Every finding on record at Willow Tree Healthcare Center

Based on interview, and record review, the facility failed to ensure that alleged violations involving abuse, neglect, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made. Resident Identifier: #31. Facility Census: 98.Findings Include Ra) Resident #31Record review revealed that Resident #31 was diagnosed with Type II Diabetes Mellitus with Hyperglycemia. The resident had been prescribed Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 38 units subcutaneously at bedtime for diabetes.During an interview with Resident #31 on 10/28/25 at approximately 9:28 AM, resident stated that on the night of 10/16/25, he was not feeling well and had asked Nursing Aide (NA) #36 for something to eat because he was not feeling well. Resident #31 stated that NA #36 had responded, saying, There are no sandwiches, shut up and go to sleep! Resident #31 stated that he was very upset about what had happened. Resident #31 also noted that after his complaint, a nurse and NA #36 came into his room, and NA #36 denied saying that to him. The resident stated that he had responded, Bullshit, she said that!Upon being asked what action had been taken to address his allegation, the resident stated that he had been told that snacks would be available at night.A review of the Initial report submitted to the Office of Health Facility Licensing and Certification (OHFLAC) revealed the following description of the allegation, [Typed as written], by the Assistant Director of Nursing (ADON): On 10/17/25 at 7:20 AM, patient experienced an episode of hypoglycemia. Blood glucose was checked and found to be 40/42 mg/dl. Appropriate interventions were initiated per hypoglycemia protocol. Including administration of oral glucose/juice/snack. Blood glucose was rechecked and noted to be within normal range following treatment. Patient became alert and stable after intervention.After stabilization, patient reported that on the night of 10/17/25 at approximately midnight, he requested something to eat because he was not feeling well. Patient stated that the CNA who responded told him to shut up and go to sleep and that there was nothing to eat. Patient expressed frustration regarding the incident. Charge nurse notified. Follow up planned with dietary services and CNA staff regarding nighttime snack availability and staff-patient interaction. Patient currently awake, alert, and resting comfortably in bed. No acute distress noted. Will continue to monitor and support as necessary.The initial report was submitted to OHFLAC on 10/20/25 at 5:40 PM, which had not met the mandated reporting window for abuse.During an interview with the Director of Nursing (DON) and ADON on 10/29/25 at approximately 10:35 AM, the ADON insisted that she had been involved in the resident's care, and stated that she had not been aware of the details of the incident until 10/20/25. Upon being questioned about her written statement dated 10/17/25, in the initial report, ADON stated the resident had not made any statement at the time of the hypoglycemic episode because he was out of it. ADON stated that they had been unaware of the incident until she had received the complaint from the resident on 10/20/25.However, record review on 10/28/25 at 10:00 AM revealed that the facility had been aware of the circumstances of the incident on 10/17/25, as evidenced by the following:An order on 10/17/25 which stated:Please give resident a small snack of crackers and cheese before bedtime to prevent hypoglycemia. In addition, the resident's previous order for insulin dated 01/12/25, which stated:Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 38 unit subcutaneously at bedtime for diabetes, had been discontinued on 10/17/25, and a new order had been placed on 10/17/25, which stated:Insulin Glargine yfgn - Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-yfgn) Inject 30 unit subcutaneously one time a day for DM2 Further review of records revealed that the five day follow up report to OHFLAC had been submitted on 10/22/25 at approximately 3:26 PM.The investigative summary stated the following: On 10/20/25, at approximately 7:20 AM, a resident reported a prior incident allegedly involving verbal mistreatment by an NA that occurred on 10/17/25 around midnight. The resident stated that when requesting food, the NA told him to shut up and go to sleep, and there was nothing to eat.Immediate actions:Resident safety ensured, reassurance provided that the allegation would be reported and investigated as per facility policy. Charge Nurse, Supervisor, and DON notified immediately .NA was suspended pending investigation to protect resident safety and maintain impartiality.Incident reported to the Sheriff's Office per mandatory reporting guidelines. Interviews conducted with the resident, involved NA, and other staff on duty at the time of the alleged incident. No witnesses or corroborating evidence were found to support the allegation. The facility documented that the Investigation had determined that there was insufficient evidence to substantiate the allegation of verbal mistreatment.Notwithstanding the fact that Resident #31 had presented with a blood glucose level of 40 mg/dl on the morning of 10/17/25, and had also expressed his frustration regarding the incident, the facility investigation and summary of the incident stated that No physical or emotional harm identified in the resident.

Based on interview, and record review, the facility failed to ensure that residents were free from abuse and neglect, as evidenced by the facility staff failing to accommodate the resident's request for a snack. Resident Identifiers: Resident #31. Facility Census: 98.Findings Includea) Resident #31Record review revealed that Resident #31 was diagnosed with the following:Type II Diabetes Mellitus with HyperglycemiaHemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side.Acquired absence of left leg above the kneeAcquired absence of right leg above the kneeChronic Obstructive Pulmonary Disease Dysphagia following Cerebral InfarctionGastrointestinal Hemorrhage UnspecifiedMuscle Weakness (Generalized)Unspecified Lack of Coordination Resident #31 has capacity and has a Brief Interview for Mental Status (BIMS) score of 15. During an interview with Resident #31 on 10/28/25 at approximately 9:28 AM, resident stated that on the night of 10/16/25, he was not feeling well and had asked Nursing Aide (NA) #36 for something to eat because he was not feeling well. Resident #31 stated that NA #36 had responded, saying, There are no sandwiches, shut up and go to sleep! Resident #31 stated that on the morning of 10/17/25 he had woken up with a blood glucose level of 40. Resident #31stated that he was very upset about what had happened. Resident #31 also stated that after his complaint, a nurse and NA #36 had come into his room, and NA #36 denied saying that to him. The resident stated that he had responded, Bullshit, she said that!Upon being asked what action had been taken to address his allegation, the resident stated that he had been told that snacks would be available at night.A review of the Initial report submitted to the Office of Health Facility Licensing and Certification (OHFLAC) revealed the following description of the allegation, [Typed as written], by the Assistant Director of Nursing (ADON): On 10/17/25 at 7:20 AM, the patient experienced an episode of hypoglycemia. Blood glucose was checked and found to be 40/42 mg/dl. Appropriate interventions were initiated per hypoglycemia protocol. Including administration of oral glucose/juice/snack. Blood glucose was rechecked and noted to be within normal range following treatment. The patient became alert and stable after the intervention.After stabilization, patient reported that on the night of 10/17/25 at approximately midnight, he requested something to eat because he was not feeling well. Patient stated that the CNA who responded told him to shut up and go to sleep and that there was nothing to eat. Patient expressed frustration regarding the incident. Charge nurse notified. Follow up planned with dietary services and CNA staff regarding nighttime snack availability and staff-patient interaction. Patient currently awake, alert, and resting comfortably in bed. No acute distress noted. Will continue to monitor and support as necessary.The initial report was submitted to OHFLAC on 10/20/25 at 5:40 PM, which had not met the mandated reporting window for abuse.During an interview with the Director of Nursing (DON) and ADON on 10/29/25 at approximately 10:35 AM, the ADON insisted that she had been involved in the resident's care and stated that she had not been aware of the details of the incident until 10/20/25. Upon being questioned about her written statement dated 10/17/25, in the initial report, ADON stated the resident had not made any statement at the time of the hypoglycemic episode because he was out of it. ADON stated that they had been unaware of the incident until she had received the complaint from the resident on 10/20/25.However, record review on 10/28/25 at 10:00 AM revealed that the facility had been aware of the circumstances of the incident on 10/17/25, as evidenced by the following:An order on 10/17/25, which stated:Please give resident a small snack of crackers and cheese before bedtime to prevent hypoglycemia. In addition, the resident's previous order for insulin dated 01/12/25, which stated:Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 38 units subcutaneously at bedtime for diabetes. had been discontinued on 10/17/25, and a new order had been placed on 10/17/25 which stated:Insulin Glargine yfgn - Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-yfgn) Inject 30 units subcutaneously one time a day for DM2 Further review of records revealed written statements by Licensed Practical Nurse (LPN) #11, and NA #36.LPN #11's statement dated 10/21/25, stated: [Typed as written] I never heard [NA #36] tell resident to shut up. Resident had asked for a sandwich, [NA #36] asked me if we had any. I stated that we don't have any sandwiches. [NA #36] responded to resident saying [LPN #11] said we don't have any sandwiches. NA #36 and LPN #11 went back to the nurses' station afterward. NA #36's statement dated 10/20/25 stated: [Typed as written] On 10/16/25 at around 1or 2 am, [Resident #31] asked me for a sandwich. [LPN #11] was in the hallway and heard him ask, and she said We don't have any sandwiches. I said to [Resident] that [LPN #11] said we don't have any sandwiches.Someone told me that [Resident #31] said I told him to shut up and go to bed. I may have told him to try to get some sleep which I tell a lot of residents to try to get some sleep. I've been a NA for 32 years and have never told a resident to shut up. On 10/28/25 at approximately 1:55 PM, during an interview with Resident #30, a roommate of Resident #31, Resident #30 stated that he had been out of the facility on 10/16/25. Still, he stated, I heard about it when I got back!Ongoing record review revealed that the five-day follow-up report to OHFLAC had been submitted on 10/22/25 at approximately 3:26 PM.The investigative summary stated the following: On 10/20/25, at approximately 7:20 AM, a resident reported a prior incident allegedly involving verbal mistreatment by an NA that occurred on 10/17/25 around midnight. The resident stated that when he requested food, the NA told him to shut up and go to sleep and that there was nothing to eat.Immediate actions:Resident safety ensured, reassurance provided that the allegation would be reported and investigated as per facility policy. Charge Nurse, Supervisor, and DON notified immediately .NA was suspended pending investigation to protect resident safety and maintain impartiality.Incident reported to the Sheriff's Office per mandatory reporting guidelines. Interviews conducted with the resident, involved NA, and other staff on duty at the time of the alleged incident. No witnesses or corroborating evidence were found to support the allegation. The facility documented that the Investigation had determined that there was insufficient evidence to substantiate the allegation of verbal mistreatment.Notwithstanding the fact that Resident #31 had presented with a blood glucose level of 40 on the morning of 10/17/25, and had also expressed his frustration regarding the incident, the facility investigation and summary of the incident stated that No physical or emotional harm identified in the resident.

Based on interviews and record review, the facility failed to ensure that residents received person-centered care and treatment in accordance with professional standards of practice. Resident Identifiers: Resident #12 and #31. Facility census:98Findings Include The resident had repeated episodes of nausea and vomiting over a period of over ten (10) days, and the facility failed to refer the resident to the hospital for evaluation. The resident was finally transferred to the hospital due to a family member's insistence. At the hospital, he was treated for acute metabolic encephalopathy. Acute kidney injury, aspiration pneumonia, and a UTI.a) Resident #12Resident #12 lacks capacity and has a Brief Interview of Mental Status (BIMS) score of 1.An attempt was made to contact the residents' Power of Attorney (POA), but the call went unanswered.Record review on 10/27/25 at 3:10 PM revealed that Resident #12 was diagnosed with:Peripheral Vascular Disease, UnspecifiedDiabetes Mellitus due to underlying condition with HyperglycemiaComplete traumatic amputation at knee level, Right lower legComplete traumatic amputation of left lower leg, level unspecifiedMajor Depressive DisorderGastroesophageal Reflux Disease without EsophagitisChronic Kidney Disease Stage 3 unspecified. Further record review revealed the following notes: 07/07/25 at 11:00 PMChief Complaint / Nature of Presenting Problem:Nausea and vomitingHistory Of Present Illness:[Resident #12] is a resident of [NAME] Tree with multiple chronic medical conditions including but not limited to: HTN, PAD, iron deficiency, CKD, type 2 diabetes, depression, bilateral below the knee amputations. He is a full code and lacks capacity to make medical decisions. He is being seen today for report of nausea and vomiting. Dark brown emesis was noted and tested heme positive. He was previously on a PPI and stopped due to CKD and anemia. Zofran has been minimally improving his symptoms. He continues with dysphagia and is followed by ST. 07/08/25 at 02:46 AM CNA came to this writer after cleaning up resident stating, [Resident] threw up; we cleaned him up it was a little bit of brown throw up and clear stuff but we changed him and changed his bed. Asked CNA to get vitals and to let this writer know if it happens again and that this writer needs to see the throw up.07/08/25 at 06:04 AMLipid Panel, HgbA1c, CBC, CMP.one time only for HTN, DM2, CVA, HLD until 07/08/2025 23:59Blood obtained via right arm for labs and placed in the fridge. 07/08/25 at 6:34 AMVomiting without pain, low susp of SBO or serious pathology at this time. Will write for zofran, call back if vomiting continues. Pt can be seen today by in house provider, they should be on site. Labs already ordered and pending. Re: FS, pt non-insulin dependent, about to get breakfast. 07/08/25 at 6:42 AMOndansetron HCl Tablet 4 MGGive 1 tablet by mouth every 4 hours as needed for Nausea and Vomiting for 1 DayN/V 07/08/25 at 7:08 AM Large amounts of clear mucus with small amount of brown particles. PHP was notified and ordered Zofran 4mg PRN one was administered at 0642. And PHP wants him to be seen in house.07/08/25 at 1:18 PMSucralfate Tablet 1 GMGive 1 tablet by mouth four times a day for gastric protection for 1 Day now, before meals and at bedtime 07/09/25 at 5:37 PM by Registered Nurse (RN) #62Kidney, Ureter, and Bladder (KUB)one time only for nausea/vomiting for 11 Days. Exam to be administered 07/10/2025 07/09/25 5:37 PM by RN #62LAB: Urinalysis w/reflex cxone time only for leukocytosis, chills, SP TTP for 2 DaysExam to be performed 07/10/2025 07/09/25 at 5:38 PMrefer to GI ASAP one time only for hematochezia for 5 D. To be scheduled 07/10/2025 07/09/25 at 5:51 PMCefTRIAXone Sodium Solution Reconstituted 1 GMInject 1 gram intramuscularly every 24 hours for infection, URI for 3 DaysOne gram Rocephin administered to right gluteus maximus per order. Topical lidocaine placed 10 minuetes prior to adminsitration. Resident tolerated well. Poor po intake at dinner, only taking fluids. No emesis noted or reported thus far this shift. 07/09/25 at 11:00 PMHistory Of Present Illness:[Resident] with multiple chronic medical conditions including but not limited to: HTN, PAD, iron deficiency, CKD, type 2 diabetes, depression, bilateral below the knee amputations. He is a full code and lacks capacity to make medical decisions. He is being seen today for follow up of labs and xrays. Leukocytosis was noted >13 and IM rocephin was started, CXR was negative for acute changes and KUB showed ileus type pattern. He stated he was feeling better and taking in PO fluids. SQ 1/2 NS was [placed on hold while his mentation and PO intake improved. 07/10/25 at 12:16 PMreceived chest x ray results and KUB results. MD present in building. made him aware. waiting for new orders. 07/10/25 at 6:20 PMSodium Chloride Intravenous Solution 0.45 %Inject 500 ml subcutaneously every shift for Dehydration 50ml/hr x 0.5 liters. Leave heplock in place until repeat labs obtained. DC once IV therapy is complete.On hold per provider 07/10/25 at 6:45 PMCNA reports that [Resident] was not taking liquids normally but rather pocketing the liquid and coughing. Assessed patient and attempted to try a syringe to give him liquids, was able to get approximately 60cc water in him until he began to cough and it was an aspiration risk. He was not able to speak any words. He had his eyes rolled to the top and would flutter them with loud verbal or sternal rub. Son had arrived due to a phone call prior in the day to him. He was concerned about his decline and attempted as well to give him fluids with same unsuccessful outcome. He was updated on the events of the last several days and what tests had been done, medications that were being used and care being provided. He states he would feel better if we would send himto the hospital to be more aggressive. Assistant Direcror of Nursing (ADON) called to the room to speak with him and it was decided he would be sent out per the POA request. 911 called and report given to them and the hospital ER charge nurse. Convergence concurred with the decision when called. 07/10/25 at 7:36 PM Sent to jmc 7:10 PM 07/10/25 at 8:42 PM - Physician notePatient has abnormal KUB today and urine results were bad. Became more unresponsive this evening Family/POA came in and requested transfer. Patient was transferred to ED by facility at 7:10 PM EST. PHP was notified of transfer. PHP did not evaluate patient 07/22/25 at 11:00 PM - Physician's note[Resident] is being seen today for a return form hospital visit. He was admitted on [DATE]th and discharged on July 22nd. He was seen and treated for acute metabolic encephalopathy. Of his brain was negative for acute findings. He was treated for acute no no kidney injury as well as aspiration pneumonia and a UTI. He completed a course of Zyvox and Unasyn. His hypernatremia resolved after IV fluids. His HTN was managed with hydralazine and metoprolol. He remains on atorvastatin for HLD. His PVD and bilateral carotid stenosis is managed with Plavix, ASA, and a statin. He continues on flomax for his BPH. b) Resident #31Record review revealed that Resident #31 was diagnosed with the following:Type II Diabetes Mellitus with HyperglycemiaHemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side.Acquired absence of left leg above the kneeAcquired absence of right leg above the kneeChronic Obstructive Pulmonary Disease Dysphagia following Cerebral InfarctionMuscle Weakness (Generalized)Unspecified Lack of Coordination Resident #31 has capacity, and has a Brief Interview for Mental Status (BIMS) score of 15. The resident had been prescribed Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 38 units subcutaneously at bedtime for diabetes.During an interview with Resident #31 on 10/28/25 at approximately 9:28 AM, the resident stated that on the night of 10/16/25, he was not feeling well and had asked Nursing Aide (NA) #36 for something to eat because he was not feeling well. Resident #31 stated that NA #36 had responded, saying, There are no sandwiches, shut up and go to sleep! Resident #31 stated that he was very upset about what had happened. Resident #31 also noted that after his complaint, a nurse and NA #36 came into his room, and NA #36 denied saying that to him. The resident stated that he had responded, Bullshit, she said that!Upon being asked what action the facility had taken to address his complaint, the resident stated that he had been told that snacks would be available at night. A review of the Initial report submitted to the Office of Health Facility Licensing and Certification (OHFLAC) revealed the following description of the allegation, [Typed as written], by the Assistant Director of Nursing (ADON): On 10/17/25 at 7:20 AM, patient experienced an episode of hypoglycemia. Blood glucose was checked and found to be 40/42 mg/dl. Appropriate interventions were initiated per hypoglycemia protocol. Including administration of oral glucose/juice/snack. Blood glucose was rechecked and noted to be within normal range following treatment. Patient became alert and stable after intervention.After stabilization, patient reported that on the night of 10/17/25 at approximately midnight, he requested something to eat because he was not feeling well. Patient stated that the CNA who responded told him to shut up and go to sleep and that there was nothing to eat. Patient expressed frustration regarding the incident. Charge nurse notified. Follow up planned with dietary services and CNA staff regarding nighttime snack availability and staff-patient interaction. Patient currently awake, alert, and resting comfortably in bed. No acute distress noted. Will continue to monitor and support as necessary.During an interview with the Director of Nursing (DON) and ADON on 10/29/25 at approximately 10:35 AM, the ADON insisted that she had been involved in the resident's care, and stated that she had not been aware of the details of the incident until 10/20/25. Upon being questioned about her written statement dated 10/17/25, in the initial report, ADON stated the resident had not made any statement at the time of the hypoglycemic episode because he was out of it. ADON stated that they had been unaware of the incident until she had received the complaint from the resident on 10/20/25.However, record review on 10/28/25 at 10:00 AM revealed that the facility had been aware of the circumstances of the incident on 10/17/25, as evidenced by the following:An order on 10/17/25, which stated:Please give resident a small snack of crackers and cheese before bedtime to prevent hypoglycemia. In addition, the resident's previous order for insulin dated 01/12/25, which stated:Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 38 unit subcutaneously at bedtime for diabetes. had been discontinued on 10/17/25, and a new order had been placed on 10/17/25 which stated:Insulin Glargine yfgn - Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-yfgn) Inject 30 unit subcutaneously one time a day for DM2 Further review of records revealed written statements by Licensed Practical Nurse (LPN) #11, and NA #36.LPN #11's statement dated 10/21/25, stated: [Typed as written] I never heard [NA #36] tell resident to shut up. Resident had asked for a sandwich, [NA #36] asked me if we had any. I stated that we don't have any sandwiches. [NA #36] responded to resident saying [LPN #11] said we don't have any sandwiches. NA #36 and LPN #11 went back to nurses' station afterwards. NA #36's statement dated 10/20/25 stated: [Typed as written] On 10/16/25 at around 1or 2 am [Resident #31] asked me for a sandwich. [LPN #11] was in the hallway and heard him ask, and she said We don't have any sandwiches. I said to [Resident] that [LPN #11] said we don't have any sandwiches.Someone told me that [Resident #31] said I told him to shut up and go to bed. I may have told him to try to get some sleep which I tell a lot of residents to try to get some sleep. I've been a NA for 32 years and have never told a resident to shut up. On 10/28/25 at approximately 1:55 PM during an interview with Resident #30, a roommate of Resident #31, Resident #30 stated that he had been out of the facility on 10/16/25, but he stated, I heard about it when I got back! During the interview on 10/28/25 at 9:28 AM, Resident #31 was asked whether he has encountered any other issues since the hypoglycemic episode. Resident responded by saying Not until last night!Resident stated that on the night of 10/27/25 the Nursing Assistant (NA) #90 had checked on him a little while earlier. He then went on to state that he had had a bowel movement (BM) and had used his call light to request assistance. Resident #31 stated that when he asked NA #90 to check him, she said, Checks are every two hours, then walked away. Resident's roommate, Resident #32, then leaned out around his curtain and confirmed Resident #31's statement by saying, I heard it! Resident #31 stated that a nurse had come into the room a little while later, and he had complained to her. The nurse checked him and, upon finding that Resident #31 had soiled himself, called NA #90 back and asked her to get him cleaned up.During an interview with the Director of Nursing (DON) at approximately 10:00 AM, on 10/28/25, the DON stated that she was unaware of the incident. The DON immediately began an investigation and submitted an initial report to the Office of Health Facility Licensing and Certification (OHFLAC).

Based on observations and staff interviews, 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 with regards to, resident hand washing, medical equipment, and meal tray place This practice had the potential to affect all residents that reside in the facility. Facility census: 98.Findings included: a) An observation on 07/21/25 at 12:20 PM of the dining room lunch meal tray pass found the staff using three (3) trays to pass meals. Staff would pass lunch to a resident. Return to the service line and pass the tray down through the staff to the stream table to be used for the next resident without cleaning the tray. During an interview with Licensed Practical Nurse #9 she stated that this is the practice serving meals in the dining room. She verified the service tray is never cleaned between residents. b) On 07/22/25 between the hours of 7:45 AM and 7:55 AM., observation revealed Employee #89 failed to offer residents any type of hand sanitation to Resident #94 and #21 during breakfast in the main dining room. During the same observation period, observed Employee #114 failed to offer residents any type of hand sanitation to Resident #88 and #37 during breakfast in the main dining room. Interview with Employee #117 verified this deficient practice. c) Resident #72:During an interview with resident #72, on 07/22/25 at 1145AM, a wheelchair near the resident's bed, had rips and holes in the plastic cover on both arm rests, and on the top of the back rest and on the seat, exposing the inner padding. Resident #72 stated that the wheelchair belonged to her. d) Resident #77:During an interview with Resident #77 on 07/22/25 at 2:35 PM, it was observed a Geri-Chair with scratches and tears in the head rest, exposing the inner padding. During a facility walkthrough and interview with The Facility Corporate RN on 07/23/25 at 3:10 PM, she acknowledged both Resident #72's wheelchair and #77's Geri chair needed repair.

Based on observation and staff interview the facility failed to store and serve food in accordance with professional standards for safe food service. This practice had the ability to affect all Residents that get their nutrition from the kitchen. Facility census: 98. During a Dining Room Observation on 07/21/2025 at 12:45 PM, Nurse Aide(NA), #70 was observed touching multiple surfaces while setting up Resident #77's tray and then feeding him without washing hands or using hand sanitizer. In an interview with NA #70 on 07/21/25 at 12:55 PM, she acknowledged she did not wash or sanitize her hands after touching multiple surfaces before setting up Resident #70's tray and then feeding him. An observation on 07/24/25 at 11:30 AM, found: the walk-in freezer with sausage patties , pancakes, and Salisbury steak patties open to air. 3 ice cream cups on the floor. During an interview with the Dietary Manager 07/24/25 at 1:12 PM she verified the food was open to air. She also verified the ice cream cups on the floor and at this time placed the ice cream cups back in the box.

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment relating to maintenance services necessary to maintain a comfortable interior for resident room numbers 112, 119, 121, 123, 124, and 126, pest control for room #'s 118, 121,123,124, and 126 and Low to no water pressure in rooms [ROOM NUMBERS]. These failed practices were random opportunities for discovery. Census 98. Findings include:a) Maintenance Services:Upon survey entrance on 07/21/25 at 1:30PM, the following issues were observed in room [ROOM NUMBER]-bathroom areas: - approximate1/2-inch-long chip in the wood on the bathroom door near the handle- black scuff marks on backside of bathroom door- Rust spots across the white wall heater on the wall behind the toiletUpon survey entrance on 07/21/25 at 1:35 PM, the following issues were observed in room [ROOM NUMBER]-bathroom areas:- Cracks in caulking around the sink - Black scuffmarks on the back side of bathroom door- Black scuff marks on the sink next to water faucet baseUpon survey entrance on 07/21/25 1:40 PM the following issues were observed in room [ROOM NUMBER]-bathroom areas:- Black scuffmarks on the back side of bathroom door- Bathroom floor loose with air bubbles underneath - Black scuff marks on the sink next to water faucet base - Door jamb with holes and scrapes in the woodUpon survey entrance on 07/21/25 1:40 PM the following issues were observed in room [ROOM NUMBER]-bathroom areas: - Black scuffmarks on the back side of the bathroom door and on bathroom door - Black scuff marks on the sink next to water faucet base- Baseboard trim hanging loose from bathroom wallUpon survey entrance on 07/21/25 01:48 PM the following issues were observed in room [ROOM NUMBER], room and bathroom areas:- Black scuffmarks on the back side of bathroom door- hole in the drywall right wall behind beside table near bed #3- Rust spots across the white wall heater under the window - Scuff marks on wall above the heater b) Pest Control Resident Interviews:-During an interview with Resident #23 in room [ROOM NUMBER], on 07/21/25 at 1:00 PM, Employee # 42 came into the room, picked up a package of cookies off the floor and told Resident #23 the cookies couldn't be left out or the mice would get them. The resident stated he had seen mice in his room in the past week. -During an interview with Resident #58 in room [ROOM NUMBER], on 7/21/25 at 1:20 PM, she stated she sees mice all the time and saw one last Saturday night. It was observed there were 8 traps set in her room. -During an interview with Resident #20 in room [ROOM NUMBER], on 07/21/25 at 1:15 PM, he stated he had seen mice in his room last night and pointed to a mouse trap located under the wheelchair in his room.-In an interview with Resident #77 in room [ROOM NUMBER] on 07/22/25 at 9:45AM, he stated he had seen a mouse in his room the past weekend and again one in his room the night before. During a facility walk through with the Corporate RN, on 07/23/25 at 1:45PM, she acknowledged the maintenance issues in room [ROOM NUMBER], #119, #121, #123, #124, and #126 and Mouse citing's in resident's rooms. She stated she would make a list for the Maintenance Department. Facility Administrator interview:During an interview with The Facility Administrator on 07/24/25 at 11:20AM, he stated the facility has been logging the citing's of mice and working with a pest control company, acknowledged the mice were still a problem.c) Water Pressure - room [ROOM NUMBER], and #121:During a facility walk through on 07/21/25 at 1:25 PM, It was observed in room [ROOM NUMBER] and #121, that there was low to no water pressure from the bathroom faucets in each room.In an interview with Resident #51, on 07/21/25 at 1:25 PM, she stated the maintenance crew had worked on the sink a few weeks ago and the water barely runs now.During a facility walk through with the Corporate RN, on 07/23/25 at 1:45 PM, she acknowledged the water pressure was low and stated the issue would be added to the maintenance list.

Based on observations and staff interviews, the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident's room. This failed practice was a random opportunity for discovery. Resident Identifiers #23, and #50. Facility Census: 98. Findings include:a) Resident #23On 07/21/25 at 12:35 PM upon the facility entrance and interview with Resident #23, it was observed that Resident #23 was sitting on the side of his bed, and the call light was on the floor approximately 3 feet away from him. The resident walks with a walker and could not reach his call light. b) Resident #50On 07/22/25 at 2:35 PM, it was observed that Resident #50 asked surveyor to get a nurse for her roommate in bed #1 but her call light was not within reach. She was sitting on the right side of her bed, and the call button was hanging off the left side of the bed on the floor.c) Staff Interviews:Nurse Aide (NA) #48On 07/22/25 at 12:45 PM in an interview with staff member NA #48, She acknowledged the call light was not within Resident #23's reach.Licensed Practical Nurse (LPN) #17On 07/22/25 at 2:43 PM, in an interview with LPN, #17, she acknowledged the call button was not within reach of Resident #50 and stated that she was unaware the call light was not within resident's reach because a Nurse Aide had just been in the room with the resident.

Based on interview and record review, the facility failed to honor and facilitate the resident's choice and right to self-determination regarding the resident's preference for showers. Resident Identifier #80. Facility Census: 98.a) Resident #80During an interview on 07/22/25 at 12:09 PM, Resident #80 reported that she was scheduled for showers on Tuesdays and Fridays. She expressed a desire to have more frequent showers but noted that the staff were unable to accommodate her request. Additionally, she indicated that once she is seated on the shower chair, she can shower herself; the only assistance she required was with scrubbing her back.A review of records on 07/23/25 at approximately 10:54 AM revealed the following:Resident #80's preferences dated 02/05/25 revealed the resident's answer to the question;How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? was Very Important!Record review on 07/23/25 at approximately 1:55 PM revealed the following:06/25/25 - Bed Bath06/28/25 - Response Not Required07/02/25 - Response Not Required07/05/25 - Response Not Required07/09/25 - Response Not Required07/12/25 - Response Not Required07/16/25 - Response Not Required07/19/25 - Response Not Required b) Resident #19On 07/22/25 at approximately 10:57 AM, Resident #19 stated that he did not remember when he had last had a shower. The resident had a Brief Interview for Mental Status (BIMS) of 4. A review of shower records revealed the resident had not received showers or bed baths between 07/16/25 and 07/23/25 - a period of six (6) days, as evidenced by the record below:-06/29/25 - Shower-07/02/25 - Bed Bath-07/06/25 - Bed Bath-07/09/25 - Shower-07/13/25 - Refused-07/16/25 - Shower No additional shower records were provided by the facility for review.During an interview with the Director of Nursing (DON) on 07/23/25 at 3:15 PM, the DON reviewed the shower log and stated that she could not understand why the documentation stated, Response Not Required.DON confirmed that the documentation did not indicate showers were provided to Resident #80 and Resident #19. Additionally, there was no documentation that residents had refused showers.

Based on observations, interviews, and record reviews, the facility did not implement proper monitoring and assessments for a resident who had close contact with another resident diagnosed with Varicella. Additionally, the facility failed to recognize and assess the potential risks to other residents due to unrestricted access to all areas of the facility by this resident. This was a random opportunity for discovery. Resident Identifier: #63 and #38. Facility Census: 98. Findings include:a) Resident #38Findings included:On 07/23/25 at approximately 10:42 AM, Resident #38 was observed under contact isolation. Record review revealed that Resident #38 had been moved out of the room she shared with Resident #63. Further record review revealed the following:A note was entered on 07/23/25 at 9:10 AM for Valacyclovir HCl Oral Tablet 1 GM. Give 1 tablet by mouth every 8 hours for shingles for 7 Days.Valacyclovir is a prescription antiviral medication used to treat infections caused by herpes simplex virus (HSV) and varicella-zoster virus (VZV).Another note on 07/23/25 at 9:58 AM stated the resident would be on contact Isolation related to shingles.Nursing observations, evaluation, and recommendations were documented as follows: Patient presents with clusters of red rash located to right buttock. She states burning/stinging sensation that radiates to right thigh area.The primary care provider (PCP) responded with the following feedback:A. Recommendations: Serum varicella zoster igg/igm, varicella zoster PCR, ValtrexB. New Testing Orders:C. New Intervention Orders:Further record review on 07/24/25 at approximately 10:15 AM revealed that on 07/23/2025 6:02 PM Varicella PCR specimen obtained per order from right posterior thigh. The lab slip was completed and placed in specimen refrigerator.On 07/23/2025 9:03 PM Valacyclovir HCL oral table 1 gm was not given due to being unavailable. A note dated 07/24/2025 at 1:58 AM revealed the following: Resident remains on isolation d/t possible shingles per previous nurse. Resident reports no complaints of pain/discomfort at this time. VSS. Call light, bed control and hydration are within resident's reach. Valacyclovir HCL 1gm is not available at this time per 3-11 nurse.A note dated 07/24/2025 10:31 AM revealed the following: Resident remains on contact isolation for possible shingles and has been maintained. Labs are pending for confirmation. She denies any concerns or discomfort thus far.b) Resident #63 At approximately 11:05 AM on 07/23/25, during an interview with Resident #63, he stated, my wife is in isolation due to an infection and pointed to the other bed in the room, which had been stripped of its bed linen and mattress. When questioned about whether he had contracted chickenpox during his childhood, the resident stated that he had not. The resident, who was in a wheelchair, stated that he was the only artist in the facility and that he was allowed to go everywhere.Upon being asked whether anyone had checked his temperature, the resident stated that he did not have orders for temperature checks. He went on to ask, Why are you asking me these questions? During an interview with the Nurse Practitioner (NP) on 07/23/25 at 11:40 AM, the Nurse Practitioner (NP) noted there was no need to confine Resident #63 to his room, as he had not exhibited any signs of infection. However, the NP did not mention any measures that would be put in place to monitor Resident #63 for potential signs or symptoms of infection.At approximately 11:55 AM on 07/23/25, the Regional Clinical Nurse (RCN) was asked what steps were being taken to verify that Resident #63 had not contracted the infection. And since Resident #63 was mobile, what precautions were being taken to ensure that the virus did not spread. RCN stated that Resident #63 had not shown any signs of infection and could not be isolated based on the chance that he had contracted the virus. RCN further stated that the facility had implemented temperature checks and skin assessments to monitor Resident #63. During the record review on 07/24/25 at approximately 10:15 AM the following order was revealed: 07/23/25 at 3:08 PMVital Signs Q (every) shift X 72 hours for 3 DaysA review of Resident #63's Treatment Administration Record (TAR) revealed that the first temperature check was performed on 07/23/25 during the evening shift.Record review revealed that these interventions were implemented after surveyor intervention on 07/23/25 at 11:55 AM.

Based on record review, observation, and staff interview the facility failed to ensure theresident environment over which it had control was as free from accident hazards aspossible. This failed practice was a random opportunity for discovery, Resident Identifier #69Facility Census 98 Findings Include:a) Resident #69During the facility entrance interview on 07/22/25 at 1:45 PM an observation revealed a medicine cup of ointment creme was left on the bedside table. Resident #69 stated it was ointment the nurse aides left there for her to use on her bed sores. In an interview with LPN # 6 on 07/22/25, at 1:48 PM, she stated she did not know what the medicine cup of ointment was and stated it should not have been left in the resident's room.

Based on resident and staff interviews, the facility failed to ensure an allegation of suspected staff to resident verbal abuse was reported to the appropriate State Agencies, within a 2-hour time frame. This failed practice was a random opportunity for discovery. Resident identifier: #47 Facility Census: 98. Findings Include: a) Resident #47 Interview with Resident #47, on 07/22/25 at 9:35AM, she reported Licensed Practical Nurse (LPN) #35 had called her a liar two (2) nights previous when she reported she had not had a bowel movement in five (5) days and asked for a laxative. Facility Policy and Standard Procedures Policy #NS1018-03:Mental Abuse is the use of verbal or nonverbal conduct which causes or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation and may be considered a type of mental abuse.During an interview with the Facility Administrator on 07/22/25 at 9:44 AM, the suspected staff to resident abuse was reported and he stated he would investigate it. In a follow up interview with the Facility Administrator on 07/24/25, H stated he had not made a report to the appropriate agencies as he had not spoken to LPN #35. She was off the date it was reported to him, but she was scheduled to work that afternoon and was waiting to talk to her regarding the report.

Based on interview and record review, the facility failed to provide residents with assistance during showers. Resident Identifiers #80 and #19. Facility Census: 98.a) Resident #80 Findings Include: During an interview on 07/22/25 at 12:09 PM, Resident #80 reported that she is scheduled for showers on Tuesdays and Fridays. She expressed a desire to have more frequent showers but noted that the staff were unable to accommodate her request. Additionally, she indicated that once she is seated on the shower chair, she can shower herself; the only assistance she requires is with scrubbing her back. A perusal of records on 07/23/25 at approximately 10:54 AM revealed the following: A resident #80's preferences dated 2/05/25 revealed that the resident's answer to the question; How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? was Very Important Record review on 07/23/25 at approximately 1:55 PM revealed the following:06/25/25 - Bed Bath06/28/25 - Response Not Required07/02/25 - Response Not Required07/05/25 - Response Not Required07/09/25 - Response Not Required07/12/25 - Response Not Required07/16/25 - Response Not Required07/19/25 - Response Not Required b) Resident #19On 07/22/25 at approximately 10:57 AM, Resident #19 stated that he did not remember when he had last had a shower. The resident has a Brief Interview for Mental Status (BIMS) of 4.However, a review of shower records revealed that the resident had not received showers or bed baths between 07/16/25 and 07/23/25 - a period of six (6) days, as evidenced by the record below: 06/29/25 - Shower07/02/25 - Bed Bath07/06/25 - Bed Bath07/09/25 - Shower07/13/25 - Refused07/16/25 - Shower No additional shower records were provided by the facility for review. During an interview with the Director of Nursing (DON) on 07/23/25 at 3:15 PM, the DON reviewed the shower log and stated that she couldn't understand why the documentation stated, Response Not Required''. DON confirmed the documentation did not indicate showers were provided to Resident #80 and Resident #19. Additionally, there was no documentation that any residents had refused showers.

Based on interview and record review, the facility failed to follow recognized standards of care, and in addition, failed to follow the facility's own policy and procedures with regards to monitoring residents after a fall. This citation is cited at past non compliance. Resident identifier: #111. Facility Census 107. Findings include: a) Resident #111 Record review on [DATE] at approximately 11:15 AM revealed that the resident had an unwitnessed fall in his room on [DATE]. Record review revealed that the resident was found on the floor on [DATE] at around 9:15 AM. On [DATE] at 10:58 AM the Nurse Practitioner (NP) 171's notes stated the following: Per nurse, his spO2 on 2 liters NC. He was confused but redirectable. He had taken off his oxygen and it was replaced. Per staff, he was found on the floor near some wet towels. Patient stated he was getting back into bed when he fell. He knew it was 2024. He knew his name but could not say where he was located. A post fall evaluation nursing note by Registered Nurse (RN) #170 on [DATE] at 9:15 AM stated there were no injuries noted from this unwitnessed fall. The resident was not transferred to the hospital and the family/responsible party was notified and the resident had no complaints of pain. A review of the documentation about the neuro checks performed on Resident #111 at 9:15 AM revealed the resident was confused and did not follow commands. In addition, the assessment noted that the nurse was unable to assess pupillary reaction in both eyes due to the resident not following commands. A nursing note by RN #170 at 2:01 PM on [DATE] stated the following: Was observed on floor at approx. 09:15. Respirations 16 and Sp02 96% on 2L 02. Assessed. Transferred to bed via total lift and x3 assist. Alert with confusion. Cognition and ROM at baseline. Unable to follow commands to check pupils. Hand grips equal. Denied pain. Assessed again at approx. 0945. It was observed by CNA at around the same time. Was observed unresponsive at approx. 10am. Compressions started, 911 called and CPR continued until EMS arrived. Emergency contact made aware. A review of the facility's neuro check policy on [DATE] at 2:35 PM showed that neuro checks were to be performed on all unwitnessed falls at the following frequency: Every fifteen (15) minutes for one hour Every one (1) hour for four (4) hours Every four (4) hours for sixteen (16) hours Every twenty-four (24) hours for four (4) days. Record review on [DATE] at approximately 12:25 PM regarding the post fall documentation for Resident #111 on [DATE] revealed that neuro checks were not performed at fifteen (15) minute intervals as specified in facility protocol. The resident had been assessed at 9:15 am, and the next assessment had been performed at 9:45 AM. During an interview with the Director of Nursing (DON) at 2:50 PM on 05/07//25, DON stated that the neuro checks had to be completed. She stated that the protocol was every 15 min x4, then every hour x4, every 4 hrs. x 4, and then everyday x 4. Upon being notified that the neuro checks had not been performed on Resident #111 on [DATE]. Regional Clinical Nurse (RCN) #172 stated the facility had identified the lapse in protocol and documentation on [DATE]. RCN #172 further stated the facility had taken immediate action, implemented a QA study, performed education for all nursing staff, and performed audits going back three (3) months on all falls, to ensure that documentation and neuro checks were being performed as per protocol. A review of the documentation provided revealed that the facility had taken the following steps beginning on [DATE]: Notified the Medical Director regarding the incomplete neuro checks Suspended the nurse involved, pending the investigation. (The nurse was no longer employed at the facility during the complaint survey). as of [DATE] Facility reviewed and audited falls for post fall documentation and neuro checks. Completed [DATE] Education and questionnaires were provided to all nursing staff regarding post fall evaluations and documentation, including neuro checks. No nursing staff were allowed to work until education was completed. Completed on [DATE]. All falls audited for complete documentation 5 times a week for 4 weeks, weekly for 4 weeks, and monthly for 3 months. Completed on [DATE] Audit results were reported to QAPI monthly for 3 months, and randomly thereafter, Completed [DATE]

Based on discharge electronic medical review (EMR) and staff interviews, the facility failed to complete a safe and complete discharge. Resident #103 was discharged to a homeless shelter which did not have an available space and could not meet the medical needs of the resident. This failed practice had the potential to affect a limited number of residents. Resident #103. Facility census: 99. Findings included: a) Resident #103 A review of the discharge EMR on 07/23/24 at 10:59 AM found Resident #103 was admitted on [DATE]. Diagnoses included Diabetes Mellitus type 2 (insulin dependent), traumatic brain injury, major depressive disorder, bipolar disorder, and unspecified dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/24 had a Brief Interview of Mental Status (BIMS) score of 12. The BIMS score of 12 denotes moderate cognitive impairment. Resident #103 had capacity to make decisions. On 07/24/24 at 12:15 PM in an interview with the Nursing Home Administrator (NHA) when asked how was the decision made for the facility to discharge Resident #103 the NHA stated that the decision was made in consultation with the corporate Risk Manager. Resident #103 was presented with a Notice of Discharge and Transfer of (resident name) dated 07/12/24. Type of discharge: 30 day discharge notice. Under the section Reason for discharge: a check mark was beside The safety of individuals in the center is endangered due to the clinical or behavioral status of the resident. The Location of discharge: (local city) Union Rescue Mission with the address. Also there was an appeal rights and process, Assistance with a list of state agencies who could provide assistance and the Bed Hold Policy. When Resident #103 was presented with the Discharge Notice, he stated that he would like to leave now (07/12/24). A review of communication notes by the NHA found the following: 7/12/2024 11:15 Communications Note Text: Resident was picked up and arrested by (name of City) Police Dept related to incident with employee on 7/4/24 and released back to facility on his own recognizance. Resident was provided a 30 day discharge notice. Physician notified of behaviors leading to notice. Resident was provided face sheet, order summary, insulin administration instructions, and medications. Provided information on follow up dental appointment. Offered to set up PCP (Primary Care Provider) appointment for resident, which he declined. Offered home health, which resident declined. Resident was provided transportation with all belongings to location of discharge. Resident is independent with all ADLs, and has capacity to make his own decisions. Resident had no questions, and voiced understanding notice was not immediate. Resident chose to leave today with facility transportation. An additional nurses note by the Director of Nursing (DON) found the following: 7/12/2024 10:59 Nurses Note Note Text: Resident alert and oriented x 4 upon return to facility. Resident notified of 30-day discharge notice. Resident declined and opted to leave facility immediately. This nurse provided education to resident regarding medication administration including oral medication and insulin administration. Resident verbalized understanding and demonstrated proper utilization of insulin pen. Resident's belongings were collected. Resident transported to (city name) Mission via facility transportation. An interview with the Maintenance Director at 11:45 AM on 07/23/24 who transported Resident #103 to the area homeless shelter stated that he observed Resident #103 enter the facility and appeared to be signing papers. The left his belongings on a couch in the back of the facility. In an interview with the NHA, DON, and the Corporate RN, at 2:00 PM on 07/24/24 found the following: When asked for a copy of the reconciliation of the residents' medication, the NHA stated that Resident #103 was given a copy of his physician orders that listed his medications and presented a copy of the orders to the surveyor. When asked if the facility had a reconciliation of the medications, the DON stated that she did not complete a reconciliation of the medications. The resident medications consisted of Depakote DR 500 mg (milligrams) twice a day for bipolar order; Fandga Oral 10 mg daily for DM; Glipiide 10 mg twice a day for DM; lactobacillus 1 capsule for probiotic; Melaton 5 mg at bedtime for insomnia; Insulin 30 units twice a day for DM; Olanzapine 5 mg at bedtime for psychotic disorder; Trazodone 50 mg at bedtime for depression and Trulicity pen-injector 3 mg daily every seven (7) days for DM2. She further stated that she instructed the resident on how to use an insulin pen and the resident completed a return demonstration. In addition the DON stated that she gave the resident 10 needles to be used with the insulin pen. She further stated that Insulin vial was given but no syringes or needles due to being discharged to the shelter and potential for syringes and needles could be used by others at the shelter. No evidence was found in the EMR to this confirm this. When the NHA was asked if the homeless shelter was notified that the resident was going to be admitted to their facility, the NHA stated that he attempted to call the shelter several times but no one answered the call. In addition he stated the facility had discharged several residents to the shelter and never had a problem. When asked if he was aware the shelter had no openings for Resident #103 nor had a refrigerator for the insulin pen or could not meet the medical needs of the resident. He again stated he tried to call the shelter several times but there was no answer.

Based on record review, observation, and staff interview, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed. A Nursing Assistant (NA) was observed to not be wearing the proper personal protective equipment (PPE) when providing direct resident care to a resident in EBP due to a wound. This was a random opportunity for discovery. Resident identifier: #28. Facility census: 99. Findings included: a) Resident #28 The facilty's policy and standard procedure titled Enhanced Barrier Precautions, with no implementation date given, stated the required Personal Protective Equipment (PPE) was gowns and gloves. The policy also stated PPE would be donned when providing high contact care activities as described above. Resident #28 had an order written on 04/04/24 for Enhanced Barrier Precautions related to: sacral pressure ulcer. A sign was posted on the door to the resident's room indicating EBP were in effect. The sign stated as follows: Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing Bathing/showering Transferring Changing linens Providing hygiene Changing briefs or assisting with toileting Devise care or use: central line, urinary catheter, feeding tube, tracheostomy Wound care: any skin opening requiring a dressing Do not wear the same gown and gloves for the care of more than one person. The front of the resident's door had a PPE caddy containing gloves and gowns. On 07/24/24 at 9:55 AM, Nurse Practitioner (NP) entered Resident #28's room to assess the resident's sacral pressure ulcer. However, the resident stated she was incontinent of stool. The NP exited the resident's room and stated a Nursing Assistant (NA) would provide incontinence care to the resident. On 07/24/24 at 10:10 AM, NA #106 was observed entering Resident #28's room. She donned gloves but did not don a gown. She went to Resident #28's bedside, behind the privacy curtain, and provided care to the resident. On 07/24/24 at 10:20 AM, NA #106 exited Resident #28's room with a bag of what appeared to be a soiled brief in a clear plastic bag. NA #106 confirmed she had performed stool incontinence care for Resident #28. NA #106 was shown the EPB sign on the resident's door and was asked which resident in the room was on enhanced barrier precautions. There were three (3) residents residing in the room. NA #106 stated Possibly [Resident #28]. On 07/24/24 at 10:35 AM, the Director of Nursing was notified that CNA #106 had not followed EBP when providing direct resident care to Resident #28.

Based on record review, observation, and staff interviews, the facility failed to ensure residents were not neglected. The facility failed to follow physician's orders in transferring resident. This caused actual harm to the resident by causing bruises to his right elbow, right hand, right wrist, and right forearm. This was true for one (1) of one (1) resident reviewed for neglect. Resident identifier: #1. Facility census: 103. Findings included: On 03/20/24 the facility reported an incident to all required entities. According to the reportable, Resident #1 was observed to have bruising of unknown origin. Resident #1 is a [AGE] year-old male on hospice with multiple diagnoses including: dementia, muscle weakness, need for assistance with personal care, lack of coordination, right sided hemiparesis with flaccidity. The resident lacked the capacity to make medical decisions. The resident was receiving aspirin 325 milligrams of aspirin (MG) daily due to a history of stroke. A side effect of aspirin therapy is a risk for bruising. On 02/01/24 the physician entered an order for the resident to be transferred by mechanical lift with assistance of two (2) staff. Prior to the resident required extensive assistance of one (1) person. On 02/02/24 the resident's care plan was updated for the following intervention Resident requires use of mechanical lift with 2 person support. According to a progress note written on 03/19/24, the resident stated that his arm got banged while being transferred into the chair for bathing on 03/18/24. He denied pain to the extremity. Skin assessments performed on 03/19/24 show: - Right elbow, purple discoloration of 5x4.5 centimeters (cm), - Right hand, purple discoloration of 3x3 cm, - Right wrist, purple discoloration of 1x1 cm, - Right forearm, purple discoloration of 3x2.5 cm. During facility investigation of the bruising of unknown origin, Nursing Assistant (NA) #31 stated that she saw the bruise but did not report it because the nurse was busy, and then she forgot. When asked how she transferred the resident, she stated by extensive assistance. As a result of the injury, nurse practitioner evaluated resident, and reduced the daily aspirin dose to 81 milligrams. As a result of the investigation, the facility disciplined and re-educated NA #31 regarding transferring residents according to their orders and care plan. Other facility NAs were re-educated on transfer status as well. During investigation, NA #31 was on vacation and unavailable for interview. On 05/21/24 at 1:11pm NA #113 was interviewed and asked how she would determine the type of transfer required for a resident. She replied that she would check the [NAME] for any orders. Upon being asked how she would proceed if she wasn't able to transfer the resident using the specified transfer mode; NA #113 replied that if she encountered difficulty with the transfer, she would ask the nurse to assess the resident, or she would use a mechanical lift. NA #2 was interviewed on 05/21/24 at 1:56pm. She stated that she would check the [NAME] before transferring a resident. She also stated that she would notify the nurse and consult physical therapy if she encountered any difficulty with a transfer. Upon being interviewed on 05/21/24 at 1:35pm. NA #25 stated that she would check the [NAME] if the resident needed to be transferred. When asked how she would proceed if she had difficulty with transferring a resident by the prescribed means, she stated that she would notify the nurse, and use a mechanical lift. On 05/21/24 at 2:15pm. The administrator acknowledged NA#31 did not follow Resident #1's care plan and physicians orders. He stated that NA #31 had been disciplined and in-service.

Based on record review, and staff interviews, the facility failed to ensure injuries of unknown origin were reported in a timely fashion. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 103. Findings included: a) Resident #1 On 03/20/24 the facility reported an incident to all required entities. According to the reportable, Resident #1 was observed to have bruising of unknown origin. According to a progress note written on 03/19/24, the resident stated that his arm got banged while being transferred into the chair for bathing on 03/18/24. He denied pain to the extremity. Resident #1 is a [AGE] year-old male on hospice with multiple diagnoses including: dementia, muscle weakness, need for assistance with personal care, lack of coordination, right sided hemiparesis with flaccidity. The resident lacks the capacity to make medical decisions. The resident was receiving aspirin 325 milligrams (MG) daily due to a history of stroke. A side effect of aspirin therapy is a risk for bruising. On 02/01/24 the physician entered an order for the resident to be transferred by mechanical lift with assistance of two (2) staff. Prior to the resident required extensive assistance of one (1) person. On 02/02/24 the resident's care plan was updated for the following intervention Resident requires use of mechanical lift with 2 person support. Skin assessments performed on 03/19/24 show: - Right elbow, purple discoloration of 5x4.5 centimeters (cm), - Right hand, purple discoloration of 3x3 cm, - Right wrist, purple discoloration of 1x1 cm, - Right forearm, purple discoloration of 3x2.5 cm. During facility investigation of the bruising of unknown origin, Nursing Assistant (NA) #31 stated that she saw the bruise but did not report it because the nurse was busy, and then she forgot. When asked how she transferred the resident, she stated by extensive assist. As a result of the injury, nurse practitioner evaluated resident, and reduced the daily aspirin dose to 81 milligrams. As a result of the investigation, the facility disciplined and re-educated NA #31 regarding immediately reporting the incident to the nurse in charge. During investigation, NA #31 was on vacation and unavailable for interview. On 05/21/24 at 1:11 PM NA #113 was interviewed on the procedure for reporting new injuries. She stated that any new injury was to be reported immediately to the nurse for assessment. She also stated that they are required to write a written report of the circumstances under which the new injury occurred or was discovered. NA #48 was interviewed on the policy and process of reporting resident injuries. She stated that any new injury was to be reported immediately to the RN, and a report handwritten by the CNA. NA #2 was interviewed on 05/21/24 at 2:08 PM regarding the process for reporting new injuries. She stated that they were immediately required to report to the nurse and write out a report. On 05/22/24 at 10:26am the Regional Director of Clinical Operations and the Director of Nursing (DON) were interviewed about the reporting and assessment of injuries. They stated that all new injuries were to be immediately reported to the nurse on duty for assessment. In addition, they said that the facility had installed a new protocol called Stop and Watch. They explained that when NAs clicked on a resident's name in the Point of Care system, a question immediately pops up asking whether there was a change in the residents' condition or status. If Yes was clicked, an alert was sent to the Point Click Care dashboard alerting the nurse and other clinical staff to make them aware. A nurse could clear the alert after an assessment, but if it was not cleared, the DON would investigate.

Based on record review and staff interview, the facility failed to revise the comprehensive care plan when the resident's capacity to make medical decisions changed. This was a random opportunity for discovery. Resident identifier: #58. Facility census: 103. Findings included: a) Resident #58 Review of Resident #58's medical records showed a Physician Determination of Capacity dated [DATE] which determined the resident had the capacity to make medical decisions. Another Physician Determination of Capacity was performed on [DATE] and determined the resident lacked the capacity to make medical decisions. Resident #58's comprehensive care plan contained the following focus, Resident has a CPR code Status Ability to make health care decisions, Disease process (Focus typed as written.) The focus had been initiated on [DATE] and had not been revised since then. On [DATE] at 4:42 PM, the Administer acknowledged Resident #58's care plan needed revised to reflect the resident no longer had capacity to make medical decisions. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to complete a thorough investigation of a family member's allegation of resident neglect, maintain documentation that the alleged violation was thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. Resident Identifier: #7. Facility Census: 103. Findings included: a) Resident #7 During a record review it was noted there was a written statement from CNA #96, dated 10/30/23. The statement indicated that once CNA #96 had picked up all resident breakfast trays on the hall she checked on Resident #7. Approximately 20 minutes later, Resident #96's family member reported the resident had bowel movement all over her. CNA #96 reported she immediately changed Resident #7 and gave her a complete bed bath. Additionally, CNA #96 stated she reported the family member's concern to the Administrator. On 01/16/23 at 11:30 AM, review of the facility's Abuse and Neglect policy revealed -The accurate and timely identification of any event which would place residents at risk is a primary concern of the facility. -An event may not be perceived by staff to constitute resident neglect; however, if a resident, family member, or visitor perceived the event to be neglect, the facility must report the event. -In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. -An employee, who is alleged or accused of being a party to neglect will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. -Statements will be obtained from the resident or from the reporter of the incident, in writing whenever possible by the Executive Director or designee. -By the fifth day, the alleged neglect investigation form is completed and reviewed for completeness and accuracy by the Executive Director or designee and submitted to the state. Review of the facility's reportable log, completed on 01/16/23 at 11:46 AM, revealed the allegation of abuse had not been reported to appropriate state agencies. Additionally, a five-day follow-up was not reported to Adult Protective Services and the Office of Health Facility and Licensure (OHFLAC) in accordance with State law. During a telephone interview on 01/16/26 at 12:30 PM, the Administrator confirmed he had failed to identify the family's concern as an allegation of neglect. The Administrator said as a result this issue had never been reported and had never been investigated further. WV Code S9-6-11 states the report of neglect must be made to the Department of Health and Human Resources immediately, but not more than 48 hours after suspecting these circumstances. Under WV Code S9-6-9 certain persons are mandated reporters of adult abuse or neglect. Any employee of any nursing home is considered a mandated reporter of abuse and neglect.

Based on record review and staff interview, the facility failed to ensure that an alleged violation involving resident neglect was reported within 24 hours of the event / allegation being brought to the facility's attention, to appropriate state agencies as required. Resident identifier: #7. Facility census: 103. Findings included: a) Resident #7 During a record review it was noted there was a written statement from CNA #96, dated 10/30/23. The statement indicated that once CNA #96 had picked up all resident breakfast trays on the hall she checked on Resident #7. Approximately 20 minutes later, Resident #96's family member reported the resident had bowel movement all over her. CNA #96 reported she immediately changed Resident #7 and gave her a complete bed bath. Additionally, CNA #96 stated she reported the family member's concern to the Administrator. On 01/16/23 at 11:30 AM, review of the facility's Abuse and Neglect policy revealed that an event may not be perceived by staff to constitute resident neglect; however, if a resident, family member, or visitor perceived the event to be neglect, the facility must report the event. Review of the facility's reportable log, completed on 01/16/23 at 11:46 AM, revealed the allegation of abuse had not been reported to appropriate state agencies. During a telephone interview on 01/16/26 at 12:30 PM, the Administrator confirmed the allegation had not been reported to the appropriate state agencies as per the facility's policy. WV Code S9-6-11 states the report of neglect must be made to the Department of Health and Human Resources immediately, but not more than 48 hours after suspecting these circumstances. Under WV Code S9-6-9 certain persons are mandated reporters of adult abuse or neglect. Any employee of any nursing home is considered a mandated reporter of abuse and neglect.

Based on record review, resident interview and staff interview, the facility failed to ensure residents are free from abuse and neglect. The facility's failure to provide effective interventions to ensure the safety of residents while utilizing mechanical lifts (Hoyer lift) resulted in serious injury with actual physical harm to residents #[AGE] and #57. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #[AGE] and #57. Facility census: 102. Findings included: a) Facility policy Review of the facility policy titled: West Virginia Abuse, Neglect &Misappropriation, Policy #NS 1018-02 with an effective date of 10/07/17 and revised date: 02/12/18 and 04/01/19. revealed the following (typed as written): --Adverse Event: untoward, undesirable and usually unanticipated event that causes death or serious injury or the risk thereof. --Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. --Serious bodily injury: an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member. b) Resident #[AGE] On 02/25/20 at 1:50 PM Resident #[AGE] reported, In mid September 2019, can't remember the exact date, I was being transferred with a Hoyer lift from my chair to the bed when I was dropped to the floor by the Nurse Aides (NA's). I was sitting on the floor with my right leg under my body. The NA's said we did not drop you and I told them, well I am sitting on the floor with my leg under my body. I was sent to (name of hospital) and the x-ray's showed a bad fracture, but they could not do any surgery so I have to wear this boot. Resident continued to state, I am afraid every day when I have to be transferred because they might drop me again and I can only be transfered with the Hoyer. I only have one leg because my left leg was amputated and now I might lose this leg if it doesn't get better. I only had the one leg before this happened and at least I could use it somewhat, now it is useless. Resident #[AGE] denies being assessed after being dropped. She states, I complained of pain that night and the next day but nothing was done until I went to the Director's office. Resident #[AGE] further stated, They were supposed to investigate it but I have never heard anything concerning the investigation. Record review on 02/25/20 at 2:30 PM found Resident #[AGE] has a Brief Interview for Mental Status (BI[CONDITION]) score of 14, indicating the resident is cognitively intact. Attending physician documented Resident #[AGE] has the capacity to make her own medical decisions. An X-ray report of right ankle dated 09/23/19 stated (typed as written): --Results: There is an angulated and slightly displaced [MEDICAL CONDITION] malleolus (the bump on the inner side of the ankle joint at the end of the tibia (also know as the shin bone) as well as the posterior malleolus (fracture at the back of the tibia). There is an angulated [MEDICAL CONDITION] fibula (the bone that starts just below the knee joint on the outside and extends all the way down to the ankle joint) above the lateral malleolus (bone on the outside of the ankle joint). No significant callus formation noted and the fracture appears recent. --Conclusion: [MEDICAL CONDITION] malleolus and posterior malleolus. Angulated distal fibular fracture. Also included an X-ray report showing a [MEDICAL CONDITION] left rib. Review of an Unusual Occurrence form dated 09/24/19 authored by the Director of Nursing (DON)stated (typed as written): --Details: On 09/22/19 at approx 1900 hrs the resident was being transferred from her wheelchair to her bed. The resident already had a Hoyer pad underneath of her while she as sitting in her wheelchair. The resident's pad was hooked into the Hoyer lift. As one staff member was operating the Hoyer lift the second aid was straightening the sheets on the bed. While being lifted it was noticed that the resident was slipping out of the Hoyer pad. The resident had swung away from her wheelchair and was not able to be lowered back into her wheelchair. For safety of resident she was lowered to the floor. Upon lowering to the floor the resident' right leg folded underneath of her. On 09/23/19 1430 hrs at the resident reported pain in her right ankle and left side of abdomen to the DON. An X-ray was ordered and found to be positive for fracture. In the morning of 09/24/19 CNA came to writer to explain what had happened to the resident during transfer. --Conclusion: Resident was being transferred with the Hoyer lift and the sling had slipped. The CNA's lowered the resident to the floor and when resident was all the way to the floor they noticed that her right leg was underneath her. The following morning the resident went to the DON's office and c/o pain in her right ankle. An x-ray was ordered and noted to have a fracture. Notified MD and ordered to get into ortho and if couldn't get appt soon enough to send to ER. Sent resident to ER. A splint was placed and ortho appointment for following day. A repeated x-ray completed and showed a fracture more complex. A hard splint placed and wrapped and has follow-up appt with ortho. Education provided by ADON on transferring technique using Hoyer-all nurses and CNA's equipment was assessed and functioning properly, assessed all slings and slings that had a lot of stress noted were disposed. The Administrator provided hand written statements by two (2) Nurse Aides (NA) regarding the incident occurring on 09/22/20. Neither statement was dated as to the time it was written. Both statements describe the Hoyer pad not being under the resident correctly prior to transfer and resident sliding out of lift. Nurse Aide (NA) #37 describes the resident being on the floor, the Hoyer pad removed and correctly placed under the resident. The Licensed Practical Nurse (LPN) was notified. NA #99 describes standing next to the resident talking with her while operating the Hoyer lift, then noticing the resident was slipping out of the Hoyer pad. When on the floor moved her leg out placing it on the Hoyer lift. During this time the LPN walked in and walked back out. Both describe after correctly placing the lift pad the resident was transferred to the bed. Neither witness statements explains why if the lift pad was not under the resident correctly, it was not positioned correctly prior to transfer. In addition, if the resident was lowered to the floor why her right leg was positioned under her. Lacked a witness statement from the LPN , who walked in and walked back out. The medical record (electronic and hard copy) was silent for a physical assessment following the resident's allegation of being dropped on the floor or the documentation of the LPN observing the incident. During an interview with the regional consultant #100 present on 02/25/20 at 12:30 PM, the DON reported only an unusual occurrence form was completed for the incident. She explained, It was not a fall since the resident was lowered to the ground. On 02/25/20 at 4:40 PM the regional consultant #100 reported, An unusual occurrence form was completed for the incident and it was not reported because it was not recognized as abuse and the need to be reported. Only abuse is to be reported and this was not abuse. We were following the policy. She did not reply when inquired if it was considered neglect, since according to the facility policy: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Employee #F reported in a confidential interview, She (Resident #[AGE]) was dropped on the floor and was seriously hurt. The staff were too afraid to admit it because they were not watching her like they should have been. We all know that she is afraid every time the Hoyer lift is used, because she tells everyone. Resident #[AGE] experienced actual harm when the facility failed to ensure appropriately trained staff were available to correctly transfer the resident with a hoyer lift. The resident experienced actual physical harm due to this failed practice as a result of a medial malleolus and posterior malleolus and angulated distal fibular fracture and sixth left rib fracture. The facility failed to timely transfer the resident to the emergency department for evaluation despite the fall and the resident expressing pain. In addition, the medical record was silent to indicate the facility assessed the resident immediately following the incident. Resident #[AGE] experience further actual harm related to the fear she experiences every time staff use the hoyer lift to transfer or lift her. Resident #[AGE] continued to express this fear five months after the incident, and this was confirmed through a confidential interview with staff. This failed practice resulted in actual physical and psychosocial harm to Resident #[AGE]. b) Resident #57 Review of medical records reveals the following nursing note with a date of 10/16/19 at 1:15 PM. This nurse was walking down the hall to take another resident some medication and noticed the CNA along with the PCT using the hoyer lift to transfer the resident from the stretcher back to the wheelchair, at this time while the hoyer was up in the air the grab bar shifted, causing the whole hoyer to shift and the resident fell to the floor on his right side, at the time, while being assessed for injury on the floor, he grimaced and yell out in pain and holding his right leg, the right leg was noted to be externally rotated and shorter than the left, while being lifted the hoyer lift did the same as before, he was place on the stretcher, and this nurse received order to send to ED for evaluation and treatment, ADON notified, unable to start vital signs at this time but the fall was witness and he did not hit his head, sent to Jefferson Memorial. The PCT is a person doing medical transport (not facility staff). This resulted in a [MEDICAL CONDITION] femur. Hospital admission records on 10/16/19 reveal the resident's weight to be 151.7 kilograms or 333 pounds. During an interview on 02/25/20 Resident #57 explained his arm and leg was hurt while on a hoyer lift, about three (3) or four (4) months ago. Review of medical records found no order to use a hoyer lift while transferring this resident. The hoyer lift transfer that occurred on 10/16/19 had one staff member and one medical transport person who was not employed by the facility. On 02/25/20 the corporate consultant #100 agreed the hoyer lift required two facility staff to transfer the resident. Resident #57 experienced actual harm when the facility failed to ensure appropriately trained staff were available to transfer the resident with a hoyer lift, including with the correct number of staff. The facility failed to develop a comprehensive care plan to address the lifting and transferring needs of a resident who weighs 333 pounds. The resident experienced actual harm due to this failed practice as a result of a femur fracture requiring emergency medical treatment at the emergency room via ambulance due to a serious bodily injury.

Based on resident interview, record review and staff interview, the facility failed to provide adequate supervision, and environment free from accident hazards over which the facility had control concerning falls and the use of the hoyer lift. This failed practice caused actual harm to two (2) of (2) residents reviewed. Resident #57 experience actual physical harm as a result of fractures post fall from a hoyer lift. Resident #[AGE] experienced actual physical and emotional harm as a result of fractures post fall from a hoyer lift. Resident identifiers: #57 and #[AGE]. Facility census: 102. Findings included: a) Resident #57 Review of medical records reveals the following nursing note with a date of 10/16/19 at 1:15 PM (typed as written): --This nurse was walking down the hall to take another resident some medication and noticed the CNA along with the PCT (person doing medical transport) using the hoyer lift to transfer the resident from the stretcher back to the wheelchair, at this time while the hoyer was up in the air the grab bar shifted, causing the whole hoyer to shift and the resident fell to the floor on his right side, at the time, while being assessed for injury on the floor, he grimaced and yell out in pain and holding his right leg, the right leg was noted to be externally rotated and shorter than the left, while being lifted the hoyer lift did the same as before, he was place on the stretcher, and this nurse received order to send to ED for evaluation and treatment, ADON notified, unable to start vital signs at this time but the fall was witness and he did not hit his head, sent to Jefferson Memorial. This resulted in a [MEDICAL CONDITION] femur. Hospital admission records on 10/16/19 reveal the resident's weight as 333 pounds. During an interview on 02/25/20 Resident #57 explained his arm and leg were hurt while on a hoyer lift, about three (3) or four (4) months ago. Review of medical records found no order to use a hoyer lift while transferring this resident. The current Kardex (bedside care instructions) with a start date of 10/21/19 (return from hospital after injury) does not include the use of a hoyer lift. Review of medical records found an order to use a hoyer lift with transfer, with a date of 02/25/20 (same date this information was brought to the attention of the facility). A hoyer lift transfer requires two staff members to complete. The hoyer lift transfer that occurred on 10/16/19 had one staff member and one medical transport person who was not employed by the facility. On 02/25/20 the corporate consultant #100 agreed the hoyer lift required two facility staff to transfer the resident. Resident #57 experienced actual harm when the facility failed to ensure appropriately trained staff were available to transfer the resident with a hoyer lift, including with the correct number of staff. The facility failed to develop a comprehensive care plan to address the lifting and transferring needs of a resident who weighs 333 pounds. The resident experienced actual harm due to this failed practice as a result of a femur fracture requiring emergency medical treatment at the emergency room via ambulance due to a serious bodily injury. b) Resident #[AGE] On 02/25/20 at 1:50 PM Resident #[AGE] reported, In mid September 2019, can't remember the exact date, I was being transferred with a Hoyer lift from my chair to the bed when I was dropped to the floor by the Nurse Aides (NA). I was sitting on the floor with my right leg under my body. The NAs said we did not drop you and I told them, well I am sitting on the floor with my leg under my body. I was sent to (name of hospital) and the x-ray's showed a bad fracture, but they could not do any surgery so I have to wear this boot. The resident further stated, I am afraid every day when I have to be transferred because they might drop me again. I only have one leg because my left leg was amputated and now I might lose this leg if it doesn't get better. I only had the one leg before this happened and at least I could use it somewhat, now it is useless. Resident #[AGE] denies being assessed after being dropped. She stated, I complained of pain that night and the next day but nothing was done until I went to the Director's office. Resident #[AGE] further stated, They were supposed to investigate it but I have never heard anything concerning the investigation. Record review on 02/25/20 at 2:30 PM found Resident #[AGE] has a Brief Interview for Mental Status (BI[CONDITION]) score of 14, indicating the resident is cognitively intact. Attending physician documented Resident #[AGE] has the capacity to make her own medical decisions. Resident #[AGE] was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An X-ray report of right ankle dated 09/23/19 stated (typed as written): --Results: There is an angulated and slightly displaced [MEDICAL CONDITION] malleolus (the bump on the inner side of the ankle joint at the end of the tibia (also know as the shin bone) as well as the posterior malleolus (fracture at the back of the tibia). There is an angulated [MEDICAL CONDITION] fibula (the bone that starts just below the knee joint on the outside and extends all the way down to the ankle joint) above the lateral malleolus (bone on the outside of the ankle joint). No significant callus formation noted and the fracture appears recent. --Conclusion: [MEDICAL CONDITION] malleolus and posterior malleolus. Angulated distal fibular fracture. Also included an X-ray report showing a [MEDICAL CONDITION] left rib. Review of an Unusual Occurrence form dated 09/24/19 authored by the Director of Nursing (DON) stated (typed as written): -- On 09/22/19 at approx 1900 hrs the resident was being transferred from her wheelchair to her bed. The resident already had a Hoyer pad underneath of her while she as sitting in her wheelchair. The resident's pad was hooked into the Hoyer lift. As one staff member was operating the Hoyer lift the second aid was straightening the sheets on the bed. While being lifted it was noticed that the resident was slipping out of the Hoyer pad. The resident had swung away from her wheelchair and was not able to be lowered back into her wheelchair. For safety of resident she was lowered to the floor. Upon lowering to the floor the resident' right leg folded underneath of her. On 09/23/19 1430 hrs at the resident reported pain in her right ankle and left side of abdomen to the DON. An X-ray was ordered and found to be positive for fracture. In the morning of 09/24/19 CNA came to writer to explain what had happened to the resident during transfer. --Resident was being transferred with the Hoyer lift and the sling had slipped. The CNA's lowered the resident to the floor and when resident was all the way to the floor they noticed that her right leg was underneath her. The following morning the resident went to the DON's office and c/o pain in her right ankle. An x-ray was ordered and noted to have a fracture. Notified MD and ordered to get into ortho and if couldn't get appt soon enough to send to ER. Sent resident to ER. A splint was placed and ortho appointment for following day. A repeated x-ray completed and showed a fracture more complex. A hard splint placed and wrapped and has follow-up appt with ortho. Education provided by ADON on transferring technique using Hoyer-all nurses and CNA's equipment was assessed and functioning properly, assessed all slings and slings that had a lot of stress noted were disposed. The Administrator provided handwritten statements by two (2) Nurse Aides (NA) regarding the incident occurring on 09/22/20. Neither statement was dated as to the time it was written. Both statements described the Hoyer pad not being under the resident correctly prior to transfer and resident sliding out of lift. Nurse Aide (NA) #37 describes the resident being on the floor, the Hoyer pad removed and correctly placed under the resident. The Licensed Practical Nurse (LPN) was notified. NA #99 describes standing next to the resident talking with her while operating the Hoyer lift, then noticing the resident was slipping out of the Hoyer pad. When on the floor moved her leg out placing it on the Hoyer lift. During this time the LPN walked in and walked back out. Both describe after correctly placing the lift pad the resident was transferred to the bed. Neither witness statements explained why if the lift pad was not under the resident correctly, it was not positioned correctly prior to transfer. In addition, if the resident was lowered to the floor why her right leg was positioned under her. Also lacked a witness statement from the LPN who witnessed the incident. The medical record (electronic and hard copy) was silent for a physical assessment following the resident's allegation of being dropped on the floor or the documentation of the LPN observing the incident. During an interview with the regional consultant #100 present on 02/25/20 at 12:30 PM, the DON reported only an unusual occurrence form was completed for the incident. She explained, It was not a fall since the resident was lowered to the ground. Employee #F reported in a confidential interview, She (Resident #[AGE]) was dropped on the floor and was seriously hurt. The staff were too afraid to admit it because they were not watching her like they should have been. We all know that she is afraid every time the Hoyer lift is used, because she tells everyone. Confidential interviews throughout the survey reported staffing is not adequate to care for the residents. Employee's #A and #B explained residents are not receiving the monitoring for fall prevention, shower assistance, ADL care, or the required two person for Hoyer lifts. Both Employee's stated, Management will tell you different but they stay in their offices most of the time. If they do come out of the offices, they certainly are not going to help with any resident care. But since you are here from the state, we will have more staff on the units, because they think you will not know any better. Resident #[AGE] experienced actual harm when the facility failed to ensure appropriately trained staff were available to correctly transfer the resident with a hoyer lift. The resident experienced actual physical harm due to this failed practice as a result of a medial malleolus and posterior malleolus and angulated distal fibular fracture and sixth left rib fracture. The facility failed to timely transfer the resident to the emergency department for evaluation despite the fall and the resident expressing pain. In addition, the medical record was silent to indicate the facility assessed the resident immediately following the incident. Resident #[AGE] experience further actual harm related to the fear she experiences every time staff use the hoyer lift to transfer or lift her. Resident #[AGE] continued to express this fear five months after the incident, and this was confirmed through a confidential interview with staff. This failed practice resulted in actual physical and emotional harm to Resident #[AGE].

Based on clinical record review and staff interview, the facility failed to obtain prompt emergency medical services, resulting in Immediate Jeopardy, for one (Resident #143) of 21 sampled residents whose clinical records were reviewed for quality of care. One additional resident (Resident #41) was placed at no actual harm but potential for more than minimal harm that is not Immediate Jeopardy when the facility failed to provide care and treatment for [REDACTED]. On [DATE] at 1:36 PM, the Administrator and Regional Director of Clinical Operations #135 were notified Immediate Jeopardy began on [DATE] at 3:40 AM, when Resident #143 became short of breath, requested the inner cannula of her [MEDICAL CONDITION] be re-inserted and be suctioned. Attempts to re-insert the inner cannula were unsuccessful, Resident #143's shortness of breath worsened, and her oxygen saturation went down to 52% (normal range is 95%-100%). Blood oxygen saturation levels below 80% can compromise organ function. The Licensed Practical Nurse (LPN) #73 in charge did not call 911 for 29 minutes. Subsequently, Resident #143 went into respiratory arrest and required cardiopulmonary resuscitation as emergency medical services arrived nine minutes after 911 was called. The Immediate Jeopardy was removed on [DATE] at 4:43 PM, when the facility reduced the potential for imminent danger as no other residents had a [MEDICAL CONDITION]. Additionally, the facility conducted an audit for all residents for a change in condition and notification of the physician. The facility provided in-service for nurse regarding notification of change in condition, notification of physician and sending residents out 911. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until all staff attended inservice training and completed competencies on [MEDICAL CONDITION] care and change of condition. Findings include: 1. On [DATE] at 3:36 PM, the closed clinical record of Resident #143 was reviewed. The electronic clinical record documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A history and physical, written by the resident's primary care physician at the facility, on [DATE], documented Resident #143 had been admitted from the hospital and was receiving IV [MEDICATION NAME] pneumonia. The physician documented the Plan was to Continue current management. Discussed with staff for ([MEDICAL CONDITION]) care especially (suctioning) if any mucus plug happens (patient) to evaluation The admission Minimum Data Set (MDS) assessment, dated [DATE], documented Resident #143 had moderate cognitive impairment; received oxygen, suctioning, [MEDICAL CONDITION] care, IV medications; and expected to be discharged to the community. The assessment documented she had received 30 minutes of respiratory therapy during the 7 days prior to the assessment date. The admission physician's orders [REDACTED]. The clinical record contained no 48-hour baseline care plan to guide care and services to address the [MEDICAL CONDITION] and respiratory care for Resident #143. A nurse's progress note, written by Licensed Practical Nurse (LPN) #73 on [DATE] at 09:01 AM, documented the following: .This nurse got in report at the beginning of shift ([DATE] at 11:00 PM) that this resident had her inner cannula out and would not let him put it back in. Vitals at this time is BP (blood pressure) ,[DATE], P (pulse) 64, T (temperature) 98.6, R (respirations) 20, (oxygen saturation) 92%. (12:30 AM) went in to check resident and do (nebulizer treatment. Tried to insert inner cannula, not able to go more than 1.5 (inches) and resident started to gag. Nurse added saline to ([MEDICAL CONDITION]) and tried to suction to loosen secretions to get cannula in. (Oxygen saturation) at this time was 93%. Attempted to put cannula in again, same results, she started to gag and told me to stop. I told her I was coming back in again to try, if not able to get in would have to call the doctor. I kept checking on her and she was sleeping. Approximately three hours later at 3:40 AM on [DATE], LPN #73 documented the following. (3:40 AM) Resident rang call light, asked this nurse to put cannula in and to suction her. Attempted to insert cannula again, started to gag again and seemed to have more shortness of breath. BP ,[DATE], T 98.4, P 54, R 20 (oxygen saturation) 52%. (Per the Mayo Clinic, the normal range of oxygen saturation by pulse oximeter reading is ,[DATE] percent.) Started breathing treatment and (oxygen saturation) came up to 80%. Did not want to be left alone, had aide come in with her. (3:48 AM) Called DON (director of nursing) left message. Attempted a few more times to call later. (3:50 AM) Called (name withheld, resident's physician) and left a message. (3:52 AM) Asked (name withheld, LPN #24) to try and help with cannula. Asked (name withheld, LPN #49) about sending her out without an order (4:05 AM) (name withheld, LPN #24) attempted to insert cannula. (Oxygen saturation) dropped to 42%. (Name withheld, LPN #24) upped (increased) the O2 (oxygen) to 6 (liters)/minute. (4:09 AM) called 911, gave report (4:11 AM) hung up with 911, went back in with resident, she was unresponsive. (4:20 AM) EMTs (emergency medical technicians) arrive, (oxygen saturation was 80%, Pulse 78, Respirations 8 (4:22 AM) As they enter the room she stopped breathing. (LPN #24) and myself started CPR. (LPN #2) started compressions, I kept (oxygen) on while EMTs (emergency medical technicians) brought equipment in and set up bag for airway. When (LPN #24) was tired I took over compressions. When I got tired an EMT took over for me. (4:32 AM) I called a code blue overhead even though EMSs were here .' With the exception of an oxygen saturation reading of 92%, documented at 2:11 AM, there was no documentation in the progress notes or assessments which indicated the resident's status between 12:30 AM and 03:40 AM. No observations/assessments regarding the characteristics of the resident's breathing and/or her appearance were documented in the progress notes or assessment sections of the electronic clinical record. A Resident Occurrence Report Result, completed on [DATE], documented under the Occurrence Type of Unexpected Death, the nurse's note, dated [DATE] for Resident #143. The report documented the Director of Nursing, risk management, and the Administrator had reviewed the document. The conclusion, written by the DON on [DATE], documented: .Resident was admitted to facility on [DATE]. Resident (diagnosed ) with ([MEDICAL CONDITIONS]), tracheal stenosis, and [MEDICAL CONDITIONS]. Resident had multiple admission to hospital and to this facility. The Administrator documented on [DATE]: This incident has been reviewed and discussed with the DON. On [DATE] at 11:26 PM, an interview was conducted with LPN #24 in the dining room. The documented nurse's progress note regarding Resident #143, dated [DATE] at 9:01 AM, written by LPN #73, was shown to the LPN. He stated the inability to replace the [MEDICAL CONDITION] inner cannula at 3:40 AM and the oxygen saturation reading of 80% constituted an emergency situation. He stated the EMS had not been notified to transport the resident for 30 minutes after the emergency situation arose. He stated 30 minutes was not a reasonable time in which to react to the emergency situation. LPN #24 stated he did not know for sure but assumed a licensed nurse could call 911 in an emergency situation without having talked to the physician first. On [DATE] at 11:36 PM, an interview with LPN #49 was conducted in the dining room. The documented nurse's progress note regarding Resident #143, dated [DATE] at 09:01 AM, written by LPN #73, was shown to the LPN. The LPN stated she knew nothing about the status of Resident #143 prior to the resident coding. She stated she was on lunch break when LPN #73 told her Resident #143's [MEDICAL CONDITION] cannula was out and LPN #73 was unable to get it back in. She stated LPN #73 asked about sending the resident out without a physician's orders [REDACTED].#73 to try to call the doctor and, if he did not answer, nursing judgement was to send the resident out. LPN #49 acknowledged the inability to replace the [MEDICAL CONDITION] inner cannula at 3:40 AM and the resident oxygen saturation of 80% constituted an emergency. She stated it was 29 minutes before the EMS (emergency medical services) was notified to transfer the resident and acknowledged that was not a reasonable time to react to the emergency situation. LPN #49 stated the facility's protocol in an emergency was to call the primary physician and DON first. She stated, At that time and now, nurses are to call the DON with any medical emergency. The LPN was asked if having to call the DON in an emergency situation took time away from the resident. She stated, Yes. On [DATE] at 4:40 PM, an interview was conducted with LPN #73 at the station 1 nurses' station. The documented nurse's progress note regarding Resident #143, dated [DATE] at 9:01 AM, was shown to LPN #73. The LPN stated prior to the Resident #143 going into respiratory arrest, the resident had taken her [MEDICAL CONDITION] inner cannula out and she, LPN #73, tried to put it back in. She was shown the documentation of the oxygen saturation of 80% at 3:40 AM and was asked if 80% was a good reading. She stated, No, but it's better than it was. She acknowledged, at 3:40 AM, Resident #143 complained of shortness of breath., She (LPN #73) gave a breathing treatment and oxygen was administered. She stated the physician was notified at 3:50 AM but he did not answer. LPN #73 stated she had called EMS for transport out of the facility at 4:09 AM. LPN #73 was asked if the inability to replace the [MEDICAL CONDITION] inner cannula and an oxygen saturation of 80% at 3:40 AM constituted an emergency. She stated, Yes, to me. LPN #73 acknowledged she had waited 29 minutes to notify EMS to request a transfer. She stated she could have called EMS faster, but I tried to follow protocol and call the DON and the doctor. LPN #73 was asked if it was more important to get emergency help for the resident or to call the DON and the doctor. She stated, To get help for the resident. I was following procedure. I didn't realize it took so long to do all that. LPN #73 was asked, in her opinion, when the emergency situation began. She stated, At 3:40 AM, when the resident stated she was having shortness of breath. LPN #73 stated she should have called EMS sooner. On [DATE] at 10:36 AM, an interview was conducted with the DON in her office. Assistant Director of Nursing #133 was also present for most of the interview. The documented nurse's progress note regarding Resident #143, dated [DATE] at 9:01 AM, written by LPN #73, was shown to the DON. The DON stated she had reviewed the documentation, dated [DATE], for Resident #143. She was asked if she had seen any problems with the care/services provided for the resident. She stated, She (Resident #143) should have been monitored between 12:30 AM and 3:40 AM. She stated she thought there were more nurse's notes documented between those times. The DON stated the facility's protocol was to call the physician if a resident's oxygen saturation level was below 92%. She stated, The physician should be notified if the (oxygen saturation) is below 92%. She stated LPN #73 should have called the doctor at 3:40 AM, when the [MEDICAL CONDITION] inner cannula could not be inserted and the resident complained of shortness of breath. The DON stated a nurse could call 911 without a physician's orders [REDACTED]. She stated LPN #73 should have called 911 a few minutes earlier, by documentation. She stated the LPN could have called another LPN seven minutes earlier, per documentation to get assistance with the emergency situation. The DON stated it would have been good nursing judgement to call 911 rather than to take time to call the DON and the physician. She stated, The protocol is valid if the situation is not emergent, but this was emergent. On [DATE] at 11:45 AM, Resident #143's primary care physician at the facility was interviewed by phone. The nurse's notes of the events on [DATE] regarding Resident #143 were reviewed with the physician. He stated, They should have called 911 when she was short of breath. She was sick. He stated it was an emergency situation. He stated 911 should have been called at 03:40, when the resident was short of breath and the nurse could not insert the cannula. He stated, She (Resident #143) may have had a mucous plug and needed to be sent to the hospital. They should have called 911. On [DATE] at 12:05 PM, the Administrator and Regional Director of Clinical Operations #135 were interviewed in the administrator's office. Regional Director of Clinical Operations #135 stated the facility's protocol for an unexpected death was to fill out an incident/accident report and fill out a time line. She stated no corrective measures had been taken in regard to the emergency situation with Resident #143 because we didn't identify any problems that needed to be corrected. 2. Review of the clinical record on [DATE] at 1:22 PM revealed a re- admission history dated [DATE]. The admission history documented that Resident #41 was re- admitted into the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #41 independently ambulates around the facility. Resident #41 had an Activities of Daily Living (ADL) Plan of Care (P[NAME]) dated [DATE] with an intervention to avoid scrubbing and pat dry sensitive skin during bathing. The P[NAME] dated [DATE] for chronic pai[DIAGNOSES REDACTED] had an intervention to provide treatment as directed by dermatologist. Documentation from a dermatologist was not found. During the initial resident interviews on [DATE] at 12:45 PM, Resident #41 was observed to have red bumps and dry flakes of skin that went across his forehead and down the right side of his face and into the area around his temple. Resident #41 stated that he's had the rash for a long time and it comes and goes. Resident #41 stated that it did not bother him, and he had not received any treatment for [REDACTED]. Further review of the clinical record revealed a physician's orders [REDACTED]. Licensed Practical Nurse (LPN) #14 documented in a nurse's note on [DATE], Red rash noted on forehead. Resident denies itching. LPN #14 documented in a nurse's note on [DATE], During skin assessment no skin issues noted except ongoing rash on face which worsens during shower. On [DATE] at 9:39 AM, LPN #57 was interviewed. LPN #57 stated when a resident had a skin issue they inform the would care nurse, Registered Nurse (RN) #72. LPN #57 stated that Resident #41 has had the rash on his forehead on and off for a long time, but she cannot recall Resident #41 ever receiving any kind of treatment for [REDACTED].#57 stated that if a treatment was ordered it would be after RN #72 was to evaluate the rash and call the doctor for an order to treat. On [DATE] at 2:26 PM, RN #72 was interviewed. RN #72 stated that she was not aware that Resident #41 had a rash on his forehead. RN #72 stated that when nurses have an order for [REDACTED].#72 stated that she does not read the nursing progress notes and would not have seen the notes documented on [DATE] or [DATE]. On [DATE] at 9:01 AM, LPN #14 was interviewed. LPN #14 stated that after she observed the rash on Resident #41's forehead she put it on the list for the doctor to address. LPN #41 stated that a rash on the forehead is not something she would pass on to the wound care nurse (RN #72). LPN #41 continued by stating that a rash should be a part of the head to toe skin assessment, but it's not something urgent to call the doctor about. LPN #41 stated that since she is a nurse who floats to all the units, she does not necessarily know if there is any follow up. On [DATE] at 9:14 AM, Assistant Director of Nursing (ADON) #133 was interviewed. ADON #133 stated that the physician and the would care nurse (RN #72) should have been notified. ADON #133 was unable to find documentation of the weekly skin grids for Resident #41 since the original order on [DATE]. Additionally, ADON #133 was unable to find documentation of a P[NAME] that addressed the forehead rash. ADON #133 stated that if the weekly head to toe assessment was being completed, then the rash on Resident #41's forehead should have been identified and reported.

Based on record review and interviews, the facility's quality assessment and assurance (QAA) committee failed to have a system in place to identify quality of care problems and to develop/implement measures to correct the problems and maintain ongoing compliance with the Code of Federal Regulations. This resulted in a pattern of harm in quality of care areas. The facility census was 96. Findings include: On 12/07/18 at approximately 4:40 PM, the Director of Nursing (DON), who was the contact person for the QAA committee, was interviewed in the conference room. She stated issues which require the QAA committee's attention are discussed in the facility's morning meeting. She stated the QAA committee compared the facility's percentage of quality of care issues to the state and federal percentage to determine when a deviation for performance or a negative trend was occurring. The DON stated staff know to tell their charge nurse/supervisor about quality concerns which need the QAA committee's attention. She stated the charge nurse/supervisor reports the concern to the assistant director of nursing who takes it to the QAA committee. The DON stated the QAA committee decided which issues to work on by using Care Watch. She stated the QAA committee knew that corrective action had been implemented for concerns because it was discussed during QAA meetings and weekly risk meetings. She stated the QAA committee knew when improvement of problems was occurring through review and discussion during the QAA meetings. The DON stated the QAA committee continued to monitor an issue which had been corrected all the time because it can change at any time. She stated the QAA committee's decision to monitor an issue which had been corrected was decided by looking at interventions that had been initiated and using the state, federal and facility statistics and quality of care areas of concerns. She stated a resident with an identified quality of care concern would be evaluated. The DON was asked if the QAA committee had functioned effectively to identify systems failures, implement measures to correct the systems failures, and follow through with the corrective measures to ensure the systems failures had been corrected. The following systems failures, identified by the survey team, were reviewed with the DON: a. Staff's failure to obtain prompt emergency transport as necessary/required for residents: The facility had not identified any problems with the care/services provided for Resident #143 and therefore, no corrective actions had been taken to prevent recurrence. Refer to F684. b. Care/services for prevention/healing of pressure ulcers: The same deficient practice existed in 12/2018 and in 06/2018, when a staff member had not notified the physician/wound nurse regarding the presence of a newly identified pressure ulcer. Refer to F686. c. Licensed nurse competencies: Eight of 27 licensed nurses had no training and had not been assessed to be competent in the provision of care/services for a resident with a [MEDICAL CONDITION]. Refer to F726. d. Certified nurse aide (CNA) performance reviews: No CNA performance reviews had been completed during the past year. Refer to F730. e. Development of the comprehensive care plan: The Centers for Medicare & Medicaid Services (CMS) Casper Provider History Profile documented the facility had also been cited for this deficient practice in the previous four surveys in a row. This is five surveys in a row that care plan were cited. Refer to F656. f. Kitchen sanitation: The CMS Casper documented the facility had been cited for this deficient practice on the previous two surveyors in a row. Refer to F812. The DON stated the QAA committee had identified quality issues in regard to the care/services provided to prevent/heal pressure ulcers but that the problems still need work. The DON stated the QAA committee had not identified systems failures in the other areas documented above.

Based on observation, record review and staff interviews, the facility failed to ensure residents receive pressure ulcer care, consistent with professional standards of practice. Specifically, the facility failed to follow their protocol after the identification of a newly developed pressure ulcer. This resulted in no treatment being done and the worsening of the pressure ulcer. This affected two (Residents #24 and #142) of four residents investigated for pressure ulcers. This resulted in actual harm for resident #24.The facility census was 96. See F692 for additional information regarding Resident #24 and severe weight loss. Findings include: 1. Review of the face sheet for Resident #24 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of the annual Minimum Data Set (MDS) assessment, dated 09/25/18, revealed the resident did not have a Brief Interview for Mental Status (BIMS) completed. According to section V, the resident's previous BIMS score was three out of 15 which indicated severe cognitive impairment. The resident's functional status for bed mobility was extensive assistance. The resident was assessed as high risk for pressure ulcers. The MDS assessment documented Resident #24 had no unhealed pressure ulcers at the time of the assessment. The resident was observed on 12/04/18 at 10:28 AM. She was lying in bed on her right side. The resident was observed on 12/04/18 at 2:35 PM. She was lying on her back in her bed, sleeping. Review of the progress notes on 12/03/18 at 2:06 PM revealed: 11/27/18 at 22:11: New area on sacrum area observed, is red and opened approximately the size of a half dollar, [MEDICATION NAME] was applied, turned and repositioned every two hours for comfort and care. Will continue to monitor and inform oncoming nurse of new concerns. Observation of the resident's skin with the Wound Care Nurse (WCN-RN) #72 on 12/05/18 at 10:19 AM revealed the resident had a sacral ulcer with approximate measurements of 1.0 cm (centimeter) x 1.0 cm x 0.1 cm. The WCN-RN #72 was interviewed on 12/05/18 at 11:46 AM. She was a Registered Nurse (RN) and had wound training. She stated she was not aware of this resident's sacral wound until the morning of 12/05/18. She was looking through the nurse's notes and found the note regarding a new sacral wound. When asked how soon she should be notified, she stated Quickly, and she should get a note in her mailbox. She also looked at the skin grids (wound assessments). They should notify the MD (medical doctor) and put treatment in place. When asked if there was a skin grid for this sacral wound, she stated No. She confirmed she had no idea how it looked when it was first identified. She notified the MD this day. They ordered a low air loss mattress for this resident. She stated this resident had a Stage 3 because the wound had slough (necrotic/dead tissue). Review of the MD progress note on 12/09/18 at 4:21 PM revealed: 11/28/18: Skin: inspection: no rash or ulcers on exposed areas. Review of the skin grid on 12/09/18 at 4:23 PM revealed: Dated 12/05/18: Is this a new pressure area: Yes -Resident refused wound assessment: No -Progression of wound from last assessment: No change -Date area was first observed: 11/27/18 -House/Community acquired: House acquired -Sacrum pressure: 1.0 cm x 1.0 cm x 0.1 cm: stage III -Appearance of wound bed: Slough present -Has the care plan been reviewed and revised as necessary: Yes Director of Nurses (DON) was interviewed on 12/05/18 at 1:38 PM. She stated when the wound was first identified, they should have documented in the progress notes, documented in the skin grid and started an incident report. They should have called the Assistant Director of Nurses (ADON) or whoever was on call. She stated they would have notified the MD and the family from the incident report. The DON was just informed of the sacral wound on this day. She confirmed the progress note was the only measure completed until today. Review of the Skin Care and Wound Management policy effective 07/01/16, revealed residents/patients admitted with or develop skin integrity issues will receive treatment as indicated on location, stage and drainage. (No other wound policies available) 2. Review of a closed record face sheet for Resident #142 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. This resident was discharged on [DATE] to hospice. Review of the 14-day Minimum Data Set (MDS) assessment, dated 06/12/18, revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score 15 out of 15. The resident's functional status for bed mobility was extensive assistance. Review of the order summary report revealed hospice consult: 06/25/18. Review of the skilled documentation notes on 12/09/18 at 5:27 PM revealed: Dated 04/17/18: Sacrum- redness Review of the wound observation notes on 12/09/18 at 5:32 PM revealed: Dated 06/26/18: Wound observation: Sacrum-small open area. Licensed Practical Nurse (LPN) #3 was interviewed on 12/07/18 at 11:55 AM. She stated she was not in the facility the day the resident was discharged . She was told the resident went to hospice care. She was unable to remember what the resident's legs looked like, but she remembered the resident was wrapped due to the [MEDICAL CONDITION]. She did not remember this resident having a pressure ulcer. WCN-RN #72 was interviewed on 12/07/18 at 11:59 AM. She stated this resident's legs were very [MEDICAL CONDITION] and her blisters were getting better on her lower extremities. She had some hematomas (bruises). She bumped her legs into things. She got the hematomas from the hospital. She came back with treatment orders. Her skin was fragile. With a reddened area, the nurse should have completed a skin grid, called the MD and put treatment in place. She said a skin grid should have been completed immediately after the progress noted was written. She confirmed there was no way to know the progression of this sacral wound. She confirmed there was no skin grid completed for this resident's sacral wound. She would have seen the resident's wound if they had completed a skin grid. Certified Nurse Aide (CNA) #83 was interviewed on 12/07/18 at 2:08 PM. Her feet were black and blue. Her bottom area was a little red. She thought it was from diarrhea. She would have notified the nurse. She could not remember if she did. The DON was interviewed on 12/07/18 at 2:16 PM. The CNA should have notified nursing. She stated the nurse should have completed a skin grid as soon as the wound was identified. Review of the skin grids completed from 04/09/18 through 06/19/18 were void of any documentation regarding the sacral wound.

Based on observation, record review and staff interviews, the facility failed to ensure a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Specifically, the facility failed to adequately assess the effectiveness of current nutritional interventions along with ensuring the resident received needed assistance with meals. This lead to continued nutritional decline and severe weight loss. This affected one (Resident #24) of four residents investigated for nutritional status which resulted in actual harm. The facility census was 96. See F686 for additional information regarding Resident #24 developing pressure ulcers. Findings include: Review of the face sheet on 12/10/18 at 2:00 PM for Resident #24 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of the annual Minimum Data Set (MDS) assessment, dated 09/25/18, revealed the resident did not have a Brief Interview for Mental Status (BIMS) completed. According to section V, the resident's previous BIMS score was three out of 15 which indicated severe cognitive impairment. The resident's functional status for eating was supervision. Resident #24 was observed on 12/03/18 at 9:33 AM. She was lying in bed. Her facial feature and upper extremities had a bony prominence. -At 12:55 PM, the resident was observed in her bed with food on the table in front of her. No staff assistance was observed. She was feeding herself with her fingers. She had a plate of cake in her lap and she was eating the cake with her hands. She picked up spaghetti noodles and pieces of chicken with her fingers and tried placing in her mouth. She appeared to have difficulty feeding herself. She did not use any silverware throughout the observation. She was able to pick up a glass of juice and drink from a straw. Her frozen nutritional treat was noted as unopened. Resident #24 was observed on 12/04/18 at 8:04 AM. She was in her bed feeding herself. The milk carton was open with a straw. No staff was present and no assistance was provided. At 8:28 AM. She was observed picking up hot cereal with her fingers and placing in her mouth. She tried to use a fork with great difficulty. She then placed the hot cereal back down. The orange juice container had a slit along the top with no straw. There was no nutritional treat on her tray. Resident #24 was observed on 12/05/18 at 8:05 AM. The resident was lying in bed with her breakfast tray on the table in front of her. No staff were present during the observation. Her milk carton had spilled over onto her tray. Her omelet was cut up and untouched. Resident #24 was observed on 12/05/18 at 12:58 PM. Certified Nurse Aide (CNA) #132 was observed assisting the resident with her lunch meal. She was feeding the resident potatoes. Then she gave the resident some of the nutritional treat. She got called away and another staff member took over with assistance. This new staff member was observed cutting up the food. CNA #132 came back at 12:59 PM. She gave the resident part of her buttered roll and the resident was feeding herself the roll. The resident was very talkative and fed herself slowly. The CNA asked her if she wanted some turkey and the resident said, Yes. She gave the resident a piece of turkey. By 1:04 PM, the CNA had put her tray on table away from the resident and left the room. (Assistance lasted for six minutes.) CNA #132 was interviewed on 12/05/18 at 1:30 PM. She stated she didn't think the resident liked being fed. She said she ate about 25%. She ate some of the sweet potatoes, turkey and nutritional treat. When asked about the tray taken from her, she said she would leave it for the resident to try and feed herself some of the food next time. Review of the weight summary on 12/10/18 at 2:10 PM revealed: -12/03/18: 96 pounds (6.3% loss x 1 month; 19.6% loss x 3 months; 25.5% loss x 6 months) -11/01/18: 102.5 pounds -09/01/18: 119.5 pounds -06/01/18: 129 pounds Review of the order summary report on 12/10/18 at 2:20 PM for (MONTH) (YEAR) revealed: 10/10/18: Regular diet: regular texture, thin consistency, fortified all meals, frozen nutritional treat, every day for weight management and inconsistent intake. -10/10/18: Med pass 2.0 three times a day for weight loss. Give 4-ounces. -11/28/18: Feed group- assist with tray set up and feeding Review of the resident's tray card: No added salt (NAS) diet which was inconsistent with diet order. Review of the progress notes on 12/10/18 at 2:30 PM revealed: -12/06/18: Nurses Note: Resident had been sent out to the emergency room (ER) and had returned to the facility with Diagnosis: [REDACTED]. -12/05/18: Nurses Note: Spoke with Assistant Director of Nurses (ADON) and Medical Doctor (MD), new orders to send to hospital for evaluation for change in mental status, hallucination and low-grade temperature of 100.5. -12/05/18: Nurses Note: Notify hospice . order for hospice consult. -12/03/18: Weight Change Note: weight stable x 1 week. No improvement in oral (PO) intakes with feed group. Recommendation for hospice consideration. No other nutritional interventions at this time. -11/28/18: Weight Change Note: recommendations: consider hospice care if condition continues to decline; feed group- assist with setup and feeding. Review of the most recent nutritional review, dated 09/29/18, revealed: -Does the patient receive a medical food supplement: Yes -Indicate current supplement order: offer snacks, med pass 2.0 (4-ounce twice a day (BID)) -Are there any skin problems: No -Most recent height: 63 inches -Most recent weight: 108 pounds, wheelchair -Body mass index (BMI): 19.1 (Within normal limits) -Usual body weight (UBW): not available -Weight one month ago: 124.5 pounds -Comments: Resident had a significant weight changes with 30 days, 90 days and 180 days. -Average PO intake: PO intake varies: 25-50% during breakfast and dinner. Lunch: eats >75% as per registered nurse (RN). -Average fluid intake: [PHONE NUMBER] milliliters (ml) -Comments: Resident is seen for nutrition quarterly review .significant weight loss .resident continues to eat what she wants independently in the dining room. Able to feed self .Continue current diet, honor food preferences, snacks and med pass. Will continue to monitor weights, labs, skin, PO intake, and PO intake tolerance. Review of the care plan, revised on 05/01/18, revealed potential for nutritional risk related to: history of fracture to dominant arm, [MEDICAL CONDITION] with fluid imbalance changes, history of abnormal labs related to [MEDICAL CONDITION], [DIAGNOSES REDACTED]. Weight change 05/01/18- 9-pound weight loss past 60 days. Interventions include: encourage fluids, monitor diet tolerance .offer alternate food and fluid choices .provide assistance at meal times: cut/chop food, aide in assistance with eating as needed .provide diet as ordered NAS reg consistency and thin liquids. Review of the care plan, revised on 09/29/18, revealed resident is at risk for nutrition/hydration imbalances related to unintentional weight loss as evidenced by significant weight loss within 30 days. Interventions include: Continue current diet-regular, regular, thin liquids. Review of the physician/nurse practitioner progress notes revealed: -11/28/18: General: This patient is well developed and in no acute distress. [DIAGNOSES REDACTED]. -11/20/18: General: This patient is well developed .Plan: Patient is treated in the ER or UTI. Continue antibiotics as ordered. -11/12/18: General: appetite is satisfactory. No significant weight change .This patient is well developed. (There was no mention of weight loss) -09/12/18: General: appetite is satisfactory. No significant weight change .This patient is well developed. [DIAGNOSES REDACTED]. There was no mention of weight loss. Review of the Medication Administration Record [REDACTED] -Med pass 2.0 three times a day for weight loss: average intake was 28% x 15 days. Review of the meal percentages task revealed resident intake mostly 0-25%. The Administrator was interviewed on 12/06/18 at 9:02 AM and she stated the facility did not have a policy related to Nutrition. She was unable to locate one. CNA #32 was interviewed on 12/04/18 at 2:39 PM. When asked if this resident required assistance, she said Yes.' She stated she helped this resident at lunch and she only ate two bites. She is on nutritional treat and only takes a small amount. She should be getting assistance when she eats in her room. She usually assisted this resident at the evening meal. She had not noticed this resident eating with her hands. She said she and noticed this resident put food in her mouth and take it back out. She noticed a decline in this resident about three weeks ago. She used to eat 100%. She won't take her snacks. She used to love spaghetti and bread. She had tried to get her to eat her bread. She was on med pass and taking sips. The Registered Dietitian (RD) was interviewed on 12/03/18 at 3:20 PM. She stated she worked in the facility two days a week. During that time, she focused on MDS, new admissions, annuals, quarterlies, residents with weight loss and as needed. The RD was interviewed on 12/05/18 at 2:03 PM. She said she had not observed this resident during her meals. She was not in the facility very long and was short on time. She was not aware the resident was not receiving adequate assistance with her meals. -At 2:58 PM, she said she talked to therapy about adaptive equipment They told her they had noticed her grabbing more with her fingers. More after she returned from the hospital. She used her utensil well before her hospital visit. The RD talked to dietary and were going to add more finger foods. They don't have a finger food' diet. She would add more sandwiches with protein for wound healing. The Director of Nurses (DON) was interviewed on 12/07/18 at 9:22 AM. She stated she had observed this resident in the dining room and she had fed herself well. She had not observed her eating in her room. Maybe positioning in the dining room versus positioning in her bed. She had been working with the RD and have been trying to figure out what to do. Review of Nutrition for the Older Adult: Clinical Assessment. 2nd ed. Burlington, MA: Jones and Bartlett Learning; (YEAR):172 revealed Severe malnutrition: >5% in 1 month; >7.5% in 3 months and >10% in 6 months.

Based on observation and performance testing, record review, and staff interview, the facility failed to provide an environment as free as possible of accident hazards, by failing to ensure the delayed-egress magnetic locks on three (3) designated doors of emergency egress automatically released upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm, when tested with the application of force at 9:30 a.m. on 01/26/10, and again with the onset of the fire alarm system at 10:30 a.m. on 01/26/10. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room 101 (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when a contracted service company identified these concerns during an inspection of the facility's fire alarm system, yet no affirmative action had been taken to ensure this identified problem had been corrected at that time. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. At 1:05 p.m. on 01/26/10, the life safety code surveyor relayed he had informed the State survey and certification agency's program manager of the situation. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. Upon removal of the immediate jeopardy, a deficient practice remained until the locks were repaired and/or other systems were put into place to prevent unauthorized exit of residents through these doors, which posed the potential for more than minimal harm affecting more than an isolated number of residents. Facility census: 100. Findings include: a) The most recent facility fire alarm inspection report, which was provided by the facility upon request, was reviewed at approximately 3:00 p.m. on 01/25/10. This fire alarm inspection was conducted by SimplexGrinnell and bore the date of 11/04/09. Review of this report revealed, under the title of "Recommendation", the following: "The access control doors located on the ground floor entrance by the nurse station, the ground floor stairs by the nurse station, first floor by room 101 and first floor break room exit do not release automatically during the on set of a fire alarm. SimplexGrinnell recommends that these doors do release automatically during the on set of a fire alarm." b) When questioned, on 01/25/10 at approximately 4:00 p.m., if the facility had corrected the issue pertaining to automatic release of these doors upon activation of the fire alarm system, the facility's plant operations director stated he was not sure and would research his files for an answer. c) During a tour of the facility on 01/26/10 at approximately 9:30 a.m., the emergency release process was tested on the double outside egress doors located near the Station 3 Nurse Station (identified as the ground floor above). These doors failed to initiate an irreversible release process when a force greater than 15 lbf was applied for a period of greater than three (3) seconds. When questioned if he had been able to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected, the plant operations director stated he had not. d) At the request of the life-safety code surveyor on 01/26/10 at approximately 10:30 a.m., the facility's fire alarm system was activated. At this time, the double outside egress doors located near the Station 3 Nurse Station were tested and were found to be locked. The remaining delayed-egress locks listed on the fire alarm inspection reported, and others, were tested at this time with the following additional findings: - The designated outside exit door near resident room #101 was locked and had failed to release with the fire alarm. - The stairway door located near the Station 3 Nurse Station was locked and had failed to release failed to release with the fire alarm; however, this door was not situated within the designated means of egress and was, therefore, not a delayed-egress lock. - The designated outside exit door located near the break room was difficult to open (bound within the door frame); however, the delayed-egress lock had released. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. At 1:05 p.m. on 01/26/10, the life safety code surveyor relayed he had informed the State survey and certification agency's program manager of the situation. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. The survey team leader informed the facility's representatives of the needs to provide an action plan. The action plan was delivered at 3:00 p.m. on the same day and read as follows: "Corrective Action For Resident Affected: "Immediately upon notification of malfunction with the delayed egress system for the Station 1 Emergency Exit and the Station 3 Entrance doors, the locking mechanism was disabled. "Immediately upon disarming the locking mechanism at the egress doors, a staff member was posted at each malfunctioning door to maintain safety and supervise the entrance / exit area. "An outside contractor was called to initiate repairs of the delayed egress system at the Station 1 Emergency Exit door and the Station 3 Entrance / Exit door." Prior to leaving the facility for the day at 5:00 p.m., the maintenance director stated the 300 hall doors were working appropriately and, while the 100 hall door had not been placed on the fire alarm system, it now sounded a loud alarm when opened. On 01/27/10, the life safety code surveyor confirmed, after additional testing of the fire alarm, the doors were not functioning as required and presented to the team leader a copy of the work order from the service company stating this. Upon removal of the immediate jeopardy, a deficient practice remained until the locks were repaired and/or other systems were put into place to prevent unauthorized exit of residents through these doors, which posed the potential for more than minimal harm affecting more than an isolated number of residents. .

Based on observation and performance testing, record review, and staff interview, the facility was not administered in an manner that enabled it to use its resources effectively and efficiently to maintain a resident environment as free as possible of accident hazards. A fire inspection report, provided to the facility by a contracted service company and dated 11/04/09, identified "access control doors" equipped with delayed-egress locks did not automatically release as designed upon activation of the fire alarm system. Interview with the plant operations director, on the morning of 01/26/10, found he was unable to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected in reaction to the 11/04/09 fire inspection report. Performance testing, on the morning of 01/26/10, found the delayed-egress magnetic locks of three (3) designated doors of emergency egress failed to automatically release as intended upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room [ROOM NUMBER] (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when the contracted service company identified these concerns during an inspection of the facility's fire alarm system, yet no affirmative action had been taken to ensure this identified problem had been corrected at that time. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. At 1:05 p.m. on 01/26/10, the life safety code surveyor relayed he had informed the State survey and certification agency's program manager of the situation. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. Upon removal of the immediate jeopardy, a deficient practice remained until the locks were repaired and/or other systems were put into place to prevent unauthorized exit of residents through these doors, which posed the potential for more than minimal harm affecting more than an isolated number of residents. Facility census: 100. Findings include: a) The most recent facility fire alarm inspection report, which was provided by the facility upon request, was reviewed at approximately 3:00 p.m. on 01/25/10. This fire alarm inspection was conducted by SimplexGrinnell and bore the date of 11/04/09. Review of this report revealed, under the title of "Recommendation", the following: "The access control doors located on the ground floor entrance by the nurse station, the ground floor stairs by the nurse station, first floor by room [ROOM NUMBER] and first floor break room exit do not release automatically during the onset of a fire alarm. SimplexGrinnell recommends that these doors do release automatically during the onset of a fire alarm." b) When questioned, on 01/25/10 at approximately 4:00 p.m., if the facility had corrected the issue pertaining to automatic release of these doors upon activation of the fire alarm system, the facility's plant operations director stated he was not sure and would research his files for an answer. c) During a tour of the facility on 01/26/10 at approximately 9:30 a.m., the emergency release process was tested on the double outside egress doors located near the Station 3 Nurse Station (identified as the ground floor above). These doors failed to initiate an irreversible release process when a force greater than 15 lbf was applied for a period of greater than three (3) seconds. When questioned if he had been able to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected, the plant operations director stated he had not. d) At the request of the life-safety code surveyor on 01/26/10 at approximately 10:30 a.m., the facility's fire alarm system was activated. At this time, the double outside egress doors located near the Station 3 Nurse Station were tested and were found to be locked. The remaining delayed-egress locks listed on the fire alarm inspection reported, and others, were tested at this time with the following additional findings: - The designated outside exit door near resident room [ROOM NUMBER] was locked and had failed to release with the fire alarm. - The stairway door located near the Station 3 Nurse Station was locked and had failed to release failed to release with the fire alarm; however, this door was not situated within the designated means of egress and was, therefore, not a delayed-egress lock. - The designated outside exit door located near the break room was difficult to open (bound within the door frame); however, the delayed-egress lock had released. e) At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. (See also citation at F323.) f) The facility was aware of this quality deficiency as early as 11/04/09, but there was no evidence the facility developed / implemented a plan of action to correct this problem until after the life-safety code surveyor intervened on 01/26/10. (See also citation at F520.) .

Based on observation and performance testing, record review, and staff interview, the facility failed to develop and implement plans of action to correct quality deficiencies of which it was aware, to ensure the resident environment was as free as possible of accident hazards. A fire inspection report, provided to the facility by a contracted service company and dated 11/04/09, identified "access control doors" equipped with delayed-egress locks did not automatically release as designed upon activation of the fire alarm system. Interview with the plant operations director, on the morning of 01/26/10, found he was unable to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected in reaction to the 11/04/09 fire inspection report. Performance testing, on the morning of 01/26/10, found the delayed-egress magnetic locks of three (3) designated doors of emergency egress failed to automatically release as intended upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room [ROOM NUMBER] (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when the contracted service company identified these concerns during an inspection of the facility's fire alarm system, yet no affirmative action had been taken to ensure this identified problem had been corrected at that time. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. At 1:05 p.m. on 01/26/10, the life safety code surveyor relayed he had informed the State survey and certification agency's program manager of the situation. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. Upon removal of the immediate jeopardy, a deficient practice remained until the locks were repaired and/or other systems were put into place to prevent unauthorized exit of residents through these doors, which posed the potential for more than minimal harm affecting more than an isolated number of residents. Facility census: 100. Findings include: a) The most recent facility fire alarm inspection report, which was provided by the facility upon request, was reviewed at approximately 3:00 p.m. on 01/25/10. This fire alarm inspection was conducted by SimplexGrinnell and bore the date of 11/04/09. Review of this report revealed, under the title of "Recommendation", the following: "The access control doors located on the ground floor entrance by the nurse station, the ground floor stairs by the nurse station, first floor by room [ROOM NUMBER] and first floor break room exit do not release automatically during the onset of a fire alarm. SimplexGrinnell recommends that these doors do release automatically during the onset of a fire alarm." b) When questioned, on 01/25/10 at approximately 4:00 p.m., if the facility had corrected the issue pertaining to automatic release of these doors upon activation of the fire alarm system, the facility's plant operations director stated he was not sure and would research his files for an answer. c) During a tour of the facility on 01/26/10 at approximately 9:30 a.m., the emergency release process was tested on the double outside egress doors located near the Station 3 Nurse Station (identified as the ground floor above). These doors failed to initiate an irreversible release process when a force greater than 15 lbf was applied for a period of greater than three (3) seconds. When questioned if he had been able to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected, the plant operations director stated he had not. d) At the request of the life-safety code surveyor on 01/26/10 at approximately 10:30 a.m., the facility's fire alarm system was activated. At this time, the double outside egress doors located near the Station 3 Nurse Station were tested and were found to be locked. The remaining delayed-egress locks listed on the fire alarm inspection reported, and others, were tested at this time with the following additional findings: - The designated outside exit door near resident room [ROOM NUMBER] was locked and had failed to release with the fire alarm. - The stairway door located near the Station 3 Nurse Station was locked and had failed to release failed to release with the fire alarm; however, this door was not situated within the designated means of egress and was, therefore, not a delayed-egress lock. - The designated outside exit door located near the break room was difficult to open (bound within the door frame); however, the delayed-egress lock had released. e) At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. (See also citation at F323.) f) The facility was aware of this quality deficiency as early as 11/04/09, but there was no evidence the facility developed / implemented a plan of action to correct this problem until after the life-safety code surveyor intervened on 01/26/10. .

Based on record review, staff interview, review of facility policies and procedures, and the State's legislative rule related to the duties of a registered professional nurse, the facility failed to complete and/or communicate to the physician the results of a comprehensive nursing assessment following falls involving two (2) of eighteen (18) sampled residents, both of whom expressed complaints of severe pain after their falls. Both residents were later found to have sustained fractures associated with the falls, and the failure to perform and/or communicate the results of a comprehensive nursing assessment to the physician immediately after the falls resulted in delayed identification and treatment of [REDACTED].#71. Facility census: 100. Findings include: a) Resident #84 Review of Resident #84's medical record revealed the resident fell from the bed to the floor at 7:50 a.m. on 09/16/09, sustaining two (2) skin tears. The skin tears were cleaned and dressed, staff assisted the resident was assisted to chair, and neurological checks were initiated. The medical record did not contain any evidence to reflect the resident's range of motion was assessed prior to transferring the resident from the floor to the chair. Upon further review, vital signs were obtained at 10:00 a.m. on 09/16/09, and nursing documentation noted the resident was complaining of pain to the right groin area. This documentation revealed that passive range of motion was successful with the left leg; however, passive range of motion to the right leg was unsuccessful due to the resident's complaints of pain at a level of "10" (based on a scale of 1 to 10). At 10:30 a.m., the nurse contacted the physician, who ordered [MEDICATION NAME] for pain, a low bed, and floor mats, as well as labs. The medical record revealed the next entry occurred at 8:45 a.m. on 9/17/09, when the resident complained of pain with movement. The right leg appeared externally rotated with [MEDICAL CONDITION] noted in the groin area. The physician, when contacted, ordered the resident be sent out to the emergency room for evaluation. The resident was transported via 911 at 9:20 a.m., more than twenty-five (25) hours after the fall. The resident was diagnosed with [REDACTED]. b) Resident #71 Review of Resident #71's medical record revealed the resident sustained [REDACTED]. The medical record did not contain any evidence to reflect the resident's range of motion was assessed prior to transferring the resident from the floor to the geri chair. Review of the 12/22/09 Comprehensive Evaluation of Change in Condition form found the vital signs recorded at 11:30 a.m. were identical as those recorded as taken at 10:30 a.m. listed on the original Accident/Incident report done at 11:15 a.m. There was no evidence that neuro checks were initiated or that the resident was immediately and thoroughly assessed. In addition, there was no evidence that neuro checks were completed again until the 3/11 shift, as documented on the 12/22/09 Comprehensive Evaluation of Change in Condition report. The physician ' s 12/22/09 progress noted assessment of the resident ' s open wounds, but did not address the resident ' s comprehensive assessment post fall for injury. There was no evidence in the medical record or the Comprehensive Evaluation of Change in Condition report on 12/23/09 from 7:00 a.m. to 7:30 p.m. to indicate that follow up physical and neurological assessments were completed to assess for post fall injuries. The resident received scheduled [MEDICATION NAME] 5/500 mg every four (4) hours. Neuro checks were not initiated until after the resident returned from the hospital on [DATE] at 11:35 p.m. The medical record revealed the resident was not sent out to the hospital until 8:25 p.m. on 12/23/09, more than twenty-four (24) hours after the initial fall. The medical record revealed the resident was " yelling out and crying " in pain at 7:30 p.m. and was unable to move her right leg freely; the physician was then contacted and orders were received to have the resident sent out to the emergency room for evaluation. The resident was diagnosed with [REDACTED]. c) On 01/28/10 at 8:20 a.m., an interview was done with the director of nursing (DON), assistant director of nursing (ADON), and the medical director (Employees #41, #90, and #128, respectively), regarding the two (2) residents mentioned above. This surveyor reviewed with them findings from the medical records of both residents, which did not demonstrate that a range of motion assessment was performed prior to moving the residents from the floor to the chair. During the interview the director of nursing acknowledged that a range of assessment was not performed prior to moving the residents immediately after the fall. A potential delay in treatment was caused by the failure to perform comprehensive assessments. d) Review of information provided by the facility found the following: 1) The facility form titled Resident Examination and Assessment, revised 10/16/08, and received on 01/26/10 at 4:00 p.m. was reviewed. Section E, Musculoskeletal System: stated, " Observe the resident ' s gait, mobility, and range of motion. Observe for joint deformity, contractures, muscle tone, and any signs of fracture. " Section D, Neurological system: stated, " Notice the strength and equality of hand grasps and if the resident is able to move all his/her extremities. " 2) The Nursing Policy and Procedures, Subject: Fall Prevention, dated 01/08, and received on 01/26/10 at 3:45 p.m. was reviewed. Section 5; Practice Guidelines, stated, " ...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. " 3) On 01/29/10 at 11:00 a.m. the DON presented a page titled, Lippincott Manual, Policy dated 06/09. It stated, " The Lippincott Manual of Nursing Practice shall act as the Facilities comprehensive reference for general nursing practice and standard procedures. " The information presented did not include any specific policies or procedures regarding physical assessments post fall. e) According to Title 19 Legislative Rule Board of Examiners for Registered Professional Nurses: Series 10-Standards For Professional Nursing Practice: 2.1. The registered professional nurse shall conduct and document nursing assessments of the health status of individuals or groups by: 2.1.1. Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner. 2.4. The registered professional nurse shall develop and modify the plan of care based on assessment and nursing [DIAGNOSES REDACTED]. This includes: 2.4.2. Prescribing nursing intervention(s) based upon the nursing [DIAGNOSES REDACTED]. 2.4.3. Identifying measures to maintain comfort, to support human functions and responses, to maintain an environment conducive to well being, and to provide health teaching and counseling. 2.5 The registered professional nurse shall implement the plan of care by: 2.5.1. Initiating nursing interventions through: 2.5.1. a. Writing nursing orders and/or directives; 2.5.1. b. Providing direct care; 2.5.1. c. Assisting with care 2.5.3. Documenting nursing interventions and responses to care. .