Every finding on record at Williamsburg Village Healthcare Campus

Based on observation, interview and record review the facility failed to develop the comprehensive care plan within seven days of the completion of the comprehensive assessment and review and revise the care plan after each assessment for 2 of 3 residents (Resident #1 and Resident #2) reviewed for comprehensive care plans in that: The facility failed to ensure Resident #1's care plan, dated 05/21/26, was revised to address his recent incident of aggression toward another resident on 07/15/2026.The facility failed to ensure Resident #2's care plan, dated 07/03/26, was revised after completion of the comprehensive assessment to include goals, preferences and care needs of the resident. This failure placed residents at risk of not receiving timely and appropriate individualized care to prevent harm.Findings included: Record review of Resident #1's Quarterly MDS dated [DATE], reflected he was a [AGE] year-old male admitted on [DATE]. Resident #1 had a BIMS score of 05, indicating he was severely impaired cognitively. Section D: Mood and Section E: Behaviors reflected no issues. Resident #1's ADL functional abilities reflected that he required substantial assistance from staff. Section I Active Diagnosis reflected Resident #1 had Dementia (memory loss), he was hemiplegia (paralyzed on one side of the body), anxiety disorder (mood disorder of excessive worrying), Depression (mood disorder of sadness). Record review of Resident #1's care plan dated 05/21/26 reflected Goal Psychotropic Medication-Antidepressant: Consult MD and psychiatric services.Administer medication as ordered.Monitor for adverse reactions.Monitor for effectiveness.Monitor behavior and mood.Administer medication as ordered.monitor for adverse reactions, effectiveness, behavior and mood.Report new onset or worsening of cognitive impairment promptly to MD and psychiatric services.Treat underlying cause per MD orders.Calm quiet environment Redirection.Analyze key times, places, circumstances, triggers, and what de-escalates behavior.Calm quiet environment Redirection as needed. Goal dated 05/21/2026 Behaviors breaking Targeted behaviors breaking window on 05/21/2026.Calm quiet environment, redirection as needed. Analyze key times, places, circumstances, triggers, and what de-escalates behavior. The care plan did not address resident-to-resident alterations that occurred on 07/15/2026. Record review of Resident #1's incident report dated 07/15/2026 by LVN-W, reflected Resident # 1 was observed confused, moderately impaired cognitively (a clear and noticeable decline in thinking skills, memory, and reasoning that begins to disrupt a person's everyday life and independent tasks.).no injuries observed. Incident Comments reflected resident entered his room and another resident was in his bed, and he attempted to get him out of his bed. Record review of Resident #1's psychiatric follow up evaluations dated 07/15/26 by MD-F reflected the Chief Complaint reflected seen for Psychotropics Management (MD monitoring, adjusting, and prescribing mental health drugs) and evaluate for Depression (Mood disorder with feelings of sadness), Disruptive Mood Disorder mental illness with severe frequent temper outburst), Dementia (loss of memory), and spontaneous psychosis (sudden loss of reality) .patient cognitively impaired (trouble with mental functions like thinking, learning, and remembering). Recommendations: Plan: continue with current medications. He was educated on crisis prevention strategies (plans such as seeking help if needed).he was encouraged to seek help from staff members and informed that the staff are obliged (thankful) to help keep him comfortable. The patient verbalized understanding.monitor for change in mood or behaviors, and resident follow up with PCP for all medical needed. Record review of Resident #1's MD orders dated 07/22/25 reflected an order for (Escitalopram Oxalate) 10 MG tablet for Major depressive disorder, recurrent, severe with psychotic symptoms for Depression 1 tablet by mouth One time daily.an order dated 05/21/2026 for Seroquel 25 MG PO BID X 14 days . In an observation and interview with Resident #1 on 07/30/26 at 9: 30 a.m., he was observed lying in bed covered with a blanket. He was slow to respond in the interview, however after providing some time to respond, he stated that an incident occurred with another resident lying in his bed asleep. He said he asked the resident to get out of his bed, and when he did not move, he pulled him out of the bed to the floor. An observation revealed no visible injuries on Resident #1. In a second interview Resident #1 on 07/30/26 at 1:00 p.m., Resident was observed lying in bed resting. An attempted interviewed to further explore details of the resident-to-resident altercation, concluded with Resident #1 not remembering the incident. Record review of Resident #2's admission MDS Assessment, dated 07/05/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #2's BIMS score was not indicated on the document. The MDS Assessment under Section GG-Functional Abilities reflected Resident #2 was dependent on staff for all ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #2 had medically complex conditions and diagnoses that included: cerebral infarction (stroke), hemiplegia, and hemiparesis (total or partial paralysis on one side of body), aphasia (brain disorder that affects speech and understanding), acute respiratory failure, and acute kidney failure. Record review of Resident #2's Care Plan on 07/30/26 at 2:08 p.m., dated 07/03/26, reflected that the document was not revised and did not address Resident #2's health conditions, treatments, or care needs to help the staff manage their caregiving responsibilities. Further review of the document on 07/30/26 at 6:00 p.m. reflected that it had been revised to include all current measurable goals, interventions, and care needs based on the MDS assessment. In an observation and interview on 07/30/26 at 1:12 p.m., Resident #2 was observed lying in bed with his eyes closed and no response to verbal stimuli. Resident #2 was receiving oxygen via tracheostomy with no visible signs of distress. Resident #2 was unable to participate in an interview due to severe cognitive impairment. In an interview on 07/30/26 at 6:50 p.m., the MDSC stated she was aware of Resident #1's recent resident to resident altercation, and it was the responsibility of the DON to update and revise Resident #1's care plan during IDT meetings for acute (sudden) changes. The MDSC stated that it was important for the care plan to reflect the residents individualized goals, interventions, and care to maintain their highest level of functioning and provide safety. She said failing to update a resident care plan after an incident could lead to the resident not receiving the most recent monitoring, supervision, and interventions. In an interview on 07/30/2026 at 7:15 p.m., DON said the clinical staff (nursing) were responsible for initiating the baseline care plan based on MD orders and resident assessments and evaluations at the time of admissions. She said the baseline care plan facilitates the plan of care until the comprehensive care plan was developed in 14 days. DON stated it was ADON's responsibility to update the care plan after the IDT members discussed the resident's individualized goals and interventions. Ongoing monitoring and reviews of the care plan was the responsibility of the DON, ADON, and the IDT members. DON said it was important to update the care plan with new changes in medications, interventions, and other MD recommendations to ensure proper immediate care to the residents. The DON said the risk of failing to update the care plan could result in resident care, monitoring, reporting, and MD contact not being conducted. She stated that it was her expectation for the ADON to update the care plan immediately after IDT meeting. In an interview on 07/30/26 at 7:20 p.m., ADON A stated he worked at the facility for about 3 weeks. He stated he was being oriented and trained on the system and learned how to complete care plans today. ADON A stated he was assigned to Resident #2; however, he was unable to update the resident's care plan as soon as possible or within seven days after the MDS assessment was completed per the facility's policy because he was still being trained. ADON A stated the DON was responsible for overseeing the care plans until he was trained and had access to the system. He stated the purpose of care plans were to document the residents' care needs, establish goals and interventions, and monitor progression towards goals. ADON A stated not having a complete and accurate care plan could place residents at risk of not having care needs met which could cause a decline in health. ADON A stated that the comprehensive care plan must be completed within 14 days after admission. In an interview on 07/30/2026 at 7:25 p.m., ADON-B said it was the DON was the responsibility to revise and update Residents care plans after an incident, change in condition, behaviors. ADON-B stated she knew about the incident and had not updated or reviewed the care plan after they addressed the incident in the IDT meeting on 07/16/2026, due to changing positions. She said the care plan window to update was 72 hours, but then said it was within 24 hours of the IDT meeting and incident. ADON-B said failing to update the care plan would fail to give the staff a comprehensive individualized care plan with interventions that the MD provided for resident care and safety. ADON-B said the resident was at risk of not receiving the most recent care and interventions. In an interview on 07/30/2026 AT 7:29 PM with the ADM, she said it was DON'S responsibility to update care plan with revisions after an incident to ensure the staff were aware of the new interventions, behaviors, and care needs. ADM stated the DON and ADON were responsible for updating the care plan after the IDT meeting. ADM said failing to update the resident care plan could cause harm to self and others, incorrect interventions from staff, and incident reoccurring. Record review of the facility's policy titled Care Plan-Process, reviewed 03/27/23, reflected in part the following: Standard of Practice: The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames.Procedure: Interdisciplinary Team meets & reviews the care plan as follows: Seven (7) days after the closure on the date of the admission MDS Quarterly and annually Within fourteen (14) days after a significant change MDS With any change of condition The team directs care planning toward attaining and maintaining the highest optimal physical, psychosocial, functional status including Advance Directives, and signs the approved Plan of Care.The Plan of Care identifies the: Date Problem Goals, measurable and realistic Time frames for achievement Interventions, discipline specific services, and frequency Resolution/Goal analysis Discharge option

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 7 residents (Residents #3, #4, and #5) reviewed for accommodation of needs.The facility failed to ensure Resident #3, #4, and #5's call lights were placed within reach on 07/10/26. These failures could place residents at risk of injuries and unmet needs. Findings included:Review of Resident #3's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), end stage renal disease (final stage of chronic kidney disease), cerebrovascular accident (stroke), hemiplegia (paralysis that affects only one side of the body), and non-Alzheimer's dementia. The resident had a BIMS score of 3 which indicated her cognition was severely impaired. The MDS further reflected the resident required substantial/maximal assistance with transfers, sit to lying and was dependent for toilet transfers and sit to stand.Review of Resident #3's care plan dated 01/08/26 reflected the resident's problem was mobility and interventions included to assist the resident with daily living activities as needed. Observation and interview on 07/10/26 at 9:43 AM of Resident #3 revealed she was in bed watching TV sitting at an almost 90-degree angle. Her call light was noted to be out of reach and on the floor behind her. The resident said she used her call light to get staff's assistance and then she began to look for it but was not able to find it or reach it when she noticed it on the floor. Interview on 07/10/26 at 2:05 PM with CNA E revealed she had worked with Resident #3 and did not realize her call light was not within reach that day. CNA E said the residents should always have their call lights within reach so they could call on staff when they needed something. Review of Resident #4's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), end stage renal disease (final stage of chronic kidney disease), diabetes, malnutrition, and respiratory failure. Resident #4 had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected the resident was dependent for all ADLs including transfers and hygiene and used a wheelchair for mobility. Review of Resident #4's care plan dated 04/15/26 reflected the resident had limited range of motion of lower bilateral extremities, related to motor vehicle accident with femur, pubic bone, and rib fractures. The care plan further reflected the resident was unable to care for self and was dependent and required extensive assistance. Observation and interview on 07/10/26 at 1:14 PM with Resident #4 revealed she was in bed and had just finished eating her lunch tray. The resident's call light was tied to the bottom rail of her bed and the resident said she was not able to reach it. Resident #4 further stated if she needed assistance from staff, she would have to wait for staff to enter her room and check on her. Interview on 07/10/26 at 2:24 PM with CNA F revealed he/she?? was responsible for making sure the resident's call light was within reach but had not noticed Resident #4 could not get to hers. CNA F said it was important for residents to have access to their call lights so they could call for help or if they needed anything. Review of Resident #5's admission MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart failure, hypertension (high blood pressure), end stage renal disease (final stage of chronic kidney disease), diabetes, arthritis, and pain. Resident #5 had a BIMS score of 12 which indicated her cognition was moderately impaired. The MDS further reflected the resident was dependent with dressing, toileting, and personal hygiene and used a walker/wheelchair for mobility.Observation and interview on 07/10/26 at 1:19 PM of Resident #5 revealed she was sitting in bed eating her lunch. The resident's call light was noted to be on the floor behind her bed, out of reach. The resident said she used her call light when she needed the staff to help her but also said she did not know where it was and had been looking for it. Interview on 07/10/26 at 5:51 PM with LVN G revealed he worked with both Residents #4 and #5 and their call lights were within reach when he had checked their vitals that morning but had not noticed they had become out of reach. LVN G said it was important for residents' call lights to be within reach so they could call staff if they needed assistance. Interview on 07/10/26 at 6:16 PM with the ADON revealed the expectation was that everyone that entered the residents' rooms was responsible for making sure the residents' call lights were within reach. The ADON said it was important for the residents to have access to their call light so they could call for help if they needed something. Interview on 07/10/26 at 6:37 PM with the DON revealed resident call lights should be within their reach, and it was everyone's responsibility to ensure that the residents could call for help or alert staff in case of an emergency. Review of the facility's policy titled Call Lights Answering reviewed on 01/2023 reflected the following: PurposePolicy: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately.Procedure:.7. When leaving the room, be sure call light is placed within the resident's reach.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #1 and #2) reviewed for infection control.1. The facility failed to ensure the Wound Care Nurse performed hand hygiene and changed gloves during wound care for Resident #1.2.CNA A failed to perform hand hygiene while providing incontinence care to Resident #2.This failure could place residents at risk for cross-contamination and infection.Findings included:1. Review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, hemiplegia (paralysis to one side of the body), malnutrition, and respiratory failure. Resident #1 had a BIMS score of 9 which indicated his cognition was moderately impaired. The MDS reflected the resident was dependent with most all ADLs including toileting and personal hygiene. The MDS further reflected Resident #1 was always incontinent of both bowel and bladder. The MDS further reflected Resident #1 was at risk of developing pressure ulcers/injuries. Review of Resident #1's care plan dated 06/08/26 reflected the resident was at risk of skin breakdown and interventions included to keep the skin clean. The care plan further reflected Resident #1 was at severe risk of skin breakdown. Interventions included to keep the skin clean and moisturized. Review of Resident #1's Treatment Record revealed he was receiving care to his end-stage skin failure (irreversible breakdown of skin caused by the body shutting wound of the sacrum. Cleanse with normal saline, pat dry, apply Medi-honey and collagen powder. Cover with a dry dressing on Tuesday, Thursday, and Saturday.Observation on 07/10/26 at 10:20 AM, revealed the Wound Care Nurse got all supplies ready outside Resident #1's room. He disinfected the table and left it to dry. He washed hands, put on gown and gloves. He entered Resident #1's room and explained the procedure. He put all the supplies together and wheeled the table to the bedside. He sanitized and put on clean gloves. He removed the old dressing which was observed soaked with drainage. He failed to change gloves and wash hands. He cleansed Resident #1's pressure ulcer on the sacrum with normal saline soaked gauze. He removed gloves sanitized and applied gauze soaked with 1/4 strength Dakin's and applied the dry dressing dated 07/10/26. He removed the gown and gloves and washed his hands.Interview with the Wound Care Nurse on 07/10/26 at 03:00 PM revealed he was supposed to remove the old dressing, remove gloves and wash hands before cleaning the wound but he forgot. He stated failure to perform hand hygiene and change of gloves would cause cross contamination and spread of infection. He stated he had done training on infection control and handwashing.2. Review of Resident #2's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included aphasia, cerebrovascular accident (stroke), and hemiplegia. A BIMS could not be completed due to the resident's short- and long-term memory impairment. The MDS reflected Resident #2 used a wheelchair for mobility and required partial to moderate assistance for toileting hygiene and dressing and was always incontinent of both bowel and bladder. Review of Resident #2's care plan dated 04/21/26 reflected the resident needed to be lifted manually with two or more people via mechanical lift support. During an observation on 07/10/26 at 02:03 PM, CNA A entered Resident #2's room to provide the resident with incontinence care. After explaining the procedure to Resident #2, she washed hands, put on gloves, and pushed him to the bathroom with his wheelchair and got the wipes. The shirt, socks and the trousers were observed soaked with urine. CNA A then helped the Resident to stand and unfastened the resident's brief. Resident #2's socks and was heavily soaked with urine. She cleansed the abdominal folds and penis in a clockwise direction. She cleansed his bottom area inside out with wipes, and he was observed to have a bowel movement. CNA A did not complete hand hygiene or change the soiled gloves and she applied the clean brief, clean shirt, socks and trousers. CNA A was observed leaving the room after removing gloves without washing hands and walked down the hall with barrels. The resident's skin was intact.During an interview on 07/10/26 at 02:20 PM, CNA A, who worked the 6:00AM to 2:00 PM shift, revealed she forgot to perform hand hygiene during incontinent care. CNA A stated she was expected to wash hands between the care if gloves were soiled and after care, but she did not because she was too fast. She said she was supposed to complete hand hygiene and change gloves during incontinent care to prevent cross contamination. She stated failure to wash hands before and between care and after removing gloves and when moving from dirty to clean could lead to cross contamination. She stated she had not done training on handwashing and infection control because she was newly hired.Interview on 07/10/26 at 03:38 PM, the DON revealed her expectation was the Wound Care Nurse was supposed to change gloves from dirty to clean and wash hands. She stated she expected the Wound Care Nurse to change gloves to wash hands after removal of old dressing and before cleaning the wound. She stated the Wound Care Nurse missed all steps because he failed to wash hands and put in new gloves after they were soiled and before cleaning the wound. She stated failure to change gloves and perform hand hygiene could risk infection. She stated she had done training with staff on infection control hand washing and wound care.Interview on 07/10/26 at 03:52 PM, the DON revealed her expectation during incontinent care was CNA A to complete hand hygiene when gloves were soiled and when moving from dirty to clean and after care. She stated staff were expected to perform hand hygiene to prevent the spread of infection. The DON stated the nursing staff had been offered the in-service on hand hygiene/infection during orientation.Interview on 07/10/26 at 4:32 PM, the ADON revealed his expectation during incontinent care was staff to complete hand hygiene before contact with residents, during care, and after care and to perform hand hygiene when moving from dirty to clean before applying a clean brief. The ADON stated CNA A was supposed to complete hand hygiene and change gloves while performing incontinent care on Resident #2 to prevent cross contamination and infection. He stated the Wound Care Nurse was expected to complete hand hygiene during wound care to prevent cross contamination. He said he was supposed to change gloves and wash hands after removing old dressing and before cleaning the wound. He said failure to wash hands after removing old dressing and before cleaning the wound could lead to cross contamination. The ADON stated he was new and he had not offered in-services to staff.Review of the facility's policy titled Treatment of Wound: Dressing Changes-Performing effective July 2018 reflected the following: PolicyPatients/Residents will have topical dressings selected in accordance with generally accepted guidelines. Procedure.2. Follow standard precautions and infection control methods depending on the appropriate type of transmission based precautions.Review of the facility's policy titled Hand Hygiene for Staff and Residents revised on February 2025 reflected the following: PurposeTo reduce the spread of infection with proper hand hygienePolicyProper hand hygiene technique is completed whenever hand hygiene is indicated. Note:Hand Hygiene is the most important component for preventing the spread of infection. Maintaining clean hands is important for residents/visitors as well as staff. Procedures:Hand hygiene is done:.After A.Contact with soiled or contaminated articles, such as articles that are contaminated with body fluids.C. contact with contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds.D. Toileting or assisting other with toileting, or after personal grooming.

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 5 residents (Resident #3) reviewed for medication administration. The facility failed to ensure Resident #3 was administered all of her medications when the medication Ropinirole was found on the floor of her room on 07/10/26. This failure placed residents at risk of not receiving medications as prescribed, decreased therapeutic effects of the medications, risk for drug diversion, delay in medication administration and worsening of their medical conditions.Findings included:Review of Resident #3's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), end stage renal disease (final stage of chronic kidney disease), cerebrovascular accident (stroke), hemiplegia (paralysis to one side of the body), and non-Alzheimer's dementia. The resident had a BIMS score of 3 which indicated her cognition was severely impaired. Review of Resident #3's care plan dated 05/04/26 reflected the resident had the diagnoses of cerebral infarction and end stage renal disease. Interventions included to observe for edema, warmth, and color of extremities, shortness of breath and vital signs and administer medications as ordered and monitor for adverse side effects. Review of Resident #3's active orders printed on 07/10/26 reflected the resident was taking Ropinirole HCL 1mg tablet three times a day (5:00AM, 2:00 PM, 9:00 PM) for renal failure.Review of Resident #3's MAR revealed the resident had received the medication Ropinirole the past two days (07/08/26, 07/09/26) and the morning of 07/10/26.Observation and interview on 07/10/26 at 9:43 AM revealed Resident #3 was in bed watching TV. A small white round pill was noted to be on the floor next to the foot of resident's bed. Resident #3 was asked if she had taken all her medications that morning and the resident smiled and said she was given all her medications. MA C was called into Resident #3's room and asked about the pill on the floor and the MA identified the pill as being Ropinirole, which the resident took three times a day.Interview on 07/10/26 at 10:00 AM with MA C revealed she had witnessed Resident #3 take all of her morning medications that morning and the day prior (07/09/26) and further said it was not her who had dropped the pill on the floor. MA C said there was not a medication aide the previous evening (07/09/26) so the night nurse (RN D) must have dropped it when she was passing medications. Attempts to contact RN D on 07/10/26 at 6:00 PM were unsuccessful. Interview on 07/10/26 at 6:16 PM with the ADON revealed that during medication pass, the nurses were to stay and watch each resident take all of the medication. The ADON said it was important because all medications were prescribed to treat a specific diagnosis. Interview on 07/10/26 at 6:37 PM with the DON revealed she was not aware a pill had been found on the floor in Resident #3's room. The DON said it was important that the nurse ensured the residents took all of their medications because they were being given to treat certain conditions and diagnoses therefore should be appropriately administered. Review of the facility's policy titled Medication-Guidelines on Clinical Practice revised on 01/2020 reflected the following: Standard of Practice: Staff will provide medications in accordance with standard practice guidelines.Medication Administration.Orals.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for 1 (Resident #2) of 5 residents reviewed for ADL care.The facility failed to ensure Residents #2 received timely incontinent care on 07/10/26 which caused the resident to remain in urine soaked clothing.This failure had the potential to affect residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. Findings included:Review of Resident #2's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included aphasia (impaired ability to speak, understand, read, and write), cerebrovascular accident (stroke), and hemiplegia (paralysis that affects only one side of the body). A BIMS could not be completed due to the resident's short- and long-term memory impairment. The MDS reflected Resident #2 used a wheelchair for mobility and required partial to moderate assistance for toileting hygiene and dressing and was always incontinent of both bowel and bladder. Review of Resident #2's care plan dated 04/21/26 reflected the resident needed to be lifted manually with two or more people via mechanical lift support. Observation and interview on 07/10/26 at 10:40 AM of Resident #2 revealed he was in his wheelchair watching videos on his tablet. The resident was wearing gray sweatpants, and they were noted to be wet in the front and there was a slight odor of urine. The resident was asked if he had recently been changed and he smiled and said yes and continued to watch his videos. Observation on 07/10/26 at 12:31 PM revealed Resident #2 remained in his room, and he was still wearing the same wet pants. During an observation on 07/10/26 at 02:03 PM, CNA A entered Resident #2's room to provide the resident with incontinence care. After explaining the procedure to Resident #2, she washed hands, put on gloves, and pushed him to the bathroom with his wheelchair and got the wipes. The shirt, socks and the trousers were observed soaked with urine. CNA A then helped the Resident to stand and unfastened the resident's brief. Resident #2's brief and was heavily soaked with urine. She cleansed the abdominal folds and penis in a clockwise direction. She cleansed his bottom area inside out with wipes, and he was observed to have a bowel movement. CNA A did not complete hand hygiene or change the soiled gloves and she applied the clean brief, clean shirt, socks and trousers. CNA A was observed leaving the room after removing gloves without washing hands and walked down the hall. The resident's skin was intact.During an interview on 07/10/26 at 02:20 PM, CNA A, who worked the 6:00 AM to 2:00 PM shift, revealed she was the assigned aide for Resident #2. CNA A stated she was supposed to provide ADLs to Resident #2. She said she last saw Resident #2 before breakfast, and that is when she provided incontinent care on him and she had not gone back to his room. She stated she was aware she was supposed to do rounds every two hours and as needed, but she was busy with her residents. She stated failure to round and change a resident every two hours could lead to residents having skin breakdown and infection. Interview on 07/10/26 at 5:00 PM with LVN B revealed residents should have incontinent care every two hours or as needed. LVN B said Resident #2 was not one to let staff know of his needs therefore had to be checked on routinely. LVN B said during her rounds she would check on the residents, and she had not noticed Resident #2 was wet or she would have alerted the aides he needed to be changed. LVN B said it was important that incontinent care was provided routinely so residents did not run the risk of UTIs or skin breakdown. During an interview on 07/10/26 at 3:52 PM, the DON revealed her expectation was CNAs performed rounds every two hours and as needed, and the nurses were responsible for monitoring the CNAs during their shifts to ensure residents were being changed. She stated the risk of not performing two-hour rounds was it could lead to skin breakdown. The DON stated she had done training with staff on providing incontinence care every two hours.During an interview on 07/10/26 at 4:32 PM, the ADON revealed his expectation was the CNAs performed rounds every two hours and as needed, and the nurses were responsible for monitoring the CNAs during their shifts. He stated the risk of not performing every two-hour rounds was it could lead to skin breakdown and infection.Review of the facility's policy titled Perineal Care reviewed on 04/2024 reflected the following: PolicyStaff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control.CNA A and CNA B failed to perform hand hygiene while providing incontinence care to Resident #1.This failure could place residents her at risk for cross-contamination. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 05/18/26, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1 had a diagnosis which included cerebrovascular accident, (commonly known as a stroke, which occurs when blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients). The resident's cognition was intact with a BIMS score of 14, and she was incontinent of bowel and bladder. Record review of Resident #1's Care Plan, dated 05/12 /26, reflected Resident #1 was at risk for problems with bowel and bladder incontinence. The care plan reflected: Goal: Incontinent of bladder and bowel with occasional awareness of need to defecate . intervention: Complete bladder and bowel incontinence risk. Check and change, keep clean and dry During an observation on 05/28/26 at 5:30 AM, CNA A and CNA B entered Resident #1's room to provide the resident with incontinence care. After explaining the procedure to Resident #1, CNAs A and B washed their hands, put on gloves, and put their supplies together. The CNAs then unfastened the resident's brief. CNA B cleansed the resident's abdominal folds and perineal area (area between the genitals and anus). Next, CNA B removed her gloves and put on new gloves without washing her hands. The CNAs then positioned Resident #1 on her side, and CNA B cleansed the resident's buttocks and thighs. Resident #1's brief and the draw sheet under the resident were soaked with urine, and the draw sheet was stained with bowel movement (feces). While wearing the same gloves, CNA B picked up a clean brief and clean linen. CNA B then put the linen on the bed, and the clean brief was placed on Resident #1. CNA A removed the soiled linen and put it in a plastic bag. CNA A and CNA B then removed their gloves and put on new gloves without washing their hands. CNA B applied petroleum jelly to Resident #1's legs and hands. CNA B then removed her gloves and left Resident #1's room without performing hand hygiene.During an interview on 05/28/26 at 5:47 AM, CNA B revealed she forgot to perform hand hygiene when she provided care to Resident #1. CNA B stated she was expected to wash her hands before contact with a resident, between care if her gloves were soiled, and after care, but she forgot. CNA B said she was supposed to complete hand hygiene and change gloves during incontinence care to prevent cross contamination. She stated failure to wash her hands before and between care and after removing her gloves could lead to cross contamination and infection. During an interview on 05/28/26 at 5:55 AM, CNA A revealed she forgot to perform hand hygiene when she changed her gloves while providing Resident #1 with care. CNA A said she was expected to wash her hands before contact, between care if her gloves were soiled, and after care. CNA A said she was supposed to complete hand hygiene with glove changes during incontinence care to prevent cross contamination. She said failure to wash her hands before and between care and after removing her gloves could lead to cross contamination and infection.During an interview on 05/28/26 at 10:58 AM, the ADON revealed she expected staff to complete hand hygiene before contact with residents, during care, after care, and when they changed gloves during incontinence care. The ADON stated CNA A and CNA B were supposed to complete hand hygiene and change their gloves while providing Resident #1 with incontinence care to prevent cross contamination and infection. The ADON stated the nursing staff were offered an in-service training on hand hygiene/infection control.During an interview on 05/28/26 at 11:19 AM, the DON revealed she expected staff to complete hand hygiene before and after incontinence care. She said CNA A and CNA B were supposed to perform hand hygiene before contact, during care since Resident #1 had a bowel movement, after care, and when moving from dirty to clean. She also said they should perform hand hygiene when they changed their gloves. She said staff were expected to perform hand hygiene to prevent the spread of infection. The DON stated the nursing staff were offered an in-service training on hand hygiene/infection.Record review of the facility's Hand Hygiene for Staff and Residents policy, dated July 2024, reflected: .The purpose of this procedure is to reduce the spread of infection with proper hand hygiene '1.Hand hygiene is done:BeforeA. Resident contactAfter:A. Contact with soiled or contaminated articles, such as articles that are contaminated with body fluids.B. Resident contact.D. Toileting or assisting others with toileting, or after personal grooming.H. Removal of medical/surgical or utility gloves.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care.The facility failed to provide Resident #1 with incontinence care every two hours and as neededThis failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included:Record review of Resident #1's quarterly MDS assessment, dated 05/18/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnosis which included cerebrovascular accident, (commonly known as a stroke, which occurs when blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients). Resident #1 was cognitively intact with a BIMS score of 14, and she was always incontinent of bowel and bladder.Record review of Resident #1's Care Plan, dated 05/12/26, reflected Resident #1 was at risk for problems with bowel and bladder incontinence. The care plan reflected: Goal: Incontinent of bladder and bowel with occasional awareness of need to defecate . intervention: Complete bladder and bowel incontinence risk. Check and change, keep clean and dry During an observation and interview on 05/28/26 at 5:26 AM, revealed Resident #1 was in her room in bed. Resident #1 said the last time she was changed was at 11:00 PM. She stated staff came to her room at 1:00 AM, but they did not change her brief. She stated she could not tell whether she was wet. She stated she had called to be pulled, and they came they pulled her up and left the room. After they left the room, she said she slept until the morning. When she awakened, she stated she was heavily wet with urine. She denied having any skin issues. The resident did not have odors. During an observation on 05/28/26 at 5:30 AM, CNA A and CNA B entered Resident #1's room to provide the resident with incontinence care. After explaining the procedure to Resident #1, they both washed their hands, put on gloves, and put their supplies together. CNA A and CNA B then unfastened the resident's brief. Resident #1's brief and draw sheet were heavily soaked with urine and the draw sheet was stained with bowel movement (feces). The resident's skin was intact.During an interview on 05/28/26 at 5:47 AM, CNA B, who worked the 10:00 PM-6:00 AM shift, revealed CNA A was the assigned aide for Resident #1. CNA B stated she was supposed to assist CNA A with Resident #1 because the resident required two staff to assist her. She said she last saw Resident #1 at 1:00 AM when she helped the nurse pull the resident up in bed. She stated she did not see Resident #1 again until this morning when CNA A called her to assist with changing Resident #1 when incontinent care was observed. She stated she was aware they were supposed to do rounds every two hours and as needed, but she was busy with her residents. She stated failure to round and change a resident every two hours could lead to residents having skin breakdown and infection. CNA B stated they were trained to do rounds every two hours, and she did on residents assigned to her.During an interview on 05/28/26 at 5:55 AM, CNA A, who worked the 10:00 PM-6:00 AM shift, revealed she was the CNA assigned to Resident #1. She said she last changed the Resident #1 around 1:00 AM and the resident required two staff to assist her, but she could not recall who helped her. She stated she was aware they were supposed to do rounds every two hours and as needed, but she was busy with other residents and waited for help. She stated failure to round and change the resident every two hours could lead to the resident having skin breakdown. CNA A stated they were trained to do rounds every two hours.During an interview on 05/28/26 at 6:39 AM, LVN C, who worked the 10:00 PM-6:00 AM shift, revealed she had been to Resident #1's room, at around 1:00 AM because the resident had her call light on. She said CNA B helped her pull Resident #1 up in bed, and she did not notice Resident #1 was wet. She said it was her responsibility to go behind the CNAs to ensure they were rounding every two hours and changing residents timely. She said she could not recall CNA A asking her for assistance. She stated CNAs were supposed to perform incontinence care rounds every two hours and as needed. She stated residents were at risk of skin irritation and urinary tract infections if they were left wet for long periods.During an interview on 05/28/26 at 10:58 AM, the ADON revealed her expectation was the CNAs performed rounds every two hours and as needed, and the nurses were responsible for monitoring the CNAs during their shifts. She stated the risk of not performing every two-hour rounds was it could lead to skin breakdown.During an interview on 05/28/26 at 11:19 AM, the DON revealed her expectation was CNAs performed rounds every two hours and as needed, and the nurses were responsible for monitoring the CNAs during their shifts to ensure residents were checked for wetness. She stated if a resident required two-person assistance, she expected the CNAs to call nurses for assistance with care. She stated the risk of not performing two-hour rounds was it could lead to skin breakdown and infections. The DON stated she had done training with staff on providing incontinence care every two hours.Record review of the facility's Perineal Care policy, revised April 2024, reflected the following: .Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection .

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent avoidable accidents for one (Resident #1) of eleven residents reviewed for supervision. The facility failed to ensure Resident #1, who resided on the facility's secured unit, received adequate supervision to prevent him from eloping on two separate occasions. On 04/20/26, Resident #1 eloped from the facility at 2:00 a.m. and was found 2.5 hours later by law enforcement approximately 2 miles away from the facility. On 04/24/26, Resident #1 eloped from the facility at 1:30 a.m. and was found on 04/27/26 at a local hospital where he was being treated for chest pain. An Immediate Jeopardy (IJ) was identified on 04/24/26 at 12:02 p.m. and an IJ Template was provided to the Interim Administrator at 12:45 PM. While the IJ was removed on 04/27/26, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not an immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents that could lead to serious injury or harm.Findings included:Record review of Resident #1's admission MDS Assessment, dated 03/12/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #1 had a BIMS score of 7, which indicated severe cognitive impairment, with inattention and disorganized thinking. The MDS Assessment under Section E-Behavior reflected Resident #1 did not present with wandering behavior. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 did not have limited range of motion or require any mobility devices. The MDS Assessment under Section GG-Functional Abilities (self-care) reflected Resident #1 required moderate assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: non-Alzheimer's dementia (cognitive disorder that causes decline in memory, thinking, and behavior), hypertension (high blood pressure), and thyroid disorder. Record review of Resident #1's care plan, revised 04/22/26, reflected the resident had cognitive loss due to neurocognitive disorder and dementia. Interventions included: tasks segmentation as needed, explaining procedures and care before performing, and eye contact when speaking. This document reflected that Resident #1 had exit-seeking behaviors. Interventions included: redirection as needed and resident moved closer to the nurses' station for monitoring. Record review of Resident #1's progress notes, dated 04/20/26 at 7:17 a.m. by RN A, reflected the following: [Resident #1] was noticed to be missing from the room around 02.00am. Code green was activated. [Interim Administrator], DON, and ADON were notified. The police were also notified. [Resident #1] was found and returned to the building around 4.30am. Family member aware. Vital signs stable, BP 112/63, P-83, R-18, O2 sat 95% Resident refused skin assessment. The NP was notified. The [Resident #1] states I have been trying to get out of that door everyday [sic] for 20 days and today is the 21st day. When asked how he got out, he said, 'I just got out through the door'. Record review of Resident #1's elopement assessment, dated 04/20/26, reflected the following: Mobility Status: ambulated independentlyEmotional Status: noneMental Status: noneElopement History: attempts to leave one time within last monthBehaviors: nonePlacement History: noneAssessment Information: score 10 (0-10-low risk) Record review of in-service, dated 04/20/26, reflected staff were educated on the facility's policy and procedures regarding missing residents. Record review of in-service, dated 04/20/26, reflected the Floor Technician received one-on-one education on the facility's policy and procedures regarding missing residents. Record review of Resident #1's progress notes, dated 04/24/26 at 4:28 a.m. by LVN C, reflected the following: [LVN C] making rounds and seen that the [Resident #1] wasn't in his room or in his bathroom. [LVN C] notified staff on unit, every room and bathroom was checked and then the [Floor Tech] said the window in room [XXX] was open. A code green was called and everyone was checking the building parameter and all the rooms within in [sic] the building, Once staff realized [Resident #1] wasn't anywhere to be found, 911 and DON was called. MD notified, several attempts to notified [sic] [RP] was made, [LVN C] left a message on [RP's] voicemail. Record review of Resident #1's progress notes, dated 04/24/26 at 8:48 a.m. by the SW, reflected the following: [SW] called [PD] and asked them to go to the address [Resident #1] believes to be his [home address], to see if [Resident #1] may have gone there as that is where the resident was originally brought to the hospital from . [SW] informed [PD] that their police department had located [Resident #1] at that address previously. [PD] stated they would send officers to the address to look for [Resident #1]. Record review of Resident #1's progress notes, dated 04/24/26 at 9:15 a.m. by the SW, reflected the following: [SW] received a call from [PD] informing [SW] that they went by the address, and [Resident #1] was not there. [PD] stated they would try to stop by again later to see if [Resident #1] makes his way there later. [SW] thanked [PD]. Record review of Resident #1's hospital records, dated 04/24/26, reflected in part the following: Patient name: [[NAME] name]Chief Complaint: Chest PainHistory of Presenting Illness:[AGE] year-old male with past medical history of hypertension depression hyperlipidemia presented to ED with complaints of chest pain. [Resident #1] states he feels chest pressure Also came to the ER for further evaluation. [Resident #1] denied nausea or diaphoresis (excessive, sudden sweating). Reports compliance with his medications lives with the fiance. And uses a cane for walking. On arrival to the ER [Resident #1's] vitals were stableLab work was done and showed hemoglobin (iron-rich protein in red blood cells that transport oxygen throughout the body) of 12 (normal range 12-16), BMP with normal electrolytes and elevated proBNP (blood test used to diagnose or monitor heart failure) of 766 (normal value below 300). [Resident #1] was admitted for the [sic] management.Neurological: alert & oriented to person, place and time. No focal motor deficits (impairments in movement) . In an observation and interview on 04/23/26 at 10:00 a.m., Resident #1 was observed sitting in the dining area being closely monitored by staff. Resident #1 stated he eloped from the facility because he did not feel safe and needed to get back to his house. He was able to provide the surveyor with detailed directions to an address. Resident #1 stated he waited a while for an opportunity to get out of the door on the secured unit when he finally found that it was cracked open after staff exited, and he was able to walk out of the building. Resident #1 stated he walked for 2-3 hours looking for public transportation until he ran into several officers who returned him to the facility. An attempted interview on 04/23/26 at 10:47 a.m. with Resident #1's family was unsuccessful due to no response to call. In an interview on 04/23/26 at 12:15 p.m., the Interim Administrator stated the facility was in the process of hiring a new administrator and he had been covering for about a week. The Interim Administrator stated on 04/20/26 at about 3:00 a.m., he was notified that Resident #1 eloped from the facility. The Interim Administrator stated it was reported that Resident #1 was able to leave the secured unit through a door that did not lock behind staff and the resident was observed walking out of the back door by the Floor Technician. The Interim Administrator stated the Floor Technician ran to get help instead of intervening and following Resident #1, and when staff made it outside, they were unable to locate the resident, so law enforcement was called. The Interim Administrator stated he arrived at the facility at approximately 4:30 a.m. as law enforcement was returning Resident #1. The Interim Administrator stated he immediately had the maintenance director check the locking mechanism on all doors with issues found. The Interim Administrator stated Resident #1 was moved closer to the nurses' station to a room with a window that opened to an enclosed courtyard, and all staff were in-serviced regarding the facility's policy and procedure on elopement. He stated it was the responsibility of all staff to keep the facility secure and supervise residents to prevent elopements and not doing so could place residents at risk of eloping. An attempted interview on 04/23/26 at 1:17 p.m. with RN A, who worked with Resident #1 during the first incident, was unsuccessful due to no response to call. In an interview on 04/23/26 at 2:03 p.m., the Floor Technician stated he was pulling the trash at approximately 2:00 a.m. on the west hall, outside of the secured unit when he saw a man in a gray hoodie exiting the back door. The Floor Technician stated he immediately went to inform one of the aides and after she confirmed that her residents were accounted for, he followed the aide outside to see who it was; however, they did not see anyone. He stated he alerted the staff on the secured unit, and they found that Resident #1 was missing. The Floor Technician stated the exit door was supposed to sound an alarm when opened but the alarm had been turned off by someone. He stated staff would sometimes do this to go out for a break without disturbing the facility or getting locked out. The Floor Technician stated he was employed by the facility and received the same training as all caregivers, including elopement prevention. He stated he received a one-on-one refresher regarding the facility's policy and procedures on elopements after the incident and now understood that he should have followed the resident to re-direct him back into the building. In an interview on 04/24/26 at 9:00 a.m., the Interim Administrator informed the surveyor that Resident #1 eloped from the facility again at approximately 1:30 a.m. and had not been found. The Interim Administrator stated there were additional staff working on the secured unit monitoring the doors, and Resident #1 exited through the window of his previous room. The Interim Administrator stated the window alarm and brackets used to prevent the window from rising more than 6 inches had been broken off, and Resident #1 was able to elope without staff noticing. He stated law enforcement was currently searching for Resident #1. In an interview on 04/24/26 at 12:40 p.m., the NP stated Resident #1 was admitted to the facility's secured unit due to his history of wandering according to his admission clinicals. The NP stated Resident #1 was diagnosed with dementia and neurocognitive disorder, which caused confusion. He stated it was safer for the resident to reside on the secured unit and possibly transition to the general area after a re-assessment later. The NP stated the facility notified him that Resident #1 eloped from the facility on 04/20/26 and his medications were adjusted with closer monitoring. The NP stated he was informed that Resident #1 eloped again this morning and was currently still missing. The NP stated the IDT would have to decide how to proceed once Resident #1 was found. An attempted interview on 04/24/26 at 1:42 p.m. with LVN C, who worked with Resident #1 during the second elopement incident, was unsuccessful due to no response to call. In an interview on 04/24/26 at 1:50 p.m., CNA B stated he worked at the facility for 3 months on the secured unit. CNA B stated he worked overnight (04/23/26-04/24/26) with Resident #1 when he eloped from the facility. CNA B stated Resident #1 was observed sitting in the common areas near the nurses' station eating snacks and writing at approximately 12:30 a.m. and the resident was not showing any signs of exit-seeking. CNA B stated it was not unusual for Resident #1 to be up late writing. CNA B stated he continued to do rounds and check on other residents, then at approximately 1:00 a.m. LVN C alerted all staff on the secured unit that Resident #1 was missing. CNA B stated they started searching in every room for Resident #1 when they found the window opened in the resident's old room. CNA B stated all windows had alarms, but the alarm on that window had been removed so the staff were not alerted. CNA B stated they received routine training on exit-seeking and elopements, especially working on the secured unit and he knew that the residents had to be monitored closely and any changes reported to the charge nurse. CNA B stated he was not always assigned to Resident #1, but the staff worked together to monitor all residents, and Resident #1 did not show any exit-seeking. CNA B stated Resident #1 was quiet and non-aggressive and always asked for paper so that he could sit and write. In an interview on 04/24/26 at 1:56 p.m., the DON stated Resident #1 admitted to the facility from the hospital where he was being assessed after he wandered into his neighbor's house. The DON stated Resident #1 was still new to the facility and the staff were still learning things about him. She stated the resident had now eloped from the facility twice although there were interventions in place and a full staff. The DON stated if a resident exhibited exit-seeking behaviors, they were placed on close monitoring every 15 minutes for 72 hours and only removed if the behavior resolved. She stated if the behavior was not resolved, the monitoring would be increased to one-on-one supervision until a re-assessment and clearance from psych was completed. The DON stated after Resident #1 eloped on 04/20/26 he was moved closer to the nurses' station and placed on close monitoring every 15 minutes, and his behavior seemed to resolve. She did not provide surveyor evidence of 15-minute checks completed on Resident #1. The DON stated Resident #1 was not placed on one-to-one supervision, and the 72-hour close monitoring period ended a day before he eloped for the second time. An attempted interview on 04/24/26 at 4:00 p.m. with Resident #1's family was unsuccessful due to no response to call. In an interview on 04/25/26 at 11:24 a.m., LVN C stated she worked overnight (04/23/26-04/24/26) when Resident #1 eloped from the facility the second time. LVN C stated Resident #1 was fine earlier that night and did not show any changes in his behavior. She stated Resident #1 was hanging out in the common area right in front of the nurses' station. She stated Resident #1 stayed up late eating snacks and writing and was last seen napping on the couch at approximately 12:30 a.m. LVN C stated during her rounds at approximately 1:30 a.m. she found that Resident #1 was not in the common area or in his room. LVN C stated they had just been in-serviced on missing residents after Resident #1's elopement on 04/20/26, so she knew to alert the staff and check every room. LVN C stated they found that the window in Resident #1's old room was cracked open with a piece of the alarm removed. LVN C stated they searched the entire building and after not being able to find Resident #1, she notified the police, Interim Administrator, DON, MD, and resident's family. LVN C stated Resident #1 had not been found by the end of her shift. In an interview on 04/25/26 at 12:15 p.m., RN A stated she worked overnight (04/19/26-04/20/26) when Resident #1 eloped from the facility the first time. RN A stated when she arrived on shift, she did not receive any reports regarding Resident #1, and the resident did not exhibit any changes or behaviors throughout the night. RN A stated at approximately 12:00 a.m. Resident #1 came to the nurses' station and informed her that his roommate was on the floor. RN A stated she and RN S rushed to the room and Resident #1 followed them. RN A stated she found the roommate on the floor and started an assessment, while Resident #1 got back in bed. RN A stated she returned to the nurses' station to document, then at approximately 2:30 a.m. the Floor Technician came on the unit and informed all staff that he saw someone leaving the facility. RN A stated they immediately checked on all residents and found that Resident #1 was missing. RN A stated staff searched inside and outside of the facility and could not find Resident #1. RN A stated she left a voice message for the Interim Administrator and DON, and by the time they returned her call 911 had already been notified. RN A stated officers returned Resident #1 to the facility at approximately 4:30 a.m. and the resident refused an assessment but appeared to be okay. RN A stated she was not sure how Resident #1 was able to get out of the door because staff are trained to check for residents and ensure that the door locks behind them when they exit the unit. RN A stated Resident #1 told her that he had been trying the door every day and finally found it unlocked. Review of the facility's policy titled Elopement Management, dated 02/12/20, reflected the following: Standard of Practice: An immediate investigation and search will be conducted if a resident is considered missing. The resident will be located and returned to a safe environment within standard practice guidelines.Procedure:1. Once it has been established that a resident is missing, the following staff membersare notified immediately: The Administrator, Director of Nursing, Charge Nurse(s) and Social Service Designee. 2. The Administrator or Director of Nursing/designee will announce code green which signals that an elopement procedure is activated. 3. Staff will respond to a predetermined location such as the front desk. A description of the missing resident to include a photo (if available), physical and clothing description. 4. The Administrator and DON/designee organizes and institutes an immediate and thorough search of the center and surrounding grounds. Specifically, search the area outside the nearest exit to the resident's room or the exit where he/she was last seen, and the entire unit where the resident resides or was last seen. Then, search the remainder of the community (all rooms, closets, bathrooms and grounds). 5. The entire search process of the community and grounds, from the time the resident is missing, will be completed within (30) thirty minutes. 6. If the search fails to locate the missing resident in the (30) thirty minutes from the time the resident is found to be missing, then the Administrator and/or designee contacts the appropriate community agencies (Police, Local Health Department and Corporate Administration) and the resident's family and attending physician. 7. Staff will provide the police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex and clothing if known. 8. The search is continued. Two staff members search the surrounding streets by car for a two (2) mile radius around the community. 9. When the Resident is locateda. Charge Nurse completes a head to toe assessment, including vital signs.b. Social Service Designee evaluates the resident for emotional distress.c. Staff provides resident with nutrition, hydration, additional or less clothing as appropriate 10. The Charge Nurse reports any findings to the Director of Nursing and places a call to the attending physician and the appropriate family member or responsible party. 11. Staff will monitor resident for 72 hours for change of condition.a. If changes in condition warrant medical or psychiatric assistance, proper transportation will be set up and the resident will be transferred as appropriate and as ordered by the physician 12. Reporting guidelines will be followed, and the Administrator will contact the Corporate Office for support and will be responsible for public relations issues. Document Requirements in the EHR: Incident/Accident Report. Nursing Notes should reflect an accurate account of situation and outcome. Social Services note needs to address emotional assessment and interventions. Update the Elopement Risk Assessment. Update Care Plan. An Immediate Jeopardy (IJ) was identified on 04/24/26 at 12:02 p.m. The Interim Administrator was notified of an Immediate Jeopardy (IJ) on 04/24/26 at 12:25 p.m., due to the above failures and the IJ template was provided at 12:45 p.m. A Plan of Removal was requested. The facility's Plan of Removal (POR) was accepted on 04/25/26 at 7:46 a.m. and included:[Nursing Facility] Elopement Plan of removal for IJ called on 4/24/2026 at 12:45 PM for the facility's alleged failure to provide adequate supervision for Resident #1 resulted in the resident eloping from the facility on two different occasions, which placed him at risk of serious harm. 1.Staff development coordinator/designee provided education to staff on elopement policy and procedure completed on 4/20/26. Resident #1 was placed on frequent monitoring and moved closer to the nurses' station with a window opening to the courtyard and placed on crisis intervention with psych services on 4/20/26. Resident was seen by psychiatrist via Telehealth on 4/20/26 with medication adjustments made and planned follow up for 4/24/26. 2. When it was discovered Resident #1 was out of facility, charge nurse and staff immediately searched both buildings and grounds then notified DON, Administrator, and police were notified by charge nurse on 4/24/26. Charge nurse notified family member and nurse practitioner for Resident #1. 3. Administrator and Director of Nursing are educated by Regional Director of Operation, and the education is completed on 4/24/2026. 4. Administrator checked all windows and doors in facility upon arrival completed on 4/24/26 with no issues found. Key Staff were provided key fobs to exit unit. 5. Resident #1 remains out of facility. If resident is returned to the facility, resident will be placed on one-on-one supervision until appropriate placement is found. 6. Verified all residents accounted for on 4/24/2026. 7. DON/Designee will in-service/educate all staff on elopement policy and procedure to include notification to DON/Administrator if residents are exit-seeking completed on 4/24/2026. Staff unavailable will be in-serviced prior to the start of their next shift and will not be allowed to work until education is completed. 8. DON/designee to educate staff on interventions post-exit seeking behavior to be completed on 4/24/26. Staff will follow policy for interventions when active exit seeking behavior is observed, such as 15-minute checks or one to one supervision. Staff unavailable will be in-serviced prior to the start of their next shift and will not be allowed to work until education is completed. 9. DON/designee will randomly interview staff three times weekly to ensure competency of education received. 10. An audit of nurses' notes was conducted and completed by nursing management to identify other residents that may be exhibiting exit seeking behaviors. Completed on 4/24/26. 11. DON/designee updated elopement book, kept at the nurses' stations, to include all residents who are identified as being at risk for elopement. To be completed on 4/24/26 12. Elopement risk assessments on new admissions and re-admissions will be monitored in morning clinical meeting every weekday. Care plans will be updated as needed for moderate and/or high-risk score. Individual interventions will be added to care plan as needed for higher functioning residents based on elopement risk score and IDT review. 13. Residents that return to the facility after an elopement attempt will be placed on one-to-one observation and referral to psych provider for further recommendations. 14. DON designee will monitor elopement risk assessment completion quarterly with MDS assessment completion and update care plan as needed. 15. Administrator/designee will round on memory care unit daily to ensure windows and doors are locked appropriately. 16. QA Committee meeting held on 4/24/2026 with medical director. The investigator began monitoring 04/25/26-04/27/26 to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of Resident #1's progress notes, dated 04/20/26 at 5:00 p.m. by the SW, reflected the following: [SW] and Nurse were present as [Resident #1] met with psychiatry via telehealth appointment. [Resident #1] stated he would like to meet with a dietary as well as a chaplain. Psych gave two new medication orders. Depakote Sprinkles 125mg and Zoloft 150mg. [SW] emailed [telehealth representative] to ask if their psychologist could meet with [Resident #1] to assess his decision-making capacity. [Telehealth representative] stated [behavioral health service provider] works with [psychologist] and she would get [SW] in contact with him. [SW] thanked [telehealth representative]. Record review of Resident #1's progress notes, dated 04/22/26 at 9:19 a.m. by the SW, reflected the following: [Resident #1] was moved from [old room] to [new room]. This move brought [Resident #1] closer to the nurse's station in order for closer monitoring to be provided as an intervention for the resident's previous elopement. In an interview on 04/25/26 at 9:15 a.m., the Interim Administrator revealed that all residents in the facility had been accounted for, and daily rounds on all residents would continue. Interviews on 04/25/26-04/27/26 conducted with the Interim Administrator, Assistant Administrator, DONs, ADON, Staffing Coordinator, nurses, and CNAs from North and South building: LVN A (3rd shift/rotating days), CNA B (3rd shift/rotating days), LVN C (3rd shift/rotating days), CNA D (3rd shift/rotating days), CNA E (2nd shift/rotating days), LVN F (1st shift/rotating days), CNA G (1st shift/rotating days), CNA H (2nd shift/rotating days), CNA I (1st shift/rotating days), CNA J (1st shift/rotating days), CNA K (1st shift/rotating), LVN L (1st shift/rotating days), CNA M (2nd shift/rotating days), LVN N (2nd shift/rotating), LVN O (1st shift/rotating), CNA P (2nd shift/rotating), CNA Q (3rd shift/rotating days), RN R (PRN), RN S (3rd shift/rotating days), CNA T (3rd shift/rotating days), LVN U (3rd shift/rotating days), LVN V (1st shift/rotating days), LVN W (3rd shift/rotating days), and RN X (1st shift/rotating) indicated they all participated in in-service trainings regarding the facility's policy and procedures regarding elopement management before the start of their shift. Starting on 04/24/26. All staff were able to state signs of exit-seeking and interventions to prevent it. All staff knew the procedure for a missing resident was to initiate a Code Green which included: alerting all available staff, securing all doors and windows, searching the entire facility, including outside, and notifying the Administrator, DON, MD, and family. All staff knew to notify law enforcement if the resident was not found within 30 minutes. If a resident was observed exiting the building, all staff knew to follow the resident and alert all available staff by yelling Code Green or by cell phone. All nurses were able to state that residents who exhibited signs of exit-seeking would be placed on close monitoring. All nurses knew to notify the Administrator, DON, and family and document all incidents and changes. The Interim Administrator, Assistant Administrator and DONs understood it was their responsibility to implement and monitor the effectiveness of all interventions put in place. Record review of Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12 EHRs reflected they all had appropriate interventions for care needs based on cognition and exit-seeking behaviors. Interviews with Residents #6, #8, and #10, and the RPs of Residents #3, #4, #5, #7, #9, #11, and #12, revealed no concerns regarding the supervision and safety of the residents. Observations on 04/25/26-04/27/26 of Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12, who were all at risk for elopement, revealed all residents were being adequately supervised based on care needs and interventions outlined in care plans. On 04/27/26 at approximately 9:30 a.m., the Regional Nurse informed the surveyor that Resident #1 was located at a local hospital where he was being treated under an [NAME] name. Resident #1 remained at the local hospital, pending return, during monitoring and was unable to be observed or interviewed. Record review of an in-service titled One on One Education Form, dated 04/24/26, reflected The Interim Administrator, Assistant Administrator, and DONs were educated by the Regional Director of Operations on the facility's policy and procedures regarding elopements and exit-seeking behaviors. Record review of an in-service titled Code Green: 1) Missing Person-Notifications, Searching, 2) Secure All Doors, 3) Interventions following exit-seeking behaviors, dated 04/24/26, reflected staff were educated by the staff development nurse on the facility's policy and procedures regarding elopements and exit-seeking behaviors. Record review of a document provided by the Interim Administrator, dated April 2026, reflected the facility initiated daily rounds on the memory care units to ensure that all doors and windows remained secure. Record review of a document provided by the Interim Administrator, dated 04/24/26, reflected a QAPI meeting was held to discuss the correction plan for the facility's deficiency in quality of care. Record review of a document provided by the Interim Administrator, dated April 2026, reflected the DON initiated audits of nurses notes to identify residents exhibiting changes and exit-seeking behaviors. Record review of elopement binders at the nurses' stations reflected they were updated with face sheets and elopement assessments of residents who were considered at risk for elopement. An Immediate Jeopardy (IJ) was identified on 04/24/26 at 12:02 p.m. and an IJ Template was provided to the Interim Administrator at 12:45 PM. While the Interim Administrator was informed on 04/27/26 at 12:46 p.m. that the IJ was removed, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that the discharge summary included an accurate and current description of the clinical status of the resident and sufficiently detailed individualized care instructions to ensure that care was coordinated and the resident transitioned safely from one setting to another for one (Resident #2) of three residents reviewed for discharge process. The facility failed to ensure that Resident #2's discharge summary included appropriate clinical information to ensure that the resident received continuous and coordinated care after she discharged to the community AMA (against medical advice) on 04/06/26. This failure could place residents at risk of not receiving ongoing person-centered care, which could lead to worsening of condition or serious harm.Findings included:Record review of Resident #2's Discharge MDS Assessment, dated 04/06/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on 04/06/26. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #2 had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities (self-care) reflected Resident #2 required supervision assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #2's active diagnoses included: hypertension (high blood pressure), wound infection, and risk of malnutrition. Record review of Resident #2's baseline care plan, dated 04/02/26, reflected the resident was receiving antibiotic therapy for a wound infection, pneumonia, and UTI. Interventions included: monitoring vital signs. This document reflected that Resident #2 had behaviors of talking to herself and a moderate risk of eloping. Interventions included: analyzing key times, places, and circumstances. This document reflected Resident #2 had skin issues that included a surgical wound and mild risk for pressure ulcers. Interventions included: wound care. This document also reflected Resident #2 expected to discharge to the community with no documented interventions. Record review of Resident #2's progress notes, dated 04/06/26 at 4:40 p.m. by the SW, reflected the following: [Resident #2] stated she wanted to d/c to [community shelter]. SW informed [Resident #2] that doing so right now would be discharging AMA and medication could not be sent with her. Resident stated she understood and still wanted to d/c. Resident will d/c AMA. Record review of Resident #2's progress notes, dated 04/06/26 at 4:50 p.m. by LVN Y, reflected the following: [Resident #2] continues to refuse care, medication and wound treatment. On this day the resident decided to have arrangements to leave the facility. [Resident #2] left the facility AMA with her belongings, transported safely. Administration, DON, ADON, Social Worker aware of discharge. Record review of Resident #2's physician Discharge summary, dated [DATE], reflected the following: Resident Name: [Resident #2]Attending Physician: [MD]admission Date: 04/02/26discharge date : [DATE]Discharge To: AMAadmission Diagnosis: cellulitis (skin infection) of right lower limb, essential hypertensionCondition upon discharge: (blank)Other information: medications locked up in med room. Personal property taken with resident.Signed by [Medical Records Staff] on 04/07/26Prognosis: (blank)Discharge Diagnosis: (blank)Signed by [NP] on 04/09/26Further review reflected there was no information regarding special instructions or precautions for ongoing care or risks associated with discharging AMA. Record review of Resident #2's EHR reflected there was no AMA document completed and signed by staff or the resident per the facility's policy. In an interview on 04/23/26 at 12:40 p.m., the Interim Administrator stated Resident #2 was discharged before he started working at the facility. The Interim Administrator stated he was informed that Resident #2 was only at the facility for a few days before discharging home AMA, and he was not familiar with the resident's condition or reason for discharge. The Interim Administrator stated he was also not familiar with the facility's policy and procedures regarding AMA discharges. An attempted interview on 04/23/26 at 12:57 p.m. with Resident #2's family was unsuccessful due to no response to call. In an interview on 04/23/26 at 1:07 p.m., the SW stated she worked at the facility since July 2025. She stated she did not have much interaction with Resident #2 as the resident was only at the facility for 4 days. The SW stated that on 04/06/26 Resident #2 requested to speak with her and she found the resident waiting by the front door stating that she was ready to leave. The SW stated Resident #2 was admitted to the facility from the hospital, and according to the hospital records Resident #2's home was listed as a community shelter. The SW stated Resident #2 was not diagnosed with dementia or an intellectual disability and had the capacity to make her own decisions. The SW stated Resident #2 had a family member listed in her records for contact but not as her RP. The SW stated she did not contact Resident #2's family prior to her discharge because the contact was initially overlooked; however, she later notified the family. The SW stated she was not aware that Resident #2 was supposed to sign an AMA discharge form at that time; however, the physician discharge summary was completed. The SW stated she was now aware of the AMA discharge form, and it was important to have it signed or an attempt to show that the resident understood and agreed to the AMA discharge process. In an interview on 04/24/26 at 12:40 p.m., the NP stated Resident #2 was alert and oriented and did not have a POA or RP on file. The NP stated it was Resident #2's right to be discharged from the facility and she had the cognition to make her own decisions. The NP initially denied being a part of Resident #2's discharge process and later acknowledged signing the discharge summary 3 days after the resident discharged from the facility. The NP stated he only saw Resident #2 once at the facility and she was being treated with antibiotics for an infection on her leg, which was a treatment that needed to be completed. In an interview on 04/24/26 at 1:56 p.m., the DON stated Resident #2 admitted to the facility from the hospital with a wound that required antibiotics; however, the resident refused care and medications. The DON stated Resident #2 wanted to leave the facility AMA and was able to make that decision based on having the mental capacity and being her own RP. The DON stated the facility's process for AMA discharges included ensuring the resident had a safe place to go, notifying the MD and family if applicable, and explaining to the resident any risks involved with leaving AMA. The DON stated AMA forms also needed to be signed by the IDT and resident as evidence that the process and risks were explained and understood. The DON stated the SW confirmed that Resident #2's home was at the community shelter, and the facility transported her there. Record review of the facility's policy titled Discharge/Transfer Policy, reviewed 04/24/24, reflected in part the following: Policy: The resident will be discharged /transferred (home/another entity) by order of his/her attending physician in accordance with standard practice guidelines. Procedure:1. Obtain a discharge order from the physician2. Notify resident, their legal representative, if any, or an interested family member and document the discharge3. Provide written discharge instructions/education to the resident and family when discharged to a lower level of care, in a language they can understand and document in a medical record. EHR>Discharge>Instructions if discharged to an equal or lower level of care setting to transfer if discharged to a higher level of care such as an acute hospital. 4. Types of discharges:.D. Against Medical Advice (Refer to Discharge (AMA) Procedures) If the resident wishes to leave the community without a physician's order, the community designee will immediately notify the resident's treating physician and schedule a care conference by and between the resident and/or their legal representative and the treating physician. Other personnel may attend as needed. During the care conference, the treating physician will inform the resident of the risks and consequences associated with his/her decision to leave the health care community. If the resident still wishes to leave AND the resident has the ability to make his/her own health care decisions (as documented in the medical record by the treating physician), the community designee shall have the resident complete and execute all required AMA forms.

Based on observations, interviews and record reviews, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for 1 of 5 residents (Resident #1) reviewed for change in condition. LVN L failed to immediately consult with Resident #1's physician and failed to notify the resident's family when Resident #1 fell hard against a rail in the hallway hitting his face/head and torso, which resulted in immediate bleeding to the resident's cheek on 03/22/26 at 7:30 AM. The resident's family noticed a change in the resident's mental status at 5:00 PM and noted a bloody bandage on the resident's face. The family had the resident transported to the hospital where he found to have sustained a right adrenal hematoma, a Grade 3 laceration of the liver through segments 5 and 6, and two rib fractures. On 03/25/2026 at 5:10 PM an IJ was identified. While the IJ was removed on 03/26/2026 at 4:21 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed the resident at increased risk for complications from a head injury, hospitalization and death due to delayed physician intervention. Findings included:Record review of Resident #1's admissions MDS assessment, dated 01/07/26, revealed he was an [AGE] year-old male, was admitted on [DATE]. He had a BIMS score of 00, indicating the resident was unable to complete the interview (severely impaired cognition). Resident #1 had no behaviors or moods of sadness, hopelessness or worrying at the time of admission. The MDS Assessment, under Section GG-Functional Abilities, reflected Resident #1 required supervision and touching assistance for toileting hygiene, transfers, mobility, and ambulating. He required partial assistance with eating and ADLs. Further review of this document, under Section H-Bladder and Bowel, reflected Resident #1 had occasional urinary incontinence, and always continent of bowel. Section I-Active Diagnoses, Anemia (iron deficiency), Hypertension (high blood pressure), diabetes mellitus (changes in blood sugar levels), Alzheimer's Dementia (brain disorder with symptoms often involving severe behavioral changes, movement disorders, or language dysfunction rather than just memory loss), and Non-Alzheimer's Dementia (brain disease causing cognitive decline not related to Alzheimer's.) Section N Medications indicated resident received high risk medications for anti-psychotic and antidepression.Record review of Resident #1's baseline care plan dated 01/01/2026 reflected that the resident had severe cognitive impairment, he was Spanish-speaking only, and he was able to communicate his needs. The baseline care plan reflected Resident #1 had impaired functional abilities related to his impaired cognition, and he required some assistance from staff.Record review of Resident #1's care plan dated 01/07/2026 reflected the following:Communication.Resident will communicate basic needs to staff daily Spanish speaking only.Resident will demonstrate improved ability to understand speech. as needed Speak in a way that minimizes inability to understand. Anticipate needs. Fall/wandering, last updated on 03/24/2026. Resident at Risk for Falls resident safety will be maintained.Assess contributing factors related to fall history, Resident at risk of falls while wandering in and out of other residents' rooms. Assistance with standing and moving from one place to the next as needed. 03/02/2026. Wandering, 01/08/2026. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist, is the resident looking for something, does it indicate the need for more exercise. redirect; Frequent visual checks.mental health diagnosis.Record review of Resident #1's physician order dated 01/01/2026 by NP-A reflected an order for Haloperidol 1 mg tablet for anxiety.1 tab by mouth at bedtime, admit to long term care, vitals, and weekly weights on day shift. Record review of Resident #1's physician order dated 01/01/2026 by NP-A for Trazadone Hydrochloride 100 mg. for insomnia.1 table by mouth at bedtime 9:00 PM. This order was discontinued on 03/03/2026.Record review of Resident #1's physician orders dated 03/03/2026 reflected an order by NP-A, Lorazepam 0.5 mg for agitation, 1 tablet by mouth every 12 hours as needed 2 times a day . The Lorazepam was discontinued on 03/13/2026 by NP-A. Record review of Resident #1's sign out sheet reflected he was out with family, 03/22/2026, at 5:45 PM. Record review of Resident #1's progress notes by LVN-I, dated 03/22/2026 at 11:38 PM, reflected: Resident was sent to the hospital on day shift for change of condition of N/V per family request. DON-T communicated with this nurse [LVN-I] instructed that his face sheet and medication lists should be faxed to RN-J (phone number provided). Transmittal confirmation was received ok. Residents are placed on LOA and all medications on hold. Record review of Resident #1's skin assessment dated [DATE] was completed by Staff Development Nurse reflected he had an abrasion to his head. HIs peri-wound margins and surrounding tissue was normal. Resident was not experiencing any pain and the MD had had assessed the wound or was notified and no new orders. The family was not notified Additional notes: Per nurse on duty resident ambulatory, attempted to swing at nurse, lost his balance, and fell hitting side rail. causing abrasion to right temple, first aid provided. The skin assessment was initiated by Staff Development Nurse on 03/24/2026 at 10:54 AM and concluded at 03/24/2026 at 11:00 AM. Record review of Resident #1's progress note dated 03/24/2026 at 11:05 AM by DON-T titled nursing incident reflected there was a late entry for 03/22/2026 at 07:30 AM which reflected the following: per report from primary nurse, resident was roaming in and out of rooms this morning requiring frequent redirection. During such times, residents were redirected from the room at approximately 7:00 AM and became aggressive. He attempted to swing and hit the nurse causing him to lose his balance and fall against the handrail on his left side. Per report he sustained a small abrasion to left temple area, no other injuries noted by primary nurse. Resident was ambulatory after fall and functioning at baseline. Nurse will provide frequent monitoring s/p fall. Completed 03/24/2026 11:24 AM.Record review of Resident #1's progress note dated 03/24/2026 at 11:24 AM by DON-T reflected late entry for 03/22/2026 07:30 AM. Per report from primary nurse [LVN-L], resident was roaming in and out of rooms this morning requiring frequent redirection. During that time resident was redirected from another resident's room at approximately [7:00 AM] and became aggressive, [Resident #1] attempted to swing and hit the nurse causing him to lose his balance and fall against the handrail on his left side. Per report he sustained a small abrasion to left temple area, no other injuries noted by primary nurse [LVN-L]. Resident was ambulatory after fall and functioning at baseline. Nurse ill provides frequent monitoring s/p fall. Record review of Resident #1's fall risk assessment completed by ADON-B on 03/24/2026 at 11:41 AM, reflected that Resident #1 was at risk of falls, and his last fall was on 03/22/2026. ADON-B wrote that Resident #1 had no changes in cognitive status in the last 90 days He displayed altered perception ( inaccurate, or unfamiliar interpretation of reality.) .ambulates with no problems and does not use any devices for mobility assistance. Other behaviors observed included disorganized speech, restlessness, changes in mental function, wandering, abusive and resistant to care. Resident #1's was independent with toileting and always continent. Resident #1 blood pressure was not assessed due to being discharged from the facility. There were no completed assessments in the resident's medical records completed by LVN-L regarding the fall on 03/22/2026.by ADON-B for Resident #1's fall on 03/22/2026 at 7:00 AM reflected LVN-L had not completed the required, immediate, comprehensive post-fall assessment (head-to-toe assessment, neurological checks, and vital signs), resulting in ADON-B completing the assessment after the resident was admitted to the hospital 2 days later. LVN-L failed to document any resident assessments or care notes in the file of Resident #1 on 03/22/2026, reflected Record review of Resident #1's incident report dated 03/24/2026 at 12:15 PM was completed by Staff Development Nurse for an incident that occurred on 03/22/2026 at 7:00 AM. The assessment reflected that Resident #1 had a fall in the hallway of the memory unit. LVN-L was present and reported to DON-T on 03/24/2026. Observations reflected that he was moderately impaired, and independently ambulatory. A neurological assessment was completed, and facility findings indicated origin was established, and the injury was not preventable. Facility comments, Resident roaming in and out of rooms, during redirection from [room] resident became aggressive and attempted to swing and hit nurse [LVN-L] causing him to lose his balance and fall against side rail, hitting his left side, sustaining abrasion to left temple area it is important to note that Staff Development Nurse electronically signed the report that she conducted the observations, actions, findings, case report, and reporting, and that the MD, DON-T, and RP were notified on 03/22/2026 at 7:30 AM by LVN-L. The resident was at the hospital at the time of this report. Record review of Resident #1's EHR for the date of 03/22/2026, revealed missing clinical assessments consistent with the falls: Vital signs, fall assessment, post fall monitoring, neurological assessment (alert and function) and post neurological, pain assessments, and functioning and supervision after the fall as well as any changes to his condition. Record review of Resident #1's hospital records reflected he was admitted to the hospital on [DATE] with the chief complaint by the RP that he fell (initial encounter), and fall initial encounter was not resolved. Resident #1 condition was fair and stable. Resident #1 sustained injuries to the right 6th and 7th lateral rib fractures (Right 6th and 7th lateral rib fractures are common chest wall injuries, usually caused by blunt trauma. And sharp pain.), right adrenal hematoma (An adrenal hematoma is a collection of blood within the adrenal gland, often resulting from trauma, severe infection, or anticoagulant use.), and grade 3 Liver laceration involving segments 5 and 8 (These are shallower tears, often less than 3 cm(metric unit used to measure dimensions and size.) deep, or smaller blood clots. Admissions indicators reflected [Resident #1's] past medical history of HTN (High blood pressure), DM (disorder of high blood sugar), CKD (slow progressing conditions of kidney failure). stage 2, and Alzheimer's dementia, who presented s/p, reported fall at his nursing home residence. A comprehensive trauma evaluation identified the injuries above, and the [Resident #1] was admitted to the PCU for pulmonary monitoring, serial hemoglobin monitoring, and pain control measures.During an interview on 03/24/2026 at 9:45 AM with the Administrator, he reported receiving a call from RN-J on 03/22/2026 at 7:04 PM. He then forwarded RN-J's phone number to DON-T to follow up with the hospital nurse for information. He was not aware that Resident #1 had changes per RP and transported the resident to the hospital by the family. The Administrator reported that nursing staff were expected to immediately assess the residents for changes in condition after an incident and observed injuries and follow notification protocols to MD and supervisors to ensure the resident received immediate care. The Administrator did not respond to the risk of not reporting. During an interview with the DON-T on 03/24/2026 at 9:50 AM she stated that LVN- L did not report that Resident #1 fell, sustained an injury to his cheek. DON-T said Resident #1 was signed out by the family and transported to the hospital. DON-T stated LVN-L reported following that resident had an incident obtaining abrasions to his temple on 03/22/2026. DON-T stated LVN-L did not report the incident to her; she was notified by the Administrator after receiving a call from RN-J. LVN-L failed to document the assessments in Resident 1's EHR. DON-T stated that LVN-L will receive one on one training for reporting, and corrective action would be taken. The DON-T stated the protocol of resident injuries and changes in condition includes assessing the resident head-to-toe before moving him/her, checking for obvious injuries, complete neurological checks including assessing eyes for alertness and focus. DON-T stated that the risk of not completing an assessment after an incident with an injury could cause further harm to the residents. During a phone interview on 03/24/2026 at 10:52 AM with the Hospital Social Worker, she stated Resident #1 was brought to the hospital by the family and admitted after a reported fall on 03/22/2026. She stated that Resident #1 sustained injuries of a grade 3 liver laceration and right sided rib fractures. She stated Resident #1 was currently receiving treatment for injuries in PCU (progressive care unit). She reported that Resident #1 did not have an anticipated date of discharge. She stated she would have the assigned NP to contact the surveyor. During an interview on 03/24/26 at RN-M at 1:31 PM, stated she worked at the facility as a PRN staff until recently being hired full time. RN-M was not working on 03/22/2026. She observed a note in Resident #1's EHR that he was transported to the hospital by his family. RN-M stated that when a resident falls, the nurse should assess the resident for injuries, notify the MD for additional guidance and orders. Notify the Family, Admin, and DON. She stated that failing to assess, document, and notify the MD, RP, and DON could result in residents not receiving treatment and additional injuries. During an interview on 03/24/2026 at 1:35 PM, CNA-J stated that she worked at the facility for almost 2 years. She worked with Resident #1 from 2:00 PM to 10:00 PM on 03/22/2026. CNA-J stated that she was told on 03/23/2026 that the resident was at the hospital. She stated that the resident was observed on 03/22/2026 wandering throughout the facility. She said the resident was not acting like he was in pain, nor did he verbalize having pain. She had not received any reports of the residents being monitored for neuros and special supervision. She was notified on 03/23/2026 that Resident #1 fell on [DATE] during the morning shift. She said all changes with the resident's normal baseline should be reported to the charge nurse immediately to ensure the resident was assessed and MD notified for further observation and care to ensure the resident's safety. CNA-J said she did not observe any changes in his normal baseline. During an interview on 03/24/2026 at 2:35 PM with ADON-B, stated that she completed the fall assessment upon being notified by the DON-T on 03/24/2026 after the surveyor entrance. Resident #1 fell on [DATE]. The nurse was expected to complete a series of assessments for injury, vitals, neurological status, supervision, monitoring, change in condition notification, and reporting of the resident's ongoing condition. She stated that when a resident has a head injury from fall, the nurse should notify the MD, RP, DON, and ADON immediately for further guidance and updates to ensure the resident was provided timely and immediate care. Residents are usually sent to the hospital for further assessments and acute procedures. The ADON stated it was her responsibility to ensure that assessments and notifications of incidents were conducted in a timely manner. She stated that the risk of not reporting an incident and changes could result in further injuries to the residents. During an attempted phone interview on 03/24/2026 at 6:45 PM with LVN-L resulted in the surveyor leaving a voice message with call back information and request to return. During an interview on 03/24/2026 at 6:56 PM with CNA-O, she stated that she worked from 2:00 PM to 10:00 PM on the memory unit. She was not assigned to Resident #1. She did not know who was assigned. She denied observing Resident #1's fall, yet she was notified by staff that the resident fell. She observed the resident during her shift wandering. She observed no changes in his abilities. She stated that resident falls should be reported immediately to the charge nurse to assess the resident for injuries and report to the MD, DON, and RP. She stated that failing to report an incident could place the resident at risk of increased pain and injuries that were not addressed immediately. During an interview on 03/24/26 at 7:30 PM with LVN I, she said she works from the 6:00 PM to 6:00 AM shift with Resident #1. LVN-I was notified by LVN L that Resident #1 had fallen, and the family transported him to the hospital's ER. The DON later notified her to send a medication list to RN-J. During an interview with LVN-L on 03/25/2026 at 8:03 AM, he stated that on 03/22/2026 at approximately 7:30 AM, Resident #1 was wandering in and out of another resident's room. LVN-L stated he escorted Resident #1 out of the room more than once, and the resident became angry and fell while attempting to hit him, by swinging hard. The nurse reported that the resident swung and tried to hit him, lost his balance, and fell and hit his head hard and torso (trunk of the body) on the rail in the hallway. He stated that after Resident #1's fall, he observed an abrasion to the right side of his head by the temple and cheek area. He immediately helped the resident off the floor, cleaned the area, and bandaged. Then he completed vitals, skin assessment, fall assessment, and neuro assessments with regular observations. LVN-L stated the resident was not in pain, and he had not observed any changes in the resident's baseline. LVN-L reported that the skin assessment had not revealed any other injuries. LVN-L stated the family visited later at approximately 12:00 PM. He stated that at 5:21 PM, Resident #1's RP and Family Member A approached the nursing station, with Family Member S on the phone via 3-way calling. Family Member S was inquiring about injury and bloody bandage on Resident #1's head, and observations of increased confusion during their visit. LVN-L told the family that Resident #1 fell and hit his head on the rail in the hallway earlier this morning. Family Member S asked LVN-L why the family was not notified of the fall and injury. LVN-L told Family Member S that he was monitoring and assessing Resident #1 for changes. Family Member S reported concerns with Resident #1's changes in alertness and confusion. LVN-L apologized for not reporting the incident to the family, as he was not aware that he needed to notify the family. LVN-L ensured the family that Resident #1 was fine and had been assessed and was being monitored for changes. LVN-L said Family Member S asked if they could sign Resident #1 out and take him to the hospital for further evaluation. LVN-L told the family that they could sign the resident out on leave, because it would take over 2 hours if he contacted transportation to arrive and transport, and his assessment revealed no concerns with changes in condition, alertness, pain, nor alertness that would cause him to be sent out to the hospital via emergency transport. LVN-L signed Resident #1 out at 03/22/2026 to the family on leave. LVN-L told this surveyor that he was not aware that Resident #1 sustained injuries of right adrenal hematoma, a Grade 3 laceration of the liver through segments 5 and 6, and two rib fractures until he received a call from DON-T on 03/24/2026. LVN-L stated that he did not notify the MD, ADON, or DON, however he did notify the weekend supervisor (LVN-G). LVN-L could not recall what time, and stated that she came on the unit, but did not assess the resident. He said he could not recall her name. LVN-L stated with 60 residents on the unit and ongoing behaviors he was busy and failed to document the incident, assessments, call MD and RP. He did not call for assistance from other clinical staff. He stated that he failed to notify MD, DON-T, ADM, and RP, and document assessments after an incident and this placed the resident at risk of additional health complications and injuries. During a hospital visit with Resident #1 on 03/25/2026 at 9:55 AM, Resident #1 could not be interviewed as he was asleep. Resident #1 was observed lying on his back with his eyes closed asleep. Surveyor observed spirometer (a handheld device used to measure lung capacity and airflow speed.) on his bedside table, breakfast tray. A fall mat was located on the left side of the bed. The family was not at the hospital during the interview. The surveyor attempted to locate and interview the MD and assigned nurse, but neither were available. During an attempted interview on 03/25/2026 at 10:05 AM, the Hospital Social Worker revealed she could not provide any information due to confidentiality. During an interview on 03/25/2026 at 11:00 AM, Resident #1's Family Member S stated the resident had a fall on 03/22/2026, and he was observed by the RP and FM at 03/22/2026 at 5:00 PM with a bloody band aid on his cheek. FM stated that the RP nor family were notified that he fell on [DATE]. During a visit with Resident #1 the RP observed a bloody band-aid on his right cheek. She stated that Resident #1 could not provide the details due to his dementia. Family Member S and Family Member A contacted LVN-L on a conference call for further information and details. Family Member S inquired about the injury to Resident #1's face, and LVN-L stated that Resident #1 fell that morning, when asked to leave another resident's room. LVN-L told Family Member S that Resident #1 became angry, swung at the nurse, and fell hitting his face on the railing then falling to the floor. LVN-L stated to Family Member S that he was not aware of the need to report the incident to the family. Family Member S asked LVN-L if Resident #1 was monitored for neurological changes, because the RP reported that the resident was confused and different. LVN-L stated that the resident was fine. Family Member S asked LVN-L could Resident #1 go to the hospital. Family Member S said the nurse told her that the resident was fine, and there were no changes. Family Member S asked if the family could sign Resident #1 out on leave and transport him to the hospital for an evaluation. LVN-L told Family Member S that the family could transport the resident to hospital, because if he called non-emergency transportation to transfer the resident to the hospital, it would take 2 or more hours before they arrived. The RP and Family Member A signed Resident #1 out for leave and transported to the ER. Family Member S stated that Resident #1 sustained injuries of abrasion to right cheek, bruised liver, and fractures of the rib. She stated that the facility staff had not followed up with the family about the hospitalization or to address the incident. Family Member S stated that she went to the facility to pick up Resident #1's personal items and told them he would be discharged home with family from the hospital. Family Member S spoke with the DON, and she minimized the injuries reported by the hospital. Family Member S said she was disheartened when the facility failed to provide the immediate needed care to Resident #1 after a fall and not informing the family of the injury to his face. During an interview on 03/25/2026 at 12:33 PM, CNA-P stated she had worked at the facility for two years. She was not working on 03/22/2026. CNA-P was informed that Resident #1 was in the hospital after falling on Sunday. She attended training for dementia patients. The training conducted for the staff that worked directly with residents on the Memory care included how to de-escalate agitated residents, report incidents immediately to the nurse and Administrator. The nurse will assess the residents for injuries, confusion, vitals, and report to the MD and family. Resident altercations interventions included step between the residents, redirect, offer a snack as a diversion. If this does not work, she will notify the nurse supervisor. In the event there are multiple alterations and behaviors outburst, the unit supervisors will be called for assistance. She works with Resident #1, and he has not been aggressive. She stated that he responds to redirection by staff, diversion of television, group activity, or snacks. She said he does not fight the residents, only the staff. When the staff prevents him from entering a room, he will be aggressive. She has not received any reports of him hitting any other staff, During an interview with LVN B on 03/25/2026 at 12:36 PM she stated that she was working on 03/22/2026 with LVN-L. LVN-B said she did not observe the resident fall. She was notified by LVN-L during the shift that the resident fell and that the family was signing him out to be transported to the hospital for further evaluations. LVN-B stated that all nursing should assess the residents for injuries prior to moving the resident. If the resident can't move, then notify MD for further guidance and orders. She observed the resident wandering throughout the facility with no concerns prior to family arriving to visit. During an interview on 03/25/2026 at 12:59 PM, with Staff Development Nurse staff that conduct training and development. She has been working here for a year. She stated that a recent training was conducted by NP-O, for dementia. The training consisted of identifying the stages of dementia, behaviors, observations, and reporting of increased agitation, wandering, altercations, personal space, and other areas. She stated the training addressed activities, supervision, interventions, redirections, and other tools to use. She stated that all staff complete dementia training at the time of hiring. Staff Development Nurse was notified by DON on 03/24/2026 that Resident #1 fell and had an abrasion to his right cheek. The family transported him to the ER. Staff Development Nurse completed the skin assessment on 03/24/2026 once being notified by the DON that he was in the hospital. She stated that nursing and facility protocol requires the nurse to assess the resident after a fall for injuries, vitals, treatments, first aide, notify provider, responsible party, and if charge nurse notify ADON and DON. The provider and DON give the staff guidance. She said the risk to the residents for not reporting immediately, assessing changes could result in severe injuries. Staff Development Nurse was responsible for ensuring PRN staff receive updated training in person or online. During an interview on 03/25/2026 at 1:38 PM, LVN-G (Weekend Supervisor) stated that she was the supervisor on duty 03/22/2026. LVN-G conducted unit rounds every 2 hours. LVN-G said she was not notified by LVN-L during unit rounds nor received a call reporting that Resident #1 had fallen on 03/22/2026 at 7:00 AM. LVN-G said the nurses were expected to notify the weekend supervisor immediately to assist, oversee, and monitor the Assessments, resident changes, MD orders, and to maintain resident safety. LVN-G said then the nurse notifies the MD for further guidance. Once the MD was notified of the incident, the DON and RP were notified. She stated that failing to report the incident places the residents at risk for serious illnesses and injuries.During an attempted phone interview on 03/25/2026 at 2:30 PM, neither MD-B and NP-W were available at the time. The surveyor left a message with the receptionist to have them call me regarding Resident #1. During an interview on 03/31/2026 at 8:49 AM, NP-A stated that the facility staff did not provide notification of Resident #1's fall details, until 03/24/2026. He stated on 03/24/2026 a facility nurse (could not recall name or position) notified him that the resident was transported to the hospital by the family. NP-A stated that he had no contact with the family or hospital following Resident #1's admission. NP-A stated that he expects immediate notification when a resident falls with head injury to send out to ER for further evaluation. The risk to the patient when MD's not notified could result in serious internal injuries. Review of the facility's policy titled Change in a Resident's Condition or Status, revised 02/13/2023, reflected in part the following: The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the community's staff and practitioners must recognize an ACOC (is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. (and identify its nature, severity, and cause(s). The practitioner needs a detailed description of the patient's condition to determine whether a Symptom is problematic or simply a normal or expected variant. Care-giving staff should describe and document the nature, extent, and severity of symptoms, abnormalities, and condition changes clearly and in sufficient detail to help Practitioners distinguish their potential causes and consequences .A brief review of the patient's known medical history (e.g., synopsis of a recent hospital course) is vital. This was determined to be an IJ on 03/25/2026 at 5:10 PM. The Administrator and DON were notified. The Administrator was provided the IJ Template on 03/25/2026 at 5:19 PM. The following Plan of Removal submitted by the facility was accepted on 03/26/2026 at 6:19 PM:Plan of removal for IJ-F580-State alleges facility failed to ensure physician was notified of injury post fall on one resident.IJ called at 5:10PM facility for F580.Medical Director Notified at 5:20PM.Ad hoc [created for a particular purpose] QA completed to address notification protocols of family and physician for incident/accidents and change of condition.[Resident #1] is currently out of facility.Immediate Correction/Client protectionDON/designee to educate licensed nurses on proper notification of physician and family for incident/accidents to include any resident change of condition. Completion date 03/25/2026DON/designee to educate licensed nurses to notify DON and administrator of all incident/accidents and change of condition that require hospital transfer. Completion date 03/25/2026.DON/designee performed assessments on all residents with falls in the past 30 days to ensure proper notifications and assessments in place. Completion date: 03/25/2026MDS/designee updated care plans for all residents with falls in the last 30 days. Completion date 03/25/2026All licensed nurses will be educated on incident/accident protocols, to include notification of DON, Administrator, physician and family and resident assessment prior to working their next assigned shift. DON/designee will complete this. Completion date: 03/25/2026MonitoringDON and/or designee will monitor residents with falls daily to ensure notifications were appropriately made to physician and family.Administrator to review with the DON weekly to ensure continued compliance.Results of all audits will be brought to the QAPI committee by DON to review for continued recommendations and compliance.This protocol will be covered on new-hire orientation by DON/designee. Record review of in-service training dated 02/19/2026 and 02/23/2026 titled Navigating Cognitive Changes: Dementia, Delirium, and AMS for clinical staff reflected in part: identifying changes in conduction, comprehending the stages of Dementia, understanding Delirium, and AMS (a change in mental function. It stems from certain illnesses, disorders and injuries affecting your brain.) Detecting change in SMI Patients.developing and implementing resident intervention protocols, assessing, reporting, documenting, and notifying providers. Record review of CNA-O's personnel file reflected CNA O's date of hire was 0

Based on observation, interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 8 residents (Resident #1) reviewed for quality of care. LVN L failed to complete an immediate, comprehensive post-fall assessment to include neurological checks after Resident #1 had a fall when the resident swung hard towards LVN L in an attempt to hit him on 03/22/2026 at 7:30 AM, which resulted in the resident losing his balance and hitting his face/head and torso against a rail in the hallway. The resident had bleeding on his cheek which LVN L put a bandage on; however, LVN L did not notify the physician of the fall nor did he notify the resident's family. The family noticed a change in the resident's mental status on 03/22/2026 and saw the bloody bandage on the resident's cheek. The family had the resident transported to the hospital where he was found to have sustained a right adrenal hematoma, a Grade 3 laceration of the liver through segments 5 and 6, and two rib fractures. LVN L's failure to provide treatment and care in accordance with professional standards of practice resulted in Resident #1 not receiving appropriate treatment and care for approximately 10 hours.On 03/25/2026 at 5:10 PM an IJ was identified. While the IJ was removed on 03/26/2026 at 4:21 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure could affect residents currently residing in the facility, resulting in them not receiving the necessary care needed to maintain optimal health and placing them at risk for injury or deterioration in their condition. Findings included:Record review of Resident #1's admissions MDS assessment, dated 01/07/2026, revealed he was an [AGE] year-old male, was admitted on [DATE]. He had a BIMS score of 00, indicating the resident was unable to complete the interview (severely impaired cognition). Resident #1 had no behavior or moods at the time of admission. The MDS Assessment, under Section GG-Functional Abilities, reflected Resident #1 required supervision and touching for toileting hygiene, transfers, mobility, and ambulating. He required partial assistance with eating and ADL's Further review of this document, under Section H-Bladder and Bowel, reflected Resident #1 had occasional urinary incontinence urine, and always continent for bowel. Section I-Active Diagnoses, Anemia (iron deficiency), Hypertension (high blood pressure), diabetes Mellitus (changes in blood sugar levels), Alzheimer's Dementia (brain disorder with symptoms often involving severe behavioral changes, movement disorders, or language dysfunction rather than just memory loss, and Non-Alzheimer's Dementia (brain disease causing cognitive decline not related to Alzheimer's.) Section N Medications indicated residents received high risk medications anti-psychotic and antidepression. Record review of Resident #1's baseline care plan dated 01/01/2026 reflected: he was severely impaired cognitively, with goals to improve. Resident #1 was Spanish speaking only and able to communicate his needs. Resident #1 had impaired functional abilities related to impaired cognition and requires some assistance from staff. Improve mobility, evaluate for speech and physical therapy.Record review of Resident #1's care plan dated 01/07/2026 reflected: Fall/wandering, last updated on 03/24/2026. Resident at Risk for Falls resident safety will be maintained.Assess contributing factors related to fall history, Resident at risk of falls while wandering in and out of other residents' rooms. Assistance with standing and moving from one place to the next as needed. 03/02/2026. Wandering, 01/08/2026.Resident safety will be maintained.Orient to surroundings; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist, is the resident looking for something, Does it indicate the need for more exercise.redirect; Frequent visual checks.mental health diagnosis. Record review of Resident #1's MD order dated 01/01/2026 by NP-A reflected an order for Haloperidol 1 mg tablet for anxiety.1 tab by mouth at bedtime, admit to long term care, vitals, and weekly weights on day shift. Record review of Resident #1's MD order dated 01/01/2026 by NP-A for Trazadone Hydrochloride 100 mg. for insomnia.1 table by mouth at bedtime 9:00 PM. This order was discontinued on 03/03/2026.Record review of Resident #1's sign out sheet reflected he was out with family, 03/22/2026, at 5:45 PM.Record review of Resident #1's progress note by LVN-I, dated 3/22/2026 at 11:38 PM, reflected: Resident was sent to the hospital on day shift for change of condition of N/V per family request. DON-T communicated with this nurse [LVN-I] instructed that his face sheet and medication lists should be faxed to RN-J (phone number provided). Transmittal confirmation was received ok. Resident is placed on LOA and all medications on hold. Record review of Resident #1's skin assessment dated [DATE] at 11:00 AM conducted by Staff Development Nurse. The peri wound was normal. MD notified. Additional notes: Per nurse on duty resident ambulatory, attempted to swing at nurse, lost his balance, and fell hitting side rail. causing abrasion to right temple, first aid provided. The assessment skin evaluations, wound identification, and summary of each section was initiated at 10:54 AM and concluded at 03/24/2026 at 11:00 AM. This assessment was completed after the resident was hospitalized . Record review of Resident #1's progress note dated 03/24/2026 at 11:05 AM by DON-T titled nursing incident -Late entry for 03/22/2026 at 07:30 AM reflected per report from primary nurse, resident was roaming in and out of rooms this morning requiring frequent redirection. During such time resident was redirected from room at approximately 7:00 AM and became aggressive, he attempted to swing and hit the nurse causing him to lose his balance and fall against the handrail on his left side. Per report he sustained a small abrasion to left temple area, no other injuries noted by primary nurse. Resident was ambulatory after fall and functioning at baseline. Nurse will provide frequent monitoring s/p fall. Completed 03/24/2026 11:24 AM.Record review of Resident #1's fall risk assessment dated [DATE] at 11:41 AM by ADON-B for Resident #1's fall on 03/22/2026 at 7:00 AM reflected LVN-L had not completed the required, immediate, comprehensive post-fall assessment (head-to-toe assessment, neurological checks, and vital signs), resulting in ADON-B completing once the resident was taken to the hospital 2 days later. LVN-L failed to document any resident assessments or care notes in the file of Resident #1 on 03/22/2026, reflected Resident #1 was a fall risk with his last fall being 03/22/2026. Resident #1 had a total of 1 to 2 falls since being admitted . ADON-B wrote that Resident #1 had no changes in cognitive status in the last 90 days. Cognition: displays altered perception, Resident #1 ambulates without a problem and without devices. Disorganized speech, restlessness, varying mental function, wanders, abusive and resistance to care. Resident #1's incontinent status reflected that he was independent and incontinent. Resident #1 pressure was not assessed due to him being at the hospital at the time of this assessment.Record review of Resident #1's incident report dated 03/24/2026 at 12:15 PM was completed by Staff Development Nurse for an incident that occurred on 03/22/2026 at 7:00 AM. The assessment reflected that Resident #1 had a fall in the hallway of the memory unit. LVN-L was present and reported to DON-T on 03/24/2026. Observations reflected Resident #1 was moderately impaired, and independently ambulatory. A neurological assessment was completed, and facility findings indicated origin was established and the injury was not preventable. Facility comments, Resident roaming in and out of rooms, during redirection from [room] resident became aggressive and attempted to swing and hit nurse [LVN-L] causing him to lose his balance and fall against side rail, hitting his left side, sustaining abrasion to left temple area it is important to note that Staff Development Nurse electronically signed the report that she conducted the observations, actions, findings, case report, and reporting, and that the MD, DON-T, and RP were notified on 03/22/2026 at 7:30 AM and DON-T by LVN-L. The resident was at the hospital at the time of this report. Record review of Resident #1's EHR dated 03/22/2026, revealed missing clinical assessments consistent with the falls: Vital signs, fall assessment, post fall monitoring, neurological assessment (alert and function) and post neurological, pain assessments, and functioning and supervision after the fall as well as any changes to his condition. Record review of Resident #1's hospital records reflected he was admitted on [DATE] with family with complaints that he fell (at the nursing facility initial encounter). Resident #1's condition was fair and stable. Resident #1 sustained injuries to the right 6th and 7th lateral rib fractures (Right 6th and 7th lateral rib fractures are common chest wall injuries, usually caused by blunt trauma. And sharp pain.), right adrenal hematoma (Adrenal hematoma is a collection of blood within the adrenal gland, often resulting from trauma, severe infection, or anticoagulant use.), and grade 3 Liver laceration involving segments 5 and 8 (These are shallower tears, often less than 3 cm (metric unit used to measure dimensions and size.) deep, or smaller blood clots. Admissions indicators reflected [Resident #1's] past medical history of HTN (High blood pressure), DM (disorder of high blood sugar), CKD (slow progressing conditions of kidney failure.) stage 2, and Alzheimer's dementia who presented s/p reported fall at his nursing home residence. A comprehensive trauma evaluation identified the injuries above, and the [Resident #1] was admitted to the PCU for pulmonary monitoring, serial hemoglobin monitoring, and pain control measures.Record review of CNA-O one on one training dated 03/25/2026 reflected Acknowledgment of abuse and reporting requirements, incident of abuse, and neglect, as well as reporting any such incidents to the abuse prevention coordinator, community administrator, and DON. CNA-O signed receipt of the training on reportable to the State by facilities.Review of Facility policy titled Fall Management reviewed on 10/16/2025 reflected in part the following: Purpose: The community will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The community will manage falls by providing an environment that is free from potential hazards. Procedures: If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason, and determines the intervention to prevent future falls - complete the incident/accident report in the EHR. The physician and family are notified.During an interview on 03/24/2026 at 9:45 AM with the Administrator, he reported receiving a call from RN-J on 03/22/2026 at 7:04 PM. He then forwarded RN-J's phone number to DON-T to follow up with the hospital nurse for information. He was not aware of the fall or that the RP transported the resident to the hospital. The Administrator reported that nurses are expected to assess the residents after a fall and notify the MD to ensure the proper nursing protocols for falls were followed. During an interview with the DON-T on 03/24/2026 at 9:50 AM she stated that LVN- L did not report that Resident #1 fell, sustained an injury to his cheek. DON-T said the Resident was signed out by the family and transported to the hospital. DON-T stated LVN-L reported following fall protocols on 03/22/2026 during a phone interview 03/24/2026. LVN-L reported assessing Resident #1 before moving him off the floor. DON-T stated LVN-L did not report that he had not documented the assessments in the EHR. DON-T stated that LVN-L will receive one on one training for reporting, and corrective action would be taken. The DON-T stated the protocol for a witnessed fall with an injury to the head includes assessing the resident head-to-toe before moving him/her, check for obvious injuries, complete neurological checks including assessing eyes for alertness and focus. DON-T stated the risk of not completing an assessment before moving a resident after an unwitnessed fall or a fall with an injury could cause further harm to the residents. During a phone interview on 03/24/2026 at 10:52 AM with HSW, revealed Resident #1 was brought to the hospital by the family and admitted after a reported fall on 03/22/2026. HSW stated that Resident #1 sustained injuries of a grade 3 liver laceration and right sided rib fractures. HSW stated Resident #1 was currently receiving treatment for injuries in PCU (progressive care unit). HSW reported that Resident #1 did not have an anticipated date of discharge. HSW stated she would have the assigned NP to contact the surveyor. During an interview on 03/24/26 at RN-M at 1:31 PM, stated she worked at the facility as a PRN staff until recently being hired full time. RN-M was not working on 03/22/2026. She observed a note in Resident #1's EHR that he was transported to the hospital by his family. RN-M stated that when a resident falls, the nurse should assess the resident for injuries, notify the MD for additional guidance and orders. Notify the Family, Admin, and DON. She stated that failing to assess, document, and notify the MD, RP, and DON could result in residents not receiving treatment and additional injuries.During an interview on 03/24/2026 at 1:35 PM with CNA-J stated that she was informed that the resident was in the hospital on [DATE]. She denied observing Resident #1 falling during her shift. CNA-J reported that resident observations did not reveal he was experiencing any pain, nor had he verbalized pain. CNA-J stated that staff must report concerns, changes, behaviors, and falls immediately to the nurse. She said failing to report an incident immediately could result in the residents not receiving timely assessments, care, and treatment.During an interview on 03/24/2026 at 2:35 PM with ADON-B, she stated Resident #1 fell on the weekend shift 03/22/2026. She was not notified of the incident until 03/24/2026 by DON-T. ADON-B stated LVN-L did not report the incident or complete comprehensive assessments for falls. ADON-B said she did not receive a call from LVN-L that he was unable to complete an assessment on Resident #1 after the fall. However, upon review of Resident #1's EHR, there were no assessments or documentation incident observed. ADON-B stated that she completed the fall assessment upon being notified by DON-T on 03/24/2026 at 12:15 PM. ADON B stated staff were in-serviced very frequently on fall protocols, today, and the training included proper assessments and notification. ADON B stated a proper assessment for a witnessed fall or a fall with an obvious head injury would be to do neurological checks, check head-to-toes for injuries, and assess for pain before moving to prevent further injury if any. ADON B stated if a nurse were unable to complete an assessment, they would be expected to call the weekend nurse and MD for further instructions. During an interview with LVN B on 03/24/2026 at 3:40 PM she stated that she was working on 03/22/2026 with LVN-L. LVN-B said she did not observe the resident fall. She was notified by LVN-L during the shift that the resident fell and that the family was signing him out to be transported to the hospital for further evaluations. LVN-B stated that all nursing should assess the residents for injuries prior to moving the resident. If the resident can't move, then notify MD for further guidance and orders. She observed the resident wandering throughout the facility with no concerns prior to family arriving to visit. During an attempted phone interview on 03/24/2026 at 6:45 PM with LVN-L resulted in the surveyor leaving a voice message with call back information and request to return. During a phone interview on 03/24/2026 at 6:56 PM with CNA-O, stated that she worked from 2:00 PM to 10:00 PM on the memory unit. She was not assigned to Resident #1. She did not know who was assigned. She denied observing Resident #1 fall, yet she was notified by staff that the resident fell. She observed the resident during her shift wandering. She observed no changes in his abilities. She stated that resident falls should be reported immediately to the charge nurse to assess the resident for injuries and report to the MD, DON, and RP. She stated that failing to report an incident could place the resident at risk of increased pain and injuries that were not addressed immediately.During a phone interview on 03/24/26 at 7:30 PM with LVN I, she works from the 6:00 PM to 6:00 AM shift with Resident #1. LVN-I was notified by LVN L that Resident #1 had fallen, and the family transported him to the hospital ER. The DON later notified her to send a medication list to RN-J. During an interview with LVN-L on 03/25/2026 at 8:03 AM, he stated that on 03/22/2026 at approximately 7:30 AM, Resident #1 was wandering in and out of another resident's room. LVN-L stated he escorted Resident #1 out of the room more than once, and the resident became angry and fell while attempting to hit him, by swinging hard. The nurse reported that the resident swung and tried to hit him, lost his balance, and fell and hit his head hard and torso (trunk of the body) on the rail in the hallway. He stated that after Resident #1's fall he observed an abrasion to the right side of his head by the temple and cheek area. He immediately helped the resident off the floor, cleaned the area bandaged. Then he completed vitals, skin assessment, fall assessment and neuro assessments with regular observations. LVN-L stated the resident was not in pain, and he had not observed any changes in the residents baseline. LVN-L reported the skin assessment had not revealed any other injuries. LVN-L stated the family visits later and at approximately 12:00 PM. He stated that at 5:21 PM, Resident #1's RP and Family Member A approached the nursing station, with Family Member S on the phone via 3-way calling. Family Member S was inquiring about injury and bloody bandage on Resident #1's head, and observations of increased confusion during their visit. LVN-L told the family that Resident #1 fell and hit his head on the rail in the hallway earlier this morning. Family Member S asked LVN-L why the family was not notified of the fall and injury. LVN-L told Family Member S that he was monitoring and assessing Resident #1 for changes. Family Member S reported concerns with Resident #1's changes in alertness and confusion. LVN-L apologized for not reporting the incident to the family, as he was not aware that he needed to notify the family. LVN-L ensured the family that Resident #1 was fine and had been assessed and was being monitored for changes. LVN-L said Family Member S asked if they could sign Resident #1 out and take him to the hospital for further evaluation. LVN-L told the family that they could sign the resident out on leave, because it would take over 2 hours if he contacted transportation to arrive and transport, and his assessment yielded no concerns regarding hospital resident's alertness LVN-L signed out at 03/22/2026 to the family on leave. LVN-L told this surveyor that he was not aware that Resident #1 sustained injuries of right adrenal hematoma, a Grade 3 laceration of the liver through segments 5 and 6, and two rib fractures until he received a call from DON-T on 03/24/2026. LVN-L stated that he did not notify the MD, ADON, or DON, however he did notify the weekend supervisor. LVN-L could not recall what time, and stated that she came on the unit, but did not assess the resident. He said he could not recall her name. LVN-L stated with 60 residents on the unit and ongoing behaviors he was busy and failed to document the incident, assessments, call MD and RP. He did not call for assistance from other clinical staff. He stated that failing to notify MD, DON-T, Administrator, and RP, and document assessments after an incident placed the resident at risk of additional health complications and injuries. During a hospital visit with Resident #1 on 03/25/2026 at 9:55 AM, Resident #1 could not be interviewed as he was asleep. Resident #1 was observed lying on his back with his eyes closed asleep. Surveyor observed spirometer (a handheld device used to measure lung capacity and airflow speed.) on his bedside table, breakfast tray. A fall mat was located on the left side of the bed. The family was not at the hospital during the interview. The surveyor attempted to locate and interview the MD and assigned nurse, but neither were available. During an attempted interview on 03/25/2026 at 10:05 AM, the hospital SW revealed she could not provide any information due to confidentiality. On 03/25/2026 at 10:15 AM, while visiting the hospital, the surveyor requested Resident #1's physical records onsite to determine the resident's current medical condition: Right 6th and 7th lateral rib fractures (usually caused by blunt trauma. And sharp pain.), right adrenal hematoma (is a collection of blood within the adrenal gland, often resulting from trauma, severe infection, or anticoagulant use.), and grade 3 Liver laceration involving segments 5 and 8 (These are shallower tears, often less than 3 cm (metric unit used to measure dimensions and size.) deep, or smaller blood clots. During an interview on 03/25/2026 at 11: 00 AM, Resident #1's Family Member S stated the resident had a fall on 03/22/2026, and he was observed by the RP and FM at 03/22/2026 at 5:00 PM with a bloody band aid on his cheek. FM stated that the RP nor family were notified that he fell on [DATE]. During a visit with Resident #1 the RP observed a bloody band-aid on his right cheek. She stated that Resident #1 could not provide the details due to his dementia. Family Member S and Family Member A contacted LVN-L via conference-3-ways call for further information and details. Family Member S inquired about the injury to her Resident #1's face, and LVN-L stated that Resident #1 fell this morning, when asked to leave a resident room. LVN-L told Family Member S that Resident #1 became angry, swung at the nurse, and fell hitting his face on the railing then falling to the floor. LVN-L stated to Family Member S that he was not aware of the need to report the incident to the family. Family Member S asked LVN-L if Resident #1 was monitored for neurological changes, because the RP reported that the resident was confused and different. LVN-L stated that the resident was fine. Family Member S asked LVN-L could Resident #1 went to the hospital. Family Member S said the nurse told her that the resident was fine, and there were no changes. Family Member S asked if the family could sign Resident #1 out on leave and transport him to the hospital for an evaluation. LVN-L told Family Member S that the family could transport the resident to hospital, because if he called non-emergency transportation to transfer the residents to the hospital, it would take 2 or more hours before they arrived. The RP and Family Member A signed Resident #1 out for leave and transported to the ER. Family Member S stated that Resident #1 sustained injuries of abrasion to right cheek, bruised liver, and fractures of the rib. She stated that the facility staff had not followed up with the family about the hospitalization or to address the incident. Family Member S stated that she went to the facility to pick up Resident #1's personal items and told them he would be discharged home with family from the hospital. Family Member S spoke with the DON, and she minimized the injuries reported by the hospital. Family Member S said she was disheartened when the facility failed to provide the immediate needed care to Resident #1 after a fall and informing the family of the injury to his face. During an interview on 03/25/2026 at 12:33 PM with CNA-P she has worked at the facility for 2 years. She was not working on 03/22/2026. CNA-P was informed that Resident #1 was in the hospital after falling on Sunday. She attended training for dementia patients. The training for memory included [NAME] to de-escalate agitated residents, report incidents immediately to the nurse and administrator. The nurse will assess the residents for injuries, confusion, vitals, and report to the MD and family. altercation, step in, redirect, offer a snack. If this does not work, she will notify the nurse supervisor. In the event there are multiple alterations and behaviors outburst, the unit supervisors will be called for assistance. She works with Resident #1, and he has not been aggressive. She stated that he responds to redirection by staff, diversion of television, group activity, or snacks. She said he does not fight the residents, only the staff. When the staff prevents him from entering a room, he will be aggressive. She has not received any reports of him hitting any other staff, During an interview on 03/25/2026 at 12:59 PM, with Staff Development Nurse staff that conduct training and development. She has been working here for a year. She stated that a recent training was conducted by NP-O, for dementia. The training consists of identifying the stages of dementia, behaviors, observations, and reporting of increased agitation, wandering, altercations, personal space, and other areas. She stated the training addresses activities, supervision, interventions, redirections, and other tools to use. She stated that all staff complete dementia training at the time of hiring. LNV-D was notified by DON on 03/24/2026 that Resident #1 fell and had an abrasion to his right cheek. The family transported him to the ER. She completed the skin assessment. She stated that nursing and facility protocol requires the nurse to assess the resident after a fall for injuries, vitals, treatments, first aide, notify provider, responsible party, and if charge nurse notify ADON and DON. The provider and nurse DON's give the staff guidance. She said the risk to the residents for not reporting immediately, assessing changes could result in severe injuries. Staff Development Nurse was responsible for ensuring PRN staff receive updated training in person or online. During an interview on 03/25/2026 at 1:38 PM, with LVN-G weekend supervisor, stated that she was the supervisor on duty 03/22/2026. LVN-G conducted unit rounds every 2 hours. LVN-G said she was not notified by LVN-L during unit rounds nor received a call reporting that Resident #1 had fallen on 03/22/2026 at 7;00 AM. LVN-G said the nurses were expected to notify the weekend supervisor immediately to assist oversee and monitor the Assessments, resident changes, MD orders, to maintain resident safety. LVN-G said then the nurse notifies the MD for further guidance. Once the MD was notified of the incident, the DON and RP were notified. She stated that failing to report the incident places the resident at risk for serious illnesses and injuries.During an attempted phone interview on 03/25/2026 at 2:30 PM with MD-B and NP-W neither were available at the time. The surveyor left a message with the receptionist to have them call me regarding Resident #1. During an interview on 03/31/2026 at 8:49 AM with NP-A, he stated that the facility staff did not provide notification of Resident #1's fall details, until 03/24/2026; He stated on 03/24/2026 a facility nurse (could not recall name or position) notified him that the resident was transported to the hospital by the family. NP-A stated that he had no contact with the family or hospital following Resident #1's admission. NP-A stated that he expects immediate notification when a resident falls with head injury to send out to ER for further evaluation. The risk to the patient when MD's not notified could result in serious internal injuries. During an interview on 03/26/2026 at 9:55 AM with DON-T, stated that LVN-L did not notify DON that Resident #1 fell on [DATE] until she reached out on 03/24/2026 via phone. The DON stated the protocol for a witnessed fall with an injury was to assess the resident head-to-toe before moving him/her, check for obvious injuries, complete neurological checks including assessing eyes for alertness and focus. The DON stated the risk of not completing an assessment before moving a resident after a witnessed fall or a fall with an injury could be causing further harm to the resident. The Administrator and DON were notified of Immediate Jeopardy (IJ) on 03/25/2025 at 5:10 PM, due to the above failures and the IJ Template was provided at 5:19 PM. The following Plan of Removal submitted by the facility and accepted on 03/26/2026 at 6:19 PM and included:Plan of removal for IJ-F684-State alleges facility failed to ensure proper assessment and documentation on one resident post fall.1. IJ called at 5:10PM facility for F684.2. Medical Director Notified at 5:20PM.3. Ad hoc [as need] QA completed to address notification protocols of family and physician for incident/accidents and change of condition to include proper assessments and documentation.4. [Resident #1] is currently out of facility.5. Immediate Correction/Client protectiona. DON/designed to educate licensed nurses on proper assessments and documentation for incident/accidents to include any resident change of condition. Completion date 03/25/2026.b. DON/designee to educate licensed nurses to notify DON and administrator of all incident/accidents and change of condition that require hospital transfer. Completion date 03/25/2026. c. DON/designee performed assessment on all residents with falls in the past 30 days to ensure proper notifications and assessments in place. Completion date: 03/25/2026.d. MDS/designee updated care plans for all residents with falls in the last 30 days. Completion date 03/25/2026.e. All licensed nurses will be educated on incident/accident protocols, to include notification of DON, Administrator, physician and family and resident assessment and documentation prior to working their next assigned shift. DON/designee will complete this. Completion date: 03/25/2026.6. Monitoring:a. DON and/or designee will monitor residents with falls daily to ensure notifications, assessments, and documentation are in place.b. Administrator to review with the DON weekly to ensure continued compliance.c. Results of all audits will be brought to QAPI committee by DON to review for continued recommendations and compliance.d. This protocol will be covered on new-hire orientation by DON/designee. Monitoring of the POR included the following: Record review of facility all staff in-service dated 03/25/2026, completed by Staff Development Nurse, the staff development coordinator titled Incidents and Accidents: Reporting, Investigating, and Notifying the provider, ADON, DON, Administrator and Family.to do list by ADON: Patient falls, and patient transferring to hospital. Change in condition: assessing, documenting and reporting to physician and family., recognizing change in condition, and when to notify physician of a change in condition all staff in-services received a posttest over the following materials: behavior health monitoring, fall prevention, and Dementia, changes in condition, reporting and documenting resident abuse, neglect, changes and incidents immediately to provider, DON, RP, and Administrator.On 03/26/2026 the investigator began monitoring (12:17 PM through 4:00 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observations, interviews, and record reviews on 03/26/2026 9:00 AM-11:00 AM of Residents #1, 2, 3, 4, and 5 were all a fall risk and stated they had no concerns regarding falls, assistance, and supervision. Residents EHR reflected plans, interventions and documentation addressing the resident falls. Record reviews of Residents #1, #2, #3, #4, and #5 EHR fall a

Based on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 1 resident (Resident #1) reviewed for reportable incidents of abuse and neglect.LVN-L failed to report an allegation of abuse and neglect immediately to the Administrator, physician, and family for further actions and guidance after Resident #1 fell on [DATE] sustaining an abrasion to his head, and progressive changes in health that resulted in hospitalization and diagnosis as followed: A right adrenal hematoma, a Grade 3 laceration of the liver through segments 5 and 6, and two fractured ribs. This facility failure could place residents at risk for abuse and neglect. Findings included:Record review of Resident #1's admissions MDS assessment, dated 01/07/2026, revealed he was an [AGE] year-old male, was admitted on [DATE]. He had a BIMS score of 00, indicating the resident was unable to complete the interview (severely impaired cognition). Resident #1 had no behavior or moods at the time of admission. The MDS Assessment, under Section GG-Functional Abilities, reflected Resident #1 required supervision and touching for toileting hygiene, transfers, mobility, and ambulating. He required partial assistance with eating and ADL's Further review of this document, under Section H-Bladder and Bowel, reflected Resident #1 had occasional urinary incontinence urine, and always continent for bowel. Section I-Active Diagnoses, Anemia (iron deficiency), Hypertension (high blood pressure), diabetes Mellitus (changes in blood sugar levels), Alzheimer's Dementia (brain disorder with symptoms often involving severe behavioral changes, movement disorders, or language dysfunction rather than just memory loss, and Non-Alzheimer's Dementia (brain disease causing cognitive decline not related to Alzheimer's.) Section N Medications indicated residents received high risk medications anti-psychotic and antidepression.Record review of Resident #1's baseline care plan dated 01/01/2026 reflected: He was severely impaired cognitively, with goals to improve. Resident #1 was Spanish speaking only and able to communicate his needs. Resident had impaired functional abilities related to impaired cognition and requires some assistance from staff. Improve mobility, evaluate for speech and physical therapy.Record review of Resident #1's care plan dated 01/07/2026 reflected: Communication.Resident will communicate basic needs to staff daily Spanish speaking only.Resident will demonstrate improved ability to understand speech. as needed Speak in a way that minimizes inability to understand. Anticipate needs. Fall/wandering, last updated on 03/24/2026. Resident at Risk for Falls resident safety will be maintained.Assess contributing factors related to fall history, Resident at risk of falls while wandering in and out of other residents' rooms. Assistance with standing and moving from one place to the next as needed. 03/02/2026. Wandering, 01/08/2026. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist, is the resident looking for something, does it indicate the need for more exercise. redirect; Frequent visual checks.mental health diagnosis.Record review of Resident #1's progress note by LVN-I, dated 03/22/2026 at 11:38 PM, reflected: Resident was sent to the hospital on day shift for change of condition of N/V per family request. DON-T communicated with this nurse [LVN-I] instructed that his face sheet and medication lists should be faxed to RN-J (phone number provided). Transmittal confirmation was received ok. Resident is placed on [leave of absence] and all medications on hold.Record review of Resident #1's hospital records reflected he was admitted to the hospital on [DATE] with the chief complaint by the RP that he fell (initial encounter), and fall initial encounter was not resolved. Resident #1 sustained injuries to the right 6th and 7th lateral rib fractures (Right 6th and 7th lateral rib fractures are common chest wall injuries, usually caused by blunt trauma. And sharp pain.), right adrenal hematoma (Adrenal hematoma is a collection of blood within the adrenal gland, often resulting from trauma, severe infection, or anticoagulant use.), and grade 3 Liver laceration involving segments 5 and 8 (These are shallower tears, often less than 3 cm (metric unit used to measure dimensions and size.) deep, or smaller blood clots. A comprehensive trauma evaluation identified the injuries above, and the [Resident #1] was admitted to the PCU for pulmonary monitoring, serial hemoglobin monitoring, and pain control measures.Record review of Resident #1's progress note dated 03/24/2026 at 11:05 AM by DON-T titled nursing incident -Late entry for 03/22/2026 at 07:30 AM reflected per report from primary nurse, resident was roaming in and out of rooms this morning requiring frequent redirection. During such time resident was redirected from room at approximately 7:00 AM and became aggressive, he attempted to swing and hit the nurse causing him to lose his balance and fall against the handrail on his left side. Per report he sustained a small abrasion to left temple area, no other injuries noted by primary nurse. Resident was ambulatory after fall and functioning at baseline. Nurse will provide frequent monitoring s/p fall. Completed 03/24/2026 11:24 AM.During an interview on 03/24/2026 at 9:45 AM with the Administrator, he reported receiving a call from hospital RN-J on 03/22/2026 at 7:04 PM. He then forwarded RN-J's phone number to DON-T to follow up with the hospital nurse for information. During an interview with the DON-T on 03/24/2026 at 9:50 AM she stated that once she was notified of the fall by RN-J she did not submit a report to HHSC. DON-T said that she contacted RN-J on 03/22/2026 (time unknown). At the time of the call, RN-J informed her that Resident #1 fell at the facility earlier that day and was transported by the family for further evaluation. DON-T stated that the hospital nurse reported that Resident #1 had fallen at the facility and sustained an abrasion to the right side of cheek, a bruised liver, and rib fractures. This report caused no concerns of abuse and neglect. During a hospital visit with Resident #1 on 03/25/2026 at 9:55 AM, Resident #1 could not be interviewed as he was asleep. Resident #1 was observed lying on his back with his eyes closed asleep. The surveyor attempted to locate and interview the MD and assigned nurse, but neither were available to provide medical updates.During a second interview on 03/24/2026 at 9:45 AM with the Administrator, he said he was later informed by DON-T that Resident #1 sustained injuries to the liver and fractures to his ribs. The Administrator stated that he had not reported the incident to HHSC, because the fall was witnessed, and the family transported the resident to the hospital at their discretion. During a second interview with DON-T on 03/26/2026 at 3:50 PM, DON-T said she contacted LVN-L the assigned LVN on 03/24/2026 at 11:24 AM revealing that Resident #1 fell on [DATE] at the facility, sustaining an abrasion to his cheek. The family was concerned and wanted the resident evaluated at the hospital and signed the resident out. DON-T stated that residents are at risk of continued abuse and neglect when allegations are not reported and investigated to confirm the findings. DON-T stated that she did not report the incident to HHSC once she completed further assessments and interviews, abuse and neglect was ruled out. Record review of the facility's Duty to Report Violations Internally and to Applicable Agencies policy, dated October 2022, reflected the following: All residents, family members, visitors, and others are encouraged to report actual or suspected incidents of resident abuse, neglect, exploitation, and/or misappropriation of resident property without fear of retaliation. All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, who serves as the Abuse Coordinator. In the Administrator's absence, the Director of Nursing ( DON) or another designee will be appointed to function as the interim Abuse Coordinator. Upon learning of a suspected incident of resident abuse, neglect, exploitation, and/or misappropriation of resident property, the Charge Nurse or her Department Manager or Supervisor must immediately notify the Abuse Coordinator or the DON of the incident. The person receiving the report or designee must document all incidents of alleged abuse/neglect on incident reports, which are to forwarded directly to the Abuse Coordinator.Upon receiving an allegation abuse, neglect, exploitation or misappropriation, the Abuse Coordinator will a) notify the Regional Director of Operations and Regional Nurse Consultant, b) initiate an investigation into the allegation, c) in conjunction with the Regional Director of Operations and Regional Nurse Consultant determine whether the allegation is reportable under federal and state regulations, and d) if the allegation is reportable, report such allegation to the State Regulatory Agency, Adult Protective Services (where state law provides for jurisdiction in skilled nursing or assisted living facilities), and in certain cases, local law enforcement, within the following timeframes: a. not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or b. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.Record review of the facility's Fall Management policy, dated 01/12/2022, reflected the following: Purpose: 1. The community will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The community will manage falls by providing an environment that is free from potential hazards.2.The qualified staff will complete the Fall Risk Data Collection upon admission and quarterly with fall or change of condition.3.A resident fall management program will be implemented that educates staff in creative, functional strategies while recognizing resident's rights and their need to maintain the highest practical level of function.Definitions:A fall can be defined as when a resident is found on the floor, a resident slides to the floor unassisted, a resident rolls off the bed or chair onto the floor, a resident falls off or out of equipment/apparatus used for therapy or a transfer. A fall also includes when a resident trips or slips and complains of or sustains bodily injury or an episode where a resident lost his or her balance and would have fallen, were it not for staff intervention (intercepted fall). A fall may also be reported by a resident, visitor, or family member.Procedures:1.The qualified staff assesses all residents for fall risk through the admission Nursing Assessment form upon admission, quarterly, and with a significant change.2.Upon determination that the resident is at risk, the qualified staff creates an individualized plan of care that includes the appropriate preventative interventions to reduce potential for fall.3.Part of the management program is the implementation of visual identifiers for those residents at risk.4.If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls - complete the Incident/Accident Report in the EHR.5.The physician and family are notified.6.All reports of resident falls within the community are monitored through the QAPI process within the community at the Standards of Care Meeting.7.Data is also reported in the community's monthly QAPI Meeting.

Based on interview and record review, the facility failed to have evidence allegations of neglect were thoroughly investigated and documented for 1 of 1 resident (Resident #1) reviewed for neglect. The Administrator failed to conduct a thorough investigation after being notified by the hospital on [DATE] that Resident #1 had sustained serious bodily injury after a fall on 03/22/2026 at the facility which LVN L had failed to report to the Administrator and had failed to notify the physician and the resident's family member. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. Findings included: Record review of Resident #1's admissions MDS assessment, dated 01/07/2026, revealed he was an [AGE] year-old male, was admitted on [DATE]. He had a BIMS score of 00, indicating the resident was unable to complete the interview (severely impaired cognition). Section GG-Functional Abilities, reflected Resident #1 required supervision and touching for toileting hygiene, transfers, mobility, and ambulating. He required partial assistance with eating and ADL's Further review of this document, under Section I-Active Diagnoses, Anemia (iron deficiency), Hypertension (high blood pressure), diabetes Mellitus (changes in blood sugar levels), Alzheimer's Dementia (brain disorder with symptoms often involving severe behavioral changes, movement disorders, or language dysfunction rather than just memory loss, and Non-Alzheimer's Dementia (brain disease causing cognitive decline not related to Alzheimer's.)Record review of Resident #1's baseline care plan dated 01/01/2026 reflected: He was severely impaired cognitively. Spanish speaking only and able to communicate his needs. Resident had impaired functional abilities related to impaired cognition and requires some assistance from staff. Improve mobility, evaluate for speech and physical therapy.Record review of Resident #1's care plan dated 01/07/2026 reflected: Communication.Resident will communicate basic needs to staff daily Spanish speaking only.Resident will demonstrate improved ability to understand speech. as needed Speak in a way that minimizes inability to understand. Anticipate needs. Fall/wandering, last updated on 03/24/2026. Resident at Risk for Falls resident safety will be maintained.Assess contributing factors related to fall history, Resident at risk of falls while wandering in and out of other residents' rooms. Assistance with standing and moving from one place to the next as needed. 03/02/2026. Wandering, 01/08/2026. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist, is the resident looking for something, does it indicate the need for more exercise. redirect; Frequent visual checks.mental health diagnosis.Record review of Resident #1's progress note by LVN-I, dated 3/22/2026 at 11:38 PM, reflected: Resident was sent to the hospital on day shift for change of condition of N/V per family request. DON-T communicated with this nurse [LVN-I] instructed that his face sheet and medication lists should be faxed to RN-J (phone number provided). Transmittal confirmation was received ok. Resident is placed on LOA and all medications on hold. Record review of Resident #1's hospital records reflected he was admitted to the hospital on [DATE] with the chief complaint by the RP that he fell (initial encounter), and fall initial encounter was not resolved. Resident #1 sustained injuries to the right 6th and 7th lateral rib fractures (Right 6th and 7th lateral rib fractures are common chest wall injuries, usually caused by blunt trauma. And sharp pain.), right adrenal hematoma (Adrenal hematoma is a collection of blood within the adrenal gland, often resulting from trauma, severe infection, or anticoagulant use.), and grade 3 Liver laceration involving segments 5 and 8 (These are shallower tears, often less than 3 cm (metric unit used to measure dimensions and size.) deep, or smaller blood clots. A comprehensive trauma evaluation identified the injuries above, and the [Resident #1] was admitted to the PCU for pulmonary monitoring, serial hemoglobin monitoring, and pain control measures.Record review of Resident #1's progress note dated 03/24/2026 at 11:05 AM by DON-T titled nursing incident -Late entry for 03/22/2026 at 07:30 AM reflected per report from primary nurse, resident was roaming in and out of rooms this morning requiring frequent redirection. During such time resident was redirected from room at approximately 7:00 AM and became aggressive, he attempted to swing and hit the nurse causing him to lose his balance and fall against the handrail on his left side. Per report he sustained a small abrasion to left temple area, no other injuries noted by primary nurse. Resident was ambulatory after fall and functioning at baseline. Nurse will provide frequent monitoring s/p fall. Completed 03/24/2026 11:24 AM.Record review of facility all staff in-service dated 03/25/2026, completed by DLVN, the staff development coordinator titled Incidents and Accidents: Reporting, allegations of abuse to the Administrator immediately for investigating and reporting. The staff were tested on their knowledge. During a second interview on 03/24/2026 at 9:45 AM with the Administrator, he reported that after being notified that Resident #1 was hospitalized for a witnessed on 03/22/2026. Administrator stated he was later informed that Resident #1 sustained injuries to the liver and fractures to his ribs. The Administrator stated that he had not investigated the incident. However, he said further follow-up that included staff interviews of Resident #1's fall on 03/24/2026 ruled out abuse. During an interview with the DON-T on 03/24/2026 at 9:55 AM she stated that once she was notified that Resident #1 was in the hospital for a fall RN-J she did not investigate the incident, due to the hospital report that the resident was not experiencing any changes other than the bruised liver and fractured ribs. During a second interview with DON-T on 03/26/2026 at 3:50 PM, she stated that after further follow up and interviews she was provided more information about the incident by the assigned nurse, LVN-L on 03/24/2026 and 3/25/2026 and hospital records that Resident #1 had sustained internal injuries of adrenal hematoma, fractures of the right 6th and 7th lateral ribs (Right 6th and 7th lateral rib fractures are common chest wall injuries, usually caused by blunt trauma. and sharp pain.), right adrenal hematoma (Adrenal hematoma is a collection of blood within the adrenal gland, often resulting from trauma, severe infection, or anticoagulant use.), and grade 3 Liver laceration involving segments 5 and 8 (These are shallower tears, often less than 3 cm). DON-T said she proceeded to follow up with the staff that was on duty 03/22/2026, RN-J on 03/22/2026, FM-S and FM-A on 03/24/2026, contact with the MD, LVN-L, and other staff, ruled out abuse or neglect. DON-T stated that failing to investigate allegations of abuse, neglect, resident rights, and exploitation could result in further injuries and abuse to the resident.During a second interview with the Administrator on 03/26/2026 at 3:59 PM, he stated that once DON-T was notified that Resident #1 had fallen, she proceeded to review EHR records, contacting LVN-L, and interview LVN-B, CNA-O, LVN-G, RP, FM-S. and RN-J for more information, and the incident findings ruled out abuse and neglect of Resident #1.Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property Internal Investigation Guidelines Event and Concern Form, policy dated 06/23/2017, reflected the following: Purpose The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. All managed healthcare facilities and all management company staff members or third parties providing services to such facilities and/or their residents.

Based on observations, interviews and record review, the facility failed to ensure the residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 2 of 10 residents (Residents #169 and #195) reviewed for resident rights.The facility failed to provide privacy covers for the urinary collection bags for Residents #169 and #195.This failure could place residents at risk of a lessened sense of self-worth.Findings included: 1.Review of Resident #169's admission MDS assessment, dated 01/11/26, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, unspecified (a diagnosis of the progressive brain disorder where the onset, early or late, is not specified); Heart failure, unspecified (indicates a diagnosis of heart failure where the specific type, systolic, diastolic, acute, or chronic has not been detailed); and Adult failure to thrive (a syndrome of unintentional weight loss, malnutrition, dehydration, and physical/functional decline. Her BIMS score was 3, indicating she had severe cognitive impairment. Her Functional Assessment indicated she required assistance with all her ADLs. Her Bowel and Bladder assessment indicated she was always incontinent of bowel and bladder. Record review of Resident #169's care plan, dated 3/10/26, reflected she had Alzheimer's Disease, had cognitive and mobility impairments, and required the use of a urinary catheter for wound healing. Observation made on 03/08/2026 at 11:00 a.m. of Resident #169 resting in bed. Resident #169 had a catheter hooked on the right side of the bed full of urine. Catheter bag was not in a privacy bag. Catheter bag was facing the entry door to the room. Resident has DX of Alzheimer's Disease and unaware. In an interview on 03/10/2026 at 1:36 p.m. with LVN-A revealed that the nurses are responsible for providing care to the residents. The CNAs are responsible for providing incontinent care for the residents. The policy of the facility is for the catheter bags to have privacy bags in place to keep the bag from touching the floors and for the residents' privacy. If the CNA needs a privacy bag for a resident's catheter, the nurse can provide one from the supply room. In an interview on 03/10/2026 at 1:50 p.m. with CNA- B revealed that residents should always have a privacy bag over them. If the resident does not have one, the CNAs can ask the nurse for a bag. The bag is used for a resident's dignity and privacy. In an interview on 03/10/2026 at 2:00 p.m. with CNA-C stated residents who have catheters are to have a privacy bag. The Nurses have the privacy bags available in the supply closet when needed. The bag is used for residents' privacy. 2. Record review of Resident #195's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #195 had with diagnoses which included a stroke leaving her paralyzed in all four extremities, pressure ulcers, and contractures. Her BIMS score was 7, indicating which indicated she had severe cognitive impairment. Her Functional Ability assessment revealed reflected she was dependent on staff for all her ADLs. Her Bowel and Bladder assessment indicated she was always incontinent of bowel and bladder. Record review of Resident #195's care plan, dated 07/24/25, reflected she had speech deficits, cognitive and mobility impairment, and a self-care deficit. Observation on 03/08/26 at 10:40 a.m. revealed Resident #195 was in bed, her urinary collection bag was suspended from her bed, visible from the hall, and no privacy cover was in place to protect her dignity. Observation on 03/08/26 at 12:30 p.m. revealed Resident #195's urinary collection bag remains remained in the same position, and still not covered with a privacy cover. Observation on 03/10/26 at 9:50 a.m. revealed Resident #195's urinary collection bag remains remained in the same position, and still not covered with a privacy cover. In an interview on 03/10/26 at 11:56 a.m., CNA-D stated he was Resident #195's CNA and he did not notice the lack of a privacy cover on her collection bag. He stated it was important to cover the collection bags to preserve the residents' dignity. He stated he would have to notify the nurse. In an interview on 03/10/26 at 12:03 p.m., LVN-E stated residents with urinary bags needed to have a privacy cover, even when they were in their rooms. He stated it was a dignity issue for the resident . In an interview on 03/10/26 at 12:10 p.m., LVN-F stated all residents with a urinary collection bag were required to have a privacy cover in place, even when they were in bed. She stated she thought Resident #195 had her urinary catheter placed while in the hospital recently, and the hospitals do did not use privacy covers. LVN-F stated the bag would have to be changed out for one of the facility's bags, which have had privacy covers. She stated it helped with the residents' sense of dignity. Interview on 03/10/26 at 12:15 p.m., CNA-G stated any resident with a urinary catheter in place needed a privacy cover for the collection bag for the residents' dignity. She stated that the bag needed to be in place when they were out of their rooms, as well as when they were in bed because it could be seen from the doorway. In an interview on 03/10/26 at 3:42 p.m., the DON stated privacy covers on urinary collection bags was a dignity issue, and residents needed to have them in place all the time. She stated bags that did not have one in place, usually came in with the system in place and staff had not changed them out. The DON stated the collection bag could be changed out without disturbing the actual catheter.

Based on observations, interviews, and record review the facility failed to ensure a residents who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 35 residents (Residents #15 and #69) reviewed for ADLs. 1. The facility failed to ensure Resident #15's fingernails were routinely trimmed. 2. The facility failed to ensure Resident #69's fingernails were trimmed routinely, and her facial hair was shaved regularly. These failures could place residents at risk for a decreased sense of self-worth, as well as potential skin injury. Findings included: 1. Record review of Resident #15's quarterly MDS assessment, dated 02/14/16, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #15 had with diagnoses which included a stroke affecting the left side of his body, dementia , and legal blindness. His BIMS score was not calculated due to his medical condition. His Functional Ability assessment indicated he required staff assistance with all of his ADLs. Record review of Resident #15's care plan, dated 02/12/26, reflected he had Alzheimer's Disease , was unable to speak, and had a self-care deficit. The resident was not diabetic. Observation on 03/08/26 at 11:58 AM revealed Resident #15 was in bed, his left arm and hand were contracted with a cloth roll in his left hand. Resident #15's left 4th and 5th digit's fingernails were extremely overgrown. Observation on 03/08/26 at 1:32 PM revealed Resident #15's fingernails were measured with a disposable paper ruler. The left 4th digit's fingernail measured about 1/4th of an inch. The 5th digit's fingernail measured almost 1/2 an inch. Both nails had an upward curve and were not digging into the palm of the hand. Observation on 03/10/26 at 10:44 AM revealed, Resident #15 appeared unchanged. He did not appear to have been bathed , and his fingernails remained un-trimmed. 2. Record review of Resident #69's quarterly MDS assessment, dated 12/12/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]., with Resident #69 had diagnoses which included a stroke affecting her left side, substance abuse, and chronic pain. Her BIMS score was 15, indicating which indicated she was cognitively intact. Her Functional Ability assessment indicated she required staff assistance with her ADLs. Record review of Resident #69's care plan, dated 8/25/25, reflected she had short term memory loss, had a fall risk, had mobility issues, a self-care deficit, was diabetic, and visually impaired. Observation and interview on 03/08/26 at 11:21 AM revealed Resident #69 was in bed, her left hand was contracted, no soft roll was in her palm, and the fingernails to her left 4th and 5th digits were overgrown. The 2nd digit's fingernail was not totally visible, and her grip would not allow full visualization. Resident #69 stated she did not like anyone to mess with her left hand and arm, because they were painful. She stated staff did not take time to work with her arm and hand; they would just try to rush through everything. She stated she could not tell how long her nails were and she would allow the nurse to cut them if they took their time. Resident #69 also had facial hair on her chin and upper lip, and the chin hair was about 1/2 inch long. Resident #69 stated her family had shaved her when they visited about a month prior, but she had not been shaved by staff since then. She stated she was scheduled for a bed bath on 03/09/26 and would ask to be shaved then. Observation and interview on 03/09/26 at 2:30 PM, Resident #69 stated her bath time was scheduled for the evening shift.Observation and interview on 03/10/26 at 10:10 AM, Resident #69 stated she had been bathed the previous evening, and the CNA told her a nurse had to shave her and trim her nails since she was diabetic. She did not know if the CNA had notified the nurse. Interview on 03/10/26 at 12:00 PM, the PTA stated Resident #69 needed a soft roll, or carrot, in her palm to help with her finger contractures but the resident was resistant with anyone working with her hand. The PTA stated it was important to reduce the contractures as much as possible to prevent things like her fingernails from growing into her palm and causing a wound, which had not happened yet. The PTA stated she would talk with the resident and see if she would allow a carrot to be placed today. Interview on 03/10/26 at 12:05 PM, LVN-E stated he was Resident #69's nurse, he was unaware the resident needed to be shaved or have her nails cut. He stated diabetic residents had to be shaved and their nails trimmed by a nurse and he did not know why it had not been done the previous evening, but he would address both. He stated the resident was hesitant to let anyone do anything with her left hand, due to it causing her pain. He stated the risk of not keeping nails trimmed could be wounds to the palm. Interview on 03/10/26 at 3:42 PM, the DON stated her expectation was for all residents to be bathed and groomed on a regular basis. She stated she knew Resident #69 was hesitant to let staff touch her left hand and arm, but they could still take their time and provide appropriate care. She stated being well groomed, especially for females, was a big dignity issue. The DON stated no female wanted to be seen with facial hair. Record review of the facility's policy Hair Care- Combing and Shaving, dated 02/12/20, did not state diabetic residents required a nurse to shave them. Residents could be shaved with a disposable or electric razor.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 2 of 2 kitchens (North Kitchen and South Kitchen) reviewed for kitchen sanitation. 1. The facility failed to ensure freezers in the North and South Kitchen were functioning to prevent thawing and to keep food solid. Food items that had been thawed and were soft to touch, and kept between 40 and 50 degrees Fahrenheit, were not discarded.2. The facility failed to correctly thaw beef patty fritters served for lunch on 03/09/26 from the South Kitchen.3. The facility failed to label, date, and discard items in the reach in refrigerator, and label and date items in the dry storage in the South Kitchen.4. The facility failed to ensure the dishwasher's chemical concentration and water temperatures were logged for 4 of 9 days of March 2026 in the South Kitchen.These failures could place residents at risk of foodborne illness.North Kitchen Observation on 03/08/26 at 9:12 AM, in the North kitchen, revealed the following in one of the reach in freezers: - on the top shelf, unlabeled, undated, thawed and soft to touch chicken cubes, beef in a sauce, crumbled pork sausage, breaded chicken patties. In the middle of the freezer 1 large pork roast 1 soft with touch along with 2 unidentified pies thawed with no label or date. - the freezer had a temperature of 40 degrees Fahrenheit outside and 50- and 48-degrees Fahrenheit based on 2 thermometers inside the freezer. - a rack in the kitchen revealed 2 boxes of bagels that indicated Keep Frozen zero degrees F or below, the bagels were with condensation within the plastic bags, and the bread was soft to touch. Interview and observation on 03/08/26 at 9:34 AM, [NAME] K identified unlabeled and undated food items to be cubed chicken, BBQ beef, breakfast sausage, and breaded chicken patties. [NAME] K stated items in freezer should be frozen solid, [NAME] K stated the freezer was repaired about 2 weeks ago and had been working with no issues. [NAME] K stated she was not aware of the temperature reaching 50 degrees, [NAME] K stated she was responsible for checking the temperatures. Observation of the temperature log revealed it was blank, [NAME] K stated she had not completed temperature checks since her shift started. [NAME] K stated they had delivered on 03/06/26 and the bagels were delivered then and left out for use on Tuesday during breakfast. [NAME] K stated it was her responsibility to notify the Dietary Manager when equipment was not working properly, not doing so placed residents at risk of being served expired foods. Interview on 03/08/26 at 9:40 AM, Dietary Aide N revealed [NAME] K was responsible for checking the temperatures of the fridges and freezers. Dietary Aide N stated she had not noticed the freezer temperature showing 40 degrees because she did not use the freezer during her shift. Dietary Aide N stated if she noticed the freezer was not working properly she would notify the Cook, not doing so placed residents at risk of becoming sick. Interview on 03/08/26 at 9:45 AM, Dietary Aide O revealed [NAME] K was responsible for checking the temperatures of the fridges and freezers. Dietary Aide O stated she had not noticed the freezer temperature showing 40 degrees because she was the dishwasher. Dietary Aide O stated if she noticed the freezer was not working properly, she would notify the Cook, not doing so placed residents at risk of being served expired foods. Record review of the March 2026 freezer temperature log reflected the temperature was blank on the AM shift for Sunday 03/08/26, indicating the temperature had not been checked. Interview on 03/08/26 at 10:25 AM, Dietary Manager HH revealed the freezer recently had the controller replaced about two weeks ago. Dietary Manager HH stated after the repair there had not been any further issues with keeping the food frozen. According to Dietary Manager HH the Cooks were responsible for making rounds to check all the temperatures at the start of their shift and document on the temperature logs. Dietary Manager HH stated the Cooks were to contact her immediately if equipment was not functioning properly so that the Maintenance Supervisor could be contacted. Dietary Manager HH stated she was notified this morning by [NAME] K that the meat freezer was reading 40 degrees ono the freezer and 50 degrees by the inside thermometer. The Dietary Manager HH stated she then involved the Maintenance Supervisor to take a look at the freezer. Not having properly working equipment in the kitchen placed residents at risk of becoming ill if we are cooking spoiled foods. Interview on 03/08/26 at 10:54 AM, with the Maintenance Supervisor revealed the meat freezer was repaired recently, vendors came out and replaced the controller, there had not been any issues with he freezer working since then. According to the Maintenance Supervisor he noticed that the doors on the freezer were not fully closed, indicating that was the reason for the temperature rising. The Maintenance Supervisor stated it was the responsibility of the dietary staff to notify him if equipment was not working properly, not doing so placed residents at risk of food born illnesses. South Kitchen Observation on 03/08/26 at 9:19 AM, in the South kitchen, revealed the following in one of the reach in refrigerators: - 3 bags of shredded lettuce not dated, one bag had brown and wilted lettuce pieces, - a large bowl of what appeared to be chocolate pudding, not labeled or dated - a large bowl of an unknown dark red and thick substance, not labeled or dated. Observation on 03/08/26 at 9:21 AM, in the South kitchen dry storage revealed a large container of cereal with plastic wrap covering it, not labeled or dated. Observation on 03/08/26 at 9:23 AM, in the South kitchen, revealed the following in one of the reach in freezers: - on the middle shelf, meat that was unlabeled and undated, in a resealable plastic bag, was leaking onto a box and shelf underneath. - on the middle shelf was 2 packages of ground beef and about 6 other packaged meats lying on top of a towel - other freezer items included chicken patty fritters, pork sausage, diced white turkey, cubed potatoes, and cheese and garlic biscuit dough - the freezer had a temperature of 50 degrees Fahrenheit, and 46 degrees Fahrenheit based on 2 thermometers inside the freezer. Observation on 03/08/26 at 9:34 AM, in the South kitchen, revealed 3 boxes of western style beef patty fritters sitting on the counter. Interview on 03/08/26 at 9:34 AM, [NAME] T stated items in the fridge and dry storage should be labeled and dated. She stated the bags of lettuce should have been dated. She said one bag looked wilted and it came in Friday, and she was supposed to let the Dietary Manager know when it came in like that. She said the aides were responsible for dating the pudding. She said items should be labeled and dated for freshness. [NAME] T stated the freezer had been out for a week and no residents had been served food from the freezer. She said she pulled the 3 boxes of beef patties early this morning around 7:00 AM. [NAME] T opened 2 boxes of beef patties and the patties were soft to touch. Interview on 03/08/26 at 9:44 AM, [NAME] T stated she did not have a menu for today or last week because it was locked in the Dietary Managers office. Record review of the freezer temperature log reflected the temperature was -3 degrees Fahrenheit on the AM shift on Thursday 03/05/26 with no other temperatures documented for the PM shift on 03/05/06 or for the AM and PM shifts for 03/06/26, 03/07/26 and 03/08/26. Interview on 03/08/26 at 11:16 AM, Dietary Aide U stated he did not know what the temperatures should be for fridge and freezers and did not check the temperatures. He stated he believed it was the cook's responsibility to do so. He did not know if food was served from the nonfunctioning freezer and did not know how to properly thaw meat. Interview on 3/8/26 at 11:20 AM, [NAME] T stated everybody knew the freezer was not working, especially Dietary Manager V, who told them to report it to the Administrator. She stated she was responsible for taking freezer and fridge temperatures, and the freezer was supposed to be in the negative. When asked why she did not take the freezer temperatures Friday and yesterday, [NAME] T did not provide an answer and then said Dietary Manager V was well aware and the last time the cooler was out the corporate lady instructed him to draw a line through it and write freezer was not working. [NAME] T stated according to Dietary Manager V, it was okay to keep the food stored in the freezer. She said this morning she saw a box of bread that had poofed all the way up. When asked why she did not discard any of the food items, she said it was up to Dietary Manager V and what he said to do. She said on her shift they had not served residents any food from the non-working freezer. [NAME] T stated meat to be thawed should be put on a sheet pan and put in the fridge. She said the reason she pulled out the beef patties was to keep them from being frozen and undercooked when she fried them. Interview on 03/08/26 at 11:28 AM, Dietary Manager V stated he knew the freezer was not working since Friday (03/06/26) because the Maintenance Supervisor called and told him the vendor was out working on it. He stated [NAME] T also reported on Friday it was not working and she had not reported any issues to him before Friday. He stated cooks were responsible for taking fridge and freezer temps. He said staff had put some items from the nonworking freezer into the back freezer, went day by day on the menus, and items in the nonworking freezer were what was left. He said he did not know why those items were not discarded because he was not there over the weekend. He said they should have been because it would have been outside of the appropriate temperature. Dietary Manager V stated the beef patties should not have been sitting out to thaw and should have been in the freezer. He stated keeping freezers at the proper temperature and safely thawing meat would prevent cross contamination and foodborne illness. Attempted interview on 03/08/26 at 11:54 AM with [NAME] W, via phone, was unsuccessful. Interview on 03/08/26 at 11:57 AM, with the Maintenance Supervisor revealed he was aware of the freezer issue in the South kitchen. He said it had gone down again on Friday (03/06/26). He said the vendor tried to fix it but said they had to order a part, so he contacted Dietary Manager V to move the food from the freezer. The Maintenance Supervisor stated he did not take the freezer temperature on Friday and just knew it was not working because he was notified by Dietary Manager V. He stated if the food was not moved, it was trash and could make residents sick. He stated he was not aware the food was not moved and was told by Dietary Manager V he was on his way up here (on Friday 03/06/26) to move the food items. He stated he reported to the Administrator that the freezer was not working. He said he did not follow up to ensure the food was moved from the freezer after contacting Dietary Manager V. Record review of work order request for South Kitchen created by Maintenance Supervisor on 03/05/26 reflected the following: Reach-in Freezer Temperature issues.The temp is increasing again it is up to 32.Tech arrived at 10:06 AM. Tech Departed at 4:30 PM. The work for this job is not yet complete for the following reason: Parts Needed.Comments from your technician: Arrived onsite. Found freezer evap coil frozen up. Removed evap coil cover and thawed out unit. plugged unit back in and unit would not power up. Check voltage and unit is receiving voltage but will not turn on. Will need to replace controller on unit. Interview on 03/08/26 at 12:06 PM, the Administrator stated no food was used from the nonworking freezer in the South Building. Attempted interview on 03/08/26 at 12:08 PM, with Dietary Manager V, via phone, was unsuccessful. Observations, interviews, and record review on 03/08/26 between 12:42 PM and 1:02 PM revealed residents in the dining room eating country fried steak for lunch. Review of meal tickets revealed Country Fried Steak, Scalloped Potatoes, and [NAME] Beans w/Bacon & Onion. Observation of outside dumpsters revealed no boxes of beef patties. [NAME] T stated she had not used the beef patties that were thawing on the counter previously. When asked where they were, [NAME] T showed surveyor 2 boxes of beef patties that she threw away in the trash bin. Each box contained about half of the patties. [NAME] T stated she was going to try and salvage some to put back in the freezer to use. Observation of the working freezer revealed no other boxes of beef patties. The nonworking freezer had no food items inside. Record review of facility's policy titled Food Storage revised 04/08/25, reflected Sufficient storage facilities are provided to keep food safe, wholesome and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 1. Storeroom: .Air-tight containers or bags are sued for all opened packages of food. All containers are accurately labeled with the item and the date opened. 2. Refrigerator: . All food are covered, labeled, and dated. Defrosting meat, eggs, and milk shakes are labeled with the date pulled for thawing. 3. Freezer: .Temperatures are checked and logged at least twice daily. Freezer temperature must be sufficient to keep all foods frozen during storage. Frozen items are thawed in a refrigerator for 24-72 hours. Foods are covered, labeled, and dated. Any item out of the original case must be properly secured and labeled.

Based on observations, interviews and record reviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition by failing to maintain freezers in two of two kitchens (North and South Kitchen) and failed to maintain 1 of 13 (Resident #147) bed in safe operating condition.1.The facility failed to ensure freezers in the North and South Kitchens were functioning to prevent thawing and to keep food solid. Food items that had been thawed and were soft to touch and kept between 40- and 50-degrees Fahrenheit, were not discarded.2. The facility failed ensure the Resident #147's bed was in proper working condition. These failures could place residents at risk of foodborne illness and at risk for injury and a decreased quality of life. Findings included: North Kitchen Observation on 03/08/26 at 9:12 AM, in the North Kitchen, revealed the following in one of the reach in freezers: - on the top shelf, unlabeled, undated, thawed and soft to touch chicken cubes, beef in a sauce, crumbled pork sausage, breaded chicken patties. In the middle of the freezer 1 large pork roast 1 soft with touch along with 2 unidentified pies thawed with no label or date. - the freezer had a temperature of 40 degrees Fahrenheit outside and 50- and 48-degrees Fahrenheit based on 2 thermometers inside the freezer. - a rack in the kitchen revealed 2 boxes of bagels that indicated Keep Frozen zero degrees F or below, the bagels were with condensation within the plastic bags, and the bread was soft to touch. Interview and observation on 03/08/26 at 9:34 AM, [NAME] K identified unlabeled and undated food items to be cubed chicken, BBQ beef, breakfast sausage, and breaded chicken patties. [NAME] K stated items in freezer should be frozen solid, [NAME] K stated the freezer was repaired about 2 weeks ago and had been working with no issues. [NAME] K stated she was not aware of the temperature reaching 50 degrees, [NAME] K stated she was responsible for checking the temperatures. Observation of the temperature log revealed it was blank, [NAME] K stated she had not completed temperature checks since her shift started. [NAME] K stated they had delivered on 03/06/26 and the bagels were delivered then and left out for use on Tuesday during breakfast. [NAME] K stated it was her responsibility to notify the Dietary Manager when equipment was not working properly, not doing so placed residents at risk of being served expired foods. Interview on 03/08/26 at 9:40 AM, Dietary Aide N revealed [NAME] K was responsible for checking the temperatures of the fridges and freezers. Dietary Aide N stated she had not noticed the freezer temperature showing 40 degrees because she did not use the freezer during her shift. Dietary Aide N stated if she noticed the freezer was not working properly she would notify the Cook, not doing so placed residents at risk of becoming sick. Interview on 03/08/26 at 9:45 AM, Dietary Aide O revealed [NAME] K was responsible for checking the temperatures of the fridges and freezers. Dietary Aide O stated she had not noticed the freezer temperature showing 40 degrees because she was the dishwasher. Dietary Aide O stated if she noticed the freezer was not working properly, she would notify the Cook, not doing so placed residents at risk of being served expired foods. Record review of the March 2026 freezer temperature log reflected the temperature was blank on the AM shift for Sunday 03/08/26, indicating the temperature had not been checked. Interview on 03/08/26 at 10:25 AM, Dietary Manager HH revealed the freezer recently had the controller replaced about two weeks ago. Dietary Manager HH stated after the repair there had not been any further issues with keeping the food frozen. According to Dietary Manager HH the Cooks were responsible for making rounds to check all the temperatures at the start of their shift and document on the temperature logs. Dietary Manager HH stated the Cooks were to contact her immediately if equipment was not functioning properly so that the Maintenance Supervisor could be contacted. Dietary Manager HH stated she was notified this morning by [NAME] K that the meat freezer was reading 40 degrees on the freezer and 50 degrees by the inside thermometer. Dietary Manager HH stated she then involved the Maintenance Supervisor to take a look at the freezer. Not having properly working equipment in the kitchen placed residents at risk of becoming ill if we are cooking spoiled foods. Interview on 03/08/26 at 10:54 AM, the Maintenance Supervisor revealed the meat freezer was repaired recently, vendors came out and replaced the controller, there had not been any issues with the freezer working since then. According to the Maintenance Supervisor he noticed that the doors on the freezer were not fully closed, indicating that was the reason for the temperature rising. The Maintenance Supervisor stated it was the responsibility of the dietary staff to notify him if equipment was not working properly, not doing so placed residents at risk of food born illnesses. South Kitchen Observation on 03/08/26 at 9:23 AM, in the South kitchen, revealed the following in one of the reach in freezers: - on the middle shelf, meat that was unlabeled and undated, in a resealable plastic bag, was leaking onto a box and shelf underneath. - on the middle shelf next to the meat was 2 packages of ground beef and about 6 other packaged meats lying on top of a towel - other freezer items included chicken patty fritters, pork sausage, diced white turkey, cubed potatoes, and cheese and garlic biscuit dough - the freezer had a temperature of 50 degrees Fahrenheit and 46 degrees Fahrenheit based on 2 thermometers inside the freezer. Interview on 03/08/26 at 9:34 AM, [NAME] T stated the freezer had been out for a week and no residents had been served food from the freezer. Interview on 03/08/26 at 9:44 AM, [NAME] T stated she did not have a menu for today or last week because it was locked in the Dietary Managers office. Record review of the freezer temperature log reflected the temperature was -3 degrees Fahrenheit on the AM shift on Thursday 03/05/26 with no other temperatures documented for the PM shift on 03/05/06 or for the AM and PM shifts for 03/06/26, 03/07/26 and 03/08/26. Interview on 03/08/26 at 11:16 AM, Dietary Aide U stated he did not know what the temperatures should be for fridge and freezers and did not check the temperatures. He stated he believed it was the cook's responsibility to do so. He did not know if food was served from the nonfunctioning freezer. Interview on 11:20 AM, [NAME] T stated everybody knew the freezer was not working, especially Dietary Manager V, who told them to report it to the Administrator. She stated she was responsible for taking freezer and fridge temperatures, and the freezer was supposed to be in the negative. When asked why she did not take the freezer temperatures Friday and yesterday, [NAME] T did not provide an answer and then said Dietary Manager V was well aware and the last time the cooler was out the corporate lady instructed him to draw a line through it and write freezer was not working. [NAME] T stated according to Dietary Manager V, it was okay to keep the food stored in the freezer. She said this morning she saw a box of bread that had poofed all the way up. When asked why she did not discard any of the food items, she said it was up to Dietary Manager V and what he said to do. She said on her shift they had not served residents any food from the non-working freezer. Interview on 03/08/26 at 11:28 AM, Dietary Manager V stated he knew the freezer was not working since Friday (03/06/26) because the Maintenance Supervisor called and told him the vendor was out working on it. He stated [NAME] T also reported on Friday it was not working and she had not reported any issues to him before Friday. He stated cooks were responsible for taking fridge and freezer temps. He said staff had put some items from the nonworking freezer into the back freezer, went day by day on the menus, and items in the nonworking freezer were what was left. He said he did not know why those items were not discarded because he was not there over the weekend. He said they should have been discarded because it would have been outside of the appropriate temperature. He stated keeping freezers at the proper temperature would prevent foodborne illness. Attempted interview on 03/08/26 at 11:54 AM, with [NAME] W, via phone, was unsuccessful. Interview on 03/08/26 at 11:57 AM, with the Maintenance Supervisor revealed he was aware of the freezer issue in the South kitchen. He said it had gone down again on Friday (03/06/26). He said the vendor tried to fix it but said they had to order a part, so he contacted Dietary Manager V to move the food from the freezer. The Maintenance Supervisor stated he did not take the freezer temperature on Friday and just knew it was not working because he was notified by Dietary Manager V. He stated if the food was not moved, it was trash and could make residents sick. He stated he was not aware the food was not moved and was told by Dietary Manager V he was on his way up there (on Friday 03/06/26) to move the food items. He stated he reported to the Administrator that the freezer was not working. He said he did not follow up to ensure the food was moved from the freezer after contacting Dietary Manager V. Record review of work order request for the South Kitchen freezer was created by the Maintenance Supervisor on 03/05/26 reflected the following: Reach-in Freezer Temperature issues.The temp is increasing again it is up to 32.Tech arrived at 10:06 AM. Tech Departed at 4:30 PM. The work for this job is not yet complete for the following reason: Parts Needed.Comments from your technician: Arrived onsite. Found freezer evap coil frozen up. Removed evap coil cover and thawed out unit. plugged unit back in and unit would not power up. Check voltage and unit is receiving voltage but will not turn on. Will need to replace controller on unit. Interview on 03/08/26 at 12:06 PM, the Administrator stated no food was used from the nonworking freezer in the South Building. Attempted interview on 03/08/26 at 12:08 PM, with Dietary Manager V, via phone, was unsuccessful. Observations on 03/08/26 between 12:42 PM and 1:02 PM, the nonworking freezer had no food items inside. Record review of facility's policy titled Food Storage revised 04/08/25, reflected Sufficient storage facilities are provided to keep food safe, wholesome and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 3. Freezer: .Temperatures are checked and logged at least twice daily. Freezer temperature must be sufficient to keep all foods frozen during storage.

Based on observation, interview and record review the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 33 of 35 and resident's admission Records and 2 of 10 (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for personal privacy. The facility administration failed to protect the residents' privacy by having private information of residents in a binder in the front lobby of the facility.The facility failed to ensure resident rooms had full visual privacy, Rooms #114 did not have a privacy curtain and room [ROOM NUMBER] did not have window blinds. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to lack of privacy during care.Findings include:In an observation on 03/08/2026 at 9:15 a.m. revealed a red notebook on a table located in the south building facility labeled, Elopement Binder South Building. Included in the book revealed the policy and procedure, Elopement Management. The book included 33 admission records of residents in the memory care unit, Halls 200 and 300. Of the 33 admission records in the Elopement Binder, 28 were current residents on the memory care unit. In an observation on 03/08/2026 at 10.00 a.m. revealed the resident admission records included resident names, social security numbers, Medicare numbers, Medicaid numbers, responsible party information, addresses and phone numbers. In an interview on 03/09/2026 at 2:22 p.m. with the ADM revealed the policy for protecting residents' privacy r/t medical records would have to be located to be provided. The ADM could not recall when an in-service was held r/t HIPPA laws. The ADM stated the purpose of the Elopement Binder was to have a list of residents with pictures who were at risk of elopement from the facility. The binders were normally left at the nurses' station on the Memory Care Unit. The ADM stated the staff had access to the binders. The ADM revealed the risk of the Elopement Binder left on the table at the front of the building was the personal information would be seen by unauthorized individuals. The ADM stated the Elopement Binder was in the lobby for other staff to have access in the event of a resident elopement. In an interview on 03/09/2026 at 1:36 p.m. with LVN A revealed she was familiar with what HIPPA law referred to. LVN A stated staff had training on HIPPA, but could not remember the date of training. LVN A revealed the Elopement Binder was located on the Memory Care Unit at the nurse's station. The residents were at risk of elopement, and the binder had the admission record and pictures of residents on the Memory Care Unit. LVN A revealed the risk if the Elopement Book was left in the lobby was the resident's personal information and family member's personal information could be seen by others who should not have access to it. In an interview on 03/10/2026 at 3:31 p.m. with DON revealed there was a written policy r/t to HIPPA. The DON stated the nursing staff, business office, and administration had access to resident's personal medical records. The DON stated there were in-services held on residents' personal privacy of medical records. The DON revealed the Elopement Binder was normally kept out in the lobby but would now be kept at the nurses' station. The DON stated the risk of the Elopement Binder left in lobby of the building would be exposure of resident's names, social security numbers, Medicare numbers, Medicaid numbers, family members names, addresses, and phones numbers would fall into unauthorized hands causing identity theft. Observation on 03/08/26 at 11:16 AM, the resident in room [ROOM NUMBER]-B was visible from the hallway using his urinal. In an interview on 03/08/26 at 11:18 AM, the resident in room [ROOM NUMBER]-B stated the curtain at the end of his bed had been taken down about a month ago and never put back up. The curtain between the two beds was not long enough to provide privacy. Observation and interview on 03/08/26 at 11:48 AM, of room [ROOM NUMBER] revealed there were no blinds in the window. The window faced a parking lot. There were marks indicating blinds had been in place before. stated there had been no blinds in the window since they were admitted last month. He did not like that he could easily be seen at night when the lights were on. Interview on 03/10/26 at 11:56 AM, CNA -D stated resident privacy was necessary for their happiness and dignity. He stated housekeeping was responsible for the privacy curtains. He was not aware of any privacy issues as residents had not complained to him. Interview on 03/10/26 at 12:05 PM, LVN-E stated privacy was a priority for residents, it protected their dignity. He stated no one wants to be seen changing clothes. LVN-E stated housekeeping was responsible for the privacy curtains. Maintenance was responsible for the blinds in the windows. He was not aware of any privacy issues as residents had not complained to him. Interview on 03/10/26 at 12:12 PM, LVN-F stated resident privacy was very important for their dignity, and the privacy curtain also defined their living area. She stated housekeeping was responsible for changing out the curtains, and maintenance was notified about things like the blinds via the maintenance repair logbook. She was not aware of any privacy issues as residents had not complained to him. Interview on 03/10/26 at 1:33 PM, the Housekeeping Supervisor stated nursing staff was responsible for letting her know when a privacy curtain needed to be changed out and she would coordinate with maintenance to change them out. She had clean ones in storage that could be changed out for a dirty ones. Interview with the Maintenance Supervisor on 3/10/26 at 2:10 PM, he stated nursing staff have to notify him whenever there is a maintenance issue, and he will address it the same day usually. Occasionally he will have to order something, but blinds can be replaced the same day. Interview on 03/10/26 at 3:45 PM, the DON stated privacy for the residents is a priority for their dignity. She stated she was unaware of the missing privacy curtains, but she would have a sweep of the facility done to identify rooms in need of privacy curtains. Record review of the facility's Safeguarding and Storing of Protecting Health Information, revised March 21, 2017 revealed in part, The policy of this facility is to provide guidelines for the safeguarding of Protecting Health Information (PHI) in the facility and to limit unauthorized disclosures of PHI that is contained in a resident's medical record, while at the same time ensuring that such PHI is easily accessible to those involved in the treatment of the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure rooms were equipped to assure full visual privacy for each resident for 3 (Rooms # 115, #116, #119) of 18 rooms reviewed for visual privacy.The facility failed to ensure resident rooms had full visual privacy, Rooms # 115, #116, and #119, did not have a privacy curtain. This failure could place residents at risk of being exposed during cares or when changing clothes.Findings included:Observation on 03/08/26 at 11:24 AM, of room [ROOM NUMBER] there was no privacy curtain for the resident in the bed closest to the door. There was a track mounted to the ceiling for a curtain, as well as the hanger clips, but no curtain. Observation on 03/08/26 at 11:31 AM, of room [ROOM NUMBER] there was no privacy curtain at the foot of the bed closest to the window. There was a track mounted to the ceiling for a curtain, as well as the hanger clips, but no curtain.Observation on 03/08/26 at 11:38 AM, of room [ROOM NUMBER] there was no privacy curtain at the foot of the bed for the bed closest to the window. There was a track mounted to the ceiling for a curtain, as well as the hanger clips, but no curtain.Interview on 03/10/26 at 11:56 AM, CNA -D stated resident privacy was necessary for their happiness and dignity. He stated housekeeping was responsible for the privacy curtains. He was not aware of any privacy issues as residents had not complained to him. Interview on 03/10/26 at 12:05 PM, LVN-E stated privacy was a priority for residents, it protected their dignity. He stated no one wants to be seen changing clothes. LVN-E stated housekeeping was responsible for the privacy curtains. Maintenance was responsible for the blinds in the windows. He was not aware of any privacy issues as residents had not complained to him. Interview on 03/10/26 at 12:12 PM, LVN-F stated resident privacy was very important for their dignity, and the privacy curtain also defined their living area. She stated housekeeping was responsible for changing out the curtains, and maintenance was notified about things like the blinds via the maintenance repair logbook. She was not aware of any privacy issues as residents had not complained to him. Interview on 03/10/26 at 1:33 PM, the Housekeeping Supervisor stated nursing staff was responsible for letting her know when a privacy curtain needed to be changed out and she would coordinate with maintenance to change them out. She had clean ones in storage that could be changed out for a dirty ones . Interview with the Maintenance Supervisor on 3/10/26 at 2:10 PM, he stated nursing staff have to notify him whenever there is a maintenance issue, and he will address it the same day usually. Occasionally he will have to order something, but blinds can be replaced the same day . Interview on 03/10/26 at 3:45 PM, the DON stated privacy for the residents is a priority for their dignity. She stated she was unaware of the missing privacy curtains, but she would have a sweep of the facility done to identify rooms in need of privacy curtains. The Administrator was unable to provide a policy addressing privacy curtains or resident privacy prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest for 1 of 5 residents (Resident #232), 1 of 2 kitchens (North Kitchen), and 1 of 2 halls reviewed for pest control. The facility failed to ensure the facility was free of gnats in Resident #232 room, North kitchen and 700 Hall.This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.Findings included: Observation and interview on 03/08/26 at 9:14 AM, revealed there were gnats in the kitchen, in the dishwasher area. According to [NAME] K, she was aware of gnats in the dishwashing area. [NAME] K stated dishwashers were responsible for reporting the gnats to the Dietary Manager and the Maintenance Supervisor . She stated the Maintenance staff were aware of the problem. Observation and interview on 03/08/26 at 4:00 PM, Resident #232 revealed about 8-10 gnats at his bedside table, in his orange juice and on his sandwich. According to Resident #232 gnats had been an ongoing problem and he had reported to the nursing staff . Resident #232 stated he did not eat the food in his room due to the gnats. Resident #232 stated he felt he lived in an unhealthy environment. Observation and interview on 03/08/26 at 4:17 PM, with LVN I in Resident #232's room revealed he saw 8-10 gnats flying around Resident #232's bedside table. LVN I stated he was aware of the gnats in the facility. LVN I stated he has notified the Maintenance Supervisor of the gnats and has seen pest control contractors in the building. LVN I stated he was responsible for reporting the sight of gnats to the maintenance department by documenting in the log book at the nurses station. LVN I stated having gnats in the building and on resident foods placed residents at risk of illnesses and cross contamination. Interview on 03/09/26 at 2:59 PM, Dietary Aide N revealed she had observed gnats on the 700 hallway when serving resident meals. According to Dietary Aide N the gnats were annoying when trying to keep them out of resident food. Dietary Aide N stated she was responsible for notifying the Dietary Manager of the gnats, not doing so placed residents at risk of illnesses and not living in a clean environment. Dietary Aide N stated she did see a pest control contractor entering the building today (03/09/26); however, she was not sure if it was helping with the pest problem. Interview on 03/09/26 at 3:06 PM, Dietary Aide O revealed she worked in the kitchen as a dishwasher. Dietary Aide O stated she observed the gnats in the kitchen, she thought it was due to the leaking water, garbage disposal, and leftover foods after meal services. Dietary Aide O stated that she had not reported the gnats to the Dietary Manager or the maintenance department. Dietary Aide O stated she was responsible for reporting the gnats and not doing so placed residents at risk of getting sick. Interview on 03/09/26 at 3:30 PM, Dietary Manager HH revealed she recognized the gnats in the kitchen, however, had not been informed that staff were seeing gnats on the hall while serving meals. Dietary Manager HH stated it was the responsibility of the kitchen staff to report issues with gnats to her or the maintenance department. Dietary Manager HH stated she would then report the issue to the Maintenance Director so that he could contact the pest control vendor. Dietary Manager HH stated having gnats around the kitchen created an unhealthy environment and placed residents at risk for foodborne illness. Interview and observation on 03/09/26 at 4:46 PM, Maintenance Assistant H revealed he was aware of gnats in the building. He stated their pest control vendor was recently in the facility. He stated it was the responsibility of everyone to report to the maintenance department when they saw pests in the building. He stated if there was an issue with gnats, staff would write their concerns in a book located at the nursing station. He stated having problems with gnats in the building and in resident rooms could place residents at risk of becoming ill or living in unsafe conditions. Interview on 03/10/26 at 2:30 PM, the Administrator revealed they have a pest control vendor entering the facility biweekly. According to the Administrator, he expected all staff to follow chain of command and communicate with the maintenance department when there was a problem with pests. The Administrator stated having pest in the building placed residents at risk for illnesses. Review of the facility's Pest Control policy, revised 12/2004, reflected:Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interviews, observations, and record reviews, the facility failed to ensure residents remained free of accident hazards as possible for 1 (Resident #1) of 5 residents reviewed for quality of care.The facility failed to provide Resident #1, who had dementia, with adequate supervision on 01/29/26 when the resident was left unattended and unsupervised on the facility's van from approximately 4:30 PM until 9:00 PM when temperatures were in the 30 degree Fahrenheit range.The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 01/29/26 and ended on 02/02/26. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk of death, related to cold or heat exposure, discomfort, pain, and anxiety. Findings Include:Record review Resident #1's quarterly MDS assessment, dated 01/29/26, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney failure requiring dialysis, dementia, and paranoid schizophrenia. Resident #1's BIMS score was 6, indicating he had severe cognitive impairment. His Behaviors assessment did not indicate he did not wander. Resident #1's Functional Ability assessment indicated he used a wheelchair for mobility and required assistance with his ADLs. Record review of Resident #1's care plan, dated 9/29/25, reflected he had delirium, impaired mobility, and required dialysis three times a week. Record review of Resident #1's EHR revealed no progress notes about the incident on 01/29/26, what interventions had been done, and who was notified. Record review of the facility's corrective measures, consisted of staff in-service forms, revealed the Driver had been in-serviced 1:1 by the Administrator on a Transportation Safety Check which included carrying out a final check of the van to ensure no residents remained in the vehicle, having a nurse confirm the resident's return to the unit, a visual inspection of all areas of the van, ensuring the vehicle was turned off and all doors were secured. The nursing staff had been in-serviced on the new process of all residents leaving the unit had to be signed out, and when they returned a nurse had to confirm they were back on the unit. Observation on 03/03/26 at 9:50 AM, revealed the facility transport van was parked under the portico, doors were locked, and the engine was off. No residents were observed to be in the van. In an interview on 03/03/26 at 10:00 AM Resident #1's family member stated they were notified on 01/29/26 around 8:30 PM that Resident #1 was not on the Memory Care unit. When they asked how long he had been missing, staff were unable to give a time frame. The family member stated around 9:00 PM, the family received a phone call saying that he had been located in the transport van. The family member stated Resident #1 returned from dialysis between 4:30 and 5:00 PM depending on traffic. They stated the resident had been missing for about 4 hours without anyone noticing. The family member stated the temperature on 01/29/26 was in the 30's. In an interview on 03/03/26 at 1:30 PM, the Driver stated he did not leave Resident #1 in the van when they returned from dialysis, the resident was taken back to his unit, and the staff were told he had returned. The Driver stated he did not know how Resident #1 got back to the van, he was off duty at 5:00 PM. The Driver stated he was surprised when he was called late at night on 01/29/26 telling him about the incident and that he was suspended pending an investigation. When he returned, he was in-serviced on Transportation Safety and Signing residents out and back in. He stated he documented on the log at the nurse's station, as well as his logbook he carries, which must be signed by the nurse to verify the resident had returned. In an interview on 03/03/26 at 2:05 PM, CNA-E stated she had been working on 01/29/26 when Resident #1 was found outside in the van. She stated Resident #1 had returned from dialysis between 4:30 and 5:00 pm. CNA-E stated it was not unusual for Resident #1 to go straight to bed when he returned; dialysis made him tired. CNA-E stated she had noted Resident #1 was not in the common area of the unit, nor in his room when she checked around 8 or 8:30 PM. She notified the nurse she could not locate the resident. CNA-E stated all staff began looking for the resident on the unit, and when he could not be located, they called the other units to look for him on their units. CNA-E stated she had gone out to her car she noticed movement inside the van. She tried to open the driver's side door, and it was locked so she went back to get the nurse. CNA-E stated they were able to open the passenger side doors, and the resident was sitting in a seat with his seat belt in place. CNA-E stated staff had to bring out another wheelchair because they could not get the resident's wheelchair out of the back with the engine off. CNA-E stated when they had the resident back on the unit, the nurse checked him. She stated he stated he was not cold, he was wearing a heavy jacket and a sweater. CNA-E asked him what happened and Resident #1 stated That [NAME] left me in the van. I thought he was going to come back but he didn't. In an interview on 03/03/26 at 2:40 PM, the DON stated she could not recall what date this incident had occurred, but she was called at home and told Resident #1 could not be found in the facility. She advised staff to search the facility grounds while she drove to the facility. The DON stated she received a call that the resident had been found in the transport van. The DON stated she assessed the resident when she arrived, and he was not cold and did not appear to have any complications from being outside. The DON called the Driver and asked him how he had left the resident in the van. The DON stated The Driver had stated he had brought the resident back to the unit around 5:00PM, and told staff he was back. The Driver did not know how the resident got back out to the van. The DON stated, the next day, she initiated an in-service with the staff about a new process for signing residents out and back in, and a nurse had to verify the resident was back. In a phone interview on 03/03/26 at 3:10 PM with LVN-F, she stated she was on duty when Resident #1 was found outside in the van. She stated when he was found she went out to the van and found Resident #1 in a seat and buckled in. The resident was wearing a coat as well. LVN-F stated they were unable to get Resident #1's wheelchair out of the back of the van without the keys, so they used another wheelchair. LVN-F stated she did not believe Resident #1 was capable of getting off the locked unit, wheeling himself out the front of the facility, folding up his wheelchair and placing it in the back of the van, getting in the front of the van, and buckling himself in. With his dementia and physical state, it would be highly unlikely. In a phone interview on 03/03/26 at 3:20 PM, LVN-G stated when Resident #1 was found in the van, he was buckled into a seat, and his wheelchair was in the back of the van. Resident #1 did not seem to be suffering any ill-effects of being out in the cold. In an interview on 03/03/26 at 3:25 PM, the Administrator stated his investigation into the situation revealed the Driver had returned Resident #1 back to the unit, and the resident managed to get himself back to the van somehow. He felt Resident #1 was capable of doing so. The resident might have followed a visitor off the unit, and the front door is not locked at night, and the van sits right outside the front door in the portico. The facility implemented the following corrective actions following the incident: The Driver was in-serviced on:Transportation Safety Check to includeCarry out final check, no residents in the vehicle Have a staff member confirm the resident's return to the unit. Visual Inspection of all areas of the vehicle.Turn engine offSecure the vehicle. The Driver also was required to carry a daily logbook to record when he takes a resident off a unit, what time he brings them back, and a nurse must sign verifying the resident is back on the unit. Review of the facility's in-service documentation revealed the Nurses and CNAs were in-serviced on: The new procedure of tracking residents when they leave the unit and when they return. Frequent monitoring of residents to ensure a resident is identified as missing quickly. In an interview on 03/03/26 at 5:35 PM, CNA-D stated she had been in-serviced on ensuring residents that left the secured unit are signed out, and signed back in when they return.In an interview on 03/03/26 at 5:38 PM, CNA-H stated she had been in-serviced on making sure anyone who takes a resident off the unit, signs them back in when they return, and checked frequently to ensure all residents are present. In an interview on 03/03/26 at 5:42 PM, LVN-I stated staff had been in-serviced on ensuring residents are back on the unit before signing the Driver's logbook. They are supposed to monitor the residents frequently to ensure anyone missing is quickly identified. If a resident has routine outings like dialysis, to know what time they are normally back. In an interview on 03/03/26 at 5:47 PM, CNA-C stated she had been in-serviced on making sure residents are signed out and back in when they leave the unit, and making sure they are back on the unit. She is also to report when a resident is not back at their normal time. In an interview on 03/03/26 at 5:52 PM, LVN-J stated everyone had been in-serviced to ensure the new procedure for checking residents out and in is followed, They must ensure the resident is on the unit before signing the logbook. They are also to be aware of when a resident is not back at their normal time. In an interview on 03/03/26 at 5:57 PM, CNA-K stated she had been in-serviced on monitoring when patients leave the unit, that they are signed out and back in when they return. She is to be aware of when a resident is late returning to the facility. In an interview on 03/03/26 at 6:00 PM, LVN-L stated she had been in-serviced on the new process of signing residents back in, and she had to see the resident present on the unit before she signed the logbook. She was also to call the Driver if a resident was not back from an appointment at their normal time. In an interview on 03/03/26 at 6:05 PM, LVN-N stated she had been in-serviced on ensuring residents were on the unit before signing for them, and to be aware when a resident was late in returning. Observation on 03/03/26 at 6:10 PM, revealed a clipboard at the nurses' station with residents signed out and in. iIt appears to have been in place since 02/02/26 . In an interview on 03/03/26 at 6:25 PM, LVN-Q stated she had been in-serviced on the new process for tracking residents who leave the unit, and ensuring they are back before signing the logbook. In an interview on 03/03/26 at 7:00 PM, CNA-T stated she had been in-serviced on checking residents out and in from the unit, and notifying the nurse if a resident is not found on the unit. In an interview on 03/03/26 at 7:10 PM, CNA-U stated they were in-serviced on the process of the residents being signed out and in from the unit. The nurse must sign for the resident's return. Review of temperatures for 01/29/26 from World Weather Online revealed the temperature in Zip Code 75115 at 6:00 PM was 36 F, and at 9:00 PM it was 33 F. 75115, [NAME], Texas Historical Weather AlmanacReview of the facility's policy Safety System for Residents, dated 08/14/22, does not address leaving residents outside. It addresses general resident safety.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure a mechanical lift was used to transfer Resident #1 from her bed to the wheelchair on 12/23/25 when they were getting the resident up to go to the dialysis center. During the transfer, the resident reported that her leg got twisted which caused her severe pain. The resident was then sent to the dialysis center where she complained of severe pain and was transferred to the hospital where she was diagnosed with a comminuted fracture (a severe injury where a bone breaks into three or more fragments, typically caused by high-impact trauma), which required surgery. An IJ was identified on 02/12/26. The IJ template was provided to the facility on [DATE] at 4:22 PM. While the IJ was removed on 02/13/26, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to implement corrective systems. This failure could place residents at risk for accidents that could lead to serious injury or harm. Findings included:Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female resident whose most recent admission entry was on 04/10/25. Resident #1 had a BIMS score of 10 which indicated she had moderately impaired cognition. The residents' diagnoses included stroke, end stage renal disease, and there was no diagnosis of dementia or Alzheimer's disease. The MDS also reflected that the resident did not have inattention, disorganized thinking or altered level of consciousness and she did not exhibit any type of behaviors. Resident #1 used a wheelchair for mobility and required substantial/maximal assistance which indicated the helper did more than half the effort. The resident did not attempt to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed due to medical conditions or safety concerns. The MDS further reflected that the resident did not have any pain. Review of Resident #1's facesheet printed on 02/13/26 reflected her original admission date was on 08/14/19Record review of Resident #1's care plan with an original date of 02/12/26 reflected the resident needed to be lifted mechanically using a Hoyer lift (mechanical device designed to safely transfer patients with limited mobility between beds, chairs or toilets using a sling-and-mast system) with two or more persons support due to impaired mobility. Interventions included to provide extensive assistance with bed mobility and lift mechanically using mechanical lift with two or more persons support from staff. Record review of Resident #1's hospital records dated 12/23/25 reflected the following: .Reason for admission: Left distal femur fracture.[Resident #1].with residual left-sided weakness, bedbound.Patient presented to ED with left knee pain that started today during transferring to her dialysis, patient said that her foot got stuck then her leg was twisted during transfer, pain was severe 10/10, pain increased with minimal movement, it was associated with recurrent vomit.Femur x-ray showed acute comminuted fracture of distal left femur.Principal Problem:Closed fracture of left distal femurAssessment: Patient did not have a fall, her leg got twisted during transfer to dialysis.possible surgery in the morning.Active Problems:.Osteoporosis.Review of the dialysis Nursing Progress Notes Report dated 12/23/25 documented by the Dialysis RN reflected the following: Pt came in with c/o severe pain to her left knee, painful to touch. Pt unable to move her foot. Pt requested to call EMS to send her to ER. Called nursing home and spoken [sic] to the clerk re: pt complaints. [DON] of [nursing home] called, spoken [sic] with her and inform her of pt complaints. Tx not started. MD informed. Pt left via stretcher at 1150hrs, pt was crying out loud d/t pain to her knee. Record review of Resident #1's progress notes dated 12/24/25 at 5:15 AM documented by the DON reflected the following: contacted [facility] nursing staff for update on resident return. Per [facility] charge nurse [LVN C], she contacted nurse caring for resident at [First Hospital] on 9th floor and was informed [Resident #1] has a femur fracture and was transferred from [First Hospital] to [Second Hospital] for higher level of care due to injury sustained while at the dialysis center. According to [Second Hospital] primary nurse [Resident #1] sustained LLE injury during transfer from WC to dialysis chair. Resident stated her left leg was twisted during transfer and was unable to continue dialysis due to pain/discomfort to LLE and requested to be sent to emergency department Record review of Resident #1's progress notes dated 12/24/25 at 5:46 AM documented by LVN C reflected the following: Resident transfer to [Second Hospital] from her dialysis appt. Resident was admitted for left femur fx, nurse stated she twisted her leg at dialysis when trying to put her in dialysis chair. DON notified, ADON notified.Record review of Resident #1's progress notes dated 12/24/25 at 3:17 PM documented by the DON reflected the following: LATE ENTRY FOR 12/23/25 11:45 AM: spoke with [Dialysis RN] regarding need for transfer to hospital from dialysis center due to complaints of left knee pain. Nurse stated resident was unable to transfer to chair due to pain in LLE after transfer attempt. Resident stated knee was twisted, during transfer attempt at dialysis center and requested to be transported to emergency department for evaluation and treatment. Resident transfer to [Second Hospital] from her dialysis appt. Resident was admitted for left femur fx, nurse stated she twisted her leg at dialysis when trying to put her in dialysis chair. DON notified, ADON notified.Interview on 02/12/26 at 9:39 AM with Resident #1's family revealed the resident had to undergo femur surgery because it had broken during a transfer from her bed to the wheelchair. The resident's family said they were told by the resident that there were some male staff that helped her from the bed to the chair and the guy turned her the wrong way. The resident told the family she reported to the staff that her leg was hurt but she had been taken to dialysis anyways where she again reported to the dialysis staff, she thought the facility staff had broken her leg. The family further stated Resident #1 had requested to go to the hospital because she was not able to get out of her wheelchair at the dialysis center because of her pain. Observation and interview on 02/12/26 at 10:22 AM with Resident #1 revealed she was sitting in her wheelchair in her room at the nursing facility with padded foot protectors on each foot. The resident stated she could not walk or move her legs and had not been able to in a long time. Resident #1 was asked about the incident (12/23/25) when her leg was broken and she said there were several staff in her room but could not remember how many. Resident was able to recall one of the female aides was chubby (later identified as CNA A) and a bald male (later identified as CNA B). The resident said she was normally transferred via Hoyer lift but the day of the incident the staff that included a tall bald man had picked her up with their hands and transferred her over to the wheelchair and during the transfer, her left leg had gone through CNA B's legs and twisted. Resident #1 said her left leg immediately began to hurt and she told the staff I think you broke my leg to which the male staff (CNA B) responded with I didn't break your leg. The resident said she had only seen the male staff (CNA B) once or twice and did not know if he still worked at the facility. Resident #1 said once she was put in her wheelchair she was just put in the van and taken to dialysis, which was located across from the facility. The resident said once she arrived at the dialysis center, she told the dialysis staff her left leg hurt, and she wanted to go to the hospital because she thought it was broken. Resident #1 said she was never transferred out of her wheelchair at the dialysis center because she was in so much pain. Resident #1 stated I never told anyone the incident happened at the dialysis center; I haven't lost my mind yetInterview on 02/12/26 at 10:53 AM with LVN J revealed she worked the morning of 12/23/25 and all she knew was that the DON had gotten a call from Resident #1's dialysis center and told the DON the resident was being sent to the emergency room because the resident had complained of leg pain. LVN J said Resident #1 was always required to be a Hoyer lift transfer and she did not know who assisted the resident out of bed that day and no one had reported anything to her. LVN J further stated she did not ask Resident #1 what happened to her leg when she returned from the hospital. Interview on 02/12/26 at 11:24 AM with a Dialysis Case Manager revealed he was not there when Resident #1 arrived at the dialysis center and complained about her leg pain. The Dialysis Case Manager said once the resident had gotten out of the hospital and returned to dialysis he asked her what happened and Resident #1 told him that while the nursing home staff were transferring her from the bed to the wheelchair her leg and a staff member's leg had gotten tangled together and she immediately had felt pain to her left leg. The Dialysis Case Manager said he heard (did not say by who) the nursing facility had tried to blame the dialysis center for the incident but he was also told Resident #1 had never transferred out of her wheelchair because she had been in too much pain so she sent to the hospital. Interview on 02/12/26 at 12:03 PM with the ADON revealed she had had been told, did not say by who, that Resident #1 had been taken to her dialysis appointment and they later had gotten a call from the dialysis center who said the resident had been transferred to the hospital because she had complained of leg pain. The ADON said LVN C called the hospital for a follow-up on Resident #1 and LVN C was told the incident happened at the dialysis center. The ADON further stated she never talked to Resident #1 about the transfer incident, and the DON had spoken to the dialysis center. The ADON also said Resident #1 required a Hoyer lift for all transfers as far as she could recall. Interview on 02/12/26 at 12:13 PM with the DON said Resident #1 left the facility via a third-party transport to her dialysis appointment. Once the resident was at the dialysis center, the facility got a call from their nurse (Dialysis RN) who said Resident #1 said her leg was hurting and had requested to go the hospital. The DON said the LVN C had talked to a hospital nurse who told LVN C Resident #1 had been dropped at dialysis. The DON said she spoked to Resident #1, but did not say when, and the resident told the DON the incident happened at the nursing facility when she had been transferred by a tall black man that was light skinned, and the DON stated there was no one at the facility that matched that description. The DON then said Resident #1 stated two men had transferred her to the chair but the resident never told the DON the incident had happened at the nursing facility. The DON was asked if she had called the dialysis center to ask if Resident #1 had fallen or been dropped there and the DON said No, what for, there would be no reason because they (dialysis center) did not offer any information. The DON further stated she spoke with the facility staff, who had worked with Resident #1, and they all told her, nothing happened. She stated there was no incident to lead them to believe it had happened at the nursing facility. Interview on 02/12/26 at 6:28 PM with the Dialysis RN revealed the day Resident #1 arrived at the dialysis center (12/23/25) it had been reported to her by the dialysis techs (Dialysis Tech D) that the resident had been noted crying in the dialysis center lobby. The Dialysis RN said one of the dialysis techs took Resident into the room where the residents are in their dialysis chairs and notified her the resident was crying and complaining of pain. The Dialysis RN said Resident #1 was normally very quiet, pleasant and with little to no complaints and never had any concerns with her cognition so the resident would have been able to tell them what happened. The Dialysis RN said she saw Resident #1 crying, so she asked her what happened and the resident said the nursing home aides had twisted her leg when they transferred her into her wheelchair. The Dialysis RN said she assessed the resident and when she touched her left knee, the resident cried out in a lot of pain, she could not move her leg and the resident requested to be sent out to the hospital. Per her assessment, the Dialysis RN said she thought Resident #1 had a leg fracture and described her pain being at a 10/10. When EMS arrived and tried to put her on the stretcher, the Dialysis RN said the resident screamed out in pain as she could not straighten her leg. The Dialysis RN the Dialysis Nurse Manager called the nursing facility to let them know the resident had been sent to the hospital and the DON had called back and spoke to the Dialysis RN. The Dialysis RN said she told the DON what the resident had told her happened at the nursing facility and the DON asked the Dialysis RN to send Resident #1 back to the facility so they could do an in-house x-ray but she told the DON they had to send the resident to hospital due to her severe leg pain. The Dialysis Nurse further stated Resident #1 told her the nursing facility had tried to blame the incident on the dialysis center but there was no incident at the center, and their nurse manager and techs were witness to how the resident arrived at the dialysis center and she never told the DON the incident happened at the dialysis center. Interview on 02/13/26 at 9:45 AM with CNA A revealed she never asked CNA B to help her transfer Resident #1 with a Hoyer sling and drawsheet, nor did she recall the resident stating she was in pain. Interview on 02/13/26 at 10:00 AM with CNA B revealed he had never worked with Resident #1 but CNA A had called him to assist with a transfer (12/23/25). CNA B said he did not work at the facility full time but only worked as they needed him. CNA B said he was told Resident #1 was already late for dialysis and the Hoyer lift was broke so he, CNA A and two other aides, later identified as CNA E and CNA F all transferred the resident from the bed to the wheelchair using the Hoyer sling under the resident and a draw sheet. CNA B said he did not notice during the transfer but once the resident was in her wheelchair, she complained of leg pain. CNA B said the other aides tried to console the resident and then told him (CNA B) that Resident #1's pain was part of the resident's condition because the resident did not walk. CNA B further stated he did not report the resident's pain to the nurse because he was not the resident's aide and would have expected the other aides to report any incidents because they worked with the resident. Interview on 02/13/26 at 10:27 AM with CNA E denied Resident #1 was transferred to her wheelchair with a sling and a draw sheet, the day of the incident, 12/23/25. CNA A said she did not recall any other details from that date. Interview on 02/13/26 at 10:56 AM with CNA F revealed she did not work at the facility full time and only as needed, and she did not recall any resident transferred with a Hoyer sling and draw sheet. Interview on 02/13/26 at 2:21 PM with the Dialysis Tech revealed he was working the day Resident #1 arrived at the dialysis center complaining of leg pain. The Dialysis Tech said another tech, did not recall which one, had alerted him that Resident #1 was crying in the lobby of the dialysis center, so he went to get the resident and took her back to where the residents got dialysis. The Dialysis Tech said Resident #1 was crying and stated the nursing staff had twisted her knee during her transfer to the wheelchair. The Dialysis Tech said he tried to reposition the resident in her chair as she still had a Hoyer sling under her and the resident began to scream and cry, stating she was in severe pain. At the time the Dialysis Tech said he called the Dialysis RN to assess the resident and Resident #1 told her the same story about how the nursing facility staff had twisted her knee. The Dialysis Tech said Resident #1 was normally very calm and pleasant and had never complained of any pain during her dialysis treatments and they had never had any concerns with her cognition during her treatments. The Dialysis Tech said Resident #1 was never moved into a dialysis chair because of her severe pain. Interview on 02/13/26 at 2:28 PM with the Dialysis Nurse Manager revealed she was with another patient when she heard Resident #1 crying, so she went over to the resident to ask what was wrong and the resident said the nursing facility staff hurt her leg during the transfer to the wheelchair. The Dialysis Nurse Manager asked Resident #1 if she had reported the pain to the nursing facility staff and the resident said, yes I told them I was in pain, and they just told me I had to go to dialysis, so they put me in the van and brought me to the clinic (dialysis). At that time the Dialysis RN began to assess the resident and because she was crying in pain, they decided to call 911 and have her sent out for further evaluation. The Dialysis Nurse Manager said Resident #1 was very alert and oriented and normally calm during her dialysis treatments. The Dialysis Nurse Manager said Resident #1 was never transferred to the dialysis chair because any little movement caused the resident so much pain. The Dialysis Nurse Manager said she called to speak with a facility nurse, and did not recall who, to let them know Resident #1 would be sent to the hospital and the DON later called and spoke with the Dialysis RN. She further stated that at no point did she or any of the dialysis staff tell the facility the incident had occurred at the dialysis center. Interview on 02/18/26 at 10:42 AM with the Transportation Operations Manager revealed he spoke with the transportation driver, and he did not recall Resident #1 but also did not recall anything out of the ordinary with any patient the driver had transported during that time. The Transportation Operations Manager further stated there was nothing documented for the day of 12/23/25. Record review of the facility's policy titled Mechanical Lifts (Hoyer/Sit-to-Stand) reviewed on 05/2023 reflected the following: PolicyResidents will be assisted with the Activities of Daily Living, utilizing lifts according to manufacturers' guidelines. Procedure:1. Mechanical Lift Pre-Operations Checka. Understand why Resident needs lift.3. Report any change in condition to Charge Nurse.Record review of the facility's policy titled Change of Condition revised on 02/2023 reflected the following:.1. As part of the Interdisciplinary team, Certified Nursing Assistants (CNAs).are expected to report findings that might represent ACOC's.This was determined to be an Immediate Jeopardy (IJ) on 02/12/26 at 4:11 PM. The Administrator, Assistant Administrator, and DON were notified. The Administrator was provided with the IJ template on 02/12/26 at 4:22 PM. The following Plan of Removal submitted by the facility was accepted on 02/13/26 at 9:48 AM: Plan of removal for IJ-F689-State alleges facility failed to ensure each resident received adequate supervision to include prevention of accidents during mechanical transfer/ two person assists.1. IJ called at 4:22PM at facility for F689.2. Medical Director Notified at 4:30pm.3. Ad hoc QA completed to address employee transfer techniques using mechanical lifts.4. Immediate Correction/Client protectiona. DON/designee to educate all clinical staff on mechanical lift transfers to include 2 persons assist. Completion date 2-12-26.b. DON/designee to educate all clinical staff to notify nurse of any pain or change of condition during transfers. Completion date 2-12-26.c. DON/designee performed assessment on all residents requiring mechanical lift transfers to ensure safety. Completion date: 2-12-26d. Residents who require mechanical lift transfers will be added to ADL Kardex by DON/designee. Completion date 2-12-26e. MDS/designee updated care plans for all residents requiring mechanical lift transfers. Completion date 2-12-26f. All clinical staff will be educated on proper transfer techniques to include mechanical lifts prior to working their next assigned shift. This will be completed by DON/designee. Completion date: 2-12-26.5. Monitoringa. DON and/or designee will monitor residents requiring mechanical lifts for transfers 3 times weekly to ensure compliance.b. Administrator to review with the DON the 3 times weekly monitoring to ensure continued compliance.c. Results of all audits will be brought to QAPI committee by DON to review for continued recommendations and compliance.d. This protocol will be covered on new-hire orientation by DON/designee.Monitoring of the Plan of Removal included the following:Record review of the facility's resident mechanical audit revealed there were 39 residents that required a mechanical lift for transfers. Observation on 02/12/26 and on 02/13/26 of Residents #1, #2, and #3 during a Hoyer lift transfer revealed there were 2 staff members present, there were no concerns about the procedure of using the Hoyer lift, and the resident did not express pain or discomfort during the process. Record review of Residents #1, #2, #3, #4, and #5's clinical record revealed their plan of care had been updated in the computer system and an alert came on the screen that identified the residents as a Hoyer lift transfer and staff were to acknowledge before they could proceed with documentation. Record review of the in-services dated 02/12/26 reflected nursing staff were re-educated on mechanical lift transfers process and procedure, resident pain management, and change of condition and what to do in case those concerns are noted. Record review on 02/13/26 of the competency evaluations revealed nursing staff were checked off on their performance of using a mechanical lift. Interviews on 02/13/26 from 9:53 AM to 3:31 PM with aides from various shifts were able to describe the process and procedure on how to use the mechanical lift with no less than 2 staff members, they knew they could look in the computer plan of care to identify which resident required a mechanical lift, if a resident complained of discomfort or pain they were to stop the transfer, ensure the resident was safe and notify the charge nurse. Those staff members included CNA A, CNA E, CNA F, CNA H, CNA K, CNA L, CNA M, CNA N, CNA P, CNA R, CNA S, CNA W, and CNA X. Interviews on 02/13/26 from 9:53 AM to 3:31 PM with nurses from various shifts were able to describe the process and procedure on how to use the mechanical lift with no less than 2 staff members. The nurses knew to look at the resident's care plan to identify which residents required a mechanical lift during a transfer. The nurses said if a resident complained of pain or discomfort during the transfers, they were to stop the transfer and notify them so the resident could be assessed. During the assessment they would check the resident for pain and identify the location of the pain and give PRN pain medications or call the physician for further instructions if the pain medication was not effective. Those staff members included the ADON, DON, LVN C, LVN G, LVN I, LVN J, LVN O, LVN Q, LVN T, LVN U, LVN V, and LVN Y. The Administrator was informed the Immediate Jeopardy was removed on 02/13/26 at 4:34 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 6 residents (Resident #6 and Resident #8) reviewed for abuse. 1. The facility failed to ensure Resident #8 had the right to be free from abuse on 03/01/25 when Resident #9 hit him with a ruler 2-3 times, as the argument escalated further, Resident #9 then stabbed Resident #8 with a pen which resulted in scratches on his abdomen and the back of his neck. Resident #8 was sent to the hospital for further evaluation. 2. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 pushed her on 03/09/25 while on the secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury. The noncompliance was identified as PNC. The IJ began on 03/01/25 and ended on 03/09/25. The facility had corrected the noncompliance before the investigation visit began. This failure placed residents at risk for injury, hospitalization, and emotional distress. Findings included: 1. Record review of Resident #8's face sheet, dated 06/19/25, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #8's Quarterly MDS Assessment, dated 05/15/25, reflected his BIMS score was blank, indicating severe cognitive impairment. Her diagnoses included Seizure Disorder or Epilepsy, Bipolar Disorder and Schizophrenia. Record review of Resident #'8s care plan, updated 02/20/25, reflected Resident #8 was a fall risk related to fall [03/01/25]. Goals: Resident will be free from complications related to falling. Resident at risk for falls, resident safety will be maintained. Interventions included to Administer first aid as needed. Assess contributing factors related to fall history. Assess for potential fall-related injury prevention, looking at circumstances, location, new or worsening medical problems. Keep call light and most frequently used personal items withing reach. Record review of Resident #8's Nurses Notes dated 03/01/25 written by LVN AA reflected the following: Upon arrival to resident room, Resident witnessed to be positioned on the floor of his room perpendicular to the foot of his bed. Resident noted to have [varies] wounds on his body starting at the base of his neck an approximate 1.5-2 cm laceration, on his right proximate of spine there are 2 bright red scratched on his back. There were two superficial lacerations observed on upper abdomen. On the left shoulder the resident appears to possess a contusion. The neighboring end table appeared to have been flipped over laying on top of a broken bedside table. Various contents of food were on the floor of the room. The resident's G-tube was still connected at the item of the incident. When arriving to the room the G-tube was paused and disconnected. When assessing the resident, breathing was even but labored related to an emotional state of distress. Resident was redirected verbally to a state of ease. Resident was alert and oriented to person and place. Resident stated, I'm ok, but my neck hurts a little, resident was referred to hospital for further evaluation due to unwitnessed patent altercation. Family and Administrative staff has been notified of incident. Record review of Resident #8's Nurses Notes dated 03/01/25 written by LVN OO reflected the following: Resident was evaluated after altercation between roommate and self. Due to present injuries on body, Resident will be sent emergency room by Emergency Service to hospital. Resident is alert and orientated to person, place, and time. Resident sated to possess pain localized at the back of his head. Record review of Resident #8's Nurses Notes dated 03/01/25 written by LVN AA reflected the following: Resident returned from hospital with no change in condition. Resident was transferred to room [ROOM NUMBER]a. Vistal signs 119/96-83-17-98.5 New order for Bacitracin 500gm apply topically twice a day for 7 days. Nurse Practitioner made aware of new order. Skin assessment completed left voice message with his mother to contact the facility regarding update. Call light in reach. Plan of care ongoing. Record review of LVN OO's interview statement dated 03/01/25 at 12:30 PM reflected Did not hear commotion, was alerted resident was on the floor. When I arrived to the room, I witnessed [Resident #9] ]sitting at the end of hall and [Resident #8] was on the floor. I asked [Resident #8] how he got on the floor he stated, he did it. First aide was provided for superficial scratches, transported to the emergency room for evaluation and treatment. Record review of Resident #8's Psychiatric Periodic Evaluation, dated 03/03/25, reflected the following: Patient lying in bed with multiple scratches/abrasions over body. Tube feeds infusing. Patient was involved in altercation with his roommate 2 days ago. Per nursing report roommate attacked the patient. Patient was sent out to the ER for evaluations of wounds and PEG tube positioning. Patient was sent back to facility with bacitracin ordered twice daily to wounds. Patient denies any complaints at this time. Observation and interview on 06/18/25 at 10:35 AM with Resident #8 revealed him stating he stabbed me, and I had to go to the hospital, he wanted to get his anger out on me. He had a weapon, stabbing me in the stomach and the neck area. (Surveyor observations did not reveal any skin tears or scratches) To be that angry and take it out on someone, it was methodically planned out. Resident #8 stated he stayed at the hospital for a day and returned to the facility to a new room. Resident #8 stated he felt nervous and upset about the incident at the time, however now felt safe to remain in the facility, that he did not see Resident #9, but if he did, he would avoid him. Resident #8 expressed he never got his map pencils and activity books back, he believed that Resident #9 stole them, he did not want to bring that up to staff, he would let it go. Interview on 06/18/25 at 11:34 AM with Resident #9 revealed he was in his room, sitting in wheelchair soaking his feet looking at activity books. According to Resident #9, there was a lot going on between he and Resident #8, Resident #9 stated it escalated so fast that it got out of hand. We both said some racial things to each other, then it got physical between us. I was trying to defend myself, I hit him on the right shoulder with a wood staff, like a ruler 2-3 times. [Resident #8] kept talking and agitating me, so I picked up a pen and stabbed him in the left collar bone. One of the nurses came by and stopped the incident. When she asked what happened I told her that I was in the restroom and when I came out, I saw him on my side of the room trying to get something. [Resident #9] stated that he knew [Resident #8] was weak on one side of his body therefore he could have very well just fell out of the bed and landed on his side of the room, but it all escalated very fast. Interview on 06/18/25 at 1:32 PM with CNA I revealed Resident #8 was seen on the floor when she entered the room to pick up food trays. CNA I stated Resident #8 was laying flat on his back, Resident #9 was sitting on the side of his bed. CNA I stated Resident #8 was saying something like he did it, my roommate did this to me. CNA I stated Resident #8 was yelling and upset, when she entered the room she noticed Resident #8 with scratches with some bleeding, at this point she alerted the nurse. According to CNA I, Resident #9 was usually a loner and keeps to himself. Interview on 06/18/25 at 2:18 PM with LVN AA revealed she was working the opposite side of the hall, but due to the situation she came to help LVN OO. LVN AA stated Resident #9 was removed from the room to keep both residents safe. Resident #9 was sitting down the hall away from the room. LVN AA stated the room presented that violence had occurred, room was in shambles, furniture was flipped over, food was all over the floor, Resident #8 was on the floor. Resident #8 had abrasion to his abdomen and there was a laceration to the back of his neck. LVN AA explained Resident #9 was sitting down the hall, with a blank stare, rocking back and forth. According to LVN AA she did not see a weapon or device in Resident #9's hands, but she did not want to get too close. LVN AA stated she had never observed any aggressive behaviors with Resident #9 prior to this incident. LVN AA stated when speaking with the MDS Coordinator, Resident #9 reported he needed help, mediation was provided to him, and he was sent out to hospital for evaluation. LVN AA stated Resident #8 was transported to the hospital for further evaluation, returned to the facility, and relocated to a different room. LVN AA stated Resident #9 also transferred for medication evaluation. She stated upon his return, he was also relocated to a private room. Interview on 06/18/25 at 3:04 PM with MDS Coordinator PP revealed she was alerted to the altercation between Resident #8 and Resident #9, Resident #9 was on my angel rounds, we had a good rapport, so I went to speak with him. At the time, Resident #8 was sent out to hospital for further evaluation, Resident #9 was sitting on his bed. MDS Coordinator PP stated, the room was disheveled with stuff all over the floor from the altercation., She stated when asked if he was ok, Resident #9 responded he was ok, just injustice going on, I just need my medications. MDS Coordinator PP stated Resident #9 stated he had refused his medication that morning, so she went to consult with staff to his medication administered. MDS Coordinator PP stated, there had not been any concerns or behaviors expressed by Resident #9 prior to this incident, he is usually quiet and to himself. Interview on 06/19/25 at 12:30 PM with the Assistant Administrator revealed she was notified about the altercation between Resident #8 and Resident #9. she was told that Resident #8 was found on the floor by staff, and that he was yelling he did it referring to Resident #9 whom was his roommate at the time. The Assistant Administrator stated Resident #8 was assessed and sent out the hospital for further evaluation, and Resident #9 remained in his room with one-on-one monitoring until he was sent out for psychiatric evaluations that day as well. According to the Assistant Administrator, in-services were completed with all staff on abuse, neglect, and resident to resident altercations; to also notify the Administrator, DON, family, and physician. The Assistant Administrator stated resident to resident altercations placed residents at risk of harm, all staff were responsible for resident safety and to separate immediately when there is a reported resident to resident altercation. 2. Record review of Resident #6's face sheet, dated 06/19/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #6's Quarterly MDS Assessment, dated 12/15/24, reflected her BIMS score was blank, indicating severe cognitive impairment. Her diagnoses included hip fracture, Non-Alzheimer's Dementia, and anxiety disorder. The MDS indicated she utilized a walker and wheelchair for mobility. Record review of Resident #6's care plan, updated 03/14/25, reflected she was a fall risk evidenced by fall within the last month. Goal: Resident at risk for fall resident safety will be maintained. Interventions included to anticipate resident's needs check frequently. Assess contributing factors related to fall history. Assess medications for contributing factors. Assist resident with toileting as needed. Keep call light and most frequently used personal items within reach. Keep glasses clean and fit with adequate prescription. Remind resident to call when needing assistance. Impaired physical mobility evidenced by left side weakness. Goal: Resident will maintain or improve physical function in Bed Mobility, Transfer, Ambulation, Locomotion, and Range of Motion. Interventions included to provide appropriate level of assistance to promote safety of resident. Record review of Resident #6's Nurses Notes dated 03/09/25 written by LVN QQ reflected the following: 4:21 PM - Resident was standing in common area on the side of another resident's wheelchair, when the resident pushed her down causing her to fall to the floor landing on her back. While attempting to stand Resident up, she began to yell she is also noted to yell when left hand is touched. There is no discoloration noted to hand. Nurse Practitioner notified with new order given for x-rays. Xray notified. Responsible Party and DON notified with message left as there were no answers. 6:26 PM - Xray performed to bilateral hips, bilateral femurs, and left wrist at 5:00 PM. Awaiting results at this time. 8:41 PM - Spoke with DON regarding incident. Xray confirms fracture to left wrist and hip. Nurse Practitioner was called and new order to transport to hospital emergency department was received and processed. Transportation notified with an estimated time of arrival 1 hour and 15 minutes. Resident at this time remains lying in bed on back with eyes closed. Attempts X 3 made to call report to RN at the hospital emergency room, with no answer to call. Resident transferred by stretcher to emergency department accompanied by emergency medical transportation service X2 at 9:30 PM. 03/14/25 8:06 PM - Resident readmitted to facility by stretcher accompanied by emergency medical transportation service X2. Alert to name, orders and advance directive verified by Nurse Practitioner on call for doctor. Resident admitted to hospice. Resident is noted with bruising to back of both hands, there are 24 staples noted to left hip. There is no cast or sling noted to fracture of left wrist. All activities of daily living are provided by 1-2 staff members, resident not able to make needs known due to not making complete sentences, needs are anticipated by staff. Record review of Resident #6's hospital records dated 03/18/25 with discharged date of 03/14/25 reflected the following: Reason for Admission- Chief complaint Patient presents with Fall. Discharge Diagnoses - Principal Problem: Hip Fracture. Active Problem: Wrist fracture. Operative Procedures: Hemi Arthroplasty Hip Anterior Approach Left. Hospital Course: Comminuted and displaced left femoral neck fracture s/p fall . Record review of LVN QQ's interview statement dated 03/09/25 at 7:00 PM reflected [Resident #6] approached Resident #7 while siting the in the wheelchair. Resident #7 began arguing with Resident #6 to move away from her wheelchair and pushed her away from her. Resident #6 fell on her left side and had difficulty bearing weight on her left leg. Physician was contacted and stat x-ray was ordered as a precaution, pain medication given and assisted to bed for comfort. Resident #7 was placed on 15-minute checks as a precaution. Interview on 06/18/25 at 4:07 PM with CNA JJ revealed she worked closely with both Resident #6 and Resident #7. CNA JJ stated Resident #6 used to walk really good around in the television room, had never had behaviors towards staff or other residents, however now upon her return from the hospital she is wheelchair bound. Resident #7 can be aggressive at times and will push others. According to CNA JJ staff often will educate Resident #7 on resident-to-resident altercations, redirect her and complete one on one monitoring when was having behaviors. Interview on 06/18/25 at 3:56 PM with LVN Y revealed during the 2:00 PM-10:00 PM shift, she was sitting at the nursing station when she heard Resident #7 get upset, she was loudly screaming at Resident #6. LVN Y stated by the time she got to both residents to separate them, Resident #7 had pushed Resident #6 down. LVN Y stated she asked what happened however she stated I knew quickly that [Resident #6] was in pain when she grabbed her hip, and I observed her foot was turned in. I called emergency services and she was transferred to the hospital. According to LVN Y the altercation was not provoked, Resident #7 had a temper and did not like to be touched. LVN Y stated, [Resident #7] was educated on sharing space in the television room and on altercations. She was placed on 15-minute checks for behaviors. Attempted interview by phone on 06/18/25 with LVN QQ was unsuccessful. Interview on 06/18/25 at 4:24 PM with the ADON revealed she was not present during the resident-to-resident altercation between Resident #6 and Resident #7. The ADON stated Resident #7 was someone staff had to keep an eye on with constant monitoring because she does not like others in her space. The ADON stated she expected staff to act quickly when there was an altercation between residents. The ADON stated staff were to separate, deescalate the situation, keep residents safe, document the incident and provide 15-minute checks on residents for further behaviors. The ADON stated the CNAs were to notify nursing staff with any allegations of abuse and incidents between residents. The Nurses were to investigate, contact family, physician, and management after assessing to ensure residents were safe. Not doing so placed residents at risk of unknown or delayed injuries. Interview on 06/19/25 at 2:30 PM with the DON revealed Resident #6 had a fall in the memory care unit during an altercation with Resident #7. The DON stated Resident #6 was sent to the hospital in pain. The DON stated, upon findings from the hospital, [Resident #6] had a pathological fracture which led me to believe the fracture could have been there regardless of the fall, The DON stated she did not believe the fracture resulted from Resident #7 pushing Resident #6. The DON further stated upon her investigation with Resident #8, he reported to her that he slid out of his bed, there was not an actual altercation between he and Resident #9. The DON stated in both altercations residents were separated, Resident # 6 was sent to the hospital immediately after the incident due to complaint of pain, Resident #7 was placed on monitoring, Resident #8 was sent to hospital for further evaluation to ensure he was ok, and Resident #9 was sent out for psychiatric evaluation. The DON stated she expected all staff to report any allegations of abuse to the Abuse Coordinator which was the Administrator and herself immediately. The DON stated all staff was to intervene and separate residents to deescalate the situation. The DON stated residents are monitored every 15 minutes for safety for 72 hours, the family and physicians were notified of the incidents. The DON stated the inhouse psychiatrist was also notified to evaluate medications, and if he was not available, residents were sent to a psychiatric facility to be evaluated. The DON stated if these steps were not followed, residents are placed at risk for safety and feeling secure in their environment. The DON stated in-services were completed on both reported incidents to ensure resident safety. Interview on 06/19/25 at 2:59 PM with the Administrator revealed he was the abuse coordinator for the whole campus. The Administrator said all staff were responsible for monitoring residents and their behaviors to ensure they were not getting into an altercation with each other. The Administrator said several things could happen to residents if they were to get into an altercation with each other such as harm or injury. The Administrator said because of the residents' diagnoses, a lot of times they did not remember what they did or who they did something to. The Administrator stated all staff were in-serviced on signs and symptoms of abuse and neglect along with resident-to-resident altercations. Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 02/12/20, reflected: Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property. This was determined to be a Past Non-Compliance Immediate Jeopardy on 06/18/23 at 4:45 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 06/18/25 at 6:35 PM. The facility took the following actions to correct the non-compliance prior to the abbreviated survey: 1. Record review of an in-service, dated 03/01/25, reflected 34 staff including nurses, nurse aides, housekeeping, medication aide, Business Office Manager, and dietary aides were in-serviced regarding Abuse & Neglect, Abuse Coordinator, Resident Behaviors, Fall Prevention. Record review of Safe surveys were completed on 03/01/25 with five residents with no issues noted. Record review of Resident #8's clinical records reflected Resident # 8was transported to the hospital on [DATE] for further evaluation. Upon return Resident #8 was relocated to another room on 03/01/25. Record review of Resident #8's psych services notes reflected Resident #8 was seen by psych on 03/03/25, and no medication adjustments were made. Record review of Resident #9's clinical records reflected Resident #9 was placed on one-on-one supervision until he was sent to the hospital for further evaluation and medications adjustment. Record review of Resident #9's clinical records reflected Resident #9 was relocated to a private room on 03/01/25. Record review of Resident #9's psych services notes reflected Resident #9 was seen by psych on 03/04/25, medications were adjusted. Resident #9 received an order for Seroquel 150MG, 1.5 TAB PO BID for schizoaffective disorder. Record review of Resident #9's clinical records reflected Resident #9 was being monitored for behaviors throughout each shift. 2. Record review of an in-service, dated 03/09/25, reflected 50 staff including nurses, nurse aides, housekeeping, medication aide, Business Office Manager, dietary aides, and transportation staff were in-serviced regarding Abuse, neglect and exploitation and misappropriation of resident property, Fall Precaution/Fall management, Behaviors (Altercations) of Residents. Record review of safe surveys completed by the facility on 03/10/25 reflected five residents reported no issues. Record review of Resident #6's clinical records reflected Resident #6 was at the hospital from [DATE] and discharged on 03/14/25. Resident #6 had surgery. Resident #6 was provided with pain medication every 4 hours as needed for pain. Record review of Resident #6's clinical records reflected Resident #6 was being monitored for pain. Record review of Resident #7's clinical records reflected she was placed on q15 check for 72 hours. Facility continued to monitor behaviors and document. Record review of Resident #7's progress notes reflected Resident #7's medications were reviewed by Hospice and no new orders were given. Observations completed on 06/18/25 from 11:00 AM through 06/19/25 4:00 PM in the South building and North building memory care unit revealed residents engaged in activities, staff were providing snacks. Observed staff monitoring and redirecting residents from wandering and unwanted behaviors. No observations of aggressive behaviors. Observed staff answering call lights and completing rounds every 2 hours. Interviews on 06/18/25 from 11:22 AM through 06/19/25 3:30 PM with MDS Coordinator PP, LVN OO, LVN LL, CNA JJ, CNA EE, ADON, CNA B, Wound Care Nurse F, CAN I, CNA L, CMA K, RN X, CNA V, LVN Y, LVN AA, CMA RR, CNA SS, CMA TT, LVN UU, Activity Director, [NAME] K, Housekeeping R, Floor Tech Q, CNA J, CNA W. The facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize abuse and neglect, how to work with residents with behaviors, immediately separate residents in altercations and report and fall prevention. Facility staff stated they monitor residents throughout the shifts, if known behaviors they will redirect them, placed them on 1:1 or q15 minute checks depending on the behavior. Staff stated for residents who have had altercations or incidents they monitor closely, keep them separated to prevent any further incidents. Staff stated they provide activities to keep them engaged and provide snacks throughout the day. Staff stated upon shift change they will notify the incoming staff of any incidents or behaviors.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 who had a history of wandering and exit-seeking, was provided with adequate supervision to prevent her from eloping on 06/09/25. Resident #1 was found 5 minutes away from the facility by police and was transported to the hospital for evaluation due to the resident experiencing hallucinations and delusions. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 06/09/25 and ended on 06/10/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's face sheet, dated 06/18/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's quarterly MDS assessment, dated 06/05/25, reflected her diagnoses included unspecified dementia, severe, with other behavioral disturbance, schizophrenia, and delusional disorders. Resident #1's BIMS score was 00 which indicated severe cognitive impairment. The MDS further revealed Section E - Behaviors indicated Resident #1 exhibited wandering behaviors. Record review of Resident #1's care plan, dated 06/04/25, reflected: Care Area/Problem: Attempted to Elopement: Resident is Exit seeking, high elopement risk. Goal: Resident safety will be maintained over the next 90 days. Interventions: Assess for contributing sensory. Check resident location every 15 minutes. Maintain behavior log. Notify physician and family/responsible party. Remove resident from immediate situation to assure safety. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1's Resident Visual Monitoring dated 06/04/25-06/05/25 reflected Resident #1 was on 1:1 supervision. Record review of Resident #1's Nurse Visual Check Individual Resident Monitoring dated 06/06/25 - 06/09/25 reflected Resident #1 was on 15 minutes checks. Record review of Resident #1's progress notes dated 06/09/25 at 6:54 PM by LVN A reflected the following entries: 7:30 AM - in room dressed for the day 7:46 AM - CNA summoned resident to the dining room for breakfast and noted resident not in room and window broken. CNA notified nurse and I contacted DON and Administrator. Staff began searching unit and grounds. All other doors and courtyard exit found to be in locked position. 8:00 AM - unable to find resident in building or on grounds, contacted PD [Police Number] for missing resident. 8:15 AM [Police Department] police contacted nurse, [LVN A], LVN stating they have resident in custody. 8:20 AM - Administrator and nursing staff attempting to calm resident along with PD, but resident remained belligerent and psychotic. Currently, she is delusional and believes buzzards are raping her and nursing staff are putting a curse on her. 8:25 AM - Attempted to transport resident for further evaluation and care via facility van without success. 8:39 AM - [Police Department] PD unable to coax resident in car or ambulance and were forced to restrain resident with handcuffs for everyone's safety and then transported to [Hospital] for further evaluation and treatment. 8:39 AM - Nursing staff at ER bedside to give report on patient. ER nurse stated they would have to continue to restrain her and give her some medication in order to do a proper exam. At bedside, no outward sign of injury or c/o pain noticed. unable to contact family members on file as there is no working number. PCP notified of incident. Record review of the facility's Provider Investigation Report, completed by the Assistant Administrator on 06/16/25, reflected the following: Incident date: 06/09/2025, Time of Incident: 07:45 AM Resident noted by staff to not be in room and window broken. Perimeter search completed and [Police Department] police notified. Assessment Date 06/09/25; Time: 08:15 AM; Resident assessed and no apparent injuries noted. Perimeter search and [Police Department] police notified. Physician [name], notified. Family [name], notified. Safe surveys completed. Staff in-service on Elopement procedures. Entire facility check to ensure all residents accounted for. Investigation Summary: Resident noted by nursing staff to not be in room or on south memory community. Resident room noted with broken window. Perimeter search completed and [Police Department] located resident after resident noted missing and transported resident to [hospital] ER for psychiatric evaluation. Staff interview state resident was currently on every 15 minute checks and when checked resident not in room and window broken. Staff state perimeter check completed and when not able to locate during perimeter check [police department] police were notified. Staff interview stat resident had no attempted to leave memory unit prior to this incident. Resident placed on q 15 minute checks due to pacing and wandering in and out of other resident rooms. Chat review reflects resident referred to psych service for behavioral and medication management. Provider Action Taken Post-Investigation: Resident care plan to be updated upon return from hospital. All staff in-service on Elopement procedures. Window alarms ordered for memory care windows. Resident elopement risk assessments updated. Care plans reviewed and updated for elopement risk residents. QAPI meeting conducted with Medical Director to review elopement protocols and action plan. Record review of CNA C statement, dated 06/09/25 at 9:00 AM, reflected: Summoned resident for breakfast and noticed she was missing from her room and window was broken notified charge nurse immediately and assisted in search for resident. Record review of LVN A statement, dated 06/09/25 at 9:00AM reflected: CNA notified nurse that resident was missing from room and window was broken. We immediately contacted DON/admin and began search on unit and grounds. Admin assisted with search effort and 911 called; last time seen: 7:30, summoned for breakfast 0745, called DON/ED 0746, began search 0746, called 911 0800, police located resident 0815, staff/admin 0820, 0839 [Police} police restrained resident and escorted to [hospital] for further evaluation and treatment. Interview on 06/18/25 at 11:27 AM, CNA B revealed she worked the day Resident #1 eloped from the facility. She stated she was not the CNA assigned to Resident #1. She stated she could not recall the exact time, but she observed Resident #1 standing by her room door and then she closed the door. She stated Resident #1 was on q15 minutes checks and LVN A was completing them. She stated from what she was told Resident #1 was last seen at 7:30 AM in her room, then at 7:45 AM CNA C went to inform Resident #1 it was time for breakfast and that is when they realize she was gone. She stated Resident #1 broke the window and jumped the fence. She stated they called Code Green and initiated a search inside and outside the facility and notified the police department. She stated Resident #1 was found by the police department, unknown where she found. She stated prior to Resident #1's elopement, the resident was placed on 1:1 supervision and then q15 minute checks because Resident #1 was having behaviors and pacing up and down. She stated they were in-serviced on abuse, neglect, and elopement. She stated the facility added alarms to all residents' windows. An attempt was made to contact LVN A on 06/18/25 at 11:55 AM by phone; however, there was no answer. Interview on 06/18/25 at 2:05 PM, the DON revealed Resident #1 eloped from the facility on 06/09/25. She stated she received a call from LVN A at 7:46 AM and informed her Resident #1 had broken the window from her room. She stated they initiated a search inside and outside the facility. She stated the police was notified and they were able to locate Resident #1 about .5 miles from the facility. She stated Resident #1 was a fast walker, when she was found she had no injuries; however, resident was having behaviors and the police decided to take her to the hospital for further evaluation. She stated prior to Resident #1 elopement, resident was not exit-seeking; however, she was pacing the hall and wandering into residents' rooms. She stated Resident #1 had history of eloping at home. She stated since Resident #1 was wandering into residents' room and pacing the hall, as an intervention, they placed Resident #1 on 1:1 supervision and then she was doing better and placed Resident #1 on q15 minute checks. She stated staff were completing q15 minutes checks when Resident #1 eloped, the last time she was observed was at 7:30 AM and then noticed she was gone at 7:45 AM. She stated all staff were in-serviced on abuse and neglect, and elopement. She stated alarms were also added to both North and South memory care unit and they also implemented resident logs which have to be completed before a resident was taken off the unit either for a visit or therapy session. Interview on 06/18/25 at 3:26 PM, the Administrator revealed he had arrived at the facility when he was informed Resident #1 had broken her room window and eloped. He stated the staff had initiated a search inside and outside facility grounds. He stated the police were notified, and the police was able to locate Resident #1 about 5 minutes from the facility. He stated he went to the scene were Resident #1 was located, he stated resident was having behaviors and was transported to the hospital for further evaluation. He stated prior to Resident #1's elopement, they had interventions in place due to Resident #1 having behaviors and refusing medications. He stated Resident #1 was placed on 1:1 and then q15 minute checks due to the resident pacing the halls and wandering into residents' rooms. He stated when Resident #1 eloped, staff were still completing q15 minute checks on Resident #1. He stated they in-serviced all staff on abuse and neglect and elopement. He stated they added alarms to all windows in the memory care unit. The Administrator stated Resident #1 had not returned to the facility since incident. Interview on 06/19/25 at 10:16 AM, CNA C revealed she was the CNA assigned to Resident #1 when she eloped. She stated the last time she observed Resident #1 was around 6:15 AM in her room. She stated Resident #1 was on q15 minutes check and LVN A was completing them while she was assisting other residents with getting them up for the day. She stated when it was time for breakfast, she went to Resident #1's room and that was when she noticed Resident #1 was not in the room and the window was broken. She stated she notified LVN A and they began a search for Resident #1. She stated she was in-serviced on abuse and neglect, and elopement. Record review of facility Elopement Management policy, revised 05/02/25, reflected the following: An immediate investigation and search will be conducted if a resident is considered missing. The resident will be located and returned to a safe environment within standard practice guidelines. This was determined to be a Past Non-Compliance Immediate Jeopardy on 06/18/23 at 4:45 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 06/18/25 at 6:35 PM. The facility took the following actions to correct the non-compliance prior to the abbreviated survey: Record review revealed an elopement assessment were reviewed and completed on residents on 06/09/25. Record review of safe surveys completed by the facility on 06/09/25 with five residents reflected there were no issues noted. Record review of the facility's South Memory Unit Elopement binder located at the nurses' station reflected the binder contained pictures of residents, who were elopement risk, and contained information regarding the residents. Record review of the facility's Resident Log on North and South Memory Unit reflected residents were being signed out when taken off unit for therapy sessions. Observation on 06/18/25 at 11:34 AM revealed all windows in the South Memory Unit had an alarm. Alarms were loud enough to be heard throughout the unit. Record review of the following in-services dated 06/09/2025 reflected all facility staff were in-serviced on abuse, neglect, elopement, missing person, and Code [NAME] for elopements/missing persons. The in-services were conducted and signed by all facility staff. Interviews on 06/18/25 from 11:22 AM through 06/19/25 at 3:30 PM with CNA B, CNA C, LVN D, CNA E, Wound Care Nurse F, MDS Coordinator G, MDS Coordinator H, CNA I, CNA J, CMA K, CNA L, CNA M, [NAME] K. Physical Therapy O, CNA P, Floor Tech Q, Housekeeping R, Housekeeping Supervisor S, LVN/Coordinator T, LVN U, CNA V, CNA W, RN X, LVN Y, LVN Z, LVN AA, LVN BB, LVN CC, CNA EE, CNA FF, CNA GG, CNA HH, Activity Assistant, and the Assistant Administrator revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize missing person/elopement policy, missing/elopement code, abuse and neglect, completing head counts before and after shift change and alarms added to all windows in the memory care unit.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #6) reviewed for abuse. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 punched and then pushed her on 02/05/25 located on a secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury. The noncompliance was identified as PNC. The IJ began on 02/05/25 and ended on 02/05/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for abuse. Findings included: Record review of Resident #6's face sheet, dated 02/26/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #6's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her diagnoses included hip fracture, anxiety disorder, and other orthopedic condition. The MDS indicated she had no behaviors of any kind and that she utilized a wheelchair. Record review of Resident #6's care plan, updated 01/13/25, reflected she was a fall risk. Record review of Resident #6's Nurses Notes reflected the following: - Resident noted standing up off from couch when another resident pushed her, and she went down landing on her sacral area resident removed from area made safe during assessment resident screaming and protecting right leg and hip area prn apap given dr [Physician Z] called 911 called DON preset and aware family called and message left resident transferred to [Hospital Y] for evaluation. Written on 02/05/25 by LVN X. - 1830; Met with [Resident #6's RP] in person to discuss fall and injury. She was made aware, per investigation, fell ow resident pushed her as she was standing from sofa, she lost her balance and fell landing on her buttocks. [Resident #6] complained of pain to her right hip and thigh area, could not recall event or how she landed on floor. [Resident #6's RP] informed resident was sent to ER at [Hospital Y] due to c/o pain and inability to bear weight on right leg . written on 02/05/25 by the DON. - Resident returned from [Hospital Y] via stretcher and EMT with oxygen therapy at 2L/min via nasal cannula at 1810. Resident diagnosed with subcapital fracture of the right femoral neck. Resident surgical wound is clean and dry, with no signs of infection . Written by RN W on 02/08/25. Record review of Resident #6's hospital records reflected the following: Hospital Course: patient got into physical altercation with another resident, they pushed to this patient [sic] to the ground when she landed on her bottom, she developed severe pain in the right hip, presented to the ER where she was found to have right neck femur fracture, s/p surgery 02/06 .Active Problems: Closed fracture of neck of right femur . Observation and interview on 02/26/25 at 1:40 PM with Resident #6 revealed she was sitting on the couch in the common area. Resident #6 had her wheelchair next to her and said she was doing okay. Resident #6 said she was not in any pain and felt safe in the facility. Resident #6 said she never had a fall or had anyone push her in the facility before. Attempted phone interview on 02/26/25 at 1:57 PM with Resident #6's RP was unsuccessful as they did not answer or call back. Record review of Resident #7's face sheet, dated 02/26/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #7's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 07, indicating severe cognitive impairment. Her diagnoses included other neurological conditions, Alzheimer's disease, and anxiety disorder. Her MDS indicated she did not have any behaviors towards anyone. Record review of Resident #7's care plan, updated 04/08/25, did not reflect or include anything about her behaviors. Record review of Resident #7's Nurses Notes reflected the following: - Resident very disruptive and verbally aggressive with other residents, walked over to sofa and pushed another resident unprovoked and then went directly to her room. Dose not recall incident but is paranoid that fell ow residents are taking her belongings. DON notified and gave directive to contact PCP for order to send resident to [Hospital S] for eval and treatment, message left with [Resident #7's RP] NO ANSWER WHEN CALLED, [NP N] contacted, order received to send out for eval. Resident placed on 1:1 monitoring until transferred to [Hospital S]. written on 02/05/25 by the DON. - Resident return from [Hospital S] via EMT at 10:19. Resident is alert, appears calm and cooperative at this time. DON and family member notified. Plan of care continues. Written on 02/05/25 by the DON. Record review of Resident #7's Psychiatric Periodic Evaluation, dated 02/07/25, reflected the following: .[Resident #7] is seen today per staff request due to reports of increased anxiety, compulsivity, restlessness, and for psychotropics management. Resident is sitting up in the common area, she is calm at the moment and denying any pain or discomfort. Aspiration of reports of recent mood swing, agitation, and restlessness reported by nursing staff, patient started crying, and reports that people are 'getting to her face'. She reports mood swing, and spontaneous anxiety and agitation. Chart reviewed, medication profile reviewed, she is on the following psychotropics with no noticeable adverse effects: Aricept 10mg po daily for dementia, Levothyroxine 100 mcg for hypothyroidism, Cymbalta 20 mg p.o. twice daily for depression/anxiety lamotrigine 25 mg p.o. twice for mood regulation, and Atarax 25 mg po daily for anxiety. Due to reports of mood swing, and spontaneous combativeness, will increase lamotrigine and monitor closely. Nursing staff notified. Observation and interview on 02/26/25 at 1:42 PM with Resident #7 revealed she was sitting on a different couch in the common area. Resident #7 said she was doing okay and sometimes argued with others, but she never got into a fight with anyone or pushed anyone down. Resident #7 said she felt safe in the facility. Attempted phone interview on 02/26/25 at 1:55 PM with Resident #7's RP was unsuccessful as they did not answer or call back. Interview on the phone on 02/26/25 at 12:15 PM with CNA V revealed Resident #7 had a tendency to go off and always think someone was in her room. CNA V said she was down the hall making up a resident's bed when Resident #7 was upset at another resident saying things like she's going to jail and I'm going to kill her. CNA V said Resident #7 was not referring to Resident #6 at this time, but she de-escalated the situation and sat Resident #7 down on the couch. CNA V said she turned around and started to walk to the nurse's station when Resident #6 asked to go to the bathroom and stood up to get off the couch. CNA V said Resident #7 went over to Resident #6, punched her, then pushed her to the ground. CNA V said she ran over to the residents and asked Resident #7 why she did that and noticed Resident #7 was still trying to go after Resident #6 who was on the ground. CNA V said everything happened so fast but she was trying to get Resident #7 away from the situation and have her go to her room. CNA V said Resident #6 went to the hospital that night and did not come back for a few days and had a hip fracture. CNA V said Resident #7 was more alert than other residents on the secured unit because one of her triggers was when residents went down the hall who did not have rooms down there. CNA V said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. Interview on the phone on 02/26/25 at 12:43 PM with CNA U revealed it was after a meal one day (02/05/25), Resident #7 said that Resident #6 went to her room and stole something and then there was a lot of commotion. CNA U said she went towards Residents #6 and #7 to divide them up because Resident #7 had punched Resident #6 and then pushed her down to the ground. CNA U said she told Resident #7 not to do that and to let staff handle the situation but Resident #6 was already on the ground. CNA U said she was not working on the secured unit at the time but had just stopped by to drop something off. CNA U said she thought Resident #6 was injured when she said her head was hurting and she could not walk. CNA U said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. Interview on 02/26/25 at 1:34 PM with LVN X revealed Resident #6 was a sweet lady and Resident #7 was very nasty with her mouth and bossy. LVN X said on 02/05/25, Resident #7 was amped up for whatever reason and staff were not sure why. LVN X said Resident #6 was getting off the couch while talking to Resident #7 when Resident #7 pushed Resident #6. LVN X said she did not witness what happened but heard about it from another aide. LVN X said when Resident #6 was on the ground she called 911 and sent her to the hospital. LVN X said during her assessment while checking Resident #6's range of motion, she yelled when assessing her right side. LVN X said after the incident happened, the NP came to see Resident #7 and adjusted her medications which seems to have worked because she's been extremely pleasant and calm ever since. LVN X said she's never seen Resident #7 be physically aggressive towards others, only verbally aggressive. LVN X said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. Interview on 02/26/25 at 1:43 PM with CNA T revealed she was leaving the shower room and heard Resident #7 talking loudly and arguing about something when she hauled off and hit Resident #6 who fell down. CNA T said Resident #7 did not have any injuries from this situation but Resident #6 did because she was grabbing her leg and crying and saying her leg was hurting. CNA T said Resident #6 was sent to the hospital afterwards. CNA T said Resident #7 yells at others when she thought someone was stealing her clothes, but no one was. CNA T said she had never seen Resident #7 be physically aggressive towards anyone before this. CNA T said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. Interview on the phone on 02/26/25 at 2:14 PM with NP O revealed Resident #7 she had episodes of psychosis based on her thinking people were taking her things from her room. NP O said Resident #7 was very paranoid and had mood swings with agitation, so she was eventually moved to the all-female secured unit. NP O said he was informed Resident #7 was involved in a resident-to-resident altercation, so he went to assess her and review her medications. NP O said based on the assessment, he thought she needed mood stabilizers, so he added those to her orders. NP O said since then, Resident #7 was more stable and engaged in activities that she's participating more in. NP O said he was not aware of any other physical altercation Resident #7 was involved in. NP O said Resident #7 was now more redirectable. Interview on 02/26/25 at 3:19 PM with the DON revealed the day the incident occurred, LVN X was here and came to get the DON because she was concerned about Resident #6's leg. The DON said she was told that Resident #6 was trying to stand and Resident #7 pushed her, causing Resident #6 to lose her balance and fall in a squatting position since she's so tall. The DON said Resident #6 fell on her bottom and complained of her leg hurting. The DON said she was worried Resident #6 had a fracture from the incident. The DON said Resident #7 had walked away from the situation and went to her room but was clueless about what had just happened. The DON said Resident #7 was put on one-to-one care until she was sent to [Hospital S] where she was evaluated and sent back to the facility the same day. The DON said Resident #7 was also seen by the NP who adjusted her meds and she had been quiet ever since. The DON said Resident #7 had a behavior of thinking someone was stealing her clothes and would get upset but never became violent with anyone. The DON said she was not told that Resident #7 had first punched Resident #6 before pushing her down. The DON said after the situation happened, staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents. Interview on 02/26/25 at 4:01 PM with the Administrator revealed he was the abuse coordinator for the whole campus, but he had an Administrator's Assistant who was also the abuse coordinator for the South building where Residents #6 and #7 were. The Administrator said he understood that Resident #6 stood up from the sofa and Resident #7 pushed her causing her to fall to the ground when she started to complain of pain. The Administrator said Resident #6 was sent out to have x-rays done which showed she had a fracture. The Administrator said all staff were responsible for monitoring resident's and their behaviors to ensure they were not getting into an altercation with each other. The Administrator said several things could happen to residents if they were to get into an altercation with each other such as harm. The Administrator said because of the resident's diagnoses a lot of times they did not remember what they did or who they did something to. Interview on 02/26/25 at 4:17 PM with the Administrator's Assistant revealed based on what she heard and through her investigation, Resident #7 was the aggressor towards Resident #6. The Administrator's Assistant said Resident #6 was on the couch and as she was getting up, Resident #7 pushed her causing her to fall to the ground. The Administrator's Assistant said the charge nurse did an assessment on Resident #6 and found that she was complaining of pain, so she was sent to the hospital. The Administrator's Assistant said at the hospital, x-rays were done where it was found she had a fracture which required surgery to repair it. The Administrator's Assistant said there had not been any other instances of physical aggression from Resident #7 before this. The Administrator's Assistant said she was also the abuse coordinator for the facility and staff were to report any instance or allegation of abuse to her. The Administrator's Assistant said all residents have the right to be free from abuse in the facility. The Administrator's Assistant said she was not told that Resident #7 punched Resident #6 in the face. The Administrator's Assistant said staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents. Record review of a provider investigation report reflected the following information: Investigation Summary: On 2/5/25, a resident-to-resident altercation occurred between [Resident #6] and [Resident #7], both residing in the South Memory Community. The incident occurred when [Resident #7], who was loudly fussing, accused [Resident #6] of entering her room. As [Resident #6] attempted to rise from the couch in the dining room, [Resident #7] pushed [Resident #6], causing [Resident #6] to fall to the floor and land on her sacral area. Nursing staff were present and immediately intervened, separating the residents. A head-to-toe assessment was conducted for both residents by the charge nurse, [LVN X]. [Resident #6] complained of right hip pain, held her right leg, and was unable to bear weight on it. Although no visible injuries were noted and vital signs stable. Pain medication was administered and [Resident #6] was sent to the ER for further evaluation and treatment. [Resident #7], [sic] no adverse effect and injuries noted, vital signs stable. Placed on 1:1 supervision pending a transfer to [Hospital S]. Notifications made to Family, [Resident #6's RP and Resident #7's RP] notified. [Physician R and Physician Q] notified. Interview and statements collected from witnesses present attached. Social worker conducted safety survey, noting no concerns. Staff in-service [sic] resident to resident altercation, resident behaviors, resident 1:1, abuse and neglect. [Resident #6] was admitted to the hospital and underwent surgery for a right hip repair. She returned to the facility on [DATE] with new order for Tylenol 3 and a follow-up appointment scheduled with [Physician P] on 2/20/25 at 11:30 AM. She is currently alert and resting in bed. [Resident #7] was placed on 1:1 supervision pending a transfer to [Hospital S]. On 2/5/25, [Resident #7] was evaluated by [Hospital S] and cleared to return to the facility the same day. Q15-minute checks were conducted for 72 hours per facility. [Resident #7] is currently cooperative and participating in normal activities without further incidents. Record review of resident safe surveys revealed 5 were completed with residents on 02/05/25 with no additional findings of any other abuse in the facility. Record review of an in-service, dated 02/05/25, reflected staff were in-serviced regarding abuse, falls, resident monitoring, injury of unknown origin, and resident-to-resident altercation. Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 02/12/20, reflected: Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property. The Administrator was notified on 03/12/25 at 10:00 AM that a past non-compliance IJ situation had been identified due to the above failures. It was determined this failure placed Resident #6 in an IJ situation on 02/05/25.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for 1 (Resident #11) of 6 residents reviewed for abuse. The facility failed to supervise and protect Resident #11 from Resident #12, who had a diagnosis of dementia with a behavioral disturbance and was acting out on auditory hallucinations to hit other residents. On 04/02/24, Resident #11 was found on the floor, crying with bloody nostrils, while Resident #12 was standing over her yelling in an aggressive manner. The noncompliance was identified as PNC. The IJ began on 03/27/24 and ended on 04/03/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Finding included: Review of Resident #11's face sheet, dated 04/18/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by the gradual decline of memory, language, and other cognitive abilities). Review of Resident #11's quarterly MDS assessment, dated 03/15/24, reflected she had a BIMS score of 00, indicating sever cognitive impairment. Further review revealed Resident #11 had not had any physical or verbal behaviors directed towards others. Review of Resident #11's undated care plan reflected: Care Area/Problem: *Fall Risk [04/03/24: Updated], Related To: Fall 4/2/24 .[sic]. Review of Resident #11's Psychiatric Periodic Evaluation, dated 03/21/24, reflected under History of Present Illness: Today, resident is seated in the TV room alert and oriented x1 in no distress or discomfort. She is pleasantly confused and collateral information is gathered from Medical records adn staff. Per satf, residenthas been calm with less aggression and is redirectable [sic] Review of Resident #11's hospital records, dated 04/05/24, reflected the following: Chief complaint: Domestic Violence .[Resident #11] .presents to the ED with epistaxis [Bleeding from the nostril, nasal cavity or nasopharynx] secondary to an assault which occurred prior to arrival by another fell ow nursing home resident. EMS brought patient from facility and reports that they found patient on the ground bleeding from bilateral nares [ the external openings in human nose that leads to the nasal cavity] .Patient endorses facial pain and neck pain . and Discussed case with [hospital doctor]. Reviewed CT and states that current fracture is benign and non displaced (meaning the bone cracked in only one place and remained aligned without shifting). And Final diagnoses: epistaxis due to trauma, facial pain, assault, maxillary fracture (a break in the upper jaw bone) , left side, initial encounter for closed fracture. Review of Resident #12's face sheet, dated 04/18/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental illnesses that cause constant fear and worry), senile degeneration of the brain (the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age), and dementia with behavioral disturbance (a condition characterized by the gradual decline of memory, language, and other cognitive abilities). Review of Resident #12's quarterly MDS assessment, dated 03/08/24, reflected she had a BIMS score of 00, indicating severe cognitive impairment. Further review revealed Resident #12 had not had any physical or verbal behaviors directed towards others. Review of Resident #12's physician's orders, printed 04/18/24 , reflected the following: Transfer to hospital for increased aggression and psych evaluation with a start date of 04/03/24. Review of Resident #12's undated care plan reflected: Care Area/Problem: *Behavioral Changes, Evidence By: Behavioral Aggression, angry/aggressive behavior .Interventions: Frequent visual checks, Maintain behavior log .[sic]. And Physically Aggressive, Related To: Altercation 3/27/24, Altercation 3/28/24 x2, Altercation 3/29/24, Altercation 03/30/24 .Interventions: 15min monitoring . Review of Resident #12's Psychiatric Periodic Evaluation, dated 03/26/24, reflected under History of Present Illness: .[Resident #12] is being seen for follow up, medication check and to monitor for staff c/o of increased anxiety, aggression and irritability .Per staff, resident has been walking up and down the hallway hitting other residents with her doll and getting aggressive and unredirectable. resident is posing a risk to self and others and staff is having to monitor her 1:1. I have instructed staff to continuously monitor and redirect resident. [sic] Review of Resident #12's progress notes reflected the following entries: - On 03/13/24 written by ADON Y, Resident noted with increased agitation, routine buspar administered per orders , redirected to activities, psych NP notified. - On 03/21/24 written by LVN X, Resident is exhibiting aggressive behaviors, constant redirecting by staff noted. - On 03/27/24 written by ADON W, 0930- Resident walking past nurse's station and physically hit another resident on the side of the head with her hand unprovoked. Resident continued walking down hallway and threw garment down while yelling out. - On 03/27/24 written by ADON W, 0939- contacted [Psych NP]. Received new telephone orders .for aggression and agitation .Initiated increased monitoring. - On 03/27/24 written by ADON W, 0955- Contacted patient's [family member], [Resident #12's RP] for update and consent for new medication orders. [Resident #12's RP] refused medications at this time. States, Because [Resident #12] hit someone today yall want to drug her up with medications? No. Don't give her anything. I'm coming up there. Attempted to educate on medications and increased aggression. [Resident #12's RP] continued to refuse treatment. Notified DON. [sic] - On 03/27/24 written by ADON W, 1600 [4:00 PM]- New order per [NP V]: Collect UA .for increased agitation . - On 03/27/24 written by LVN U, 7:30pm- Resident was involved in altercation with another resident. She was swinging her baby doll at the other resident hitting her in the face. Residents were separated. Resident was assessed and no injuries were observed. - On 03/28/24 written by LVN T, Pt is continuing to have random outburst where she is aggressive and agitated for no apparent reason. Pt outburst are not directed towards any individual but general to whomever .Later that day around 10:30 Pt hit a random resident for no reason and walk off afterwards. will continue to monitor. [sic] - On 03/29/24 written by NP Z, .Patient with dementia with agitation and behaviors. Patient resides on memory care unit. She is uncooperative with care .Had an incident where she was aggressive towards another resident for no reason . - On 03/29/24 written by LVN S, 0900:) Resident observed standing in the hallway near her room yelling and making threats at other resident walking in the hallway. Staff re-directed resident and escorted the other residents to their destination. 0930:) Resident observed hitting a male resident with a closed fist in his chest while walking past him in the hallway. Staff re-directed patient and escorted the male resident to his destination. No injuries noted. Management contacted resident's [family member] to notify of behaviors and also requested the [family member] to come into facility to discuss a treatment plan to reduce/prevent these episodes. - On 03/30/24 written by LVN T, Pt was walking down the hallway to hit another resident with her baby doll. Family and MD was noticed will continue to monitor. [sic] - On 04/02/24 written by LVN U, Resident is having auditory hallucinations, she stated her [family member] is telling her to hit other residents. - On 04/02/24 written by LVN R, resident noted with aggression towards other residents, RP contacted and made aware of situation stated [NAME] wanted to speak with social worker at this time. - On 04/02/24 written by ADON Y, Spoke to NP regarding family refusal to allow psych treatment, per NP attempted to call family on multiple attempts with no return call or answer. Resident observed with no behaviors at this time per NP if aggressive behaviors send to ER for further psych evaluation. - On 04/02/24 written by LVN U, Resident was involved in an altercation with another resident. Resident was found standing over another resident while they were on the floor and yelling at them. - On 04/03/24 written by ADON W, 0140- New order to send to [hospital] for increased and psych evaluation. Review of Resident #12's social services notes reflected the following: - On 04/01/24 written by the SW, Call placed to the [family member] and RP for the resident in order to discuss the increased aggression by the resident toward the other residents on the unit. The residents current medical status was discussed and the resident currently has a UTI that is on the second day of treatment . - On 04/02/24 written by the SW, Report received from the Unit staff that the resident continues to be a danger to the other residents on the Memory Unit due to increasing aggression toward residents on the unit. This resident has initiated two physical altercations towards other residents and is stating her [family member] is telling her to 'get them'. The resident has verbalized Auditory Hallucinations and admits to acting out as a result of the voices and commands she believes she is hearing. Medication management has been attempted but the residents' [family member] continues to refuse any attempts at medical intervention. The resident will be referred again for Inpatient psychiatric evaluation for stabilization due to increasing physical aggression and Auditory Hallucinations. [sic]. Review of Resident #12's Individual Resident Monitoring Nurse Visual Checks revealed they were started on 03/27/24 and ended on 03/29/24. Staff were documenting where the resident was seen every 15 minutes . Interview via phone on 04/18/24 at 12:37 PM with RN P revealed the incident between Residents #12 and #11 occurred during her shift. RN P said she turned the corner and Resident #11 was on the floor and Resident #12 was standing over her. RN P said she found the residents like this outside of Resident #12's room. RN P said as she got closer to the two residents, she noticed that Resident #11 was bleeding from her nostrils, and she kept putting her head down as if she was traumatized from what happened. RN P said Resident #11 could not and did not vocalize anything due to her cognitive condition. RN P said she rendered first aid to Resident #11 but when the bleeding did not stop the doctor was notified and she was sent to the hospital. RN P said Resident #12 just kept saying she was tired of this but was unharmed. RN P said she worked PRN, and this was her first time working on the unit in a while, but she was told that Resident #12 had become aggressive in the last week or so towards other residents. RN P said she was not told what to do during her shift to care for Resident #12 and her increased behaviors. RN P said neither Residents #11 or #12 were her residents at the time, but she heard Resident #11 whining and moaning which was what made her go around the corner to see what was happening. RN P said she was not sure how Resident #11 ended up on the floor. Interview on 04/18/24 at 1:17 PM with LVN R revealed she had only recently started working with Resident #12. LVN R said Resident #12 was showing physical aggression towards other residents by randomly hitting other residents. LVN R said she was not told to do anything specifically regarding Resident #12's increased behaviors. LVN R was able to explain what to do when there was a resident-to-resident altercation. LVN R was able to explain the facility's abuse and neglect policies and how to handle a resident with behaviors. Interview on 04/18/24 at 2:44 PM with LVN U revealed she cared for Resident #12 who normally had moods but recently had a UTI that caused her to go on a rampage and wanted to hit and fight everyone. LVN U said she heard yelling in the direction of Resident #12's room where both Residents #11 and #12 were. LVN U said she went to see what happened and saw Resident #11 on the floor and Resident #12 yelling and standing over her. LVN U said she assessed Resident #11 who had a nosebleed which kept bleeding, so she was sent to the hospital for further treatment. LVN U said she was able to look through the window of the closed double doors where the residents were on the other side of the door, and it looked like Resident #12 was fighting with Resident #11 and that it appeared Resident #12 hit Resident #11. LVN U said Resident #11 was crying and was unable to say what happened due to her cognitive condition. LVN U said Resident #12 was yelling but did not sustain any injuries. LVN U said Resident #12 was on observations before this incident which meant staff were documenting where she was every 15 minutes. LVN U said Resident #12 was not currently on every 15-minute checks at the time of this incident though. LVN U said she knew that other staff had contacted the psych doctor who ordered medications, but the family refused them. LVN U said she tried making sure to keep a close eye on Resident #12 because of the increase in behaviors because she had heard Resident #12 had been hitting people lately. LVN U was able to explain the facility's abuse and neglect policies, how to handle a resident with behaviors, and what to do when there was a resident-to-resident altercation. Interview on 04/18/24 at 3:37 PM with ADON W revealed she cared for Resident #12 as her nurse before becoming the unit manager. ADON W said Resident #12 started having outbursts where she was assaulting other residents on the unit. ADON W said Resident #12's attacks were random and unprovoked. ADON W said Resident #12 told her that [Resident #12's family member] was telling her to do these things. ADON W said Resident #12 was being frequently monitored and at one point was on every 15-minute checks by staf f. ADON W said staff communicated with the psych doctor to make medication adjustments for Resident #12, but her family refused it. ADON W said she was not here for the incident between Resident #11 and #12 but heard that Resident #12 hit Resident #11 who fell to the floor. ADON W said Resident #11 was sent to the hospital and returned with a facial fracture. ADON W was able to explain the facility's abuse and neglect policies, how to handle a resident with behaviors, and what to do when there was a resident-to-resident altercation. Interview on 04/18/24 at 4:09 PM with the Administrator revealed Resident #12 was a challenge who started having an increase in behaviors and outbursts. The Administrator said he tried to get psych involved in Resident #12's care, but the family was adamant that they would not allow for any medication adjustments. The Administrator said he told Resident #12's family if her behaviors continued, they would have to consider an inpatient psych facility next. The Administrator said after the first incident Resident #12 was placed on frequent checks and staff were monitoring her consistently. The Administrator said regarding Resident #11 and #12's incident, he was told that they had an altercation and had to send Resident #11 to the hospital because she had a maxillary fracture. The Administrator said Resident #12 was also taken to the hospital for a psychological evaluation, The Administrator said staff could not see what happened between the two residents to determine if Resident #12 pushed or hit Resident #11. The Administrator said Resident #12 had six incidents with other residents in a short period of time from 03/27/24 to 04/02/24. The Administrator said he had tried to send Resident #12 out multiple times related to the behaviors, requested a care conference with her family, had her on every 15-minute checks, and asked staff to redirect her. The Administrator said Resident #12 was not on every 15-minute checks the entire time she was having behaviors, including when she had the incident with Resident #11 on 04/02/24. The Administrator said he thought the behaviors were due to Resident #12 having a UTI at the time of the incidents and she was being treated for that. The Administrator said he continued notifying the psych doctor of Resident #12's behaviors but since the family refused any additional medication adjustments there was nothing to be done. The Administrator said all staff assigned to the unit were responsible for making sure all residents were safe. The Administrator said the purpose of making sure residents were safe was the facility's due diligence to monitor them and try to prevent any accidents/incidents. The Administrator said the risk of not keeping residents safe was that they can have injuries from resident-to-resident altercations. The Administrator was able to explain the facility's abuse and neglect policies, how to handle a resident with behaviors, and what to do when there was a resident-to-resident altercation. Interview on 04/18/24 at 4:26 PM with the SW revealed Resident #12 all of a sudden had a violent streak with multiple physical altercations with other residents. The SW said Resident #12 was actually hitting and fighting people. The SW said he was in the process of getting Resident #12 set up to go to a psych hospital when she was sent to the hospital to try and get an evaluation regarding her medications. The SW said Resident #12's family members refused any medication adjustments from the facility's doctors which would have helped to lessen Resident #12's aggressive behaviors. The SW said Resident #12 reported hearing her dead family members voices telling her to hit and beat people up. The SW said Resident #12 could not go to a psych facility originally because she had been diagnosed with a UTI that she was being treated for. Interview on 04/18/24 at 5:15 PM with the DON revealed the situation with Residents #11 and #12 was not witnessed. The DON said staff observed Resident #11 on the floor and she had an injury which was a facial fracture. The DON said Resident #12 was found standing over Resident #11 who did not have any injuries. The DON said the facility had tried to send Resident #12 out for a psych evaluation, but no facility would take her since she was being treated for a UTI. The DON said the psych doctor had also tried to make medication adjustments for Resident #12, but the family refused them all. The DON said staff were monitoring Resident #12 for her increased aggressive behaviors and were monitoring her every 15 minutes while she still had seven incidents with other residents in a short span of time. The DON said the facility also took her dolls away from her so that she could not use them to continue hitting others with them. The DON said the facility only had Resident #12 on every 15-minute checks from 03/27/24 to 03/29/24. The DON said Resident #12 did not have any noted aggressive behaviors past 03/30/24 so there was no need to continue every 15-minute checks. The DON said the entire nursing department made the decision to keep a resident on every 15-minute checks or not. The DON said the facility was not going to keep Resident #12 on every 15-minute checks for too long of a time. The DON said staff were supposed to be monitoring the residents on the unit in general and separating them if there were any altercations that occurred. Follow-up interview on 05/06/24 at 1:52 PM with ADON W revealed Resident #12's situation taught the facility the harm of delay. ADON W said the facility thought they had intervened and tried things before sending Resident #12 out because they knew the family truly did not want that. ADON W said now the facility understands that they have to think of all the other residents in the facility. ADON W said there were not any current residents on the memory care unit who had aggressive tendencies or any behaviors right now. Follow-up interview on 05/06/24 at 2:27 PM with the DON revealed there were not any current residents on the memory care unit who had aggressive tendencies or behaviors right now. The DON said Resident #11 has not had any changes in her behavior after the incident on 04/02/24. Follow-up interview on 05/06/24 at 3:07 PM with the Administrator revealed there were not any current residents on the memory care unit who had aggressive tendencies or behaviors right now. The Administrator said Resident #11 has not had any changes in her behavior after the incident on 04/02/24. Review of a census, dated 05/06/24, revealed Resident #12 was not a resident of the facility. Review of the facility's Incident Report log from 04/06/24 to 05/06/24 revealed there were no altercations with injuries amongst the residents. Review of the facility's training in-service form, dated 04/03/24, revealed all staff were trained regarding abuse, neglect, exploitation, misappropriation of resident property and resident to resident behaviors. Review of the facility's training in-service form, dated 04/20/24, revealed all staff were trained regarding abuse, neglect, exploitation, misappropriation of resident property and fall prevention/fall management. Review of the facility's policy, revised February 2020, and titled Behavior Management reflected: .A. Anticipating Behaviors: 1. Staff is responsible for preempting behavior problems before they occur. 2. At onset of anxiousness, agitation, or any behavior that signifies the resident is having difficulty, staff is responsible for immediately attempting to rule any unmet needs .[sic]. Review of the facility's policy revised 02/12/20, and titled Abuse, Neglect and Exploitation and Misappropriation of Resident Property reflected: .Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. On 05/06/24 at 5:05 PM the Administrator was informed an Immediate Jeopardy was determined to have existed from 03/27/24 to 04/02/24. The IJ was determined to have been removed on 04/03/24 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of COVID-19 for 1 of 2 (Resident # 2) residents and 3 of 5 (CNA B, CNA C, and Med Aide D) staff reviewed for infection control. The facility failed to ensure CNA B, CNA C, and Med Aide D were wearing appropriate PPE and following infection control practices during care of residents positive with COVID-19. The staff subsequently entered rooms of residents who were negative for COVID-19 and did not perform hand hygiene during meal service. An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM. These failures could place residents at risk of exposure of Covid-19 virus which could result in serious illness, hospitalization , and/or death. Findings included: Record review of Resident # 2's face sheet, dated 12/23/22, revealed an [AGE] year-old female admitted to the facility on [DATE]. Record review Resident # 2's consolidated orders, dated 12/23/22, revealed she had a diagnosis of COVID-19. Review of the Resident Census Roster dated 12/20/22 revealed as of 12/20/22 two residents (including Resident # 2) were positive for COVID-19 and Resident # 2 was assigned to Rm 124. Review of Admission/Discharge log revealed Resident # 2 went to the hospital on 12/17/22 and returned to the facility on [DATE]. Review of Isolation list revealed Resident # 2 was placed on isolation upon return to the facility on [DATE] because she tested positive for COVID-19 while at the hospital. Interview with Resident # 2's family representative on 12/20/22 at 8:54 AM revealed there was a camera in Resident # 2's room. Review of video footage on 12/20/22 at 9:15 AM revealed CNA A and an unknown agency staff were at bedside of Resident # 2 to perform incontinent care at 4:40 AM that morning. Both staff wore a N95 mask and gloves. No eye protection or gowns were noted. CNA A wore two N95 masks with the top strap of both masks behind her head, while the bottom straps of both masks hung underneath her chin. Review of the staff schedule dated 12/19/22 revealed CNA A was assigned to 23 residents on 12/19/22 10PM-6AM shift, including Residents #2 and #3. The schedule also revealed 2 agency aides had worked on that shift as well. Interview via telephone with CNA A on 12/21/22 at 7:07 AM revealed she did not know the name of the aide that helped her change Resident # 2 in the morning on 12/20/22. When asked what the appropriate PPE was for entering a covid-19 positive room, CNA A stated gown, gloves, face shield and mask. Interview with Staffing Coordinator on 12/20/22 at 3:30 PM revealed she did not have access to the phone numbers of the staff sent to her from the agency company with whom the facility had a contract. Observation on 12/20/22 at 5:56 PM revealed CNA B entered Resident # 2's room to answer the call light. CNA B was wearing an N95 and a face shield. He did not wear a gown. Review of video footage of Resident # 2's room from 12/20/22 at 5:56 PM when CNA B answered the call light revealed CNA B reached over without gloves, grabbed the resident with both hands and pulled her over so that she was positioned in the center of the bed. The video footage revealed hand hygiene was not performed while CNA B was in the room. Observation on 12/20/22 at 5:58 PM revealed CNA B exited Resident # 2's room pushed his face shield up to his forehead leaving the face shield at an angle and pulled his N95 down below his chin and turned around to speak with the resident from the doorway. No hand hygiene was performed. Observation on 12/20/22 at 6:02 PM to 6:14 PM revealed CNA B in a COVID-19 negative room delivering dinner meals. CNA B exited the COVID-19 negative room and proceeded to the beverage cart on the hallway. CNA B picked up drinking cups by the rim and lined them up on the cart, grabbed pitchers of water and iced tea and poured drinks into the respective cups. CNA C then grabbed those same beverage pitchers to pour drinks that were delivered to other residents as well. CNA B delivered resident meals and beverages, and helped residents get set up to eat in four covid negative resident rooms. Each room housed two residents each (8 residents total). CNA B used hand sanitizer only once upon exit of one of the four rooms. Observation on 12/20/22 at 6:15 PM revealed CNA C and the kitchen server pushed the beverage and hot food cart down to the other side of the 100 hall to continue serving meals to covid negative residents (the same cart CNA B had touched to deliver food to residents after entering Resident #2's room). Interview via telephone on 12/21/22 at 12:36 PM with CNA B revealed he recalled entering Resident # 2's room without a gown during the evening shift on 12/20/22. CNA B stated there were gowns available in the gray container outside the resident's room and stated he could not explain why he did not wear a gown before entering the room. He stated he had been in-serviced recently on the need to wear N95, face shield and gown to enter a covid positive room. He stated handwashing was covered in the recent in-services. CNA B stated entering a covid positive room without proper PPE and then entering a covid negative room could increase the chances of getting other residents sick or contamination of other things. Review of video footage revealed on 12/20/22 at 7:13 PM Med aide D entered Resident # 2's room with medications and a cup. Med aide D wore gloves, N95 mask and goggles. He was not wearing a gown. Observation on 12/20/22 at 7:30 PM revealed Med aide D entered a covid negative room to administer medications to both residents in that room. In an interview on 12/21/22 at 4:10 PM Med aide D revealed he gave Resident # 2 her medications first for the 7PM medication pass on 12/20/22. Med aide D stated after Resident # 2, he gave meds to two residents on the same side of the hall as Resident # 2, and then gave meds to the residents on the A side of 100 hall as most of the residents on that hall had 7PM meds ordered. Med aide D stated it escaped his mind to use the gown when he administered meds to Resident # 2 on 12/20/22. He stated the risk for entering covid negative rooms after not wearing appropriate PPE in a covid positive room was transmission of covid-19. Record review of the Coronavirus Management Plan Texas Phase 2 & 3, which the facility was using as their policy, dated 11/03/22, revealed COVID Positive Unit .Personnel who enter the room will wear N95 respirators. In addition, staff should wear a gown, gloves, and face shield or goggles. Review of the CDC Guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-10) Pandemic, dated 09/23/22, reflected HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). On 12/21/22 at 1:11 PM the Assistant Administrator, DON and Regional Director of Operations were notified an Immediate Jeopardy (IJ) situation was identified due to the above failures. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM. The facility's Plan of Removal was accepted on 12/22/22 at 12:14 PM and reflected the following: [name of the facility] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY on 12/21/22 To Whom it May Concern, Infection Control F880- 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. Identify residents who could be affected All residents have the potential to be affected by this alleged proficient practice Problem Staff members were seen providing care for a COVID positive resident without wearing appropriate PPE and/or wearing PPE in an inappropriate manner. Staff members were seen not performing hand hygiene after entering a COVID positive resident's room and when passing meal trays to residents. Action Taken Infection Control c ICP will re-educate Director of Nursing and Assistant Director of Nursing on company's infection control policy related to Covid 19 by end of day on 12/22/2022. c Use of alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer c Donning/Doffing of proper PPE for N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms c ICP is responsible for monitoring the education of the Director of Nursing and the Assistant Director of Nursing on company's infection control policy related to Covid 19 Hand Hygiene and Competency c Staff in-servicing on alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer with competency conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or Designee include staff handwashing and when to use hand sanitizer. c Competencies consist of review of necessary steps and 100 % accuracy on return demonstration. c Inservicing was implemented on 12/21/2022. All staff to be included in training. Training to be completed by 12/23/22. Staff not physically in community to receive their education in person prior to their next shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration. c This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their next shift. c Monitoring will begin 12/22/2022 and will be conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or designee to observe and document hand hygiene compliance twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given. PPE and Competency c ICP, Director of Nursing, Assistant Director of Nursing, and Designee in-serviced all staff on what PPE to wear to include type of mask i.e. N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms c All staff will be in-serviced in person prior to working their shift. Training to be completed by 12/23/22 Those not physically in community will receive their education in-service in person prior to working their shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration prior to working their next shift. c This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their first shift. c Monitoring began 12/22/2022 and will be done by ICP, Director of Nursing, Assistant Director of Nursing, or designee through random questioning on PPE and hand hygiene to ensure knowledge has been retained on various eight hour shifts to begin 12/22/2022. c Director of Nursing or designee is rounding twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance ensuring proper infection control practices are in place through observation and questioning. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given. On 12/22/22 to 12/23/22 the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by: Review of the facility's in-service and competency testing records revealed: 1.The DON's name was listed as the facilitator of the in-services. The in-service topic was Infection Control, Covid-19 with an emphasis on hand hygiene and donning/doffing PPE. 2.As of 12/23/22 at 4:40 PM a total of 132 staff employed at the facility had been in-serviced and passed the hand hygiene and PPE competency. Observations conducted from 12/22/22 at 10:55 AM to 5:00 PM on 12/23/22 revealed staff were donning and doffing PPE appropriately upon entrance and exit of covid-19 positive rooms. Interviews conducted on 12/23/22 from 9:48 AM to 5:30 PM with staff from all three shifts(LVN E, Med aide F, CNA G, CNA H, CNA I, CNA J, COTA, ST Assistant Director, LVN K, Housekeeper L, Environmental Director, Laundry aide, Dietary cook M, Dietary cook N, PT O, CNA P, RN Q, CNA R, LVN S, CNA T, LVN U, LVN V, Housekeeper Z, LVN W, RN X, CNA Y, and Rehab tech), revealed staff were knowledgeable about what PPE was required to enter a COVID-19 positive room and why hand hygiene was important after doffing to prevent the spread of infection. The staff stated they had to watch videos on hand hygiene and PPE and had to perform a skills test. In an interview with the ADON on 12/23/22 at 4:56 PM it was revealed that utilizing PPE and performing hand hygiene was the way to ensure COVID-19 was not being spread when going from a positive room to a negative room. The ADON stated charge nurses, direct supervisors and everyone was in charge of going behind staff to ensure they followed infection control protocols. They could make rounds and address any issues at that time. The ADON stated an IJ was identified because the staff were not following the proper PPE and hand hygiene protocols, thereby placing residents at risk. The ADON stated the facility was going to implement ongoing monitoring, monitoring tools and schedules to ensure proper infection control measures were followed. In an interview with the DON on 12/22/22 at 8:39 AM she stated an IJ was identified because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. In an interview with the DON on 12/22/22 at 8:39 AM she stated she understood why this was identified as an IJ because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. In an interview on 12/23/22 at 5:48 PM, the Assistant Administrator stated an IJ was identified because of the failure of staff to wear the proper PPE, going in and out of resident rooms that were covid positive and negative in addition to concerns with handwashing and sanitizing. She stated all this could lead to potential harm or spread of infections and diseases. An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices to meet each resident's physical mental and psychosocial needs for one (Resident #6) of seven residents reviewed for quality of care. The facility failed to ensure Resident # 6 received medications according to physician orders for pain management when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 was in pain for three days before being sent to the hospital. This failure placed residents at risk of unrelieved pain and discomfort. An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM. Findings included: Review of Resident # 6's Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on [DATE]. Resident # 6's diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome. Review of Resident # 6's Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined. Review of Resident # 6's NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell . Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected. Review of the Incident Report dated 11/04/22 reflected Resident # 6 was involved in a witnessed altercation with a fall and had pain upon movement at a level four on a scale of 1-10. Review of Resident #6's Physician's Orders reflected the only pain ordered for Resident # 6 was 500 mg of Naproxen. One tablet was to be given twice per day as needed for Mild pain on a scale of 1-3. This Naproxen medication was to be given with food and the diagnosis for this medication was central pain syndrome. Review of the Medication Administration Record (MAR) in the electronic medical record on 01/12/23 for Resident #6 revealed she had pain at a level six to her left hip on 11/06/22 in the evening. The MAR also revealed Naproxen was not administered to Resident # 6 from 11/4/22 through 11/7/22. The MAR reflected that no pain medication was given to Resident #6 during that time frame. Review of Resident # 6's Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out. Review of Resident # 6's Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport. Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell . LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation. Review of the Witness Statement dated 11/08/22 reflected CNA AF witnessed the incident with Resident # 6 and notified LVN S immediately. CNA AF's written statement indicated, Resident #6, continued to have symptoms of pain to her left hip and decreased mobility on 11/5/22 and 11/6/22, I notified the charge nurse and resident remained in bed on those dates. Interview on 12/22/22 at 10:20 AM with LVN S revealed the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. In a later interview on 01/12/23 at 10:09 AM LVN S stated she gave Resident #6 pain medication after she fell on [DATE]. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. A later phone Interview on 01/12/23 at 3:01 PM with LVN S revealed she attributed not documenting the administration of the Naproxen to the adrenaline of the whole issue. Interview on 01/12/23 at 11:27 AM with CNA AF stated Resident # 6 was able to walk to the dining room on 11/4/22 after the fall with no problem after LVN S did all the assessments. CNA AF stated that on 11/5/22 Resident # 6 was no longer getting up, could not walk and was screaming of pain. CNA AF stated that Resident #6 was able to walk before the fall, although if the staff would let her, she would lay in bed all day. In an interview on 01/12/23 at 12:45 PM the ADON stated she checked their system and did not find any documentation of pain medication given to Resident #6, however she spoke with LVN S who stated she gave Resident # 6 Naproxen. Interview on 12/22/22 at 3:38 PM with Resident # 6's Primary Contact listed on Face Sheet stated Resident #6 was diagnosed with left hip fracture and had surgery where her socket was removed. The primary contact stated the resident was still in pain and was at another (different) facility and had to go on hospice after the surgery. The Primary contact stated Resident #6 used to walk and now she stayed in a fetal position in bed because she was in too much pain. Interview on 01/12/23 at 5:30 PM DON stated if a Resident has had a fall, their pain should be treated. DON stated that if pain medication was not adequate, the staff should contact the doctor to get something stronger so that the resident is not in distress. DON stated If the stronger medication does not help, the resident should be sent to the hospital. DON also stated that in the nursing world if it was not documented, it was not done. Review of the facility's Pain Management and Basic Comfort Measures policy, revised 01/12/20, revealed, .Provide pain medication as prescribed by an authorized prescriber . Consult with family members, other health care providers for assistance with pain management techniques . Observe for unresolved pain and address per physician's orders . Record pain management techniques in the record. The Plan of Removal process was not needed at this time because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey on 12/20/2023. The facility implemented the following interventions to address non-compliance: Review of the facility's one on one in-service (training) titled Fall prevention, Xray ordering process, family communication, dated 11/07/22 with LVN included: pain management, Xray process, review of adverse events that occurred as a purpose for the training or identified gaps during facility assessment (these must be part of the in-service and discussed), all steps in the fall management process and the credentials to login to the online portal for the x-ray company. Review of the facility's In-Service for all nursing staff on falls with injury dated 11/8/22, included pain management. Review of additional in-services dated and completed on 11/29/22, 12/19/22, 12/22/22, 12/23/22 and 1/5/23 revealed staff were trained on all aspects of the fall management process especially when the resident was injured. In an interview on 01/12/23 at 10:09 AM LVN S stated she was in-serviced (one on one) by the Unit Manager (LVN U) after the incident where Resident #6 was sent to the hospital. In a later interview on 1/13/23 at 3:01 PM LVN S stated the Unit Manager discussed with her about the fall process and stressed the importance of documenting administration of medication because if it is documented it means it was not done. The Unit Manager pointed out to her that she needed to call the doctor for a stronger medication since the Naproxen was only for pain on a scale of 1-3. LVN S stated she has since had to call the doctor for stronger pain meds for a different patient with a similar issue. Interviews beginning on 12/20/22 at 7:53 AM through 01/12/23 at 4:30 PM with the nursing staff included: LVN E, LVN V, LVN W, LVN AA, LVN AB, LVN AG, LVN AH, LVN AI, RN AJ, and LVN AK. Interviews revealed nurses knew the procedure for pain management, communicated via the 24 hr report and gave a verbal report at shift change to each other, the nursing staff knew the steps to follow if a resident had a fall with suspected injury, and the nursing staff had been in-serviced on these topics. The nurses also were aware that if there was not a medication to cover the pain level indicated, that they should call the doctor to get another order. Observations from 12/20/22 at 7:40 PM to 01/12/23 at 3:30 PM revealed fall protocols were in place for residents who required such protocols (Resident #'s 4, 7, 8, 10, 11 and 13). Interviews with Residents with PRN pain management on 01/12/23 revealed they got medication when requested and they were not in any pain (Resident #'s 11, 12 and 13). Review of the MAR for Residents with PRN pain management revealed pain assessments were completed and pain medications administered as ordered for Resident #'s 11, 12, 13, 15, 16, 17 and 18. Review of a facility Monitoring Tool dated from 11/7/2022 to 01/12/23 titled Incident/Accident Report and Diagnostic Review was used daily from 11/7/22 to 01/12/23 by the ADON. In an interview on 01/12/23 at 5:45 PM DON revealed signing off on the monitoring tool meant the incident reports were reviewed daily by the ADON and the DON. The ADON and DON were following up to check what was done to address the pain scale on the incident reports. The ADON and DON were monitoring pain meds and ensuring they had meds ordered that covered all numbers on the pain scale. The DON stated for example that if a Resident only had pain medication coverage for pain level of 1-3, the facility would call the doctor to get a medication to cover a higher level of pain. DON stated the IDT team met daily to review each fall and to ensure follow up from each department as needed.

Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical procedures for notification of the ordering physician for one (Resident #6) of five residents reviewed for diagnostic services. The facility did not ensure diagnostic services were provided for Resident #6 as ordered when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 remained at the facility for three days before being sent to the hospital where the x-rays were obtained. These failures could place residents at risk for delayed identification and treatment of undiagnosed illnesses, hospitalization , pain, and suffering. An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM. Findings included: Review of Resident # 6's Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on [DATE]. Resident # 6's diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome. Review of Resident # 6's Care Plan dated 12/23/22 revealed a 'fall care plan was in place with the following intervention added on 11/04/22, Assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc. Review of 24-hour report dated 11/4/22 reflected a comment written by LVN S, resident was pushed down by another resident, exhibited pain in left hip call Dr and ordered x-ray. Review of Resident # 6's Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined. Review of Resident # 6's Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out. Review of Resident # 6's Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport. Review of Resident # 6's NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell . Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected. Review of facility's Provider Investigation Report dated 11/15/22 revealed Resident # 6 was pushed by another resident on 11/08/22 which resulted in a witnessed fall. Resident # 6 was assessed and complained of pain to left lower leg. Further review of the report indicated the resident was sent to ER for further evaluation where x-rays revealed a fracture to the left hip. This report reflected the incident occurred on 11/8/22 even though it occurred on 11/4/22. The facility was informed of Resident # 6's x-ray results on 11/8/22 after sending her to the hospital on 11/7/22. The facility in-serviced (trained) staff on abuse, neglect, resident to resident behaviors, fall with injury and x-ray ordering on 11/8/22. Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell . LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation. Interview and record review on 12/20/22 beginning at 7:53 AM with LVN AA revealed a one-time left hip x-ray (2 views) was ordered for Resident # 6 on Friday 11/04/22. A Stat x-ray with the same views was ordered for Resident # 6 on Sunday 11/06/22. LVN AA stated he did not know why the x-rays were not done. LVN AA stated after reviewing the record that it was LVN S that entered the x-ray orders. LVN AA stated that it was the doctor and not the LVN that determined the type of x-ray that was ordered, whether stat or regular. LVN AA stated that normal practice was if someone had a fall and was in pain, to get an order from the doctor, enter the order into the system and then call it into the x-ray company. Interview on 12/22/22 at 10:20 AM with LVN S stated she entered an x-ray order after Resident # 6 fell on [DATE]. LVN S stated she had some time off in between the two x-ray orders on 11/04/22 and 11/06/22. LVN S stated the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. Interview on 01/12/23 at 10:09 AM with LVN S revealed at the time of the fall LVN S did not know she had to call the x-ray company after entering the order in the facility's electronic medical record. LVN S stated she did not call the company on 11/4/22, however she stated she called them on 11/06/22. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. Interview via telephone on 12/22/22 at 11:22 AM with NP AD revealed the x-ray company typically obtained the x-ray the same day it was ordered whether he ordered a stat x-ray or not. He stated that when x-ray orders came in, the facility was supposed to informed him right away. NP AD stated if an x-ray revealed a fracture, it would be an immediate transfer to the ER. NP AD stated with a fall on 11/4/22, if the staff called him on 11/6/22 he would have told them if an x-ray was not done within the hour, that the Resident should be sent out to the hospital. When informed Resident # 6 was not sent out until 11/7/22 after falling on 11/4/22, NP AD was surprised at the length of time that had elapsed, NP AD stated he did not know what happened, and stated that he always answered his phone. Interview on 12/22/22 at 3:38 PM with Resident # 6's primary contact listed on Resident # 6's Face Sheet on revealed Resident was diagnosed with left hip fracture and had surgery where her socket was removed. She stated the resident was still in pain and was at another facility and had to go on hospice after the surgery. She stated Resident #6 used to walk and now she stayed in the fetal position in bed because she was in too much pain. Interview on 12/22/22 beginning at 5:02 PM with the Assistant Administrator and DON revealed LVN S should have called the x-ray company to find out the estimated time of arrival of the x-ray company. They stated LVN S thought that when she entered the order in the facility's electronic medical record platform, that it automatically went to the x-ray company, but there was actually an additional step. DON stated The facility needed to fax the company and then the company would call to confirm. The Assistant Administrator stated that after the incident she told LVN U, the Unit Manager to educate LVN S on the process of x-ray ordering. The Assistant Administrator stated x-ray ordering should have been part of LVN S's new hire training process. The DON stated the LVN that worked 2-10 PM shift on 11/06/22 should have sent Resident # 6 out to the hospital when it was realized that the x-ray was not obtained in the time frame (3-4 hr span of time) provided by the nurse practitioner. The DON stated she understood the danger of having a long-time lapse before being sent to the hospital after a fall. She stated if a person was normally ambulatory and then that changes, they should have an x-ray and often those patients need to be sent out to the hospital for further evaluation. In a later interview on 01/12/23 at 12:01 PM with the DON and ADON, it was clarified that staff could either enter the x-ray order in the online portal of the x-ray company or call them on the phone to communicate the x-ray order. The Plan of Removal process was not needed at this time because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey on 12/20/2023. The facility implemented the following interventions to address non-compliance: Review of the facility's In-Service (training) dated 11/07/22 reflected LVN U, the Unit Manager provided one on one training to LVNS S titled Fall prevention, Xray ordering process, family communication, included pain management, Xray process, review of adverse events that occurred as a purpose for the training or identified gaps during facility assessment (these must be part of the in-service and discussed), all steps in the fall management process and the credentials to login to the online portal for the x-ray company. Review of the facility's in-service dated 11/8/22 reflected training for all nursing staff on Falls with Injury, included instructions on ordering x-rays from the x-ray company. Review of additional in-services dated and completed on 11/29/22, 12/19/22, 12/22/22, 12/23/22 and 1/5/23 revealed staff were trained on all aspects of the fall management process especially when the resident was injured. In an interview on 01/12/23 at 10:09 AM LVN S stated she was in-serviced (one on one) by the Unit Manager (LVN U) after the incident where Resident #6 was sent to the hospital. LVN S stated she was given instructions on the entering the x-ray orders on the online portal of the x-ray company and on calling the company on the phone to get confirmation that the order was received. Interviews beginning on 12/20/22 at 7:53 AM through 01/12/23 at 4:30 PM with the nursing staff included: LVN E, LVN V, LVN W, LVN AA, LVN AB, LVN AG, LVN AH, LVN AI, RN AJ, and LVN AK. Interviews revealed nurses knew the procedure for ensuring x-ray orders were carried out, communicated via the 24 hr report and gave a verbal report at shift change to each other, the nursing staff knew the steps to follow if a resident had a fall with suspected injury, and the nursing staff stated they had been in-serviced on these topics. Observations from 12/20/22 at 7:40 AM to 01/12/23 at 3:30 PM revealed fall protocols were in place for residents who required such protocols (Resident #'s 4, 7, 8, 10, 11 and 13). Review of facility Fall Incidents between November 2022 and December 2022, aside from Resident # 6, reflected facility residents with a fall were sent out to the hospital in a timely manner when a change of condition was identified for Resident #'s 4, 8, 9 and 10. Review of a facility Monitoring Tool dated from 11/7/2022 to 01/12/23 titled Incident/Accident Report and Diagnostic Review was used daily from 11/7/22 to 01/12/23 by the ADON. In an interview on 01/12/23 at 5:45 PM DON revealed signing off on the monitoring tool meant the incident reports were reviewed daily by the ADON and the DON. The ADON and the DON were following up to check that x-rays were completed if ordered. DON stated the IDT Team met daily to review each fall and to ensure follow up from each department as needed.

Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 6 residents (Resident #1 and Resident #2) reviewed for pressure ulcers/wounds. The facility failed to ensure Resident #1's wound treatments and wound assessments was completed daily to prevent the worsening of her pressure ulcer on her sacrum. The facility failed to promptly intervene when Resident #1's wound increased in size within six days: 03/16/22 the wound measured 1.7 CM x 0.3 CM X 0.1 CM and on 03/22/22 the measurements increased to 6.2 CM X 5.1 CM X 0.1 CM, which progressed to a Stage IV pressure ulcer with [CONDITION(S)] and required hospitalization . The facility failed to ensure Resident #2 received interventions to prevent him from developing a pressure ulcer on his sacrum, that was already a Stage 3 when it was discovered. An Immediate Jeopardy (IJ) was identified on 05/13/22 at 12:19 PM. While the IJ was removed on 05/14/22 at 4:00 PM the facility remained out of compliance at scope of a pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of developing or worsening of wounds and placing them at risk of infection, a decline in health, pain, hospitalization , or death. Findings include: Review of Resident #1's face sheet dated 05/10/22 revealed she was an [AGE] year-old female readmitted to the facility on [DATE] and discharged to the hospital on 04/12/22. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly MDS dated [DATE], revealed she was rarely or never understood and rarely or never understands and her cognitive skills for daily decision making was severely impaired and she had no behaviors. Resident #1 was a total assist of two plus persons for bed mobility, transfer, and toilet use. Resident #1 required total assistance from one person for locomotion on unit, dressing, eating, personal hygiene and bathing. Resident #1 had impairment to one side of her upper extremity, both sides of her lower extremities and was always incontinent of bowel and bladder. The MDS also revealed she received 51% or more of her nutrition through a G-Tube (feeding tube) and was at risk for but had no pressure ulcers. Review of Resident #1's care plan dated 02/23/22 revealed she was at risk for problems with elimination of bowel and bladder, with a goal of residents elimination status will be maintained or improved over the next 90 days. Review of Resident #1's Care Plan dated 02/23/22 revealed she was resistant to care. Interventions included: Cue resident prior to delivery, use on-step directions and a slow pace. Respect resident's right to refuse, and show respect for resident's decisions. Discuss with resident her objections, reasons, fears, ideas. Give positive feedback and reinforcement for resident's compliance. Inform resident about risks of non-compliance. Offer as many alternatives as possible for resident to choose from. Psychiatric consult if indicated. Assess residents understanding of the situation, coping skills and support system. Emphasize positive aspects of compliance. Review of Resident #1's care plan updated 04/06/22 revealed she was at risk for/actual skin breakdown related to stage 3 pressure ulcer, incontinent of bowel. The goal was to have Resident #1 maintain clean and intact skin over the next 90 days, take measures to prevent skin breakdown over the next 90 days and the open area would be healed over the next 90 days. Interventions included to apply a protective or barrier lotion after incontinent episodes, assist her to turn and reposition frequently, inspect skin complete body head to toe every week and document results, and inspect skin daily with care and bathing, and report any changes to charge nurse. Keep skin clean, dry, and free of irritants. Position resident properly, use pressure reducing or pressure-relieving devices (e.g., pillows, positioning wedges, and alternating pressure mattress if indicated. Treatments and dressings as ordered per physician. Review of Resident #1's eTAR dated 02/24/22-02/28/22 reveled an order, Cleanse wound every AM PM shift (6am-2pm-10pm) SHEAR WOUND OF LEFT BUTTOCKS: Apply house barrier cream with collagen (to attract fibroblasts and encourage new collagen to the wound bed) twice a day & LOTA (Leave Open to Air). Dx (Diagnosis): Non-pressure chronic ulcer of skin of other sites with unspecified severity. Start Date: 02/25/2022 End Date: 03/24/2022 There were Xs or Os in the areas for each day. Per the Key, O indicated she received the treatment and X indicated she did not receive the treatment. Per the February 2022 eTAR Resident #1 received the treatment both shifts for 4 days but the dates 29-31 were cut off so do not know it the treatment was received. Review of Resident #1's March 2022 eTAR revealed she received treatment to her left buttocks on both shifts as ordered on 3/01/22, 03/02/22, 03/08/22, 03/09/22, 03/10/22, 03/15/22, 03/16/22, 03/17/22, 03/19/22 and03/20/22. She received the ordered treatments on the evening shift only for 03/03/22, 03/05/22, and 03/12/22. She received the ordered treatment on the day shift only on 03/07/22, 03/23/22 and 03/24/22. Resident #3 did not receive the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's e-Tar dated for March 2022 revealed an order dated 03/24/22 which read, CLEANSE SITE every am shift (6am-2pm) 23 Days SHEAR WOUND OF LEFT BUTTOCK: Cleanse area with NS (Normal Saline) or wound cleanser apply [MEDICATION(S)] (skin/wound cleanser solution) w/ (with) Collagen (to attract fibroblasts and encourage new collagen to the wound bed) with dry dressing and PRN if soiled or dislodged. DX: Other Skin Changes. Start Date: 03/24/2022 End Date: 04/06/2022 Review of Resident #1's eTAR for March 2022 revealed she received the ordered treatment on 03/25/22, 03/26/22, 03/27/22, 03/30/22 and 03/31/22 and did not receive the new treatment on 03/28/22 and 03/29/22. Review of Resident #1's eTAR for April 2022 revealed she received the ordered treatment on 04/03/22 and did not receive the treatment on 04/01/22, 04/02/22, 04/04/22, 04/05/22 and 04/06/22. Review of Resident #1's eTAR for April 2022 revealed an order, CLEANSE SITE every am shift (6am-2pm) STAGE 3 PRESSURE WOUND TO THE LEFT BUTTOCKS: Cleanse area with NS or wound cleanser apply Santyl (Chemical debridement ointment) and calcium alginate cover with dry dressing daily and prn (as needed) if soiled/dislodged DX: Other skin changes START DATE: 04/06/2022 END DATE: 04/16/2022 Review of Resident #1's April 2022 eTAR she received the ordered treatment on 04/07/22 and 04/11/22 and did not receive it on 04/08/22, 04/09/22 and 04/10/22. She went to the hospital per her family request in 04/11/22. Review of Resident #1's April 2022 eTAR revealed an order, MAY HAVE PRESSURE ALTERNATING LOW AIR LOSS MATTRESS FOR WOUND 1 time per day DX: Pressure ulcer of sacral region, unstageable Review of Resident #1's eTAR for April 2022 also revealed an order, Santyl 250 units/g (gram) Ointment 1 time per day DX: Pressure ulcer of sacral region, unstageable Start Date: 04/11/2022 End Date: 04/11/2022 Review of Resident #1's Wound Evaluation and Management Summary note written by Wound Physician dated 12/29/21 revealed, .Wound Sacrum (Resolved on 12/29/21) Review of Resident #1's nursing note dated and signed by LVN DD on 02/15/22 at 7:40 PM revealed, opening observed on right buttocks cheek, skin on left buttocks cheek observed as thin. No opening to left cheek yet, opening cleaned with NS, dressing applied to entire buttocks, rp (responsible party) made aware Review of Resident #1's nursing notes from 03/16/22 to 04/12/22 revealed no documentation regarding the resident's refusal of care. Review of Resident #1's Wound Evaluation and Management Summary note written by Wound Physician dated 02/23/22 revealed, SHEAR WOUND OF LEFT BUTTOCK FULL THICKNESS .Wound Size (L x W x D) 3.7 x 4.1 x 0.1 cm .Cluster Wound .Exudate .Light Sero-sanguinous It further reflected: Granulation tissue .20% Skin .80%. Review of Resident #1's Wound Evaluation and Management Summary note written by Wound Physician dated 03/16/22 revealed, SHEAR WOUND OF LEFT BUTTOCK FULL THICKNESS .Wound Size (L x W x D) 1.7 x 2 x 0.1 cm .Cluster Wound .Exudate .Light sero-sanguinous It further reflected, Granulation tissue .25% Other viable tissue .25% (Dermis) Skin .50% Wound Progress: Deteriorated. Review of Resident #1's Wound Evaluation and Management Summary note written by Wound Physician dated 03/23/22 revealed, STAGE 3 PRESSURE WOUND OF THE LEFT BUTTOCK FULL THICKNESS .Wound Size (L x W x D) 6.2 x 5.1 x 0.1 cm .Cluster Wound . Exudate .Light sero-sanguinous It further reflected, Thick adherent devitalized necrotic tissue .10% Granulation tissue .30% Skin: 60% Wound progress: Deteriorated Review of Resident #1's Wound Evaluation and Management Summary note written by Wound Physician dated 03/30/22 revealed, STAGE 3 PRESSURE WOUND OF THE LEFT BUTTOCK FULL THICKNESS .Wound Size (L x W x D) 8 x 7.5 x 0.1 cm .Cluster Wound . Exudate .Light sero-sanguinous It further reflected, Thick adherent devitalized necrotic tissue .30% Granulation tissue .30% Skin: 40% Wound progress: Deteriorated Review of Resident #1's Wound Evaluation and Management Summary note written by Wound Physician dated 04/06/22 revealed, STAGE 3 PRESSURE WOUND OF THE LEFT BUTTOCK FULL THICKNESS .Wound Size (L x W x D) 8.2 x 7.3 x 0.1 cm .Cluster Wound Exudate .Moderate Sero-sanguinous It further reflected, Thick adherent devitalized necrotic tissue .50% Granulation tissue .10% Skin: 40% Wound progress: Deteriorated Review of Resident #1's nurse's note dated 04/06/22 and signed by the DON revealed, Resident daughter, __________, in the facility and requested to speak with this nurse. This nurse updated family about the wound orders and nutritional supplements being given. Also was informed that resident will be switched from a regular mattress to low air loss mattress for comfort and healing. Dr. ____was in facility and aware of resident's treatment changes and my communication with family. No other concern at this time. Review of Resident #1's nurse's note dated 04/06/22 at 12:04 PM and signed by the Wound Nurse revealed, Spoke with daughter about wound during family visit with resident post (Wound Physician) visit. Family understood treatment and is [sic] providing wound bandages. Review of Resident #1's nurse's note dated 04/12/22 at 12:15 AM written by RN EE revealed, 0015: Resident's [family member]continuing to wait on _____ (ambulance company) to transport resident to Baylor. Per family, nurse during prior shift was suppose [sic] to have called _____ (ambulance company), family states they never call. Per report, family called for transport. RN called (ambulance company) for transportation, spoke with rep. (Ambulance company representative), required info given. Confirmation # 27, per staff, transportation would be here within 45mins (minutes). Update provided to resident's daughters who appear upset with the situation. RN reassured [family members] that _____ (ambulance company) had been called and was [sic] now on their way. No other issues voiced at this time, daughter's calm, resident resting w(with)/no noted distress. Review of Resident #1's nurse's note dated 04/12/22 at 12:15 AM written by RN EE revealed, ____ (ambulance company) arrived, resident to be transported to _____(Hospital) . Review of Resident #1's weekly skin assessments indicated the following: There were assessments for March 2022-03/03/22, 03/10/22, 03/17/22, 03/24/22, 03/31/22 but no weekly skin assessments for April 2022. In an interview with the DON on 05/12/22 at 2:46 PM, revealed he had done a skin assessment on Resident #1 but must have not gotten it into the computer, he stated he did have a nurse's note from that day 04/06/22, where he had spoken to Resident #1's family member regarding the wound. The DON said he did not know where the skin assessment went but felt he was probably interrupted while doing it and did not complete it. He said Resident #1's wound had not looked that bad when he assessed it. It was like the first layer of skin had been sheared off. The surveyor went over the Wound Evaluation and Management Summary's and the DON agreed the wound was not stageable because of the necrotic tissue, which would require debridement. In an interview with Resident #1's family member on 05/09/22 at 12:01 PM, revealed the family member requested Resident #1 be sent to the hospital again. The hospital told her the resident could not go back to the facility. The hospital said Resident #1 should be on antibiotics. After being in the hospital for 8 days on IV antibiotics she had been sent to a long-term acute care (LTAC) center. The LTAC had informed her caring for the wound would be a long process and Resident #1 would be sent to another long-term care (LTC) facility after. She stated they had to insist she be sent out to the hospital in April 2022 as the facility was not going to send her out. It had taken all day to get the ambulance to come. Resident #1 was finally sent out around 2 AM on 04/12/22. Review of Resident #1's hospital records dated 04/12/22 with discharge 04/20/22 revealed the reason for the visit was a sacral wound. The visit diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital's emergency room physician's provider note dated 04/12/22 at 5:03 AM revealed, Skin: .8 cm x 4 cm sacral decubitus ulcer with overlying purulence (containing or forming pus), [sic] poor wound margins. It further reflected, Critical care time was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Severe skin infection, [CONDITION(S)]. Review of a picture from the hospital of Resident #1's wound dated 04/12/22 revealed a large necrotic slough filled wound that appears to be very moist and had jagged edges. An interview with the DON on 05/10/22 at 3:36 PM, revealed they had two treatment nurses, one for each building and had just hired a treatment nurse for the weekends. The weekend charge nurses did the wounds on the weekends before the new treatment nurse was hired. They also had a wound physician that would come every Wednesday and make rounds on the residents with wounds. He also stated Wound Care Nurse B came in to do rounds with the wound physician weekly on Wednesday, early in the morning. An interview with LVN C on 05/11/22 at 10:54 AM, revealed she had worked with Resident #1 but was not here when she was sent out to the hospital. She stated she had not known until she came back and in report the outgoing nurse did not know why Resident #1 had been sent out. LVN C said Resident #1 could move herself in bed a little bit, and she needed moderate assist. She did not think Resident #1 could turn back on her back if she was on her side but said she would push back and may take a swing at staff. LVN C said Resident #1 was feisty but had no real behaviors, she would grab your lanyard. She also said Resident #1 had some contractures of her hands, they would get her up in a wheelchair but could not stay up for long because of her sacral wound. LVN C felt Resident #1 did not refuse care and she was not able to speak so would not refuse care but would let you know she was unhappy. When informed of the large increase in size of her sacral wound from 1.7 cm x 2 cm x 0.1 cm to 6.2 cm x 5.1 cm x 0.1 cm one week later, LVN C said, that was a huge [NAME] in the size. She also said she was not sure if it was her nutrition and that she was not very familiar with her. She said one of her CNAs had given her a stop and watch (a monitoring task) that said there was an odor to Resident #1's wound. She said she went to go assess it and called her physician to let him know about the change so the wound physician could come back by and look at it to make sure the treatment was ok. She had looked at the wound but could not remember what day it was or what it looked like but felt she needed to make a note and had the wound care physician come and check it. Review of Resident #1's nurses note dated and signed by LVN C on 04/05/22 at 14:43 (2:43 p.m.) revealed, Performed dressing change to resident wound to sacral area applied skin protectant underneath R buttock area skin break. (This was the only nurses note about Resident #1's wound by LVN C found and there was no mention of an odor or contacting the physician.) An interview with NCNA E on 05/11/22 at 11:27 AM, revealed she had taken care of Resident #1. She said Resident #1 could not move herself in bed, she did not have any behaviors and sometimes she wound pinch you. NCNA E said she had a place on her bottom that would get small, dry up and heal then it would get moist and open again. She said they would clean her and put moisture cream on her, and they would get her up in a wheelchair. She said when Resident #1 was up in a WC she would check her every hour for incontinence. During an interview with LVN D on 05/11/22 at 12:07 PM, revealed Resident #1used to be in room [ROOM NUMBER] A. She could minimally move herself in bed but most of the time she was total care. They used to get her up in a wheelchair every day but could not propel herself. If she was in bed she would be in bed. She had a G-tube, and we stopped the feeding at 7AM and put it back up at 7 PM. She ate by mouth a little during the day and would be taken to the dining room. LVN D said sometimes she would be combative but not always and sometimes when trying to feed or change her she would resist. LVN D said they would need help of two as she would try to pull out her G-tube so they would need two to work with her. LVN D said Resident #1 had a wound on her bottom. The wound nurse would change it and sometimes when she was soiled, we would change the dressing. Surveyor explained that it went from 1.7 X2 X 0.1 on 03/16/22 to 6.2 X 5.1 X 0.1 on 03/22/22. LVN D stated, Oh my God, that is a big increase. She already had the wound when I started, and the wound nurse would change it. I was PRN and when I came here Resident #1 had left to go to the hospital, she did not know why and had since heard she was transferred somewhere else. An interview with Wound Nurse A on 05/11/22 at 2:39 PM, revealed most of the time they had two CNAs back there, not often that only one CNA was back there on the secure unit. She said there were usually 2 CNAs and 2 nurses. She stated they had just hired a weekend nurse to do wounds on the weekends. Wound Nurse A said when they didn't have a weekend wound nurse the staff nurses were supposed to do the wounds, but they were not done at times. Wound Nurse A said the weekend nurses had a hard time getting the wounds done on weekends prior to getting the wound nurse for the weekends. She said she had worked with Resident #1 and she could not move herself in bed but could move her arms well. Wound Nurse A said Resident #1 was mainly total care and had not liked to be changed or liked her to change her dressings. She said Resident #1 would try to hit my hands, pinch, grab my badge. She also said she not like people pulling up her gown or getting into her personal space. Wound Nurse A said she had found the dressing soiled and even Resident #1 soiled at times. An interview with CNA F on 05/12/22 at 1:25 PM, revealed she had taken care of Resident #1 and she was totally dependent on staff for bed mobility, transfers, and locomotion in the wheelchair. She also said Resident #1 would fight them when they tried to clean her up. She felt one person could take care of her by themselves and she would talk to her about where they both had come from and she would calm down. CNA F said when Resident #1's wound had first started she told the nurse (LVN D) the wound had opened back up at the scaring on her bottom. CNA F said she had been off for three- four days and when she came back Resident #1 had gone to the hospital. She said Resident #1's wound had developed a black and squishy wound bed with an odor, and she told the nurse that it had developed an odor. CNA F said Resident #1 also had 6 bowel movements that day before she had notified the nurse because of the odor. She stated she thought the odor was from the bowel movement, so she told the nurse Resident #1's dressing was dirty, and the nurse went and changed it. CNA F said Resident #1's family member was by the bedside at that time and saw the wound as well. CNA F said her responsibility when caring for wounds and preventing them from worsening was if the dressing was dirty, she would get the nurse to change it and if the dressing had come off, she would go let the nurse know so she could replace it. An interview with LVN D on 05/12/22 at 1:58 PM, revealed she had not taken care of Resident #1 every day because the wound nurse took care of it every day. The wound nurse was there every day and did the dressings. She stated she had changed Resident #1's dressing one time when it had become soiled, and the CNA (CNA F) came and told her it was soiled. LVN D stated the time she had changed the dressing the wound was not that bad. LVN D said when Resident #1 was sent to the hospital she had not known how big it was. LVN D again stated she had worked PRN (as needed). LVN D said red flags they should watch for that indicate a wound is deteriorating wase if it changed in size, color, or smelled different and if was not improving but staying the same. LVN D said to help prevent a wound from deteriorating if they were bed bound, they must reposition them and try not to lay them on their side with the wound, incontinent care should be done frequently, they needed to make sure they were eating good, getting supplements and change the dressing if it got soiled. LVN D also said Resident #1 stayed in bed most of the time the last few weeks and was total care, she also had a G-tube. She said she would do rounds every two hours and if Resident #1 was in the same position, she would help them change it if needed. An interview with the DON on 05/12/22 at 2:46 PM, revealed he did not think Resident #1 could move herself in bed as she was a total assist. He stated her family wanted her up for breakfast so they would get her up in her wheelchair. The DON also said Resident #1 did not eat well and could not swallow very well so she had nocturnal feeds and bolus feeds if she ate less than 50%. Yes, she had behaviors, she would try to hit you even when the daughter was there, she was fighting but her daughter was talking to her and calmed her down. The DON said she had a scar on her sacrum, and she had a decubitus previously, so she was prone to break down. He again said Resident #1 wound just the top skin, there was no depth, so it was just the first layer, so it was a shear. He also said if they suspected a wound was getting infected or if it was getting worse, they would change the treatments and if they were not able to get it to improve, they would send them to a LTAC. He said if a wound was infected and needed antibiotic therapy, they would send them to the hospital. The DON said Resident #1's pressure ulcer did not appear infected when he saw it on 04/06/22. He stated they had started an air mattress on that day. When asked why he had not ordered her an air mattress prior especially since she was prone to developing a pressure ulcer the DON said her family had a special mattress they wanted on her bed, so I told them maybe we need to change out the mattresses and we did. Resident #1 had a problem with weight loss previously, but we had it stable. He said at one time the doctor had been concerned with Resident #1's nutrition, so it had already been addressed. The DON said he did not do the skin assessments on residents but would help if they needed help and he was standing in as the unit manager at that time. He said the nurses were to do the skin assessments weekly. When asked what they could do to prevent pressure ulcers from developing or deteriorating the DON said turning and repositioning them timely, getting an air mattress, making sure they have proper nutrition, and they are receiving incontinent care timely. The DON revealed nurses were in charge of completing skin assessments and stated skin assessments were not conducted because he had forgotten to complete them. An interview with MA G on 05/12/22/at 3:11 PM, revealed she would check her residents every 2 hours for incontinence care and /or to change their position if they were bed bound. If a resident called and was wet or dirty, she would answer the call light and if the supplies were in the room, she would change them if not she would go get the supplies and come back and change them. MA G said her role in preventing pressure ulcers was if they are incontinent, we changed them every 2 hours, make sure they are clean and use cream after wiping, turning them every 1 or 2 hours and if they had a wound, after cleaning them up, she would use a pillow to pad them to help keep pressure off. MA G said if she finds a new bruise or wound the first thing, she would do was tell the nurse in charge. MA G said there was supposed to be two CNAs, a MA and two nurses on the north secure unit. She also said if they were short. A CNA from another hall would help them care for the residents. She said she had worked with Resident #1 before she moved out and she did have a wound, could not move herself in the bed and she was generally up in a wheelchair when she came on at 2:00 PM. She said they would get Resident #1 up in the morning and when she came on at 2:00 they would put her in bed and had to change her, clean her, and get her back up because that was what the family wanted. She said she would get another CNA to help as Resident #1 would scratch staff so the other CNA kept would help by protecting the CNA that was doing the actual changing. An interview with Wound Nurse A on 05/12/22 at 3:31 PM revealed she had worked there officially almost a year. She started as the wound nurse a couple months ago, not too long, she thought she started as wound nurse in March. Wound Nurse A said before she was the wound nurse she had worked on the floor, was PRN but had worked full time hours. She said regarding the residents with wounds, she expected staff to turn them every two hours but felt they should turn them every 1-2 hours, as well as change them and clean them up in the same time frame. Wound Nurse A also stated to prevent pressure ulcers they should keep bedbound residents off bony prominences, rotate them every 2-4 hours, keep them clean and dry, and if not bedbound then up ambulating or up sitting check them for incontinence, adequate diet nutrition, being bathed and changed properly. Wound Nurse A said usually, the CNAs or the nurse would tell her if they found a new bruise or open area on a resident. She said she felt they usually had enough help as the unit had 2 aides and two nurses there most of the time, she said she had not seen only 1 CNA on the unit very often. Wound Nurse A said the weekend nurses were to do the wound care on the weekends prior to the new weekend treatment nurse. They are supposed to do the wounds when wound nurses were not on call, they just changed it. On another shift/on floor (when on call not as wound nurse) the nurses are supposed to do the treatments. She said resident wounds were not done at times as the nurses had a hard time getting treatments done. She also said the nurses were supposed to do skin assessment every day during their assessments and it was documented in the electric medical record under routine data. Wound Nurse A said she had worked with Resident #1 and she could not move herself in the bed as she was total care even though she could move her arms. As far as behaviors Resident #1 did not like to be changed and did not like Wound Nurse A to do her wound care as she would try to hit your hand or pinch you. She was sweet unless you were invading her personal space, Resident #1 did not like people trying to pull up her gown or change her. She said she had found her wet and dirty a couple of times but had never found her with her dressing removed. It may be soiled but never completely removed. She said she was not the treatment nurse when the wound physician healed Resident #1's sacral wound in December 2021 but in March around the same time as the wound physician began to see her again was when she first cared for Resident #1 as wound nurse. When asked Wound Nurse A about what may have caused Resident #1's wound going from 1.7 cm x 2 cm x 0.1 cm to 6.2 cm x 5.2 cm x 0.1cm in a week she said could be the aides weren't changing her, were not careful when they moved her around or put her in the chair and left her. Wound Care Nurse said Resident #1 went out on 4/12, and she just remembered reading the note about why, but had not been there when Resident #1 went out to the hospital. She stated she had not been there a couple days prior to her being sent out because she had been working the floor as a charge nurse and there was a week in there when she had the flu and had not seen her. Wound Nurse A said her part in preventing a wound from getting worse was to let the nurses know that she would not be there so they could do the residents wounds and that she could see the bandage when she came back meaning if the bandages had not been changed her initials would still be on them. Showed her the picture of Resident #1's wound from the hospital and she said she had seen Resident #1's wound on 04/06/22 because when the wound physician came, she always removed the dressings and would not re-dress them, so she had redressed Resident #1's that day. She said the edges of the wound were not like that. The edges were more defined, not raggedy and the wound bed was not mostly slough (a yellow-tannish viscous fribrinous tissue). An interview with Wound Nurse A on 05/13/22 at 10:47 AM, revealed if she came back to work after being off for the weekend or working someplace else in the facility what she would do if the same dressing she had put on was still there she said she would change them. She also said she would tell the nurse and sometimes tell the DON that they had not been changed. An interview with LVN I on 05/13/22 at 10:54 AM, revealed she knew Resident #1 but had never taken care of her because she worked on the other side of the secure unit. She said some of her residents had skin issues she cared for and if the wound nurse was not there a notice usually pops up in the electronic chart that the wound needs to be done on the eTAR. She did not know what the X meant on a day and time slot and said that meant it needed to be done right? LVN I said usually it would pop up so they would initial it on the mar, on the day it was to be done, and if the wound nurse was not there, they would know to do the treatments. LVN I also said when you signed off, it would show7 up on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with LVN C on 05/13/22 at 10:59 AM, revealed when she does a wound treatment on any resident, it should be charted on the eTAR. When shown Resident #1's eTAR she said that was not what the eTAR looked like. She said when they did them it did not come out like that, when they looked at it in their view, they were typing yes, no and answering questions. Surveyor showed her a resident's eTAR on the computer [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #34) of 7 residents reviewed for accidents The facility failed to assess Resident # 34 after she was found on the floor after an unwitnessed fall. CNA B picked the resident up and placed her in bed without an assessment being completed. The resident was sent to a local emergency room and diagnosed with separated shoulder and fall. The failure placed residents at risk of injury, pain, hospitalization and a diminished quality of life. Findings include: Record review of Resident # 34's face sheet dated 10/12/21 revealed she was an [AGE] year old female admitted to the facility on [DATE]. Her diagnoses included COVID-19, Dementia and muscle weakness. Record review of Resident #34 's annual MDS assessment, dated 09/10/21, revealed Resident #34 had a BIMS score of 00 out of 15 which indicated severe cognitive impairment. She required extensive assistance from one staff for transfers and bed mobility. She was always incontinent of bowel and bladder. The resident had falls listed. Record review of Resident #34's Comprehensive Plan of Care dated 07/18/18 revealed she had short term memory loss. The resident was identified as high risk for falls. The facility would Fall-related complications, such as injury or change in cognitive function, will be promptly assessed and treated to prevent adverse outcomes dated 09/22/21. Interventions included, assess contributing factors related to fall history. Assist resident with toileting. Frequent visual checks. Observation on 10/21/21 at 12:45 pm revealed Resident # 34 in bed. The resident had discoloration to her left shoulder that was red and purple. The residents left shoulder did not align with the right shoulder, it was elevated. During an interview with CNA B on 10/12/21 at 10:07 am revealed she had worked with Resident # 34 on 10/9/21 and 10/10/21 as the primary aide for the resident. On 10/10/21 she provided incontinent care on Resident # 34. She stated on the same day she entered the room of Resident # 34 and saw the resident on the floor. She stated when she saw the resident on the floor, she asked the resident if she had fallen and the resident replied yes. The resident stated did not have injures. She stated and she picked up the resident and placed the resident back into bed. She stated later during the shift she informed LVN C Resident # 34 had fallen out of bed and she helped her back into bed. She did not know Resident #34 had suffered a dislocated shoulder and was sent to the emergency room . She had not returned to work since the resident had the fall at the facility. Record review revealed CNA B last received training regarding fall management on 09/07/21 . She completed a fall prevention test on 08/05/21. She had a good knowledge of the facility's fall management. An interview with LVN C on 10/12/21 at 10:32 am revealed she worked on the evening of 10/10/21 with CNA B. During the shift she stated everything went well, there had not been any concerns regarding Resident # 34. She was not aware the resident had a fall. She stated CNA B had not informed her the resident had fallen. She stated if she was aware the resident had fallen, she would have instructed the aide to leave the resident on the floor until she was assessed for injury, she would have completed neuro checks, informed the physician, the resident family, contacted the DON. Review of the emergency room notes provided by the hospital dated 10/11/21 revealed Resident # 34 final diagnose was Left separated shoulder and fall. The x-ray revealed abnormal elevation of the clavicle relative to acromion compatible with AC joint injury . The left shoulder was raised, above the right shoulder. Review of the Incident/Accident reports for October 2021, revealed no evidence Resident # 34 had a fall on 10/10/21. Review of the nurse's notes dated 10/10/21 revealed no documentation of the resident having a fall and being assessed. Review of the nurse notes dated 10/11/21 revealed the following at 6:35 am the hospice notified the nurse of bruising to Resident #34's left shoulder. Head to toe assessment completed noted bruising/discoloration to left shoulder with minimal swelling. While attempting ROM resident unable to raise left arm c/o pain with facial grimacing noted .Completed by the nurse that work the day shift . An interview with the DON on 10/12/21 at 11:41 am revealed she was not aware Resident # 34 had a fall over the weekend, she stated nothing had been reported. She revealed CNA B had not communicated with the nursing staff regarding the fall. Her expectations were, if a resident is believed to have a fall the aides must immediately notify the nurse on the unit . From there the nurse would assess the resident, prior to removing the resident from the floor. She expected to receive a call or contacted regarding the fall. Review of the Incident/Accident Reporting policy dated 02/12/20 revealed In addition to the Incident/Accident report, for any unwitnessed incident/accident resulting in an injury, an investigation of injury of Unknown origin will be completed immediately upon facility staff becoming aware of the occurrence of the incident/accident. Review of the facility's Fall Management policy dated 02/12/20 If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls-complete the Incident/Accident report in the electronic health records. The physician and family are notified.

Based on interview and record review, the facility failed to permit the resident to remain in the facility, and not transfer or discharge the resident from the facility from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility and documented the reason for the transfer/discharge for one (Resident #1) of six residents reviewed for discharge. The facility failed to to provide sufficient evidence they could not meet Resident #1's needs or that the resident was a danger to herself of others. Resident #1 was discharged after being transferred to the hospital for an acute medical event and experienced sadness when she was not allowed to return to the facility following her hospitalization . This failure placed residents at risk of not getting the necessary care and services to meet their physical and psychological needs. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was totally dependent on staff for all ADLs and was cognitively intact. The resident was discharged on [DATE]. Review of Resident #1's nurse's progress notes dated [DATE] reflected Resident approached this nurse at 13:00 (1:00 p.m.) diaphoretic (sweating) from head to waist/resident's shirt was soaking wet/(Vital Signs)-130/68 (blood pressure), (pulse)-103, (temperature)-[AGE].1, (respirations)-18, (oxygen saturation level)-96%, skin pallor/resident responsive, but lethargic from baseline/called NP (Nurse Practitioner). NP gave order to send resident to hospital for observation for [MEDICAL CONDITION]. Review of Resident #1's physician's orders did not reveal a telephone order to transfer/discharge the resident to the hospital. Interview with the DON on 0[DATE] at 2:40 PM revealed there was no physician's discharge order for Resident #1 to go to the hospital, and there was not a transfer/discharge summary found in Resident #1's clinical record. Review of Resident #1's clinical record revealed no evidence of active discharge planning or an explanation of the intent to discharge the resident. During a telephone interview on 01/11/19 at 3:00 PM with Resident #1, she stated she had to stay in the hospital over the necessary time because she was denied return to the facility. She said she did not receive a 30-day notice of discharge nor did she receive any explanation as to why she was being denied readmission to the facility. She stated the hospital social worker made several calls to the facility and tried to work with the facility, but they refused to let her come back. She said she was not told why her return was denied. She said she was very sad because she had been at the facility for nine years and considered it her home. During a telephone interview on 01/07/19 at 10:09 AM with the Ombudsman, she stated Resident #1 went to the local hospital emergency department, but the facility refused to allow the resident to return, citing it was because the resident was non-compliant with care. The Ombudsman stated Resident #1 had a discharge overturned the earlier part of December 2019. She said the facility discharged her immediately at that time because she had significant behaviors and her needs could not be met by the facility. The facility attempted to discharge Resident #1 two or three times. She said they (the facility and Resident #1) had a cycle of not getting along. Resident #1 got very upset about something and she complained and refused care. She said Resident #1 was verbally aggressive, but she was total care, so she could not really get physically aggressive. She said Resident #1 refused a lot of care but that was her right. She said the hospital reported the discharge as dumping and Resident #1 planned on appealing her discharge from the facility. Review of a Fair Hearing Letter, dated 11/15/19, reflected the facility's decision to discharge Resident #1 was reversed following the fair hearing. The letter reflected the following: Instructions: In accordance with this decision, (the facility), is instructed to allow (Resident #1) to remain in the facility if (Resident #1) so desires, and not transfer or discharge (Resident #1) from the facility During a telephone interview on 01/09/18 at 12:30 PM with the local hospital's Director of Case Management, she said that she had many phone conversations with the facility regarding Resident #1 and they told her that the resident was not going to be readmitted . She said the hospital held her several extra days while they were waiting for the facility's decision. She said the facility told her that the resident needed a psychiatric evaluation prior to them deciding whether to readmit the resident to the facility. She said that when the resident was deemed to not be a danger to herself or others, the facility then told her they had to discuss it with their legal department. She said after a few days, she contacted the facility again about the resident and was told they would not be taking her back. She said the hospital finally told the facility that they needed a letter addressing their decision not to take the resident back which was provided to her after several days of waiting. She said the letter advised her that they would not be able to take the resident back at the facility and was signed by the facility Executive Director and the Medical Directors. The letter was not dated. She said the hospital was ultimately able to place the resident in a facility close to her family. She said that during one of her conversations with the facility administrator, she advised him that she was obligated to report the facility for dumping the resident to which he told her to go ahead and report them, they would take the tag. Interview with the Executive Director on 01/07/19 at 12:10 PM revealed Resident #1 was at the facility for approximately six years and during that time she was non-compliant with care, belligerent, and refused care. He said that the facility tried to manage her care and she did not comply with her care. He said during the last discharge on [DATE], she was sent to the hospital due to refusal of treatments, smoking unsupervised in poor weather, and she ultimately discharged to the hospital due to respiratory distress. He said that the facility held a conference with the Medical Directors to discuss Resident #1's care and concluded that the facility could no longer meet her needs due to her noncompliance and behaviors. The decision was made to decline her returning to the facility. He said that the facility was in contact with the hospital administration to help find alternate placement for Resident #1 once the decision had been reached about not accepting her back to the facility. He said the facility had numerous conversations with the Ombudsman about Resident #1's needs but the facility felt the Ombudsman was undermining the facility efforts to care for the resident. He said due to the Ombudsman impeding the care of the resident, the facility Executive Director had a meeting with the regional Ombudsman to request a change in the Ombudsman assigned to the facility. Interview with the Executive DON on [DATE] at 11:55 AM revealed Resident #1 was sent to the hospital for respiratory distress due to her not allowing the staff to provide the prescribed treatments for her. She would refuse her nebulizer treatments daily as well as her other medication. She said Resident #1 would dictate who could come into her room when she requested assistance; eventually, only a few of the staff were allowed in her room to provide care. The Executive DON stated this caused a problem because the staff she would allow were assigned to different halls throughout the facility. She said they tried to get them all on the same schedule but could not consistently do so. She stated Resident #1 would get angry and refuse care because of this. She said Resident #1 would curse and threaten the staff including herself (the Executive DON) if she did not get her way. She said Resident #1 did not care for her (the Executive DON) and therefore she would let the DON or ADON communicate with Resident #1 whenever possible. Review of a letter, signed by the facility's Executive Director and addressed to Resident #1, dated 12/26/19 reflected the following: This letter will confirm that pursuant to State Regulation 40 TAC Section 19.502, (Resident #1) will be discharged immediately from and not be readmitted to (the facility) following discharge from (the hospital) because (the facility) has determined that it cannot meet (Resident #1's) needs and discharge is necessary for her health, safety and/or welfare. As (Resident #1's) attending physician, (Physician) has documented, (the facility) cannot meet (Resident #1's) needs because she requires significant behavioral interventions that cannot be provided by (the facility). As (Resident #1's) medical record demonstrates: - she has consistently refused psychiatric medications, psychiatric therapy services, and other psychiatric interventions attempted by (the facility), her attending physician and psychiatric specialists. As a result, for her own safety, (Resident #1) was recently discharged to (the hospital) for involuntary psychiatric evaluation. Upon her return to the facility, (Resident #1) still refused psychiatric services and interventions. (Resident #1's) untreated psychiatric condition results in her using improper language with employees, exhibiting violent behavior, making threats of physical harm to others, and using anger to jeopardize her own safety and well-being. - she has often refused to follow the plan of care developed by the facility interdisciplinary team, including but not limited to, refusing to allow facility staff to provide the needed activities of daily living services for her safety and well-being, such as Foley catheter care and meal services, and, at times, has refused even to allow staff even to enter her room to provide any care. As (Physician) has documented, (Resident #1's) refusal of care has resulted in two recent hospitalization s, including her current hospitalization beginning on [DATE]. - she has refused to attend follow-up medical appointments and despite recommendations from her attending physician the facility Medical Director, she refuses to obtain treatment from a hospital or other provider that (the facility) cannot provide. - she has refused to comply with the facility's non-smoking policy and (Physician) admonitions that she not smoke. As (Physician) and the facility staff have explained to (Resident #1) and have documented, smoking poses a high risk to (Resident #1). However, she continues to ignore such warnings and frequently exits the facility to smoke, sometimes in extreme weather conditions, exposing herself to additional health risks. Various medical interventions have been attempted by (Resident #1's) attending physician (Physician), and (the facility) staff members, including inpatient treatment at (the hospital) without success. (The facility's) management staff have attempted to meet with (Resident #1) in an effort to resolve these issues, but she has been unwilling to do so. The Ombudsman has also been actively involved in this case in an effort to reach a resolution, but unfortunately, (Resident #1's) continued refusal of care has prevented a resolution. In summary, as (Physician) has documented, (the facility) cannot meet the needs of (Resident #1) and her urgent medical needs require an immediate transfer or discharge. (Resident #1) needs significant behavioral interventions that cannot be provided by (the facility). Because (the facility) is not licensed or equipped to manage her behaviors, the facility cannot provide necessary care or services to her, such as intensive psychiatric care, medication administration and assistance with activities of daily living. Therefore, (Resident #1) should not be readmitted to (the facility), but rather should be immediately discharged from the facility for her own welfare to a facility that cannot (sic) provide such services. Accordingly, we will immediately discharge (Resident #1) to (the hospital), unless you provide us with a written designation of an alternate location Review of the facility's undated policy titled Notice of a Transfer and/or Discharge revealed, Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Review of the facility's undated policy titled Readmission to the Facility, revealed, A resident who has been discharged to the hospital or for therapeutic leave will be given priority in returning to the facility . 3. Readmission procedures apply equally to all residents

Based on interview and record review, it was determined the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administwring of all drugs to meet the needs of each resident for one (Resident #7) of 24 residents reviewed for pharmacy services. 1. The facility failed to have an effective system in place to ensure physician-ordered medications were administered to Resident #7. The facility failed to administer a total of 51 daily doses of Divalproex Sodium (Depakote) an anticonvulsant, from 04/18/15 through 06/07/15 as ordered by the physician. 2. LVN B failed to transcribe the physician's orders [REDACTED].#7 correctly. 3. The facility failed to have a physician-orderd medication, Vimpat, available for Resident #7 and she missed one dose. These failures resulted in Resident #7 experiencing an increase in seizure activity. Resident #7 had a total of four seizures from 05/14/15 through 06/07/15. These failures had the potential to affect the 29 residents who had [DIAGNOSES REDACTED].#7, and could result in an increase in seizures and the possibility of developing life-threatening seizures including death. On 06/09/15 at 4:45 PM , an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 06/11/15 at 4:19 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. 4. The facility failed to ensure that staff (MA PP) accurately documented the administering of medications to three (Residents #16, #21 and #24) of seven residents reviewed for pharmacy services who resided on the 100 Hall. MA PP was responsible for administering medications to the residents on the 100 Hall of the Scotland Building. These failures created the potential for residents to not receive the physician-ordered medications, thus not receiving the full therapeutic benefits of the medications, which could result in serious medical complications [REDACTED]. These failures had the potential to affect any of the 65 residents who resided on the 100 Hall of the Scotland Building, who MA PP had been responsible for administering medications. Findings included: Review of Resident #7's quarterly MDS dated [DATE] revealed the resident was a [AGE] year-old female who had been admitted to the facility on [DATE] with diagnoses, which included Epilepsy and Recurrent Seizures. Resident #7 was alert and oriented and was able to understand others and was understood by others. Review of Resident #7's the physician's orders [REDACTED]. The neurologist's report dated 04/16/15 reflected Resident #7 had told him she felt drowsy in the morning after taking the morning Depakote. The physician documented since the resident was drowsy in the morning after taking her medication he was making a change for her to take Depakote ER, two tablets at bedtime. The nurses' notes dated 04/16/15 reflected Resident #7 had returned from the physician's office with a new order for Depakote ER 500 mg, two tablets every night at bedtime. The physician orders [REDACTED]. On 04/17/15, the order for Resident #7 to receive the medication, two tablets each night at bedtime was discontinued. Resident #7 April 2015, reflected the resident received Divalproex 500 mg, one tablet twice a day at 8:00 AM and 8:00 PM from 04/01/15 through 04/16/15. The MAR indicated [REDACTED]. The MAR(S) dated for 04/18/15 through 04/30/15 and 05/01/15 through 05/31/15 reflected that Resident#7 never received any of the physician-ordered Divalproex ER 500 mg at bedtime. (This was a total of 51 days.) Resident #7's nurses' notes dated 05/14/15 and timed at 10:15 AM reflected staff was calling for help in activity room. Resident #7 was sitting in a chair with her head leaning on the left side of the bookcase with her eyes closed. Visitors who had been present in the activity room stated Resident #7 was shaking her legs and that staff members reported jerking movements and that the resident was waking up and becoming more alert and responsive. Resident #7 told the staff she did not know what had happened. Resident #7 was taken back to her room and vital signs were taken and assessments made. The physician was notified and no new orders were received. Resident #7's nurses' notes dated 05/14/15 and timed at 1:30 PM reflected the van diver had stated Resident had a seizure while she was sitting in the van. The notes reflected the staff called the physician and he ordered another appointment to be made with her neurologist. (The appointment was scheduled for 04/16/15.) Resident #7's June 2015 MAR indicated [REDACTED]. Resident #7's nurses' notes dated 06/01/15 and entered into the computer at 9:02 PM, The nurse was called to the activity room because Resident #7 was having a seizure. The resident was observed lying on her left side on the table still having jerking movements. The seizure was documented as lasing three minutes. Resident #7 was confused and unable to follow commands. Resident #7 was taken to her room and placed in bed. Vital signs were taken and the physician was called. Resident #7 stated she remembered playing bingo when the seizure started but not much after that. An observation on 06/07/15 at 2:35 PM revealed Resident #7 was observed in her room. She was identified by staff, CNA A as being alert and oriented. Resident #7 was sitting in a chair and told the surveyor she had not gotten her seizure medication last night, (Saturday, 06/06/15). She had checked with the nurse around 8:00 PM and was told it was not in yet but she would give it if it came in before she left at 10:00 PM. She stated the nurse left without giving it. The medication the resident missed one dose of was Vimpat (anticonvulsant) An observation at approximately 3:00 PM on 06/07/15, Resident #7 was observed lying on her back in the activity room with facility staff attending to her. It was reported by staff that she had a seizure. (Staff called for help as Resident was having a seizure) The nurses' notes dated 06/07/15 reflected that Resident #7 had a seizure at 2:45 PM in the activity room and the seizure had lasted approximately three minutes. Resident #7 was observed on the floor lying on her back. The nurse documented that the seizure activity was over when the nurse arrived but the resident was agitated and confused and trying to get up from the floor. Resident #7 was transferred to a wheelchair and taken to her room and placed in bed. The physician was called and he ordered a CBC, CMP, Urinalysis and a Valproic acid level and a new order for Depakote 500 mg. extended release, one tablet orally twice a day for seizure. At 2:45 PM on 06/10/15 an interview was conducted with LVN B revealed Resident #7 had been receiving Depakote ER, one 500 mg tablet twice a day but when she came back on 04/16/15 from the doctor he had changed it to two 500 mg tablets at bedtime. She stated when she put the order in; she clicked on the wrong button and only ordered it for a one time dose. When she clicked on that button it automatically discontinued it after one dose. LVN B stated she had been there on 06/07/15 when Resident #7 had her seizure. She stated she told the physician and told him she was surprised by the seizure because she was taking medications for it. When she went into check on her medications it was then she noticed she had not been taking the Depakote. LVN B stated she was so surprised the resident had not been receiving the medication. At 11:40 AM on 06/10/15 an interview was conducted with ADON C who was also the Unit Manager of South Hall. She stated the new order for Resident #7 to get the Divalproex, two tablets at bedtime was written on a Thursday night. She stated she was responsible for reviewing all new orders the next morning before she took them to their daily meetings. ADON C stated that she had been out sick on that Friday and did not get to check the new orders. She stated if she had been there on that Friday, when she reviewed the orders she would have noticed the error where the nurse put it in for one time only and accidentally checked the wrong box. At 10:45 AM on 06/09/15 an interview was conducted with the DON. She stated that Resident #7 had a seizure on Sunday and that was when they found out they had a problem with her Depakote. She stated on 04/16/15 she had a new order to get two tablets of the Depakote 500 mg ER to be given at bedtime. The nurse put in in the orders on 04/16/15 and then discontinued the order at the same time due to a glitch in the system. The DON stated they got a new order from the Physician and Resident #9 received it last night on 06/08/15. She stated they had QA'd the issue, disciplined the nurse and in-service all nurses and did medication cart audits on all residents who had Seizure diagnoses. The DON stated with the electronic system they do not do an end-of- month checks on the orders because they are put in each day. At 9:30 AM on 06/08/15 an interview with Resident #7. She revealed on Saturday night she did not get her evening dose he seizure medication ( Vimpat). She did, however get both of her doses on Sunday. Resident #7 stated that a couple of weeks ago she started to have her seizures more frequently. She also stated that she did not get any auras before the seizures she would just have the seizures. The Medication Error Report dated 06/07/15 reflected that LVN B had made a transcription error for the Divalproex ER 500 mg. LVN B had ordered the medication to be given one time at bedtime and did not realize she had entered the medication order incorrectly. Review of the Depakote level which was drawn at 8:15 AM on 06/08/15 revealed Resident #7's level was 1.3 ug/ml. The normal parameters for Depakote were 50.0 - 100.0 ug/ml. This level was below the normal parameters but not considered critical. According to <http://www.drugs.com>, accessed on 06/15/15, Depakote is used to treat various types of seizure disorders .Do not stop using Depakote suddenly, even if you feel fine. Stopping suddenly may cause a serious life-threatening type of seizure. Follow your doctor ' s instructions about tapering your dose. An IJ was identified on 06/09/15. The facility's Executive Director, Administrator and DON was notified at 4:45 PM on 06/09/15 of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted at 1:30 PM on 06/10/15 and reflected the following: Immediate Jeopardy Plan of Removal Significant Med Error (Quality of Care); Administration, and Pharmacy Procedures June 10, 2015 The allegedly effected resident (Resident #7) was admitted on [DATE] with [DIAGNOSES REDACTED].>· other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy; · Anemia, unspecified; · Anxiety, unspecified Resident #7 again had seizures on May 14,2015,while In the van, noted at 1:30pm;and the activity room, noted at 10:15pm, June 1, 2015,and June 7 ,2015,as observed by the surveyor in the activity. Resident #7 had a physician order [REDACTED].#7 was seen by her Neurologist who wrote a new order changing her order to: Depakote ER 500 mg 2 tabs by mouth daily at bedtime. The new order was entered into the resident medical record on April 16th as a one-time dose by LVN B, and subsequently signed by the attending physician on April 26th. Resident #7 received her one-time dose on April 17, 2015. Resident #7 missed 51 doses of Divalproex from April 18th, thru June 7th, 2015. The Divalproex medication error was discovered on Monday, June 8th when reviewing medication orders with the physician. New order was received and processed. LVN B received counseling on entering the Divalproex order incorrectly on June 9th by Unit Manager/ADON C. Resident #7 has also been treated with routine Vimpat 200 mg in the AM (since 5/22/13) and Vlmpat 300 mg in the PM (since 3/30/14). VIMPAT is a prescription medicine that can be used alone or with other medicines to treat partial-onset seizures in people [AGE] years of age and older, per the manufacturer. The resident (Resident #7) wrote a grievance to facility staff on Sunday, June 7th that she missed her Saturday evening dose of VIMPAT. Resident #7 missed the PM dose of Vimpat on June 7, 2015, due to alleged medication availability. The medication was delivered on June 7, at 10:42 PM. Medication Aide E was counseled for failing to reorder medication and/or reporting medication not available to the charge nurse on June 7th by ADON C/Unit Manager and Medication Aide F was also counseled for failing to reorder medication and/or reporting medication not available to the charge nurse on June 9th by ADON C/Unit Manager. Med Error reports were completed on the 1 allegedly affected resident {Resident #7}, which includes physician notification. Completed by 5 pm 6/09/15. All residents with a Seizure [DIAGNOSES REDACTED]. On June 9, 2015 between 6pm and 8:00pm.The following residents were reviewed by Nurse Consultant D, LVN, Nurse Consultant, RN, Nurse Consultant: Resident #19, Resident 28, Resident # 29, Resident # 21,Resident #30, Resident #24, Resident #22, ,Resident #31, Resident #32, Resident #33, Resident #34, Resident #35, Resident #36, Resident #37, Resident # 38, Resident # 39, Resident #7, Resident #40, Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #9, Resident 46, Resident #47, Resident #48, Resident #49, and Resident #50. No resident has had an active Seizure other than Resident #7 on Sunday, subject of this Plan of Removal. Any resident that has missed a dose of Seizure medication since June 1st, the physician has been notified, Responsible Party notified and labs were drawn. Care Plans have been reviewed and updated as needed for residents on anti-seizure medications. Care Plans for residents: were updated by DON on June 9th, between 6:30PM and 9:00pm for the following residents: Resident # 19, Resident #28, Resident 29, Resident #21, Resident # 30, Resident #24, Resident #22, Resident #33, Resident #34, Resident #35, Resident #36, Resident #37, Resident #38, Resident #39, Resident #40, Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #9, Resident #47, Resident #48, Resident #49, and Resident #50. Medication Carts were audited for the availability of prescribed anti-Seizure medication on June 9, 2015 between the hours of 5:30pm and 7:30pm. The audits were conducted by: DON, RN Educator G, ADON/LVN H, ADON/LVNC, LVN I and LVN X. Outcome of the audit was as follows: There were no misssing medication. There was no need to contact the physician or pharmacy as a result. All anti-Seizure medication has been moved to the nurses MAR for administration and monitoring. Licensed Nurses and Nedicatiion Aides have been re-educated on: Physician orders [REDACTED].>Reordering of medications Escalation process for missing medications. In-servicing, RN Educator G began with the 2p-10p shift on June 9.2015 at 6:30 pm-7:00pm on June 9, 2015., conducted the 10p-6a shift from 10:00pm to 10:30pm; and continued the training for 6a-2p shift on June 10, 2015 from 6:00am - 6:30am, Administrator is responsible for ensuring all staff have received this in-service. All nurses and medication aides not in attendance will be re-educated prior to the start of their shift. Expected completion date June 11th. In addition, this training has been added to the orientation process for licensed nurses and medication aides presented by RN Educator G. Attachment 2 is the In-service sign in sheets, including who presented, content and posttest. Medication Cart audit began on May 7,2015 and have continued: May 7th one eye drops OTC missing, replaced from stock May 19th no medications missing May 29th no medications missing June 2d no medications missing June 7th one triplicate needed for narcotic, triplicate received and ordered the same day. All of the above audits have been completed between the hours of 5am and 5pm. These will continue as Identified in the QA. This tool will be completed by the Unit Managers and submitted to the EDON/AOON upon completion each week and will be on-going. Any medication issues identified will be addressed immediately. All ordered medications will be confirmed it has arrived. Off cycle QA was held on June 9, 2015 at 6:30PM on the concerns identified and plans to address and correct identified issues. Medical Director was informed of the IJ and the plan to remove. All audits will be reviewed weekly at the Standards of Care meeting, and results followed up at the monthly QI/PI to address trends and/or irregularities. When a routine medication is due to be re-ordered the medication aide and/or the charge nurse will click on the Reorder button in LG. There is an interface with LG and Omnicare (the pharmacy) that automatically alerts the pharmacy the need to refill and send the medication. If the medication has been re-ordered too soon, the pharmacy will send the facility a message via LG to alert them the medication was not sent. Medications are delivered twice daily from the pharmacy. Stat medication are delivered with 4 hours. Medications ordered will be verified they arrived using the LG medication confirmation tracking. Medications not confirmed will be called to the pharmacy within two hours to confirm delivery time. If a stat medication does not arrive within the four hours, the ADON on call will be notified to contact the pharmacy. During Clinical Morning Meeting ,Unit Managers ADON, and EDON will review all new physician orders [REDACTED]. The weekend supervisor will complete said duties. EDON, RN, Nurse Consultant, and Executive Director are responsible for plan oversight and implementation. At 8:55 AM on 06/11/15 an interview with the Executive Director revealed that since she and the DON had been in the building they have had an influx of state visits. When the State comes in we all stop everything and we all go out to take care of what the state surveyors need.At 8:55 AM on 06/11/15 an interview was conducted with the Executive Director. She stated that since she and the DON had been in the building they have had an influx of state visits. When the State comes in we all stop everything and we all go out to take care of what the state surveyors need. The Executive Director stated that Friday ( after the order was written on Thursday night) they were in a Stand-up Meeting and when the state surveyor came in to conduct an investigation, all the staff left the meeting. At that time she stated the facility was down three managers. ADON C who was the Unit Manager for the 100 Unit was out sick and the RN Educator was out and we did not have an ADON for the other units. This was just a Fluke. The Executive Director stated the Unit Managers were responsible for going over the 24-Hour Report and new orders each morning and for bringing the information to the Stand-Up Meeting where we all go over them. ADON C was out sick and they all left the meeting and did not go back to check on the orders. We have even had the weekend supervisor working the floor and she was not able to check on the orders or do the tasks she was supposed to check. A few weeks ago we stopped the weekend supervisor from working the floor and she is now responsible for checking all new orders, discontinued orders and the 24-Hour Report. The Executive Director stated that Resident #7 had been having seizures all along and was not seizure free even when her blood levels of the medication were within therapeutic levels. She stated they had now implemented if they are in the Stand-Up meeting and the state surveyors come in the building, only she and the DON will go out initially to see what they need and then we would go back and finish the meeting. If the ADON/Unit Manager is out then RN Educator G or the Executive DON will be responsible for checking the new orders and 24-Hour Report. When asked about what training the staff was given on medication orders the Executive Director stated when new nurses and medication aides are hired, they receive orientation for the computer system regarding medications and documentation. She also stated if any staff is having trouble with the computer system, the RN Educator G is on duty Monday-Friday and is available for one-on-one training. At 3:17 PM on 06/10/15 an interview was conducted with the DON revealed when asked what caused the Immediate Jeopardy situation, she stated the nurse who input the order did not do it correctly. She stated when they talked with the nurse she told them she did not know what happened. The DON stated unit managers are responsible for checking all new orders the next morning but ADON C/Unit Manager was out sick on the next day, April 17, 2015. She stated on that day a State surveyor came in to conduct an investigation and the meeting was interrupted before they had time to go over the new orders. The DON stated the nurses and medication aides receive training ion the use of the computer and on orders during orientation. RN Educator G does the in-service trainings. If they have any problems or issues which come up, she will do more training and then they will take it to the QA committee for review. She stated she would review it and then make an action plan. The DON stated now if the state enters the building she would leave the stand-up meeting and go see what they needed and the meeting would continue and address all business. Interviews were conducted on 06/11/15 between 9:45 AM and 5:00 PM with the following staff: ADON/LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, MA N, LVN O, LVN P, LVN Q, LVN R, LVN S, RN T, MA U, LVN V, LVN W, LVN X, LVN Y, LVN Z, LVN AA, LVN BB, LVN CC, LVN DD, LVN EE, LVN FF, MA GG, LVN HH, LVN II, LVN JJ, LVN KK, and MA LL . All nurses interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do if medications which had been re-ordered were not available, who to contact, how to put in new medications orders and where they were to document them and that the nurses were the only ones who could give anti-convulsive medications. All medication aides who were interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do if medications were not available and who they were to notify and that the nurses were the only ones who could give the anti-convulsive medications. On 06/11/15 at 4:19 PM, The Executive Director was notified the IJ was removed. While the IJ was removed on 06/11/15, the facility remained out of compliance at a severity level of Actual harm that is not an Immediate Jeopardy and a scope of pattern, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. A list provided by the facility on 06/09/15 reflected there were 29 residents in the facility who had diagnoses, which included Seizures. A list provided by the facility on 06/09/15 reflected there were four residents in the facility who had orders for Divalproex medications. :

Based on interview and record review, it was determined the Executive Director and the DON failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for one (Resident #7) of 24 residents reviewed for significant medication errors. 1. The Executive Director failed to ensure staff received appropriate and effective training to ensure they were fully knowledgeable about how to input physician orders [REDACTED]. 2. The Executive Director failed to supervise the DON to ensure she was monitoring the staff to ensure they were proficient in putting physician orders [REDACTED]. 3. The DON failed to ensure there was adequate staff available and assigned to conduct the daily reviews of all new physician orders [REDACTED]. An Immediate Jeopardy (IJ) was identified on 06/09/15. While the IJ was removed on 06/11/15, the facility remained out of compliance at a severity level of Actual Harm that is not Immediate Jeopardy and a scope of Pattern because the facility was still in-servicing staff and monitoring the implementation of the Plan of Removal. These failures to ensure that Resident #7 received her anti-[MEDICAL CONDITION] medications as ordered by the physician resulted in her experiencing an increase in her [MEDICAL CONDITION] activity. These failures had the potential to affect not only Resident #7 but also the other 28 residents who had [DIAGNOSES REDACTED]. These failures had the potential to result in serious injuries and trauma and to result in the development of life-threatening [MEDICAL CONDITION] and/or death. Findings included: 1) Review of Resident #7 ' s quarterly MDS dated [DATE] revealed the resident was a [AGE] year-old female who had been admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION] and Recurrent [MEDICAL CONDITIONS], Anxiety State, [MEDICAL CONDITION] and [MEDICAL CONDITION] Reflux Disease. The MDS also reflected that Resident #7 was alert and oriented and was able to understand others and was understood by others. 2) At 2:35 PM on 06/07/15, Resident #7 was observed in her room. She was identified by staff, CNA A as being alert and oriented, ambulatory and continent of both bowel and bladder. Resident #7 was sitting in a chair and told the surveyor she had not gotten her [MEDICAL CONDITION] medication last night. She had checked with the nurse around 8:00 PM and was told it was not in yet but she would give it if it came in before she left at 10:00 PM. She stated the nurse left without giving it. The medication the resident missed one dose of was [MEDICATION NAME] (anticonvulsant). At approximately 3:00 PM, Resident #7 was observed lying on her back in the activity room with facility staff attending to her. It was reported she had a [MEDICAL CONDITION]. 3) The nurses ' notes dated 06/07/15 reflected that Resident #7 had a [MEDICAL CONDITION] at 1445 in the activity room and the [MEDICAL CONDITION] had lasted approximately three minutes. Resident #7 was observed on the floor lying on her back. The nurse documented that the [MEDICAL CONDITION] activity was over when the nurse arrived but the resident was agitated and confused and trying to get up from the floor. Resident #7 was transferred to a wheelchair and taken to her room and placed in bed. The physician was called and he ordered a CBC, CMP, Urinalysis and a [MEDICATION NAME] acid level and a new order for [MEDICATION NAME] 500 ng. extended release, one tablet orally twice a day for [MEDICAL CONDITION]. Review of the physician's order [REDACTED]. The MAR for the month of January 2015 reflected Resident #7 received the [MEDICATION NAME] ER, one tablet twice a day all days except for one day, 01/05/15. The MARs for February, March 2015 and through April 16, 2015 reflected Resident #7 received the [MEDICATION NAME] ER twice a day as ordered by the physician. Review of the neurologist ' s report dated 04/16/15 reflected Resident #7 had told him she felt drowsy in the morning after taking the morning [MEDICATION NAME]. The physician documented since the resident was drowsy in the morning after taking her medication he was making a change for her to take [MEDICATION NAME] ER, two tablets at bedtime. The nurses ' notes dated 04/16/15 reflected Resident #7 had returned from the physician ' s office with a new order for [MEDICATION NAME] ER 500 mg, two tablets every night at bedtime. Review of the physician orders [REDACTED]. On 04/17/15, the order for Resident #7 to receive the medication, two tablets each night at bedtime was discontinued. The MAR for the month of April 2015, reflected Resident #7 received [MEDICATION NAME] 500 mg, one tablet twice a day at 8:00 AM and 8:00 PM from 04/01/15 through 04/16/15. The MAR indicated [REDACTED]. The MARS dated for April 18 - April 5, May 01 through May 31, 2015 and June 01 through June 7, 2015 reflected that Resident#7 never received any of the physician-ordered [MEDICATION NAME] ER 500 mg at bedtime. This was a total of 51 days. The Medication Error Report dated 06/07/15 reflected that LVN B had made a transcription error for the [MEDICATION NAME] ER 500 mg. LVN B had ordered the medication to be given one time at bedtime and did not realize she had entered the medication order incorrectly. Review of the nurses ' notes from 04/17/15 through 06/10/15 reflected the following dates; Resident #7 had a witnessed [MEDICAL CONDITION]: 05/14/15 - At 10:15 AM, staff was calling for help in activity room. Resident #7 was sitting in a chair with her head leaning on the left side of the bookcase with her eyes closed. Visitors who had been present in the activity room stated Resident #7 was shaking her legs and that staff members reported jerking movements and that the resident was waking up and becoming more alert and responsive. Resident #7 told the staff she did not know what had happened. Resident #7 was taken back to her room and vital signs were taken and assessments made. The physician was notified and no new orders. 05/14/15 - 1:30 PM it was noted the van diver had stated Resident had a [MEDICAL CONDITION] while she was sitting in the van. The notes reflected the staff called the physician and he ordered an appointment to be made with her neurologist. The appointment was made for 04/16/15. 06/01/15 - The nurse was called to the activity room because Resident #7 was having a [MEDICAL CONDITION]. The resident was observed lying on her left side on the table still having jerking movements. The [MEDICAL CONDITION] was documented as lasing three minutes. Resident #7 was confused and unable to follow commands. Resident #7 was taken to her room and placed in bed. Vital signs were taken and the physician was called. Resident #7 stated she remembered playing bingo when the [MEDICAL CONDITION] started but not much after that. The nurses ' notes dated 06/07/15 reflected that Resident #7 had a [MEDICAL CONDITION] at 1445 in the activity room and the [MEDICAL CONDITION] had lasted approximately three minutes. Resident #7 was observed on the floor lying on her back. The nurse documented that the [MEDICAL CONDITION] activity was over when the nurse arrived but the resident was agitated and confused and trying to get up from the floor. Resident #7 was transferred to a wheelchair and taken to her room and placed in bed. The physician was called and he ordered a CBC. CMP, Urinalysis and a [MEDICATION NAME] acid level and a new order for [MEDICATION NAME] 500 ng. extended release, one tablet orally twice a day for [MEDICAL CONDITION]. At 9:30 AM on 06/08/15 an interview was conducted with Resident #7. She stated on Saturday night she did not get her evening dose he [MEDICAL CONDITION] medication, [MEDICATION NAME]. She did, however get both of her doses on Sunday. Resident #7 stated that a couple of weeks ago she started to have her [MEDICAL CONDITION] more frequently. She also stated that she did not get any auras before the [MEDICAL CONDITION] she would just have the [MEDICAL CONDITION]. At 11:40 AM on 06/10/15 an interview was conducted with ADON C who was also the Unit Manager of South Hall. She stated the new order for Resident #7 to get the [MEDICATION NAME], two tablets at bedtime was written on a Thursday night. She stated she was responsible for reviewing all new orders the next morning before she took them to their daily meetings. ADON C stated that she had been out sick on that Friday and did not get to check the new orders. She stated if she had been there on that Friday, when she reviewed the orders she would have noticed the error where the nurse put it in for one time only and accidentally checked the wrong box. Review of the 24-Hour Report dated 04/16/15 revealed on the evening shift, the LVN B documented Resident #7 had returned from doctor with a prescription of [MEDICATION NAME] 500 mg, 2 tablets q hour of sleep. Review of the [MEDICATION NAME] level which was drawn at 8:15 AM on 06/08/15 revealed Resident #7 ' s level was 1.3 ug/ml. The normal parameters for [MEDICATION NAME] were 50.0 - 100.0 ug/ml. At 10:45 AM an interview was conducted with the DON. She stated that Resident #7 had a [MEDICAL CONDITION] on Sunday and that was when they found out they had a problem with her [MEDICATION NAME]. She stated on 04/16/15 she had a new order to get two tablets of the [MEDICATION NAME] 500 mg ER to be given at bedtime. The nurse put in in the orders on 04/16/15 and then discontinued the order at the same time due to a glitch in the system. The DON stated they got a new order from the Physician and Resident #9 received it last night on 06/08/15. She stated they had QA ' d the issue, disciplined the nurse and in-service all nurses and did medication cart audits on all people who had [MEDICAL CONDITION] diagnoses. The DON stated with the electronic system they do not do an end-of- month checks on the orders because they are put in each day. At 2:45 PM on 06/10/15 an interview was conducted with LVN B. She stated that Resident #7 had been receiving [MEDICATION NAME] ER, one 500 mg tablet twice a day but when she came back on 04/16/15 from the doctor he had changed it to two 500 mg tablets at bedtime. She stated when she put the order in; she clicked on the wrong button and only ordered it for a one time dose. When she clicked on that button it automatically discontinued it after one dose. The medication aide was responsible for giving the medications to Resident #7. LVN B stated she had been there on Sunday when Resident #7 had her [MEDICAL CONDITION]. She stated she told the physician and told him she was surprised by the [MEDICAL CONDITION] because she was taking medications for it. When she went into check on her medications it was then she noticed she had not been taking the [MEDICATION NAME]. LVN B stated she was so surprised the resident had not been receiving the medication. According to <http://www.drugs.com>, accessed on 06/15/15, [MEDICATION NAME] is used to treat various types of [MEDICAL CONDITION] disorders . Do not stop using [MEDICATION NAME] suddenly, even if you feel fine. Stopping suddenly may cause a serious life-threatening type of [MEDICAL CONDITION]. Follow your doctor ' s instructions about tapering your dose. An IJ was identified on 06/09/15. The facility ' s Administration including the Administrator and DON was notified at 4:45 PM on 06/09/15 of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted at 1:30 PM on 06/10/15 and reflected the following: Immediate Jeopardy Plan of Removal Significant Med Error (Quality of Care); Administration, and Pharmacy Procedures June 10, 2015 The allegedly effected resident (Resident #7) was admitted on [DATE] with [DIAGNOSES REDACTED].> · other forms of [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION], without mention of intractable [MEDICAL CONDITION]; · [MEDICAL CONDITION], unspecified; · Anxiety, unspecified Resident #7 again had [MEDICAL CONDITION] on May 14,2015,while In the van, noted at 1:30pm;and the activity room, noted at 10:15pm,June 1,2015,and June 7,2015,as observed by the surveyor in the activity. Resident #7 had a physician order [REDACTED].#7 was seen by her Neurologist who wrote a new order changing her order to: [MEDICATION NAME] ER 500 mg 2 tabs by mouth daily at bedtime. The new order was entered into the resident medical record on April 16th as a one-time dose by LVN B, and subsequently signed by the attending physician on April 26th. Resident #7 received her one-time dose on April 17, 2015. Resident #7 missed 51 doses of [MEDICATION NAME] from April 18th, thru June 7th, 2015. The [MEDICATION NAME] medication error was discovered on Monday, June 8th when reviewing medication orders with the physician. New order was received and processed. LVN B received counseling on entering the [MEDICATION NAME] order incorrectly on June 9th by Unit Manager/ADON C. Resident #7 has also been treated with routine [MEDICATION NAME] 200 mg in the AM (since 5/22/13) and Vlmpat 300 mg in the PM (since 3/30/14). [MEDICATION NAME] is a prescription medicine that can be used alone or with other medicines to treat partial-onset [MEDICAL CONDITION] in people [AGE] years of age and older, per the manufacturer. The resident (Resident #7) wrote a grievance to facility staff on Sunday, June 7th that she missed her Saturday evening dose of [MEDICATION NAME]. Resident #7 missed the PM dose of [MEDICATION NAME] on June 7, 2015, due to alleged medication availability. The medication was delivered on June 7, at 10:42 PM. Medication Aide E was counseled for failing to reorder medication and/or reporting medication not available to the charge nurse on June 7th by ADON C/Unit Manager and Medication Aide F was also counseled for failing to reorder medication and/or reporting medication not available to the charge nurse on June 9th by ADON C/Unit Manager. Med Error reports were completed on the 1allegedly affected resident {Resident #7}, which includes physician notification. Completed by 5 pm 6/09/15. All residents with a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. On June 9, 2015 between 6pm and 8:00pm.The following residents were reviewed by Nurse Consultant D, LVN, Nurse Consultant, RN, Nurse Consultant: Resident #19, Resident 28, Resident # 29, Resident # 21,Resident #30, Resident #24, Resident #22, ,Resident #31, Resident #32, Resident #33, Resident #34, Resident #35, Resident #36, Resident #37, Resident # 38, Resident # 39, Resident #7, Resident #40, Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #9, Resident 46, Resident #47, Resident #48, Resident #49, and Resident #50. No resident has had an active [MEDICAL CONDITION] other than Resident #7 on Sunday, subject of this Plan of Removal. Any resident that has missed a dose of [MEDICAL CONDITION] medication since June 1st, the physician has been notified, Responsible Party notified and labs were drawn. Care Plans have been reviewed and updated as needed for residents on anti-[MEDICAL CONDITION] medications. Care Plans for residents: were updated by DON on June 9th, between 6:30PM and 9:00pm for the following residents: Resident # 19, Resident #28, Resident 29, Resident #21, Resident # 30, Resident #24, Resident #22, Resident #33, Resident #34, Resident #35, Resident #36, Resident #37, Resident #38, Resident #39, Resident #40, Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #9, Resident #47, Resident #48, Resident #49, and Resident #50. Medication Carts were audited for the availability of prescribed anti-[MEDICAL CONDITION] medication on June 9, 2015 between the hours of 5:30pm and 7:30pm. The audits were conducted by: DON, RN Educator G, ADON/LVN H and ADON/LVN X. Outcome of the audit was as follows: There were no missing medication. There was no need to contact the physician or pharmacy as a result. All anti-[MEDICAL CONDITION] medication has been moved to the nurses MAR for administration and monitoring. Licensed Nurses and Medication Aides have been re-educated on: · Physician orders [REDACTED]. · o Reordering of medications o Escalation process for missing medications In-servicing by RN Educator G began with the 2p-10p shift on June9, 2015 at 6:30pm-7:00pm on June 9, 2015, conducted the 10p-6a shift from 1O: OOpm to lO: 3Opm; and continued the training for 6a-2p shift on June 10, 2015 from 6:00am -6:30am., Administrator is responsible for ensuring all staff have received this in-service. All nurses and medication aides not in attendance will be re-educated prior to the start of their shift. Expected completion date June 11th. In addition, this training has been added to the orientation process for licensed nurses and medication aides presented by RN Educator G. Attachment 2 is the In-service sign in sheets, including who presented, content and posttest. Medication Cart audit began on May 7, 2015 and have continued: May 7th one eye drops OTC missing, replaced from stock May 19th no medications missing May 29th no medications missing June 2d no medications missing June 7th one triplicate needed for narcotic, triplicate received and ordered the same day. All of the above audits have been completed between the hours of 5am and 5pm. These will continue as Identified in the QA. This tool will be completed by the Unit Managers and submitted to the EDON/AOON upon completion each week and will be on-going. Any medication issues identified will be addressed immediately. All ordered medications will be confirmed it has arrived. Off cycle QA was held on June 9, 2015 at 6:30PM on the concerns identified and plans to address and correct identified issues. Medical Director was informed of the IJ and the plan to remove. All audits will be reviewed weekly at the Standards of Care meeting, and results followed up at the monthly QI/PI to address trends and/or irregularities. When a routine medication is due to be re-ordered the medication aide and/or the charge nurse will click on the Reorder button in LG. There is an interface with LG and Omnicare (the pharmacy) that automatically alerts the pharmacy the need to refill and send the medication. If the medication has been re-ordered too soon, the pharmacy will send the facility a message via LG to alert them the medication was not sent. Medications are delivered twice daily from the pharmacy. Stat medication are delivered with 4 hours. Medications ordered will be verified they arrived using the LG medication confirmation tracking. Medications not confirmed will be called to the pharmacy within two hours to confirm delivery time. If a stat medication does not arrive within the four hours, the ADON on call will be notified to contact the pharmacy. During Clinical Morning Meeting ,Unit Managers ADON, and EDON will review all new physician orders [REDACTED]. The weekend supervisor will complete said duties. EDON, RN, Nurse Consultant, and Executive Director are responsible for plan oversight and implementation. At 8:55 AM on 06/11/15 an interview was conducted with the Executive Director. She stated that since she and the DON had been in the building they have had an influx of state visits. When the State comes in we all stop everything and we all go out to take care of what the state surveyors need. The Executive Director stated that Friday (after the order was written on Thursday night) they were in a Stand-up Meeting and when the state surveyor came in to conduct an investigation, all the staff left the meeting. At that time she stated the facility was down three managers. ADON C who was the Unit Manager for the 100 Unit was out sick and the RN Educator was out and we did not have an ADON for the other units. This was just a Fluke. The Executive Director stated the Unit Managers were responsible for going over the 24-Hour Report and new orders each morning and for bringing the information to the Stand-Up Meeting where we all go over them. ADON C was out sick and we all left the meeting and did not go back to check on the orders. We have even had the weekend supervisor working the floor and she was not able to check on the orders or do the tasks she was supposed to check. A few weeks ago we stopped the weekend supervisor from working the floor and she is now responsible for checking all new orders, discontinued orders and the 24-Hour Report. The Executive Director stated that Resident #7 had been having [MEDICAL CONDITION] all along and was not [MEDICAL CONDITION] free even when her blood levels of the medication were within therapeutic levels. We have now implemented if we are in the Stand-Up meeting and the state surveyors come in the building, only I and the DON will go out initially to see what they need and then we will go back and finish the meeting. If the ADON/Unit Manager is out then RN Educator G or the Executive DON will be responsible for checking the new orders and 24-Hour Report. When asked about what training the staff was given on medication orders the Executive Director stated when new nurses and medication aides are hired, they receive orientation for the computer system regarding medications and documentation. She also stated if any staff is having trouble with the computer system, the RN Educator G is on duty Monday-Friday and is available for one-on-one training. At 3:17 PM on 06/10/15 an interview was conducted with the DON. When asked what caused the Immediate Jeopardy situation, she stated the nurse who input the order did not do it correctly. She stated when they talked with the nurse she told them she did not know what happened. She stated unit managers are responsible for checking all new orders the next morning but ADON C/Unit Manager was out sick on the next day, April 17, 2015. She stated on that day a State surveyor came in to conduct an investigation and the meeting was interrupted before they had time to go over the new orders. The nurses and medication aides receive training ion the use of the computer and on orders during orientation. RN Educator G does the in-service trainings. If we have any problems or issues which come up, she will do more training and then we will take it to the QA committee for review. She stated she would review it and then make an action plan. The DON stated now if the state enters the building she would leave the stand-up meeting and go see what they needed and the meeting would continue and address all business. Interviews were conducted on 06/11/15 between 9:45 AM and 5:00 PM with the following staff: ADON/LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, MA N, LVN O, LVN P, LVN Q, LVN R, LVN S, RN T, MA U, LVN V, LVN W, LVN X, LVN Y, LVN Z, LVN AA, LVN BB, LVN CC, LVN DD, LVN EE, LVN FF, MA GG, LVN HH, LVN II, LVN JJ, LVN KK, and MA LL . All nurses interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do if medications which had been re-ordered were not available, who to contact, how to put in new medications orders and where they were to document them and that the nurses were the only ones who could give anti-convulsive medications. All medication aides who were interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do if medications were not available and who they were to notify and that the nurses were the only ones who could give the anti-convulsive medications. On 06/11/15 at 4:19 PM, The Executive Director was notified the IJ was removed. While the IJ was removed on 06/11/15, the facility remained out of compliance at a severity level of Actual harm that is not an Immediate Jeopardy and a scope of pattern, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. A list provided by the facility on 06/09/15 reflected there were 29 residents in the facility with diagnoses, which included [MEDICAL CONDITION]. A list provided by the facility on 06/09/15 reflected there were four residents in the facility with orders for [MEDICATION NAME] medications. The CMS-672, Resident Census and Conditions of Residents, dated as completed on 06/07/15 by the DON reflected there were 177 residents

Based on interview and record review, it was determined the facility failed to ensure one (Resident #7) of 24 residents reviewed for medications was free of a significant medication error. 1. The facility failed to have an effective system in place to ensure physician-ordered medications were administered to Resident #7. The facility failed to administer a total of 51 daily doses of [MEDICATION NAME] Sodium ([MEDICATION NAME]) an anticonvulsant, from 04/18/15 through 06/07/15 as ordered by the physician. 2. LVN B failed to transcribe the physician's orders [REDACTED].#7 correctly. 3. The facility failed to have a physician-orderd medication, [MEDICATION NAME], available for Resident #7 and she missed one dose. These failures resulted in Resident #7 experiencing an increase in [MEDICAL CONDITION] activity. Resident #7 had a total of four [MEDICAL CONDITION] from 05/14/15 through 06/07/15. These failures had could affect the 29 residents who had [DIAGNOSES REDACTED].#7. In addition, these failures could result in an increase in [MEDICAL CONDITION] and the possibility of developing life-threatening [MEDICAL CONDITION] including death. On 06/09/15 at 4:45 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/11/15 at 4:19 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. Findings included: Review of Resident #7's quarterly MDS dated [DATE] revealed the resident was a [AGE] year-old female who had been admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION] and Recurrent [MEDICAL CONDITION]. Resident #7 was alert and oriented and was able to understand others and was understood by others. Review of Resident #7's the physician's orders [REDACTED]. The neurologist's report dated 04/16/15 reflected Resident #7 had told him she felt drowsy in the morning after taking the morning [MEDICATION NAME]. The physician documented since the resident was drowsy in the morning after taking her medication he was making a change for her to take [MEDICATION NAME] ER, two tablets at bedtime. The nurses' notes dated 04/16/15 reflected Resident #7 had returned from the physician's office with a new order for [MEDICATION NAME] ER 500 mg, two tablets every night at bedtime. The physician orders [REDACTED]. On 04/17/15, the order for Resident #7 to receive the medication, two tablets each night at bedtime was discontinued. Resident #7 April 2015, reflected the resident received [MEDICATION NAME] 500 mg, one tablet twice a day at 8:00 AM and 8:00 PM from 04/01/15 through 04/16/15. The MAR indicated [REDACTED]. The MAR(S) dated for 04/18/15 through 04/30/15 and 05/01/15 through 05/31/15 reflected that Resident#7 never received any of the physician-ordered [MEDICATION NAME] ER 500 mg at bedtime. (This was a total of 51 days.) Resident #7's nurses' notes dated 05/14/15 and timed at 10:15 AM reflected staff was calling for help in activity room. Resident #7 was sitting in a chair with her head leaning on the left side of the bookcase with her eyes closed. Visitors who had been present in the activity room stated Resident #7 was shaking her legs and that staff members reported jerking movements and that the resident was waking up and becoming more alert and responsive. Resident #7 told the staff she did not know what had happened. Resident #7 was taken back to her room and vital signs were taken and assessments made. The physician was notified and no new orders were received. Resident #7's nurses' notes dated 05/14/15 and timed at 1:30 PM reflected the van diver had stated Resident had a [MEDICAL CONDITION] while she was sitting in the van. The notes reflected the staff called the physician and he ordered another appointment to be made with her neurologist. (The appointment was scheduled for 04/16/15.) Resident #7's June 2015 MAR indicated [REDACTED]. Resident #7's nurses' notes dated 06/01/15 and entered into the computer at 9:02 PM, The nurse was called to the activity room because Resident #7 was having a [MEDICAL CONDITION]. The resident was observed lying on her left side on the table still having jerking movements. The [MEDICAL CONDITION] was documented as lasing three minutes. Resident #7 was confused and unable to follow commands. Resident #7 was taken to her room and placed in bed. Vital signs were taken and the physician was called. Resident #7 stated she remembered playing bingo when the [MEDICAL CONDITION] started but not much after that. An observation on 06/07/15 at 2:35 PM revealed Resident #7 was observed in her room. She was identified by staff, CNA A as being alert and oriented. Resident #7 was sitting in a chair and told the surveyor she had not gotten her [MEDICAL CONDITION] medication last night, (Saturday, 06/06/15). She had checked with the nurse around 8:00 PM and was told it was not in yet but she would give it if it came in before she left at 10:00 PM. She stated the nurse left without giving it. The medication the resident missed one dose of was [MEDICATION NAME] (anticonvulsant) An observation at approximately 3:00 PM on 06/07/15, Resident #7 was observed lying on her back in the activity room with facility staff attending to her. It was reported by staff that she had a [MEDICAL CONDITION]. (Staff called for help as Resident was having a [MEDICAL CONDITION]) The nurses' notes dated 06/07/15 reflected that Resident #7 had a [MEDICAL CONDITION] at 2:45 PM in the activity room and the [MEDICAL CONDITION] had lasted approximately three minutes. Resident #7 was observed on the floor lying on her back. The nurse documented that the [MEDICAL CONDITION] activity was over when the nurse arrived but the resident was agitated and confused and trying to get up from the floor. Resident #7 was transferred to a wheelchair and taken to her room and placed in bed. The physician was called and he ordered a CBC, CMP, Urinalysis and a [MEDICATION NAME] acid level and a new order for [MEDICATION NAME] 500 mg. extended release, one tablet orally twice a day for [MEDICAL CONDITION]. At 2:45 PM on 06/10/15 an interview was conducted with LVN B revealed Resident #7 had been receiving [MEDICATION NAME] ER, one 500 mg tablet twice a day but when she came back on 04/16/15 from the doctor he had changed it to two 500 mg tablets at bedtime. She stated when she put the order in; she clicked on the wrong button and only ordered it for a one time dose. When she clicked on that button it automatically discontinued it after one dose. LVN B stated she had been there on 06/07/15 when Resident #7 had her [MEDICAL CONDITION]. She stated she told the physician and told him she was surprised by the [MEDICAL CONDITION] because she was taking medications for it. When she went into check on her medications it was then she noticed she had not been taking the [MEDICATION NAME]. LVN B stated she was so surprised the resident had not been receiving the medication. At 11:40 AM on 06/10/15 an interview was conducted with ADON C who was also the Unit Manager of South Hall. She stated the new order for Resident #7 to get the [MEDICATION NAME], two tablets at bedtime was written on a Thursday night. She stated she was responsible for reviewing all new orders the next morning before she took them to their daily meetings. ADON C stated that she had been out sick on that Friday and did not get to check the new orders. She stated if she had been there on that Friday, when she reviewed the orders she would have noticed the error where the nurse put it in for one time only and accidentally checked the wrong box. At 10:45 AM on 06/09/15 an interview was conducted with the DON. She stated that Resident #7 had a [MEDICAL CONDITION] on Sunday and that was when they found out they had a problem with her [MEDICATION NAME]. She stated on 04/16/15 she had a new order to get two tablets of the [MEDICATION NAME] 500 mg ER to be given at bedtime. The nurse put in in the orders on 04/16/15 and then discontinued the order at the same time due to a glitch in the system. The DON stated they got a new order from the Physician and Resident #9 received it last night on 06/08/15. She stated they had QA'd the issue, disciplined the nurse and in-service all nurses and did medication cart audits on all residents who had [MEDICAL CONDITION] diagnoses. The DON stated with the electronic system they do not do an end-of- month checks on the orders because they are put in each day. At 9:30 AM on 06/08/15 an interview with Resident #7. She revealed on Saturday night she did not get her evening dose he [MEDICAL CONDITION] medication ( [MEDICATION NAME]). She did, however get both of her doses on Sunday. Resident #7 stated that a couple of weeks ago she started to have her [MEDICAL CONDITION] more frequently. She also stated that she did not get any auras before the [MEDICAL CONDITION] she would just have the [MEDICAL CONDITION]. The Medication Error Report dated 06/07/15 reflected that LVN B had made a transcription error for the [MEDICATION NAME] ER 500 mg. LVN B had ordered the medication to be given one time at bedtime and did not realize she had entered the medication order incorrectly. Review of the [MEDICATION NAME] level which was drawn at 8:15 AM on 06/08/15 revealed Resident #7's level was 1.3 ug/ml. The normal parameters for [MEDICATION NAME] were 50.0 - 100.0 ug/ml. This level was below the normal parameters but not considered critical. According to <http://www.drugs.com>, accessed on 06/15/15, [MEDICATION NAME] is used to treat various types of [MEDICAL CONDITION] disorders .Do not stop using [MEDICATION NAME] suddenly, even if you feel fine. Stopping suddenly may cause a serious life-threatening type of [MEDICAL CONDITION]. Follow your doctor ' s instructions about tapering your dose. An IJ was identified on 06/09/15. The facility's Executive Director, Administrator and DON was notified at 4:45 PM on 06/09/15 of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted at 1:30 PM on 06/10/15 and reflected the following: Immediate Jeopardy Plan of Removal Significant Med Error (Quality of Care); Administration, and Pharmacy Procedures June 10, 2015 The allegedly effected resident (Resident #7) was admitted on [DATE] with [DIAGNOSES REDACTED].>· other forms of [MEDICAL CONDITION] and recurrent [MEDICAL CONDITION], without mention of intractable [MEDICAL CONDITION]; · [MEDICAL CONDITION], unspecified; · Anxiety, unspecified Resident #7 again had [MEDICAL CONDITION] on May 14,2015,while In the van, noted at 1:30pm;and the activity room, noted at 10:15pm, June 1, 2015,and June 7 ,2015,as observed by the surveyor in the activity. Resident #7 had a physician order [REDACTED].#7 was seen by her Neurologist who wrote a new order changing her order to: [MEDICATION NAME] ER 500 mg 2 tabs by mouth daily at bedtime. The new order was entered into the resident medical record on April 16th as a one-time dose by LVN B, and subsequently signed by the attending physician on April 26th. Resident #7 received her one-time dose on April 17, 2015. Resident #7 missed 51 doses of [MEDICATION NAME] from April 18th, thru June 7th, 2015. The [MEDICATION NAME] medication error was discovered on Monday, June 8th when reviewing medication orders with the physician. New order was received and processed. LVN B received counseling on entering the [MEDICATION NAME] order incorrectly on June 9th by Unit Manager/ADON C. Resident #7 has also been treated with routine [MEDICATION NAME] 200 mg in the AM (since 5/22/13) and Vlmpat 300 mg in the PM (since 3/30/14). [MEDICATION NAME] is a prescription medicine that can be used alone or with other medicines to treat partial-onset [MEDICAL CONDITION] in people [AGE] years of age and older, per the manufacturer. The resident (Resident #7) wrote a grievance to facility staff on Sunday, June 7th that she missed her Saturday evening dose of [MEDICATION NAME]. Resident #7 missed the PM dose of [MEDICATION NAME] on June 7, 2015, due to alleged medication availability. The medication was delivered on June 7, at 10:42 PM. Medication Aide E was counseled for failing to reorder medication and/or reporting medication not available to the charge nurse on June 7th by ADON C/Unit Manager and Medication Aide F was also counseled for failing to reorder medication and/or reporting medication not available to the charge nurse on June 9th by ADON C/Unit Manager. Med Error reports were completed on the 1 allegedly affected resident {Resident #7}, which includes physician notification. Completed by 5 pm 6/09/15. All residents with a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. On June 9, 2015 between 6pm and 8:00pm.The following residents were reviewed by Nurse Consultant D, LVN, Nurse Consultant, RN, Nurse Consultant: Resident #19, Resident 28, Resident # 29, Resident # 21,Resident #30, Resident #24, Resident #22, ,Resident #31, Resident #32, Resident #33, Resident #34, Resident #35, Resident #36, Resident #37, Resident # 38, Resident # 39, Resident #7, Resident #40, Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #9, Resident 46, Resident #47, Resident #48, Resident #49, and Resident #50. No resident has had an active [MEDICAL CONDITION] other than Resident #7 on Sunday, subject of this Plan of Removal. Any resident that has missed a dose of [MEDICAL CONDITION] medication since June 1st, the physician has been notified, Responsible Party notified and labs were drawn. Care Plans have been reviewed and updated as needed for residents on anti-[MEDICAL CONDITION] medications. Care Plans for residents: were updated by DON on June 9th, between 6:30PM and 9:00pm for the following residents: Resident # 19, Resident #28, Resident 29, Resident #21, Resident # 30, Resident #24, Resident #22, Resident #33, Resident #34, Resident #35, Resident #36, Resident #37, Resident #38, Resident #39, Resident #40, Resident #41, Resident #42, Resident #43, Resident #44, Resident #45, Resident #9, Resident #47, Resident #48, Resident #49, and Resident #50. Medication Carts were audited for the availability of prescribed anti-[MEDICAL CONDITION] medication on June 9, 2015 between the hours of 5:30pm and 7:30pm. The audits were conducted by: DON, RN Educator G, ADON/LVN H, ADON/LVNC, LVN I and LVN X. Outcome of the audit was as follows: There were no misssing medication. There was no need to contact the physician or pharmacy as a result. All anti-[MEDICAL CONDITION] medication has been moved to the nurses MAR for administration and monitoring. Licensed Nurses and Nedicatiion Aides have been re-educated on: Physician orders [REDACTED].>Reordering of medications Escalation process for missing medications. In-servicing, RN Educator G began with the 2p-10p shift on June 9.2015 at 6:30 pm-7:00pm on June 9, 2015., conducted the 10p-6a shift from 10:00pm to 10:30pm; and continued the training for 6a-2p shift on June 10, 2015 from 6:00am - 6:30am, Administrator is responsible for ensuring all staff have received this in-service. All nurses and medication aides not in attendance will be re-educated prior to the start of their shift. Expected completion date June 11th. In addition, this training has been added to the orientation process for licensed nurses and medication aides presented by RN Educator G. Attachment 2 is the In-service sign in sheets, including who presented, content and posttest. Medication Cart audit began on May 7,2015 and have continued: May 7th one eye drops OTC missing, replaced from stock May 19th no medications missing May 29th no medications missing June 2d no medications missing June 7th one triplicate needed for narcotic, triplicate received and ordered the same day. All of the above audits have been completed between the hours of 5am and 5pm. These will continue as Identified in the QA. This tool will be completed by the Unit Managers and submitted to the EDON/AOON upon completion each week and will be on-going. Any medication issues identified will be addressed immediately. All ordered medications will be confirmed it has arrived. Off cycle QA was held on June 9, 2015 at 6:30PM on the concerns identified and plans to address and correct identified issues. Medical Director was informed of the IJ and the plan to remove. All audits will be reviewed weekly at the Standards of Care meeting, and results followed up at the monthly QI/PI to address trends and/or irregularities. When a routine medication is due to be re-ordered the medication aide and/or the charge nurse will click on the Reorder button in LG. There is an interface with LG and Omnicare (the pharmacy) that automatically alerts the pharmacy the need to refill and send the medication. If the medication has been re-ordered too soon, the pharmacy will send the facility a message via LG to alert them the medication was not sent. Medications are delivered twice daily from the pharmacy. Stat medication are delivered with 4 hours. Medications ordered will be verified they arrived using the LG medication confirmation tracking. Medications not confirmed will be called to the pharmacy within two hours to confirm delivery time. If a stat medication does not arrive within the four hours, the ADON on call will be notified to contact the pharmacy. During Clinical Morning Meeting ,Unit Managers ADON, and EDON will review all new physician orders [REDACTED]. The weekend supervisor will complete said duties. EDON, RN, Nurse Consultant, and Executive Director are responsible for plan oversight and implementation. At 8:55 AM on 06/11/15 an interview with the Executive Director revealed that since she and the DON had been in the building they have had an influx of state visits. When the State comes in we all stop everything and we all go out to take care of what the state surveyors need.At 8:55 AM on 06/11/15 an interview was conducted with the Executive Director. She stated that since she and the DON had been in the building they have had an influx of state visits. When the State comes in we all stop everything and we all go out to take care of what the state surveyors need. The Executive Director stated that Friday ( after the order was written on Thursday night) they were in a Stand-up Meeting and when the state surveyor came in to conduct an investigation, all the staff left the meeting. At that time she stated the facility was down three managers. ADON C who was the Unit Manager for the 100 Unit was out sick and the RN Educator was out and we did not have an ADON for the other units. This was just a Fluke. The Executive Director stated the Unit Managers were responsible for going over the 24-Hour Report and new orders each morning and for bringing the information to the Stand-Up Meeting where we all go over them. ADON C was out sick and they all left the meeting and did not go back to check on the orders. We have even had the weekend supervisor working the floor and she was not able to check on the orders or do the tasks she was supposed to check. A few weeks ago we stopped the weekend supervisor from working the floor and she is now responsible for checking all new orders, discontinued orders and the 24-Hour Report. The Executive Director stated that Resident #7 had been having [MEDICAL CONDITION] all along and was not [MEDICAL CONDITION] free even when her blood levels of the medication were within therapeutic levels. She stated they had now implemented if they are in the Stand-Up meeting and the state surveyors come in the building, only she and the DON will go out initially to see what they need and then we would go back and finish the meeting. If the ADON/Unit Manager is out then RN Educator G or the Executive DON will be responsible for checking the new orders and 24-Hour Report. When asked about what training the staff was given on medication orders the Executive Director stated when new nurses and medication aides are hired, they receive orientation for the computer system regarding medications and documentation. She also stated if any staff is having trouble with the computer system, the RN Educator G is on duty Monday-Friday and is available for one-on-one training. At 3:17 PM on 06/10/15 an interview was conducted with the DON revealed when asked what caused the Immediate Jeopardy situation, she stated the nurse who input the order did not do it correctly. She stated when they talked with the nurse she told them she did not know what happened. The DON stated unit managers are responsible for checking all new orders the next morning but ADON C/Unit Manager was out sick on the next day, April 17, 2015. She stated on that day a State surveyor came in to conduct an investigation and the meeting was interrupted before they had time to go over the new orders. The DON stated the nurses and medication aides receive training ion the use of the computer and on orders during orientation. RN Educator G does the in-service trainings. If they have any problems or issues which come up, she will do more training and then they will take it to the QA committee for review. She stated she would review it and then make an action plan. The DON stated now if the state enters the building she would leave the stand-up meeting and go see what they needed and the meeting would continue and address all business. Interviews were conducted on 06/11/15 between 9:45 AM and 5:00 PM with the following staff: ADON/LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, MA N, LVN O, LVN P, LVN Q, LVN R, LVN S, RN T, MA U, LVN V, LVN W, LVN X, LVN Y, LVN Z, LVN AA, LVN BB, LVN CC, LVN DD, LVN EE, LVN FF, MA GG, LVN HH, LVN II, LVN JJ, LVN KK, and MA LL . All nurses interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do if medications which had been re-ordered were not available, who to contact, how to put in new medications orders and where they were to document them and that the nurses were the only ones who could give anti-convulsive medications. All medication aides who were interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do if medications were not available and who they were to notify and that the nurses were the only ones who could give the anti-convulsive medications. On 06/11/15 at 4:19 PM, The Executive Director was notified the IJ was removed. While the IJ was removed on 06/11/15, the facility remained out of compliance at a severity level of Actual harm that is not an Immediate Jeopardy and a scope of pattern, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. A list provided by the facility on 06/09/15 reflected there were 29 residents in the facility who had diagnoses, which included [MEDICAL CONDITION]. A list provided by the facility on 06/09/15 reflected there were four residents in the facility who had orders for [MEDICATION NAME] medications. :

Surveyor: Oboyle, Sharon Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for one (Resident #14) of four residents reviewed for pressure ulcers. 1. The facility failed to follow the care plan to prevent Resident #14, who was at high risk for developing pressure ulcers, from developing an unstageable pressure ulcer to the Right Ankle. 2. The facility staff failed to address proper cushioning devices to prevent bone on bone pressure resulting from Resident #14's scissoring (crossing one leg over the other)and favoring of the right side. 3. The facility failed to ensure the physician was notified and a treatment order obtained when Resident #14's right ankle pressure ulcer was first observed. On 04/10/15, Resident #14 was found with a pressure ulcer to his Right lateral ankle. The physician was not notified and the site went untreated until four days later (04/14/15), when the wound care nurse, LVN QQ, contacted the Wound Care MD for orders. LVN QQ stated the site looked the same on 04/14/15 as it did on 04/17/15, when the Wound Care MD evaluated Resident #14's right lateral ankle and diagnosed the site as an unstageable pressure ulcer. These failure could place the the 110 residents who were bedfast or in a chair all or most of the time; the 62 residents with contractures, and the 11 residents in the facility with existing pressure ulcers, including Resident #14, at risk for the development of new sites due to the lack of assessment, delayed notification of the physician for a change of condition and treatment orders, delayed healing, and infection. Findings included: 1. A review of Resident #14's 08/03/14 MDS assessment revealed he was an eighty-year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment also reflected Resident #14 had severely impaired skills for daily decision making, was rarely understood, and rarely understood others, had difficulty focusing attention, disorganized thinking, and unclear speech. He was totally dependent on the physical assistance of one staff member for bathing; extensively dependent on the physical assistance of two staff members for bed mobility, transferring, toilet use, and bathing; and required extensive assistance with the physical assistance of one staff member for locomotion, dressing and hygiene, and eating. He was at risk for pressure ulcers but did not have any at the time. He also had lower extremity range of motion limitations. Resident #14 declined between the 08/03/14 MDS assessment and the 05/04/15 MDS assessment when he was assessed to now be totally dependent on the physical assistance of two staff members for bed mobility, transfers, and bathing; totally dependent on the physical assistance of one staff member for locomotion, dressing, and eating. He now had an unstageable pressure ulcer which measured 0.8 by 0.8 centimeters. 2. A review of Resident #14's care plan revealed it only had goals and interventions since 04/14/15 forward. This care plan had a care area problem of an unstageable pressure ulcer to the right lateral ankle. The interventions, which included the treatment for [REDACTED]. On 06/10/15 at 9:45 AM, MDS Coordinator RR was asked and provided , a care plan for Resident #14 which reflected issues before 05/13/15. MDS Coordinator RR stated the care plan covered the issues from 08/01/14 forward. This care plan reflected Resident #14 had limitations in range of motion. An intervention for this problem dated 11/28/14 reflected staff were to assess contracted area/areas with decreased range of motion for evidence of skin breakdown and report significant changes to the physician. Another intervention for this issue was to use devices, appliances splints, or positioning pillows as indicated. The care plan also addressed a problem of skin breakdown risk due to fragile skin. The interventions for this problem included to apply a protective or barrier lotion after incontinence, assist resident to turn and reposition frequently, keep skin clean, dry, and free of irritants, keep nails short, inspect skin daily with care and bathing, and report any changes to charge nurse, change incontinent pad as soon as possible after voiding or bowel movement, increase out of bed activity as tolerated, inspect skin completely from head to toe weekly and document results, keep skin clean and dry, and maintain adequate nutrition and hydration. 3. Resident # 14 was observed during the initial tour with LVN FF on 06/07/15 at 2:35 PM. LVN FF stated Resident #14 had a pressure ulcer on his right ankle, was incontinent of bowel and bladder, required one to two staff for activities of daily living, had no limitations with range of motion, and was alert only to his name. 4. On 06/08/15 at 9:38 AM, LVN QQ was observed during treatment to Resident #14's right ankle. Resident #14 was up in a wheelchair and had on large foam protectors to both legs which extended from mid-shin and encompassed his entire foot. He was observed to cross his right leg from below the knee, over and on top of his left leg, which resulted in direct pressure to the right ankle. LVN QQ stated the pressure ulcer developed on 04/14/15 and the Wound Care MD first saw it on 04/17/15 and stated it was unstageable. The right ankle pressure ulcer was surrounded by approximately once centimeter of red tissue. The ulcer was approximately 0.5 centimeters by 0.6 centimeters, oval in shape. Approximately half of the wound was covered with yellow necrotic (dead) tissue. 5. Review of Resident #14's nursing notes revealed that the pressure ulcer to the right ankle developed on 04/10/15, not on 04/14/15: 04/10/2015: Skin care assessment and observed reddened, slightly open dime size area to right outer ankle. Placed pillow under right ankle and continue to turned (sp) and reposition resident q (every) 2 houirs (sp). Resident's wife and unit manager notified. This entry was made by LVN FF at 8:46 PM. 6. The very next entry in the nursing notes was made on 04/14/2015 by LVN QQ, the wound care nurse, at 4:13 PM: Tx (treatment) nurse assessed resident noted with non-blanchable red open area to right ankle 2 X 2.5 X 1 cm (centimeter). Area cleansed with n/s (normal saline), pat dry, applied Collagen and covered with dry dressing. Resident wincing in pain when dressing. Nurse notfied (sp) to give him prn (as needed) pain meds (medication) as ordered. Notified MD. Dr. ____ (wound care MD) notified. Family present at facility and aware. Another entry was made by LVN QQ on the same day, at 4:14 PM: measurement clarification of above note. Right ankle wound 2 X 2.5 X 0.1 cm. 7. The wound care physician's 04/17/15 initial evaluation of Resident #14 was reviewed and revealed Resident #14 had an unstageable wound, to the right lateral ankle. The etiology (cause) of the ulcer was documented as Pressure. The wound was 0.5 X 0.7 centimeters but the depth was not measurable due to the, 100% of thick adherent devitalized necrotic (dead) tissue. The evaluation also reflected there was, no relevant family history identified which includes a negative family history for immunosuppressive conditions, collagen-vascular disease or bleeding disorders. The most current wound care physician's note dated 06/08/15, reflected the wound was, 0.5 X 0.5 centimeters but the depth could not be measured as there was still devitalized necrotic tissue present over 50% of the ulcer. 8. LVN FF was interviewed on 06/09/15 at 1:54 PM and stated she found the area on Resident #14's right ankle. LVN FF stated the skin was barely open but she called the responsible party and informed LVN X. LVN FF stated she tried calling the physician but did not get a call back. LVN FF stated she therefore followed the standing orders for pressure ulcers and cleansed it with normal saline and covered it with a dry dressing. LVN FF could not recall if she informed the next shift of Resident #14's ankle. LVN FF stated she got busy and forgot to try and call the physician again. LVN FF stated she was counseled by the treatment nurse, who instructed her on what to do when she found a pressure ulcer. LVN FF stated she did not have anything to pad his feet so she elevated his right foot with a pillow. LVN FF stated it was not until the site developed that the facility started padding his feet with the foam protectors currently in place. 9. The Unit Manager, LVN X, was interviewed on 06/09/15 at 1:28 PM. LVN X stated LVN FF did inform her about Resident #14's ankle. LVN X stated LVN FF said she had cleaned it with normal saline and applied a dry dressing. LVN X stated LVN FF failed to call the physician for treatment orders and that it was not until the treatment nurse observed it on 04/14/15, that the physician was contacted and a treatment order obtained. LVN X stated LVN FF was counseled and inservices were held to make sure nurses understood procedures when a new pressure ulcer was discovered. 10. Nurse Consultant D was asked to provide the standing orders for a pressure ulcer on 06/09/15 at 2:24 PM. On 06/10/15 at 5:46 PM, the DON stated there were no standing orders for pressure ulcers. The DON stated there was however, a standing order for skin tears, and that is what LVN FF used when treating Resident #14's ankle. The DON provided Resident #14's attending physician's standing orders and there were no standing orders for pressure ulcers. 11. A review of the staffing schedule for April 2015 revealed LVN FF worked the 2 PM to 10 PM shift on the unit where Resident #14 resided on 04/10/15, 04/11/15, 04/12/15; and 04/14/15. 12. LVN FF was interviewed again on 06/10/15 at 2:36 PM regarding her actions on 04/11/15, 04/12/14, and 04/14/15. She stated she could not recall if she tried calling the doctor more than once on 04/10/15 or on the following days to try and get treatment orders for Resident #14's ankle. LVN FF stated she also could not recall if she if she treated Resident #14's ankle other than the day she found it on 04/10/15. LVN FF stated she also could not recall if she informed the oncoming 10 PM to 6 AM shift nurse, LVN DD, of Resident #14's ankle on 04/10/15. LVN FF stated, I think I would put it in the notes or E-TAR (electronic treatment sheet) if I did, but I can't remember. LVN FF also stated if she told the oncoming nurse it would probably be on the 24-hour report. 13. A review of Resident #14's April 2015 treatment record revealed his ankle was only treated once with normal saline and a dry dressing, on 04/10/15. The record also reflected 04/14/15 was the next time it was treated by LVN QQ with normal saline, collagen and a foam dressing. 14. A review of the 24-Hour report for April 10th through the 14th of 2015 was conducted with LVN UU, the Clinical Information Technology Educator: On 04/10/15, the report reflected Resident #14 was stable. No other documentation was on the report about Resident #14's ankle until 04/12/15, when LVN FF documented he had a pressure ulcer to the right outer ankle. 15. LVN DD was interviewed on 06/10/15 at 11:44 AM and stated she was the on-coming nurse for the 10 PM to 6 AM shift on 04/10/15. LVN DD stated she was not told about Resident #14's right ankle ulcer when she came on duty that night. LVN DD stated LVN FF was really good about sharing important information but did not recall being told about the ankle pressure ulcer. 16. CNA SS and CNA TT were interviewed on 06/10/15 at 10:49 AM. Both CNAs stated they worked with Resident #14 and that the current foam boots in place were put there after Resident #14 developed the pressure ulcer. Both stated they had not used anything on his feet before then except pillows to elevate his feet when in bed. Both stated Resident #14 crossed his legs all the time. 17. CNA VV was interviewed on 06/10/15 at 2:41 PM and stated she recalled Resident #14's ankle sore because she found it and notified LVN FF. CNA VV stated it was just opened some and there was no blood. CNA VV stated LVN FF assessed the site and put a dressing on Resident #14's ankle. CNA VV stated Resident #14 did not have foam protectors on and that his feet were elevated by a pillow. CNA VV stated she thought Resident #14's ankle opened up because he crossed his right leg over his left leg often. Also, CNA VV stated Resident #14 would pull himself over often onto his right side. CNA VV added, shortly after Resident #14's ankle opened up, he was put in the, big blue boots. 18. CNA WW was interviewed on 06/10/15 at 2:49 PM and stated she was helping CNA VV when Resident #14's pressure ulcer on the ankle was found. CNA WW stated LVN FF took care of it and it was just a bright red area with no blood. CNA WW stated Resident #14 did not have on boots before the pressure ulcer was discovered. 19. LVN QQ, the wound care nurse was interviewed on 06/10/15 at 10:01 AM. LVN QQ stated she worked on 04/13/15 but was not aware of the pressure ulcer until 04/14/15. LVN QQ stated she did not recall the specifics on how she became aware of the pressure ulcer but thought one of the nurses told her Resident #14 had a dressing to the right ankle. LVN QQ stated she went and assessed Resident #14 on 04/14/15, and the dressing to the right ankle looked as though it had been there a while. LVN QQ stated she did not stage pressure ulcers but described them in her notes. LVN QQ stated she called the wound care MD and obtained orders. LVN QQ stated the wound care MD came on 04/17/15, and the site looked as it did on 04/14/15. LVN QQ stated the wound care MD said it was unstageable because the necrotic tissue covered up the wound. 20. The facility's Practice Guidelines for Prevention and Management of Pressure Ulcers dated April 2012, were reviewed. Movement or Management of Tissue Load .Staff should use pressure redistributing surfaces (mattresses, wheelchair cushions etc.) to decrease ischemia (insufficient blood flow) of bony prominences. III. Principles for Managing and Treating Pressure Ulcers: Immediate Treatment/Data collection: Once a resident/patient experiences a pressure ulcer, Data Collections should take place immediately that determines the severity of injury and to determine treatment interventions necessary. Once the Data Collection has been completed, the primary care provider and family must be notified of the pressure ulcer. 21. The facility took the following action to correct the non-compliance: Once Resident #20's pressure ulcer was assessed on 04/14/15, by the treatment nurse, LVN QQ, immediate action was taken. She notified Resident #14's attending physician and the facility wound MD who ordered a treatment. In addition, the wound MD went to the facility on [DATE] and initially evaluated Resident #14. On 04/16/15, LVN QQ spoke with Resident #14's attending physician and obtained an order for [REDACTED]. On 04/16/15, LVN I referred Resident #14 to the Registered Dietitian and requested Resident #14 have a [MEDICATION NAME] drawn and Pro-Stat, a calorie and protein supplement. LVN FF was counseled by the treatment nurse and Unit Manager, LVN X on 04/14/15. LVN X stated nurses were inserviced to make sure they understood the importance of contacting the physician with a change of condition and to obtain treatment orders if necessary. In discussing pressure ulcers with the following staff, it was determined the facility staff nurses understood what to do with a change of condition: LVN II (6 AM to 2 PM shift)on 06/10/15 at 10:41 AM; LVN DD (10 PM to 6 AM shift) on 06/10/15 at 11:44 AM; LVN JJ (6 AM to 2 PM shift) on 06/10/15 at 11:50 AM; LVN FF (2 PM to 10 PM shift) on 06/09/15 at 1:54 PM. In addition, three other residents with pressure ulcers(Residents #18, #20, and #23) were also reviewed and there were no concerns regarding their care. 21. The Form CMS-672, Resident Census and Conditions of Residents, signed a dated by the DON on 06/07/15, revealed there were three bedfast and 107 chair-fast residents; 62 residents with contractures; and eleven residents with pressure ulcers.

Based on interview and record review, it was determined the facility failed to implement its policies and procedures that prohibit neglect for one (Resident #1) of 10 residents reviewed for sliding scale insulin coverage. 1) LVN D failed to administer [MEDICATION NAME] as ordered and contact Resident #1's physician when the resident's blood sugar results were 47 on 01/17/14, 44 on 01/18/14, 34 on 01/28/14 and 34 on 01/29/14. 2) LVN B failed to administer [MEDICATION NAME] as ordered and contact Resident #1's physician when the resident's blood sugar result was 52 on 01/11/14. 3) LVN B failed to notify the physician when Resident #1's blood sugar results were 451 - 500, and administered insulin to the resident without a physician's order on "multiple" occasions. Resident #1 was transferred to the emergency roiagnom on [DATE] due to a low blood sugar result for further evaluation and treatment. An Immediate Jeopardy (IJ) was identified on 02/13/14. While the IJ was removed on 02/16/14, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the other 32 residents, who were ordered sliding scale insulin coverage and/or blood sugar monitoring, by placing them at risk of [MEDICAL CONDITION] or Hypoglycemic episodes to include coma, shock and even death. Findings included: A review of the ROA, dated 02/14/14 at 10:25 AM, for Resident #1 revealed she was admitted on [DATE] and was 90-years-old. A review of the MDS assessment for Resident #1, dated 01/24/13, revealed Resident #1 had adequate hearing, clear speech, she had the ability to express ideas and wants and was understood and she had the ability to understand. Resident #1 required limited assistance of one for mobility and transfers, dressing, and personal hygiene. Resident #1 normally used a wheelchair for mobility. [DIAGNOSES REDACTED]. A Care Plan, dated 10/25/13 and reviewed 01/28/14 for Resident #1, revealed she was diabetic and the goal was for Resident #1 to remain stable as evidenced by the blood sugar staying within the resident's normal limits over the next 90 days. The approaches included the monitoring of labs and reporting abnormal labs to the physician. During an interview with UM C on 02/12/14 at 3:00 PM, the surveyor requested a copy of the January 2014 Physician's Orders and MARS for Resident #1. A review of Resident #1's January 2014 Physician's Orders, identified by UM C, as the orders for January 2014, revealed an order, with a start date of 10/06/13, which reflected [MEDICATION NAME] 1 mg (used in the management of low blood sugar), to be administered if the blood sugar was less than 60. These same orders also included the following insulin orders: [MEDICATION NAME] 70/30 100 units/ml 4 solution SQ one time per day and [MEDICATION NAME] 70/30/ 100 units/ml 5 units SQ two times per day. A review of the MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of the January 2014 Physician's Orders for Resident #1 revealed an order, with a start date of 10/15/13, which reflected sliding scale insulin coverage: [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's Nurse's Notes, dated 01/07/14, did not reflect any entries regarding her blood sugar result of 565 or an assessment by the nurse to determine if Resident #1 had any signs or symptoms of [MEDICAL CONDITION] (high blood sugar) or whether the physician was notified of the blood sugar of 565. Based on this sliding scale insulin order for January 2014, the attending physician of Resident #1 should have been notified for further orders. A review of Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of Resident #1's Nurse's Notes for 01/11/14 did not reveal an entry that addressed her high blood sugar of 590. The Notes also did not reflect the physician was notified as ordered. Based on the January 2014 Physician's Orders for sliding scale insulin, the attending physician should have been notified for further orders. Further review of this same MAR for Resident #1 revealed a documented blood sugar result of 52 at 5:00 PM on 01/11/14. A review of Resident #1's Nurse's Notes, dated 01/11/14, did not reveal any documentation regarding a nursing assessment or action taken when her blood sugar was 52. The Notes did not reflect the physician was notified of her low blood sugar of 52. The Notes also did not reflect [MEDICATION NAME] was administered per the January 2014 Physician's Orders. The Medication Error Report, dated 02/12/14 after surveyor intervention, reflected LVN B was the nurse on duty on 01/11/14 when Resident #1's blood sugar result was 52. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/17/14 and documented by LVN B, reflected at 6:30 AM her blood sugar measured high on the glucometer and 10 units [MEDICATION NAME] R insulin and 5 units NPH were administered. The Notes reflected, "...Pushed H2O (water). Patient peaceful, BP 139/74 HR 95. No complaints of pain. Resident lying in bed sleeping." The Notes did not reflect the physician was notified of the resident's high blood sugar of 500. (Note: Resident #1's January 2014 Physician's Orders reflected to contact the physician when the blood sugar was between 451 - 500.) Resident #1's January 2014 Physician's Orders did not reflect an order for [REDACTED]. An interview was conducted with LVN B on 02/12/14 at 1:38 PM. When asked if there was a reason she gave Resident #1 regular insulin 10 units without a physician's order on 01/17/14 at 6:30 AM when the blood sugar level for Resident #1 measured 500, she replied she was instructed by UM C to give the maximum insulin dose of what was listed on the MAR for Resident #1. She said she had asked other nurses also, and they told her the same thing, and then instructed her to re-check the blood sugar. LVN B was unable to provide the names of the other nurses who had given her that directive. When asked if there was a reason she had not contacted the physician when she obtained the blood sugar of 500 on 01/17/14 at 6:30 AM, LVN B replied she had attempted in the past to contact the NP and her calls were never returned, so after two or three times, she just stopped trying to contact the NP. LVN B was asked if she informed UM C or the DON that she had difficulty getting the NP to return a phone call, and she said she did not report the problem. LVN B asked, "What's the right way?" She stated she wanted to learn. LVN B revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. An interview with UM C on 02/15/14 at 10:33 AM revealed she did not tell LVN B to give the insulin without physician's orders. She stated once LVN B called her about a high blood sugar and she (UM C) asked the LVN what the physician's orders were. UM C revealed she told LVN B to follow the orders and call the physician. Resident #1's Nurse's Note, dated 01/17/14, timed at 8:00 AM and written by LVN B, reflected, "Resident blood sugar now reading 540. Pushed H2O 16 ounces." The Note did not reflect the physician was notified of the resident's high blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/17/14, did not reflect the physician was notified of the resident's low blood sugar of 47 at 9:00 PM. There was no documentation reflecting an assessment of the resident. Resident #1's January 2014 MAR indicated [REDACTED]. The facility's Staff Sign-In Sheet, dated 01/17/14, reflected LVN D worked the 2:00 PM to 10:00 PM shift. Resident #1's Nurse's Note, dated 01/18/14, at 9:41 PM and written by LVN D, reflected, "Blood sugar read 44 this evening. gave milk and sugar. 16 oz of water. continue to monitor." The Note did not reflect [MEDICATION NAME] was administered for the low blood sugar or that the physician was notified. (Note: Resident #1's January 2014 Physician's Orders reflected [MEDICATION NAME] 1 mg if the blood sugar was less than 60.) An interview with LVN G on 02/12/14 at 2:51 PM revealed LVN D was no longer worked at the facility. During an interview with the UM C on 02/12/14 at 3:30 PM, she was asked to review the January MAR for Resident #1 to determine if Resident #1 received a [MEDICATION NAME] injection for the low blood sugars of 47 and 44 that was documented. UM C reviewed the MAR indicated [REDACTED]. Further interview with UM C on 02/12/14 at approximately 3:50 PM revealed when asked if the [MEDICATION NAME] should have been administered, UM C replied "Yes." Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/21/14, did not reflect the high blood sugar result of 545 or that the physician was contacted as ordered. Resident #1 January 2014 MAR indicated [REDACTED]. Review of Resident #1's clinical record did not reveal any Nurse's Notes for 01/27/14. There was no documentation of an assessment of the resident or that [MEDICATION NAME] was administered as ordered by the physician for the low blood sugar result. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/28/14, at 9:47 PM, and written by LVN D, reflected, "Monitor patient blood sugar 34 this evening. gave 16oz of water and milk and sugar." The Note did not reflect a nursing assessment of the resident or physician notification of the low blood sugar result. There were no other entries for 01/28/14 regarding a follow-up assessment or check of the resident's blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/29/14 and completed by LVN D at 10:01 PM, reflected, "Transferred to hospital. patient had hypoglycemic episode. Checked patient's blood sugar 34 gave patient two peanut butter sandwiches and 8 oz water. patent was confused and didn't know where she was. after checking patent's bloods (sic) sugar again it was 76 but patient still could not identify her surroundings. Called 911 at 1730 (5:30 PM). upon waiting for 911 gave patient oj with sugar. once 911 came patient's blood sugar went down to 32. patient transferred to hospital. Dinner didn't come out until 1743 (5:43PM)...." The reference below included information regarding the administration of insulin and a delay in meal service that could contribute to a Hypoglycemic episode. The reference below also provided a product description for Insulin 70/30 that included time of onset and duration, since Resident #1 per documentation in the nurses notes had been administered insulin at 4:30 PM and meal service not begun until 5:43 PM, 1.25 hours after insulin had been administered. dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= reflected, INSULIN REACTION AND SHOCK "...Insulin reaction '[DIAGNOSES REDACTED]' occurs when the blood glucose falls very low. This can happen if you take too much insulin, miss or delay a meal, exercise more than usual or work too hard without eating, or become ill (especially with vomiting or fever). [DIAGNOSES REDACTED] can also happen if you combine insulin therapy and other medications that lower blood glucose, such as oral antidiabetic agents or other prescription and over-the-counter drugs. The first symptoms of an insulin reaction usually come on suddenly. They may include a cold sweat, fatigue, nervousness or shakiness, rapid heartbeat, or nausea. Personality change or confusion may also occur. If you drink or eat something right away (a glass of milk or orange juice, or several sugar candies), you can often stop the progression of symptoms. If symptoms persist, call your physician - an insulin reaction can lead to unconsciousness. If a reaction results in loss of consciousness, emergency medical care should be obtained immediately. If you have had repeated reactions or if an insulin reaction has led to a loss of consciousness, contact your physician. Severe [DIAGNOSES REDACTED] can result in temporary or permanent impairment of brain function and death...Product Description. [MEDICATION NAME] 70/30 has an intermediate duration of action. The effect of [MEDICATION NAME] 70/30 begins approximately 1/2 hour hour after injection. The effect is maximal between 2 and approximately 12 hours. The full duration may last up to 24 hours after injection...." (Retrieved on 02/20/14) A review of the ambulance record, dated 01/29/14, revealed the vital signs of Resident #1 on 01/29/14 at 5:45 PM were as follows: BP 136/60 HR 82 and Glucose of 32. A review of the notes that were entered in the comment section of the ambulance report revealed: "...AOS (Arrived on scene) TO FIND A 90 Y/O (year old) F (female) PT SITTING IN HER WHEELCHAIR IN THE HALLWAY OF A NURSING HOME. PT WAS EXPERIENCING SUDDEN ONSET OF [DIAGNOSES REDACTED]. PT WAS BEING CARE FOR BY A NURSE...AND THEY WERE UNABLE TO CORRECT THE ISSUE. PTS VITALS AND BGA (blood glucose analysis) WERE TAKEN ON SCENE. PTS BLOOD SUGAR WAS 32. PT WAS LOADED ON COT AND TAKEN TO MICU (mobile intensive unit). AN IV (intravenous) WAS ESTABLISHED AND 500 BAG OF NS (normal saline) HUNG. 25 G (grams) OF D50 ([MEDICATION NAME]) WAS PUSHED IV AND PT IMMEDIATELY REGAINED NORMAL ORIENTATION. PT WAS TRANSPORTED TO...." A review of the hospital history and physical for Resident #1 dated 01/29/14 revealed she presented to the emergency room when EMS reported she was found seated in a wheelchair when she suddenly became unresponsive about one hour prior. The history revealed Resident #1 was Hypoglycemic with a blood sugar in the 30's and was given one [MEDICATION NAME] of D50 with improvement to mentation. The history further revealed Resident #1 had no recollection of the episode. Resident #1's blood sugar result on 01/29/14, obtained after treatment enroute to the hospital and in the emergency room , was 114 at 6:47 PM. Another blood sugar result on 01/29/14 at 9:11 PM was 219 mg/dl. Resident #1's facility Nurse's Note, dated 01/29/14 and timed at 11:39 PM, reflected she returned to the facility, vital signs were documented and she was asleep. Resident #1's Physician's Orders, dated 12/01/2013 through 02/13/2014, reflected an order, with a start date of 10/15/13, which reflected [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 02/02/14 and written by LVN B, did not reflect the resident's high blood sugar result or that the physician was notified. An interview with LVN B on 02/12/14 at 1:38 PM revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes did not reflect an entry for 02/07/14. An interview with Resident #1 on 02/12/14 at 2:59 PM revealed she was alert and oriented, but had short-term memory loss. She had the ability to self-propel her wheelchair. Resident #1 did not recall if her medications, including insulin, had been administered late at any time. The facility's current undated Abuse Prohibition Management Program reflected, "h. Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." On 02/13/14, an IJ was identified. On 02/13/14 at 10:32 AM the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 02/14/14, reflected, "All nurses have been counsled (sic). Licensed nurse (LVN B) was removed from her assignment and suspended pending facility investigation at 10:00pm on February 12, 2014. During the audit, this nurse was identified as making 9 of the 15 errors identified on (Resident #1). An allegation of Neglect has been self-reported to DADs at 11:00 am, February 13, 2014 was completed...In-Serviced licensed staff on...Diabetic clinical protocols; obtaining finger sticks (sic) glucose levels insulin administration acute change of condition guidelines for notification to physician Nursing care for residents with diabetes...An audit of all insulin dependent diabetic residents was completed by 1:45am on February 13, 2014...The audit consisted of review of insulin dependent diabetic residents physician orders to ensure order accuracy (any one on insulin had orders for finger sticks, accuracy of sliding scale insulin, [MEDICATION NAME] orders, and physician parameters.) All 53 insulin dependent residents in the 2 buildings on the campus...were audited...During the licensed nurse staff training which began on Wednesday, February 12th at 9:45pm and continued with 39 training session (sic) thru (sic) 11:00am on February 14, 2014. Licensed Staff were presented with lecture of policies as identified in this plan and question and answer session (interviews) to review staff's understanding of training...Monitoring of staff competencies began on February 14, 2014 and will continue daily for 7 days...." Interviews with LVN N, LVN P and LVN O on 02/14/14 between 6:55 AM and 3:58 PM revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. Interviews with LVN G, ADON I, RN J, LVN E, LVN K, LVN Q, LVN L, LVN M, LVN R, LVN S, LVN T, and the DON on 02/15/14 between 7:44 AM and 3:53 PM revealed revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. On 02/16/14 the IJ was removed. On 02/16/14 at 3:21 PM, the Administrator, DON, Director of Operations, and Regional Nurse Consultant were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. The "Medication Orders (FSBS & Insulin)" for Halls 100, 200 and 300, dated 02/01/14 through 02/12/14 reflected 33 residents, including Resident #1.

Based on interview and record review, it was determined the facility failed to implement its written policies and procedures that prohibit abuse and neglect of residents for one (Resident #1) of 10 residents reviewed for sliding scale insulin coverage. 1) LVN D failed to administer [MEDICATION NAME] and contact Resident #1's physician when the resident's blood sugar results were 47 on 01/17/14, 44 on 01/18/14, 34 on 01/28/14 and 34 on 01/29/14. 2) LVN B failed to administer [MEDICATION NAME] as ordered and contact Resident #1's physician when the resident's blood sugar result was 52 on 01/11/14. 3) LVN B failed to notify the physician when Resident #1's blood sugar results were 451 - 500 and administered insulin to the resident without a physician's order on "multiple" occasions. Resident #1 was transferred to the emergency roiagnom on [DATE] due to a low blood sugar result for further evaluation and treatment. An Immediate Jeopardy (IJ) was identified on 02/13/14. While the IJ was removed on 02/16/14, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the other 32 residents, who were ordered sliding scale insulin coverage and/or blood sugar monitoring, by placing them at risk of [MEDICAL CONDITION] or Hypoglycemic episodes to include coma, shock and even death. 4) LVN F failed to immediately report an allegation of abuse to the Administrator. He waited three days to report the allegation 5) The Administrator of Record failed to report LVN F's allegation of abuse to the State survey and certification agency. These failures could affect the 125 residents, including Resident #1, who had Dementia, by placing them at risk for abuse, injuries, and fear. Findings included: The facility's current undated Abuse Prohibition Management Program reflected, "h. Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...17. Upon receiving reports of abuse, the charge nurse will immediately examine the resident and notify the Abuse Prevention Coordinator. Findings of the examination should not be recorded in the medical record but should be written in the summary of the Provider Investigation Report Form. 18. The Abuse Prevention Coordinator will immediately report to the State Agency and other appropriate authorities, incidents of resident abuse as required under applicable regulations and regulatory guidance. 19. The Abuse Coordinator will provide to the person in charge of the investigation, (if not the Abuse Coordinator), a copy of the 'investigation and any supporting documents relative to the alleged incident...20. The Abuse Prevention Coordinator will: a. Report all alleged and substantiated incidents of resident abuse to the Texas Department of Aging and Disability Services...." A review of the ROA, dated 02/14/14 at 10:25 AM, for Resident #1 revealed she was admitted on [DATE] and was 90-years-old. A review of the MDS assessment for Resident #1, dated 01/24/13, revealed Resident #1 had adequate hearing, clear speech, she had the ability to express ideas and wants and was understood and she had the ability to understand. Resident #1 required limited assistance of one for mobility and transfers, dressing, and personal hygiene. Resident #1 normally used a wheelchair for mobility. [DIAGNOSES REDACTED]. A Care Plan, dated 10/25/13 and reviewed 01/28/14 for Resident #1, revealed she was diabetic and the goal was for Resident #1 to remain stable as evidenced by the blood sugar staying within the resident's normal limits over the next 90 days. The approaches included the monitoring of labs and reporting abnormal labs to the physician. During an interview with UM C on 02/12/14 at 3:00 PM, the surveyor requested a copy of the January 2014 Physician's Orders and MARS for Resident #1. A review of Resident #1's January 2014 Physician's Orders, identified by UM C, as the orders for January 2014, revealed an order, with a start date of 10/06/13, which reflected [MEDICATION NAME] 1 mg (used in the management of low blood sugar), to be administered if the blood sugar was less than 60. These same orders also included the following insulin orders: [MEDICATION NAME] 70/30 100 units/ml 4 solution SQ one time per day and [MEDICATION NAME] 70/30/ 100 units/ml 5 units SQ two times per day. A review of the MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of the January 2014 Physician's Orders for Resident #1 revealed an order, with a start date of 10/15/13, which reflected sliding scale insulin coverage: [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's Nurse's Notes, dated 01/07/14, did not reflect any entries regarding her blood sugar result of 565 or an assessment by the nurse to determine if Resident #1 had any signs or symptoms of [MEDICAL CONDITION] (high blood sugar) or whether the physician was notified of the blood sugar of 565. Based on this sliding scale insulin order for January 2014, the attending physician of Resident #1 should have been notified for further orders. A review of Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of Resident #1's Nurse's Notes for 01/11/14 did not reveal an entry that addressed her high blood sugar of 590. The Notes also did not reflect the physician was notified as ordered. Based on the January 2014 Physician's Orders for sliding scale insulin, the attending physician should have been notified for further orders. Further review of this same MAR for Resident #1 revealed a documented blood sugar result of 52 at 5:00 PM on 01/11/14. A review of Resident #1's Nurse's Notes, dated 01/11/14, did not reveal any documentation regarding a nursing assessment or action taken when her blood sugar was 52. The Notes did not reflect the physician was notified of her low blood sugar of 52. The Notes also did not reflect [MEDICATION NAME] was administered per the January 2014 Physician's Orders. The Medication Error Report, dated 02/12/14 after surveyor intervention, reflected LVN B was the nurse on duty on 01/11/14 when Resident #1's blood sugar result was 52. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/17/14 and documented by LVN B, reflected at 6:30 AM her blood sugar measured high on the glucometer and 10 units [MEDICATION NAME] R insulin and 5 units NPH were administered. The Notes reflected, "...Pushed H2O (water). Patient peaceful, BP 139/74 HR 95. No complaints of pain. Resident lying in bed sleeping." The Notes did not reflect the physician was notified of the resident's high blood sugar of 500. (Note: Resident #1's January 2014 Physician's Orders reflected to contact the physician when the blood sugar was between 451 - 500.) Resident #1's January 2014 Physician's Orders did not reflect an order for [REDACTED]. An interview was conducted with LVN B on 02/12/14 at 1:38 PM. When asked if there was a reason she gave Resident #1 regular insulin 10 units without a physician's order on 01/17/14 at 6:30 AM when the blood sugar level for Resident #1 measured 500, she replied she was instructed by UM C to give the maximum insulin dose of what was listed on the MAR for Resident #1. She said she had asked other nurses also, and they told her the same thing, and then instructed her to re-check the blood sugar. LVN B was unable to provide the names of the other nurses who had given her that directive. When asked if there was a reason she had not contacted the physician when she obtained the blood sugar of 500 on 01/17/14 at 6:30 AM, LVN B replied she had attempted in the past to contact the NP and her calls were never returned, so after two or three times, she just stopped trying to contact the NP. LVN B was asked if she informed UM C or the DON that she had difficulty getting the NP to return a phone call, and she said she did not report the problem. LVN B asked, "What's the right way?" She stated she wanted to learn. LVN B revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. An interview with UM C on 02/15/14 at 10:33 AM revealed she did not tell LVN B to give the insulin without physician's orders. She stated once LVN B called her about a high blood sugar and she (UM C) asked the LVN what the physician's orders were. UM C revealed she told LVN B to follow the orders and call the physician. Resident #1's Nurse's Note, dated 01/17/14, timed at 8:00 AM and written by LVN B, reflected, "Resident blood sugar now reading 540. Pushed H2O 16 ounces." The Note did not reflect the physician was notified of the resident's high blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/17/14, did not reflect the physician was notified of the resident's low blood sugar of 47 at 9:00 PM. There was no documentation reflecting an assessment of the resident. Resident #1's January 2014 MAR indicated [REDACTED]. The facility's Staff Sign-In Sheet, dated 01/17/14, reflected LVN D worked the 2:00 PM to 10:00 PM shift. Resident #1's Nurse's Note, dated 01/18/14, at 9:41 PM and written by LVN D, reflected, "Blood sugar read 44 this evening. gave milk and sugar. 16 oz of water. continue to monitor." The Note did not reflect [MEDICATION NAME] was administered for the low blood sugar or that the physician was notified. (Note: Resident #1's January 2014 Physician's Orders reflected [MEDICATION NAME] 1 mg if the blood sugar was less than 60.) An interview with LVN G on 02/12/14 at 2:51 PM revealed LVN D was no longer worked at the facility. During an interview with the UM C on 02/12/14 at 3:30 PM, she was asked to review the January MAR for Resident #1 to determine if Resident #1 received a [MEDICATION NAME] injection for the low blood sugars of 47 and 44 that was documented. UM C reviewed the MAR indicated [REDACTED]. Further interview with UM C on 02/12/14 at approximately 3:50 PM revealed when asked if the [MEDICATION NAME] should have been administered, UM C replied "Yes." Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/21/14, did not reflect the high blood sugar result of 545 or that the physician was contacted as ordered. Resident #1 January 2014 MAR indicated [REDACTED]. Review of Resident #1's clinical record did not reveal any Nurse's Notes for 01/27/14. There was no documentation of an assessment of the resident or that [MEDICATION NAME] was administered as ordered by the physician for the low blood sugar result. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/28/14, at 9:47 PM, and written by LVN D, reflected, "Monitor patient blood sugar 34 this evening. gave 16oz of water and milk and sugar." The Note did not reflect a nursing assessment of the resident or physician notification of the low blood sugar result. There were no other entries for 01/28/14 regarding a follow-up assessment or check of the resident's blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/29/14 and completed by LVN D at 10:01 PM, reflected, "Transferred to hospital. patient had hypoglycemic episode. Checked patient's blood sugar 34 gave patient two peanut butter sandwiches and 8 oz water. patent was confused and didn't know where she was. after checking patent's bloods (sic) sugar again it was 76 but patient still could not identify her surroundings. Called 911 at 1730 (5:30 PM). upon waiting for 911 gave patient oj with sugar. once 911 came patient's blood sugar went down to 32. patient transferred to hospital. Dinner didn't come out until 1743 (5:43PM)...." The reference below included information regarding the administration of insulin and a delay in meal service that could contribute to a Hypoglycemic episode. The reference below also provided a product description for Insulin 70/30 that included time of onset and duration, since Resident #1 per documentation in the nurses notes had been administered insulin at 4:30 PM and meal service not begun until 5:43 PM, 1.25 hours after insulin had been administered. dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= reflected, INSULIN REACTION AND SHOCK "...Insulin reaction '[DIAGNOSES REDACTED]' occurs when the blood glucose falls very low. This can happen if you take too much insulin, miss or delay a meal, exercise more than usual or work too hard without eating, or become ill (especially with vomiting or fever). [DIAGNOSES REDACTED] can also happen if you combine insulin therapy and other medications that lower blood glucose, such as oral antidiabetic agents or other prescription and over-the-counter drugs. The first symptoms of an insulin reaction usually come on suddenly. They may include a cold sweat, fatigue, nervousness or shakiness, rapid heartbeat, or nausea. Personality change or confusion may also occur. If you drink or eat something right away (a glass of milk or orange juice, or several sugar candies), you can often stop the progression of symptoms. If symptoms persist, call your physician - an insulin reaction can lead to unconsciousness. If a reaction results in loss of consciousness, emergency medical care should be obtained immediately. If you have had repeated reactions or if an insulin reaction has led to a loss of consciousness, contact your physician. Severe [DIAGNOSES REDACTED] can result in temporary or permanent impairment of brain function and death...Product Description. [MEDICATION NAME] 70/30 has an intermediate duration of action. The effect of [MEDICATION NAME] 70/30 begins approximately 1/2 hour hour after injection. The effect is maximal between 2 and approximately 12 hours. The full duration may last up to 24 hours after injection...." (Retrieved on 02/20/14) A review of the ambulance record, dated 01/29/14, revealed the vital signs of Resident #1 on 01/29/14 at 5:45 PM were as follows: BP 136/60 HR 82 and Glucose of 32. A review of the notes that were entered in the comment section of the ambulance report revealed: "...AOS (Arrived on scene) TO FIND A 90 Y/O (year old) F (female) PT SITTING IN HER WHEELCHAIR IN THE HALLWAY OF A NURSING HOME. PT WAS EXPERIENCING SUDDEN ONSET OF [DIAGNOSES REDACTED]. PT WAS BEING CARE FOR BY A NURSE...AND THEY WERE UNABLE TO CORRECT THE ISSUE. PTS VITALS AND BGA (blood glucose analysis) WERE TAKEN ON SCENE. PTS BLOOD SUGAR WAS 32. PT WAS LOADED ON COT AND TAKEN TO MICU (mobile intensive unit). AN IV (intravenous) WAS ESTABLISHED AND 500 BAG OF NS (normal saline) HUNG. 25 G (grams) OF D50 ([MEDICATION NAME]) WAS PUSHED IV AND PT IMMEDIATELY REGAINED NORMAL ORIENTATION. PT WAS TRANSPORTED TO...." A review of the hospital history and physical for Resident #1 dated 01/29/14 revealed she presented to the emergency room when EMS reported she was found seated in a wheelchair when she suddenly became unresponsive about one hour prior. The history revealed Resident #1 was Hypoglycemic with a blood sugar in the 30's and was given one [MEDICATION NAME] of D50 with improvement to mentation. The history further revealed Resident #1 had no recollection of the episode. Resident #1's blood sugar result on 01/29/14, obtained after treatment enroute to the hospital and in the emergency room , was 114 at 6:47 PM. Another blood sugar result on 01/29/14 at 9:11 PM was 219 mg/dl. Resident #1's facility Nurse's Note, dated 01/29/14 and timed at 11:39 PM, reflected she returned to the facility, vital signs were documented and she was asleep. Resident #1's Physician's Orders, dated 12/01/2013 through 02/13/2014, reflected an order, with a start date of 10/15/13, which reflected [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 02/02/14 and written by LVN B, did not reflect the resident's high blood sugar result or that the physician was notified. An interview with LVN B on 02/12/14 at 1:38 PM revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes did not reflect an entry for 02/07/14. An interview with Resident #1 on 02/12/14 at 2:59 PM revealed she was alert and oriented, but had short-term memory loss. She had the ability to self-propel her wheelchair. Resident #1 did not recall if her medications, including insulin, had been administered late at any time. The facility's current undated Abuse Prohibition Management Program reflected, "h. Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." On 02/13/14, an IJ was identified. On 02/13/14 at 10:32 AM the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 02/14/14, reflected, "All nurses have been counsled (sic). Licensed nurse (LVN B) was removed from her assignment and suspended pending facility investigation at 10:00pm on February 12, 2014. During the audit, this nurse was identified as making 9 of the 15 errors identified on (Resident #1). An allegation of Neglect has been self-reported to DADs at 11:00 am, February 13, 2014 was completed...In-Serviced licensed staff on...Diabetic clinical protocols; obtaining finger sticks (sic) glucose levels insulin administration acute change of condition guidelines for notification to physician Nursing care for residents with diabetes...An audit of all insulin dependent diabetic residents was completed by 1:45am on February 13, 2014...The audit consisted of review of insulin dependent diabetic residents physician orders to ensure order accuracy (any one on insulin had orders for finger sticks, accuracy of sliding scale insulin, [MEDICATION NAME] orders, and physician parameters.) All 53 insulin dependent residents in the 2 buildings on the campus...were audited...During the licensed nurse staff training which began on Wednesday, February 12th at 9:45pm and continued with 39 training session (sic) thru (sic) 11:00am on February 14, 2014. Licensed Staff were presented with lecture of policies as identified in this plan and question and answer session (interviews) to review staff's understanding of training...Monitoring of staff competencies began on February 14, 2014 and will continue daily for 7 days...." Interviews with LVN N, LVN P and LVN O on 02/14/14 between 6:55 AM and 3:58 PM revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. Interviews with LVN G, ADON I, RN J, LVN E, LVN K, LVN Q, LVN L, LVN M, LVN R, LVN S, LVN T, and the DON on 02/15/14 between 7:44 AM and 3:53 PM revealed revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. On 02/16/14 the IJ was removed. On 02/16/14 at 3:21 PM, the Administrator, DON, Director of Operations, and Regional Nurse Consultant were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. The "Medication Orders (FSBS & Insulin)" for Halls 100, 200 and 300, dated 02/01/14 through 02/12/14 reflected 33 residents, including Resident #1. Non-Immediate Jeopardy findings An interview was conducted with Resident #1 on 02/12/14 at 2:59 PM. She was alert and oriented, but she had signs of short-term memory loss. She had the ability to self-propel her wheelchair. Resident #1 did not recall if her medications, including insulin, were administered late at any time. Resident #1 denied abuse or neglect by staff. During an interview with the Administrator of Record on 02/012/14 at 11:12 AM, he said LVN F told him that he had witnessed resident abuse. The Administrator said LVN F told him it was Resident #1. The Administrator said he requested additional information from the LVN regarding the specific abuse he alleged to have witnessed. According to the Administrator, LVN F reported a new nurse (name unknown), had allegedly administered insulin late to Resident #1. The Administrator revealed LVN F did not report his allegation of abuse until 01/29/14, but told the Administrator that "it happened" on 01/26/14. The Administrator said LVN F told him that according to the nursing board, what he witnessed was abuse. The Administrator stated he told LVN F it was not abuse he witnessed but it would be a medication error. The Administrator said when he attempted to obtain further clarification of the abuse allegation made by LVN F, LVN F said he no longer wanted to discuss the matter. The Administrator of Record provided documentation, which he signed on 01/30/14, which reflected, "On 1/30/2014 was interviewing (LVN F) when he informed me he had witnessed resident abuse. I asked who it was and he informed me it was (Resident #1). I asked what type of abuse and he stated untimely medication administration of insulin. He stated he did not know the nurses (sic) name but she was new. He stated the incident occurred Sunday January 26th at approximately 2300 (11:00 PM) but did not attempt to report the incident until January 29th. I asked him if he understands this is three days from observation to reporting and he stated he understood. I informed him this is not abuse but a medication error. He stated it was abuse per the Texas Board of Nursing to which I replied per Texas Administrative Code it does not meet the definition of abuse. He stated he no longer wished to discuss and wanted to contact the corporate office. I thanked him for his time and dismissed him." The Administrator of Record provided statements from the DON, the Assistant Administrator, the Administrator, and a former Administrator. There was no evidence the facility spoke to Resident #1 about the allegation. There was no evidence the facility interviewed nurses or tried to determine who the alleged perpetrator was. The Administrator of Record in-serviced staff on Abuse and Neglect notification. A telephone interview was conducted with LVN F on 02/12/14 at approximately 12:35 PM. LVN F stated the nurse (name unknown) was new, and she was behind with passing her medications. LVN F said she (name unknown) was drawing up insulin and "popping" the pills to be administered. LVN F revealed he saw the unknown nurse as she exited the room of Resident #1 around 11:00 PM. He stated that was about four or five hours after she was scheduled to have insulin. LVN F said he had not actually observed this unknown nurse give the insulin late to Resident #1, but he said he reported what he considered abuse, to the Administrator. LVN F said, "If you aren't giving the medications on time, it was abuse of a resident." An interview with the Administrator on 02/12/14 at 10:47 AM revealed when asked why he did not report to DADS the allegation made by LVN F, he replied the facts reported to him by the LVN were more of an untimely medication concern. The facility's Form CMS-672, Resident Census and Conditions of Residents, provided on 02/16/14, reflected 125 residents identified with Dementia.

Based on interview and record review, it was determined the facility failed to consult with the resident's physician when a resident had a change in physical status for one (Resident #1) of 10 residents reviewed sliding scale insulin coverage. 1. LVN D failed to consult with Resident #1's physician when the resident's blood sugar results were 47 on 01/17/14, 44 on 01/18/14, 34 on 01/28/14 and 34 on 01/29/14. 2) LVN B failed to consult with Resident #1's physician when the resident's blood sugar result was 52 on 01/11/14. 3) LVN B failed to consult with Resident #1's when the resident's blood sugar results were 451 to 500 on 01/07/14, 01/11/14, 01/17/14, 01/21/14, 02/02/14, and 02/07/14. LVN B Resident #1 was transferred to the emergency roiagnom on [DATE] due to a low blood sugar result for further evaluation and treatment. An Immediate Jeopardy (IJ) was identified on 02/13/14. While the IJ was removed on 02/16/14, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the other 32 residents, who were ordered sliding scale insulin coverage and/or blood sugar monitoring, by placing them at risk of [MEDICAL CONDITION] or Hypoglycemic episodes to include coma, shock and even death. Findings included: A review of the ROA, dated 02/14/14 at 10:25 AM, for Resident #1 revealed she was admitted on [DATE] and was 90-years-old. A review of the MDS assessment for Resident #1, dated 01/24/13, revealed Resident #1 had adequate hearing, clear speech, she had the ability to express ideas and wants and was understood and she had the ability to understand. Resident #1 required limited assistance of one for mobility and transfers, dressing, and personal hygiene. Resident #1 normally used a wheelchair for mobility. [DIAGNOSES REDACTED]. A Care Plan, dated 10/25/13 and reviewed 01/28/14 for Resident #1, revealed she was diabetic and the goal was for Resident #1 to remain stable as evidenced by the blood sugar staying within the resident's normal limits over the next 90 days. The approaches included the monitoring of labs and reporting abnormal labs to the physician. During an interview with UM C on 02/12/14 at 3:00 PM, the surveyor requested a copy of the January 2014 Physician's Orders and MARS for Resident #1. A review of Resident #1's January 2014 Physician's Orders, identified by UM C, as the orders for January 2014, revealed an order, with a start date of 10/06/13, which reflected [MEDICATION NAME] 1 mg (used in the management of low blood sugar), to be administered if the blood sugar was less than 60. These same orders also included the following insulin orders: [MEDICATION NAME] 70/30 100 units/ml 4 solution SQ one time per day and [MEDICATION NAME] 70/30/ 100 units/ml 5 units SQ two times per day. A review of the MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of the January 2014 Physician's Orders for Resident #1 revealed an order, with a start date of 10/15/13, which reflected sliding scale insulin coverage: [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's Nurse's Notes, dated 01/07/14, did not reflect any entries regarding her blood sugar result of 565 or an assessment by the nurse to determine if Resident #1 had any signs or symptoms of [MEDICAL CONDITION] (high blood sugar) or whether the physician was notified of the blood sugar of 565. Based on this sliding scale insulin order for January 2014, the attending physician of Resident #1 should have been notified for further orders. A review of Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of Resident #1's Nurse's Notes for 01/11/14 did not reveal an entry that addressed her high blood sugar of 590. The Notes also did not reflect the physician was notified as ordered. Based on the January 2014 Physician's Orders for sliding scale insulin, the attending physician should have been notified for further orders. Further review of this same MAR for Resident #1 revealed a documented blood sugar result of 52 at 5:00 PM on 01/11/14. A review of Resident #1's Nurse's Notes, dated 01/11/14, did not reveal any documentation regarding a nursing assessment or action taken when her blood sugar was 52. The Notes did not reflect the physician was notified of her low blood sugar of 52. The Notes also did not reflect [MEDICATION NAME] was administered per the January 2014 Physician's Orders. The Medication Error Report, dated 02/12/14 after surveyor intervention, reflected LVN B was the nurse on duty on 01/11/14 when Resident #1's blood sugar result was 52. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/17/14 and documented by LVN B, reflected at 6:30 AM her blood sugar measured high on the glucometer and 10 units [MEDICATION NAME] R insulin and 5 units NPH were administered. The Notes reflected, "...Pushed H2O (water). Patient peaceful, BP 139/74 HR 95. No complaints of pain. Resident lying in bed sleeping." The Notes did not reflect the physician was notified of the resident's high blood sugar of 500. (Note: Resident #1's January 2014 Physician's Orders reflected to contact the physician when the blood sugar was between 451 - 500.) Resident #1's January 2014 Physician's Orders did not reflect an order for [REDACTED]. An interview was conducted with LVN B on 02/12/14 at 1:38 PM. When asked if there was a reason she gave Resident #1 regular insulin 10 units without a physician's order on 01/17/14 at 6:30 AM when the blood sugar level for Resident #1 measured 500, she replied she was instructed by UM C to give the maximum insulin dose of what was listed on the MAR for Resident #1. She said she had asked other nurses also, and they told her the same thing, and then instructed her to re-check the blood sugar. LVN B was unable to provide the names of the other nurses who had given her that directive. When asked if there was a reason she had not contacted the physician when she obtained the blood sugar of 500 on 01/17/14 at 6:30 AM, LVN B replied she had attempted in the past to contact the NP and her calls were never returned, so after two or three times, she just stopped trying to contact the NP. LVN B was asked if she informed UM C or the DON that she had difficulty getting the NP to return a phone call, and she said she did not report the problem. LVN B asked, "What's the right way?" She stated she wanted to learn. LVN B revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. An interview with UM C on 02/15/14 at 10:33 AM revealed she did not tell LVN B to give the insulin without physician's orders. She stated once LVN B called her about a high blood sugar and she (UM C) asked the LVN what the physician's orders were. UM C revealed she told LVN B to follow the orders and call the physician. Resident #1's Nurse's Note, dated 01/17/14, timed at 8:00 AM and written by LVN B, reflected, "Resident blood sugar now reading 540. Pushed H2O 16 ounces." The Note did not reflect the physician was notified of the resident's high blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/17/14, did not reflect the physician was notified of the resident's low blood sugar of 47 at 9:00 PM. There was no documentation reflecting an assessment of the resident. Resident #1's January 2014 MAR indicated [REDACTED]. The facility's Staff Sign-In Sheet, dated 01/17/14, reflected LVN D worked the 2:00 PM to 10:00 PM shift. Resident #1's Nurse's Note, dated 01/18/14, at 9:41 PM and written by LVN D, reflected, "Blood sugar read 44 this evening. gave milk and sugar. 16 oz of water. continue to monitor." The Note did not reflect [MEDICATION NAME] was administered for the low blood sugar or that the physician was notified. (Note: Resident #1's January 2014 Physician's Orders reflected [MEDICATION NAME] 1 mg if the blood sugar was less than 60.) An interview with LVN G on 02/12/14 at 2:51 PM revealed LVN D was no longer worked at the facility. During an interview with the UM C on 02/12/14 at 3:30 PM, she was asked to review the January MAR for Resident #1 to determine if Resident #1 received a [MEDICATION NAME] injection for the low blood sugars of 47 and 44 that was documented. UM C reviewed the MAR indicated [REDACTED]. Further interview with UM C on 02/12/14 at approximately 3:50 PM revealed when asked if the [MEDICATION NAME] should have been administered, UM C replied "Yes." Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/21/14, did not reflect the high blood sugar result of 545 or that the physician was contacted as ordered. Resident #1 January 2014 MAR indicated [REDACTED]. Review of Resident #1's clinical record did not reveal any Nurse's Notes for 01/27/14. There was no documentation of an assessment of the resident or that [MEDICATION NAME] was administered as ordered by the physician for the low blood sugar result. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/28/14, at 9:47 PM, and written by LVN D, reflected, "Monitor patient blood sugar 34 this evening. gave 16oz of water and milk and sugar." The Note did not reflect a nursing assessment of the resident or physician notification of the low blood sugar result. There were no other entries for 01/28/14 regarding a follow-up assessment or check of the resident's blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/29/14 and completed by LVN D at 10:01 PM, reflected, "Transferred to hospital. patient had hypoglycemic episode. Checked patient's blood sugar 34 gave patient two peanut butter sandwiches and 8 oz water. patent was confused and didn't know where she was. after checking patent's bloods (sic) sugar again it was 76 but patient still could not identify her surroundings. Called 911 at 1730 (5:30 PM). upon waiting for 911 gave patient oj with sugar. once 911 came patient's blood sugar went down to 32. patient transferred to hospital. Dinner didn't come out until 1743 (5:43PM)...." The reference below included information regarding the administration of insulin and a delay in meal service that could contribute to a Hypoglycemic episode. The reference below also provided a product description for Insulin 70/30 that included time of onset and duration, since Resident #1 per documentation in the nurses notes had been administered insulin at 4:30 PM and meal service not begun until 5:43 PM, 1.25 hours after insulin had been administered. dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= reflected, INSULIN REACTION AND SHOCK "...Insulin reaction '[DIAGNOSES REDACTED]' occurs when the blood glucose falls very low. This can happen if you take too much insulin, miss or delay a meal, exercise more than usual or work too hard without eating, or become ill (especially with vomiting or fever). [DIAGNOSES REDACTED] can also happen if you combine insulin therapy and other medications that lower blood glucose, such as oral antidiabetic agents or other prescription and over-the-counter drugs. The first symptoms of an insulin reaction usually come on suddenly. They may include a cold sweat, fatigue, nervousness or shakiness, rapid heartbeat, or nausea. Personality change or confusion may also occur. If you drink or eat something right away (a glass of milk or orange juice, or several sugar candies), you can often stop the progression of symptoms. If symptoms persist, call your physician - an insulin reaction can lead to unconsciousness. If a reaction results in loss of consciousness, emergency medical care should be obtained immediately. If you have had repeated reactions or if an insulin reaction has led to a loss of consciousness, contact your physician. Severe [DIAGNOSES REDACTED] can result in temporary or permanent impairment of brain function and death...Product Description. [MEDICATION NAME] 70/30 has an intermediate duration of action. The effect of [MEDICATION NAME] 70/30 begins approximately 1/2 hour hour after injection. The effect is maximal between 2 and approximately 12 hours. The full duration may last up to 24 hours after injection...." (Retrieved on 02/20/14) A review of the ambulance record, dated 01/29/14, revealed the vital signs of Resident #1 on 01/29/14 at 5:45 PM were as follows: BP 136/60 HR 82 and Glucose of 32. A review of the notes that were entered in the comment section of the ambulance report revealed: "...AOS (Arrived on scene) TO FIND A 90 Y/O (year old) F (female) PT SITTING IN HER WHEELCHAIR IN THE HALLWAY OF A NURSING HOME. PT WAS EXPERIENCING SUDDEN ONSET OF [DIAGNOSES REDACTED]. PT WAS BEING CARE FOR BY A NURSE...AND THEY WERE UNABLE TO CORRECT THE ISSUE. PTS VITALS AND BGA (blood glucose analysis) WERE TAKEN ON SCENE. PTS BLOOD SUGAR WAS 32. PT WAS LOADED ON COT AND TAKEN TO MICU (mobile intensive unit). AN IV (intravenous) WAS ESTABLISHED AND 500 BAG OF NS (normal saline) HUNG. 25 G (grams) OF D50 ([MEDICATION NAME]) WAS PUSHED IV AND PT IMMEDIATELY REGAINED NORMAL ORIENTATION. PT WAS TRANSPORTED TO...." A review of the hospital history and physical for Resident #1 dated 01/29/14 revealed she presented to the emergency room when EMS reported she was found seated in a wheelchair when she suddenly became unresponsive about one hour prior. The history revealed Resident #1 was Hypoglycemic with a blood sugar in the 30's and was given one [MEDICATION NAME] of D50 with improvement to mentation. The history further revealed Resident #1 had no recollection of the episode. Resident #1's blood sugar result on 01/29/14, obtained after treatment enroute to the hospital and in the emergency room , was 114 at 6:47 PM. Another blood sugar result on 01/29/14 at 9:11 PM was 219 mg/dl. Resident #1's facility Nurse's Note, dated 01/29/14 and timed at 11:39 PM, reflected she returned to the facility, vital signs were documented and she was asleep. Resident #1's Physician's Orders, dated 12/01/2013 through 02/13/2014, reflected an order, with a start date of 10/15/13, which reflected [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 02/02/14 and written by LVN B, did not reflect the resident's high blood sugar result or that the physician was notified. An interview with LVN B on 02/12/14 at 1:38 PM revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes did not reflect an entry for 02/07/14. An interview with Resident #1 on 02/12/14 at 2:59 PM revealed she was alert and oriented, but had short-term memory loss. She had the ability to self-propel her wheelchair. Resident #1 did not recall if her medications, including insulin, had been administered late at any time. The facility's current undated Abuse Prohibition Management Program reflected, "h. Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." On 02/13/14, an IJ was identified. On 02/13/14 at 10:32 AM the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 02/14/14, reflected, "All nurses have been counsled (sic). Licensed nurse (LVN B) was removed from her assignment and suspended pending facility investigation at 10:00pm on February 12, 2014. During the audit, this nurse was identified as making 9 of the 15 errors identified on (Resident #1). An allegation of Neglect has been self-reported to DADs at 11:00 am, February 13, 2014 was completed...In-Serviced licensed staff on...Diabetic clinical protocols; obtaining finger sticks (sic) glucose levels insulin administration acute change of condition guidelines for notification to physician Nursing care for residents with diabetes...An audit of all insulin dependent diabetic residents was completed by 1:45am on February 13, 2014...The audit consisted of review of insulin dependent diabetic residents physician orders to ensure order accuracy (any one on insulin had orders for finger sticks, accuracy of sliding scale insulin, [MEDICATION NAME] orders, and physician parameters.) All 53 insulin dependent residents in the 2 buildings on the campus...were audited...During the licensed nurse staff training which began on Wednesday, February 12th at 9:45pm and continued with 39 training session (sic) thru (sic) 11:00am on February 14, 2014. Licensed Staff were presented with lecture of policies as identified in this plan and question and answer session (interviews) to review staff's understanding of training...Monitoring of staff competencies began on February 14, 2014 and will continue daily for 7 days...." Interviews with LVN N, LVN P and LVN O on 02/14/14 between 6:55 AM and 3:58 PM revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. Interviews with LVN G, ADON I, RN J, LVN E, LVN K, LVN Q, LVN L, LVN M, LVN R, LVN S, LVN T, and the DON on 02/15/14 between 7:44 AM and 3:53 PM revealed revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. On 02/16/14 the IJ was removed. On 02/16/14 at 3:21 PM, the Administrator, DON, Director of Operations, and Regional Nurse Consultant were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. The "Medication Orders (FSBS & Insulin)" for Halls 100, 200 and 300, dated 02/01/14 through 02/12/14 reflected 33 residents, including Resident #1.

Based on interview and record review it was determined the facility failed to ensure residents were free of any significant medications errors for one (Resident #1) of 10 residents reviewed sliding scale insulin coverage. 1) LVN D failed to administer [MEDICATION NAME] as ordered when Resident #1's blood sugar results were 47 on 01/17/14, 44 on 01/18/14, 34 on 01/28/14 and 34 on 01/29/14. 2) LVN B failed to administer [MEDICATION NAME] as ordered when Resident #1's blood sugar result was 52 on 01/11/14. 3) LVN B failed to notify the physician when Resident #1's blood sugar results were high and outside the physician-ordered parameters and administered insulin to the resident without a physician's order on "multiple" occasions. Resident #1 was transferred to the emergency roiagnom on [DATE] due to a low blood sugar result for further evaluation and treatment. An Immediate Jeopardy (IJ) was identified on 02/13/14. While the IJ was removed on 02/16/14, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the other 32 residents, who were ordered sliding scale insulin coverage and/or blood sugar monitoring, by placing them at risk of [MEDICAL CONDITION] or Hypoglycemic episodes to include coma, shock and even death. Findings included: A review of the ROA, dated 02/14/14 at 10:25 AM, for Resident #1 revealed she was admitted on [DATE] and was 90-years-old. A review of the MDS assessment for Resident #1, dated 01/24/13, revealed Resident #1 had adequate hearing, clear speech, she had the ability to express ideas and wants and was understood and she had the ability to understand. Resident #1 required limited assistance of one for mobility and transfers, dressing, and personal hygiene. Resident #1 normally used a wheelchair for mobility. [DIAGNOSES REDACTED]. A Care Plan, dated 10/25/13 and reviewed 01/28/14 for Resident #1, revealed she was diabetic and the goal was for Resident #1 to remain stable as evidenced by the blood sugar staying within the resident's normal limits over the next 90 days. The approaches included the monitoring of labs and reporting abnormal labs to the physician. During an interview with UM C on 02/12/14 at 3:00 PM, the surveyor requested a copy of the January 2014 Physician's Orders and MARS for Resident #1. A review of Resident #1's January 2014 Physician's Orders, identified by UM C, as the orders for January 2014, revealed an order, with a start date of 10/06/13, which reflected [MEDICATION NAME] 1 mg (used in the management of low blood sugar), to be administered if the blood sugar was less than 60. These same orders also included the following insulin orders: [MEDICATION NAME] 70/30 100 units/ml 4 solution SQ one time per day and [MEDICATION NAME] 70/30/ 100 units/ml 5 units SQ two times per day. A review of the MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of the January 2014 Physician's Orders for Resident #1 revealed an order, with a start date of 10/15/13, which reflected sliding scale insulin coverage: [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's Nurse's Notes, dated 01/07/14, did not reflect any entries regarding her blood sugar result of 565 or an assessment by the nurse to determine if Resident #1 had any signs or symptoms of [MEDICAL CONDITION] (high blood sugar) or whether the physician was notified of the blood sugar of 565. Based on this sliding scale insulin order for January 2014, the attending physician of Resident #1 should have been notified for further orders. A review of Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of Resident #1's Nurse's Notes for 01/11/14 did not reveal an entry that addressed her high blood sugar of 590. The Notes also did not reflect the physician was notified as ordered. Based on the January 2014 Physician's Orders for sliding scale insulin, the attending physician should have been notified for further orders. Further review of this same MAR for Resident #1 revealed a documented blood sugar result of 52 at 5:00 PM on 01/11/14. A review of Resident #1's Nurse's Notes, dated 01/11/14, did not reveal any documentation regarding a nursing assessment or action taken when her blood sugar was 52. The Notes did not reflect the physician was notified of her low blood sugar of 52. The Notes also did not reflect [MEDICATION NAME] was administered per the January 2014 Physician's Orders. The Medication Error Report, dated 02/12/14 after surveyor intervention, reflected LVN B was the nurse on duty on 01/11/14 when Resident #1's blood sugar result was 52. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/17/14 and documented by LVN B, reflected at 6:30 AM her blood sugar measured high on the glucometer and 10 units [MEDICATION NAME] R insulin and 5 units NPH were administered. The Notes reflected, "...Pushed H2O (water). Patient peaceful, BP 139/74 HR 95. No complaints of pain. Resident lying in bed sleeping." The Notes did not reflect the physician was notified of the resident's high blood sugar of 500. (Note: Resident #1's January 2014 Physician's Orders reflected to contact the physician when the blood sugar was between 451 - 500.) Resident #1's January 2014 Physician's Orders did not reflect an order for [REDACTED]. An interview was conducted with LVN B on 02/12/14 at 1:38 PM. When asked if there was a reason she gave Resident #1 regular insulin 10 units without a physician's order on 01/17/14 at 6:30 AM when the blood sugar level for Resident #1 measured 500, she replied she was instructed by UM C to give the maximum insulin dose of what was listed on the MAR for Resident #1. She said she had asked other nurses also, and they told her the same thing, and then instructed her to re-check the blood sugar. LVN B was unable to provide the names of the other nurses who had given her that directive. When asked if there was a reason she had not contacted the physician when she obtained the blood sugar of 500 on 01/17/14 at 6:30 AM, LVN B replied she had attempted in the past to contact the NP and her calls were never returned, so after two or three times, she just stopped trying to contact the NP. LVN B was asked if she informed UM C or the DON that she had difficulty getting the NP to return a phone call, and she said she did not report the problem. LVN B asked, "What's the right way?" She stated she wanted to learn. LVN B revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. An interview with UM C on 02/15/14 at 10:33 AM revealed she did not tell LVN B to give the insulin without physician's orders. She stated once LVN B called her about a high blood sugar and she (UM C) asked the LVN what the physician's orders were. UM C revealed she told LVN B to follow the orders and call the physician. Resident #1's Nurse's Note, dated 01/17/14, timed at 8:00 AM and written by LVN B, reflected, "Resident blood sugar now reading 540. Pushed H2O 16 ounces." The Note did not reflect the physician was notified of the resident's high blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/17/14, did not reflect the physician was notified of the resident's low blood sugar of 47 at 9:00 PM. There was no documentation reflecting an assessment of the resident. Resident #1's January 2014 MAR indicated [REDACTED]. The facility's Staff Sign-In Sheet, dated 01/17/14, reflected LVN D worked the 2:00 PM to 10:00 PM shift. Resident #1's Nurse's Note, dated 01/18/14, at 9:41 PM and written by LVN D, reflected, "Blood sugar read 44 this evening. gave milk and sugar. 16 oz of water. continue to monitor." The Note did not reflect [MEDICATION NAME] was administered for the low blood sugar or that the physician was notified. (Note: Resident #1's January 2014 Physician's Orders reflected [MEDICATION NAME] 1 mg if the blood sugar was less than 60.) An interview with LVN G on 02/12/14 at 2:51 PM revealed LVN D was no longer worked at the facility. During an interview with the UM C on 02/12/14 at 3:30 PM, she was asked to review the January MAR for Resident #1 to determine if Resident #1 received a [MEDICATION NAME] injection for the low blood sugars of 47 and 44 that was documented. UM C reviewed the MAR indicated [REDACTED]. Further interview with UM C on 02/12/14 at approximately 3:50 PM revealed when asked if the [MEDICATION NAME] should have been administered, UM C replied "Yes." Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/21/14, did not reflect the high blood sugar result of 545 or that the physician was contacted as ordered. Resident #1 January 2014 MAR indicated [REDACTED]. Review of Resident #1's clinical record did not reveal any Nurse's Notes for 01/27/14. There was no documentation of an assessment of the resident or that [MEDICATION NAME] was administered as ordered by the physician for the low blood sugar result. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/28/14, at 9:47 PM, and written by LVN D, reflected, "Monitor patient blood sugar 34 this evening. gave 16oz of water and milk and sugar." The Note did not reflect a nursing assessment of the resident or physician notification of the low blood sugar result. There were no other entries for 01/28/14 regarding a follow-up assessment or check of the resident's blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/29/14 and completed by LVN D at 10:01 PM, reflected, "Transferred to hospital. patient had hypoglycemic episode. Checked patient's blood sugar 34 gave patient two peanut butter sandwiches and 8 oz water. patent was confused and didn't know where she was. after checking patent's bloods (sic) sugar again it was 76 but patient still could not identify her surroundings. Called 911 at 1730 (5:30 PM). upon waiting for 911 gave patient oj with sugar. once 911 came patient's blood sugar went down to 32. patient transferred to hospital. Dinner didn't come out until 1743 (5:43PM)...." The reference below included information regarding the administration of insulin and a delay in meal service that could contribute to a Hypoglycemic episode. The reference below also provided a product description for Insulin 70/30 that included time of onset and duration, since Resident #1 per documentation in the nurses notes had been administered insulin at 4:30 PM and meal service not begun until 5:43 PM, 1.25 hours after insulin had been administered. dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= reflected, INSULIN REACTION AND SHOCK "...Insulin reaction '[DIAGNOSES REDACTED]' occurs when the blood glucose falls very low. This can happen if you take too much insulin, miss or delay a meal, exercise more than usual or work too hard without eating, or become ill (especially with vomiting or fever). [DIAGNOSES REDACTED] can also happen if you combine insulin therapy and other medications that lower blood glucose, such as oral antidiabetic agents or other prescription and over-the-counter drugs. The first symptoms of an insulin reaction usually come on suddenly. They may include a cold sweat, fatigue, nervousness or shakiness, rapid heartbeat, or nausea. Personality change or confusion may also occur. If you drink or eat something right away (a glass of milk or orange juice, or several sugar candies), you can often stop the progression of symptoms. If symptoms persist, call your physician - an insulin reaction can lead to unconsciousness. If a reaction results in loss of consciousness, emergency medical care should be obtained immediately. If you have had repeated reactions or if an insulin reaction has led to a loss of consciousness, contact your physician. Severe [DIAGNOSES REDACTED] can result in temporary or permanent impairment of brain function and death...Product Description. [MEDICATION NAME] 70/30 has an intermediate duration of action. The effect of [MEDICATION NAME] 70/30 begins approximately 1/2 hour hour after injection. The effect is maximal between 2 and approximately 12 hours. The full duration may last up to 24 hours after injection...." (Retrieved on 02/20/14) A review of the ambulance record, dated 01/29/14, revealed the vital signs of Resident #1 on 01/29/14 at 5:45 PM were as follows: BP 136/60 HR 82 and Glucose of 32. A review of the notes that were entered in the comment section of the ambulance report revealed: "...AOS (Arrived on scene) TO FIND A 90 Y/O (year old) F (female) PT SITTING IN HER WHEELCHAIR IN THE HALLWAY OF A NURSING HOME. PT WAS EXPERIENCING SUDDEN ONSET OF [DIAGNOSES REDACTED]. PT WAS BEING CARE FOR BY A NURSE...AND THEY WERE UNABLE TO CORRECT THE ISSUE. PTS VITALS AND BGA (blood glucose analysis) WERE TAKEN ON SCENE. PTS BLOOD SUGAR WAS 32. PT WAS LOADED ON COT AND TAKEN TO MICU (mobile intensive unit). AN IV (intravenous) WAS ESTABLISHED AND 500 BAG OF NS (normal saline) HUNG. 25 G (grams) OF D50 ([MEDICATION NAME]) WAS PUSHED IV AND PT IMMEDIATELY REGAINED NORMAL ORIENTATION. PT WAS TRANSPORTED TO...." A review of the hospital history and physical for Resident #1 dated 01/29/14 revealed she presented to the emergency room when EMS reported she was found seated in a wheelchair when she suddenly became unresponsive about one hour prior. The history revealed Resident #1 was Hypoglycemic with a blood sugar in the 30's and was given one [MEDICATION NAME] of D50 with improvement to mentation. The history further revealed Resident #1 had no recollection of the episode. Resident #1's blood sugar result on 01/29/14, obtained after treatment enroute to the hospital and in the emergency room , was 114 at 6:47 PM. Another blood sugar result on 01/29/14 at 9:11 PM was 219 mg/dl. Resident #1's facility Nurse's Note, dated 01/29/14 and timed at 11:39 PM, reflected she returned to the facility, vital signs were documented and she was asleep. Resident #1's Physician's Orders, dated 12/01/2013 through 02/13/2014, reflected an order, with a start date of 10/15/13, which reflected [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 02/02/14 and written by LVN B, did not reflect the resident's high blood sugar result or that the physician was notified. An interview with LVN B on 02/12/14 at 1:38 PM revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes did not reflect an entry for 02/07/14. An interview with Resident #1 on 02/12/14 at 2:59 PM revealed she was alert and oriented, but had short-term memory loss. She had the ability to self-propel her wheelchair. Resident #1 did not recall if her medications, including insulin, had been administered late at any time. The facility's current undated Abuse Prohibition Management Program reflected, "h. Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." On 02/13/14, an IJ was identified. On 02/13/14 at 10:32 AM the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 02/14/14, reflected, "All nurses have been counsled (sic). Licensed nurse (LVN B) was removed from her assignment and suspended pending facility investigation at 10:00pm on February 12, 2014. During the audit, this nurse was identified as making 9 of the 15 errors identified on (Resident #1). An allegation of Neglect has been self-reported to DADs at 11:00 am, February 13, 2014 was completed...In-Serviced licensed staff on...Diabetic clinical protocols; obtaining finger sticks (sic) glucose levels insulin administration acute change of condition guidelines for notification to physician Nursing care for residents with diabetes...An audit of all insulin dependent diabetic residents was completed by 1:45am on February 13, 2014...The audit consisted of review of insulin dependent diabetic residents physician orders to ensure order accuracy (any one on insulin had orders for finger sticks, accuracy of sliding scale insulin, [MEDICATION NAME] orders, and physician parameters.) All 53 insulin dependent residents in the 2 buildings on the campus...were audited...During the licensed nurse staff training which began on Wednesday, February 12th at 9:45pm and continued with 39 training session (sic) thru (sic) 11:00am on February 14, 2014. Licensed Staff were presented with lecture of policies as identified in this plan and question and answer session (interviews) to review staff's understanding of training...Monitoring of staff competencies began on February 14, 2014 and will continue daily for 7 days...." Interviews with LVN N, LVN P and LVN O on 02/14/14 between 6:55 AM and 3:58 PM revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. Interviews with LVN G, ADON I, RN J, LVN E, LVN K, LVN Q, LVN L, LVN M, LVN R, LVN S, LVN T, and the DON on 02/15/14 between 7:44 AM and 3:53 PM revealed revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. On 02/16/14 the IJ was removed. On 02/16/14 at 3:21 PM, the Administrator, DON, Director of Operations, and Regional Nurse Consultant were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. The "Medication Orders (FSBS & Insulin)" for Halls 100, 200 and 300, dated 02/01/14 through 02/12/14 reflected 33 residents, including Resident #1.

Based on interview and record review ,the facility failed to ensure services provided met professional standards of quality for one (Resident #1) of of 10 residents reviewed for sliding scale insulin coverage. 1) LVN D failed to administer [MEDICATION NAME] as ordered and contact Resident #1's physician the resident's blood sugar results were 47 on 01/17/14, 44 on 01/18/14, 34 on 01/28/14 and 34 on 01/29/14. 2) LVN B failed to administer [MEDICATION NAME] as ordered and contact Resident #1's physician when the resident's blood sugar result was 52 on 01/11/14. 3) LVN B failed to notify the physician when Resident #1's blood sugar results were 451 - 500 and administered insulin to the resident without a physician's order on "multiple" occasions. Resident #1 was transferred to the emergency roiagnom on [DATE] due to a low blood sugar result for further evaluation and treatment. An Immediate Jeopardy (IJ) was identified on 02/13/14. While the IJ was removed on 02/16/14, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the other 32 residents, who were ordered sliding scale insulin coverage and/or blood sugar monitoring, by placing them at risk of [MEDICAL CONDITION] or Hypoglycemic episodes to include coma, shock and even death. Findings included: ?217.11. Standards of Nursing Practice. "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted...(B) Implement measures to promote a safe environment for clients and others... (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status... (M)Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications...." A review of the ROA, dated 02/14/14 at 10:25 AM, for Resident #1 revealed she was admitted on [DATE] and was 90-years-old. A review of the MDS assessment for Resident #1, dated 01/24/13, revealed Resident #1 had adequate hearing, clear speech, she had the ability to express ideas and wants and was understood and she had the ability to understand. Resident #1 required limited assistance of one for mobility and transfers, dressing, and personal hygiene. Resident #1 normally used a wheelchair for mobility. [DIAGNOSES REDACTED]. A Care Plan, dated 10/25/13 and reviewed 01/28/14 for Resident #1, revealed she was diabetic and the goal was for Resident #1 to remain stable as evidenced by the blood sugar staying within the resident's normal limits over the next 90 days. The approaches included the monitoring of labs and reporting abnormal labs to the physician. During an interview with UM C on 02/12/14 at 3:00 PM, the surveyor requested a copy of the January 2014 Physician's Orders and MARS for Resident #1. A review of Resident #1's January 2014 Physician's Orders, identified by UM C, as the orders for January 2014, revealed an order, with a start date of 10/06/13, which reflected [MEDICATION NAME] 1 mg (used in the management of low blood sugar), to be administered if the blood sugar was less than 60. These same orders also included the following insulin orders: [MEDICATION NAME] 70/30 100 units/ml 4 solution SQ one time per day and [MEDICATION NAME] 70/30/ 100 units/ml 5 units SQ two times per day. A review of the MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of the January 2014 Physician's Orders for Resident #1 revealed an order, with a start date of 10/15/13, which reflected sliding scale insulin coverage: [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's Nurse's Notes, dated 01/07/14, did not reflect any entries regarding her blood sugar result of 565 or an assessment by the nurse to determine if Resident #1 had any signs or symptoms of [MEDICAL CONDITION] (high blood sugar) or whether the physician was notified of the blood sugar of 565. Based on this sliding scale insulin order for January 2014, the attending physician of Resident #1 should have been notified for further orders. A review of Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. A review of Resident #1's Nurse's Notes for 01/11/14 did not reveal an entry that addressed her high blood sugar of 590. The Notes also did not reflect the physician was notified as ordered. Based on the January 2014 Physician's Orders for sliding scale insulin, the attending physician should have been notified for further orders. Further review of this same MAR for Resident #1 revealed a documented blood sugar result of 52 at 5:00 PM on 01/11/14. A review of Resident #1's Nurse's Notes, dated 01/11/14, did not reveal any documentation regarding a nursing assessment or action taken when her blood sugar was 52. The Notes did not reflect the physician was notified of her low blood sugar of 52. The Notes also did not reflect [MEDICATION NAME] was administered per the January 2014 Physician's Orders. The Medication Error Report, dated 02/12/14 after surveyor intervention, reflected LVN B was the nurse on duty on 01/11/14 when Resident #1's blood sugar result was 52. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/17/14 and documented by LVN B, reflected at 6:30 AM her blood sugar measured high on the glucometer and 10 units [MEDICATION NAME] R insulin and 5 units NPH were administered. The Notes reflected, "...Pushed H2O (water). Patient peaceful, BP 139/74 HR 95. No complaints of pain. Resident lying in bed sleeping." The Notes did not reflect the physician was notified of the resident's high blood sugar of 500. (Note: Resident #1's January 2014 Physician's Orders reflected to contact the physician when the blood sugar was between 451 - 500.) Resident #1's January 2014 Physician's Orders did not reflect an order for [REDACTED]. An interview was conducted with LVN B on 02/12/14 at 1:38 PM. When asked if there was a reason she gave Resident #1 regular insulin 10 units without a physician's order on 01/17/14 at 6:30 AM when the blood sugar level for Resident #1 measured 500, she replied she was instructed by UM C to give the maximum insulin dose of what was listed on the MAR for Resident #1. She said she had asked other nurses also, and they told her the same thing, and then instructed her to re-check the blood sugar. LVN B was unable to provide the names of the other nurses who had given her that directive. When asked if there was a reason she had not contacted the physician when she obtained the blood sugar of 500 on 01/17/14 at 6:30 AM, LVN B replied she had attempted in the past to contact the NP and her calls were never returned, so after two or three times, she just stopped trying to contact the NP. LVN B was asked if she informed UM C or the DON that she had difficulty getting the NP to return a phone call, and she said she did not report the problem. LVN B asked, "What's the right way?" She stated she wanted to learn. LVN B revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. An interview with UM C on 02/15/14 at 10:33 AM revealed she did not tell LVN B to give the insulin without physician's orders. She stated once LVN B called her about a high blood sugar and she (UM C) asked the LVN what the physician's orders were. UM C revealed she told LVN B to follow the orders and call the physician. Resident #1's Nurse's Note, dated 01/17/14, timed at 8:00 AM and written by LVN B, reflected, "Resident blood sugar now reading 540. Pushed H2O 16 ounces." The Note did not reflect the physician was notified of the resident's high blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/17/14, did not reflect the physician was notified of the resident's low blood sugar of 47 at 9:00 PM. There was no documentation reflecting an assessment of the resident. Resident #1's January 2014 MAR indicated [REDACTED]. The facility's Staff Sign-In Sheet, dated 01/17/14, reflected LVN D worked the 2:00 PM to 10:00 PM shift. Resident #1's Nurse's Note, dated 01/18/14, at 9:41 PM and written by LVN D, reflected, "Blood sugar read 44 this evening. gave milk and sugar. 16 oz of water. continue to monitor." The Note did not reflect [MEDICATION NAME] was administered for the low blood sugar or that the physician was notified. (Note: Resident #1's January 2014 Physician's Orders reflected [MEDICATION NAME] 1 mg if the blood sugar was less than 60.) An interview with LVN G on 02/12/14 at 2:51 PM revealed LVN D was no longer worked at the facility. During an interview with the UM C on 02/12/14 at 3:30 PM, she was asked to review the January MAR for Resident #1 to determine if Resident #1 received a [MEDICATION NAME] injection for the low blood sugars of 47 and 44 that was documented. UM C reviewed the MAR indicated [REDACTED]. Further interview with UM C on 02/12/14 at approximately 3:50 PM revealed when asked if the [MEDICATION NAME] should have been administered, UM C replied "Yes." Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The area designated as the area to chart the amount of insulin administered was blank. Resident #1's Nurse's Notes, dated 01/21/14, did not reflect the high blood sugar result of 545 or that the physician was contacted as ordered. Resident #1 January 2014 MAR indicated [REDACTED]. Review of Resident #1's clinical record did not reveal any Nurse's Notes for 01/27/14. There was no documentation of an assessment of the resident or that [MEDICATION NAME] was administered as ordered by the physician for the low blood sugar result. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/28/14, at 9:47 PM, and written by LVN D, reflected, "Monitor patient blood sugar 34 this evening. gave 16oz of water and milk and sugar." The Note did not reflect a nursing assessment of the resident or physician notification of the low blood sugar result. There were no other entries for 01/28/14 regarding a follow-up assessment or check of the resident's blood sugar. Resident #1's January 2014 MAR indicated [REDACTED]. Resident #1's January 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 01/29/14 and completed by LVN D at 10:01 PM, reflected, "Transferred to hospital. patient had hypoglycemic episode. Checked patient's blood sugar 34 gave patient two peanut butter sandwiches and 8 oz water. patent was confused and didn't know where she was. after checking patent's bloods (sic) sugar again it was 76 but patient still could not identify her surroundings. Called 911 at 1730 (5:30 PM). upon waiting for 911 gave patient oj with sugar. once 911 came patient's blood sugar went down to 32. patient transferred to hospital. Dinner didn't come out until 1743 (5:43PM)...." The reference below included information regarding the administration of insulin and a delay in meal service that could contribute to a Hypoglycemic episode. The reference below also provided a product description for Insulin 70/30 that included time of onset and duration, since Resident #1 per documentation in the nurses notes had been administered insulin at 4:30 PM and meal service not begun until 5:43 PM, 1.25 hours after insulin had been administered. dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= reflected, INSULIN REACTION AND SHOCK "...Insulin reaction '[DIAGNOSES REDACTED]' occurs when the blood glucose falls very low. This can happen if you take too much insulin, miss or delay a meal, exercise more than usual or work too hard without eating, or become ill (especially with vomiting or fever). [DIAGNOSES REDACTED] can also happen if you combine insulin therapy and other medications that lower blood glucose, such as oral antidiabetic agents or other prescription and over-the-counter drugs. The first symptoms of an insulin reaction usually come on suddenly. They may include a cold sweat, fatigue, nervousness or shakiness, rapid heartbeat, or nausea. Personality change or confusion may also occur. If you drink or eat something right away (a glass of milk or orange juice, or several sugar candies), you can often stop the progression of symptoms. If symptoms persist, call your physician - an insulin reaction can lead to unconsciousness. If a reaction results in loss of consciousness, emergency medical care should be obtained immediately. If you have had repeated reactions or if an insulin reaction has led to a loss of consciousness, contact your physician. Severe [DIAGNOSES REDACTED] can result in temporary or permanent impairment of brain function and death...Product Description. [MEDICATION NAME] 70/30 has an intermediate duration of action. The effect of [MEDICATION NAME] 70/30 begins approximately 1/2 hour hour after injection. The effect is maximal between 2 and approximately 12 hours. The full duration may last up to 24 hours after injection...." (Retrieved on 02/20/14) A review of the ambulance record, dated 01/29/14, revealed the vital signs of Resident #1 on 01/29/14 at 5:45 PM were as follows: BP 136/60 HR 82 and Glucose of 32. A review of the notes that were entered in the comment section of the ambulance report revealed: "...AOS (Arrived on scene) TO FIND A 90 Y/O (year old) F (female) PT SITTING IN HER WHEELCHAIR IN THE HALLWAY OF A NURSING HOME. PT WAS EXPERIENCING SUDDEN ONSET OF [DIAGNOSES REDACTED]. PT WAS BEING CARE FOR BY A NURSE...AND THEY WERE UNABLE TO CORRECT THE ISSUE. PTS VITALS AND BGA (blood glucose analysis) WERE TAKEN ON SCENE. PTS BLOOD SUGAR WAS 32. PT WAS LOADED ON COT AND TAKEN TO MICU (mobile intensive unit). AN IV (intravenous) WAS ESTABLISHED AND 500 BAG OF NS (normal saline) HUNG. 25 G (grams) OF D50 ([MEDICATION NAME]) WAS PUSHED IV AND PT IMMEDIATELY REGAINED NORMAL ORIENTATION. PT WAS TRANSPORTED TO...." A review of the hospital history and physical for Resident #1 dated 01/29/14 revealed she presented to the emergency room when EMS reported she was found seated in a wheelchair when she suddenly became unresponsive about one hour prior. The history revealed Resident #1 was Hypoglycemic with a blood sugar in the 30's and was given one [MEDICATION NAME] of D50 with improvement to mentation. The history further revealed Resident #1 had no recollection of the episode. Resident #1's blood sugar result on 01/29/14, obtained after treatment enroute to the hospital and in the emergency room , was 114 at 6:47 PM. Another blood sugar result on 01/29/14 at 9:11 PM was 219 mg/dl. Resident #1's facility Nurse's Note, dated 01/29/14 and timed at 11:39 PM, reflected she returned to the facility, vital signs were documented and she was asleep. Resident #1's Physician's Orders, dated 12/01/2013 through 02/13/2014, reflected an order, with a start date of 10/15/13, which reflected [MEDICATION NAME] R 100 units/ml four times per day: 0-150 =0 units 151-200 = 0 units 201-250 = 2 units 251-300 = 4 units 401-450 =10 units, 451-500 = 0 units *MD call. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes, dated 02/02/14 and written by LVN B, did not reflect the resident's high blood sugar result or that the physician was notified. An interview with LVN B on 02/12/14 at 1:38 PM revealed there had been "multiple" times she gave insulin 10 units to Resident #1. LVN B was then asked where she had documented the insulin she had administered on those "multiple" occasions, since the MAR indicated [REDACTED]. LVN B said she had not documented most of them. Resident #1's February 2014 MAR indicated [REDACTED]. Resident #1's Nurse's Notes did not reflect an entry for 02/07/14. An interview with Resident #1 on 02/12/14 at 2:59 PM revealed she was alert and oriented, but had short-term memory loss. She had the ability to self-propel her wheelchair. Resident #1 did not recall if her medications, including insulin, had been administered late at any time. The facility's current undated Abuse Prohibition Management Program reflected, "h. Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident...." On 02/13/14, an IJ was identified. On 02/13/14 at 10:32 AM the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 02/14/14, reflected, "All nurses have been counsled (sic). Licensed nurse (LVN B) was removed from her assignment and suspended pending facility investigation at 10:00pm on February 12, 2014. During the audit, this nurse was identified as making 9 of the 15 errors identified on (Resident #1). An allegation of Neglect has been self-reported to DADs at 11:00 am, February 13, 2014 was completed...In-Serviced licensed staff on...Diabetic clinical protocols; obtaining finger sticks (sic) glucose levels insulin administration acute change of condition guidelines for notification to physician Nursing care for residents with diabetes...An audit of all insulin dependent diabetic residents was completed by 1:45am on February 13, 2014...The audit consisted of review of insulin dependent diabetic residents physician orders to ensure order accuracy (any one on insulin had orders for finger sticks, accuracy of sliding scale insulin, [MEDICATION NAME] orders, and physician parameters.) All 53 insulin dependent residents in the 2 buildings on the campus...were audited...During the licensed nurse staff training which began on Wednesday, February 12th at 9:45pm and continued with 39 training session (sic) thru (sic) 11:00am on February 14, 2014. Licensed Staff were presented with lecture of policies as identified in this plan and question and answer session (interviews) to review staff's understanding of training...Monitoring of staff competencies began on February 14, 2014 and will continue daily for 7 days...." Interviews with LVN N, LVN P and LVN O on 02/14/14 between 6:55 AM and 3:58 PM revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. Interviews with LVN G, ADON I, RN J, LVN E, LVN K, LVN Q, LVN L, LVN M, LVN R, LVN S, LVN T, and the DON on 02/15/14 between 7:44 AM and 3:53 PM revealed revealed they had been in-serviced. They understood they needed to clarify physician's orders if there were no parameters, document the blood sugar results immediately, if the physician did not return a call, they were to notify the UM immediately, document nursing assessments, ensure [MEDICATION NAME] orders have parameters, ensure glucometer was calibrated, if the results of the blood sugars were questionable, and get a new glucometer. They were provided handouts regarding [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. When taking a blood sugar, they should review the MAR for insulin orders. If they administer [MEDICATION NAME] for low blood sugar the physician should be notified. On 02/16/14 the IJ was removed. On 02/16/14 at 3:21 PM, the Administrator, DON, Director of Operations, and Regional Nurse Consultant were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level "actual harm that was not immediate jeopardy," and a scope of "pattern" because staff were still being in-serviced and the facility was still monitoring the effectiveness of the Plan of Removal. The "Medication Orders (FSBS & Insulin)" for Halls 100, 200 and 300, dated 02/01/14 through 02/12/14 reflected 33 residents, including Resident #1.

Based on interview and record review, it was determined the facility failed to implement its written policies and procedures for two (Residents #1 and #2) of four residents reviewed for abuse. 1) RN A failed to immediately report an allegation of sexual abuse to the Administrator. She waited three days to report the allegation. This failure could affect the 108 residents who resided in the Scotland Building, by placing them at risk for abuse, injuries and fear. Findings included: 1) The facility's current undated Abuse Prohibition Management Program reflected: "Policy: All personnel, Residents, family members, visitors, etc., are encouraged to report actual or suspected incidents of Resident Abuse or inappropriate behavior that may lead to abuse... Reporting: ...15. Any person observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this protocol. All phases of the reporting process will be kept confidential... ...17. Upon receiving reports of abuse, the charge nurse will immediately examine the residents and notify the Abuse Prevention Coordinator. Findings of the examination should not be recorded in the medical record but should be written in the summary of the Provider Investigation Report Form." 2) Review of the current MDS quarterly assessment, dated 03/20/14, revealed Resident #2 was a [AGE] year-old female who had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #2 had a BIMS score of "11" which was indicative of moderately impaired cognitive status, and required extensive assistance of one staff member for transfers, dressing, eating, personal hygiene and bathing. Resident #2 was non-ambulatory and used a wheelchair for mobility. 3) Review of the current MDS quarterly assessment, dated 01/02/14, revealed Resident #1 was a [AGE] year-old male who had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #1 had a BIMS score of "4" which was indicative of severe impaired cognitive status. Resident #1 required extensive assistance of two staff for transfers and dressing and one person for eating and bathing. He was non-ambulatory and used a wheelchair for mobility and was not able to self-propel the chair. 4) Review of the Provider Investigation Report, dated 03/19/14, revealed on 03/08/14, Resident #2 was observed by CNA B and MA C with her hand between Resident #1's legs touching his genitals. The statement from MA C reflected as she was leaving the dining room she saw Resident #2 sitting next to Resident #1 with her hand between his legs. The report also reflected Resident #2 was fondling Resident #1 outside his pants. She stated Resident #2 was removed by CNA B and then MA C and CNA B told RN A about the incident. 5) On 03/27/14 at 9:00 AM during interview with the Administrator, it was revealed the facility had not been made aware of the incident between Resident #1 and Resident #2 until the afternoon of 03/10/14. On 03/27/14 at 8:40 AM during interview with Unit Manager/LVN D over the Weiner/Dowdy Unit, she stated she had been standing at the nurses' station talking with Unit Manager/LVN E over the South Unit about the incident she had that happened on her unit over the weekend and one of the staff (not sure who) in passing said something had happened between Residents #1 and #2 over the weekend. Unit Manager/LVN D stated she asked Unit manager/LVN E if she had been told about any incident which occurred on the weekend and she told her she was not aware of any incident. On 03/27/14 at 9:30 AM during interview with Unit Manager/LVN E she stated she had not been notified about the incident between Residents #1 and #2 until Monday afternoon on 03/10/14. She stated she and the ADON F started calling the people who worked on that Saturday and could not get in touch with them and she had left messages for them to call back. She stated she told the Administrator and called the DON to ask about the incident and she had not been told about the incident. She stated RN A had worked on Saturday, was off on Sunday and called in sick on Monday. She stated when RN A came in on Tuesday morning she came to talk with her. She asked her if anything had happened over the weekend and she told her then about the incident between Residents #1 and #2. RN A told her she was going to report it and she knew she should have reported it to the Executive Director. Unit Manager/LVN E stated RN A then completed an Incident/Accident Report on 03/11/14, regarding the incident. On 03/28/14 at 11:45 AM during interview with ADON F she stated she was not informed about the incident between Residents #1 and #2 until late Monday afternoon. She stated Unit Manager/LVN D had heard about the incident through "gossip" and that was when the facility started an investigation to determine what had actually happened. On 03/27/14 at 9:10 AM during interview the DON she stated she had been on her way home when she received a call from Unit Manager/LVN E and asked what to do about the issue regarding Residents #1 and #2. She told me she had been trying to find out what had happened and no one seemed to know anything about it. She stated Unit manager/LVN D had been talking to Unit Manager/LVN E about another incident which had occurred over the weekend and someone mentioned that a similar incident had happened over the weekend with Residents #1 and #2. The DON confirmed that none of the staff had called Unit Manager/LVN E or her or the Administrator over the weekend about the incident. On 03/27/14 at 9:45 AM during interview with RN A she stated around 1:00 PM on Saturday, 03/08/14, she was coming from the dining room and the medication aide (MA C) informed her that Resident #2 was touching Resident #1's genitals on the outside of his pants. She stated the staff removed Resident #2 from the area to her room. She stated neither resident appeared to be in any distress at the time. She stated it was the "change of shift" and she went to check and make sure Resident #2 was in her room. RN A stated that day she was charge nurse, treatment nurse and the medication aide for that day and she got busy at the change of shift. She stated she did not report it to the next shift, nor did she document it in the clinical records and she did not report it to the Executive Director/Abuse Coordinator or the DON. She confirmed that she was off the following Sunday and Monday. RN A stated she did receive a call from Unit Manager/LVN E on Monday asking about the incident, but she did not see the call until late and she did not call her back. She stated on Tuesday morning (03/11/14) she went in to talk with Unit Manager/LVN E. RN A stated she did not report this incident to anyone including the Executive Director, DON or Unit Manager/LVN E. She also stated she did not document it in the clinical records or on an Incident/Accident report at the time. She stated she knew she should have called and reported it immediately but just forgot. 6) The facility's resident roster, dated 03/26/14, reflected there were 108 residents who resided in the Scotland building of the facility.

Based on observation, interview and record review, the facility failed to ensure the residents received adequate supervision, assistance, and assistive devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents. 1) Resident #1, a resident with a recent history of falls, was left alone, unsupervised while sitting up in a Geri chair. Resident #1 got out of the chair and walked across the room, before falling and hitting her head. Although not included in the resident's care plan, a personal alarm was in use at the time of the fall. All staff were away from the area at the time of the fall and either did not hear or did not respond to the alarm. These failures likely caused Resident #1's Closed Head Injury, Acute Subarachnoid Hemorrhage, and Subdural Hemorrhage. These failures could affect the 29 current residents with personal chair alarms by placing them at risk of falls, abrasions, hematomas, bruises, and fractures. Findings included: 1) Resident #1's MDS assessment dated [DATE] reflected she was admitted on [DATE]. According to the assessment, she was an [AGE] year-old female with [DIAGNOSES REDACTED]. Resident #1 required assistance for transfer. The resident's cognitive skills were identified as "severely impaired." Her activities of daily living required "extensive assistance" of one to two staff persons, including bed mobility, transfers and locomotion on and off the unit. Resident #1's care plan, dated 04/26/11 and last reviewed on 05/03/12, reflected the resident was totally dependent for activities of daily living. The resident was also at risk for falls. Interventions for fall prevention included: assessing the need for adaptive/safety devices; arranging suitable seating; assessing environment for potential hazards; and assessing medications for possible factors that might contribute to falls. The care plan did not address any recent falls or special devices used for fall prevention. A care plan for Resident #1 with the handwritten date 07/14/12 marked through indicated the resident fell on [DATE] and 07/16/12. The approaches circled as implemented included: encouraging the resident to ask for assistance, ensuring the call light was within reach and answered promptly, ensuring lighting was adequate and the area free of clutter, the use of a Low bed, and the use of a personal alarm at all times. Resident #1's physician order [REDACTED]. Review of an Accident/Incident Report dated 07/15/12 revealed at 5:45 AM, Resident #1 was walking around the nursing station, lost her balance and fell , hitting her right shoulder and head. Attached to the report was a written statement signed by the LVN who witnessed the fall. The Follow-Up Implementation for the Accident/Incident Report reflected the resident would continue to be on the "falling star" program and a "Hi/Lo" bed with a floor mat. The follow-up also included frequent incontinent checks and administration of medications for anxiousness or agitation. Resident #1's nurse's notes dated 07/15/12 at 5:45 AM (late entry) reflected Resident #1 got up from the Geri chair and was walking from one side of the nurse's station to the other and she fell , hitting her right shoulder and the right side of the back of her head. X-rays to the head were ordered. The 07/15/12 nurse's note (time not legible) reflected Resident #1's physician called and informed the nurse the x-rays were normal, but he wanted the resident sent to the hospital for a C-T scan. At 11:40 PM on 07/15/12, the nurse's note reflected the resident returned from the hospital and the C-T scan report was negative. An Accident/Incident report reflected on 07/16/12 at 9:40 AM, Resident #1 "had got out of Geri chair & walked & fell ." The report reflected at the time of the incident a chair alarm was in use. LVN A, the reporting nurse, documented Resident #1 "was winesses (sic) laying on floor. Geri chair was across the room. Alarm was going off." The resident was assessed to have a laceration on the back of her head and was transferred to the hospital. An attached handwritten witness statement from LVN I reflected she was on the hall when she heard a noise. She immediately went to investigate and found the resident on the floor. A staff member from central supply (Central Supply Staff (CSS)) was there and went to get more assistance. Review of Resident #1's nurse's note dated 07/16/12 at 9:40 AM revealed the nurse was called from another resident's room by the CSS. When she got to the resident, other staff were attending to her. The resident had a bleeding laceration on the back of her head. The resident was "very alert, moving her legs & arms." The resident was transferred to the hospital at 9:50 AM. Review of Resident #1's history and physical from the emergency room visit on 07/16/12 revealed she had an Acute Subarachnoid Hemorrhage and Subdural Hemorrhage. On 08/22/12 at 1:50 PM, LVN I revealed she did not witness Resident #1's fall on 07/16/12. LVN I stated she was down the hall, but heard a noise like something fell . LVN I stated she ran down the hall and saw Resident #1 lying on her back in the TV room. LVN I stated she asked the resident, "Can you hear me?" She stated Resident #1 was babbling words. LVN I stated a laceration was found on the back of the resident's head that was bleeding. LVN I stated 911 was called and LVN J cleaned the laceration. On 08/22/12 at 2:00 PM, LVN J revealed she did not witness Resident #1's fall on 07/16/12. She stated she was on the hall passing medications. Another staff member came and got her because Resident #1 had fallen. LVN J stated when she arrived at the TV room, Resident #1 was lying on the floor and her chair was in front of her. LVN J stated Resident #1 was moaning. LVN J revealed Resident #1 was on "high fall risk precaution." When queried about residents being left unattended in the TV room, LVN J stated when the unit manager was available, she would supervise the residents while the nurses and the CNAs were on the halls. On 08/22/12 at 2:30 PM, the CSS revealed she was coming out of her office to get something, when she saw Resident #1 in the TV room. The CSS stated the resident was alone in the room, was standing, and in the process of falling when she arrived. As she helplessly watched, the resident fell and hit her head on the chair. She stated she did not hear a chair alarm. The CSS stated no one else was around, so she left to look for a nurse. On 08/25/12 at 1:15 PM, LVN A revealed Resident #1 fell on [DATE]. She stated the resident was in the lobby in her Geri chair. LVN A stated the resident fell and had a laceration on the back of her head. When she arrived, LVN J was tending to the wound and informed her no nurse was on the station at the time of the fall. All the nurses were out passing medications and the CNAs were in other residents' room providing care. LVN A stated Resident #1 was not supposed to get up and walk alone and the resident had fallen several times. When queried about residents in Geri chairs and/or personal alarms, LVN A stated the resident was to be checked and repositioned every two hours. On 08/25/12 at 12:30 PM, the Administrator was queried regarding Resident #1's fall. When asked about the resident being left alone in the TV room, the Administrator revealed the facility was not required to provide continuous supervision when residents were in the TV room or their own room. 2) The facility's undated policy on Fall Prevention and Management Program, provided as current, reflected: "Policy: A Fall Prevention Program will be established and maintained, to assess all residents to determine their risk for fall. A plan of care will be implemented based on the resident's assessed needs." Procedures included: "4. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls...Interventions should include: ...i. Personal alarms attached to chair or bed... Personal alarm devices will be used as deemed necessary by the fall prevention team. Personal alarms are used based on the fall risk assessment and may be used as an emergency measure by the charge nurse or supervisor in order to keep the resident safe until the team evaluates the residents. A Falling Star Program resident should be monitored closely for the following: Ambulating or attempting to ambulate. Standing up after sitting or lying down. Change of medication or behaviors (especially after addition of psychotic, antihypertensive, or diuretic medication)..." An article published in Rehabilitation Nursing, volume 36, No. 5, September/October titled Nurses' Experiences with Bed Exit Alarms May Lead to Ambivalence About Their Effectiveness reflected: "Nurses' comments revealed ambivalence about the effectiveness of the alarms. Some said, 'Why use the alarms? You have to make routine rounds anyway.' One nurse explained that she could not hear the alarm, while others said bed alarms represented only one type of alarm to which nurses must respond (alarms are now associated with feeding pumps, sequential compression devices, IV pumps, and bathroom call lights). Alarm overload, they said, has the potential not only to make bed alarms ineffective but also to sensitize nurses against responding to the alarm. One nurse said, 'Sometimes you just hear another beeping, and you don't know which alarm is going off.'" 3) On 08/22/12 a typed list of 30 residents, including Resident #1, using personal chair alarms was provided by administration. The facility's Form CMS 672, Resident Census and Conditions of Residents, dated 08/22/12, reflected a total of 207 residents.

Based on observation, interview and record review, it was determined the facility failed to ensure three (Residents #10, #11, and #27) of eight residents reviewed with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. 1. Resident #10 was admitted to the facility with painful contracted knees. The facility failed to perform a thorough pain and contracture assessment in order to manage his pain with routine pain medications and failed to provide comfort measures between his contracted knees. 2. Resident #11 had contractions of both his arms, elbows, wrists and hands and was able to extend all joints of his arms about 20 degrees. Resident #11's Restorative Care was discontinued because the resident was in pain when he was exercised. He was not medicated for the pain and soft hand splints were not placed consistently. 3. Resident #27 was not provided with the right anti-[DIAGNOSES REDACTED] hand splint, which the resident had been assessed as needing on 04/06/12. Following surveyor inquiry, it was learned the splint was on back-order and the splint was then ordered from another company. These failures contributed to Residents #10 and #11 experiencing a dramatic decline in ROM and increased pain/discomfort and could affect the 82 residents with contractures, including Residents #10, #11 and #27 by placing them at risk for a further decrease in range of motion, increased pain and discomfort with movement. Findings included: 1) The consolidated physician's orders [REDACTED]. His [DIAGNOSES REDACTED]. His medications included: [MEDICATION NAME] (narcotic pain reliever) 5/500 mg, give one every day, Tylenol ([MEDICATION NAME]) 500 mg, give two every four to six hours; [MEDICATION NAME] ([MEDICATION NAME]) 325 mg, give two at hour of sleep, Aspirin (blood thinner) 81 mg, give one every day, and [MEDICATION NAME] (muscle relaxant) 12.5 mg every eight hours via gastrostomy tube (GT) Review of a Pain assessment dated [DATE] and 05/02/12 for Resident #11 revealed he had no pain on a scale of 0-10 with a 10 being the very worst pain, which was to be verbalized by the resident. The Wong-Baker FACES Pain Rating Scale and the Pain Assessment in Advanced Dementia (PAINAD) were left blank. During orientation rounds with LVN C on 05/22/12 at 10:50 a.m., Resident #11 was observed in bed in his room. He had severe contractures of both his arms. No positioning/anti-pressure devices were observed between his upper arms and torso, elbow and forearm, and no positioning devices in his severely contracted hands. Observation on 05/22/12 at 1:15 p.m. and at 1:40 p.m. revealed Resident #11 had a small rolled-up wash cloth in his contracted right hand. There were no other positioning devices observed on the rest of his contracted arms and/or left hand. Multiple observations of Resident #11 on 05/23/12 at 8:55 a.m., 1:05 p.m. and 4:30 p.m. revealed the resident was in the same condition regarding the lack of positioning devices being used for the contractures of his arms, wrists and left hand, as described on 05/22/12. On 05/24/12 at 12:41 p.m., Resident #11 was observed as he sat in a wheelchair in the lobby area, watching television. He only had a small rolled-up wash cloth in his right hand and no other positioning devices for the contractures of his arms, wrists and left hand. Review of the Occupational Therapy (OT) plan of care revealed therapy assessed and treated Resident #11 for contracture management of both his arms, wrists and hands from 02/15/12 through 03/06/12. During a review of the initial OT progress report and plan of care notes dated 02/15/12 and interview with OT W on 05/23/12 at 11:41 a.m., she stated Resident #11 was able to demonstrate passive range of motion (PROM) of both his arms and wrist, including his fingers by at least 20 degrees. She said her goal for Resident #11 was to increase his PROM by 30 degrees but the resident did not reach his goal and he was discharged to Restorative Care on 03/10/12. OT W told the surveyor Resident #11 was to receive Restorative Care for 90 days, which a review of the Restorative Care notes dated 03/10/12 confirmed. The facility was also to ensure the palms of Resident #10's hands were washed and to continue with PROM of his fingers and place soft splints in both hands. In an interview with RA X on 05/23/12 at 12 noon, he stated he performed ROM, washed the palms of Resident #11's hands and placed wash towels in his hands when the resident was on Restorative Care. He said the Restorative Aides had a meeting with their supervisor, LVN MDS Coordinator, on 04/19/12, and terminated the restorative exercises and care for Resident #11, because he complained of pain. On 05/24/12 at 12:20 p.m., the surveyor queried LVN MDS Coordinator about Resident #11's contracted hands, which had no protective/positioning devices. The LVN MDS Coordinator said she was not very familiar with Restorative Care and told the surveyor, "We should not have stopped the restorative services in hindsight." She said she should have asked nursing to medicate the resident in order to continue with his PROM. Following surveyor intervention, OT U re-assessed Resident #11's contractions of his arms, wrist and hands. Her Initial Assessment progress notes dated 05/24/12 reflected, "pt presents with pain 10/10 (pain scale of 0-10 with 10 being the very worst pain) in bilateral and elbows with movement and with guarding with touch. Pt has foul odor from palms of hands bilaterally (both) and with nails digging into palms of hands in fisted position at all times and did not tolerate attempts to measure joints of hands. Elbow measurement as follows: right elbow extension 5 degrees and left elbow extension to 30 degrees... Rehab Potential: Good due to: Positive results from previous treatment." During an interview with OT U on 05/25/12 at 11:39 a.m. concerning Resident #11, she stated the resident would require multiple gentle [MEDICAL CONDITION], starting from his shoulders in order to relax his contacted muscles. She said she had provided in-service training to the day shift staff on how to position the resident with pillows for both of his arms, wrist and hands when in bed and in his wheelchair. Observation of Resident #11, on 05/25/12 at 3:25 p.m., with LVN V revealed the resident was positioned on his left side in bed with no protective devices/pillows placed for either arm, wrist and/or hand, and his left elbow was pressed deep into the mattress. When LVN V was questioned about the resident's contractures and a recent in-service training from therapy, she said she had not attended any in-service training regarding repositioning of Resident #11. She said the resident always complained of pain when you "put anything on his hand." On 05/25/12 at 4:08 p.m., the surveyor asked the Regional Nurse Consultant (RNC) to assess Resident #11's contractures of his arms, wrists and hands as observation at that time had revealed there were still no positioning devices. The RNC observed the resident lying on his left side with his left elbow digging into the mattress. She tried to move his left elbow and the resident cried out in pain saying, "It hurts." The facility conducted a pain assessment for Resident #11 using the PAINAD on 05/24/12. His score was 8. According to the legend on the PAINAD sheet, the score was based on a scale of 0-10 and a higher score indicated more severe pain. On 05/25/12 at 4:45 p.m., the DON stated she would have the Director of Rehabilitation Services in-service all staff regarding the care of Resident #11's arm, elbow, wrist and hand contractures and ask the Nurse Practitioner to reassess the resident's pain. The quarterly MDS assessments dated 11/02/11, 02/01/12 and 05/01/12 for Resident #11 reflected he was totally dependent on facility staff for all his ADLs, and he had impairment of both his arms. The section under pain management on Resident #11's quarterly MDS assessment dated [DATE] erroneously reflected the resident did not receive any pain medications. The section of the MDS assessment for pain reflected (in error) the resident did not indicate any pain or possible pain in the past five days. According to the Individual Control Drug Record for April 2012, Resident #11 was administered Tylenol and [MEDICATION NAME] as ordered. Review of the resident's current comprehensive care plans dated 11/02/11 and which was to continue for the next 90 days revealed there was no care plan formulated to address the resident's contractures and pain until surveyor intervention. 2) The admission orders [REDACTED]. His pain medications included: [MEDICATION NAME] 7.5/500 mg, give two teaspoons (10 ml), twice a day as needed; and [MEDICATION NAME] ([MEDICATION NAME]) 600 mg every eight hours as needed via his GT. Review of the initial Pain Assessment for Resident #10 dated 05/16/12 reflected he had no pain on a scale of 0-10 with a 10 being the very worst pain, which was to be verbalized by the resident. The Wong-Baker FACES Pain Rating Scale was left blank and the Pain Assessment in Advanced Dementia (PAINAD) had a line drawn through it, to indicate the assessment was not applicable to the resident. The Initial Assessment for Resident #10 by the PT on 05/17/12 reflected, "Pt unable to state pain intensity, but stated pain in BLE (Bilateral Lower Extremity, both legs) with movement." During initial tour on 05/22/12 at 10:35 a.m., with LVN C, Resident #10 was observed in bed, in a supine position, with flexion contractures of both legs. The resident's knees were drawn up and held tightly together due to his contractures. There was no pressure relief device between his legs. On 05/22/12 at 1:30 p.m., the surveyor observed the resident's contracted knees were still held tightly together, and there was no pressure relief device. On 05/23/12 at 9:05 a.m., the surveyor observed Resident #10 in bed receiving Diathermy (electrically induced heat, which is used for muscle relaxation), which was applied to his left knee. On 05/23/12 at 4:25 p.m., observation revealed there was a pillow tucked behind the resident's knees, however, there was no pressure relief device between his knees. During this observation, the resident was slumped in his bed, in a supine position, and when he saw the surveyor, cried out saying, "Oh Lord! I'm so glad you're here to help me!" The surveyor asked the resident what he needed help with, and he said he was not in a comfortable position. The surveyor then asked the resident to move his knees so they were not touching. Resident #10 was only able to pull his knees apart by about a half-inch and cried out in pain when he did so. During this observation, CNA O stated she was assigned to Resident #10. The CNA told the surveyor the resident cried out whenever a pillow was placed between his contracted knees. She said the charge nurses were aware of his pain. The surveyor asked CNA O to get the charge nurse to assess the resident's pain. According to the nurses' notes dated 05/23/12 and timed 7:00 p.m., Resident #10 was assessed for pain but he denied being in pain. As a result, no pain medication was given per the Pain Management Flowsheet. Observation on 05/24/12 at 9:30 a.m., Resident #10 had a pillow between his contracted legs to prevent pressure ulcers and further joint contractures following surveyor intervention. At that time, Resident #10 was reassessed for pain and he rated his pain intensity at a "7" on a PAINAD scale of 1-10. He was given [MEDICATION NAME] 7.5/500 mg, which was the first time it had been administered since his admission on 05/16/12. Review of Resident #10's nurses' notes dated 05/24/12 and timed 9:40 a.m.; his Pain Management Flowsheet; and the Individual Controlled Drug Record confirmed the pain assessment and administration of the [MEDICATION NAME]. On 05/25/12 at 11:40 a.m. observation revealed Resident #10 had a pillow between his knees and he was wearing a pair of waffle boots (a pressure relief device) on his legs and feet. The surveyor observed Resident #10 with LVN V on 05/25/12 at 3:11 p.m. The resident had a pillow between his knees, was wearing his pair of waffle boots, and had a sock on his left foot. The resident said his pain was worse on his left leg. LVN V proceeded to take the sock off in order to assess the resident's leg. The resident cried out repeatedly, "O Lord, it hurts!" as LVN V gently pulled the sock off his left foot. Observation of Resident #10's left toes revealed his first toe rested on his second toe. The second toe rested on top of the third toe, and the nail of the third toe was pressing under and into the bottom of the second toe. The fourth toe rested underneath the third toe. During this observation, the surveyor gently touched the waffle booth on the resident's left leg by his toes for a closer observation of his toes, and the resident cried out in pain saying, "Oh no, it hurts!" The resident flinched with obvious facial grimacing. On 05/25/12 at 4:04 p.m., the surveyor asked the RNC to assess Resident #10's pain. During this observation, the RNC touched the resident's toes and he flinched and cried out in pain. Record review and an interview with LVN C, the charge nurse for Resident #10, on 05/25/12 at 4:30 p.m. revealed a new telephone order on 05/25/12 at 12:30 p.m. for 10 ml of [MEDICATION NAME] 7.5/500 mg to be administered routinely twice a day and every four hours as needed for breakthrough pain. LVN C stated, "Resident (Resident #10) complains of pain all the time. You give him pain meds (medications); you ask him (how much pain) on a scale of 1-10, he says 7. You check on him, and he says he's still hurting, so I don't know." LVN C further stated she had medicated the resident with 10 ml [MEDICATION NAME] 7.5/500 at 1:00 p.m. and the resident was due for another dose at 5:00 p.m. On 05/25/12 at 4:47 p.m., the facility's Nurse Practitioner said she observed the resident, and agreed his pain would be better managed with the new routine pain medications and breakthrough pain medications every four hours as opposed to the prn (as needed) 10 ml [MEDICATION NAME] 7.5/500 and [MEDICATION NAME] 600 mg previously ordered. The 5-day MDS assessment dated [DATE] reflected Resident #10 was admitted to the facility on [DATE]. The MDS assessment included Contracture of his lower leg joint as an active diagnosis, and the section under functional limitation of range of motion reflected impairment of both his legs. The MDS assessment reflected Resident #10 was totally dependent on facility staff for all his ADLs. The MDS assessment erroneously reflected the resident did not receive pain medication as needed and he did not receive non-medication intervention for pain, even though he received OT services and [MEDICATION NAME] PRN during the day shift. Further review of the MDS assessment revealed Resident #10's staff assessment of pain, erroneously reflected the resident had not experienced any pain in the past five day of the assessment period. The corresponding plan of care dated 05/16/12 reflected Resident #10 experienced pain secondary to contractures and generalized discomfort. The facility approach was to assess his pain each shift, assess for pain tolerance and medicate him with [MEDICATION NAME]. There was no plan of care in the entire clinical record to provide comfort measures, prevent further contractures and/or reduce the risk of pressure ulcer development between his contracted knees until surveyor intervention. 3) Resident #27 was initially observed during rounds on 05/22/12 at 10:10 a.m. with LVN B. LVN B described the resident as having contractures and being a quadriplegic. The resident was observed sitting in a wheelchair in the day area of the York Building. Rolled washcloths were noted in both of Resident #27's hands. Review of the resident's Record of admitted d 02/02/12 reflected an initial admission date of [DATE] and a readmission date of [DATE]. A physician's telephone order dated 04/06/12 reflected Resident #27 needed a splint to address finger contractures. According to the order the current splint was not effective in extending the resident's fingers. The telephone order further included [MEDICATION NAME] (muscle relaxer) 10 mg to be administered orally every day to treat the resident's muscle spasms. The OT plan of care for Resident #27 revealed a start of care date of 04/26/12 and referenced the date of the physician's telephone order (04/06/12) as the onset date of the treatment diagnosis. According to the plan of care the reason for the referral was for orthotic and contracture management due to the resident's hand/wrist splints not fitting correctly, increasing tightness and decreasing range of motion in the resident's fingers. According to the OT discharge summary dated 05/14/12, Resident #27 was provided with a left hand splint, which was to be worn at night for eight hours. The discharge summary reflected the resident's right hand splint was on order. An interview with Resident #27 on 05/24/12 at 4:55 p.m. revealed the resident had a splint for the left hand but had been waiting for the splint for her right hand. According to the resident, the splints straightened/extended her fingers. The resident further stated the splint for her right hand had been ordered a long time ago, and she could feel the fingers on her right hand getting "tighter" (flexing). Resident #27's current MDS assessment dated [DATE] reflected the resident was totally dependent and required extensive assistance of staff for all ADLs. The MDS assessment further reflected the resident had functional limitations in range of motion in both arms and legs. A care plan related to Resident #27's hand contractures was dated 03/19/12 and addressed the potential for contractures. Interventions included OT and PT as ordered, using devices/splints and/or appliances as indicated. On 05/24/12 at 1:50 p.m., the surveyor interviewed Staff R to determine when the right hand splint for Resident #27 had been ordered. Staff R told the surveyor she was responsible for central supply in the York Building where Resident #27 resided and was the person who would have ordered the resident's splint. Staff R stated she had not ordered a right hand splint for Resident #27 and was not aware of the need to order the splint. Rehab Director T was queried on 05/24/12 at 2:10 p.m. about Resident #27's right hand splint and when it had been ordered. She stated she would check. On 05/24/12 at 3:10 p.m. Rehab Director T provided the surveyor with a carbon copy (yellow portion) of a communication form dated 05/11/12. The form reflected a right hand anti-[DIAGNOSES REDACTED] ball splint for Resident #27 had been ordered on [DATE]. Rehab Director T informed the surveyor while she had been trying to determine when the resident's splint had been ordered, she discovered the splint was on back order. Rehab Director T stated she had just found out "today" (05/24/12), and the splint would be reordered "today" (05/24/12) from a different company, who had the splint available for shipment. According to Rehab Director T, Resident #27 was assessed by the therapy department after the 04/06/12 physician's orders [REDACTED]. The DON was interviewed on 05/25/12 at 1:25 p.m., who told the surveyor she had spoken to facility staff and also contacted OT U. She stated no one was able to recall receiving the original communication form dated 05/11/12 related to the splints for Resident #27. An interview with OT U on 05/25/12 at 2:20 p.m. revealed the anti-[DIAGNOSES REDACTED] splint was used to prevent contractures by inhibiting the abnormal tone of the resident's hand. According to OT U, the hand splints Resident #27 had been using were not appropriate because they created the potential for pressure ulcer development. During an interview on 05/25/12 at 2:50 p.m., Resident #27 stated it had been a "long time" since the splint for the right hand had been ordered. The resident stated she had frequently asked different staff, including therapy staff, about the splint. The resident further stated she had not been provided a specific answer whenever she had asked about the splint. Resident #27 stated, "They just keep saying it's been ordered." On 05/25/12, the facility provided a care plan dated 05/25/12 to address Resident #27's alteration in comfort and risk for worsening contractures to both hands. The interventions did not include the use of the anti-[DIAGNOSES REDACTED] splits. Review of the CMS Form 672 (Resident Census and Conditions of Residents), signed by the DON on 05/22/12, revealed 82 residents had contractures and 73 residents had contractures on admission.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #3) of five residents reviewed for behaviors and two (Resident #10 & Resident #11) of nine residents reviewed for pain management. 1) Resident #3's behaviors had been getting worse with her being more aggressive with staff by biting, kicking, scratching, slapping and hitting them. She was also screaming and talking loudly. One staff person was afraid of the resident. Facility staff were resigned to just having to deal with the resident's behaviors. Medications were administered when the resident would take them. The resident had not had a psychiatric evaluation and the resident's care plan was not implemented. These failures could affect Resident #3 and the other 33 residents identified with behavioral symptoms at risk for reduced safety to themselves and others, verbal/physical abuse and/or neglect, resulting in the potential for tissue injury causing infection, pain and discomfort. 2) Resident #10 was admitted to the facility with painful contracted knees. The facility failed to perform a thorough pain and contracture assessment in order to manage his pain with routine pain medications and failed to provide comfort measures between his contracted knees. 3) Resident #11 was admitted to the facility with contracted arms, but was able to extend all joints of his arms by about 20 degrees with Passive Range of Motion. Resident #11 did not receive continued restorative services and the care was terminated because the resident expressed pain during care. Following surveyor intervention, an OT assessment revealed the resident had a decline in ROM of his contracted arms and he was unable to open his palms due to increased contractures and pain. These failures resulted in Residents #10 and #11 experiencing a dramatic decline in ROM and increased pain/discomfort and could affect the 82 residents with contractures, including Residents #10 and #11 by placing them at risk for a further decrease in range of motion, and increased pain and discomfort with movement. Findings included: 1) Resident #3 was observed during initial tour on 05/22/12 at approximately 9:30 a.m. sitting in a wheelchair in her hallway sleeping. Resident #3 appeared to be in no discomfort at the time of observation and was appropriately dressed, except for one sock, which had fallen off her left foot. Unit Manager LVN A reached down to place the sock back onto Resident #3's left foot, at which time LVN A told the surveyor staff had to be very careful with the resident due to having some pretty bad behaviors. As LVN A attempted to place the sock back on Resident #3's left foot, Resident #3 kicked LVN A in the chest. LVN A said, "Well, at least it was not my face... This morning we gave her a shower, and it took three staff members to complete the bath." Resident #3's "Record of Admission" dated 01/12/12 reflected an admission to the facility on [DATE] with a readmission on 08/03/11. [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #3, a [AGE] year-old female, had the following active Diagnoses: [REDACTED]. There was no psychiatric/mood disorder identified. The MDS assessment reflected Resident #3 was rarely/never understood, she sometimes understood, had short and long-term memory problems and was severely impaired cognitively. The MDS assessment did not identify any physical or verbal behavioral symptoms, which were directed toward others; and the behavior of rejecting care was not exhibited. Resident #3 required extensive and/or was totally dependent upon one or two staff for ADLs. Observation on 05/22/11 at 12:20 p.m. revealed Resident #3 was sitting in the front lobby, and LVN D was trying to look at Resident #3's feet. Resident #3 was folding her feet up under the wheelchair, and LVN D said, "I need to take her to her room to assess her feet." Observation on 05/22/12 at 1:00 p.m. revealed Resident #3 was slapping at CNA E's hands as she tried to assist with the completion of Resident #3's lunch. Interview on 05/22/12 at 1:00 p.m. with CNA E revealed Resident #3 needed very little assistance to complete her meal. CNA E said Resident #3 liked to eat lunch, sometimes she would eat a good breakfast, but not often, so she was really hungry at lunch. CNA E said if you tried to help her, she would just hit at you most of the time, so it was best to just stay away. When the surveyor queried CNA E if Resident #3 had always been that way, CNA E said as long as she (CNA E) could remember she (Resident #3) had been like that, and some days were worse than others. Observation on 05/22/11 at 2:20 p.m. revealed Resident #3 was still wearing soiled clothing from lunch. There was dried juice and food on her clothing. Observation on 05/22/11 at 4:25 p.m. revealed LVN D was assessing Resident #3's feet while the resident was in bed. During the assessment, Resident #3 was kicking at LVN D, squeezing her arms and trying to bite her. The surveyor noted Resident #3 had been placed in bed and was still wearing the same soiled clothing from lunch. Further observation revealed LVN D showing anxiety and visual guarding during the assessment. Interview on 05/22/12 at 4:25 p.m. revealed LVN D was fearful of being hurt by Resident #3. LVN D said she had been hurt before by Resident #3. LVN D told the surveyor she had been kicked in the face and bruised by Resident #3. LVN D showed the surveyor her arms, which had been scarred from Resident #3 scratching and biting at her. LVN A and the facility's only ADON were interviewed on 05/22/12 at 4:35 p.m. about Resident #3's behaviors and interventions they had implemented for the resident to keep both the resident and the staff safe. They stated the staff all knew Resident #3, and they just tried to deal with her. Resident #3 had lived there (at the facility) for a long time. They stated they could not think about sending her anyplace else. When the surveyor queried LVN A and the facility's only ADON about medications, they told the surveyor Resident #3 would not take them and asked what "else should we do?" Interview on 05/22/12 at 5:00 p.m. with CNA P revealed he had assisted Resident #3 to her bed earlier that day. CNA P said it was unusual for Resident #3 to still be up on his shift, and she was usually in bed when he came into work. When asked if it was difficult to change Resident #3's clothing, he responded it was very difficult to do anything for her. "You just have to suffer through it." Interview on 05/23/12 at 12:15 p.m. with CNA E revealed she cared for Resident #3 two out of the four days she worked. When asked about Resident #3's behaviors, CNA E said Resident #3 was tough, she would bite, kick, scratch, and hit, she just wanted you to know who was boss. CNA E said yesterday when she came to work, she was concerned because Resident #3 had the same clothing on as when CNA E had left the day before, and Resident #3 was really soiled. CNA E said she reported it to her Unit Manager LVN A. CNA E stated she and three other staff members gave Resident #3 a shower. The surveyor inquired if Resident #3 calmed down in the shower. CNA E said after the water was turned on and the shower began, she calmed down. The surveyor queried if CNA E placed Resident #3 in bed on 05/22/12. CNA E said no, because when she went to place Resident #3 in bed after lunch, the resident starting hitting her (CNA E) with a spoon, "so I left her. Sometimes you just have to do that." When informed someone on the two to ten shift put her in bed and did not change her clothing, CNA E said she could not do that. When asked if leaving the resident's clothes on after putting her to bed happened often, the CNA stated, "Probably." On 05/23/12 at 10:45 a.m., LVN A was completing a report regarding an injury, which had been found on Resident #3's right foot and was identified as being an injury of unknown source. When queried what was being done to protect the resident from further injury, LVN A said she knew it was "late," but they were going to put pillows on the footrest of her wheelchair. LVN A stated, "I know that will not keep her from hitting things..." due to her behaviors. LVN A added she would check with the therapy department to see if there was anything else that could help. Following surveyor inquiry, observation on 05/23/12 at approximately 10:50 a.m. revealed LVN A was placing foot pedals on Resident #3's wheelchair and placing a pillow under her feet. Further observation revealed LVN A was placing sheepskin around the foot pedals on Resident #3's wheelchair. During this observation, LVN A revealed she was placing protective items on the wheelchair to prevent Resident #3 from hurting herself. Observation on 05/23/12 at 1:00 p.m. revealed LVN D was preparing to go into Resident #3's room and assess her feet/ankles area. LVN D looked at the surveyor and stated, "Well, I am getting ready to go and look at Mike Tyson." During an interview on 05/23/12 at 2:00 p.m. with the DON, ADON, and LVN A, the surveyor queried them about Resident #3's behaviors and the lack of interventions. At that time, they had no information to provide in regard to what they had been doing for Resident #3. The DON then said Resident #3 needed to be assessed and properly treated for [REDACTED].#3 was capable of hurting someone and/or herself. LVN A said she would call the facility's Psychiatrist to come and evaluate Resident #3 for her behaviors and she would talk to the staff about communicating better concerning Resident #3's behaviors. Observation on 05/24/12 at 10:00 a.m. revealed the Psychiatrist was evaluating Resident #3 as a new patient. Staff communicated with the Psychiatrist about Resident #3 being combative. The Psychiatrist queried about what happened when [MEDICATION NAME] (anti-anxiety medication) was administered it to Resident #3. LVN Q replied, "Nothing." The Psychiatrist said sometimes [MEDICATION NAME] could make a person worse and the [MEDICATION NAME] had been given to Resident #3 for a long time. The staff did not tell the Psychiatrist about the difficulty they would have in administering the oral medications he ordered to the resident. The physician telephone order dated 05/24/12 reflected [MEDICATION NAME] (antidepressant), generic for Trazadone, was to be given by mouth two times a day to Resident #3. Resident #3's consolidated physician orders [REDACTED]. Resident #3's MARs for March, April and May 2012 reflected no omissions for the [MEDICATION NAME], which was given every twelve hours and only one dose of the prn [MEDICATION NAME]. Further review revealed "Monthly Behavior Flow Sheets" for Resident #3 dated March, April and May 2012 contained no documentation in regard to anxious or agitated behaviors. physician progress notes [REDACTED]. The physician had noted under Clinical Findings: "...patient was scratching and clawing nurse when tried to put on examination table, due to this we unable to examine patient....please have patient sedated prior to appointment to allow for examination...." Review of a physician progress notes [REDACTED]. Hits examiner on face... Agitated and combative throughout exam... Plan ...Continue current meds, continue plan of care...." Nurse's notes dated 04/01/12 reflected Resident #3 was uncooperative during an assessment. Review of nurse's notes dated 04/04/12 revealed Resident #3 was combative with care. Nurses notes dated 04/05/12 revealed Resident #3 was in bed screaming loud and talking very loud, medication was given, Resident #3 spit it out, and was still resisting care. Nurse's notes dated 04/08/12 reflected, "...Resident fighting, screaming, and cursing during incontinent care...." Nurse's notes dated 04/14/12 revealed Resident #3 was "...yelling and screaming during incontinent care...." Nurse's notes dated 05/18/12 reflected Resident #3 was "very combative and continues to resist care." Resident #3 was also refusing medications. "(Resident #3) cursing at everyone/staff members... Report given to oncoming nurse to call physician concerning topical meds...." Further review revealed no further follow-up in regard to calling the physician and/or the possibility of the use of topical medications. Resident #3's Care Plan dated 04/12/12 reflected she was receiving [MEDICATION NAME] for a [DIAGNOSES REDACTED].#3 to have no side effects from the [MEDICATION NAME]. Goals further reflected Resident #3 would have no signs/symptoms of anxiety i.e.: crying, agitation... Interventions for Resident #3 included she would have a "psychiatric evaluation, assess for behaviors and notify M.D., notify M.D. with problems, and assess resident for change of mood or increase of anxiety...." Another Care Plan dated 04/12/12 reflected Resident #3 cursed at staff, refused ADL care, and tried to swing at and hit staff providing care. Goals were for Resident #3 not to have complications from listed behaviors. Further review revealed four pages of interventions, i.e.: Don't stand too closely to invade their space, don't touch resident, if resistance, use non-verbal cues, take for a walk, check to see if resident needs to go to the bathroom, move to another chair, and revise care plan. Interventions had not been revised or updated. 2) Review of the facility's current policy for Social Services Behavioral Management dated 02/04/11 reflected: "1. If a resident should exhibit behavior problems, the facility will begin the assessment process. 2. Assessment process may include... ...b. Interview the staff and family and who may be able to provide information related to the behavior... ...e. assess antecedents to the behavior (what happened right before the behavior occurred?) ...g. review of medical record (medication changes, changes in bowel bladder habits, food and fluid intake changes, changes in sleep patterns, falls, injuries). 3. A plan will be developed based on the professional assessment. 4. The resident's response to the interventions will be documented and reviewed by the interdisciplinary team....if the plan is not effective in addressing the problem behavior; the team will re-assess and change the interventions. 5. Psychological or psychiatric consultation may be sought if the interdisciplinary team deems necessary...." 3) The consolidated physician's orders [REDACTED]. His [DIAGNOSES REDACTED]. His medications included: [MEDICATION NAME] (narcotic pain reliever) 5/500 mg, give one every day, Tylenol ([MEDICATION NAME]) 500 mg, give two every four to six hours; [MEDICATION NAME] ([MEDICATION NAME]) 325 mg, give two at hour of sleep, Aspirin (blood thinner) 81 mg, give one every day, and [MEDICATION NAME] (muscle relaxant) 12.5 mg every eight hours via gastrostomy tube (GT) Review of a Pain assessment dated [DATE] and 05/02/12 for Resident #11 revealed he had no pain on a scale of 0-10 with a 10 being the very worst pain, which was to be verbalized by the resident. The Wong-Baker FACES Pain Rating Scale and the Pain Assessment in Advanced Dementia (PAINAD) were left blank. During orientation rounds with LVN C on 05/22/12 at 10:50 a.m., Resident #11 was observed in bed in his room. He had severe contractures of both his arms. No positioning/anti-pressure devices were observed between his upper arms and torso, elbow and forearm, and no positioning devices in his severely contracted hands. Observation on 05/22/12 at 1:15 p.m. and at 1:40 p.m. revealed Resident #11 had a small rolled-up wash cloth in his contracted right hand. There were no other positioning devices observed on the rest of his contracted arms and/or left hand. Multiple observations of Resident #11 on 05/23/12 at 8:55 a.m., 1:05 p.m. and 4:30 p.m. revealed the resident was in the same condition regarding the lack of positioning devices being used for the contractures of his arms, wrists and left hand, as described on 05/22/12. On 05/24/12 at 12:41 p.m., Resident #11 was observed as he sat in a wheelchair in the lobby area, watching television. He only had a small rolled-up wash cloth in his right hand and no other positioning devices for the contractures of his arms, wrists and left hand. Review of the Occupational Therapy (OT) plan of care revealed therapy assessed and treated Resident #11 for contracture management of both his arms, wrists and hands from 02/15/12 through 03/06/12. During a review of the initial OT progress report and plan of care notes dated 02/15/12 and interview with OT W on 05/23/12 at 11:41 a.m., she stated Resident #11 was able to demonstrate passive range of motion (PROM) of both his arms and wrist, including his fingers by at least 20 degrees. She said her goal for Resident #11 was to increase his PROM by 30 degrees but the resident did not reach his goal and he was discharged to Restorative Care on 03/10/12. OT W told the surveyor Resident #11 was to receive Restorative Care for 90 days, which a review of the Restorative Care notes dated 03/10/12 confirmed. The facility was also to ensure the palms of Resident #10's hands were washed and to continue with PROM of his fingers and place soft splints in both hands. In an interview with RA X on 05/23/12 at 12 noon, he stated he performed ROM, washed the palms of Resident #11's hands and placed wash towels in his hands when the resident was on Restorative Care. He said the Restorative Aides had a meeting with their supervisor, LVN MDS Coordinator, on 04/19/12, and terminated the restorative exercises and care for Resident #11, because he complained of pain. On 05/24/12 at 12:20 p.m., the surveyor queried LVN MDS Coordinator about Resident #11's contracted hands, which had no protective/positioning devices. The LVN MDS Coordinator said she was not very familiar with Restorative Care and told the surveyor, "We should not have stopped the restorative services in hindsight." She said she should have asked nursing to medicate the resident in order to continue with his PROM. Following surveyor intervention, OT U re-assessed Resident #11's contractions of his arms, wrist and hands. Her Initial Assessment progress notes dated 05/24/12 reflected, "pt presents with pain 10/10 (pain scale of 0-10 with 10 being the very worst pain) in bilateral and elbows with movement and with guarding with touch. Pt has foul odor from palms of hands bilaterally (both) and with nails digging into palms of hands in fisted position at all times and did not tolerate attempts to measure joints of hands. Elbow measurement as follows: right elbow extension 5 degrees and left elbow extension to 30 degrees... Rehab Potential: Good due to: Positive results from previous treatment." During an interview with OT U on 05/25/12 at 11:39 a.m. concerning Resident #11, she stated the resident would require multiple gentle [MEDICAL CONDITION], starting from his shoulders in order to relax his contacted muscles. She said she had provided in-service training to the day shift staff on how to position the resident with pillows for both of his arms, wrist and hands when in bed and in his wheelchair. Observation of Resident #11, on 05/25/12 at 3:25 p.m., with LVN V revealed the resident was positioned on his left side in bed with no protective devices/pillows placed for either arm, wrist and/or hand, and his left elbow was pressed deep into the mattress. When LVN V was questioned about the resident's contractures and a recent in-service training from therapy, she said she had not attended any in-service training regarding repositioning of Resident #11. She said the resident always complained of pain when you "put anything on his hand." On 05/25/12 at 4:08 p.m., the surveyor asked the Regional Nurse Consultant (RNC) to assess Resident #11's contractures of his arms, wrists and hands as observation at that time had revealed there were still no positioning devices. The RNC observed the resident lying on his left side with his left elbow digging into the mattress. She tried to move his left elbow and the resident cried out in pain saying, "It hurts." The facility conducted a pain assessment for Resident #11 using the PAINAD on 05/24/12. His score was 8. According to the legend on the PAINAD sheet, the score was based on a scale of 0-10 and a higher score indicated more severe pain. On 05/25/12 at 4:45 p.m., the DON stated she would have the Director of Rehabilitation Services in-service all staff regarding the care of Resident #11's arm, elbow, wrist and hand contractures and ask the Nurse Practitioner to reassess the resident's pain. The quarterly MDS assessments dated 11/02/11, 02/01/12 and 05/01/12 for Resident #11 reflected he was totally dependent on facility staff for all his ADLs, and he had impairment of both his arms. The section under pain management on Resident #11's quarterly MDS assessment dated [DATE] erroneously reflected the resident did not receive any pain medications. The section of the MDS assessment for pain reflected (in error) the resident did not indicate any pain or possible pain in the past five days. According to the Individual Control Drug Record for April 2012, Resident #11 was administered Tylenol and [MEDICATION NAME] as ordered. Review of the resident's current comprehensive care plans dated 11/02/11 and which was to continue for the next 90 days revealed there was no care plan formulated to address the resident's contractures and pain until surveyor intervention. 4) The admission orders [REDACTED]. His pain medications included: [MEDICATION NAME] 7.5/500 mg, give two teaspoons (10 ml), twice a day as needed; and [MEDICATION NAME] ([MEDICATION NAME]) 600 mg every eight hours as needed via his GT. Review of the initial Pain Assessment for Resident #10 dated 05/16/12 reflected he had no pain on a scale of 0-10 with a 10 being the very worst pain, which was to be verbalized by the resident. The Wong-Baker FACES Pain Rating Scale was left blank and the Pain Assessment in Advanced Dementia (PAINAD) had a line drawn through it, to indicate the assessment was not applicable to the resident. The Initial Assessment for Resident #10 by the PT on 05/17/12 reflected, "Pt unable to state pain intensity, but stated pain in BLE (Bilateral Lower Extremity, both legs) with movement." During initial tour on 05/22/12 at 10:35 a.m., with LVN C, Resident #10 was observed in bed, in a supine position, with flexion contractures of both legs. The resident's knees were drawn up and held tightly together due to his contractures. There was no pressure relief device between his legs. On 05/22/12 at 1:30 p.m., the surveyor observed the resident's contracted knees were still held tightly together, and there was no pressure relief device. On 05/23/12 at 9:05 a.m., the surveyor observed Resident #10 in bed receiving Diathermy (electrically induced heat, which is used for muscle relaxation), which was applied to his left knee. On 05/23/12 at 4:25 p.m., observation revealed there was a pillow tucked behind the resident's knees, however, there was no pressure relief device between his knees. During this observation, the resident was slumped in his bed, in a supine position, and when he saw the surveyor, cried out saying, "Oh Lord! I'm so glad you're here to help me!" The surveyor asked the resident what he needed help with, and he said he was not in a comfortable position. The surveyor then asked the resident to move his knees so they were not touching. Resident #10 was only able to pull his knees apart by about a half-inch and cried out in pain when he did so. During this observation, CNA O stated she was assigned to Resident #10. The CNA told the surveyor the resident cried out whenever a pillow was placed between his contracted knees. She said the charge nurses were aware of his pain. The surveyor asked CNA O to get the charge nurse to assess the resident's pain. According to the nurses' notes dated 05/23/12 and timed 7:00 p.m., Resident #10 was assessed for pain but he denied being in pain. As a result, no pain medication was given per the Pain Management Flowsheet. Observation on 05/24/12 at 9:30 a.m., Resident #10 had a pillow between his contracted legs to prevent pressure ulcers and further joint contractures following surveyor intervention. At that time, Resident #10 was reassessed for pain and he rated his pain intensity at a "7" on a PAINAD scale of 1-10. He was given [MEDICATION NAME] 7.5/500 mg, which was the first time it had been administered since his admission on 05/16/12. Review of Resident #10's nurses' notes dated 05/24/12 and timed 9:40 a.m.; his Pain Management Flowsheet; and the Individual Controlled Drug Record confirmed the pain assessment and administration of the [MEDICATION NAME]. On 05/25/12 at 11:40 a.m. observation revealed Resident #10 had a pillow between his knees and he was wearing a pair of waffle boots (a pressure relief device) on his legs and feet. The surveyor observed Resident #10 with LVN V on 05/25/12 at 3:11 p.m. The resident had a pillow between his knees, was wearing his pair of waffle boots, and had a sock on his left foot. The resident said his pain was worse on his left leg. LVN V proceeded to take the sock off in order to assess the resident's leg. The resident cried out repeatedly, "O Lord, it hurts!" as LVN V gently pulled the sock off his left foot. Observation of Resident #10's left toes revealed his first toe rested on his second toe. The second toe rested on top of the third toe, and the nail of the third toe was pressing under and into the bottom of the second toe. The fourth toe rested underneath the third toe. During this observation, the surveyor gently touched the waffle booth on the resident's left leg by his toes for a closer observation of his toes, and the resident cried out in pain saying, "Oh no, it hurts!" The resident flinched with obvious facial grimacing. On 05/25/12 at 4:04 p.m., the surveyor asked the RNC to assess Resident #10's pain. During this observation, the RNC touched the resident's toes and he flinched and cried out in pain. Record review and an interview with LVN C, the charge nurse for Resident #10, on 05/25/12 at 4:30 p.m. revealed a new telephone order on 05/25/12 at 12:30 p.m. for 10 ml of [MEDICATION NAME] 7.5/500 mg to be administered routinely twice a day and every four hours as needed for breakthrough pain. LVN C stated, "Resident (Resident #10) complains of pain all the time. You give him pain meds (medications); you ask him (how much pain) on a scale of 1-10, he says 7. You check on him, and he says he's still hurting, so I don't know." LVN C further stated she had medicated the resident with 10 ml [MEDICATION NAME] 7.5/500 at 1:00 p.m. and the resident was due for another dose at 5:00 p.m. On 05/25/12 at 4:47 p.m., the facility's Nurse Practitioner said she observed the resident, and agreed his pain would be better managed with the new routine pain medications and breakthrough pain medications every four hours as opposed to the prn (as needed) 10 ml [MEDICATION NAME] 7.5/500 and [MEDICATION NAME] 600 mg previously ordered. The 5-day MDS assessment dated [DATE] reflected Resident #10 was admitted to the facility on [DATE]. The MDS assessment included Contracture of his lower leg joint as an active diagnosis, and the section under functional limitation of range of motion reflected impairment of both his legs. The MDS assessment reflected Resident #10 was totally dependent on facility staff for all his ADLs. The MDS assessment erroneously reflected the resident did not receive pain medication as needed and he did not receive non-medication intervention for pain, even though he received OT services and [MEDICATION NAME] PRN during the day shift. Further review of the MDS assessment revealed Resident #10's staff assessment of pain, erroneously reflected the resident had not experienced any pain in the past five day of the assessment period. The corresponding plan of care dated 05/16/12 reflected Resident #10 experienced pain secondary to contractures and generalized discomfort. The facility approach was to assess his pain each shift, assess for pain tolerance and medicate him with [MEDICATION NAME]. There was no plan of care in the entire clinical record to provide comfort measures, prevent further contractures and/or reduce the risk of pressure ulcer development between his contracted knees until surveyor intervention. 5) Review of the CMS Form 672 (Resident Census and Conditions of Residents), signed by the DON on 05/22/12, revealed 34 residents had behavioral symptoms, 70 residents were on a pain management program, 82 residents had contractures and 73 residents had contractures on admission.