to administer medications as ordered, monitor/record/report to MD prn risk for harm to self, pharmacy review monthly or per protocol, and psych services as indicated. PTSD was not care planned for Resident #32. During an interview on 4/23/2024 at 12:20 PM, MDS Coordinator D and MDS Coordinator E both said they were not aware that Resident #32 had new diagnosis of mental illness that included PTSD or major depressive disorder. They both said if a resident was a new admission, then the nursing department, and MDS Coordinators were responsible for entering the diagnosis. They said the ADON's were responsible for adding new diagnosis after admission to the facility. They both said Resident #32 received a new diagnosis of PTSD and major depressive disorder from the psychiatric doctor. MDS Coordinator D said going forward they would submit a new PL1 for Resident #32 today (4/23/2024), would get the form 1012 signed, and contact the local authority. MDS Coordinator D said she started as one of the MDS coordinators for the facility on March 11, 2024. MDS Coordinator E stated she had been employed at the facility since 2021. They stated neither one of them were aware that Resident #32 had new mental illness diagnosis. Both said residents could be at risk of missing services that they needed if they were not aware of a new diagnosis. Record review of a Mental Illness/dementia Resident Review Form 1012 dated 4/23/2024 by MDS Coordinator D for Resident #32 indicated the resident did not have a dementia diagnosis but did include diagnosis of mood disorder dated 2/19/2022 and PTSD dated 2/19/2022. If any of the responses were answered as yes, the nursing facility needed to complete a new PL1 and a full PASSR Evaluation would be conducted after the nursing facility submitted the new positive PL1. The form had not been signed by the physician. During an interview on 4/24/2024 at 9:30 AM, the DON and Administrator said the MDS Coordinators were responsible for PASSR coordination. They both said during the care plan meetings they talked about psychiatric visits and anything that was new or needed to be updated. Both said they were not aware that Resident #32 did not have a new PL1 completed and it should have been completed after the new mental illness diagnosis was added. The DON said she had training on PASSR in the past but was not too familiar with the process. Both said going forward at each care plan meeting they would review new diagnoses. Both said residents could be at risk of not getting all the support and help they needed and it could worsen their mental health. Record review of a facility policy titled PASRR Level 1 Screen Policy and Procedure revised 3/6/2019 indicated, .PASRR is a federally mandated program requiring all states to prescreen all individuals seeking admission to a Medicaid-certified nursing facility. The PASRR program has 3 goals: 1. To identify individuals with MI, ID, or DD/RC (this included adults and children); 3. To ensure individuals receive the required services for their MI, ID, or DD .

Based on interviews and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 6 residents (Resident #32) reviewed for care plans. The facility failed to ensure Resident #32's care plan reflected a diagnosis of PTSD (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). This failure could place residents at risk of not receiving appropriate care to meet their current needs. The findings included: Record review of a face sheet dated 4/23/2024 for Resident #32 indicated she admitted to the facility on [DATE] and was [AGE] year old female with diagnoses of Huntington's disease (an inherited condition in which the nerve cells in the brain break down over time), post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations), major depressive disorder with psychotic symptoms (persistent feeling of sadness and loss of interest that interferes with daily life), and heart failure. Record review of a Quarterly MDS assessment dated [DATE] for Resident #32 indicated she had moderate impairment in thinking with a BIMS score of 8. She had active diagnoses that included psychiatric/mood disorders of anxiety disorder, depression, and post-traumatic stress disorder (PTSD) during the 7 days look back period. There was no referral made to the local contact agency because the discharge date was more than 3 months away. Record review of a care plan dated 7/1/2021 revised on 2/5/2024 for Resident #32 indicated she had depression related to diagnosis of major depressive disorder with interventions to administer medications as ordered, monitor/record/report to MD prn risk for harm to self, pharmacy review monthly or per protocol, and psychiatric services as indicated. PTSD was not care planned for Resident #32. During an interview on 4/24/2024 at 9:25 AM, both MDS Coordinators D and E said they were responsible for revising and updating the care plans. Both said they were not aware of the new diagnosis for Resident #32 that included PTSD. Both said the risk to the residents could include all members of the IDT team would not know what was going on with the resident or if any support was needed for the residents. Both said going forward the ADON would get the orders and would ensure they both were aware and update the care plans as needed. During an interview on 4/24/2024 at 9:30 AM, the DON and Administrator said the MDS Coordinators were responsible for updating and revising the comprehensive care plans. Both said nursing were responsible for the acute care plans. They said during the care plan meetings they talked about psychiatric visits and anything that was new or needed to be updated. Both said they were not aware that Resident #32 did not have an updated care plan to include PTSD. Both said going forward at each care plan meeting they would review new diagnosis for residents. They stated residents could be at risk of not getting all the support and help needed and it could worsen their mental health. Record review of a facility policy titled Comprehensive Care Planning undated indicated, .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives, and timeframes to meet resident needs. In addition to addressing preferences and needed assessed by the MDS, the comprehensive care plan will coordinate with and address any specialized services or specialized serviced the facility will provide or arrange as a result of PASARR recommendations.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #65 and Resident #62) reviewed for transfers and accident hazards. The facility failed to ensure Resident #65 was transferred using a gait belt on 4/22/2024. The facility failed to ensure Resident #62 did not have his smoking materials that included a lighter and cigarettes in his possession on 4/22/2024 and 4/23/2024. These failures could place residents at risk of falls, injuries, and burns. The findings were: 1.Record review of a facility face sheet dated 4/23/2024 indicated Resident # 65 was a [AGE] year-old male that admitted to the facility on [DATE] with a diagnosis of fluid overload. Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 65 had a BIMS of 14 indicating intact cognition and was dependent on 2 persons for transfers. Record review of a comprehensive care plan dated 3/28/2024 indicated Resident # 65 was at risk for falls and required assistance x 2 person with transfers. During an observation on 4/22/2024 at 9:13 am Resident # 65 was transferred from the bed to his electric wheelchair without using a gait belt by CNA A and CNA B. Both CNA's had a gait belt around them but placed their arms under each arm of Resident # 65 and lifted him manually to place him in his wheelchair. During an interview on 4/22/2024 at 9:25 am CNA B said she had been a CNA for 1 year and Resident # 65 was transferred as a 2 person assist and she should have placed a gait belt around him. She said she should not have handled him under the arms to prevent injuries. She said she had been properly trained on gait belt transfers and got nervous. During an interview on 4/22/2024 at 9:32 am CNA A said she had been a CNA for 2.5 years and had received training on transfer safety. She said Resident # 65 was a 2 person assist and required a gait belt for transfers for safety. She said she should have used a gait belt to prevent injury. During an interview on 4/22/2024 at 9:33 am Resident # 65 said the staff were good to him and usually used a gait belt to transfer him but he did not like the gait belt because it was uncomfortable. He said he had not told anyone that he did not want to be transferred with a gait belt but would today. He said he had not been dropped or had any injury from being transferred without a gait belt. During an interview on 4/24/2024 at 8:33 am the ADON said she was responsible for competency checks for the nurses and aides. She said that CNA A and CNA B were both trained on proper transfer technique using a gait belt and Resident #65 required a 2 person assist with a gait belt for all transfers. She said that by not properly transferring a resident it could cause injury. During an interview on 4/24/2024 at 9:53 am the DON said the nursing administration was responsible for oversight of all staff regarding proper transfer technique. She said all staff were trained on hire, annually, with any incident or change in status on transfers. She said that each resident has a care plan regarding their transfer status and the aides were aware of each residents transfer needs. She said that a resident that was not properly transferred could result in injury and expected all staff to transfer residents properly based on their ability. During an interview on 4/24/2024 at 10:04 am the Administrator said that transfer training was the responsibility of the nursing administration. He said he expected all staff to follow the facility's policy for transfer and safety to prevent injuries. Record review of transfer checklist dated 04/08/2024 indicated CNA A was observed and was competent on transfers. Record review of transfer checklist dated 4/09/2024 indicated CNA B had been observed and was competent on transfers. 2. Record review of a face sheet dated 4/22/2024 for Resident #62 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of nicotine dependence, cigarettes, with withdrawal, atherosclerotic heart disease (clogged, blocked arteries), and peripheral vascular disease (decreased blood flow to the legs). Record review of a care plan dated 12/4/2023 for Resident #62 indicated he smoked with interventions for no smoking materials or igniter's to be stored in the resident's room. Record review of a safe smoking assessment dated [DATE] and 4/3/2024 for Resident #62 indicated he was deemed safe to smoke. Record review of a Discharge Return Anticipated MDS assessment dated [DATE] for Resident #62 indicated the brief interview for mental status was not evaluated. During an observation and interview on 4/22/2024 at 8:42 AM, Resident #62 was in his room in bed awake. He said he had been at the facility since December 2023. There were two lighters on his over bed table and a box of cigarettes. He said he was a smoker and he smoked after he ate, and staff were always with him when he went out to smoke. When asked if he could keep his smoking materials he did not answer. During an observation on 4/22/2024 at 12:34 PM, Resident #62 was pushed in his wheelchair from the dining room by staff after eating lunch to the outside area for a smoke break. One staff was present and told Resident #62 that he did not have a lighter. Resident #62 did not say anything and pulled out a cigarette and a lighter from his pocket and lit his cigarette. During an observation on 4/23/2024 at 9:50 AM, Resident #62 was in his room in bed and there was a lighter on his over bed table. During an interview on 4/23/2024 at 3:42 PM, CNA G said she had been employed for 6 years at the facility and was assigned to work the hall where Resident #62 resided. She said Resident #62 was a smoker and had not been at the facility long. She said they do not have anyone that can go out by themselves. She said she had seen him with cigarettes and lighter in his room a couple of times and they were taken from him. Resident #62 was fully aware that he was not supposed to have them. She said if residents kept their cigarettes and lighters, there could be a risk of a fire. During an interview on 4/23/2024 at 3:52 PM, CNA H said she had been employed at the facility for 2 years and worked the hall where Resident #62 resided. She said Resident #62 was a smoker and different staff were assigned to take the residents who smoked outside. She said they have found smoking materials that included cigarettes and a lighter last week with him, and they gave the material to the nurse to be locked up at the nurse desk. She said residents could be a risk of fire if they kept their cigarettes and lighters. During an interview on 4/23/2024 at 3:59 PM, LVN J said she had been employed at the facility for 2 years and worked the hall where Resident #62 resided. She said Resident #62 was deemed a safe smoker and knew how to light his cigarettes, but his smoking materials were kept in the medication room. She said one staff took out the residents who smoked. She said when Resident #62 first admitted to the facility, he was keeping smoking materials in his room, and it was removed. She said she was not aware that he had smoking materials in his room this week during survey. She said safe smoking assessments were completed monthly. She said if residents were allowed to keep their smoking materials on them, there was a risk of setting the facility on fire, injuring themselves, or others. Record review of a list of safe smokers undated indicated that Resident #62 was listed as a safe smoker. During an interview on 4/24/2024 at 9:50 AM, the DON and Administrator both said resident smoking materials were to be stored in the medication room and any staff could take them out to smoke. Both said Resident #62 was deemed a safe smoker and he could smoke unsupervised, but that he was not allowed to have smoking materials in his room. Both said Resident #62 has had smoking items confiscated (taken) in the past and on yesterday 4/23/2024, he had a lighter in his pocket. The DON said they have educated Resident #62 about not being able to keep smoking materials with him all the time. The DON said staff were responsible to ensure smoking materials were put back up after the resident had finished smoking. Both said going forward they would educate staff on the facility smoking policy and said residents were at risk for injuring themselves or others and there was a risk of fire in the facility if residents kept their smoking materials. Record review of a facility policy titled Moving a Resident, Bed to Chair/Chair to Bed dated 2003 indicated, .pull the cubicle curtain for privacy, if moving a resident from bed to chair, position a gait belt around the resident's waist and clasp it, if a resident requires . Record review of a facility policy titled Uniform Smoke Free Policy undated indicated, .Smoking tobacco, matches, lighters, or other smoking paraphernalia are not permitted to be kept or stored in a residents' room. A resident who is assessed safe to smoke unsupervised, will be instructed to obtain their smoking paraphernalia from a designated, secured area. The resident will be instructed to return the smoking paraphernalia following the smoking session .

46436 Based on observations, interviews, and record review, the facility failed to ensure that each resident had a right to privacy during medical care for 1 of 25 residents (Residents #13) observed for privacy. The facility failed to ensure full visual privacy during incontinent care for Resident #13 on 04/22/2024. This deficient practice placed residents at risk of loss of privacy and dignity. The findings were: Record review of a facility face sheet dated 04/23/2024 indicated Resident #13 was a [AGE] year-old female and admitted to the facility on [DATE] with a diagnosis of end stage renal disease (inability of the kidneys to filter waste), diabetes (high glucose content in the blood), and morbid obesity. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #13 had a BIMS score of 12 indicating cognition was mildly impaired and was incontinent of urine and bowel requiring total assistance with toileting. Record review of the care plan dated 02/12/2024 indicated Resident # 13 had an ADL (activity of daily living) function disorder and to assist with ADLs as needed. During an observation of incontinent care on 04/22/2024 at 9:43 am this state surveyor knocked on the door and asked permission to enter. Permission was granted. The privacy curtain was not pulled around Resident #13. Resident #13 was unclothed from the neck down exposing her breasts and her legs spread apart. Resident # 13 was being prepared for incontinent care by CNA A and CNA H. During an observation and interview on 04/22/24 at 10:00 am outside of Resident #13's window, a male worker was cutting grass and picking up the lawn. Midway into the care with resident unclothed CNA A saw the workers and said oh I've done it again. She closed the blind and said oh I should have closed it before I started. CNA H then drew the privacy curtain around Resident #13. During an interview on 04/22/24 at 1:30 pm Resident #13 said she never realized the blinds were up and the curtain was not pulled. She said not providing privacy could embarrass some residents. Resident #13 said she had been through a lot of things, and it really did not affect her. During an interview on 04/22/2024 at 12:00 pm the DON said she was very disappointed that CNA A did not follow the proper procedure for privacy. She said if privacy was not maintained, and a resident was exposed during personal care it could cause embarrassment. During an interview on 04/23/2024 at 3:20 pm the Administrator stated he expected everyone in the facility to be trained, follow resident rights, treat all residents with dignity, and maintain privacy . She stated by not doing so could cause resident embarrassment. During an interview on 04/24/2024 at 8:33 am the ADON said she was responsible for competency checks for the nurses and aides. She said that CNA A had been trained on resident rights to include providing privacy during personal care by closing the window covering, pulling the curtain, and closing the door to the room. She said if privacy was not maintained, and a resident was exposed during personal care it could cause embarrassment . Record review of an undated facility policy titled Resident Rights indicated, The resident has a right to a dignified existence, self-determination . Record review of a facility policy titled Personal Care dated 5/11/2022 indicated, .prepare: 7). provide privacy and modesty by closing the door and/or curtain .

Based on interviews and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 6 residents (Resident #4) reviewed for assessments. The facility failed to reassess Resident #4 following a hospice admission (specific care for the sick or terminally ill) on 12/15/2023. This failure could place residents at risk for not having their individual needs met due to inaccurate assessments. The findings included: Record review of a face sheet for Resident #4 dated 4/23/2024 indicated he admitted to the facility 9/3/2013 and was [AGE] years old with diagnosis of parkinsonism (brain condition that causes slowed movements, stiffness, and tremors), schizoaffective disorder, bipolar type (delusions with mood swings and depression), mild intellectual disabilities (slower in areas of thinking and development of social and daily living skills), and hypertension (high blood pressure). Record review of active physician orders dated 4/23/2024 for Resident #4 indicated an order to admit to hospice services with a start date of 12/15/2023. Record review of a Quarterly MDS Assessment for Resident #4 dated 1/5/2024 indicated he had significant impairment in thinking with a BIMS score of 3. Special Treatments and Procedures did not indicate he was on hospice services in the 14 days look back period. Record review of a care plan dated 10/23/2023 for Resident #4 indicated he had hospice services as evidenced by terminal illness with a diagnosis of senile degeneration of the brain. Interventions included: Assist with ADLS and provide comfort measures as needed. During an interview on 4/23/2024 at 12:20 PM, MDS Coordinator D and MDS Coordinator E both said Resident #4 admitted to hospice services on 10/20/2023 and did not know why his orders showed 12/15/2023. MDS Coordinator E said the previous MDS Coordinator would have been responsible for completing a significant change MDS Assessment for Resident #4 but was no longer employed at the facility. They both said the significant change MDS assessment should have been done on the day of admission to hospice services and should have been completed within 7 days. MDS Coordinator E said during the morning meetings they discussed any residents with significant changes such as declines or improvements, admission to hospice, or residents discharging from hospice, and was not aware that Resident #4 did not have a significant change MDS assessment. MDS Coordinator E said residents could be at risk of the state not being aware of changes and it affected everything. During an interview on 4/24/2024 at 9:50 AM, the DON and Administrator both said the MDS Coordinators were responsible for the resident assessments. The DON said she only signed the MDS assessments and the MDS Coordinators were responsible for accuracy. Both said they discussed significant changes in the morning meetings and there was a discussion about Resident #4 at the time he was admitted to hospice. Both said they were not sure how his significant change MDS assessment was missed. Going forward, the DON said she would question any significant changes and the residents could be a risk of not getting needed services. Record review of a facility policy titled Resident Assessment undated indicated, .1. A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI). 3. RAI assessments must be conducted within 14 days after the date of admission; promptly after a significant change in the resident's physical or mental condition (as soon as the resident stabilizes at a new functional or cognitive level, or within two weeks, whichever is earlier) .

Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 10 residents (Resident #77) reviewed for call lights. The facility failed to ensure Resident #77's emergency call button in the bathroom had a pull cord. This failure could place residents at risk of injury, pain, and hospitalization . The findings included: Record review of a face sheet dated 4/23/2024 for Resident #77 indicated she was a 94-year female admitted [DATE] with diagnosis of CKD Stage 3 (moderate kidney damage), age related osteoporosis (brittle bones), and neuromuscular dysfunction of bladder (lack of bladder control). Record review of a quarterly MDS dated [DATE] for Resident #77 indicated she did not have any impairment in thinking with a BIMS score of 13. She required setup/clean up assistance with toileting. Record review of a care plan dated 2/12/2024 revised on 4/5/2024 for Resident #77 indicated she performed self in and out catheterizations (removing urine from the bladder by placing a tube into the bladder), has signed a NRA (negotiated risk agreement) understanding the risks involved with performing her own in/out catheterizations. Interventions included to educate the resident on risks. During an observation and interview on 4/22/2024 at 8:52 AM the bathroom call button in Resident #77's room did not have a pull string. The call button was attached to the wall in the bathroom by the grab bar. Resident #77 was in the room and said she had been at the facility since January 2024 and used her bathroom all the time. During an interview on 4/23/2024 at 3:42 PM, CNA G said she had been employed at the facility for 6 years and was assigned to the hall where Resident #77 resided. She said Resident #77 admitted to the facility not long ago and was independent. They would assist her to the shower but other things she could do on her own. She said she went to the bathroom on her own and they never had to go into the bathroom with her. During an observation and interview on 4/23/2024 at 11:10 AM in the bathroom of Resident #77, the Maintenance Supervisor said he had been employed at the facility for 2 months. He said he was responsible for checking the calls lights in all the rooms in the facility and checked them weekly on Mondays. He said he checked Resident #77's call lights, where Resident #77 resided on yesterday 4/22/2024 in the room and the bathroom, and they worked properly. When asked about the string for the call light in the bathroom, he said the string needed to be longer. He said he was unaware that the strings for the bathroom call lights needed to be close to the floor in the event a resident had a fall. He said a resident would be on the floor for a while if they had a fall and could not reach the string to call for help. He said he would add a string to the call light in the bathroom. Record review of a Call light log for the month of April by the facility indicated Resident #77's room was checked on 4/22/2024, no issues noted. During an interview on 4/24/2024 at 9:30 AM, the DON and Administrator both said typically the call light strings were handled by maintenance and they should be long enough to reach the floor. They said when maintenance did the weekly checks, they would add to make sure the strings were long enough. They said if the call light strings in the bathrooms were not long enough, residents could fall and not be able to call for help. A copy of their policy on call lights was requested and was told the facility does not have a policy on call lights.

Based on observations, interviews, and record review the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 9 residents (Resident #65) reviewed for oxygen usage. The facility failed to ensure Resident #65 had oxygen humidification when in use on 4/22/2024 and 4/23/2024. This deficient practice could place residents at risk of respiratory infections and irritation to nasal passages. The findings were: Record review of a facility face sheet dated 4/23/2024 indicated Resident # 65 was a [AGE] year-old male that admitted to the facility on [DATE] with a diagnosis of fluid overload. Record review of a comprehensive care plan dated 02/15/2024 indicated Resident # 65 required oxygen therapy, monitor for signs and symptoms of respiratory distress, and had a possibility of respiratory infections, and to administer oxygen as ordered. Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 65 had a BIMS score of 14 indicating intact cognition, had shortness of breath, and required oxygen therapy. Record review of a consolidated physician order summary report dated 4/23/2024 indicated an order from 01/27/2023 for oxygen at 5 liters per nasal cannula every shift. During an observation on 4/22/2024 at 9:12 am Resident # 65 had oxygen in place at 5 liters per nasal cannula and the prefilled humidifier bottle was empty and not dated. During an observation and interview on 4/23/2024 at 8:11 am Resident # 65 was in the bed with oxygen in place at 5 liters per nasal cannula. The prefilled humidifier bottle was empty and not dated. Resident #65 stated the staff changed it a few days ago but could not remember when. He said when there was no water in the bottle his nose would get very dry, and it was uncomfortable. During an interview on 4/23/2024 at 8:17 am LVN C said she had worked at the facility for 3 years. She said Resident #65 was on a high flow of oxygen and should have water humidification. She said the bottle of water was changed frequently because of his high flow liters but was not aware that the humidifier bottle was empty. She said the bottle should be dated as well. She said that the resident could have infections or nasal dryness if the humidifier bottle was not changed appropriately. During an interview on 4/24/2024 at 8:33 am the ADON said she was responsible for competency checks for the nurses and aides. She said that the nurses were to check their oxygen setup with rounds to ensure the oxygen was working properly and to check the humidification system. She stated if the resident was on high flow oxygen, he should have humidified oxygen to prevent nasal dryness and irritation. During an interview on 4/24/2024 at 9:53 am the DON said the nursing administration was responsible for oversight of the nursing staff for oxygen administration. She said the nurses were trained to check resident oxygen setup with rounds and should ensure the humidification system had water if the resident was on a high flow of oxygen. She said if oxygen was not humidified it could cause dryness of the nares and thickened secretions. She said that she expected all nurses to check each residents oxygen and change the humidification system as needed. During an interview on 4/24/2024 at 10:04 am the Administrator said that oxygen training was the responsibility of the nursing administration. He said he expected all staff to follow the facility's policy for oxygen delivery to prevent resident discomfort. Record review of a facility policy titled Oxygen Administration dated February 13, 2007, indicated, .all sources require humidification to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely. 5. Assemble the concentrator: fill the humidifier container, note the water in the humidifier is bubbling .

Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and offered a therapeutic diet when there was a nutritional problem and the healthcare provider orders a therapeutic diet for 1 of 4 residents (#15) reviewed for weight loss and nutrition. The facility failed to provide Resident #15 with therapeutic meals as indicated by the physician orders for double portions on 4/22/2024 and 4/23/2024. These failures could place residents at risk for unplanned weight loss, malnutrition, and failure to thrive. The findings included: Record review of a face sheet for Resident #15 dated 4/23/2024 indicated he admitted to the facility 2/15/2024 and was [AGE] years old with diagnosis of Parkinsonism (caused by a brain condition with slowed movements and stiffness), dementia, dysphagia (difficulty swallowing), protein calorie malnutrition, and GERD. Record review of a Quarterly MDS assessment dated [DATE] for Resident #15 indicated he had significant impairment in thinking with a BIMS score of 3. He was dependent on staff with all ADL's. The swallowing/nutritional status indicated his weight in the last 30 days was 125 lbs. He had weight loss of 5% or more in the last month or loss of 10 % or more in last 6 months and was not on a physician prescribed weight loss regimen. He had mechanically altered diet while a resident during the 7 days look back period. Record review of a care plan dated 7/2/2021 and revised on 10/17/2023 for Resident #15 indicated he was at risk for malnutrition, puree diet. Interventions included double portions initiated on 2/5/2024 and offer diet as ordered by the physician initiated on 7/2/2021. He had a significant unplanned/unexpected weight loss initiated on 03/13/2024 and revised 03/15/2024 that included a goal for his weight to stabilize within 4 weeks. Interventions included double portions at all meals dated 3/25/2024. Record review of a nursing progress note dated 4/5/2024 by ADON F for Resident #15 indicated, .Res referred to dietician related to Weight loss she emailed: -He is on several medications that could be r/t wt loss (Carbidopa-Levodopa and Paxil). His Bun/Creatinine ratio (kidney function) was elevated as well as sodium which could mean some dehydration or possibly CHF (heart failure). He is already on nutritional support double portions with meals, fortified foods and snacks BID and his PO intake averages >75%. There is not much more we can do nutritionally other than start a probiotic. He does have some GI (stomach) issues and vitamin deficiencies so he would benefit from that. It's possible that wt loss is r/t to age PLUS comorbidities. I would continue to offer cuing and meal assistance along with the probiotic and make sure he is getting >1500ml fluid each day. MD gave new orders for Probiotic daily . Record review of active orders dated 4/23/2024 for Resident #15 indicated a diet order for a Regular diet Pureed texture, Regular consistency, No grapefruit or grapefruit juice, Double portions at all meals. Fortified pudding lunch/dinner; Fortified milk Breakfast and dinner; fortified eggs at breakfast with a start date of 4/17/2023 after State Surveyor intervention. Record review of weight logs for Resident #15 revealed: 4/17/2024 13:49 121.0 Lbs wheelchair 4/9/2024 12:56 120.8 Lbs hoyer (mechanical lift) 4/3/2024 15:01 119.3 Lbs hoyer 3/27/2024 10:45 120.8 Lbs hoyer 3/20/2024 11:14 121.5 Lbs hoyer 3/13/2024 11:16 123.2 Lbs hoyer 3/6/2024 16:47 125.2 Lbs hoyer During an observation on 4/22/2024 at 12:45 pm in the room of Resident #15, his lunch tray card read regular, puree (smooth, pudding textured), assist with completion of meals, pudding on tray. Staff was present and assisted him to eat. His tray did not have double portions. Attempted a phone interview with a family member for Resident #15 on 4/22/2024 at 2:24 PM, left a message for a return phone call. During an observation and interview on 4/23/2024 at 12:30 PM, Resident #15 was in the dining room for lunch being assisted by staff. His tray card read regular, puree texture-assist with completion of meal. Diet observed did not have double portions on tray. The DON was in the dining room and questioned about his meal. She said it looked like there was a lot of food on his tray and verified that Resident #15 should have double portions at all meals. During an interview on 4/23/2024 at 3:42 PM, CNA G had been employed at the facility for 6 years and worked the day shift from 6am-6pm. She said she was assigned to work the hall where Resident #15 was every day she worked. She said Resident #15 had to be fed and needed total assistance with care. She said he was on a puree diet with double portions. She said sometimes she fed him at breakfast, and he had double portions and a super pudding on his tray. She said it said double portions on his tray card. She said Resident #15 always ate 100% of meals and never refused but said since his diet was puree, she noticed his weight fluctuated. She said there was always a red glass on his tray for staff to indicate weight loss that would be upside on the tray. During an interview on 4/23/2024 at 4:11 PM, ADON F said she had been employed in her position for a year and was responsible for weights, pharmacy recommendations, dietary recommendations, and psychiatric consents. She said Resident #15 admitted to the facility a year ago and was on several different dietary recommendations such as fortified foods, hard to gain weight, and on weight watchers at this time. She said he triggered for a weight loss 2/7/2024 at 125 lbs. and on 3/13/2024 was 123 lbs. She said on 4/5/2024 the dietician visited the facility and said Resident #15 was on several medications that could be causing his weight loss such as carbidopa/levodopa (used to treat Parkinson's disease) and Paxil (used to treat depression). She said he was on nutritional supplements along with double portions and fortified foods and the dietician suggested adding a probiotic. She said he had been on double portions for a while. She said they had a staff member designated to weigh the residents and she checked the tray cards for the residents in the dining room on Mondays-Fridays. She said if residents did not get their assigned diet orders, they could potentially lose weight During an interview on 4/24/2024 at 7:57 AM, the Cook said she had been employed at the facility for 2 years. She said she worked on yesterday (4/23/2024) but was not assigned to cook. She said today 4/24/2024 was her first time to cook and she would be the cook full time. She said there was another cook on 4/22/2024 and 4/23/2024, but he was not working today and his last day to work at the facility would be this Friday 4/26/2024. She said there were a few residents in the facility that had diet orders for double portions. She said Resident #15 did not have an order for double portions on his tray card ticket before today and was not aware if he had received double portions or not on his meal trays. She said double portions was added to the tray card this morning to indicate he would be receiving double portions. She said double portions meant that each item that was on the tray, they should have two scoops. She said residents could be at risk of losing weight if they had orders for double portions and were not provided the portion sizes and get sicker if they did not receive it. During an interview on 4/24/2024 at 8:05 AM, the DM said he had been employed at the facility for 8 years. He said nursing staff sent him diet orders and then he entered the orders into the dietary system. He said the kitchen staff followed the orders that were printed on the tray card tickets. He said Resident #15 was entered into the dietary system for double portions this morning and prior to today, he was not on double portions according to the tray cards. He said the last diet order for Resident #15 that he received was on 2/5/2024 with a change to full liquid and prior to that diet order on 4/7/2023, there was an order to change to a pureed diet. He said Resident #15 did have an order for double portions in the charting system but was not sure why it only showed a regular diet, pureed, and did not include the special instructions of double portions. He said double portions meant to place two scoops of everything on the tray. He said he was responsible for ensuring diet orders were followed through. He said residents could be at risk for weight loss or going to the hospital for a number of things. He said going forward he would ensure his staff followed what the ticket said and would get with ADON F to ensure orders matched. He said he had been meeting with ADON F weekly before to discuss weight loss and orders. Record review of a nursing-dietary communication form dated 2/5/2024 for Resident #15 indicated a readmission with a diet order of full liquid. Record review of a nursing-dietary communication form dated 4/7/2023 for Resident #15 indicated an order for pureed. During an interview on 4/24/2024 at 9:30 AM, the DON and Administrator both said diet orders were the responsibility of the ADON's for ensuring diet changes were given to the dietary manager. They both said they were not aware until yesterday 4/23/2024 when the State Surveyor brought it to their attention about Resident #15 not having double portions on his lunch tray. Both said they would conduct random audits every 2 weeks to ensure orders were correct. Both said residents could be at risk for weight loss. Record review of a facility policy titled Diet Orders/Diet Manual undated indicated, .To ensure correct understanding and interpretation of therapeutic diets, all diets are ordered as stated in the diet manual. The physician will prescribe diets in accordance with the approved diet manual. A written order must appear on the medical record before the resident may be served. 3. Upon admission, nursing service transcribed the diet order as it is written by the physician on the diet order transmittal form. Forms are sent to dietary service prior to meal service .

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development and worsening of pressure injuries for 1 of 2 residents reviewed for pressure injuries. (Resident # 1) Resident #1 had two skin tears to the right buttock that worsened to an unstageable pressure injury. The facility did not obtain a physician's orders [REDACTED]. This failure could place residents with pressure injuries at risk for the development of new pressure injuries or worsening of existing pressure injuries. Findings included: Resident #1's physician's orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was totally dependent and required on one person to physically assist with bed mobility, and personal hygiene. Resident #1 and was incontinent of bowel and bladder. The assessment indicated Resident #1 was at risk for pressure injuries, but no skin conditions were identified. During an observation and interview on 09/03/20 at 8:59 a.m., Resident #1 was lying in bed on her left side with a wedge in place. The DON unsecured Resident #1's brief and a pungent odor was observed from the unstageable wound to the resident's right buttock. The edges of the wound were irregular there was brownish/black eschar and a small amount of exudate (drainage) to wound. The wound was not covered with a dressing and was a small amount of serosanguinous drainage was on Resident #1's brief. When the pungent odor was first observed the DON said she thought Resident #1 had a bowel movement, but the resident's brief was free of feces and urine. The resident was not observed to be resistant with being turned at the time of the observation. A Braden Scale assessment dated [DATE] indicated Resident #1 was at moderate risk of pressure injury development. A care plan initiated 08/11/20 indicated Resident #1 developed skin tears to the right buttock. The following interventions were checked on the care plan: handle carefully during transfers/repositioning, treatment to skin tears per physician orders, and use draw sheets to reposition when in bed. The care plan did not address pressure injuries. A Wound Evaluation Flow Sheet dated 08/11/20 indicated Resident #1 had a skin tear to the right buttock that measured 1.7 cm (centimeters) x 4.7 cm with irregular margins. The Wound Evaluation Flow Sheet only noted one skin tear. A Weekly Non Pressure Injury QI (Quality Improvement) Log dated 08/13/20 indicated Resident #1 had two skin tears to the right buttock on 08/11/20. One measured 2.6 cm x 4.7 cm and the other measured 1.7 x 2.3 with irregular wound margins. The skin tears were to be cleaned with wound cleanser, patted dry, collagen applied, and covered with a dry dressing daily until healed. During an interview on 09/03/20 at 2:23 p.m., the Treatment Nurse clarified the wound to Resident #1's right buttock started as two skin tears. A physician telephone order written 08/11/20 indicated Resident #1 was to receive collagen for the skin tears to the right buttocks. The order was not signed by the physician. A Weekly Pressure Injury QI Log dated 08/20/20 indicated the skin tears to Resident #1's right buttock decreased in size but worsened to a Stage 2. The Stage 2 measured 0.6 cm x 1.5 cm. The wound edges were irregular with no odor or drainage. The treatment remained unchanged but two supplements (Vitamin C and Zinc) were added as new interventions for Resident #1. The August 2020 Medication Administration Records for Resident #1 did not include Vitamin C or Zinc. During an interview on 09/04/20 at 11:26 a.m., the Treatment Nurse stated, It slipped my mind to get an order for [REDACTED].>A Weekly Pressure Injury QI Log dated 08/27/20 indicated the Stage 2 pressure injury to Resident #1's right buttock worsened to unstageable. The wound measured 5.2 cm x 5.3 cm. The Wound Evaluation Flow Sheet dated 08/27/20 indicated the wound had yellow exudate, irregular margins, and an odor. The description of the wound bed was left blank. The Weekly Pressure Injury QI Logs dated 08/20/20 and 08/27/20 noted Resident #1 was non-compliant with turning and repositioning. Nurses' notes for Resident #1 dated 06/01/20 to 09/02/20 indicated no documentation of noncompliance with repositioning and/or turning. The nurses' notes further indicated there was no documentation addressing the wound or evidence the physician was consulted about the wound between 08/11/20 to 09/03/20. During an interview on 09/03/20 at 10:30 a.m., LVN A denied Resident #1 was noncompliant with turning and repositioning. A care plan updated 08/19/20 did not indicate Resident #1 was noncompliant with repositioning and/or turning and did not address Resident #1's pressure injuries. During an interview on 09/03/20 at 9:16 a.m., the Treatment Nurse said she measured Resident #1's wound on yesterday and it measured 4 cm x 5.5 cm. During an interview on 09/03/20 at 2:23 p.m., the DON said the wound to Resident #1's right buttock started as two skin tears. The next week they merged into one and became a Stage 2. The next week the wound was unstageable. The August 2020 Treatment Administration Record for Resident #1 indicated the skin tears were treated with collagen daily from 08/11/20 until 08/26/20. During an interview on 09/04/20 at 11:26 a.m., the Treatment Nurse said initially the wound was a skin tear. When asked if she had received an order to treat the skin tear with collagen from the physician, she stated, No, I've just seen it work in the past. The Treatment Nurse said she had not notified Resident #1's physician and responsible party the wound had worsened. She stated, the last notification was when it was a skin tear. A Pressure Injuries Policy revised on January 2019 noted, .It is the policy of this facility that a resident who enters the facility without an identified pressure injury will not develop a pressure injury unless the resident's clinical condition demonstrates that it was unavoidable .The physician should be notified, and a treatment order received for each pressure injury . A Pressure Injuries Policy revised on January 2019 noted, .Pressure Injury Staging .Stage 2 Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or ruptured serum-filled blister .Unstageable Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed . The National Pressure Ulcer Advisory Panel guidelines dated 2016 noted, .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed .

Based on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment and notify the resident's representative for 1 of 1 residents reviewed for notification. (Resident #1) The facility did not consult the physician for a treatment when Resident #1 sustained two skin tears; when the skin tears worsened to a Stage 2 pressure injury; and when the Stage 2 declined to an unstageable pressure injury. The facility did not notify the Resident #1's representative when her wound worsened from skin tears to an unstageable pressure injury. This failure could place residents at risk decreased qualinty of care, health decline and having their medical needs met by a physician. Findings included: Resident #1's physician's orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was totally dependent and required on one person to physically assist with bed mobility, and personal hygiene. Resident #1 and was incontinent of bowel and bladder. The assessment indicated Resident #1 was at risk for pressure injuries, but no skin conditions were identified. A Braden Scale assessment dated [DATE] indicated Resident #1 was at moderate risk of pressure injury development. A care plan initiated 08/11/20 indicated Resident #1 developed skin tears to the right buttock. The following interventions were checked on the care plan: handle carefully during transfers/repositioning, treatment to skin tears per physician orders, and use draw sheets to reposition when in bed. The care plan did not address pressure injuries. A Wound Evaluation Flow Sheet dated 08/11/20 indicated Resident #1 had a skin tear to the right buttock that measured 1.7 cm (centimeters) x 4.7 cm with irregular margins. The Wound Evaluation Flow Sheet only noted one skin tear. A Weekly Non Pressure Injury QI (Quality Improvement) Log dated 08/13/20 indicated Resident #1 had two skin tears to the right buttock on 08/11/20. One measured 2.6 cm x 4.7 cm and the other measured 1.7 x 2.3 with irregular wound margins. The skin tears were to be cleaned with wound cleanser, patted dry, collagen applied, and covered with a dry dressing daily until healed. During an interview on 09/03/20 at 2:23 p.m., the Treatment Nurse clarified the wound to Resident #1's right buttock started as two skin tears. A physician telephone order written 08/11/20 indicated Resident #1 was to receive collagen for the skin tears to the right buttocks. The order was not signed by the physician. A Weekly Pressure Injury QI Log dated 08/20/20 indicated the skin tears to Resident #1's right buttock decreased in size but worsened to a Stage 2. The Stage 2 measured 0.6 cm x 1.5 cm. The wound edges were irregular with no odor or drainage. The treatment remained unchanged but two supplements (Vitamin C and Zinc) were added as new interventions for Resident #1. The August 2020 Medication Administration Records for Resident #1 did not include Vitamin C or Zinc. During an interview on 09/04/20 at 11:26 a.m., the Treatment Nurse stated, It slipped my mind to get an order for [REDACTED].>A Weekly Pressure Injury QI Log dated 08/27/20 indicated the Stage 2 pressure injury to Resident #1's right buttock worsened to unstageable. The wound measured 5.2 cm x 5.3 cm. The Wound Evaluation Flow Sheet dated 08/27/20 indicated the wound had yellow exudate, irregular margins, and an odor. The description of the wound bed was left blank. The Weekly Pressure Injury QI Logs dated 08/20/20 and 08/27/20 noted Resident #1 was non-compliant with turning and repositioning. The nursing notes for Resident #1 dated 06/01/20 to 09/02/20 indicated no documentation of being noncompliant with repositioning and/or turning. The nursing notes further indicated there was no documentation addressing the wound or evidence the physician was consulted about the wound between 08/11/20 to 09/03/20. During an interview on 09/03/20 at 10:30 a.m., LVN A denied Resident #1 was noncompliant with turning and repositioning. A care plan updated 08/19/20 did not indicate Resident #1 was noncompliant with repositioning and/or turning nor did it address Resident #1's pressure injuries. During an observation and interview on 09/03/20 at 8:59 a.m., Resident #1 was lying in bed on her left side with a wedge in place. The DON unsecured Resident #1's brief and a pungent odor was noted to an unstageable wound to the resident's right buttock. The edges of the wound were irregular with a small amount of exudate. Brownish/black eschar was noted to wound. The wound did not have dressing on it and there was a small amount of serosanguinous drainage noted on Resident #1's brief. The DON said she thought Resident #1 had a bowel movement, but the resident's brief was free of feces/urine. The resident was not observed to be resistant with being turned at the time of the observation. During an interview on 09/03/20 at 9:16 a.m., the Treatment Nurse said she measured Resident #1's wound on yesterday and it measured 4 cm x 5.5 cm. During an interview on 09/03/20 at 2:23 p.m., the DON said the wound to Resident #1's right buttock started as two skin tears. The next week they merged into one and became a Stage 2. The next week the wound was unstageable. The August 2020 Treatment Administration Record for Resident #1 indicated the skin tears were treated with collagen daily from 08/11/20 until 08/26/20. During an interview on 09/04/20 at 11:26 a.m., the Treatment Nurse said initially the wound was a skin tear. When asked if she had received an order to treat the skin tear with collagen from the physician, she stated, No, I've just seen it work in the past. The Treatment Nurse said she had not notified Resident #1's responsible party the wound had worsened. She stated, the last notification was when it was a skin tear. A Pressure Injuries Policy revised on January 2019 noted, .It is the policy of this facility that a resident who enters the facility without an identified pressure injury will not develop a pressure injury unless the resident's clinical condition demonstrates that it was unavoidable .The physician should be notified, and a treatment order received for each pressure injury . A Pressure Injuries Policy revised on January 2019 noted, .Pressure Injury Staging .Stage 2 Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or ruptured serum-filled blister .Unstageable Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed . The National Pressure Ulcer Advisory Panel guidelines dated 2016 noted, .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed .

Based on interview and record review the facility failed to ensure an effective discharge planning process was implemented to effectively transition to post discharge care to prevent a readmission for 1 of 5 resident reviewed for discharge. (Resident # 1) The facility did not develop and implement an effective discharge plan for Resident #1. The facility did not make referrals to appropriate agencies such as home health services, follow-up appointment with physicians, and local contact agencies, and did not provide special instructions required to care for Resident #1 upon discharge. The resident was discharged from the facility with a pureed diet, pressure ulcers, and an indwelling urinary catheter. The resident did not receive any services to meet his special needs for 15 days which led to the resident being severely neglected and admitted to the hospital. The resident was hospitalized for [REDACTED]. The resident required a ventilator machine to breathe, a [MEDICAL CONDITION], and a feeding tube while hospitalized . After seven days in the hospital the resident was transferred to a long-term acute care facility. An Immediate Jeopardy situation was identified on 10/10/19. The Immediate Jeopardy was removed on 10/11/19. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving care and services to meet his needs upon discharge. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was a [AGE] year old male with [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #1 was severely cognitively impaired. The assessment about discharge planning indicated the resident participated alone without family, guardian or a legal authorized representative. The assessment further indicated Resident #1 expected to remain in the facility and not be discharged , there was no active discharge plan in progress. The assessment indicated he did not want to talk to anyone about the possibility of discharge, returning to the community or receiving services in the community. A care plan, revised 6/25/19, indicated Resident #1 had focus areas that included pressure ulcers related to immobility, incontinence, and nutritional deficits, nutritional status. The care plan interventions indicated treatments to the pressure ulcers were to be provided as ordered by the physician. He required a therapeutic pureed diet and needed to be monitored closely with meals. The care plan further indicated he required assistance with ADLs, he had cognitive loss and it was difficult to understand others. The care plan indicated the resident had a plan for long-term care at the facility with interventions including consider preferences of resident and family, define roles and expectations with resident and support person and encourage verbalizations of fears and concerns of long-term care placement. A MDS assessment dated [DATE] indicated Resident #1 and family participated in the discharge assessment and goal setting. The resident and family expected the resident to be discharged to the community. The assessment indicated the resident wanted to talk with someone about the possibility of discharge from the facility, returning to the community and community services. The MDS assessment indicated a referral was made to a local contact agency. A physician's orders [REDACTED].#1 had the following orders: *A diet order of pureed with regular/thin liquids. * Stage 3 pressure ulcer wound on buttocks - Cleanse with wound cleanser, pack wound with silver alginate dressing and cover with a foam dressing every day. * Stage 4 pressure ulcer wound to right ankle - Cleanse with wound cleanser, apply gauze soaked with hydrogel dressing, cover with a foam dressing and secure with kerlix every day and as needed. * Unstageable right outer lower leg pressure ulcer wound - Cleanse with wound cleanser, apply hydrogel dressing cover with an ABD pad (highly absorbent dressing) every other day and as needed. *Unstageable right elbow pressure ulcer wound Cleanse with wound cleanser, apply hydrogel dressing every other day until healed. *Unstageable left heel pressure ulcer wound- Cleanse with wound cleanser, pat dry and apply skin prep and cover with a foam dressing every day. *Indwelling Foley catheter care twice day. A physician telephone order dated 8/29/19 indicated Resident #1 was to be discharged home. The order did not indicate an order or a referral for home health services or care instructions. The discharge MDS assessment dated [DATE] indicated Resident #1 was not able to answer questions and had severe cognitive impairment. The resident was totally dependent on the assistance of one to two staff for all ADLs. The resident had impaired range of motion in one upper arm, and both legs. Resident #1 had an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated Resident #1 had a swallowing disorder which included loss of liquids/solids from mouth when eating or drinking. The assessment indicated Resident #1 had two Stage 2 pressure ulcers, and two unstageable pressure ulcers. The MDS indicated this was a planned discharge, the resident was being discharged to the community, and his return was not anticipated. A Medications Taken Out of Home Consent Form dated 8/29/19 signed by LVN A for Resident #1 indicated the names of discharge medication and the amount released. The signature field for the responsible party was blank. A nursing progress note dated 8/29/19 at 3:30 p.m., by LVN A indicated Resident #1 was discharged home via medical transport. The note indicated medications were given, and the hospital bed was delivered to the home at 1:30 p.m. The Resident Discharge Summary dated 8/29/19 for Resident #1 indicated Resident #1 was to continue medication as ordered, follow up with primary care physician and home health of choice. There was no specific home health agency or referral to a home health documented. The summary indicated daily wound care for pressure ulcers as ordered, maximum assistance with ADLs and incontinent care. The discharge summary indicated Resident #1 required a pureed diet and had contractures to both arms and legs. The summary did not indicate a referral to a specific home health agency, or specific wound care orders. The summary indicated to refer to the interdisciplinary resident charge note for physician orders [REDACTED]. The Interdisciplinary Resident Discharge Note dated 8/29/19 for Resident #1 indicated the The following information is provided to you to promote the continuity of your health care after discharge. The interdisciplinary resident discharge note contained the following fields all which were blank: *Activity restrictions; *Diet restrictions; *Treatments; *Follow-up appointments; *Phone numbers; *Prescriptions received; *Medication You Will Continue to Take at Home and the Number of Doses You Will Need to Take Today; *Community Referral Agencies; *Phone Numbers; *Supplies / Equipment Sent; and *Signature. An emergency medical services note dated 9/13/19 indicated EMS staff was unable to get a stretcher in the home of Resident #1 to move the resident and had to get help from the fire department to get the resident out of the house. The resident was awake but no verbal response to EMS. Both of his arms were contracted up to his chest. The family said he had not wanted to eat and when he did he would vomit. An emergency department physician note dated 9/13/19 indicated Resident #1 was brought to the emergency department for vomiting with possible aspiration. The physician's assessment indicated chronic sores on the right lower leg, the right outer ankle, left heel and a Stage 4 pressure ulcer with green discharge on his sacrum (a portion of the lower spine that extends into the tailbone). His abdomen (stomach) was distended and bowel sounds were diminished. The noted further indicated his risk factors consisted of diabetes, gout, high blood pressure and stroke. He was diagnosed with [REDACTED]. A hospital history and physical dated 9/13/19 indicated Resident #1 was referred to case management because he appeared severely neglected. A hospital discharge plan update note dated 9/16/19 indicated Resident #1 had an abuse neglect consult because of the skin breakdown that was present on admission to the hospital. The note indicated the resident had been home with family for approximately a week and a half. He had been in a nursing home previously and the family was not satisfied with nursing home care. The family had not received or established home health services for him since he had been at home. A hospital progress note dated 9/17/19 indicated Resident #1 was admitted to the hospital on [DATE] with the following [DIAGNOSES REDACTED]. The note indicated the resident showed obvious signs of neglect and did not need to be at home without significant care provided. A hospital operative note dated 9/17/19 indicated Resident #1 had the following surgeries: -A [MEDICAL CONDITION] (an operation that creates an opening for the colon, or large intestine, through the abdomen) for the Stage 4 pressure ulcer. -A left [MEDICATION NAME] central venous catheter (catheter placed in large vein in the chest) for total [MEDICATION NAME] nutrition (feeding that bypasses the stomach and intestines) and intravenous access. -A feeding tube because of malnutrition The operative note further indicated the resident was intubated and transported to the intensive care unit. A hospital progress note dated 9/18/19 indicated Resident #1 was on a ventilator and an attempt would be made to wean him off the ventilator (a machine that breathes for or helps one to breathe). There were concerns he may have osteo[DIAGNOSES REDACTED] (a serious infection of the bone) in his pelvis due to the deep extensive pressure ulcers over his sacrum and back side. The note indicated he received a [MEDICAL CONDITION] and feeding tube during this hospitalization and was discharged to a long-term acute care center. During an interview on 9/25/19 at 12:15 p.m., the DON said Resident #1's family wanted to take him home, and his discharge was not coordinated by the facility it was coordinated by his insurance company. The facility contacted the insurance company when he was discharged . The DON said she did not have any additional information related to his discharge. The DON said she did not know the name of the home health agency or if a referral had been made. During an interview on 9/25/19 3:45 p.m., the DON said after Resident #1 was transferred to the emergency room from his home on 9/13/19, a hospital staff called the facility and said Resident #1 looked as if he had not received wound care since he was discharged from the nursing facility. The DON said Resident #1's family was not at the facility when he discharged . The discharge instructions were not provided because the insurance company handled the discharge planning. During an interview on 9/26/19 9:55 a.m., the administrator said Resident #1's discharge was voluntary. She said the facility was under the impression his insurance provider would arrange the coordination of external services for the family, including home health services. The administrator said they let the family know because Resident #1 was being discharged the facility ceased to have responsibility for the resident's care once they left the facility. The administrator said she did not have any documentation from the insurance company about his discharge and did not know the name of the home health agency or if a referral for home health was made because the insurance company handled the discharge planning. During an interview on 10/08/19 at 2:55 p.m., Resident #1's niece said she was home when an ambulance service brought him home. She said he did not get home health services while he was at home. The resident's niece said from the time he left the nursing home, they could not get a nurse to see him because there was no prescription for home health. She said she could not get the prescription because the physician would not see him on the stretcher. He could not be transported without the stretcher and the physician's office could not accommodate a stretcher. She said, I don't think she saw him in the nursing home either. She said the resident had a catheter and she did not receive any instructions from the facility on how to take care of anything. She said she went to the store and bought peroxide and antibiotic ointment to use on his wounds (pressure ulcers). She said he was on a service that dropped off meals for him. The meals were regular meals like you or I would eat. She said the facility did not tell her he was supposed to be on a pureed diet. She said he was eating the regular meals, then his stomach got bigger and hard. She said when she gave him liquids, he had a little cough. She said, I am not a nurse and he needed a nurse. A Provider Letter No. 16-14, dated 4/14/16, provided to the investigator as the discharge policy and procedure by the administrator indicated discharge planning must be done by appropriate facility staff, and that the discharge summary must include a post-discharge plan of care, developed with the participation of the resident, a family representative, responsible party and/or legal guardian, which will, after discharge, assist the resident with adjusting to his/her new living environment The administrator was notified on 10/10/19 at 9:16 a.m., an Immediate Jeopardy (IJ) situation was identified due to the above failures and the IJ template was provided. On 10/10/19 at 1:20 p.m., the facility plan of removal was accepted and included: Plan of Removal -All residents who intend to discharge the facility will have a care plan meeting to discuss the post discharge needs of the resident and coordinate for needed services to be provided to the resident upon discharge to ensure continuity of care for the resident. The Administrator or designee will be responsible for ensuring discharge care plan is held. There will be a representative from each discipline within the facility attending this meeting as well as the resident and responsible party. The appropriate outside providers will be contacted to arrange services for the resident. This meeting will be documented in the resident's medical records. The Director of Nurses (DON) or designee will be responsible to ensuring the meeting is documented in the resident's medical records. -At the time of discharge the resident and responsible party will be provided with the attached Discharge Plan of Care form to ensure that the resident and responsible party are informed on how to care for the resident post discharge from the facility. In-the-event that the resident is picked up by a transport company, a copy of this sheet will be sent with the service to be given to the individual receiving the resident. The Administrator/DON or Designee will be responsible for ensuring the Discharge Plan of Care is completed and presented to the resident and/or family. The Administrator/DON or designee will ensure that all parties in attendance, including all family members, third party members and facility staff sign said document and verbalize understanding of all discharge instructions. -Administrative and licensed nursing staff will in serviced about these procedures. DON or designee will be responsible to ensure all administrative and licensed nursing staff are in-serviced. The in-service began today at 9:30 am. Each administrative and licensed nursing staff will complete in-service prior to beginning next work shift. On 10/11/19 at 10:45 a.m. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by: In-service training reports dated 10/10/19 and 10/11/19 presented to all licensed staff indicated staff must coordinate services and document discharge planning for all residents who are discharging from the facility. During interviews on 10/11/19 the social worker and two licensed nurses were knowledgeable of the requirements for discharge planning and stated they had received training regarding discharge planning and documentation. A review of a discharge record dated 10/10/19 showed appropriate discharge planning was completed and documentation of the plan of discharge for the resident was appropriate and met the resident's needs. During interviews on 10/11/19, the administrator and DON, confirmed all licensed staff currently working at the facility had been trained on discharge planning and documentation of resident's discharge plans. The administrator said other staff will receive training before starting their next shift. On 10/11/19 at 10:45 a.m., the administrator was notified the IJ was removed. However, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 10/11/19 at 11:55 a.m. the facility was asked if they had any additional information they wanted to provide related to these findings regarding Resident #1's discharge planning. No additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure pressure sores did not develop and did not provide necessary treatment and services to prevent worsening for 2 of 5 residents reviewed for pressure sores. (Resident #s 22 and 17) 1. The facility did not provide a low air loss mattress as ordered and did not float Resident #22's heels. Resident #22 developed a pressure sore to her left heel which was not identified until it was a stage II and did not identify when the pressure sore worsened to a stage III. 2. The facility did not turn/reposition Resident #17 off of his back. Resident #17 developed a pressure sore to his sacrum which was not identified until it was a stage II and did not prevent the pressure sore from increasing in size. These failures could place the 7 residents with pressure sores at risk for worsening of the pressure sores or development of new areas. Findings included: 1. Physician orders [REDACTED].#22 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The orders included a low air loss mattress, start date 01/26/15. A skin assessment dated [DATE] indicated Resident #22 had a stage II pressure sore measuring 2.5 cm (centimeters) x 2.0 cm with clear drainage. A telephone order for Resident #22 dated 03/10/15 indicated to clean the left heel with normal saline, pat dry, apply collagen (promotes wound healing), cover with abd (abdominal) pad, and wrap with Kerlix until healed. A care plan dated 03/10/15 indicated Resident #22 had a stage II pressure sore to her left heel measuring 1.2 cm x 1.5 cm. The care plan was updated 03/24/15 indicating the pressure sore measured 0.75 cm x 1.0 cm. An approach indicated, "Pressure relieving appliances as ordered." The care plan did not indicate to float heels to relieve pressure. The most recent MDS dated [DATE] indicated Resident #22 had severely impaired cognition, was dependent for ADLs, was totally incontinent, and had one stage II and one stage III pressure sore. The most recent skin assessment dated [DATE] indicated Resident #22 had a stage II pressure sore measuring 0.75 cm x 1.0 cm with drainage. A Code Key for Pressure Ulcers (sores) at the top of the form indicated, "Stage III...Sough may be present but does not obscure the depth of tissue loss..." During an observation on 04/13/15 at 10:10 a.m., Resident #22 was lying in a low bed with a scoop mattress. There was no low air loss mattress. Resident #22 did not have on heel protectors and her heels were not floated and rested on the mattress. During an observation and interview on 04/13/15 at 3:20 p.m., the treatment nurse performed wound care to Resident #22's left heel. The resident was lying in bed without a low air loss mattress, no heel protectors, and her heels were not floated. The treatment nurse said the pressure sore was a stage II. When the treatment nurse removed the old dressing, the wound bed was covered in thick, yellow slough. The dressing had yellow drainage. The treatment nurse again said the pressure sore was a stage II. The treatment nurse measured the pressure sore and it was 1.0 cm x 0.9 cm x less than 0.1 cm. The treatment nurse cleansed the wound bed with normal saline and gauze and the yellow slough remained in the wound bed. During an observation on 04/13/15 at 5:15 p.m., Resident #22 was lying in bed. There was no low air loss mattress, no heel protectors, and her heels were not floated. During an interview on 04/13/15 at 5:20 p.m., the administrator said the nurses were putting low air loss mattresses on too many residents who did not need them. She said low air loss mattresses were now used on residents with a stage III or worse pressure sores. During an observation on 04/14/15 at 7:05 a.m., Resident #22 was not in bed. The bed had a scoop mattress, no low air loss mattress. During an observation on 04/14/15 at 7:08 a.m., Resident #22 was in her wheelchair in the dining room wearing open-toe socks with a padded foot bed. Her feet rested on the wheelchair foot pedals. During an observation on 04/14/15 at 8:55 a.m., Resident #22 was in her wheelchair at the nursing station wearing open-toe socks with a padded foot bed. Her feet rested on the wheelchair foot pedals. During an interview on 04/14/15 at 9:07 a.m., the DON brought the care plan dated 03/10/15 for Resident #22's stage II pressure sore to her left heel and said that was the only care plan she had for that wound. During an observation on 04/14/15 at 11:12 a.m., Resident #22 was lying in bed without heel protectors and her heels were not floated. There was no low air loss mattress. During an observation and interview on 04/14/15 at 12:03 p.m., Resident #22 was lying in bed without heel protectors and her heels were not floated. There was no low air loss mattress. CNA A said no one had told her to float Resident #22's heels, just to put the padded socks on. CNA A said Resident #22 used to have a low air loss mattress, but did not remember how long it had been since one was on the resident's bed. CNA A put open-toe socks with a padded foot bed on Resident #22 and transferred the resident to her wheelchair with her feet resting on the foot pedals. During an observation on 04/14/15 at 12:38 p.m., Resident #22 was in her wheelchair in the dining room wearing open-toe socks with a padded foot bed. Her feet rested on the wheelchair foot pedals. During an observation on 04/14/15 at 4:20 p.m., Resident #22 was in her wheelchair at the nursing station wearing open-toe socks with a padded foot bed. Her feet rested on the wheelchair foot pedals. During an observation on 04/14/15 at 4:22 p.m., Resident #22's bed did not have a low air loss mattress. During an observation on 04/14/15 at 5:45 p.m., Resident #22 was in her wheelchair in the dining room wearing open-toe socks with a padded foot bed. Her feet rested on the wheelchair foot pedals. During an observation on 04/14/15 at 5:47 p.m., Resident #22's bed did not have a low air loss mattress. During an observation on 04/14/15 at 5:50 p.m., Resident #22 was in her wheelchair in the dining room wearing open-toe socks with a padded foot bed. Her feet rested on the wheelchair foot pedals. During an observation on 04/15/15 at 10:40 a.m., Resident #22 was lying in bed on a low air loss mattress. She had on open-toe socks with a padded foot bed. Her heels were resting on the mattress and her heels were not floated. During an interview on 04/15/15 at 6:00 p.m., the DON said she in-serviced both the night and day shifts early that morning (4/15/15) to float Resident #22's heels when lying in bed. During an interview on 04/16/15 at 10:42 a.m., CNA A said if she saw redness to a resident's bottom or heels while doing incontinent care or shower, she would report it to the charge nurse. She said Resident #22's left heel started out red. She was unsure how long ago it was, but stated, "It's been awhile." She said she reported it to the charge nurse, but did not remember who. During an interview on 04/16/15 at 11:10 a.m., the DON said the treatment nurse did weekly skin evaluations. Between those skin evaluation times, the CNAs were to report any skin findings to the DON. If after hours or on weekends, they were to report it to the charge nurse who would give the information to the DON and the DON to the treatment nurse. She said when CNAs showered residents, they were to fill out a form with a body drawing indicating any skin findings and give it to the charge nurse. The charge nurse gave the DON the form and the DON gave it to the treatment nurse for follow up. The DON said she could not find the Braden skin risk assessment for Resident #22. A Skin -- Treatment Guidelines for Pressure Ulcers policy and procedure dated 03/2012 indicated the following: "It is the policy of this home to utilize treatment guidelines when providing care for residents with pressure ulcers and to prevent further deterioration of pressure ulcers." "Stage I...3. Institute the use of pressure reducing devices for bed and chair, and other off-loading devices as necessary..." "Stage II. Definition: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured serum-filled blister or a shiny or dry shallow ulcer without slough or bruising...Procedure...3. Institute the use of pressure reducing devices for bed and chair..." "Stage III. Definition: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss...The depth varies by anatomical location. Some locations do not have subcutaneous tissue and these Stage III ulcers can be shallow...Procedure...3. Institute the use of air fluidized therapy or low air loss therapy if appropriate. 4. Institute the use of pressure reducing devices for chair and other off-loading devices as necessary..." 2. Physician orders [REDACTED].#17 was [AGE] years old, admitted [DATE] and readmitted from the hospital 03/30/15 with [DIAGNOSES REDACTED]. Care plans updated 01/29/15 indicated Resident #17 did not have a care plan for skin risk for pressure sore development. An ADL care plan indicated he needed extensive assistance with repositioning. A telephone order for Resident #17 dated 04/07/15 indicated, "Apply DuoDerm to open area on right buttocks. Change DuoDerm q (ever) 72 hours." The most recent MDS dated [DATE] indicated Resident #17 had moderately impaired cognition, was dependent for ADLs, including bed mobility, and was usually incontinent. The MDS indicated he had no pressure sores. A Braden risk scale for pressure sore development indicated Resident #17 was assessed on 03/30/15, 04/07/15, and 04/14/15 and all three scores were 17, indicating Resident #17 was at low risk for pressure sore development. A nursing note dated 04/07/15 for Resident #17 indicated the following: "Stage II on right buttocks. Called (resident's physician) and rec'd (received) order for DuoDerm (dressing to aid with wound healing) (every) 72 (hours). Area cleaned and DuoDerm applied." No other nursing notes through 04/15/15 addressed the pressure sore. A skin assessment dated [DATE] indicated Resident #17 had a stage II pressure sore 0.5 cm x 0.5 cm. A care plan dated 04/17/15 indicated, "Right buttock stage II 0.5 cm x 0.5 cm...2. Reposition resident, if necessary, every 2 hours to relieve pressure...6.Pressure relieving appliances as ordered." A skin assessment dated [DATE] Indicated Resident #17 had a stage II pressure sore to his right buttock 1.5 cm x 1.5 cm and a stage II pressure sore to his left buttock 5.0 cm x 2.0 cm, no drainage from either wound. A telephone order for Resident #17 dated 04/14/14 indicated to discontinue the DuoDerm and start [MEDICATION NAME] (barrier cream) three times daily until healed. Nursing notes dated 04/14/15 did not indicate the physician was notified regarding the treatment change for Resident #17. During an observation on 04/13/15 at 10:00 a.m., Resident #17 was lying on his back in bed asleep. During an observation on 04/15/15 at 10:46 a.m., Resident #17 was lying on his back in bed asleep. During an interview on 04/15/15 at 6:00 p.m., the DON said Resident #17 had one pressure sore split into two pressure sores on his sacrum. The DON said she assessed the pressure sores last night (04/14/15). She said DuoDerm made the pressure sores worse and the wound care was changed to [MEDICATION NAME]. During an interview on 04/16/15 at 9:00 a.m., the DON said Resident #17 had fever with [MEDICAL CONDITION] related to his vascular wounds and would be transferred to the hospital. During an interview on 04/16/15 at 9:08 a.m., Resident #17 was lying on his back in bed, eating cereal. He did not have a low air loss mattress on his bed. He indicated he was not feeling well and refused an assessment of his sacral pressure sores. He indicated the pressures sores hurt. He indicated he turned on his side at times with the assistance of staff. During an interview on 04/16/15 at 10:53 a.m., CNA B said she had cared for Resident #17 for a long time. She said Resident #17's bottom was not red when he returned from the hospital. CNA B said, approximately two weeks ago, she got report from the CNA going off shift that Resident #17 had a red bottom and that CNA reported to her charge nurse. CNA B was unsure of the exact date. CNA B said barrier cream was used on residents when they had a red bottom. CNA B said Resident #17 used to turn himself, but required staff assistance since returning from the hospital. CNA B said Resident #17 did not like to turn on his side because he chewed tobacco and choked if he was on his back. A Skin -- Treatment Guidelines for Pressure Ulcers policy and procedure dated 03/2012 indicated the following: "Procedure...8...Per physician order, one of the following treatments may be applied based on the assessment: 9. Stage II (Partial Thickness Wounds) with LIGHT TO NO drainage: a. Apply skin prep to surrounding wound if appropriate. Allow drying. b. Apply thin transparent film. c. Apply Hydrogel (adds moisture to wound) (solid, liquid or impregnated in gauze) QD (daily). OR d. [MEDICATION NAME] (aides with wound healing). e. Petroleum gauze. f. Cover with foam or composite dressing." The CMS 672 dated 04/13/15 indicated 7 residents had pressure sores.

Based on observation, interview and record review, the facility failed to ensure nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs as identified through resident assessments and described in the plan of care for 3 of 10 residents reviewed for transfers and neglect. (Resident #1, Resident #2 and Resident #3) Resident #1 was transferred improperly resulting in her suffering a fractured leg. Resident #1's left leg fracture required surgical correction. Resident #2 had a witnessed fall to her knees with no injuries. The resident was assisted by staff from the floor by improper transfer. Resident #2 suffered bruising as a result of the transfer. Resident #3 was a total care resident with no injuries but observed to be improperly transferred during this investigation. There was no gait belt applied. Resident #3 was transferred hanging by his arms. This failure likely contributed to the fracture of Resident #1's leg. This failure could also place 38 residents who require assistance with transfers at risk for injury. Findings included: Resident #1: Computerized physician orders [REDACTED]. Resident #1 was to have a low bed with fall mat for safety due to fall risk. A nursing assistant care plan dated 08/25/13 addressed Resident #1 required two people for assistance with transfers. The 'special transfer aids' section was blank. In-service training report dated 03/14/14 indicated transferring technique instructions had been provided to thirteen other staff members. There was no evidence of return demonstration or skill competency verified for thirteen of thirteen staff members. The most recent MDS assessment dated [DATE] indicated Resident #1 had severely impaired cognitive skills for decision making and was totally dependent upon two person assistance with bed mobility and transfers. A nursing note dated 03/14/14 at 6:50 p.m. indicated Resident #1 was admitted to a local hospital due to her leg fracture. A written witness statement dated 03/14/14 provided by CNA A indicated Resident #1 was transferred from the chair to the bed and she was hollering during care. An undated written witness statement provided by CNA B indicated Resident #1 was transferred by CNAs A and B the "same as every day" and Resident #1 said "stop it." Notice of Disciplinary Actions dated 03/14/14 indicated CNAs A and B were suspended due to the investigation of a resident fracture possibly sustained at time of transfer. During an interview on 03/26/14 at 9:05 a.m., the administrator said Resident #1's roommate reported to the evening shift CNA Resident #1 was complaining of pain. She said the CNA reported to the nurse who conducted an assessment and transferred the resident to a local emergency room . She said during the facility's investigation, Resident #4 reported Resident #1 began yelling in pain immediately after transferred to bed by CNAs A & B. The administrator said Resident #1 was transferred incorrectly by CNAs A and B to a low bed. The administrator said they could not be sure if the fracture occurred from the inappropriate transfer, if it happened spontaneously, if her foot dragged the floor, or if it got caught when they turned her. She said she was not sure if the CNAs had been trained on how to properly transfer Resident #1 prior to the fracture. During an interview on 03/26/14 at 11:10 a.m., Resident #4, who was in the room when Resident #1 was transferred, said the resident was total care and two CNAs transferred her to bed at approximately 1:00 p.m. or 1:30 p.m. She said she did not observe this transfer because they pulled the privacy curtain; but Resident #1 screamed while they moved her to the bed. Resident #4 said the two CNAs left the room and Resident #1 "almost immediately" complained that her leg hurt and started screaming in pain. Resident #4 said she told the evening CNA (unknown name) that Resident #1 complained since lunch that her leg hurt and was screaming out in pain. The resident said Resident #1 went to sleep and she told CNA (unknown name) to watch Resident #1 while she attended an activity. Resident #4 said she returned to the room about 3:00 p.m. to find Resident #1 yelling in pain that her leg hurt. Resident #4 said CNA (unknown name) informed LVN D who assessed Resident #1 and sent her to the hospital. A hospital imaging report dated 03/15/14 indicated Resident #1 had a left lower leg fracture. A hospital imaging report dated 03/19/14 showed evidence that Resident #1 had surgical correction of the fracture with rod placement. During observations on 03/26/14 at 9:20 a.m., 9:45 a.m., 10:30 p.m., and 11:10 a.m., Resident #1 was lying on her right side, sleeping intermittently, with her left leg wrapped after surgery. During an interview on 03/26/14 at 9:50 a.m., Resident #1 said she did not feel well. She said she was not sure who hurt her leg, but it was painful. Resident #1 said, "They tried to kill me." During an interview on 03/26/14 at 11:28 a.m., CNA B said Resident #1 was dependent upon staff for all care and transfers. She said the resident could not assist with transfers. CNA B said Resident #1 was a two person transfer before the injury. CNA B said they transferred Resident #1 by one person on each side and under the arm on 03/14/14. She explained that one aide would stand on either side of her chair, link their arm underneath the arm of Resident #1 and, on the count of three, lifted her quickly from the chair with one arm each and her feet not on the floor, turned her body and sat her on the low bed on her bottom. She said the bed was not electric and was all the way on the floor at the time of the injury. CNA B said after Resident #1 sustained two fractures they were in-serviced as follows: resident to cross arms over chest, the biggest/tallest CNA now had to put their hands under her armpits and wrap both arms around the residents to secure them, the shortest/smallest aide was instructed to hold both legs together and then they transferred the resident with all limbs secure. This aide said everybody transferred residents differently, no two aides do it the same. CNA B said she had not ever been trained on how to transfer a resident with that technique prior to Resident #1's fracture. When asked, CNA B said when she was in-serviced with CNA A, they were instructed to use the Steps in Lifting from Chair to Bed process outlined in the facility Transfer policy. CNA B signed her name by the transfer technique she was told to use with Resident #1 when trained after the fracture 03/14/14. She said they mentioned there would be training about hoyer lifts but, until then, they were told to transfer Resident #1 with two people, as they did prior to the injury. During an interview on 03/26/14 at 11:45 a.m., CNA A said they pushed Resident #1 to her room on 03/14/14 about 1:30 p.m., lined up the chair with the bed, locked the wheels, each aide got on a side of the resident, slid one of their arms underneath hers, pulled her out of the chair, twisted her around so her butt would be toward the bed and put her in the bed. CNA A said when they transferred Resident #1 both of her legs "dangled." This aide said she heard a "thump" noise and said it sounded like your hand hitting your leg but she did not think anything of the "thump" sound. She said she thought the chair bumped the low bed. CNA A said they were suspended and had to do a transfer training with return demonstration before they could return to work. CNA A said they were instructed for the tallest person to lift the upper body and the shorter person to lift both legs and transfer her like the "firemen" do. She said they were not told to use a hoyer lift and it was not part of their training after the incorrect transfer. CNA A said she had not been trained on the "firemen" lift until after the fracture. When asked, CNA A said when she was in-serviced with CNA B, they were instructed to use the Steps in Lifting from Chair to Bed process outlined in the facility Transfer policy. CNA A signed her name by the transfer technique to indicate how she was instructed to transfer Resident #1 after the fracture 03/14/14. During an interview on 03/26/14 at 12:45 p.m., the administrator said the corrective training done with CNAs A & B was "a general in-service on transferring." She said there was a scheduled transfer in-service scheduled for Friday, 03/28/14 with therapy and all staff to discuss how to appropriately transfer residents with hoyer lifts and those with special needs. During an interview on 03/26/14 at 3:17 p.m., the ADON said during the facility investigation CNA A said she heard what sounded like a "thump or thud." She said the aide reported she thought the sound was the chair hitting the low bed. The ADON said the two aides lifted Resident #1 under her arms, each on a side and they did "not secure her legs." She said the resident's legs should never have been unsecured. The ADON said it was an improper transfer. During an interview on 03/26/14 at 4:50 p.m., the administrator said the aides were not yet trained on how to properly transfer residents with a staff member securing the upper body and a second staff securing the legs. She said they had not completed transfer training for all of the aides and that training was scheduled to be done later in the week on 03/28/14. During an interview on 03/26/14 at 5:15 p.m., the ADON said all the aides had not been trained on how to properly transfer totally dependent residents. She said that training was scheduled 03/28/14 with therapy to train all of the aides properly. Resident #2: Computerized physician orders [REDACTED]. Resident #2 was to have a wanderguard was to receive [MEDICATION NAME] 75 mg daily initiated 01/11/14 and aspirin 81 mg daily initiated 01/11/14. A care plan dated 02/12/14 indicated Resident #2 required one person extensive transfer assistance to maintain safety. The most recent MDS assessment dated [DATE] indicated Resident #2 had disorganized thinking but was able to make self understood and was able to understand others who required extensive one person physical assistance with transfers. An incident report dated 02/24/14 indicated Resident #2 fell forward to her knees, xrays were ordered and there were no injuries to this witnessed fall. Skin assessment flow sheet dated 03/11/14 indicated Resident #2 suffered bruising to the: upper right side 18 cm x 8.5 cm, lower right side 10 cm x 6 cm, right inner arm 3 cm x 2 cm and right backside of upper arm 3 cm x 2 cm. During an interview on 03/26/14 at 9:18 a.m., the administrator said Resident #2 was assisted up after a fall. She said two CNAs (not able to determine who) transferred her from the floor to her wheelchair. The administrator said she thought they put a gait belt on her but lifted her total body weight with her arms and the bruising was a result. The administrator said "it's safe to say we did it wrong." During an interview on 03/26/14 at 9:22 a.m., the ADON said she assessed Resident #2 and the bruising was consistent with a bilateral transfer from the floor. She said there was bruising to the armpit area and and upper side. The ADON said they transfer from the floor was incorrect technique. She said they should have positioned the resident onto her buttocks and assisted her by use of the gait belt. During an observation and interview on 03/26/14 at 9:43 a.m. showed Resident #2 to have a purplish bruise with red outline on the outer side of her right hand. Bruising was noted to the resident's right abdominal side. Resident #2 said she was not sure how she got the bruises. During an interview on 03/26/14 at 10:17 a.m., CNA A said the bruise on the outer side of Resident #2's right hand looked like someone pulled her up from the wheelchair by her hand when transferred. Resident #3: Computerized physician orders [REDACTED]. Resident #3 was to have nothing by mouth and all medications crushed. An undated nursing assistant care plan indicated Resident #3 was totally dependent on staff and required two person transfer assist. The most recent MDS assessment dated [DATE] indicated Resident #3 had severely impaired cognitive skills for daily decision making and was totally dependent on two persons for transfers and bed mobility. During an observation on 03/26/14 at 10:30 a.m., CNAs G and H transferred Resident #3 from the gerichair to the bed. They did not apply a gait belt. CNA G placed the bend of her arm (elbow) under the resident's right shoulder (armpit area) and CNA G placed the bend of her arm (elbow) under the resident's left shoulder (armpit area). As they lifted Resident #3 his body slipped downward, his feet hit the gerichair as they turned his body and both shoulders went up and he had to be lifted higher by his armpits. Resident #3 said, "What are you doing to me?" and CNA G said, "We got you" as they lifted his entire body weight by his arms. During an interview on 03/26/14 at 11:10 a.m., CNA H said they always use that transfer technique. During an interview on 03/26/14 at 12:00 p.m., LVN I said the resident should be transferred with a hoyer lift but depending on was working all of the aides used different techniques to transfer. During an interview on 03/26/14 at 4:50 p.m., the administrator said the aides had not been trained on how to properly transfer residents with a staff member securing the upper body and a second staff securing the legs. She said they had not completed transfer training for all of the aides and that training was scheduled to be done later in the week on 03/28/14. During an interview on 03/26/14 at 5:15 p.m., the ADON said all the aides were not yet trained on how to properly transfer totally dependent residents. She said that training was scheduled 03/28/14 with therapy to train all of the aides properly. An undated document entitled Transfers provided with the Transferring a Resident policy dated March, 2012 instructed when transferring a resident always place a belt around the waist of the resident. In the section Two Man Lift (dependent) indicated: if a resident is unable to bear weight on his/her legs, it will be necessary for two people to transfer in and out of bed. The lifting is done through proper mechanical use of the body. Staff may want to practice on another member of the staff. It may be necessary to use a mechanical lift (Hoyer). Further it instructed to lift from the chair to the bed by: placing the chair at the side of the bed, Lifter A (larger person in stature) to stand behind the chair and Lifter B at the foot of the chair, Lifter A folds the resident's arms across the chest and places own arms under the resident's armpits and grasps the arms, Lifter B places one arm under the resident's thighs and the other arm around ankles, on the count of three Lifter B pulls resident's legs away from the foot of the chair and Lifter A leans back with his/her body firmly holding the top of the resident's body to his/her chest and when the resident's body is out flat in the air, the shift is made over the arm of the chair to the bed. The CMS 672 dated 03/25/14 indicated there were 38 residents who required one or two person assist with transfers.

Based on observation, interview and record review, the facility failed to implement its policy to prevent neglect for 1 of 10 residents reviewed for neglect. (Resident #1) Resident #1 was transferred improperly resulting in her suffering a fractured leg. Resident #1's left leg fracture required surgical correction. This failure contributed to the fracture of Resident #1's leg. This failure could also place 12 residents who require total assistance with transfers at risk for injury and neglect. Findings included: Computerized physician orders [REDACTED]. Resident #1 was to have a low bed with fall mat for safety due to fall risk. A nursing assistant care plan dated 08/25/13 indicated Resident #1 required two people for assistance with transfers. The 'special transfer aids' section was blank. A care plan dated 12/26/13 indicated Resident #1 was at risk for falls with approaches listed: to change positions slowly, transfer with assistance and transfer resident towards her stronger side. A comprehensive pain assessment dated [DATE] indicated Resident #1 was in severe pain, holding her left calf area and screaming out in pain. Her left foot was red, [MEDICAL CONDITION], and warm to touch. This same assessment indicated Resident #1 had no pain previously in the last five days. The most recent MDS assessment dated [DATE] indicated Resident #1 had severely impaired cognitive skills for decision making and was totally dependent upon two person assistance with bed mobility and transfers. An incident report dated 03/14/14 at 3:30 p.m., indicated Resident #1 was lying on her left side in bed, "screaming out in pain," her left leg was swollen, red, warm and tender to touch. This report indicated Resident #1 was transferred to the emergency room for x-ray and evaluation. Also, this report indicated training of safely transferring residents was needed. A nursing note dated 03/14/14 at 6:50 p.m., indicated Resident #1 was admitted to a local hospital due to her leg fracture. A written witness statement dated 03/14/14 provided by CNA A indicated Resident #1 was transferred from the chair to the bed and she was hollering during care. An undated written witness statement provided by CNA B indicated Resident #1 was transferred by CNAs A and B the "same as every day" and Resident #1 said "stop it." A written witness statement dated 03/14/14 provided by CNA C indicated she arrived to work at 2:00 p.m. and Resident #1's roommate reported Resident #1 was in bed complaining of her leg "all evening" and asked CNA C to check on her. This statement noted CNA C found Resident #1 in bed holding her leg. A written witness statement dated 03/14/14 provided by LVN D indicated Resident #1 was "screaming out in pain" when the CNAs attempted to get her out of bed at approximately 3:20 p.m. LVN D conducted an assessment, noted redness, swelling and tenderness to touch, she called EMS for transport to local emergency room . It was noted in this statement that when Resident #1's left calf was barely touched, she became combative. An in-service training report dated 03/14/14 with only the signatures of CNA A and CNA B indicated instruction was given on transferring techniques with return demonstration. The documents provided with this training included: transfers with assistance, minimal assistance, moderate assistance, maximal assistance, two man lift (dependent) and steps in lifting from chair to bed. There was no training that instructed Resident #1 was to be transferred by hoyer lift or proper use of a hoyer lift. A second in-service training report dated 03/14/14 indicated transferring technique instructions were provided to thirteen other staff members. There was no evidence of return demonstration or competency for thirteen of thirteen staff members. Notice of Disciplinary Actions dated 03/14/14 indicated CNAs A and B were suspended due to the investigation of a resident fracture possibly sustained at time of transfer. During an interview on 03/26/14 at 9:05 a.m., the administrator said Resident #1's roommate reported to the evening shift CNA Resident #1 was complaining of pain. She said the CNA reported to the nurse who conducted an assessment and transferred the resident to a local emergency room . She said during the facility's investigation, Resident #4 reported Resident #1 began yelling in pain immediately after transferred to bed by CNAs A & B. The administrator said Resident #1 was transferred incorrectly by CNAs A and B to a low bed. The administrator said they could not be sure if the fracture occurred from the inappropriate transfer, if it happened spontaneously, if her foot dragged the floor, or if it got caught when they turned her. She said she was not sure if the CNAs had been trained on how to properly transfer Resident #1 prior to the fracture. During an interview on 03/26/14 at 11:10 a.m., Resident #4, who was in the room when Resident #1 was transferred, said the resident was total care and two CNAs transferred her to bed at approximately 1:00 p.m. or 1:30 p.m. She said she did not observe this transfer because they pulled the privacy curtain; but Resident #1 screamed while they moved her to the bed. Resident #4 said the two CNAs left the room and Resident #1 "almost immediately" complained that her leg hurt and started screaming in pain. Resident #4 said she told the evening CNA (unknown name) that Resident #1 complained since lunch that her leg hurt and was screaming out in pain. The resident said Resident #1 went to sleep and she told CNA (unknown name) to watch Resident #1 while she attended an activity. Resident #4 said she returned to the room about 3:00 p.m. to find Resident #1 yelling in pain that her leg hurt. Resident #4 said CNA (unknown name) informed LVN D who assessed Resident #1 and sent her to the hospital. A hospital imaging report dated 03/15/14 indicated Resident #1 had a left lower leg fracture. A hospital imaging report dated 03/19/14 showed evidence that Resident #1 had surgical correction of the fracture with rod placement. A nursing care plan dated 03/20/14 addressed Resident #1 was to be transferred by hoyer lift with two staff members due to left tibia and left fibia fracture. Provider Action taken Post Investigation section of the Provider Investigation Report dated 03/26/14 indicated the facility scheduled an in-service with nursing and therapy to discuss all residents to ensure all staff aware of which transfer technique to use to safely transfer each resident. CNA care plans would be updated. During observations on 03/26/14 at 9:20 a.m., 9:45 a.m., 10:30 p.m., and 11:10 a.m. Resident #1 was lying on her right side, sleeping intermittently, with her left leg wrapped. During an interview on 03/26/14 at 9:50 a.m., Resident #1 said she did not feel well. She said she did not know who hurt her leg, but it was painful. Resident #1 said, "They tried to kill me." During an interview on 03/26/14 at 11:28 a.m., CNA B said Resident #1 was dependent upon staff for all care and transfers. She said the resident could not assist with transfers. CNA B said Resident #1 was a two person transfer before the injury. CNA B said they transferred Resident #1 by one person on each side and under the arm on 03/14/14. She explained that one aide would stand on either side of her chair, link their arm underneath the arm of Resident #1 and, on the count of three, lifted her quickly from the chair with one arm each and her feet not on the floor, turned her body and sat her on the low bed on her bottom. She said the bed was not electric and was all the way on the floor at the time of the injury. CNA B said after Resident #1 sustained two fractures they were in-serviced as follows: resident to cross arms over chest, the biggest/tallest CNA now had to put their hands under her armpits and wrap both arms around the residents to secure them, the shortest/smallest aide was instructed to hold both legs together and then they transferred the resident with all limbs secure. This aide said everybody transferred residents differently, no two aides do it the same. CNA B said she had not ever been trained on how to transfer a resident with that technique prior to Resident #1 ' s fracture. When asked, CNA B said when she was in-serviced with CNA A, they were instructed to use the Steps in Lifting from Chair to Bed process outlined in the facility Transfer policy. CNA B signed her name by the transfer technique she was told to use with Resident #1 when trained after the fracture 03/14/14. She said they mentioned there would be training about hoyer lifts but, until then, they were told to transfer Resident #1 with two people, as they did prior to the injury. During an interview on 03/26/14 at 11:45 a.m., CNA A said they pushed Resident #1 to her room on 03/14/14 about 1:30 p.m., lined up the chair with the bed, locked the wheels, each aide got on a side of the resident, slid one of their arms underneath hers, pulled her out of the chair, twisted her around so her butt would be toward the bed and put her in the bed. CNA A said when they transferred Resident #1 both of her legs "dangled." This aide said she heard a "thump" noise and said it sounded like your hand hitting your leg but she did not think anything of the "thump" sound. She said she thought the chair bumped the low bed. CNA A said they were suspended and had to do a transfer training with return demonstration before they could return to work. CNA A said they were instructed for the tallest person to lift the upper body and the shorter person to lift both legs and transfer her like the "firemen" do. She said they were not told to use a hoyer lift and it was not part of their training after the incorrect transfer. CNA A said she had not been trained on the "firemen" lift until after the fracture. When asked, CNA A said when she was in-serviced with CNA B, they were instructed to use the Steps in Lifting from Chair to Bed process outlined in the facility Transfer policy. CNA A signed her name by the transfer technique to indicate how she was instructed to transfer Resident #1 after the fracture 03/14/14. During an interview on 03/26/14 at 12:45 p.m., the administrator said the corrective training done with CNAs A & B was "a general in-service on transferring." She said there was a scheduled transfer in-service scheduled for Friday, 03/28/14 with therapy and all staff to discuss how to appropriately transfer residents with hoyer lifts and special needs. During an interview on 03/26/14 at 3:17 p.m., the ADON said during the facility investigation CNA A said she heard what sounded like a "thump or thud." She said the aide reported she thought the sound was the chair hitting the low bed. The ADON said the two aides lifted Resident #1 under her arms, each on a side and they did "not secure her legs." She said the resident's legs should never have been unsecured. The ADON said it was an improper transfer. During an interview on 03/26/14 at 4:50 p.m., the administrator said the aides had not been trained on how to properly transfer residents with a staff member securing the upper body and a second staff securing the legs. She said they had not completed transfer training for all of the aides and that training was scheduled to be done for later in the week on 03/28/14. During an interview on 03/26/14 at 5:15 p.m., the ADON said all the aides were not yet trained on how to properly transfer totally dependent residents. She said training was scheduled 03/28/14 with therapy to train all of the aides properly. An undated document entitled Transfers provided with the Transferring a Resident policy dated March, 2012 instructed when transferring a resident always place a belt around the waist of the resident. In the section Two Man Lift (dependent) indicated: if a resident is unable to bear weight on his/her legs, it will be necessary for two people to transfer in and out of bed. The lifting is done through proper mechanical use of the body. Staff may want to practice on another member of the staff. It may be necessary to use a mechanical lift (Hoyer). Further it instructed to lift from the chair to the bed by: placing the chair at the side of the bed, Lifter A (larger person in stature) to stand behind the chair and Lifter B at the foot of the chair, Lifter A folds the resident's arms across the chest and places own arms under the resident's armpits and grasps the arms, Lifter B places one arm under the resident's thighs and the other arm around ankles, on the count of three Lifter B pulls resident's legs away from the foot of the chair and Lifter A leans back with his/her body firmly holding the top of the resident's body to his/her chest and when the resident's body is out flat in the air, the shift is made over the arm of the chair to the bed. The Abuse Policy dated March 2012 defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This same policy defined serious bodily injury as an injury requiring medical intervention such as surgery, hospitalization or physical rehabilitation. The CMS 672 dated 03/25/14 indicated there were 12 residents totally dependent on staff for transfers.

Based on observation, interview and record review, the facility failed to implement their written policies to prohibit neglect for 1 of 10 residents reviewed for neglect. (Resident #1) Resident #1 was transferred improperly resulting in her suffering a fractured leg. Resident #1's left leg fracture required surgical correction. This failure contributed to the fracture of Resident #1's leg. This failure could also place 12 residents who require total assistance with transfers at risk for injury and neglect. Findings included: The Abuse Policy dated March 2012 defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This same policy defined serious bodily injury as an injury requiring medical intervention such as surgery, hospitalization or physical rehabilitation. An undated document entitled Transfers provided with the Transferring a Resident policy dated March, 2012 instructed when transferring a resident always place a belt around the waist of the resident. In the section Two Man Lift (dependent) indicated: if a resident is unable to bear weight on his/her legs, it will be necessary for two people to transfer in and out of bed. The lifting is done through proper mechanical use of the body. Staff may want to practice on another member of the staff. It may be necessary to use a mechanical lift (Hoyer). Further it instructed to lift from the chair to the bed by: placing the chair at the side of the bed, Lifter A (larger person in stature) to stand behind the chair and Lifter B at the foot of the chair, Lifter A folds the resident's arms across the chest and places own arms under the resident's armpits and grasps the arms, Lifter B places one arm under the resident's thighs and the other arm around ankles, on the count of three Lifter B pulls resident's legs away from the foot of the chair and Lifter A leans back with his/her body firmly holding the top of the resident's body to his/her chest and when the resident's body is out flat in the air, the shift is made over the arm of the chair to the bed. Computerized physician orders [REDACTED]. Resident #1 was to have a low bed with fall mat for safety due to fall risk. A nursing assistant care plan dated 08/25/13 indicated Resident #1 required two people for assistance with transfers. The 'special transfer aids' section was blank. A care plan dated 12/26/13 indicated Resident #1 was at risk for falls with approaches listed: to change positions slowly, transfer with assistance and transfer resident towards her stronger side. A comprehensive pain assessment dated [DATE] indicated Resident #1 was in severe pain, holding her left calf area and screaming out in pain. Her left foot was red, [MEDICAL CONDITION], and warm to touch. This same assessment indicated Resident #1 had no pain previously in the last five days. The most recent MDS assessment dated [DATE] indicated Resident #1 had severely impaired cognitive skills for decision making and was totally dependent upon two person assistance with bed mobility and transfers. An incident report dated 03/14/14 at 3:30 p.m., indicated Resident #1 was lying on her left side in bed, "screaming out in pain," her left leg was swollen, red, warm and tender to touch. This report indicated Resident #1 was transferred to the emergency room for x-ray and evaluation. Also, this report indicated training of safely transferring residents was needed. A nursing note dated 03/14/14 at 6:50 p.m., indicated Resident #1 was admitted to a local hospital due to her leg fracture. A written witness statement dated 03/14/14 provided by CNA A indicated Resident #1 was transferred from the chair to the bed and she was hollering during care. An undated written witness statement provided by CNA B indicated Resident #1 was transferred by CNAs A and B the "same as every day" and Resident #1 said "stop it." A written witness statement dated 03/14/14 provided by CNA C indicated she arrived to work at 2:00 p.m. and Resident #1's roommate reported Resident #1 was in bed complaining of her leg "all evening" and asked CNA C to check on her. This statement noted CNA C found Resident #1 in bed holding her leg. A written witness statement dated 03/14/14 provided by LVN D indicated Resident #1 was "screaming out in pain" when the CNAs attempted to get her out of bed at approximately 3:20 p.m. LVN D conducted an assessment, noted redness, swelling and tenderness to touch, she called EMS for transport to local emergency room . It was noted in this statement that when Resident #1's left calf was barely touched, she became combative. An in-service training report dated 03/14/14 with only the signatures of CNA A and CNA B indicated instruction was given on transferring techniques with return demonstration. The documents provided with this training included: transfers with assistance, minimal assistance, moderate assistance, maximal assistance, two man lift (dependent) and steps in lifting from chair to bed. There was no training that instructed Resident #1 was to be transferred by hoyer lift or proper use of a hoyer lift. A second in-service training report dated 03/14/14 indicated transferring technique instructions were provided to thirteen other staff members. There was no evidence of return demonstration or competency for thirteen of thirteen staff members. Notice of Disciplinary Actions dated 03/14/14 indicated CNAs A and B were suspended due to the investigation of a resident fracture possibly sustained at time of transfer. During an interview on 03/26/14 at 9:05 a.m., the administrator said Resident #1's roommate reported to the evening shift CNA Resident #1 was complaining of pain. She said the CNA reported to the nurse who conducted an assessment and transferred the resident to a local emergency room . She said during the facility's investigation, Resident #4 reported Resident #1 began yelling in pain immediately after transferred to bed by CNAs A & B. The administrator said Resident #1 was transferred incorrectly by CNAs A and B to a low bed. The administrator said they could not be sure if the fracture occurred from the inappropriate transfer, if it happened spontaneously, if her foot dragged the floor, or if it got caught when they turned her. She said she was not sure if the CNAs had been trained on how to properly transfer Resident #1 prior to the fracture. During an interview on 03/26/14 at 11:10 a.m., Resident #4, who was in the room when Resident #1 was transferred, said the resident was total care and two CNAs transferred her to bed at approximately 1:00 p.m. or 1:30 p.m. She said she did not observe this transfer because they pulled the privacy curtain; but Resident #1 screamed while they moved her to the bed. Resident #4 said the two CNAs left the room and Resident #1 "almost immediately" complained that her leg hurt and started screaming in pain. Resident #4 said she told the evening CNA (unknown name) that Resident #1 complained since lunch that her leg hurt and was screaming out in pain. The resident said Resident #1 went to sleep and she told CNA (unknown name) to watch Resident #1 while she attended an activity. Resident #4 said she returned to the room about 3:00 p.m. to find Resident #1 yelling in pain that her leg hurt. Resident #4 said CNA (unknown name) informed LVN D who assessed Resident #1 and sent her to the hospital. A hospital imaging report dated 03/15/14 indicated Resident #1 had a left lower leg fracture. A hospital imaging report dated 03/19/14 showed evidence that Resident #1 had surgical correction of the fracture with rod placement. A nursing care plan dated 03/20/14 addressed Resident #1 was to be transferred by hoyer lift with two staff members due to left tibia and left fibia fracture. Provider Action taken Post Investigation section of the Provider Investigation Report dated 03/26/14 indicated the facility scheduled an in-service with nursing and therapy to discuss all residents to ensure all staff aware of which transfer technique to use to safely transfer each resident. CNA care plans would be updated. During observations on 03/26/14 at 9:20 a.m., 9:45 a.m., 10:30 p.m., and 11:10 a.m. Resident #1 was lying on her right side, sleeping intermittently, with her left leg wrapped. During an interview on 03/26/14 at 9:50 a.m., Resident #1 said she did not feel well. She said she did not know who hurt her leg, but it was painful. Resident #1 said, "They tried to kill me." During an interview on 03/26/14 at 11:28 a.m., CNA B said Resident #1 was dependent upon staff for all care and transfers. She said the resident could not assist with transfers. CNA B said Resident #1 was a two person transfer before the injury. CNA B said they transferred Resident #1 by one person on each side and under the arm on 03/14/14. She explained that one aide would stand on either side of her chair, link their arm underneath the arm of Resident #1 and, on the count of three, lifted her quickly from the chair with one arm each and her feet not on the floor, turned her body and sat her on the low bed on her bottom. She said the bed was not electric and was all the way on the floor at the time of the injury. CNA B said after Resident #1 sustained two fractures they were in-serviced as follows: resident to cross arms over chest, the biggest/tallest CNA now had to put their hands under her armpits and wrap both arms around the residents to secure them, the shortest/smallest aide was instructed to hold both legs together and then they transferred the resident with all limbs secure. This aide said everybody transferred residents differently, no two aides do it the same. CNA B said she had not ever been trained on how to transfer a resident with that technique prior to Resident #1 ' s fracture. When asked, CNA B said when she was in-serviced with CNA A, they were instructed to use the Steps in Lifting from Chair to Bed process outlined in the facility Transfer policy. CNA B signed her name by the transfer technique she was told to use with Resident #1 when trained after the fracture 03/14/14. She said they mentioned there would be training about hoyer lifts but, until then, they were told to transfer Resident #1 with two people, as they did prior to the injury. During an interview on 03/26/14 at 11:45 a.m., CNA A said they pushed Resident #1 to her room on 03/14/14 about 1:30 p.m., lined up the chair with the bed, locked the wheels, each aide got on a side of the resident, slid one of their arms underneath hers, pulled her out of the chair, twisted her around so her butt would be toward the bed and put her in the bed. CNA A said when they transferred Resident #1 both of her legs "dangled." This aide said she heard a "thump" noise and said it sounded like your hand hitting your leg but she did not think anything of the "thump" sound. She said she thought the chair bumped the low bed. CNA A said they were suspended and had to do a transfer training with return demonstration before they could return to work. CNA A said they were instructed for the tallest person to lift the upper body and the shorter person to lift both legs and transfer her like the "firemen" do. She said they were not told to use a hoyer lift and it was not part of their training after the incorrect transfer. CNA A said she had not been trained on the "firemen" lift until after the fracture. When asked, CNA A said when she was in-serviced with CNA B, they were instructed to use the Steps in Lifting from Chair to Bed process outlined in the facility Transfer policy. CNA A signed her name by the transfer technique to indicate how she was instructed to transfer Resident #1 after the fracture 03/14/14. During an interview on 03/26/14 at 12:45 p.m., the administrator said the corrective training done with CNAs A & B was "a general in-service on transferring." She said there was a scheduled transfer in-service scheduled for Friday, 03/28/14 with therapy and all staff to discuss how to appropriately transfer residents with hoyer lifts and special needs. During an interview on 03/26/14 at 3:17 p.m., the ADON said during the facility investigation CNA A said she heard what sounded like a "thump or thud." She said the aide reported she thought the sound was the chair hitting the low bed. The ADON said the two aides lifted Resident #1 under her arms, each on a side and they did "not secure her legs." She said the resident's legs should never have been unsecured. The ADON said it was an improper transfer. During an interview on 03/26/14 at 4:50 p.m., the administrator said the aides had not been trained on how to properly transfer residents with a staff member securing the upper body and a second staff securing the legs. She said they had not completed transfer training for all of the aides and that training was scheduled to be done for later in the week on 03/28/14. During an interview on 03/26/14 at 5:15 p.m., the ADON said all the aides were not yet trained on how to properly transfer totally dependent residents. She said training was scheduled 03/28/14 with therapy to train all of the aides properly. Review of employee files on 03/26/14 at 5:20 p.m. indicated CNA B was hired 06/14/12. There was a checklist entitled Initial/Annual Nurse Aide Performance Review under the section Restorative Services which included: proper body mechanics, mechanical lift (optional), positioning resident in bed, assisting resident with transfer to chair/wheelchair, moving and lifting resident to head of bed were initialed as satisfactory by CNA J and CNA K dated 01/14/13. Review of employee files on 03/26/14 at 5:30 p.m. indicated CNA A was hired 10/18/13. The CMS 672 dated 03/25/14 indicated there were 12 residents totally dependent on staff for transfers.

Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents to 1 of 10 residents reviewed for accidents. (Resident #1) Resident #1 was transferred improperly resulting in her suffering a fractured leg. Resident #1's left leg fracture required surgical correction. This failure contributed to the fracture of Resident #1's leg. This failure could also place 12 residents who require total assistance with transfers at risk for injury and neglect. Findings included: Computerized physician orders [REDACTED]. Resident #1 was to have a low bed with fall mat for safety due to fall risk. A nursing assistant care plan dated 08/25/13 addressed Resident #1 required two people for assistance with transfers. The 'special transfer aids' section was blank. A care plan dated 12/26/13 indicated Resident #1 was at risk for falls with approaches listed: to change positions slowly, transfer with assistance and transfer resident towards her stronger side. A comprehensive pain assessment dated [DATE] indicated Resident #1 was in severe pain, holding her left calf area and screaming out in pain. Her left foot was red, edematous, and warm to touch. This same assessment indicated Resident #1 had no pain previously in the last five days. The most recent MDS assessment dated [DATE] indicated Resident #1 had severely impaired cognitive skills for decision making and was totally dependent upon two person assistance with bed mobility and transfers. An incident report dated 03/14/14 at 3:30 p.m., indicated Resident #1 was lying on her left side in bed, "screaming out in pain," left leg was swollen, red, warm and tender to touch. This report indicated Resident #1 was transferred to the emergency room for x-ray and evaluation. Also, this report indicated training of safely transferring residents was needed. A nursing note dated 03/14/14 at 6:50 p.m., indicated Resident #1 was admitted to a local hospital due to her leg fracture. A written witness statement dated 03/14/14 provided by CNA A indicated Resident #1 was transferred from the chair to the bed and she was hollering during care. An undated written witness statement provided by CNA B indicated Resident #1 was transferred by CNAs A and B the "same as every day" and Resident #1 said "stop it." A written witness statement dated 03/14/14 provided by CNA C indicated she arrived to work at 2:00 p.m. and Resident #1's roommate reported Resident #1 was in bed complaining of her leg "all evening" and asked CNA C to check on her. This statement noted CNA C found Resident #1 in bed holding her leg. A written witness statement dated 03/14/14 provided by LVN D indicated Resident #1 was, "screaming out in pain" when the CNAs attempted to get her out of bed at approximately 3:20 p.m. LVN D conducted an assessment, noted redness, swelling and tenderness to touch, she called EMS for transport to local emergency room . It was noted in this statement that when Resident #1's left calf was barely touched, she became combative due to pain. An in-service training report dated 03/14/14 indicated transferring technique instructions had been provided to fifteen staff members, including CNAs A and B. There was no evidence of return demonstration or competency for thirteen of fifteen staff members. Notice of Disciplinary Actions dated 03/14/14 indicated CNAs A and B were suspended due to the investigation of a resident fracture possibly sustained at time of transfer. During an interview on 03/26/14 at 9:05 a.m., the administrator said Resident #1's roommate reported to the evening CNA Resident #1 complained of pain. She said the CNA reported to the nurse who conducted an assessment and transferred the resident to a local emergency room . She said during the facility's investigation, Resident #4 reported Resident #1 began yelling in pain immediately after transferred to bed by CNAs A & B. The administrator said Resident #1 was transferred incorrectly by CNAs A and B to a low bed. The administrator said they could not be sure if the fracture occurred from the inappropriate transfer, if it happened spontaneously, if her foot dragged the floor, or if it got caught when they turned her. She said she was not sure if the CNAs had been trained on how to properly transfer Resident #1 prior to the fracture. During an interview on 03/26/14 at 11:10 a.m., Resident #4, who was in the room when Resident #1 was transferred, said the resident was total care and two CNAs transferred her to bed at approximately 1:00 p.m. or 1:30 p.m. She said she did not observe this transfer because they pulled the privacy curtain; but Resident #1 screamed while they moved her to the bed. Resident #4 said the two CNAs left the room and Resident #1 "almost immediately" complained that her leg hurt and started screaming in pain. Resident #4 said she told the evening CNA (unknown name) that Resident #1 complained since lunch that her leg hurt and was screaming out in pain. The resident said Resident #1 went to sleep and she told CNA (unknown name) to watch Resident #1. Resident #4 said she returned to the room about 3:00 p.m. to find Resident #1 yelling in pain that her leg hurt. Resident #4 said CNA (unknown name) informed LVN D who assessed Resident #1 and sent her to the hospital. A hospital imaging report dated 03/15/14 indicated Resident #1 had a left lower leg fracture. A hospital imaging report dated 03/19/14 showed evidence that Resident #1 had surgical correction of the fracture with rod replacement. Provider Action taken Post Investigation section of the Provider Investigation Report dated 03/26/14 indicated the facility scheduled an in-service with nursing and therapy to discuss all residents to ensure all staff aware of which transfer technique to use to safely transfer each resident. CNA care plans would be updated. During observations on 03/26/14 at 9:20 a.m., 9:45 a.m., 10:30 p.m., and 11:10 a.m., Resident #1 was lying on her right side, sleeping intermittently, with her left leg wrapped. During an interview on 03/26/14 at 9:50 a.m., Resident #1 said she did not feel well. She said she did not know who hurt her leg, but it was painful. Resident #1 said, "They tried to kill me." During an interview on 03/26/14 at 11:28 a.m., CNA B said Resident #1 was dependent upon staff for all care and transfers. She said the resident could not assist with transfers. CNA B said Resident #1 was a two person transfer before the injury. CNA B said they transferred Resident #1 by one person on each side and under the arm on 03/14/14. She explained that one aide would stand on either side of her chair, link their arm underneath the arm of Resident #1 and, on the count of three, lifted her quickly from the chair with one arm each and her feet not on the floor, turned her body and sat her on the low bed on her bottom. She said the bed was not electric and was all the way on the floor at the time of the injury. CNA B said after Resident #1 sustained two fractures they were in-serviced as follows: resident to cross arms over chest, the biggest/tallest CNA now had to put their hands under her armpits and wrap both arms around the residents to secure them, the shortest/smallest aide was instructed to hold both legs together and then they transferred the resident with all limbs secure. This aide said everybody transferred residents differently, no two aides do it the same. CNA B said she had not ever been trained on how to transfer a resident with that technique prior to Resident #1 ' s fracture. When asked, CNA B said when she was in-serviced with CNA A, they were instructed to use the Steps in Lifting from Chair to Bed process outlined in the facility Transfer policy. CNA B signed her name by the transfer technique she was told to use with Resident #1 when trained after the fracture 03/14/14. She said they mentioned there would be training about hoyer lifts but, until then, they were told to transfer Resident #1 with two people, as they did prior to the injury. During an interview on 03/26/14 at 11:45 a.m., CNA A said they pushed Resident #1 to her room on 03/14/14 about 1:30 p.m., lined up the chair with the bed, locked the wheels, each aide got on a side of the resident, slid one of their arms underneath hers, pulled her out of the chair, twisted her around so her butt would be toward the bed and put her in the bed. CNA A said when they transferred Resident #1 both of her legs "dangled." This aide said she heard a "thump" noise and said it sounded like your hand hitting your leg but she did not think anything of the "thump" sound. She said she thought the chair bumped the low bed. CNA A said they were suspended and had to do a transfer training with return demonstration before they could return to work. CNA A said they were instructed for the tallest person to lift the upper body and the shorter person to lift both legs and transfer her like the "firemen" do. She said they were not told to use a hoyer lift and it was not part of their training after the incorrect transfer. CNA A said she had not been trained on the "firemen" lift until after the fracture. When asked, CNA A said when she was in-serviced with CNA B, they were instructed to use the Steps in Lifting from Chair to Bed process outlined in the facility Transfer policy. CNA A signed her name by the transfer technique to indicate how she was instructed to transfer Resident #1 after the fracture 03/14/14. During an interview on 03/26/14 at 12:45 p.m., the administrator said the corrective training done with CNAs A & B was "a general in-service on transferring." She said there was a scheduled transfer in-service scheduled for Friday, 03/28/14 with therapy and all staff to discuss how to appropriately transfer residents with hoyer lifts and special needs. During an interview on 03/26/14 at 3:17 p.m., the ADON said during the facility investigation CNA A said she heard what sounded like a "thump or thud." She said the aide reported she thought the sound was the chair hitting the low bed. The ADON said the two aides lifted Resident #1 under her arms, each on a side and they did "not secure her legs." She said the resident's legs should never have been unsecured. The ADON said it was an improper transfer. During an interview on 03/26/14 at 4:50 p.m., the administrator said the aides had not been trained on how to properly transfer residents with a staff member securing the upper body and a second staff securing the legs. She said they had not completed transfer training for all of the aides and that training was scheduled to be done later in the week on 03/28/14. During an interview on 03/26/14 at 5:15 p.m., the ADON said all the aides had not been trained on how to properly transfer totally dependent residents. She said that training was scheduled 03/28/14 with therapy to train all of the aides properly. An undated document entitled Transfers provided with the Transferring a Resident policy dated March, 2012 instructed when transferring a resident always place a belt around the waist of the resident. In the section Two Man Lift (dependent) indicated: if a resident is unable to bear weight on his/her legs, it will be necessary for two people to transfer in and out of bed. The lifting is done through proper mechanical use of the body. Staff may want to practice on another member of the staff. It may be necessary to use a mechanical lift (Hoyer). Further it instructed to lift from the chair to the bed by: placing the chair at the side of the bed, Lifter A (larger person in stature) to stand behind the chair and Lifter B at the foot of the chair, Lifter A folds the resident's arms across the chest and places own arms under the resident's armpits and grasps the arms, Lifter B places one arm under the resident's thighs and the other arm around ankles, on the count of three Lifter B pulls resident's legs away from the foot of the chair and Lifter A leans back with his/her body firmly holding the top of the resident's body to his/her chest and when the resident's body is out flat in the air, the shift is made over the arm of the chair to the bed. The CMS 672 dated 03/25/14 indicated there were 12 residents totally dependent on staff for transfers.

Based on observation, interview, and record review, the facility failed to thoroughly assess 1 of 6 residents sampled for falls. (Resident #46) On 3/13/11, Resident #46 experienced a low blood sugar (hypoglycemic) episode, fell sustaining injuries, and was transported to the ER. He was returned from the hospital 3/13/11 at 2:00 p.m. and fell again on 3/14/11. At 4:00 a.m. he was found unresponsive in his bed and again transported to the ER. From 3/13/11 at 2:00 p.m. to 3/14/11 at 4:00 a.m. (14 hours), the facility did not re-assess the resident's blood sugar or conduct a thorough skin assessment to identify or treat injuries. This failure contributed to Resident #46 being sent for emergency care twice in a 24 hour period. This failure could place 48 residents who were on fall precautions at risk for undetected injuries and delay in treatment and could place 23 residents with diabetes at risk for blood sugar fluctuations. Findings included: An MDS dated [DATE] indicated Resident #46 was [AGE] years old, admitted on [DATE], and had [DIAGNOSES REDACTED]. March 2011 physician orders [REDACTED]. Resident #46's nursing notes dated 3/13/11 at 9:20 a.m. documented an unidentified CNA called the nurse (unidentified) to the resident's room and the resident was lying face down on the floor next to the bed. Resident #46 had a laceration above his right eye, his speech was slurred and he had a decreased level of consciousness. EMS was called and arrived at 9:30 a.m. to transport the resident to the hospital. ER nursing notes dated 3/13/11 documented the following regarding Resident #46: *at 9:43 a.m., a blood sugar of 15 en route to the hospital, periods of apnea, a skin tear to his right elbow, and a laceration of right eye brow that measured 2.6 x 7.5 cm with moderate bleeding. *at 9:45 a.m., a blood sugar of 14. *at 1:42 p.m., a blood sugar of 55. *at 2:12 p.m., a blood sugar of 134. *at 2:13 p.m., returned to the facility and ER nurse reported to LVN E that the resident was administered 4 [MEDICATION NAME] of [MEDICATION NAME] IV to increase his blood sugar. Nursing notes dated 3/13/11 at 2:00 p.m. documented Resident #46 returned from the ER. He had a sutured laceration to the right eyebrow and bruising to the right side of his face and right eye. There was no documentation of the resident having other injuries or that the resident's blood sugar was checked. A nursing note dated 3/13/11 at 7:30 p.m. included no documentation regarding Resident #46's blood sugar level or that his skin was assessed. A physician telephone order dated 3/13/11 noted staff were to check Resident #46's blood sugar daily at 7:00 a.m. for one week. Resident #46's March 2011 MAR indicated [REDACTED]. Resident #46's nursing notes dated 3/14/11 documented the following: *at 1:30 a.m. - found on the floor by a CNA. No injuries were noted. The sutures to the right eye brow were intact. *at 4:15 a.m. - in bed and unresponsive. His blood sugar was checked and the glucometer noted a reading of "low." The resident's pupils were slow to react and EMS was contacted. *at 7:45 a.m. - ER nurse called and said the resident was admitted for [MEDICAL CONDITION](increase heart rate) and [DIAGNOSES REDACTED] (low blood sugar). Emergency Department Notes dated 3/14/11 at 4:45 a.m. documented Resident #46 had a decreased level of consciousness and a blood sugar of 15 en route to hospital. The note indicated the resident was seen in the ER the previous morning for a fall and [DIAGNOSES REDACTED]. The resident had a sutured laceration to the head and multiple skin tears to right forearm and left shoulder that EMS reported were from the previous fall. During an interview on 3/14/11 at 6:16 p.m., LVN E said she was the nurse in charge when Resident #46 fell on [DATE] at about 9:00 a.m. She said she did not take the resident's blood sugar. The hospital reported Resident #46 had a hypoglycemic episode. LVN E said when Resident #46 returned from the ER, she did not assess his skin and she did not check his blood sugar. During an interview on 3/14/11 at 5:23 p.m., LVN F said she was the nurse in charge on 3/13/11 from 3:00 p.m. to 10:00 p.m. She said she did not assess Resident #46's skin or check his blood sugar during her shift. During an interview on 3/14/11 at 5:53 p.m., LVN D said she administered Resident #46 his 8:00 p.m. medications on 3/13/11. She said she did not hold his Glimepiride and she did not check his blood sugar before or after she administered the medication. During an interview on 3/14/11 at 4:45 p.m., LVN G said she was the nurse in charge on 3/13/11 from 10:00 p.m. to 6:00 a.m. She said that at 1:30 a.m., CNA B reported to her Resident #46 was on the floor in his room with an injury to his shoulder. LVN G said she did not assess Resident #46's skin and did not assess or treat the injury to his shoulder. She said at 4:00 a.m. she found Resident #46 in bed unresponsive. She checked his blood sugar and the glucometer read, "low." LVN G said she called EMS and the resident was transferred to the hospital. During an interview with CNA B on 3/15/11 at 10:36 a.m., she said on 3/14/11 at about 1:30 a.m., she found Resident #46 on the floor in his room and she reported the incident to LVN G. She said LVN G checked the resident's vital signs and talked to him, but she did not assess his skin. CNA B said she transferred Resident #46 to bed and noted a large open area to his left shoulder when she changed his clothes. She said she reported it to LVN G. She said LVN G told her that either the EMS workers or the hospital questioned her (LVN G) about the resident's shirt being stuck to an open wound to his left shoulder. During an interview with EMS staff on 3/14/11 at 3:10 p.m., she said she was one of the paramedics who transported Resident #46 on 3/13/11 at 9:00 a.m. and again on 3/14/11 at about 4:00 a.m. She said the skin tear to his left shoulder had dried crusted blood and his shirt stuck to the wound that had no dressing. During an observation of Resident #46's skin in the hospital on [DATE] at 9:15 a.m., he had skin tears to his right elbow, an abrasion/skin tear to his left shoulder, a laceration with sutures to his right eye brow, and reddish purple bruising around his right eye. A list provided by RN O on 3/14/11 indicated 23 residents had diabetes and 48 residents were on fall precautions.

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent the development and worsening of pressure ulcers for 2 of 9 residents sampled with pressure ulcers. (Resident #s 15 and 59) Resident #15 returned from the hospital on [DATE] with no pressure ulcers. The facility identified an unstageable pressure ulcer on Resident #15's coccyx on 2/7/11. Resident #15 developed an unstageable pressure ulcer on her right hip 2/18/11. The facility did not provide assessments for a two week period, pressure relief, or nutritional interventions as recommended by the dietitian on 2/21/11 until after surveyor intervention. The facility did not update the plan of care from 2/18/10 which noted the resident was at risk for skin breakdown. Resident #59 was admitted [DATE] and was not assessed for pressure ulcers until 2/17/11. On 2/17/11 he had 4 pressure ulcers on his coccyx. One of the pressure ulcers was unstageable. No treatments were provided from 2/17 - 28/11. These failures contributed to the development and worsening of pressure sores for Resident #s 15 and 59. This failure could place 9 residents with pressure ulcers at risk for developing new pressure ulcers and worsening of existing pressure ulcers. Findings included: 1. Resident #15's March 2011 consolidated physician orders indicated she was an [AGE] year old female readmitted [DATE]. Resident #15's [DIAGNOSES REDACTED]. Resident #15's most recent plan of care dated 2/18/10 indicated the resident was at risk for skin breakdown. The interventions were as follows: Monitor for incontinence every two hours and as needed. Assist with repositioning as appropriate using padding between pressure areas. Encourage dietary/fluid intake within dietary limits. Assess skin on a weekly basis and as needed-report any breakdown to physician and responsible party. Provide pressure relieving and positioning devices on resident bed and wheelchair as appropriate. Treatments as ordered. Encourage to eat meat, eggs, and milk. Resident #15's quarterly MDS assessment dated [DATE] indicated the resident had no pressure ulcers. Her cognition was severely impaired. She required extensive assistance of one person for bed mobility and transfers. Resident #15's admission nursing assessment dated [DATE] at 2:30 p.m. indicated the resident returned from the hospital with no pressure ulcers. The weekly pressure ulcer record dated 1/25/11 and 2/2/11 indicated Resident #15 did not have a pressure ulcer. A Pressure Ulcer Record for Resident #15 dated 2/7/11 indicated the resident developed an unstageable pressure ulcer to her coccyx with an onset date of 2/7/11. There were no measurements documented on the pressure ulcer record or in the nursing notes for 2/7/11. A telephone physician order dated 2/7/11 noted staff were to cleanse the pressure ulcer on Resident #15's coccyx with normal saline or wound cleanser, apply Santyl (a [MEDICATION NAME] agent) and cover the wound with a dry dressing daily. A Braden scale assessment dated [DATE] indicated Resident #15 was at high risk for pressure sores. A Weekly Pressure Wound Report for Resident #15 dated 2/9/11 noted the pressure ulcer to the coccyx measured 2.7 cm x 3 cm. The ulcer was unstageable, had no drainage or odor, and there was yellow slough in the wound bed. A telephone physician order dated 2/14/11 noted Resident #15 was to have a low air loss mattress to promote wound healing and pressure relief. A Weekly Pressure Wound Report dated 2/15/11 indicated Resident #15's pressure ulcer to the coccyx measured 3 cm x 3 cm. It had serous drainage, a small amount of brown exudate (dead tissue), and black eschar (dead tissue that may appear black and leathery) in the bed of the wound. Resident #15's nursing notes dated 2/15/11 noted the responsible party was informed the pressure ulcer had worsened. Nursing notes dated 2/16/11 indicated the physician's office was notified there were no changes to Resident #15's wound. The facility continued to treat the pressure ulcer with Santyl. Resident #15's Pressure Ulcer Record dated 2/18/11 indicated the pressure ulcer on the coccyx measured 5.8 cm x 3.5 cm, had serosanguineous drainage (fluid containing serum and blood) and a moderate odor. The resident had an unstageable pressure ulcer to her right hip that measured 0.9 cm x 0.9 cm. A telephone physician order for [REDACTED]. *staff were to cleanse the ulcer to the right hip with normal saline, apply Santyl and cover with an island dressing daily, *a nutritional consult to increase protein to optimize for wound healing, *an air mattress until healed, originally ordered on [DATE], *zinc 220 mg daily, *an appointment with a surgeon for debridement, and *wound care clinic to evaluate/treat in two weeks. Resident #15's dietary progress notes dated 2/21/11 indicated the dietician recommended Prostat be given daily until the resident's wounds healed and a pre-[MEDICATION NAME] level be drawn. Resident #15's February and March 2011 physician orders did not include an order for [REDACTED]. February and March 2011 MARs indicated Resident #15 had not received Prostat. During an interview on 3/9/11 at 10:25 a.m., the ADON said she could not locate Resident #15's pre-[MEDICATION NAME] result. During an interview on 3/10/11 at 5:15 p.m., the ADON said the dietary recommendations for Resident #15 were not addressed. Pressure Ulcer Records for Resident #15 indicated the following: *on 2/24/11 (after debridement on 2/23/11), the ulcer on the coccyx measured 5 cm x 3 cm x 2.6 cm in depth. The ulcer had no eschar with 80% yellow slough and 20% granulation tissue in the wound bed. There was no odor present. *on 2/24/11, the pressure ulcer on the right hip had no changes. *on 2/28/11, the ulcer on the right hip measured 1 cm x 1 cm with less than 0.1 cm in depth. There was slough noted in the wound bed. The note indicated the pressure ulcer was a Stage III. The facility continued to treat the pressure ulcer with Santyl. According to an online source accessed on 3/24/11: <http://www>. rxlist.com/santyl-drug.htm, Santyl is used to debride necrotic tissue. *on 3/2/11, the pressure ulcer on the coccyx had a depth of 2.7 cm. The facility continued to treat the pressure ulcer with Santyl. *on 3/2/11 there was no change in the pressure ulcer on the right hip. During an observation on 3/8/11 at 2:20 p.m., Resident #15 was lying in bed on an air mattress with a turn dial setting. LVN A provided wound care. The ulcer to the resident's coccyx measured 4.5 cm x 3.5 cm x 3.5 cm. and had a foul odor. The facility continued to treat the pressure ulcer with Santyl. The pressure ulcer on Resident #15's right hip was unstageable and measured 1.3 cm x 2 cm and the entire wound bed was covered with yellow slough. During an interview on 3/8/11 at 3:05 p.m., the treatment nurse said she attempted to contact the physician yesterday regarding Resident #15 and she had still not spoken with the physician today. During an observation on 3/8/11 at 3:54 p.m., Resident #15's mattress had been changed and had a digital setting. The setting on the pump for the mattress was 9 which indicated a setting for a 350 lb individual. During an interview on 3/11/11 at 9:16 a.m., the ADON said Resident #15's weight for March 2011 was 109.8 lbs. During observations on 3/9/11 at 9:50 a.m. and 10:53 a.m., Resident #15 was lying in bed. The setting on the pump for the air mattress was 6 which indicated a setting for a 245 lb individual. During an observation on 3/9/11 at 11:30 a.m., CNAs B and C were assisting Resident #15 out of bed. The setting on the pump for the mattress was 6 which indicated a setting for a 245 lb individual. During an interview on 3/9/11 at 11:45 a.m., LVN D said she did not know what the numbers on the pump meant. She thought the numbers had to do with the weight of the resident. She verified the reading on the pump was 6. During an interview on 3/9/11 at 11:50 a.m., LVN E said the pump for Resident #15 should be on 4, which indicated a weight of 140 lbs. LVN E said the mattress with the dial had been removed from Resident #15's bed yesterday because the pump had failed. LVN E said the staff had not been in-serviced on the new mattress. 2. Resident #59's January 2011 consolidated physician orders indicated he was a [AGE] year old male admitted [DATE]. Resident #59's [DIAGNOSES REDACTED]. Resident #59's admission MDS assessment dated [DATE] indicated he was independent for daily decision making, had no pressure sores, and required total assistance of two persons for bed mobility/transfers. Resident #59's admission nursing notes dated 1/14/11 at 4:30 p.m. indicated the resident had no pressure ulcers. A Weekly Skin Assessment record for Resident #59 dated 2/17/11 indicated the resident had developed a pressure ulcer to his coccyx. The record noted, "new area of eschar et Stage II's to area tx for stage I." The assessment record indicated the following: *Pressure Ulcer 1 measured 7.5 cm x 3 cm to coccyx, unstageable, *Pressure Ulcer 2 measured 2.5 cm x 1.5 cm, Stage II, and *Pressure Ulcer 3 measured 1 cm x 1.5 cm, Stage II. There was no drainage to the pressure ulcers. During an interview on 3/9/11 at 4:00 p.m., the ADON said the facility had not routinely performed weekly skin assessments until February 2011. The facility Pressure Ulcer Risk Assessment policy, revised April 2007, indicated skin would be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. A comprehensive plan of care dated 2/17/11 indicated Resident #59 had one unstageable and three Stage II pressure ulcers to the coccyx. The approaches included: Perform treatment to area as ordered by physician. If no improvement within 2 weeks, report to physician. Inform family and MD of progress. Resident #59's February 2011 physician orders indicated there were no treatment orders for the coccyx. Resident #59's February 2011 Treatment Record indicated the coccyx was to be cleaned with normal saline or wound cleanser and Santyl ([MEDICATION NAME] agent) applied to the black eschar for Pressure Ulcer 1 and Hydrogel to the three Stage IIs daily. The treatment record was not initialed to indicate the treatments had been performed from 2/17/11 to 2/28/11 (11 days). A Pressure Ulcer Record dated 2/24/11 indicated Resident #59 had the following pressure ulcers on the coccyx: *Pressure Ulcer 1 remained unstageable and measured 7.5 cm x 3 x cm. *Pressure Ulcer 2 measured 2.5 cm x 1.5 cm with less than 0.1 cm in depth. *Pressure Ulcer 3 measured 0.8 cm x 1.3 cm with less than 0.1 in depth. Pressure ulcers 2 and 3 had serous (greenish color) drainage with an odor. There was no documentation in the nursing notes to indicate the physician or family had been notified of the changes to the pressure ulcers. The facility Weekly Pressure Log Report dated 3/2/11 indicated Resident #59's pressure ulcers were measured and there were no changes to the wounds. During an observation of wound care for Resident #59 on 3/9/11 2:45 p.m., Pressure Ulcer 1 had black eschar and a foul odor. The treatment nurse measured the ulcer directly above the sacral area between the buttock folds as 10 cm x 7 cm with a depth of 0.5 cm. Pressure Ulcer 2 measured 3.5 cm x 5 cm and Pressure Ulcer 3 measured 5.5 cm x 5 cm. During an interview on 3/9/11 at 2:50 p.m., Resident #59 said "I got the decubitus in here." He said "I can't feel anything down there" (referring to below his waist area). He said that there was one aide that always turned him when she was on duty, but she had been gone several days and when she returned she told him he had a pressure ulcer on his buttock. Resident #59's nursing notes dated 3/8/11 at 6:00 p.m. indicated a physician order for [REDACTED]. During an interview on 3/9/11 at 4:15 p.m., the DON said Resident #59 had not been seen by the wound care center because of his inability to transfer. During an interview on 3/10/11 at 11:30 a.m., the DON said Resident #59 had not been seen by an outside wound care agency because he did not have funding yet. Resident #59 was pending approval for Medicaid services. The facility Pressure Ulcer Treatment policy, revised December 2007, indicated the following definitions for stages of pressure ulcers: A stage I pressure ulcer was defined as "Intact skin with non-blanchable redness of a localized area usually over a bony prominence." A stage II ulcer was defined as "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." An unstageable pressure ulcer was defined as "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." A census list dated 3/8/11 indicated 9 residents had pressure ulcers.

Based on interview and record review, the facility failed to consult the physician and inform the resident's legal representative for 2 of 9 residents sampled with pressure ulcers. (Resident #s 15 and 59) Resident #15 returned from the hospital on [DATE] with no pressure ulcers. The facility identified an unstageable pressure ulcer on Resident #15's coccyx on 2/7/11. Resident #15 developed an unstageable pressure ulcer on her right hip 2/18/11. The facility did not consult the physician or inform the legal representative when the pressure ulcers worsened. The facility did not consult the physician to address a dietary recommendation for 15 days. Resident #59 developed 4 pressure ulcers to his coccyx on 2/17/11. One of the pressure ulcers was unstageable. No treatments were provided from 2/17 - 28/11 and the ulcer to the coccyx worsened. The physician was not consulted. These failures contributed to the development and worsening of pressure sores for Resident #s 15 and 59. This failure could place 9 residents with pressure ulcers at risk for developing new pressure ulcers and worsening of existing pressure ulcers. Findings included: 1. Resident #15's March 2011 consolidated physician orders indicated she was an [AGE] year old female and had [DIAGNOSES REDACTED]. Resident #15's quarterly MDS assessment dated [DATE] indicated the resident had no pressure ulcers. Her cognition was severely impaired. She required extensive assistance of one person for bed mobility and transfers. Resident #15's admission nursing assessment dated [DATE] at 2:30 p.m. indicated the resident returned from a hospitalization with no pressure ulcers. The weekly pressure ulcer records dated 1/25/11 and 2/2/11 indicated Resident #15 did not have pressure ulcers. A Pressure Ulcer Record for Resident #15 dated 2/7/11 indicated the resident developed an unstageable pressure ulcer to her coccyx with an onset date of 2/7/11. A telephone physician order dated 2/7/11 noted staff were to cleanse the pressure ulcer on Resident #15's coccyx with normal saline or wound cleanser, apply Santyl (a [MEDICATION NAME] agent) and cover the wound with a dry dressing daily. A Braden scale assessment dated [DATE] indicated Resident #15 was at high risk for pressure sores. A Weekly Pressure Wound Report for Resident #15 dated 2/9/11 noted the pressure ulcer to the coccyx measured 2.7 cm x 3 cm. The ulcer was unstageable, had no drainage or odor, and there was yellow slough in the wound bed. A Weekly Pressure Wound Report dated 2/15/11 indicated Resident #15's pressure ulcer to the coccyx measured 3 cm x 3 cm. It had serous drainage, a small amount of brown exudate (dead tissue), and black eschar (dead tissue that may appear black and leathery) in the bed of the wound. Resident #15's nursing notes dated 2/15/11 noted the responsible party was informed the pressure ulcer had worsened. Nursing notes dated 2/16/11 indicated the physician's office was notified there were no changes to Resident #15's wound. The facility continued to treat the pressure ulcer with Santyl. Resident #15's Pressure Ulcer Record dated 2/18/11 indicated the pressure ulcer on the coccyx measured 5.8 cm x 3.5 cm, had serosanguineous drainage (fluid containing serum and blood) and a moderate odor. The resident had an unstageable pressure ulcer to her right hip that measured 0.9 cm x 0.9 cm. A telephone physician order for [REDACTED]. *staff were to cleanse the ulcer to the right hip with normal saline, apply Santyl and cover with an island dressing daily, *a nutritional consult to increase protein to optimize for wound healing, *an air mattress until healed originally ordered on [DATE], *zinc 220 mg daily, *an appointment with a surgeon for debridement, and *wound care clinic to evaluate/treat in two weeks Resident #15's Dietary Progress Notes dated 2/21/11 indicated the dietician recommended Prostat be given daily until the resident's wounds healed and a pre-[MEDICATION NAME] level be drawn. Resident #15's February and March 2011 physician orders did not include an order for [REDACTED]. February and March 2011 MARs indicated Resident #15 had not received Prostat. During an interview on 3/9/11 at 10:25 a.m., the ADON said she could not locate Resident #15's pre-[MEDICATION NAME] result. During an interview on 3/10/11 at 5:15 p.m., the ADON said the dietary recommendations for Resident #15 were not addressed. Pressure Ulcer Records for Resident #15 indicated the following: *on 2/24/11 (after debridement on 2/23/11), the ulcer on the coccyx measured 5 cm x 3 cm x 2.6 cm in depth. The ulcer had no eschar with 80% yellow slough and 20% granulation tissue in the wound bed. There was no odor present. *on 2/24/11, the pressure ulcer on the right hip had no changes. *on 2/28/11, the ulcer on the right hip measured 1 cm x 1 cm with less than 0.1 cm in depth. There was slough noted in the wound bed. The note indicated the pressure ulcer was a Stage III. The facility continued to treat the pressure ulcer with Santyl. According to an online source accessed on 3/24/11: <http://www>. rxlist.com/santyl-drug.htm, Santyl is used to debride necrotic tissue. *on 3/2/11, the pressure ulcer on the coccyx had a depth of 2.7 cm. The facility continued to treat the pressure ulcer with Santyl. *on 3/2/11 there was no change in the pressure ulcer on the right hip. During an interview on 3/8/11 at 3:05 p.m., the treatment nurse said she attempted to contact the physician regarding Resident #15 yesterday and she had still not spoken with the physician today. 2. Resident #59's January 2011 consolidated physician orders indicated he was a [AGE] year old male admitted [DATE]. Resident #59's [DIAGNOSES REDACTED]. Resident #59's admission MDS assessment dated [DATE] indicated he was independent for daily decision making, had no pressure sores, and required total assistance of two persons for bed mobility/transfers. Resident #59's admission nursing notes dated 1/14/11 at 4:30 p.m. indicated the resident had no pressure ulcers. A Weekly Skin Assessment record for Resident #59 dated 2/17/11 indicated the resident had developed a pressure ulcer to his coccyx. The record noted "new area of eschar et Stage II's to area tx for stage I." The assessment record indicated the following: *Pressure Ulcer 1 measured 7.5 cm x 3 cm to coccyx, unstageable, *Pressure Ulcer 2 measured 2.5 cm x 1.5 cm, Stage II, and *Pressure Ulcer 3 measured 1 cm x 1.5 cm, Stage II, There was no drainage to the pressure ulcers. Resident #59's February 2011 physician orders indicated there were no treatment orders for the coccyx. Resident #59's February 2011 Treatment Record indicated the coccyx was to be cleaned with normal saline or wound cleanser and Santyl ([MEDICATION NAME] agent) applied to the black eschar for Pressure Ulcer 1 and Hydrogel to the two Stage II's daily. The treatment record was not initialed to indicate the treatments had been performed from 2/17/11 to 2/28/11 (11 days). A Pressure Ulcer Record dated 2/24/11 indicated Resident #59 had the following pressure ulcers on the coccyx: *Pressure Ulcer 1 - remained unstageable and measured 7.5 cm x 3 x cm. *Pressure Ulcer 2 - measured 2.5 cm x 1.5 cm with less than 0.1 cm in depth. *Pressure Ulcer 3 - measured 0.8 cm x 1.3 cm with less than 0.1 in depth. Pressure ulcer 2 and 3 had serous (greenish color) drainage with an odor. There was no documentation in the nursing notes to indicate the physician or family had been notified of the changes to the pressure ulcers. The facility Weekly Pressure Log Report dated 3/2/11 indicated Resident #59's pressure ulcers were measured and there were no changes to the wounds. During an observation of wound care for Resident #59 on 3/9/11 2:45 p.m., Pressure Ulcer 1 had black eschar and a foul odor. The treatment nurse measured the ulcer directly above the sacral area between the buttock folds as 10 cm x 7 cm with a depth of 0.5 cm. Pressure Ulcer 2 measured 3.5 cm x 5 cm and Pressure Ulcer 3 measured 5.5 cm x 5 cm. Resident #59's nursing notes dated 3/8/11 at 6:00 p.m. indicated a physician order for [REDACTED]. During an interview on 3/9/11 at 4:15 p.m., the DON said Resident #59 had not been seen by the wound care center because of his inability to transfer. The facility Pressure Ulcer Treatment policy, revised December 2007, indicated the following definitions for stages of pressure ulcers: A stage I pressure ulcer was defined as "Intact skin with non-blanchable redness of a localized area usually over a bony prominence." A stage II ulcer was defined as "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." An unstageable pressure ulcer was defined as "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." A census list dated 3/8/11 indicated 9 residents had pressure ulcers.

Based on interview and record review, the facility failed to perform skin assessments and provide treatment changes in a timely manner for 2 of 9 residents sampled with pressure ulcers. (Resident #s 15 and 59) Resident #15 returned from the hospital on [DATE] with no pressure ulcers. The facility identified an unstageable pressure ulcer on Resident #15's coccyx on 2/7/11. The facility did not assess the pressure ulcer for 2 days. Resident #15 developed an unstageable pressure ulcer on her right hip 2/18/11. The facility did not provide assessments for a two week period, or pressure relief or nutritional interventions as recommended by the dietitian on 2/21/11 until after surveyor intervention. Resident #59 was admitted [DATE] and was not assessed for pressure ulcers until 2/17/11. On 2/17/11 he had 4 pressure ulcers on his coccyx. One of the pressure ulcers was unstageable. No treatments were provided from 2/17 - 28/11. These failures contributed to the development and worsening of pressure sores for Resident #s 15 and 59. This failure could place 9 residents with pressure ulcers at risk for developing new pressure ulcers and worsening of existing pressure ulcers. Findings included: 1. Resident #15's March 2011 consolidated physician orders [REDACTED]. Resident #15's [DIAGNOSES REDACTED]. Resident #15's most recent plan of care dated 2/18/10 indicated the resident was at risk for skin breakdown. The interventions included assess skin on a weekly basis and as needed and report any breakdown to physician and responsible party. Resident #15's quarterly MDS assessment dated [DATE] indicated the resident had no pressure ulcers. Her cognition was severely impaired. She required extensive assistance of one person for bed mobility and transfers. Resident #15's admission nursing assessment dated [DATE] at 2:30 p.m. indicated the resident returned from the hospital with no pressure ulcers. The weekly pressure ulcer record dated 1/25/11 and 2/2/11 indicated Resident #15 did not have a pressure ulcer. A Pressure Ulcer Record for Resident #15 dated 2/7/11 indicated the resident developed an unstageable pressure ulcer to her coccyx with an onset date of 2/7/11. There were no measurements documented on the pressure ulcer record or in the nursing notes for 2/7/11. A telephone physician order [REDACTED].#15's coccyx with normal saline or wound cleanser, apply Santyl (a [MEDICATION NAME] agent) and cover the wound with a dry dressing daily. A Braden scale assessment dated [DATE] indicated Resident #15 was at high risk for pressure sores. A Weekly Pressure Wound Report for Resident #15 dated 2/9/11 noted the pressure ulcer to the coccyx measured 2.7 cm x 3 cm. The ulcer was unstageable, had no drainage or odor, and there was yellow slough in the wound bed. A telephone physician order [REDACTED]. A Weekly Pressure Wound Report dated 2/15/11 indicated Resident #15's pressure ulcer to the coccyx measured 3 cm x 3 cm. It had serous drainage, a small amount of brown exudate (dead tissue), and black eschar (dead tissue that may appear black and leathery) in the bed of the wound. Resident #15's nursing notes dated 2/15/11 noted the responsible party was informed the pressure ulcer had worsened. Nursing notes dated 2/16/11 indicated the physician's office was notified there were no changes to Resident #15's wound. The facility continued to treat the pressure ulcer with Santyl. Resident #15's Pressure Ulcer Record dated 2/18/11 indicated the pressure ulcer on the coccyx measured 5.8 cm x 3.5 cm, had serosanguineous drainage (fluid containing serum and blood) and a moderate odor. The resident had an unstageable pressure ulcer to her right hip that measured 0.9 cm x 0.9 cm. A telephone physician order [REDACTED]. *staff were to cleanse the ulcer to the right hip with normal saline, apply Santyl and cover with an island dressing daily. *a nutritional consult to increase protein to optimize for wound healing, *an air mattress until healed originally ordered on [DATE], *zinc 220 mg daily, *an appointment with a surgeon for debridement, and *wound care clinic to evaluate/treat in two weeks Pressure Ulcer Records for Resident #15 indicated the following: *on 2/24/11 (after debridement on 2/23/11), the ulcer on the coccyx measured 5 cm x 3 cm x 2.6 cm in depth. The ulcer had no eschar with 80% yellow slough and 20% granulation tissue in the wound bed. There was no odor present. *on 2/24/11, the pressure ulcer on the right hip had no changes. *on 2/28/11, the ulcer on the right hip measured 1 cm x 1 cm with less than 0.1 cm in depth. There was slough noted in the wound bed. The note indicated the pressure ulcer was a Stage III. The facility continued to treat the pressure ulcer with Santyl. According to an online source accessed on 3/24/11: <http://www>. rxlist.com/santyl-drug.htm, Santyl is used to debride necrotic tissue. *on 3/2/11, the pressure ulcer on the coccyx had a depth of 2.7 cm. The facility continued to treat the pressure ulcer with Santyl. *on 3/2/11 there was no change in the pressure ulcer on the right hip. During an observation on 3/8/11 at 2:20 p.m., Resident #15 was lying in bed on an air mattress with a turn dial setting. LVN A provided wound care. The ulcer to the resident's coccyx measured 4.5 cm x 3.5 cm x 3.5 cm. and had a foul odor. The facility continued to treat the pressure ulcer with Santyl. The pressure ulcer on Resident #15's right hip was unstageable and measured 1.3 cm x 2 cm and the entire wound bed was covered with yellow slough. In an interview on 3/8/11 at 3:05 p.m., the treatment nurse said she attempted to contact the physician for Resident #15 yesterday and she had still not spoken with the physician today. 2. Resident #59's January 2011 consolidated physician orders [REDACTED]. Resident #59's [DIAGNOSES REDACTED]. Resident #59's admission MDS assessment dated [DATE] indicated he was independent for daily decision making, had no pressure sores, and required total assistance of two persons for bed mobility/transfers. Resident #59's admission nursing notes dated 1/14/11 at 4:30 p.m. indicated the resident had no pressure ulcers. A Weekly Skin Assessment record for Resident #59 dated 2/17/11 indicated the resident had developed a pressure ulcer to his coccyx. The record noted " new area of eschar et Stage II's to area tx for stage I." The assessment record indicated the following: *Pressure Ulcer 1 measured 7.5 cm x 3 cm to coccyx, unstageable, *Pressure Ulcer 2 measured 2.5 cm x 1.5 cm, Stage II, and *Pressure Ulcer 3 measured 1 cm x 1.5 cm, Stage II, There was no drainage to the pressure ulcers. During an interview on 3/9/11 at 4:00 p.m., the ADON said the facility had not routinely performed weekly skin assessments until February 2011. The facility Pressure Ulcer Risk Assessment policy, revised April 2007, indicated skin would be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. A comprehensive plan of care dated 2/17/11 indicated Resident #59 had one unstageable and three Stage II pressure ulcers to the coccyx. The approaches were: Perform treatment to area as ordered by physician. If no improvement within 2 weeks, report to physician. Inform family and MD of progress. Resident #59's February 2011 physician orders [REDACTED]. Resident #59's February 2011 Treatment Record indicated the coccyx was to be cleaned with normal saline or wound cleanser and Santyl ([MEDICATION NAME] agent) applied to the black eschar for Pressure Ulcer 1 and Hydrogel to the two Stage II's daily. The treatment record was not initialed to indicate the treatments had been performed from 2/17/11 to 2/28/11 (11 days). A Pressure Ulcer Record dated 2/24/11 indicated Resident #59 had the following pressure ulcers on the coccyx: *Pressure Ulcer 1 - remained unstageable and measured 7.5 cm x 3 x cm. *Pressure Ulcer 2 - measured 2.5 cm x 1.5 cm with less than 0.1 cm in depth. *Pressure Ulcer 3 - measured 0.8 cm x 1.3 cm with less than 0.1 in depth. Pressure ulcer 2 and 3 had serous (greenish color) drainage with an odor. There was no documentation in the nursing notes to indicate the physician or family had been notified of the changes to the pressure ulcers. The facility Weekly Pressure Log Report dated 3/2/11 indicated Resident #59's pressure ulcers were measured and there were no changes to the wounds. During an observation of wound care for Resident #59 on 3/9/11 2:45 p.m., Pressure Ulcer 1 had black eschar and a foul odor. The treatment nurse measured the ulcer directly above the sacral area between the buttock folds as 10 cm x 7 cm with a depth of 0.5 cm. Pressure Ulcer 2 measured 3.5 cm x 5 cm and Pressure Ulcer 3 measured 5.5 cm x 5 cm. In an interview on 3/9/11 at 2:50 p.m., Resident #59 said "I got the decubitus in here." He said "I can't feel anything down there" (referring to below his waist area). He said that there was one aide that always turned him when she was on duty, but she had been gone several days and when she returned, she told him he had a pressure ulcer on his buttock. Resident #59's nursing notes dated 3/8/11 at 6:00 p.m. indicated a physician order [REDACTED]. During an interview on 3/9/11 at 4:15 p.m., the DON said Resident #59 had not been seen by the wound care center because of his inability to transfer. The facility Pressure Ulcer Treatment policy, revised December 2007, indicated the following definitions for stages of pressure ulcers: A stage I pressure ulcer was defined as "Intact skin with non-blanchable redness of a localized area usually over a bony prominence." A stage II ulcer was defined as "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." An unstageable pressure ulcer was defined as "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." A census list dated 3/8/11 indicated 9 residents had pressure ulcers.

Based on interview and record review, the facility failed to revise a comprehensive plan of care for 1 of 9 residents sampled with pressure ulcers. (Resident #15) Resident #15 returned from the hospital on [DATE] with no pressure ulcers. The facility identified an unstageable pressure ulcer on Resident #15's coccyx on 2/7/11. Resident #15 developed an unstageable pressure ulcer on her right hip 2/18/11. The facility did not update the plan of care from 2/18/10 which noted the resident was at risk for skin breakdown. This failure could place 9 residents with pressure ulcers at risk for developing new pressure ulcers and worsening of existing pressure ulcers. Findings included: 1. Resident #15's March 2011 consolidated physician orders [REDACTED]. Resident #15's [DIAGNOSES REDACTED]. Resident #15's most recent plan of care dated 2/18/10 indicated the resident was at risk for skin breakdown. The interventions were as follows: Monitor for incontinence every two hours and as needed. Assist with repositioning as appropriate using padding between pressure areas. Encourage dietary/fluid intake within dietary limits. Assess skin on a weekly basis and as needed-report any breakdown to physician and responsible party. Provide pressure relieving and positioning devices on resident bed and wheelchair as appropriate. Treatments as ordered. Encourage to eat meat, eggs, and milk. Resident #15's quarterly MDS assessment dated [DATE] indicated the resident had no pressure ulcers. Her cognition was severely impaired. She required extensive assistance of one person for bed mobility and transfers. Resident #15's admission nursing assessment dated [DATE] at 2:30 p.m. indicated the resident returned from the hospital with no pressure ulcers. The weekly pressure ulcer record dated 1/25/11 and 2/2/11 indicated Resident #15 did not have a pressure ulcer. A Pressure Ulcer Record for Resident #15 dated 2/7/11 indicated the resident developed an unstageable pressure ulcer to her coccyx with an onset date of 2/7/11. The plan of care was not revised for Resident#15. A Weekly Pressure Wound Report for Resident #15 dated 2/9/11 noted the pressure ulcer to the coccyx measured 2.7 cm x 3 cm. The ulcer was unstageable, had no drainage or odor, and there was yellow slough in the wound bed. A Weekly Pressure Wound Report dated 2/15/11 indicated Resident #15's pressure ulcer to the coccyx measured 3 cm x 3 cm. It had serous drainage, a small amount of brown exudate (dead tissue), and black eschar (dead tissue that may appear black and leathery) in the bed of the wound. Resident #15's nursing notes dated 2/15/11 noted the responsible party was informed the pressure ulcer had worsened. The resident's care plan was not revised. Nursing notes dated 2/16/11 indicated the physician's office was notified there were no changes to Resident #15's wound. The facility continued to treat the pressure ulcer with Santyl. Resident #15's Pressure Ulcer Record dated 2/18/11 indicated the pressure ulcer on the coccyx measured 5.8 cm x 3.5 cm, had serosanguineous drainage (fluid containing serum and blood) and a moderate odor. The resident had an unstageable pressure ulcer to her right hip that measured 0.9 cm x 0.9 cm. Pressure Ulcer Records indicated the following: *on 2/24/11 (after debridement on 2/23/11), the ulcer on the coccyx measured 5 cm x 3 cm x 2.6 cm in depth. The ulcer had no eschar with 80% yellow slough and 20% granulation tissue in the wound bed. There was no odor present. *on 2/24/11, the pressure ulcer on the right hip had no changes. *on 2/28/11, the ulcer on the right hip measured 1 cm x 1 cm with less than 0.1 cm in depth. There was slough noted in the wound bed. The note indicated the pressure ulcer was a Stage III. The facility continued to treat the pressure ulcer with Santyl. According to an online source accessed on 3/24/11: <http://www>. rxlist.com/santyl-drug.htm, Santyl is used to debride necrotic tissue. *on 3/2/11, the pressure ulcer on the coccyx had a depth of 2.7 cm. The facility continued to treat the pressure ulcer with Santyl. *on 3/2/11 there was no change in the pressure ulcer on the right hip. During an observation on 3/8/11 at 2:20 p.m., Resident #15 was lying in bed on an air mattress with a turn dial setting. LVN A provided wound care. The ulcer to the resident's coccyx measured 4.5 cm x 3.5 cm x 3.5 cm. and had a foul odor. The facility continued to treat the pressure ulcer with Santyl. The pressure ulcer on Resident #15's right hip was unstageable and measured 1.3 cm x 2 cm and the entire wound bed was covered with yellow slough. During an interview on 3/8/11 at 3:05 p.m., the treatment nurse said she attempted to contact the physician for Resident #15 yesterday and she had still not spoken with the physician today. The facility Pressure Ulcer Treatment policy, revised December 2007, indicated the following definitions for stages of pressure ulcers: A stage I pressure ulcer was defined as "Intact skin with non-blanchable redness of a localized area usually over a bony prominence." A stage II ulcer was defined as "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." An unstageable pressure ulcer was defined as "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." A census list dated 3/8/11 indicated 9 residents had pressure ulcers.