Every finding on record at Windcrest Nursing and Rehabilitation

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to label the name of food products (ice cream) in the food preparation refrigerator. 2. The facility failed to label dates on cheese and butter in the food preparation refrigerator. 3. In the walk-in refrigerator, the facility failed to keep food products 12 inches away from the ceiling and there was not a discard date on a pack of tortillas. These failures could place residents at risk for food borne illness. The findings included: 1. Interview and observation, during the initial kitchen tour, on 08/12/25 at 09:43AM, in the food preparation area freezer, there were containers of ice cream for lunch that were not labeled ice cream, but there was a label for the date 08/12/25. The CDM revealed sometimes they put labels of the names of the food products and sometimes they don't. (There was no reason given as to why). 2. Interview and observation, during the initial kitchen tour, on 08/12/25 at 09:43AM, in the food preparation area refrigerator, there was a clear container with butter and cheese in it. The cheese was labeled with cheese and 08/09/25. The container was labeled butter and 07/22/25. [NAME] C revealed the butter was opened today and the label 07/22/25 was probably an old label. He further revealed the date 08/09/25 for cheese was the open date and was supposed to be placed back in the freezer. He revealed there were no discard dates on either food product. 3. Interview and observation, during the initial kitchen tour, on 08/12/25 at 09:43AM, in the walk-in refrigerator, there were boxes on the top shelf that were less than 12 inches from the ceiling. The CDM revealed these boxes should be moved to lower shelves and moved them. There was a package of tortillas labeled with date 07/30/25 and no discard date. The CDM revealed the kitchen staff did not write discard dates on food products because the kitchen staff knew when to throw food products away. Interview on 08/14/25 at 10:36 AM, [NAME] C revealed he was trained to label names, dates food products were stored, and discard dates on foods. He revealed this was to ensure the proper foods were used. He revealed if a wrong food was used for meal this could also affect residents' allergies. He revealed discard dates ensured foods were thrown out correctly to prevent contamination and food poisoning. He revealed they did not have to move food products from the top shelf in the walk-in refrigerator because these food products could not catch on fire because the walk-in refrigerator had doors to prevent a fire from starting or spreading. Interview on 08/14/24 at 10:43 AM, the RD revealed food products only had to be labeled by it's name if you could not identify what the food product was. She further revealed food products did not have to be labeled with the discard dates. She revealed food products needed to be labeled with the open date and staff knew when to throw the foods out. Record review of facility's policy Food Storage, dated 2018, reflected 2. Refrigerators . c. Do not over stock the refrigerator and leave space between items to further improve air circulation, d. Date, label and tightly seal all refrigerated foods. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the FDA Food Code 2022 reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 3 of 8 residents (Residents #28, #69, and #76) reviewed for ADLs in that:The facility failed to ensure Resident #76 received consistent showers during August and July 2025. The facility failed to ensure Resident #28 was provided with appropriate feeding assistance for 08/14/25 lunch meal.The facility failed to help Resident #69 with eating on 08/14/25 lunch meal per his care plan.These failures could place residents at risk of not receiving care and services to meet their needs, including nutritional needs and/or a diminished quality of life. Findings included: 1. Record review of Resident #76's face sheet, dated 8/12/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Parkinson's Disease (a progressive neuromuscular disorder that causes tremors and weakness) and adult failure to thrive (a syndrome of decreased appetite, reduced physical activity, and/or cognitive decline). Record review of Resident #76's quarterly MDS dated [DATE] reflected a BIMS score of 10, indicating moderately impaired cognition. Record review of Resident #76's comprehensive care plan, dated 8/12/2025, revealed the resident is dependent on staff with shower (initiated 3/24/2025). Record review of Resident #76's electronic shower record, dated 8/12/2025, revealed the resident was scheduled for showers on Tuesdays, Thursdays, and Saturdays of every week. Documentation of Resident #76's showers was as follows: 8/9/2025 (Saturday) not applicable 8/7/2025 (Thursday) resident refused 8/5/2025 (Tuesday) total dependence 8/2/2025 (Saturday) resident refused 7/31/2025 (Thursday) not applicable 7/29/2025 (Tuesday) supervision-oversight help only and physical help in part of bathing activity Record review of Resident #76's progress notes revealed no bathing documentation from 7/29/2025 through 8/12/2025. Resident #76 was interviewed on 8/12/2025 at 2:57 PM. He stated he frequently went without bathing and was not consistently offered the opportunity to shower. He stated his last shower was 2 weeks prior. He denied refusing bathing when offered by staff during the 2-week period. He stated he asked the nurse for assistance with bathing and was told yes, but he was still waiting. He asked the CNA on shift if he could take a shower, and she told him that he was not scheduled for a shower that day. CNA K was interviewed on 8/14/2025 at 10:18 AM. She stated she was the CNA for Resident #76's hall on 8/9/2025 and 7/31/2025. She stated she had not assisted him with a shower on those days because she was given direction by the Administrator not to provide care for Resident #76 due to personality conflicts. She was unsure if she asked another CNA to assist him with a shower on those days. The DON was interviewed on 8/14/2025 at 10:38 AM. She stated residents were able to take showers outside of their scheduled day/time depending on the workload of the staff. She was unaware of Resident #76's complaint that he had not consistently received showers. She also stated that the CNA should switch residents if they have been directed not to work with a particular resident to ensure that all residents receive showers. Record review of the facility policy titled Activities of Daily Living, Supporting (revised March 2018) revealed the following: Appropriate care and services will be provided for residents who are unable to carry out ADLs independent, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). 2. Record review of Resident #28’s admission Record, dated 08/13/25, reflected Resident #28 was an [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include weakness, protein-calorie malnutrition (11/29/23), and Alzheimer’s disease (a degenerative brain disorder that primarily affects memory, thinking, and cognitive abilities). Record review of Resident #28’s quarterly MDS assessment, dated 05/21/25, reflected resident needed setup or clean-up assistance for eating. Record review of Resident #28’s care plan, undated, reflected “EATING: The resident requires supervision to limited assistance by 1 staff…”, revised 03/06/25. Record review of Resident #28’s weight history for the past 6 months reflected no significant weight loss. 3. Record review of Resident #69’s admission Record, dated 08/13/25, reflected Resident #69 was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dysphagia (difficulty swallowing), dementia (loss of cognitive functioning), and cognitive communication deficit. Record review of Resident #69’s quarterly MDS assessment, dated 05/07/25, reflected resident had a BIMS score of 99, indicating resident was unable to complete the interview. It further reflected resident was dependent for eating. Record review of Resident #69’s care plan, undated, reflected Resident #69 had a focus “[Resident #69] has an ADL self-care performance deficits and require staff assist r/t impaired balance, limited mobility, pain.”, revised 02/26/20, with intervention “EATING: The resident requires [extensive] assistance by (x1) staff to eat. Resident will sometimes attempt to eat without assistance.”, revised 09/10/24. Record review of Resident #69’s weight history for the past 6 months reflected no significant weight loss. Interview and observation on 08/13/25 at 12:12 PM, Nursing student G revealed Resident #28 was not able to feed himself today’s lunch meal, so he was sitting down and feeding Resident #28. Attempted interview with Resident #28 and he was unable to participate. He revealed Resident #69 was able to feed himself. (Resident #28 and Resident #69 were roommates) Observation on 08/14/25 at 12:31 PM, Resident #69 was eating his lunch meal and Resident #28 appeared to be having trouble eating. It was observed there were no staff inside their room helping Resident #69 and Resident #28 with eating their lunch meal. Observation on 08/14/25 at 12:36 PM, the Reg NS went into Resident #28 and Resident #69’s room, asking them if they needed help eating. Combined interview on 08/14/25 at 03:37 PM, Reg NS revealed Resident #69 appeared to have increase in alertness and did not need a lot of help eating his lunch meal today. She further revealed Resident #28 may need help with eating. Reg NS revealed there was no one in their room helping feed these residents for 08/14/25 lunch. ADON A revealed CNAs were to communicate with nurses if a resident required more or less assistance with ADLs. ADON A revealed she oversaw residents’ change in assistance with feeding and would update care plans in care plan meetings. The Reg NS revealed when MDS assessments were completed it was expected for the MDS nurse to physically assess residents to ensure their ADL assistance was up to date. From assessing Resident #28 and Resident #69 today, the Reg NS revealed Resident #28 needed someone to sit down and feed him while Resident #69 appeared he could feed himself. The Reg NS revealed if Resident #69 needed extensive assistance with eating, then a staff member would need to be in his room and would be able to notice Resident #28 needed assistance in eating. Interview on 08/14/25 at 04:25 PM, CNA H revealed Resident #69 needed extensive assistance with eating when she worked with him. She revealed Resident #28 was starting to need extra assistance when eating so when she was feeding Resident #69, she would also help Resident #28 when he allowed. She further revealed sometimes Resident #28 would refuse help at times. Record review of facility’s policy, revised March 2018, reflected, “2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: … d. Dining (meals and snacks)…”

Based on record reviews and interviews the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility's reviewed for nursing staffing.The facility failed to have the services of an RN (Registered Nurse) 04/13/2025, 04/19/2025, 04/27/2025, 05/04/2025, 05/10/2025, and 05/11/2025. This failure could place residents at risk of not having the critical skills of a RN.Findings included:A record review of the facility's RN staff payroll hours for the period of 1/1/2025 - 8/14/2-25 revealed no RN Services on the following dates: 04/13/25, 04/19/25, 04/27/25, 05/04/25, 05/10/25, and 05/11/25. Record review of Incidents & Accidents for April 2025 and May 2025 did not reveal any negative outcomes to residents related to not having RN services.In an interview on 8/14/25 with the Administrator, the Administrator stated she was not aware there was no RN coverage on those dates. Administrator stated the former Director of Nurses was available on-call as needed. The Administrator stated she was aware of the importance of having an RN at the facility for clinical management. The Administrator stated the Director of Nurses was responsible for ensuring RN coverage as required and notifying Administrator of non-coverage. The Administrator stated the facility follows the TAC guidelines to utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles; included the appropriate accessory and cautionary instructions and the expiration date when applicable; and under proper temperature control for 2 of 3 medication aide carts (B and C hall carts) reviewed for medication storage. The facility failed to ensure 3 vials of the medication Latanoprost, including one with no open date, were discarded within 6 weeks (42 days) of removal from refrigeration.These failures could lead to residents receiving ineffective medications and not receiving the intended therapeutic effect. Findings included:In an observation and interview on 8/13/2025 at 8:46 AM, one vial of Latanoprost was observed in the B hall cart with an opened date of 6/28/2025 (56 days). MA L stated she was unsure when the medication was supposed to be discarded after being removed from refrigeration. In an observation and interview on 8/13/2025 at 8:55 AM, one vial of Latanoprost was observed in the C hall cart without a date indicating when the vial was opened. A second vial was dated with an opened date of 7/7/2025 (47 days). RN B stated the undated vial should have had a date and would be discarded because she was not sure when it was opened. She stated the vial dated 7/7/2025 should also have been discarded. RN B stated the potential harm to residents receiving improperly stored eye drops was the medication could have degraded and not work as intended. The DON was interviewed on 8/14/2025 at 10:38 AM. She stated the Latanoprost eye drops were able to be stored at room temperature for six weeks. She was unaware that multiple vials of Latanoprost were being stored in medication carts past 6 weeks. She reported the potential harm to residents was ineffective medication. Record review of the facility policy titled Delivery, Receipt, and Storage of Medication (undated) revealed the following: The facility should ensure the medications requiring refrigeration are stored appropriately .

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 CNAs (CNAs M, N, and O) observed for infection control. The facility failed to: Ensure CNAs M and N bagged soiled linen prior to transporting. Ensure CNA O donned PPE properly and performed hand hygiene and glove changes while performing care to a foley catheter. These failures could lead to the spread of infection. Findings included: 1. In an observation and interview on 8/12/2025 at 10:24 AM, CNA N was observed leaving a resident's room with unbagged linen in the B hallway while wearing gloves. CNA N stated that she was assisting a resident with incontinent care and linen change. She stated the facility policy was that soiled linen should be bagged prior to leaving a resident's room and gloves should not be worn in the hallway. She stated she was a in a hurry and did not bag the linen. CNA N reported the potential harm to residents by wearing soiled gloves and carrying unbagged, soiled linen in the hallway was the spread of infection. In an observation on 8/14/2025 at 9:16 AM, CNA M was observed carrying unbagged linen from out of a resident's room in the acute rehabilitation hall. He stated he had assisted the resident with a linen change, and the facility policy was that soiled linen should be bagged prior to transporting it. He said he did not have a trash bag in the room, so he chose to carry it out. He stated the potential harm to residents was cross contamination. The DON was interviewed on 8/14/2025 at 10:38 AM. She stated the facility expectation was for all soiled linen to be bagged before exiting a resident's room. She stated the potential harm to residents was the spread of infection. Record review of the facility policy titled Infection Control (revised October 2018) did not reveal guidance related to transporting soiled linen. 2. In an observation on 8/14/2025 at 10:08 AM, CNA O was observed preparing to provide care for a resident with a foley catheter. As the resident required EBP precautions, CNA O donned PPE prior to entering the room. CNA O donned gloves and then put on a disposable gown. She told CNA K that the picture on the EBP sign indicated the PPE items needed as well as the order in which to put the items on. CNA K stated she was taught to put on a gown and then don gloves, but CNA O reiterated the gloves are applied first. CNA O then entered the room and was observed assisting the resident with removing his clothing and repositioning in the bed. CNA O did not change gloves or perform hand hygiene prior to providing care to the foley catheter. Using multiple disposable cleansing wipes, CNA O then cleaned the resident's groin and the catheter but was not observed changing gloves or performing hand hygiene before grasping the catheter tube. After completing the cleansing, CNA O was observed assisting the resident with repositioning in the bed and applying new clothing. CNA O did not change gloves or perform hand hygiene before these tasks. CNA O was interviewed on 8/14/2025 at 10:15 AM. She stated she should have changed gloves and performed hand hygiene after removing the resident's clothing. She again stated that the picture on the EBP sign indicated the order in which PPE should be applied. She reported the potential harm to residents by not performing glove changes and hand hygiene appropriately was cross contamination. The DON was interviewed on 8/14/2025 at 10:38 AM. She stated the order of PPE application that was taught to staff was gown and then gloves, and that she would meet with CNA O to reinforce the proper application. She also stated the facility expectation during foley catheter care was glove changes and hand hygiene before and after performing catheter care and during the procedure. She stated the potential harm of not donning PPE properly or performing hand hygiene was cross contamination. Record review of the facility policy CNA catheter care (undated) revealed the following:7. Lower head of bed and position [the resident] on back8. Wash hands and put on gloves9. Expose area surrounding catheter 10. Apply soap to wet washcloth of use wipes . clean at least four inches of catheter . 11. Remove gloves and wash hands and don new gloves

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #69) reviewed for dietary services. The facility failed to ensure Resident #69 received their prescribed diet (pureed diet) for 08/15/25 lunch meal service. This deficient practice could place residents, who were provided a mechanically altered diet, at risk of choking, aspiration (inhaling food), and diminished quality of life. The findings included: Record review of Resident #69's admission Record, dated 08/13/25, reflected Resident #69 was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dysphagia (difficulty swallowing), dementia (loss of cognitive functioning), and cognitive communication deficit. Record review of Resident #69's care plan, undated, reflected Resident #69 had a focus [Resident #69] has a diagnosis for Dysphagia: Resident is at risk for aspiration, weight loss and complication r/t diagnosis, initiated 04/18/19, with interventions to include Educated resident on importance of adhering to ordered diet and potential complications with non-compliance., initiated 04/18/29, and Provided diet as ordered., initiated 04/18/29.Record review of Resident #69's quarterly MDS assessment, dated 05/07/25, reflected resident had a BIMS score of 99, indicating resident was unable to complete the interview. It further reflected resident had a mechanically altered diet. Record review of Resident #69's order summary report, dated 08/13/25, reflected resident's diet was Pureed texture, regular consistency, start date 09/16/24. Interview and observation on 08/13/25 at 12:12 PM, Nursing student F confirmed Resident #69 had 2 baked cookies (not pureed texture) on his 08/13/25 lunch meal tray. He revealed there was a nurse who reviewed this resident's tray ticket before he gave Resident #69 his meal tray. He revealed he was unsure if Resident #69 was allowed to have cookies on his meal tray ticket, but was going to check. It was further observed Nursing student F took Resident #69's lunch meal tray (with the cookies) out of his room. Attempted interview with Resident #69 and he was unable to participate. Interview on 08/13/25 at 12:35 PM, the CDM revealed the kitchen staff checked the tray tickets before they passed out to the nursing staff to pass out to the residents. She revealed it was important to ensure the tray tickets matched the meals. Interview on 08/13/25 at 01:05 PM, ADON B revealed she checked the lunch meal tray ticket for Resident #69 and may have missed the cookie that was not pureed on his plate. She revealed she thought she had missed something when passing out the meal trays today. Interview on 08/14/24 at 10:43 AM, the RD revealed it was important to follow the texture of foods that were on the residents' diet orders. She revealed if the texture of the diet was not followed the risk could vary from person to person. Interview on 08/14/25 at 11:45 AM, [NAME] D and Dietary Aide E revealed they were trained to read the meal tray tickets before they left to ensure the tickets matched what was on the trays. They revealed it was important for pureed diets to have pureed foods on the tray to prevent possible choking. Record review of facility's policy, dated 2018, reflected 3. For tray line service, Nutrition & Foodservice staff will check each resident's tray card prior to service to ensure that preferences and dislikes are honored, the correct diet is served.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for residents for 1 of 4 rooms reviewed for physical environment. room [ROOM NUMBER] had a broken drawer placed on top of the dresser. This failure could place residents at risk for injury and experiencing a diminished quality of life.Findings included:During an observation on 8/12/25 at 10:55 a.m., a broken drawer with the drawer front of the drawer hanging off and joints bent was located on top of a dresser in room [ROOM NUMBER]. During an interview on 8/12/25 a 10:30 a.m., HSKPR A stated she would notify her supervisor if equipment was broken. She stated she was not aware the drawer was broken. During an interview on 8/12/25 at 11:00 a.m., CNA A stated that maintenance should be notified right away if something was broken so a resident could not get hurt. CNA A stated she would write it down in the maintenance book, and she did not see the broken drawer.During an interview on 8/12/25 at 11;15 a.m., RN B stated she would notify the maintenance staff right away if she saw something was broken. She stated she was not aware the drawer was broken. During an interview on 8/12/25 at 3:30 p.m., LVN A stated she would submit a work order in the electronic reporting system to notify maintenance. LVN A stated she was not aware the drawer the broken. During an interview on 8/13/25 at 9:45 a.m., Maint A stated he had not been notified that a drawer was broken, stated he would remove from room and repair right away. During an observation on 8/13/25 at 10:10 a.m. of room [ROOM NUMBER], the broken drawer was no longer present. Record review of the facility policy titled Environmental Services (dated 05/2022) revealed. resident equipment and equipment used by the residents should be clean and properly maintained

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 9 residents (Resident #76) reviewed for assessments. The facility failed to ensure the MDS accurately reflected Resident #76's diagnosis depression. This failure could lead to residents not receiving necessary care. Findings included: Record review of Resident #76's face sheet, dated 8/12/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Parkinson's Disease (a progressive neuromuscular disorder that causes tremors and weakness) and adult failure to thrive (a syndrome of decreased appetite, reduced physical activity and/or cognitive decline). Record review of Resident #76's quarterly MDS submitted 7/4/2025 reflected a BIMS score of 10, indicating moderately impaired cognition. Section I (active diagnoses) of the MDS reflected Resident #76 did not have a diagnosis of any psychiatric/mood disorders. Record review of Resident #76's active orders reflected the following:Buspirone HCl tablet 5mg, give 1 tablet my mouth three times a day for anxiety (order date 4/01/2025)Sertraline HCl Tablet 25mg, give 1 tablet by mouth one time a day for depression (order date 3/27/2025)Record review of Resident #76's progress notes revealed documentation from a psychiatric nurse practitioner evaluation dated 8/06/2025. The documentation included diagnosis: F33.1 major depressive disorder, recurrent, moderate and assessment/plan . depression: sertraline 15mg Qd/ Buspirone 5Mg TID.In an interview with MDS NS on 8/14/2025 at 11:30 AM, she stated the diagnoses related to psychotropic medications were drawn from the documentation provided by the physicians and nurse practitioners. She said discrepancies between orders and progress notes were resolved using the physician query process. She was unsure how Resident #76's MDS was completed as she had not been the nurse who completed the documentation. She stated the MDS should accurately reflect the diagnoses given by a resident's provider, and inaccurate diagnoses could potentially lead to resident's not receiving proper care. In an interview with the DON on 8/14/2025 at 1:35 PM, she stated the MDS nurse would obtain the diagnoses list from the provider's documentation. She stated the diagnoses on the MDS should match a resident's orders and diagnoses given by the provider. She stated the potential harm to a resident by having an inaccurate or missing diagnosis, was improper monitoring of psychotropic medications. The DON also stated she does not participate in the MDS report process. Record review of the facility policy titled Resident Assessments (revised March 2022) reflected the following:All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on observation, interviews and records review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #10) reviewed for oxygen use.The facility failed to ensure Resident #10 was monitored for oxygen saturation levels per physician's order to maintain oxygen saturations about 92%. This failure could place residents with respiratory illnesses at risk for a decline in health. Findings included: Record review of Resident #10's face sheet, dated 8/14/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and made it difficult to breathe), atrioventricular block (a condition where the electrical signals in the heart are completely blocked), and peripheral autonomic neuropathy (a condition where damage to the nerves affect the peripheral nervous system). Record review of Resident #10's MDS dated [DATE] revealed BIMS score of 8 indicating moderate cognitive impairment, received no special treatments and oxygen was not in use. Review of Resident #10's active physician orders, dated 8/14/2025, revealed the following: O2 @ 2L/min via nasal cannula to maintain O2 sats >92% as needed for SOB (Oxygen at 2 liters per minute by nasal cannula to maintain oxygen saturations greater than 92% as needed for shortness of breath). Record review of Resident #10's Medication Administration Record and Treatment Administration Record on 8/14/25 at 8:44 a.m. revealed no monitoring of oxygen saturation levels to ensure oxygen saturation levels remain above 92%. During observation of Resident #10 on 8/12/25 at 10:03 a.m., resident lying in bed, awake, requesting to get out of bed. No signs of respiratory distress, no oxygen in use. During an observation of Resident #10 on 8/14/25 at 7:58 a.m., resident lying in bed, anxious verbalizations and requesting assistance to get out of bed. No oxygen in use. During an interview on 8/14/25 at 8:14 a.m., RN B revealed that she does not check Resident #10's oxygen routinely and that she would monitor for shortness of breath or difficulty breathing and provide oxygen as needed to maintain saturations above 92%. During an interview on 8/14/25 at 3:30 p.m., LVN A revealed that she does not monitor Resident #10's oxygen levels and did not realize there was not an order to monitor oxygen levels. During an interview on 8/14/25 at 4:15 p.m., the ADON stated failure to monitor oxygen levels to ensure vital signs were within normal limits could result in shortness of breath, dizziness or possibly cyanosis (a medical condition when the lips, skin and/or nails turn a bluish tone due to lack of oxygen). ADON stated she would expect nursing staff to monitor the oxygen saturations levels of all residents with orders for PRN (as needed) oxygen at least one time per shift. During an interview on 8/14/25 at 5:00 p.m. with the REG NS, she stated the facility does not have a specific policy for following physician's orders.

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 8 residents (Resident #6) reviewed for clinical documentation and medical records accuracy. The Electronic Health Record for Resident #6 did not reflect a diagnosis of depression on her admission record as was indicated for taking Remeron Oral Tablet 15 MG. Resident #6's care plan did not accurately reflect that she had a history of claiming someone beat her up when no one was around her. This failure could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health. The findings included: Record review of Resident #6's admission record, dated 08/12/25, reflected Resident #6 was a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE], with diagnoses to include dementia (loss of cognitive functioning), psychotic disorder with hallucinations (an experience involving the apparent perception of something not present) due to known physiological condition, and schizophrenia (a serious mental health condition that affects how a person thinks, feels, and behaves). It did not reflect a diagnosis of depression. Record review of Resident #6's quarterly MDS assessment, dated 07/03/25, reflected resident had a BIMS of 09 out of 15, indicating moderate cognitive impairment. It did not reflect a diagnosis of depression. Record review of Resident #6's care plan, undated, reflected focus The resident uses antidepressant medication r/t poor appetite., initiated 06/28/25, with intervention Administer ANTIDEPRESSANT medications as ordered by physician. Record review of Resident #6's Order Summary Report, dated 08/12/25, reflected Remeron Oral Tablet 15 MG Give 1 tablet by mouth at bedtime for depression, with started date 07/02/25. Record review of Resident #6's care plan, undated, reflected focus The resident has a behavior problem. Resident reports she has been beat up when nobody is around her., initiated by 06/09/25 and revised on 06/29/25. Record review of Resident #6's progress notes reflected nothing noted about allegation of being beat up when nobody is around her. Interview on 08/14/25 at 12:41 PM, LVN J revealed she was not aware that Resident #6 had any incidents or allegations of abuse while she was a resident at this facility. She revealed Resident #6 had a history of abuse and she had to adjust Resident #6's care accordingly. Interview on 08/14/25 at 02:56 PM, CNA I revealed he was not aware that Resident #6 had made an allegation of abuse as a resident at this facility. Interview on 08/14/25 at 03:06 PM, MDS nurse B saw Resident #6 had medication Remeron for a diagnosis of depression but could not find in the medical record where Resident #6 had a diagnosis of depression. She revealed she left MD a note to verify if Resident #6 had a diagnosis of depression so they can add the diagnosis if Resident #6 had a diagnosis of depression. She revealed Resident #6's care plan mentioning Resident #6 reporting she had beat up did not occur at this facility and the care plan should read Resident #6 had a history of reporting she had been beat up when no one was around her. She further revealed it was important to have care plans be accurate because it allowed staff to treat the whole resident. She revealed there could be some risks but did not state specifics. Interview on 08/14/25 at 03:37 PM, ADON A revealed Resident #6 had a history of claiming she was being beat up when nobody was around her, but nothing has happened in this facility. She revealed her care plan was going to be updated. Record review of facility's policy Resident Assessments, revised March 2022, reflected . 3. A comprehensive assessment includes: a. completion of the Minimum Data Set (MDS). c. development of the comprehensive care plan. Record review of facility's policy Psychotropic Medication Use, dated July 2022, reflected 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: b. Anti-depressants.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #3) reviewed for quality of care. Resident #3 exited the facility through an alarming secure unit exit door on 5/14/2025. CNA A turned off the alarm without looking for Resident #3. Resident #3 left the facility and went missing for over 1.75 hours. The police found Resident #3 in a parking lot near an interstate highway and highway access roads. The noncompliance was identified as PNC. The IJ began on 5/14/2025 and ended on 6/4/25. The facility had corrected the noncompliance before this investigation survey began. This failure could place residents at risk of injury or death due to lack of supervision. The findings were: Record review of Resident #3's face sheet, dated 7.29.25, and EMR (electronic medical record) revealed the resident was admitted on 4.18.25 with diagnoses that included: ALZHEIMER'S DISEASE WITH LATE ONSET, insomnia, dementia, depression, and anxiety. The RP (responsible party) was a family member. Record review of Resident #3's quarterly MDS assessment, dated 5.1.25, revealed,BIMS score was 4 (0-5=severe cognitive impairment)ADLs: B/B was frequently incontinent requiring substantial/maximal supervision. Transfer independent. Bed Mobility was independent. ROM showed no impairment.Section P - Restraints and Alarms, revealed that bed/chair/out of bed restraints and alarms were not in use. Record review of Resident #3's Care Plan, dated 5.19.25, revealed the resident was a high elopement risk/wanderer, disoriented to place, with a history of attempts to leave the facility unattended, and impaired safety awareness. The goals were: the resident's safety will be maintained through the review date and the resident will not leave facility unattended through the review date. Interventions included: Document wandering behavior and attempted diversional interventions in behavior. For night shift, resident is on 1:1 visual monitoring. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Room change away from back door. The resident's triggers for wandering/eloping are (early morning and sun downing hours). The resident's behavior was de-escalated by redirecting him away from door and offering pleasant diversions, structured activities, food, conversation, television, book, and magazines. Record review of Resident #3's Wandering Risk Scale showed a score of 13 (High Risk Wanderer) on 5.14.25, a score of 14 (High Risk Wanderer) on 4.21.25, and a score of 13 (High Risk Wanderer) on 4.18.25. Record review of Resident #3's orders revealed he had an order from 4.20.25 stating he should reside on the secure unit due to wandering and high risk of elopement. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 7:23 AM, authored by LVN B, revealed CNA A notified him that the C-back alarm was set off while she was on another unit and that Resident #3 could not be found. LVN B began searching all rooms with available CNA staff and initiated a code purple. DON assisted with the search, called emergency services, and notified the ADMIN. All available staff were searching possible areas. The DON notified the RP. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 11:55 AM, authored by the DON, revealed he was notified by charge nurse LVN B that floor staff has been unable to locate Resident #3 and all current members of staff on unit C continue to look for him. The DON assisted the search. After 5 minutes of looking for the resident, a code purple was called, and the entire team began looking for the resident on and off the property. The DON called the ADMIN and informed her of the elopement. The DON called 911 at 6:50 AM. A resident flyer with personal information was copied for police and staff members. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 12:02 AM, authored by DON, revealed Resident #3 was located and brought back to the facility by the police department. He received a full head to toe assessment. Skin noted to be intact with no bruises, scrapes, or bumps noted. A neurological assessment remains at baseline. DR G was informed of the elopement and safe return with no new orders obtained. Resident placed on line-of-site (sic) monitoring to prevent reoccurrence. Nursing staff received updates and in-service training. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 12:59 PM, authored by charge nurse LVN C, revealed Resident #3 was located and brought back to the facility by the police department. A full head to toe assessment was completed. Skin noted to be intact with no bruises, scrapes, or bumps noted. A neurological assessment remains at baseline. The resident denies pain or discomfort. The RP was notified of Resident #3's return and bed change to a room closer to the nurse's station. No new orders from the NP and per the DON, the resident was placed on line-of-site (sic) monitoring and neuro checks for 72 hours. Record review of Resident #3's Nurse Note, dated 5.15.25 and created at 6:48 AM, authored by LVN B, revealed staff was on 1-to-1 monitoring and 30-minute visual checks were in place. Resident #3 will continue to be monitored for exit-seeking behaviors. Record review of Resident #3's Nurse Note, dated 5.15.25 and created at 12:59 PM, authored by charge nurse LVN C, revealed staff continue to monitor Resident #3 for elopement behaviors on day 2/3. Resident #3 continues to wander through the MCU and expresses verbally that he wishes to go outside for a walk, was seen walking up to multiple exit doors but is easily redirected. Record review of Resident #3's Nurse Notes, dated 5.16.25 and created at 6:30 AM, authored by LVN B, and dated 5.16.25 and created at 2:11 PM, authored by LVN C, revealed 30-minute checks were in place as Resident #3 continues to wander, walk up to multiple exit doors, and voice if he can go outside. Record review of Resident #3's Nurse Note, dated 5.17.25 and created at 3:40 AM, authored by charge nurse LVN D, revealed staff continue to monitor Resident #3 for elopement behaviors on day 3/3. Resident #3 continues to wander through the MCU and expresses verbally that he wishes to go outside for a walk, was seen walking up to multiple exit doors but is easily redirected. Record review of elopement investigation report for Resident #3's, dated 5.14.25 authored by the ADMIN revealed, the resident eloped on 5.14.25 at around 5:45 AM. CNA A responded to the unit C-back door alarm after returning from another unit. CNA A turned the door alarm off and returned to assisting her coworker with rounding. CNA A noticed that Resident #3 was missing from the secured area and began to look for the resident. At 6:20 AM, CNA A notified LVN B that she cannot find the resident. At 6:25 AM, LVN B notified the DON that they cannot find Resident #3. At 6:30 AM, residents in the secured unit are counted and Resident #3 was the only one not accounted for. At 6:35 AM, the DON notified the ADMIN. At 6:40 AM, the ADMIN initiated a search for Resident #3 in the facility. At 6:50 AM, the DON called the police to report a missing resident as well as assigning available staff to search an extended zone. At 7:25 AM, the facility received a call from Resident #3s RP who stated that the resident was found by the police. At 7:40 AM, the resident was returned by the police. The ADMIN suspended CNA A and terminated her employment. Additional actions the facility took to correct the immediacy (prior to the surveyor entrance) included bi-weekly elopement drills, education was provided to the Admissions/Marketing team to ensure all residents were prescreened for wandering/elopement risk, and a 6-foot wooden fence with a keypad locked gate was constructed outside of the unit C-back secure exit door on 6.4.2025. Activation of the fire alarm system disables the lock. During an observation and interview on 7.27.25 at 4:41 AM with Resident #3, he stated the employees treat him good. He also revealed that other residents treat him good. He revealed that he did not need assistance with showers stating, no I can do it myself. Resident #3 was sitting at a table in the dining room on the secured unit, had on shoes, and was well-groomed. At 4:45 PM, Resident #3 got up and walked out of the dining room. During an observation and interview on 7.30.25 at 11:30 AM, Resident #3 was sitting in the dining area alone with a drink watching TV. He was groomed and calm. During an observation on 7.31.25 at 8:59 AM of Resident #3 revealed his room to be clean and call light on his bed. Resident was not in his room and was observed sitting in the dining room at a table with several other residents and appeared with a calm demeanor. During an interview on 7.30.25 at 5:45 PM, the ADMIN revealed that Resident #3 was residing in a secure unit and was an elopement risk. Regarding the elopement incident for Resident #3 that occurred on 5.14.25, the ADMIN stated, around 5:45 am the door alarm was sounding in the facility C wing back door end of hall and the aide CNA A told me that she put the code in and turned off the alarm and began helping her colleague with rounds. The ADMIN asked if she looked outside, and she said no. During the investigation, the church camera next door caught him going toward the front of the facility on the outside of the facility at 5:47 am. At 6:00 am CNA A realized he was missing because she went to his room and did not see him in the bed and started looking for him and in between that time she is looking for him around 6:10am he was seen at the (gas station) and asked the attendee for a soda and the attendee gave him a fountain drink and the attendee said he then went outside and was sitting outside for about 10 minutes. Around 6:20am he was seen leaving the (gas station) by the attendee and pointed toward the (bus station). Around 6:20am the CNA A told her nurse LVN B that Resident #3 was missing. At approximately 6:25am the nurse called the DON and notified him. He was the DON at that time. The DON was in facility, and she went to the unit and looked for the resident and then called me around 6:35am. At 6:40am I arrived, and I spoke with CNA A and LVN B about what happened and that is when she told me she heard the alarm and turned it off and went to help her fellow aide with rounding and I talked to LVN B who said he had just found out about it from CNA A. I directed staff and assigned staff to conduct a facility search internal and external. Around 6:50am the DON called the police to report a missing resident. The police arrived between 6:55-7:15 and during that time we developed flyers with his pictures and more staff arrived and I assigned them zones to look external around the area. Around 7:15am the church next door came over and showed me the video of Resident #3 walking by the front at 5:47am. At 7:25am the facility received a call from (police department) stating the police department found him. He was found at the renting vans location in front of the (bus station) which was about 4-minute walk from the (gas station) which is .4 miles from the facility. The police brought him back to the facility at 7:40am. When he returned, we completed a full head to toe assessment, and he had no bumps, scrapes, or bruises and was very pleasant spirits. The ADMIN revealed that two elopement in-services were conducted for staff prior to this incident. CNA A received in-servicing on elopement and door alarms on 3.12.2025 and signed the sign-in sheet. The ADMIN revealed exit doors will alarm for 15 seconds while the bar was being pushed before unlocking. Once unlocked, the alarm will continue to sound until reset by keypad. Staff has access to codes at each door. The ADMIN stated that the expectation of staff when a door alarm sounds, was that they react and look outside and look to see if anyone went out the door when a door alarm sounds. The ADMIN stated that the harm that could come to a resident when door alarms are silenced without investigating for possible elopement could cause death if we don't find them. An interview with CMA E on 7.28.25 at 9:41 AM revealed Resident #3 always looked outside and would sometimes push on the doors to test them. An interview with LVN C on 7.28.25 at 4:10 PM revealed that she worked at the facility for 2.5 years and worked in the memory care unit. She revealed that Resident #3 always wanted to go outside and go for walks. When Resident #3 first entered the facility, staff would have to redirect him and find activities to keep him busy. An interview on 7.31.2025 at 9:45am with the Administrator revealed the fence on the outside of the unit C-back exit door was installed on 6.4.2025 and residents at risk for elopement on the unit started on 1-hour observation until the new fence was installed. The administrator stated elopement drills were ongoing with staff and there have been no further elopements. The administrator stated Resident #3 expressed wanting to leave at times and remains an elopement risk and continues to reside on the secure unit. Interviews on 7.31.2025 between 8:45 AM and 2 PM with 1 RN, 4 LVNs, 3 CNAs, and an Admissions/Marketing staff member from various shifts demonstrated that they were knowledgeable of what to do when a door alarm was activated, understood elopement precautions, and had received training on elopement procedures. Record review of the Ad Hoc QAPI held on 5.14.2025 regarding Resident #3's elopement from the memory care unit revealed the document was signed by the Administrator, DON, Medical Director, Regional Director of Operations and an RN. Record review of the facility's Elopement/Code Purple in-service dated 5.14.2025 defined elopement as A situation in which a resident leaves the premises without the facility's knowledge and supervision. It is the responsibility of ALL TEAM MEMBERS to direct residents away from exit doors for their safety. the facility's interior or exterior grounds. CNAs and nurses need to conduct one-hour visual checks on all When a resident is missing, staff are to notify the charge nurse immediately (if unable to locate the DON). Charge nurse is to initiate a Code Purple. Record review of facility in-service on the topic of Elopement/Code Purple conducted on 5.14.25 by the DON revealed 80 staff members received the training (100% of staff trained). Record review of doors and locks maintenance check logs dated 3.31.25 - 7.25.25 revealed exit doors with alarms were checked for operation and passed. Record review or facility's Wandering and Elopement Prevention policy, undated, read The facility will identify residents who are at risk of unsafe wandering and stive to prevent harm while maintaining the least restrictive environment for residents. During exit conference on 7.31.25 at 3:51 PM, Administrator was informed that evidence revealed a F689 past non-compliance IJ (immediate jeopardy) for elopement of Resident #3.

Based on interviews, and record reviews the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 8 Residents (Resident #4) reviewed for neurological assessments after a fall. 1. On [DATE] at approximately 5:28 AM Resident #4 had an unwitnessed fall and was discovered on the floor in her bedroom, and LVN H failed to perform neurological assessments for Resident #4 at 6:45 AM, and at 7:15 AM, and failed to report to LVN I she had not assessed Resident #4 and at 8:00 AM Resident #4 and discovered deceased . 2. On [DATE] at approximately 7:40 AM LVN I assessed Resident #4 without performing a neurological assessment at 7:45 AM and did not document Resident #4's vital signs. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began on [DATE]. These failures could place residents at risk for harm by lack of interventions up and including death. The findings included: A record review of Resident #4's admission record revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses which included atrial fibrillation (an irregular heartbeat which can lead to blood clots in the heart, can increase the risk of stroke, heart failure and other heart-related complications), atherosclerotic heart disease (plaque buildup in artery walls, can cause a heart attack) and essential hypertension (high blood pressure.) A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 was an [AGE] year-old female admitted for rehabilitation related to an implanted pacemaker (a device used to control an irregular heart rhythm) and was assessed with a BIMS score of 13 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #4's care plan dated [DATE] revealed, The resident has an ADL self-care performance deficit r/t generalized weakness new pacemaker date Initiated: [DATE], . BEDFAST: The resident is bedfast all or most of the time. I have chosen DO NOT RESUSCITATE status Date Initiated: [DATE] . Signed DNR order is in my chart. The resident has a pacemaker Date Initiated: [DATE] . Monitor / document / report PRN any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope (fainting), difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P. The resident is at risk for falls r/t Confusion, Gait / balance problems, Incontinence, Narcotic use, Antihypertensive use, Recent Surgery, Oxygen Use. Date Initiated: [DATE] . A record review of Resident #4's nursing progress notes dated [DATE] revealed LVN H documented at 6:40 AM Resident #4 was discovered on the floor due to a fall, [DATE] 06:40 . Position: *Charge Nurse Created By: (LVN H) . Note Text: CNA was doing her rounds and this resident requested medication for pain. CNA told this nurse that resident wanted something for pain. This nurse retrieved pain med and went to residents' room to give to her and found her laying on the floor beside her bed. This nurse assessed resident and had CNA to go get the other nurse to help assist resident from the floor back into her bed. Resident alert and took pain medication, no apparent injuries noted at this time. Bed put in the lowest position and call light in reach. Neuro checks have been started. All parties have been notified. A record review of Resident #4's Neurological Assessment Flow Sheet dated [DATE] revealed LVN H began and continued 4 times with neuro-check assessments on [DATE] starting at 5:30 AM which included a level of consciousness, pupil response, hand grasp, motor functions, pain response, blood pressure, temperature, pulse, and respirations. Review revealed Resident #4's assessments were as follows: ,d+[DATE] at 05:30 AM alert, pupils equal reactive to light and accommodating = brisk, hand grasp = right greater than left, motor function = moves all extremities, pain response = appropriate, blood pressure = ,d+[DATE], temperature = 97.1, pulse = 60, respirations 16 (per minute). ,d+[DATE] at 05:45 AM alert, pupils equal reactive to light and accommodating = brisk, hand grasp = right greater than left, motor function = moves all extremities, pain response = appropriate, blood pressure = ,d+[DATE], temperature = 97.5, pulse = 62, respirations 16 (per minute). ,d+[DATE] at 06:00 AM alert, pupils equal reactive to light and accommodating = brisk, hand grasp = right greater than left, motor function = moves all extremities, pain response = appropriate, blood pressure = ,d+[DATE], temperature = 97.0, pulse = 60, respirations 16 (per minute). ,d+[DATE] at 06:15 AM alert, pupils equal reactive to light and accommodating = brisk, hand grasp = right greater than left, motor function = moves all extremities, pain response = appropriate, blood pressure = ,d+[DATE], temperature = 97, pulse = 58, respirations 16 (per minute). Further review of Resident #4's Neurological Assessment Flow Sheet revealed no further assessments for the scheduled 6:45 AM, 7:15 AM, the 7:45 AM, nor the 8:15 AM assessments. During an interview on [DATE] at 9:02 AM LVN H stated she works the 11:00 PM to 7:00 AM shift and on [DATE] she discovered Resident #4 on the floor next to her bed. LVN H stated she assessed Resident #4 with the assistance of CNA K and LVN L. LVN H stated she assessed Resident #4 with no injuries and Resident #4 was a/o x 3 (alert and oriented to self, time, and place) and could state she was attempting to toilet without using the call light and fell . LVN H stated she began neuro-checks and gave a report to the on-call physician and Resident #4's family. LVN H stated she began neuro-checks at 5:30 AM and per the neuro-check protocol she checked Resident #4 every 15 minutes for the first 4 assessments, then planned to check on Resident #4 every 30 minutes for the next 4 assessments, and then every hour for the next neuro-check assessments. LVN H stated she gave report to the next nurse, and could not recall her name, to include a report on Resident #4. LVN H Stated this nurse-to-nurse report usually takes from 7:00 AM to 7:20 AM. LVN H stated she left at 7:30 AM and stated before she left a CNA reported to the next nurse Resident #4 needed to be assessed. LVN H received information that a record review of Resident #4's neuro-check worksheet document dated [DATE] revealed documentation that Resident #4 was assessed for neuro checks every 15 minutes for the first four neuro checks which began at 5:30 AM and continued at 5:45 AM, 6:00 AM, and at 6:15 AM without any documentation for 6:45 AM and no further documentation. LVN H stated she could not recall why there was no assessment for the 6:45 AM assessment and the 7:15 AM assessment was the duty of the oncoming nurse. LVN H stated she may have been busy administering medications for other residents during her end of shift. A record review of LVN H's timecard dated [DATE] through [DATE] revealed LVN H clocked out at 7:50 AM on [DATE]. During an interview on [DATE] at 3:50 PM LVN I stated she was the nurse for Resident #4 on [DATE] from 7:00 AM to 3:00 PM. LVN I stated on [DATE] she was running late and arrived for her scheduled 7:00 AM to 3:00 PM shift approximately 30 minutes late, 7:30 AM. LVN I stated LVN H was irritated because many nursing interventions had been moved to her shift (11:00 PM to 7:00 AM) and she was behind in care. LVN I stated during the nurse-to-nurse report LVN H had reported Resident #4 had a fall and was followed with neuro-checks but had not reported when the next neuro check was due nor how many she had done. LVN I stated during the nurse to nurse report a CNA interrupted and asked for LVN I to assess Resident #4. LVN I stated she stopped the nurse-to-nurse report and assessed Resident #4 as sleepy with vital signs (VS) with in normal limits. LVN I stated she had not assessed Resident #4 with a neuro-check assessment, nor documented the actual numbers of the VS, nor the actual time but did state the time must have been around 7:45 AM. LVN I stated at the completion of the nurse-to-nurse report, around 8:00 AM, she returned to assess Resident #4 and discovered her unresponsive, without respirations nor a pulse. LVN I stated Resident #4 was a do-not-resuscitate (DNR) and she reported the death to the DON. A record review of Resident #4's nursing progress notes dated [DATE] revealed the DON received a report from LVN I that Resident #4 was deceased . The DON documented her assessment, 0818 (8:18 AM) this nurse was called into residents' room being informed by charge nurse that she was unable to obtain vital signs. Confirmed in medical record that resident had DNR in place. On entering resident room resident was noted to be in bed with HOB elevated above 30 degrees, oxygen in place via nasal canula, and sling in place to left upper extremity, on assessment resident was not responsive to verbal or tactile stimuli including pain with sternal rub. No rise and fall of chest noted. No pulse present. Unable to obtain blood pressure. Once again confirmed in medical record active DNR. During a joint interview on [DATE] at 12:30 PM with the Administrator and the DON, the DON stated on the morning of [DATE] she received a report from LVN I that Resident #4 was deceased , a DNR, unresponsive without respirations, and without a pulse. The DON stated she assessed and documented her assessment. The DON stated she reported Resident #4's death to the Administrator. The Administrator stated she reported the death to the state agency and directed the DON to investigate the death, assess peer residents who may be on neuro-checks for safety, and to in-service the nursing staff on neuro-check protocols. The DON stated LVN H had not reported she had not assessed Resident #4 for the 6:45 AM nor the 7:15 AM neuro-checks and LVN I had not reported she had not assessed Resident #4 with neuro-checks at 7:45 AM nor did she document the VS for that 7:45 assessment. The Administrator and the DON stated LVN H was suspended during the investigation and received an in-service for following neuro-check protocols and reporting the assessments before returning to work aafter the investigation. The Administrator and the DON stated the expectation for nursing staff was to have a Resident first plan of care to include an immediate full assessment to include neuro-checks for all residents who had an unwitnessed fall and or head strike, to immediately SBAR a physician and to continue neuro checks and follow any additional physicians' orders. The DON stated staff were also to contact family / representatives, and document in the residents' medical record and to initiate an incident report. During an interview on [DATE] at 1:20 PM Dr. G stated he was familiar with Resident #4 and his expectation for neurological assessments was for the facility to follow their protocol. Dr. G stated it would have been ideal if the nursing staff had done the assessments to include the 3 scheduled proposed assessments prior to Resident #4's discovery of being deceased . A record review of the facility's in-service titled Neuro checks dated [DATE] revealed, neurological assessments flow sheet must be initiated immediately after each unwitnessed fall or head injury. Each check should include a full set of vital signs and a head-to-toe assessment to ensure no neurological changes have occurred. IF there are changes from the baseline noted call 911 and update MD, DON, and family. Frequency of neuro-checks 15 minutes x 4; 30 minutes x4; 1-hour x4; 4 hours x4; 8 hours x3. Further review revealed 44 of 44 nursing staff signed the in-service. PNC Verification A record review of the facility's incident reports from [DATE] through [DATE] revealed no residents with lack of neuro-check assessments. A record review of the facility's in-service titled Neuro checks dated [DATE] revealed, neurological assessments flow sheet must be initiated immediately after each unwitnessed fall or head injury. Each check should include a full set of vital signs and a head-to-toe assessment to ensure no neurological changes have occurred. IF there are changes from the baseline noted call 911 and update MD, DON, and family. Frequency of neuro checks 15 minutes x 4; 30 minutes x4; 1-hour x4; 4 hours x4; 8 hours x3. Further review revealed 44 of 44 nursing staff signed the in-service. A record review of nursing schedules for the month of [DATE] revealed 3 nursing shifts which included 7:00 AM to 3:00 PM; 3 PM to 11:00 PM; and 11:00 PM to 7:00 AM. Further review revealed the 7AM to 3PM shift comprised of 5 nurses and 7 CNAs, the 3PM to 11PM shift comprised 5 nurses and 7 CNAs, and the 11PM to 7AM shift had 2 nurses and 3 CNAs. 7AM-3PM Nurses = 5 1. During an interview on [DATE] at 3:40 PM LVN P stated she works days and evenings and usually worked the 7AM to 3PM shift in the MCU. LVN P stated she had received the ANE and the neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 2. During an interview on [DATE] at 3:10 PM LVN N stated she had received the ANE and the neuro check in-service which was universal everywhere to include neuro checks every 15 minutes then every 30 minutes followed by every hour to include pupil reactions and to document the findings on the worksheet. 3. During an Interview on [DATE] at 3:50 PM Agency LVN I stated she had received the ANE and the neuro check in-service in [DATE] which included to initiate neuro check assessments for any Resident who had an unwitnessed fall and or a head strike. LVN I stated neuro checks included a full set of VS and Pupillary reactions. LVN I stated the neuro check worksheet would serve as documentation. LVN I stated, If it was not documented - it was not done. 4. During an interview on [DATE] at 11:20 AM ADON D stated she had received the ANE and the Neuro-check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike. ADON D stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. 5. During an interview on [DATE] at 9:10 AM LVN Z stated he worked weekend days and evenings. LVN Z stated he had received the ANE and the neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 6. During an interview on [DATE] at 1:02 PM ADON E stated she had received the ANE and the neuro-check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike, ADON E stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. CNAs = 7 1. During an interview on [DATE] at 2:10 PM CNA J stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA J stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 2. During an interview on [DATE] at 6:05 PM CNA V stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA V stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 3. During an interview on [DATE] at 9:12 AM CNA Y stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA Y stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 4. During an interview on [DATE] at 9:05 AM CNA AA stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA AA stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 5. During an interview on [DATE] at 9:06 AM CNA BB stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA BB stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 6. During an interview on [DATE] at 6:13 PM CNA FF stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA FF stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 7. During an interview on [DATE] at 9:53 AM CNA HH stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA HH stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 3PM - 11PM Nurses = 3 1. During an interview on [DATE] at 3:28 PM LVN O stated she had received the ANE and the neuro check in-service which was universal everywhere to include neuro checks every 15 minutes then every 30 minutes followed by every hour to include pupil reactions and to document the findings on the worksheet. 2. During an interview on [DATE] at 4:49 PM LVN R stated he worked weekend days and evenings. LVN R stated he had received the ANE and the neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 3. During an interview on [DATE] at 11:46 AM LVN T stated she works evenings and usually worked the 3PM - 11PM shift. LVN T stated she had received the ANE and the neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 4. During an interview on [DATE] at 3:03 PM LVN Q stated she works days and could work some evenings and usually worked the 7AM to 3PM as the MDS nurse. LVN Q stated she had received the ANE and the Neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 5. During an interview on [DATE] at 9:09 AM LVN CC stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike, LVN CC stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. 6. During an interview on [DATE] at 9:34 AM LVN GG stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike, LVN GG stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. CNAs = 7* 1. During an interview on [DATE] at 6:00 PM CNA B stated she worked the 3PM -11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA B stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 2. During an interview on [DATE] at 4:20 PM CNA K stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA K stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 3. During an interview on [DATE] at 6:01 PM CNA C stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA C stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 4. During an interview on [DATE] at 6:03 PM CNA U stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA U stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 5. During an interview on [DATE] at 9:10 AM CNA DD stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA DD stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 6. During an interview on [DATE] at 9:33 AM CNA EE stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA EE stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 7. During an interview on [DATE] at 6:02 PM CNA W stated she worked the 3P - 11P shift and had received the ANE and the neuro check in service which included the fall protocol. CNA W stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 11PM - 7AM Nurses = 2 1. During an interview on [DATE] at 10:23 PM LVN H stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike. LVN H stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. 2. During an interview on [DATE] at 5:30 PM LVN L stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike. LVN L stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. 3. During an interview on [DATE] at 11:46 PM LVN T stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike. LVN T stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. CNAs = 3 1. During an interview on [DATE] at 9:46 PM CNA S stated she worked the 11PM - 7AM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA S stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 2. During an interview on [DATE] at 1:46 AM CNA X stated she worked the 11PM - 7AM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA X stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began on [DATE].

Based on observation, interviews and record reviews, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #2) reviewed for abuse, in that: The facility did not properly monitor or put in place preventative measures for Resident #2, who had a severe cognitive impairment, to prevent an act of sexual abuse by Resident #1 on 02/13/25, when he kissed Resident #2, and 02/14/25, when he fondled Resident #2. An IJ was identified on 02/27/25. The IJ template was provided to the facility on [DATE] at 06:18 PM. While the IJ was removed on 03/01/25 at 05:00 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm. This failure could result in residents suffering injury, a diminished quality of life, and psychosocial harm. The findings were: Record review of Resident #1's Admission Record reflected he was a [AGE] year-old male initially admitted [DATE] and readmitted [DATE]. It further reflected he had diagnoses to include dementia (group of symptoms affecting memory, thinking and social abilities) and major depressive disorder. Record review of Resident #1's quarterly MDS assessment, dated 01/23/25, reflected a BIMS score of 14 out of 15, indicating intact cognition. Record review of Resident #1's care plan, reflected, The resident has a behavior problem [Resident #1] goes into other residents' room, and sits in there while the resident is not in the room r/t confusion . Resident masturbates in empty rooms and during showers and when staff is providing peri care often. Resident makes sexually inappropriate comments and attempting to inappropriately touch female staff . Sexually inappropriate behaviors with female resident touching females and private areas breast and peri are in common areas at times., initiated 05/16/24 and revised 02/24/25. With interventions to include if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, initiated 05/16/24 and Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed., initiated 05/16/24. 1:1 when out of bed and room, initiated 02/11/25. During an interview on 03/03/25 at 01:48 PM, MDS nurse Q revealed the intervention for 1:1 when out of bed and room, dated on 02/11/25, was entered on 02/14/25 and accidentally back dated for 02/11/25. Record review of Resident #2's Admission Record reflected she was an [AGE] year-old female initially admitted [DATE] and readmitted [DATE]. It further reflected she had diagnoses to include dementia (group of symptoms affecting memory, thinking and social abilities), cognitive communication deficit, restlessness and agitation, generalized anxiety disorder, and senile degeneration of brain. Record review of Resident #2's quarterly MDS assessment, dated 12/12/25, reflected a BIMS score of 99, indicating resident was unable to complete the interview. It further reflected Resident #2 had a short and long-term memory problem and was severely cognitively impaired (never/rarely made decisions). Record review of Resident #1's Nurse's Note on 08/09/24 at 02:18 PM, authored by ADON D, reflected, assigned CNA for 8/9/24 7-3 reported during resident's shower the resident fondle himself, grab her breast and attempted to kiss her neck. CNA expressed to the resident that his behavior was inappropriate, and she would stop the shower to get someone else. resident stated he liked the CNA and wanted to finish; shower was completed by this time. resident was quickly taken to room where [Resident #1's RP] was present, CNA informed [Resident #1's RP] of [Resident #1]'s inappropriate touching of CNA and fondling of himself. [Resident #1's RP] stated he does that all the time, it's ok. we pay people to please him sometimes. CNA informed [Resident #1's RP] that staff is not [Resident #1]'s privately paid employee, and that is inappropriate for this facility. [Resident #1's RP] stated she would remind [Resident #1]. Record review of Resident #1's Nurse's Note on 01/21/25 at 01:48 PM, authored by LVN N, reflected, [Resident #1] was found in empty room on back of b hall masturbating. Was alone and CNA were able to take him to is room, he did not want to go back to room . Explained to [Resident #1] that he cannot be in another room in dark he needed to be in his room or let staff know where he was. He also did this yesterday that is went to another room in back of [Activity Room] where we had to look for him. Record review of Resident #1's Nurse's Note on 01/22/25 at 04:00 PM, authored by ADON E, reflected, [Resident #1] was noted to be in empty room on crescendo masturbating, resident was also seen bent forward in wheelchair trying to clean the floor. Explained to resident that for safety reasons staff needs to be aware of whereabouts. Resident expressed understanding. Record review of Resident #1's Nurse's Note on 02/11/25 at 05:18 PM, authored by ADON D, reflected, [Resident #1] seen by this nurse, other staff, and several visitors sitting in main common area/foyer next to female resident from [room number and bed identifier] holding and rubbing her forearm while she groped/fondled his penis. this nurse informed both residents this was not allowed in the common/public area. The female resident removed her hand from the male resident's crouch/groin area but left it on his thigh. this resident nodded his head and stated yes, (he) understands, thank you. they continued to sit in the common area/foyer watching the television. Record review of Resident #1's Nurse's Note on 02/13/25 at 03:45 PM, authored by ADON E, reflected, this nurse was informed this resident was witnessed blowing kisses to and then kissing a female resident who is incapable of consent on the mouth in the common area/foyer. this resident was informed not to kiss or have physical contact with this resident because she is unaware and incapable of consenting to any physical or sexual advances. this resident nodded his head, and said yes, ok. this resident remained in the common area/foyer and the other resident was removed from the area. [Resident #1's RP] called and informed of this incident and of actions facility will be taking on this repetitive matter; also informed if resident persisted with inappropriate sexual behavior after unsuccessful md/np-psych consults, possible med adjustments that resident may be discharged . [Resident #1's RP] acknowledged understanding of information provided. [Resident #1's RP] stated she spoke with him about [Resident #1's] inappropriate behavior and thought he wasn't going do anything else. And [Resident #1's RP] wanted to talk with the social worker about getting in contact with the psych doctor. this nurse let the [Resident #1's RP] know that the nurse manager will reach out to the psych np with these concerns but if she wanted to speak with the psych np, her visiting days are Tuesdays and Wednesdays, as it is not protocol for staff to give out the numbers. [Resident #1's RP] voiced understanding. [Resident #1's RP] asked to have this resident contact her. Record review of Resident #1's Nurse's Note on 02/13/25 at 03:45 PM, authored by the DON, reflected, New orders obtained from [NP F] to refer to psych services and initiate Depakote 125mg BID due to inappropriate sexual behavior. [Resident #1's RP] informed and consented to treatment. Record review of Provider Investigation Report, dated 02/14/25, reflected the [DOR] witnessed [Resident #1] caressing [Resident #2's] breasts. on 02/14/25 at 10:30 AM. Record review of Record of In-Service for Abuse/Neglect for All Departments, dated 02/13/25, reflected Neglect: HHSC defines neglect as, the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Abuse is also resident to resident contact. This document further reflected 8 out of 90 current facility staff had not signed this In-Service. Record review of a Psych note, dated 02/14/25, reflected [Resident #1] reports to I am fine. Staff report [Resident #1] is experiencing sexually inappropriate behaviors. This is first time he is having these behaviors since admission to this facility. He was observed by staff, blowing kisses to [Resident #2] and then he started kissing on her mouth without consent. [Resident #2] is A x O x 1, and incapable to make any decisions or consent. Staff witnessed this incident occurred in the common area/foyer. Redirections non effective, [Resident #1] still want to involved with [Resident #2] physically. [Resident #1's RP] made aware about incident happened by facility staff. [Resident #1] intending to go in the same room. Closed observation placed by PCP. We also reported to (local police). Although patient is A x O x 4, patient intentionally provided false information to police officer, and he was defending himself by accusing [Resident #2] and staff, when they came in the facility. Attempted interview with Resident #2 was on 02/24/25 at 08:29 AM. Resident #2 was unable to participate in interview due to confusion. During an interview on 02/25/25 at 11:30 AM, the SW revealed Resident #1 was alert and oriented with a BIMS of 15 and misread the situation. She revealed Resident #2 was not able to consent to this incident. The SW further revealed this was not typical behavior for Resident #1. She further revealed Resident #1 was on a one to one when resident was not in his room. She revealed it was Resident #1's responsibility to let someone know when he came out of the room. During an interview on 02/25/25 at 03:37 PM, CNA A revealed she was not trained about any resident needing a one to one. She revealed Resident #1 had been more touchy last week (week of 02/17/25). She revealed Resident #1 can't come out of his room. She revealed Resident #2 tended to be around the facility by herself and was not able to make her own decisions. During an interview on 02/25/25 at 04:36PM, Resident #1's RP could not recall any incident in August 2024 or any incident before last week with inappropriate behavior. She revealed Resident #1 did not think about the consequences. The RP revealed it was disgusting they didn't contact her about any other incident because she would have gotten this resident some help. During an interview on 02/25/25 at 05:25 PM CNA B stated he was a new hire, had started a week and a half ago, and was not aware of any residents being on a 1:1. He further revealed he did not know who Resident #1 was and would not be able to recognize him if Resident #1 was in the hallway. During an interview and observation on 02/26/25 at 08:08 AM, Resident #1 was in his room alone. Resident #1 stated, I'd rather not in response to an attempted discussion on his recent resident to resident incidents. Resident #1 stated he was being treated OK. During an interview on 02/26/25 at 11:01 AM, CNA C revealed she worked last week, shadowing CNA B, and was not aware of any resident having a one to one. She revealed she was trained on ANE and how to handle behaviors, but nothing for any specific behaviors for specific residents at the facility. During an interview on 02/26/25 at 12:50 PM, ADON D revealed on 02/11/25, Resident #1 had a consensual act with Resident #3 but it was inappropriate because it was in public and the facility told both residents this could not happen in public. ADON D revealed on 02/13/25, Resident #1 and Resident #2 were facing each other in a common area. She revealed a visitor reported to ADON D that Resident #1 was kissing Resident #2 and Resident #1 was told to scoot back from Resident #2 as Resident #2 could not consent. She further revealed on 02/14/25 Resident #1 was found fondling Resident #2's breasts. She revealed Resident #1 had been going to empty rooms to masturbate. ADON D confirmed her note on 08/09/24 occurred and revealed when she showered Resident #1 he also did this to her. She further revealed she thought she documented when he did this to her and there should have been interventions created for these behaviors of Resident #1. She revealed it was important for ADON D to document this to prevent anything from happening with female residents. She revealed it was possible the facility had interventions after these incidents of inappropriate behavior by Resident #1, but she could not remember exactly what. She revealed these incidents were discussed in morning meetings. ADON D revealed after the 02/14/25 incident, she communicated with B wing nurses and a B wing CNA. She revealed she hoped this nursing staff passed on this information from shift to shift. She revealed they were responsible for reading the 24-hour report or verbally passing this information on for the next shifts. She revealed she did not think there was any oversight for this process, but it was common sense. She further revealed A wing CNAs should know about the 02/14/25 incident to make sure Resident #1 did not go back into Resident #2's room. She revealed there was a doctor's order to check on Resident #1 every hour, but after nurses checked if resident was in the room or not, there was not any follow up actions for the staff to follow and there should be. During an interview on 02/26/25 at 02:47 PM, ADON E revealed they had a one to one for Resident #1 over the weekend of 02/15/25, which was an initial intervention. She revealed this was documented in the MAR that they checked on Resident #1 every hour (constantly watching where he was at). She revealed someone had to keep an eye on him so Resident #1 did not go into any ladies' rooms or go close to other females. She revealed management only told staff that needed to know, like A wing nurses, about the 02/14/25 sexual abuse incident, but was unaware if A wing CNAs were told. She revealed she expected the nurses to educate the CNAs and was unsure if anyone was overseeing this process. ADON E revealed when Resident #1 was going down to other rooms to masturbate, they educated Resident #1 that he had privacy in his room and redirected him appropriately. ADON E revealed there was no history of Resident #1 wandering into female's rooms. She was not aware of Resident #2 being kissed by Resident #1 on 02/13/25. She revealed there was probably some intervention on 02/13/25, but she could not recall. She revealed she was not aware of the incident between Resident #1 and Resident #3, but that Resident #3 was alert and oriented. She revealed she was unaware of any August incidents with Resident #1. She revealed this was not a reoccurring behavior for resident that she was aware of. During an interview on 03/03/25 at 01:48 PM, MDS nurse W and MDS nurse Q revealed for Resident #1 the interventions for his masturbation incidents were to intervene as necessary and protecting rights of residents. MDS nurse Q revealed the intervention for 1:1 when out of bed and room, dated on 02/11/25, was entered on 02/14/25 and back dated for 02/11/25 accidentally. They further revealed interventions were put in Resident #1's care plan after the team met in the morning meeting and decided this intervention would be appropriate. They revealed the DON oversaw this. They revealed it was important for interventions to be followed because it was a part of the plan for what they have done for the resident. During an interview on 03/06/25 at 04:52 PM, Resident #2's RP revealed she did not feel like Resident #2 had been neglected by the facility. She revealed she thought the facility was doing their best to protect Resident #2. She revealed Resident #2 was not alert and oriented and could not make conscious decisions for daily tasks. During an observation on 02/25/25 at 3:00 PM, Resident #1 was in a private room with no roommate and the door was open. Resident #1 was observed seated with a walker in front of him. Resident #1 was alone and without any staff supervision. It was further observed that no staff were in the hallway. Record review of facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected, 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anything including, but not necessarily limited to: b. other residents . 7. Implement measures to address factors that may lead to abusive situations, for example: a. adequately prepare staff for caregiving responsibilities. The Administrator was notified on 02/27/25 at 06:18 PM an IJ was identified on 02/27/25 due to the above failures. The IJ template was provided to the facility on [DATE] at 06:18 PM and the POR was accepted on 02/28/25 at 03:26 PM. Date: 2/27/2025 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes. On 02/24/2025, a complaint survey was initiated at [The Facility]. On 02/27/2025, A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: The facility failed to ensure that residents had the right to be free from abuse. The facility failed to provide necessary monitoring for Resident #1 to protect Resident #2 from sexual abuse. Identify residents who could be affected. All Residents have the potential to be affected. On 02/27/25, the resident census was 51. Identify responsible staff/ what action taken: Start date: 02/27/25. Completion date: 02/27/25 Responsible: Administrator/Designee Action: The Administrator/designee will place the male resident involved on 1:1 supervision immediately to ensure no sexually inappropriate behavior occurs. This 1:1 supervision will be provided until alternate placement for resident #1 is secured or he is cleared by the medical director or psychiatrist. Start date: 02/18/25. Completion Date: 02/27/25 Responsible: DON/Designee Action: Resident #2 was evaluated by the psychiatric nurse practitioner. The psychiatric nurse practitioner did not note a deviation of the resident's baseline behavior or mood. Resident #2 has an order for behavior monitoring that occurs every shift and is ongoing to monitor for mood changes. A review of this monitoring reveals no deviation of the resident's baseline behavior or mood. Start date: 02/27/25. Completion date: Ongoing Responsible: Administrator/Designee Action: The Administrator/Designee will interview all team members to determine if team members have knowledge of any inappropriate sexual behavior of male residents that may have occurred and has not been reported. If any are identified, an immediate assessment and a self-report will be completed. Start date: 02/27/25. Completion Date: 02/27/25 Responsible: Regional Director of Clinical Services Action: The Administrator and Director of Nursing will be educated by the Regional Director of Clinical Services on reportable sexually inappropriate behavior: 1. Residents must have the capacity to make decisions to give consent for sexual activity 2. Sexual activity without consent or cognitive ability to give consent is a reportable event 3. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, or mental abuse, including abuse facilitated or enabled using technology. 4. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Staff should monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to, sexually aggressive behavior such as saying sexual things and inappropriate touching/grabbing. 5. Any resident displaying sexually inappropriate behaviors involving non-cognitive residents will be placed on 1:1 supervision until evaluated by the primary provider and/or psych provider and deemed safe to have 1:1 supervision discontinued. Start date: 02/26/25. Completion Date: 02/28/25 Responsible: DON/Designee Action: DON/Designee will provide training for all team members on reportable sexual inappropriate behavior to include: 1. Team members educated on male residents' 1:1 status and sexually inappropriate behavior (i.e., touching, inappropriate sexual touching, and kissing towards residents who are unable to consent. 2. Sexual activity without consent or cognitive ability to give consent is a reportable event. 3. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, or mental abuse, including abuse facilitated or enabled using technology. 4. Sexual Abuse: is defined as non-consensual sexual contact of any type with a resident. Staff should monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to, sexually aggressive behavior such as saying sexual things and inappropriate touching/grabbing. 5. Training will include reporting all sexually inappropriate behavior to the Admin/DON immediately and intervening to prevent any injury. This training will be provided upon hire, annually and as needed. Full-time staff will be educated by end of day 02/28/25. PRN will be educated before the beginning of their next scheduled shift. Initial education may occur verbally via telephone, and in-person education will be completed prior to the beginning of their next scheduled shift. Any staff that are on leave or unavailable will receive the education before the beginning of their next scheduled shift. 6. Education was provided to all staff regarding residents who do not have the cognitive ability to give consent. Start date: 02/26/25. Completion date: 02/27/25 Responsible: Administrator/Designee Action: The Administrator/Designee conducted safe surveys with all cognitively intact residents residing on the A and B wings. The following questions were asked: 1. Question 1. Has another resident ever touched you inappropriately or made unwelcome advances towards you? If yes, tell me what happened, when it happened, if you reported it and who you reported it to. 2. Question 2. Do you feel safe? No further incidences of sexually inappropriate behavior were identified. Start Date: 02/26/25. Completion Date: 02/27/25 Responsible: DON/Designee Action: DON/Designee completed full skin assessments for non-cognitively intact residents residing on A and B wings. No evidence of sexually inappropriate behavior, such as bruising of the genitals or inner thighs, bleeding, irritation, or pain of the anus or genitals, or bloody, stained, or tattered undergarments, was identified. No behavioral signs of sexual abuse, such as new increased agitation, anxiety, social withdrawal, or fear, were identified. Start Date: 02/27/25. Completion Date: 03/27/27 Responsible: DON/Designee Action: DON/Designee will monitor process compliance and understanding daily during the morning clinical process and room rounding observations. Start Date: 02/27/25. Completion Date: 02/27/25 Responsible: Administrator Action: An Ad Hoc QAPI committee meeting was held with the Medical Director, Dr. G, regarding the current IJ and plan of correction. Start Date: 02/27/25. Completion date: 02/27/25 Responsible: Administrator/Designee Action: Results of in-servicing and interviews will be reviewed during the monthly QA meeting scheduled on 03/26/25. POR verification reads as follows: Record review of the facility's POR Binder dated 2/25/2025 revealed 51 residents were identified as vulnerable for ANE. Record review of Resident #2's PHQ-9 assessment (standardized tool used for screening, diagnosing, and measuring the severity of depression) reflected a score of 0, indicating no depression. Record review of Resident #2's doctor's orders reflected, BEHAVIOR MONITORING FOR: mood changes, verbal aggression .for every shift, as of 06/01/21, . BEHAVIOR MONITORING FOR: anxiety/restlessness . for every shift, as of 02/10/25, [Psych] to eval and treat . as of 12/20/22. Record review of the facility's POR binder reflected statements from staff regarding question do you have knowledge of any inappropriate sexual behavior made by male residents towards other residents that has not been reported? If so, what happened? revealed staff responded in a negative for inappropriate sexual behaviors. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed the Administrator documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed the Activities Assistant documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed LVN Q documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed the Social Worker documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed the Housekeeping Director documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed LVN N documented no to the question. Record review of the facility's in-service record dated 02/27/25 revealed, residents must have the capacity to make decisions to give consent for sexual activity Further record review revealed the Administrator and the DON received the in-service. Record review of the facility employee roster, dated 02/24/25, reflected 94 employees which included all departments, Administration, Nursing, Dietary, Therapy, and Housekeeping. Record review of the facility's in-service titled Sexual Abuse dated 2/26/2025 revealed, sexual inappropriate behavior . sexual activity without consent is a reportable behavior . all reports of potential abuse / neglect must be verbally reported immediately no matter the time (24 / 7) day night weekends, holidays, vacations, etc., to the abuse coordinator (the Administrator). AND One to one in-service dated 2/26/2025 revealed Resident #1 is to remain on one-to-one observation at all times and monitored for inappropriate sexual behaviors. Team-member may sit outside his room in the hallway to provide privacy but once he leaves his room the team-member must escort him and continue to monitor him. Record review of the facility's in-service titled Sexual Abuse ANE and One-to One, dated 2/26/2025, revealed 94 of 94 employees received both in-services which included the following employees: CNA A, CNA B, CNA C, ADON D, ADON E, LVN H, CNA J, CNA K, LVN L, CNA M, LVN N, LVN O, LVN P, LVN Q, LVN R, CNA S, LVN T, CNA U, CNA V, CNA X, CNA Y, LVN Z, CNA AA, CNA AB, LVN AC, CNA AD, CNA AE, CNA AF, LVN AG, CNA AH, CNA AI. Record review of nursing schedules for the month of January 2025 reflected 3 nursing shifts which included 7AM to 3PM, 3PM to 11PM, and 11PM to 7AM. Further record review revealed the 7AM to 3PM shift comprised of 5 nurses and 7 CNAs, the 3PM to 11PM shift comprised of 5 nurses and 7 CNAs, and the 11PM to 7AM shift had 2 nurses and 3 CNAs. Observation on 02/28/25 at 03:35 PM revealed the BOM was sitting, in the hall across from Resident #1. During an interview and observation on 02/28/25 at 03:36 PM, the BOM stated she was on 1:1 monitoring for Resident #1 and kept a form (1:1 sheet) she wrote on. The BOM was observed writing what she observed while she conducted the 1:1 monitoring of Resident #1. The BOM stated she did receive the in-service training on Resident #1's sexually inappropriate behavior. The BOM stated if she saw Resident #1 with inappropriate sexual behavior, she would intervene and notify DON. During an interview on 03/01/25 at 11:57 AM, the DON stated Resident #2 was ordered to receive psychiatric follow up. During an interview on 03/01/25 at 11:30 AM, the Administrator stated she and her designee interviewed all the current staff and revealed no evidence of sexual abuse and stated if any staff were not interviewed, they would not be able to assume a duty. During an interview on 02/28/25 at 03:50 PM, LVN N (who worked 7AM-3 PM) stated if she saw a resident with inappropriate sexual behavior, she would intervene and notify DON. During an interview on 02/28/25 at 04:21 PM, LVN R (who worked weekends) stated they had not seen any inappropriate sexual behavior. LVN R stated if they saw a resident with inappropriate sexual behavior, she would intervene and notify DON. During an interview on 02/28/25 at 04:30 PM, ADON D stated she had not seen any inappropriate sexual behavior. ADON D stated if she saw a resident with inappropriate sexual behavior, she would intervene and notify DON. During an Interview on 02/28/25 at 04:58 PM, Receptionist S stated he had not seen any inappropriate sexual behavior. Receptionist S stated if he saw a resident with inappropriate sexual behavior, he would intervene and notify DON. During an interview on 02/28/25 at 05:29 PM, LVN T stated she had not seen any inappropriate sexual behavior. LVN T stated if she saw a resident with inappropriate sexual behavior, she would intervene and notify DON. During a joint interview with LVN L and Receptionist S on 02/28/25 at 05:30 PM, LVN L stated he had not seen any inappropriate sexual behavior. Receptionist S stated if he saw a resident with inappropriate sexual behavior, he would intervene and notify DON. During an interview with Laundry Aide AL on 2/28/2025 at 5:54 PM Laundry Aide AL stated she had not seen any inappropriate sexual behavior. During an interview on 2/28/2025 at 06:00 PM PT AK stated he had not seen any inappropriate sexual behavior. PT AK stated if he saw a resident with inappropriate sexual behavior, he would intervene and notify DON. During an interview on 03/01/25 at 11:33 AM, the Administrator stated she received ANE prevention and reporting training from the Regional Director of Clinical Services to include sexual abuse incidents. During an interview on 03/01/25 at 11:33 AM, the DON stated she received ANE prevention and reporting training from the Regional Director of Clinical Services to include sexual abuse incidents. During an interview on 03/01/25 at 11:33 AM, the DON stated she in-serviced the entire staff on Resident #1's one to one status and ANE prevention and reporting and or suspicions of sexual abuse incidents. Intermittent daily observations from 2/24/2025 - 3/3/2025 revealed Resident #1 had not exited his room. 7AM-3PM Nurses = 5 During an interview on 02/28/25 at 03:40 PM, LVN P stated she works days and evenings and usually worked the 7AM to 3PM shift in the MCU. LVN P stated she had received the ANE in-service a couple of times to include the February 2025 in-service which included sexual abuse and Resident #1's 1/1 status when out of his room and if an incident of inappropriate sexual behavior was suspected, Resident would be redire [TRUNCATED]

Based on interviews and record reviews the facility failed to ensure alleged violations involving neglect were reported immediately, but not later than 24 hours if the events that caused the allegation do not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 8 residents (Resident #2) reviewed for reporting allegations of neglect. On 7/17/2024 CNA S assisted Resident #2 to dress while Resident #2 was seated on the bedside and during the attempt to stand CNA S and Resident #1 lost their balance and fell to the floor. CNA S failed to report the fall to the nurse, the DON, and or the Administrator. This failure could place residents at risk for neglect by not reporting allegations of ANE. The findings included: A record review of Resident #2's admission record, dated 02/25/2025, revealed an admitted [DATE] with diagnoses which included dementia (a general term for a group of brain disorders that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving), muscle weakness, and ataxic gait (an uncoordinated, awkward way of walking that's characterized by an unsteady, wide base, and irregular foot placement). A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 was an [AGE] year-old-female admitted for long term dementia care and assessed with a BIMS score of 99 which indicated Resident #2 was not able to participate in the memory interview. Further review revealed Resident #2 had short term and long-term memory impairment, Cognitive Skills for Daily Decision Making; made decisions regarding tasks of daily life; severely impaired - never / rarely made decisions. Further review revealed Resident #2 could not dress herself and needed assistance to stand and or dress, lower body dressing: the ability to dress and undress below the waist, . sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. dependent: helper does all the effort. Resident does none of the effort to complete the activity A record review of Resident #2's care plan dated 2/25/2025 revealed, (Resident #2) has an ADL self-care performance deficit related to generalized weakness and diagnosis of dementia with behaviors, date initiated 05/21/2021. Residents level of function varies due to Residents disease process, level of assistance by staff can fluctuate. transfer: the resident requires extensive assistance by x1-2 staff to move between surfaces . (Resident #2) has a behavior problem r/t resident refuses or resists ADL care at times and can be verbally and physically aggressive with staff . refuses care at times. monitor, document, report PRN any s/sx of Resident posing danger to self and others A record review of the facility's provider Investigation report, dated 7/25/2024, revealed the Administrator documented CNA S had assisted Resident #2 with dressing care on 7/17/2024, early in the morning, before Breakfast, when Resident #2 shifted herself during an assisted attempt to stand from the bed. CNA S stated both she and Resident fell , on 07/17/2024, she (CNA S) was getting resident up for breakfast. Resident became combative and aggressive while CNA (S) was putting on her pants. During this time, resident began to stumble over on the left and she might have hit her shoulder or arm on the windowsill or ac unit, . CNA (S) stated she used her strength to place her (Resident #2) on the floor. She went to get another CNA (X) to assist getting Resident off the floor. The administrator documented the fall was not reported to the nurse until the Administrators investigation on 7/18/2024 which was initiated due to the discovery of Resident #2's broken arm on 7/18/2024. Further review revealed the Administrator learned CNA S did not report the fall to the nurse LVN L due to her misunderstanding the definition of a fall, CNA S believed she assisted Resident #2 to the floor. During an interview on 2/28/2025 at 5:30 PM, LVN L stated he and CNA S worked the 11:00 PM to 7:00 AM shift on 7/17/2024 and he was not given a report by CNA S that Resident #2 had fallen or was assisted to the floor, and he had not assessed Resident #2 for injuries. LVN L stated had he known he would have assessed the Resident and reported to the physician. During an interview on 2/28/2025 at 3:40 PM LVN P stated she was the nurse on duty on 7/18/2024 from 7:00 AM to 3:00 PM and had not received a report that Resident #2 had a fall. LVN P stated CNA AJ had reported Resident #2 had shoulder pain when CNA AJ attempted to assist Resident with ADL care. LVN P stated she assessed Resident #2 with limited range of motion (ROM) and pain with movement of her left arm. LVN P stated she reported the findings to the physician and received orders for a mobile x-ray. LVN P stated the mobile x-ray revealed a fractured arm and reported again to the physician who ordered for Resident #2 to be sent to the hospital later that day for evaluation and treatment. LVN P stated she reported the broken arm to the DON. During an interview on 02/28/25 at 09:46 PM, CNA S stated she had assisted Resident ##2 to the floor during an attempt to stand when Resident #2 shifted her weight and they both were off balance and in an attempt to avoid a fall CNA S assisted Resident #2 to the floor. CNA S stated she believed this was not a fall and has received further training to report fall incidents to the nurse and the DON. During a joint interview on 2/28/2025 at 4:20 PM the DON and the Administrator stated Resident #2 had been assisted by CNA S sometime on 7/17/2024 between 5:30 AM and 6:00 AM when CNA S stated she assisted Resident #2 to the floor during an attempt to stand to dress her with pants. The DON stated CNA S did not report the fall to LVN L and learned of the fall from LVN P after the discovered broken arm on 7/18/2024. The Administrator stated she suspended CNA S pending an investigation, and the DON assessed peer residents on the unit and did not discover anyone else with limited ROM, pain, and provided all the staff with an in-service for reporting falls and the facility's fall protocol. The Administrator stated she learned of the injury from the DON, and she had reported the incident to the state agency on 7/18/2024 which included a provider investigation report. A record review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated September 2022, revealed, Policy Statement: All reports of Resident abuse (including injuries of unknown origin), neglect, exploitation, or theft / misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities: l. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury: or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: The facility failed to implement Resident #1's comprehensive person-centered care plan intervention for 1:1 supervision for Resident #1 to have fewer episodes of sexual behaviors. This deficient practice could affect residents and place them at risk for not having their needs and preferences met. The findings included: Record review of Resident #1's Admission Record reflected he was a [AGE] year-old male initially admitted [DATE] and readmitted [DATE]. It further reflected he had diagnoses to include dementia (group of symptoms affecting memory, thinking and social abilities) and major depressive disorder. Record review of Resident #1's quarterly MDS assessment, dated 01/23/25, reflected BIMS score of 14 out of 15, indicating intact cognition. Record review of Resident #1's care plan, reflected, The resident has a behavior problem [Resident #1] goes into other residents room, and sits in there while the resident is not in the room r/t confusion . Resident masturbates in empty rooms and during showers and when staff is providing peri care often. Resident makes sexually inappropriate comments and attempting to inappropriately touch female staff . Sexually inappropriate behaviors with female resident touching females and private areas breast and peri are in common areas at times., initiated 05/16/24 and revised 02/24/25, with a goal of The resident will have fewer episodes of behaviors by review date. and an intervention to include 1:1 when out of bed and room, initiated 02/11/25. During an interview on 02/26/25 at 12:50 PM, ADON D revealed Resident #1 had inappropriate behaviors that were discussed in morning meetings. She revealed interventions were discussed and added to Resident #1's care plan to prevent anything to happen with female residents. During an interview on 03/03/25 at 01:48 PM, MDS nurse W and MDS nurse Q revealed for Resident #1 the interventions for his masturbation incidents were to intervene as necessary and protecting rights of residents. MDS nurse Q revealed the intervention for 1:1 when out of bed and room, dated on 02/11/25, was entered on 02/14/25 and back dated for 02/11/25 accidentally. They further revealed interventions were put in Resident #1's care plan after the team met in the morning meeting and decided this intervention would be appropriate. They revealed the DON oversaw this. They revealed it was important for interventions to be followed because it was a part of the plan for what they have done for the resident. Record review of facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, reflected, 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 (Resident #5) residents in that: Resident #5 was not administered her Methadone oral tablet once in July 2024 and twice in February 2025. The effect could result in residents not provided medications as ordered. The Findings were: Record review of Resident #5's Admission Record dated 2/24/2025 reflected she was admitted on [DATE] and was [AGE] years old. Resident #5 was on hospice services, and her diagnoses included dementia, osteoporosis, abnormal posture, and osteoarthritis. Record review of Resident #5's Consolidated orders for July 2024 and February 2025 revealed an order for Methadone oral tablet 5 mg, give 1 tablet by mouth 2 times a day for pain. Medications to be given by nurse at 6:30 AM and 6:30 PM. Record review of Resident #5's MAR dated July 2024 revealed blank on MAR for 7/23/2024 for the 6:30 AM dose. Order was Methadone HCI oral tablet 5 mg, give 1 tablet by mouth 2 times a day for pain. Medications to be given by nurse at 6:30 AM and 6:30 PM. Record review of Resident #5's MAR dated February 2025 revealed blank on MAR for 2/15/2025, 5:30 AM dose and 2/18/2025 5:30 PM dose . Order was Methadone oral tablet 5 mg, give 1 tablet by mouth 2 times a day for pain. Medications to be given by nurse at 6:30 AM and 6:30 PM. Record review of Resident #5's Quarterly MDS dated [DATE] reflected she had short-term and long term memory problems, she was severely impaired for cognitive skills for daily decision making, she had upper/lower extremity impairment to both sides, she used a wheelchair, she was dependent for all ADLs, she was incontinent of bowel/bladder, she had non-Alzheimer's Dementia, osteo arthritis, she was at risk for pressure ulcers/injuries, she was taking diuretics, was on hospice services. Record review of Resident #5's care plan dated 12/24/2024reflected Resident #5 had a diagnosis for Osteoporosis: Resident with stiffness in joints, fatigue, pain, and disturbed sleep. Complaints of pain with movement to extremities at times related to diagnosis. Intervention was documented Administer pain medication ordered by MD. Record review of Resident #5's progress note dated, 7/23/2024 at 6:30 AM reflected, Methadone-missed. RN requested medication STAT. pain level was 0/10. Missed scheduled dose of Methadone 5mg at 6:30 am on 7/23/24. Medication not available. RN requested medication refill from hospice nurse was notified that medication was reordered and requested STAT delivery. Resident #5 assessed for pain. Resident was up in w/c, with no s/s of distress, or pain. Record review of Resident #5's progress note dated, 7/23/2024 at 10:15 AM by ADON E, reflected notified hospice nurse resident was out of her methadone pain medication. Per hospice nurse she will order medication and have it delivered STAT. Resident family at nurse station and notified of medication not given and pending delivery. During interview on 2/27/2025 at 1:58 PM DON stated Resident #5 did miss methadone that morning of 7/23/24, DON stated when hospice visits, they ask nurses how they are with medications. DON stated the facility was responsible for making sure resident medications are available per orders. Attempted interview on 2/27/25 at 2:06 PM with LVN AM, left a message. No return call. During an interview on 3/3/2025 at 1:58 PM, LVN T stated she must have forgotten to sign, but did administer medication to Resident #5 . During interview on 3/3/2025 at 2 PM with LVN H, she stated she would have to look at her schedule to see when she worked, but she gives Resident #5 her Methadone medication on time as ordered. During interview on 2/27/2025 at 2:25 PM ADON E, stated she found out, 7/23/2024 from floor LVN AM Resident #5 was missing her medication for Methadone. ADON E called hospice to ensure medications were in stock for Resident #5. ADON E stated the process was the floor nurse should let hospice or the charge nurse know that they don't have medication -Methadone. ADON E stated she reported it to the DON on 7/23/2024. During interview on 2/27/2025 at 1:30 PM DON revealed the facility was responsible for making sure residents were administered their medications as ordered. Record review of policy Refill Orders, (no date) reflected, Refill Orders -The following forms or methods are accepted means of submitting refill orders to the pharmacy: for facilities with integrated electronic records, the facility may transmit refill request via facility electronic records. In addition, the following may be used, refill order form, pharmacy link and the refill order may be called in if the circumstances require it. Refill orders will be delivered on the first respective facility run of the following business day. Urgent Orders -new orders or refills order requiring urgent delivery should be indicated in the order sheet or communicated verbally. The pharmacy had services available to deliver medications in a timely manner depending on time and location of receiving facility.

Based on interviews and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property for 3 of 5 (CNA A, B, C) new hired employee's files reviewed. 1. CNA A did not have EMR/NAR. 2. CNA B did not have EMR/NAR. 3. CNA C did not have EMR/NAR. This could place residents at risk of abuse, neglect, and exploitation. The Findings were: 1. CNA A (agency staff) the first day on the floor was 6/3/2024. Record review of CNA A's agency background check to include OIG was dated 6/2/2024. 2. CNA B (agency staff) the first day on the floor was 6/4/2024. Record review of CNA B's agency background check to include OIG was dated 6/1/2024. 3. CNA C (agency staff) first day on the floor was on 6/26/2024. Record review of CNA C's agency background check to include OIG was dated 6/22/2024. During an interview on 6/28/2024 at 5:54 PM and 7:30 PM with the ADM he stated, the facility did not check CNA A, B, and C's background check for EMR/NAR. The ADM stated the agency that hired CNA A, B, and C did complete an OIG. The ADM stated since the agency was not our team member and were self-contractors, we were not authorized to run EMR/NAR checks. The agency stated this was their reasoning for why they run the state and federal OIG several times a month. ADM was not aware of the OIG checks, included the EMR/NAR checks. Record review of policy Abuse, Neglect, Exploitation, and Misappropriation Prevention program dated April 2021 revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom form corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. Policy Interpretation and Implementation. 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has a finding entered in the stated nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property.

Based on interviews and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to Health and Human Services, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures, for 3 of 10 residents (#15, #140, and #141) reviewed for allegations of abuse, neglect, and exploitation. 1. The Administrator and the DON failed to report an allegation of neglect for Resident #15 on 03/31/2024 when Resident #15's representative alleged Resident was neglected and left in bed all weekend due to the facility had no clean mechanical lift slings. 2. The Administrator and the DON failed to report an allegation of abuse and neglect for Resident #140 on 05/06/2024 when Resident #140 alleged she had a rude overnight nurse, her lack of an arm sling, and pain medication errors. 3. The Administrator and the DON failed to report an allegation of abuse and neglect for Resident #141 on 05/06/2024 when Resident #141 alleged the overnight nurse was verbally abusive and negligent with pain medication administration. These failures could place residents at risk for harm by abuse and or neglect. The findings included: A record review of Resident #15's admission record dated 06/28/2024 revealed an admitted [DATE] with diagnoses which included dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), anxiety, and glaucoma (a group of eye diseases that lead to damage of the optic nerve, which transmits visual information from the eye to the brain). A record review of Resident #15's quarterly MDS assessment dated [DATE] revealed Resident #15 was an [AGE] year-old female admitted on hospice services for long term care and assessed with a BIMS score of 99 which indicated severe cognitive impairment due to her inability to respond in the interview. Further review revealed Resident #15 had both lower extremities impaired and was totally dependent with all transfers and used a wheelchair. A record review of Resident #15's care plan dated 06/28/2024 revealed, Special Instructions: . Hoyer for transfers . Resident #15 has impaired visual function r/t absolute Glaucoma, macular degeneration, and cataracts . Resident #15 has a diagnosis for Osteoporosis: Resident with stiffness in joints, fatigue, pain, and disturbed sleep. Complaints of pain with movement to extremities at times r/t diagnosis . Assist with ADL's, transfers, and mobility as needed . Monitor for verbal and non-verbal signs of pain or discomfort r/t diagnosis A record review of Resident #15's grievance report documented by the DON, dated 03/31/2024, revealed Resident #15's representative made a grievance and alleged Resident #15 was neglected, Sunday afternoon they couldn't get my (Resident #15) up because there were no clean slings . reportable to the state agency: no A record review of the Texas Unified Licensure Information Portal (TULIP) website accessed 06/27/2024 revealed no evidence for allegations regarding Resident #15 from 01/2024 to 06/27/2024. During an interview and record review on 06/26/2024 at 02:00, Resident #15's representative stated he made a grievance to the administrator on 03/31/2024 regarding Resident #15's neglect and that she was left in bed all weekend. Resident #15's representative stated the Administrator was aware. The representative stated, I just want my (Resident #15) to be safe and cared for, but they seem to be incapable of keeping her safe. I come see her almost every day. I would take her home, but I cannot move her safely by myself. During an interview on 06/28/24 at 07:38 PM, the DON stated Resident #15's Representative had made a complaint where Resident #15 was not assisted out of bed and since, the plan has been to have extra mechanical lift slings at the nurses' station . A record review of Resident #140's admission record dated 06/28/2024 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses which included a fracture of the right shoulder and sepsis (severe infection). A record review of Resident #140's admission MDS assessment dated [DATE] revealed Resident #140 was a [AGE] year-old female admitted for rehabilitation therapy related to a broken shoulder. Further review revealed Resident #140 was assessed with a BIMS score of 10 which indicated moderate cognitive impairment. Resident #140 was assessed to have the ability to understand others and could make herself understood. Resident #140 had clear speech and adequate hearing and vision without the need for eyeglasses and or hearing aids. A record review of Resident #140's physician's orders dated 06/20/2024 revealed Resident #140 was prescribed pain medications, acetaminophen 325mg, hydrocodone-acetaminophen - Give 1 tablet by mouth every 8 hours for pain management and Hydrocodone- 5-325mg hydrocodone-acetaminophen. Give 1 tablet by mouth every 4 hours as needed for chronic back pain. Resident #140 was prescribed a sling, Patient to wear sling on right UE when OOB for comfort . until 06/30/2024 A record review of Resident #140's care plan dated 06/20/2024 revealed, The resident has a right arm fracture r/t (related to) fall at home . Give pain, anti-inflammatory medications as ordered. Monitor/document side effects and effectiveness . The resident has chronic pain r/t history of chronic back pain . The resident prefers to have pain controlled by: medication A record review of Resident #140's grievance report dated 05/06/2024 revealed the DON documented Resident #140 made a complaint that the overnight nurse was rude, she needed a sling for her arm, and her pain medication was ineffective. She stated, the overnight nurse is rude every time she comes in here. I've been asking all the nurses to fix my pain medications. I don't have my sling for my arm. Further review revealed the DON documented the incident was not reportable to the state agency. Further review revealed the DON and the administrator signed the document. During an interview on 06/28/24 at 07:38 PM the DON stated Resident #140's complaint of a rude nurse and pain medications were addressed. She stated the nurse was provided with customer service education and the resident was ordered a new sling. The DON stated the physician was contacted and Resident #140 received a new order for pain medications therefore the grievance was not considered a reportable incident to the state agency . A record review of Resident #141's admission record dated 06/28/2024 revealed an admitted [DATE] with a discharge date of [DATE] with diagnoses which included neuropathy (nerve pain), diabetes (too much sugar in the blood), and cellulitis of right lower limb (right leg infected). A record review of Resident #141's admission MDS assessment dated [DATE] revealed Resident #141 was a [AGE] year-old male admitted for short term rehabilitation care related to an infected right leg complicated by diabetes and high blood pressure. Further review revealed Resident #141 had the ability to make himself understood and could understand others, had clear speech, adequate hearing, and vision without the need for eyeglasses and or hearing aids. Resident #141 was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #141's physicians orders dated 04/27/2024 revealed Resident #141 was prescribed pain control medication: acetaminophen-codeine Tablet 300-30mg - Give 1 tablet by mouth every 4 hours as needed for pain; acetaminophen-codeine Tablet 300-30 MG - Give 1 tablet by mouth every 6 hours as needed for Mild / Moderate Pain; and Cleanse surgical incision to dorsal foot with NS, pat dry, apply dry dressing A record review of Resident #141's care plan dated 04/27/2024 revealed, Acute Infection . The resident has acute pain r/t Medical Procedure s/p I&D (incision and drain) right foot wound, cellulitis of right foot . Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A record review of Resident #141's grievance report dated 05/06/2024 revealed Resident #141 made a complaint to the Director of Rehabilitation (DOR) and the DOR documented, patient reports having trouble with the overnight nurse. Asked for ice water and was given a cup with 2 ice cubes and nurse said, here's your damn ice water. Sunday Resident stated he asked for pain meds and got attitude regarding times of pain meds. States nurse was extremely rude the entire weekend if he asked for anything. Further review revealed the DON documented the incident was not reportable to the state agency. Further review revealed the DON, and the administrator signed the document . During an interview on 06/28/24 at 07:38 PM the DON stated Resident #141's complaint of a rude nurse and pain medications were addressed, and the nurse never provided the Resident with the water, It was a different staff member. The DON stated Resident #141 was requesting medications hourly and received education and the nurse received customer service education. The DON stated the grievance was not considered a reportable incident to the state agency . During an interview on 06/28/24 at 08:00 PM the Administrator reviewed the grievances for residents #15, #140, and #141 and stated the grievances were not reportable events to the state agency, however upon reconsideration of Resident #141's grievance she believed that complaint should have been reported to the state agency . A record review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021, revealed, Policy Statement - Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff. b. other residents. c. consultants. d. volunteers. e. staff from other agencies. f. family members. g. legal representatives. h. friends. i. visitors; and/or j. any other individual. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations

41937 Based on observations, interviews, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #51) reviewed for activities of daily living. 1. Resident #51 was observed left in bed from 09:00 AM to 06:00 PM on 06/25/2024 and again from 07:30 AM to 12:00 PM on 06/26/2024. 2. Resident #51 was observed with no hydration at his bedside from 09:00 AM to 06:00 PM on 06/25/2024 and again from 07:30 AM to 12:00 PM on 06/26/2024. 3. Resident #51 was observed with the remnants of breakfast on his gown on 06/26/2024 from 08:30 AM to 12:00 PM. These failures could place residents at risk for harm by a decline in residents' abilities to perform ADL's. The findings included: A record review of Resident #51's admission record dated 06/28/2024 revealed an admitted [DATE] which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder, and weakness. A record review of Resident #51's annual MDS assessment dated [DATE] revealed Resident #51 was an [AGE] year-old male admitted for long term care with supports for Activities of Daily Life (ADL's) complicated by Alzheimer's disease. Resident #51 was assessed with a BIMS score of 02 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #51's care plan dated 06/28/2024 revealed, Resident #51 has an ADL self-care performance deficit r/t Alzheimer's, Confusion, Impaired balance, Limited Mobility . DRESSING: The resident requires EXTENSIVE assistance by (X1) staff to dress . EATING: The resident requires limited assistance by 1 staff . PERSONAL HYGIENE: The resident requires EXTENSIVE assistance by (X1) staff with personal hygiene and oral care . TOILET USE: The resident requires EXTENSIVE assistance by (X1-2) staff for toileting . TRANSFER: The resident requires EXTENSIVE assistance by (X1-2) staff to move between surfaces as necessary . The resident is resistive to care, yells out and curses at staff when staff attempts to provide care at times r/t Dementia . If resident resists with ADLs, reassure resident, leave, and return 5-10 minutes later and try again . The resident has a communication problem r/t language barrier . Ensure/provide a safe environment: Call light in reach, adequate low glare light, bed in lowest position and wheels locked, avoid isolation . Resident #51 has potential for fluid volume deficit . Invite the resident to activities that promote additional fluid intake. Offer drinks during one-to-one visits. Ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements . The resident needs activities that minimize the potential for falls while providing diversion and distraction . Encourage fluids during the day to promote prompted voiding responses During an observation on 06/25/2024 at 10:30 AM revealed Resident #51 was in bed awake and drinking water from a small clear plastic cup. Resident #51 had his bed in the lowest position but did not have a fall mat next to his bed. During an interview on 06/25/24 at 10:34 AM Resident #51's roommate, Resident #30 and his representative, stated Resident #51 was often left in bed for days and resident #51 had no one to visit him. Resident #30's representative stated she had pity for Resident #51 since often he had no water to drink so she served him water and offered him bananas when she offered drinks and fruit to Resident #51. Resident #30's representative stated Resident #51 has been in bed this morning without any water to drink since breakfast, so she poured him some water in the small plastic cup he has now. During an observation and interview on 06/25/2024 at 05:55 PM revealed Resident #51 continued in his bed awake without any water by his bed side. Resident #51 could not participate in the interview but continued to smile and nod his head . During an observation on 06/26/2024 at 07:15 AM revealed Resident #51 asleep in his bed without any water by his bedside. During an observation on 06/26/2024 at 07:57 AM revealed Resident #51 was in his bed eating his breakfast alone without assistance. Further observation revealed Resident #51 was spilling some of his food onto himself and his bed . During an observation and interview on 06/26/2024 at 09:00 AM CNA J was observed answering call lights on Resident #51's hall. CNA J stated she was the CNA for Resident #51 had served and recovered Resident #51's breakfast meal. During an observation on 06/26/2024 at 10:10 AM revealed Resident #51 in his bed with remnants of his breakfast on his gown, on his person, and in the bed linens . During an interview and observation on 06/26/24 at 11:58 AM LVN T stated Resident #51 was in bed with a small cup of water served by his roommates' representative. Resident #51 had food debris on his person, gown, and bed linens. LVN T stated Resident #51 often refused to get out of bed. LVN T stated CNA J had not reported Resident #51's refusal to get out of bed yesterday or today. LVN T stated Resident #51 was a fall risk and should have bedside fall matts when he is in bed. LVN T stated Resident #51 ate alone and his family and or friends often send him a meal via (local delivery service). LVN T stated she did not observe a water tumbler for Resident #51 in his room . During an observation and interview on 06/26/24 at 02:52 PM the Activities Director stated she attended and facilitated an activity with Resident #51 who was observed seated in his wheelchair in the lobby of the facility participating in the activity. Resident #51 was observed dressed in a shirt and pants and was well groomed. Resident #51 was observed smiling. A record review of the facility's Activities of Daily Living (ADLs), Supporting policy dated March 2018, revealed, Policy Statement - Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation. 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). b. Mobility (transfer and ambulation, including walking). c. Elimination (toileting). d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems) . 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate

Based on observations, interviews, and record reviews the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain, for 1 of 8 (#30) residents reviewed for their right to use the bathroom. The facility failed to support Resident #30's continence and right to use the bathroom and not depend on his adult brief. This failure could place residents at risk for harm by an contributing to incontinence and an undignified lifestyle. The findings included: A record review of Resident #30's admission record dated 06/28/2024, revealed an admitted [DATE] with diagnoses which included fracture part of neck of right femur (broken right hip), hemiparesis following cerebral infarction (weakness to one side of the body after a stroke), and cerebral infarction (stroke). A record review of Resident #30's quarterly MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old male admitted for long term care and rehabilitation for a right broken hip and supportive care for a right-side body weakness. Resident #30 was assessed with a BIMS score of 12 out of a possible 15 which indicated a moderate cognitive impairment. Resident #30 was assessed with adequate hearing and speech with the ability to make himself understood and understand others. Resident #30 was assessed with the history of using a wheelchair and a walker. Resident #30 was assessed with the need for Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for the following activities of daily life: Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. Resident #30 was assessed with the need for Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently, for the following activities of daily life: Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Toilet transfer: The ability to get on and off a toilet or commode. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. Further review of Resident #30's MDS revealed no toileting program was initiated and Resident #30 was assessed as Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) . Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Further review of Resident #30's MDS revealed he was at risk for developing pressure ulcers. A record review of Resident #30's physicians' orders revealed Resident #30 was referred to physical therapy and occupational therapy on 05/31/2023 for an evaluation and treatment. A record review of Resident #30's care plan dated 06/28/2024 revealed, The resident has an ADL self-care performance deficit r/t generalized weakness. s/p (after) cva (stroke) with right sided weakness. Resident utilizes custom wheelchair for locomotion . resident will maintain current level of function in ADL care through the review date .TOILET USE: The resident requires Extensive assistance by (X1) staff for toileting . TRANSFER: The resident requires Extensive assist x1 staff assistance for transfers . resident had a cerebral vascular accident (CVA/Stroke) affecting right dominant side . Monitor/document bladder and bowel function . If incontinent monitor/document for appropriate bowel and bladder training program and implement. Monitor/document resident's abilities for ADLs and assist resident as needed. Encourage resident to do what he/she is capable of doing for self . Educate resident/family/caregivers of causative factors and measures to prevent skin injury A record review of Resident #30's Multidisciplinary Care Conference dated 04/10/2024 revealed topics discussed: What health outcome matters MOST to the Resident? To build up his strength enough to be able to transfer from wheelchair to the toilet again . SUMMARIZE DISCUSSION OF CARE PLAN CONFERENCE; RP attended care plan via phone. RP states resident would like to transfer from wheelchair to toilet. Therapy is currently working on transfers with resident. RP states the resident enjoys working out. RP with no other questions or concerns at this time. Code status confirmed. A record review of Resident #30's FUNCTIONAL ABILITIES-Charge Nurse Documentation-Q (every) shift dated 04/23/2024, revealed, Self-Care. Ask CNA for input on USUAL performance during shift. (Different than POC /ADL documentation where CNAs need to document the MOST assistance needed during ADL self-performance); . Chair/Bed-to-chair transfer-The ability to transfer to or from bed to chair/wheelchair, Substantial/maximal assistance- helper does MORE THAN HALF . Toilet transfer-The ability to get on and off a toilet or bedside commode, Substantial/maximal assistance- helper does MORE THAN HALF A record review of Resident #30's Occupation Therapy Discharge Summary dated 05/08/2024 revealed, standing during ADL's, PLOF (prior level of function) Fair, discharge, Fair (maintains standing balance 1-2 minutes without upper extremities support without loss of balance . toileting, PLOF, minimum assistance, baseline, DNT (did not test), discharge 05/28/2024 A record review of Resident #30's grievance dated 05/24/2024 revealed Resident #30 had made a grievance to the Administrator who documented, Resident stated he feels captive here because his custom wheelchair doesn't fit in bathroom and believes private skilled rooms have bigger bathroom doors .findings of investigation: I offered for Resident to have old wheelchair back. Resident refused. Offered basin and mirror, but Resident wants to go to the bathroom. Plan to resolve complaint / grievance: Spoke to DOR (director of rehab) who stated Resident is unable to self-transfer. Will work on it in therapy. Expected results of actions taken: Resident will safely be able to transfer so he can go. Complaint / grievance resolved; No, specify follow up: Resident cant transfer safely and he still wants to go into bathroom. During an observation and interview on 06/23/2024 at 10:28 AM Resident #30 and his RP stated there was an important issue he needed addressed. Resident #30 stated in January of 2023 he had fallen and suffered a broken hip. He received surgery to repair the hip and since has been in the facility. Resident #30 went on to explain that prior to January 2023 he was able to transfer from his custom wheelchair to a smaller wheelchair and then staff would assist him to his small bathroom in his room, even though he had right side body weakness. Resident #30 stated since then he had been ignored when he asked for assistance to use the toilet and instead, he was expected to soil himself and then ask for assistance with changing his adult brief. Resident #30 stated the staff would state you cannot go to the bathroom, it is dangerous. Resident #30 stated he had been assessed by the physical therapy department without resolution and has continued in his same dilemma. Resident #30 stated he has voiced his concerns to the Administrator and in care plan meetings without resolution. Resident #30 stated he felt like he was being held captive. Resident #30 and his RP stated the Administrator made an undignified offer for Resident #30 to use a bedside commode and a small vanity mirror in his shared small room. During an interview on 06/27/2024 at 09:50 AM CNA J stated she has provided care for Resident #30, and she does not take him to the toilet when he requests because she has been instructed not to. She stated, he is not safe to transfer to the toilet. CNA J stated, his wheelchair is too big, and he cannot walk to the toilet, so I change his (adult brief) when he is dirty . During a joint interview on 06/27/2024 at 09:00 AM the Director of Rehabilitation and the Physical Therapist (PT) stated prior to Resident #30's broken hip, with assistance, he could use a smaller wheelchair to go into the shared bathroom in his bedroom. The PT stated Resident #30 could not use his smaller wheelchair now due to his need for his larger wheelchair after his broken hip. The PT stated Resident #30 was not safe to use his bathroom toilet because his wheelchair would not fit into the bathroom and his toilet was not fitted with grab bars on both sides, which he needed for support when transferring from a wheelchair to the toilet. During an interview on 06/28/24 at 07:38 PM the DON stated Resident #30 refused to use a small wheelchair to use the bathroom and his larger custom wheelchair will not fit. She stated we are accommodating his needs with a small wheelchair, and he refused. During an interview and observation on 06/28/2024 at 07:54 PM the facility's Maintenance Director measured and stated Resident #30 bathroom in his share bedroom measured 4 feet 3 inches by five feet wide. The maintenance director stated all the facility's bathrooms for residents were the same size. A record review of the facility's undated public posting Resident's Rights nursing facilities revealed, Residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the Constitution and laws of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal in exercising these rights as citizens of the United States. Dignity and respect, you have the right to: Live in safe, decent, and clean conditions. Be free from abuse, neglect, and exploitation. Be treated with dignity, courtesy, consideration, and respect. A record review of the facility's policy Activities of Daily Living (ADLs), Supporting dated March 2018 revealed, Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: b. Supervision - Oversight, encouragement or cueing provided 3 or more times during the last 7 days . c. Limited Assistance - Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days . 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

Based on interviews and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 21 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA B reported when HA A allegedly abused Resident #1 on [DATE]. The facility failed to ensure HA A was not working after this alleged abuse and had access to residents for her overnight shift. The facility failed to ensure all staff members were properly educated on abuse, neglect, and exploitation after this incident. On [DATE] at 03:52 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed prior to exit on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record Review of Resident #1's Admission record, dated [DATE], revealed a female initially admitted [DATE] and expired [DATE] with diagnosis to include dementia (loss of thinking, remembering, and reasoning skills), and major depressive disorder. Record Review of Resident #1's care plan, closed date [DATE], reflected [Resident #1] has a mood problem . with an intervention of Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.), initiated [DATE]. [Resident #1] has behavior problems . with an intervention of Monitor behavior episodes and attempt to determine underlying cause., initiated [DATE]. [Resident #1] has a terminal prognosis r/t family has elected hospice services with [NAME] hospice. With an intervention of Refer to Psychiatric/Psychogeriatric consult if indicated, initiated [DATE]. Record Review of Resident #1's annual MDS assessment, dated [DATE], reflected Resident #1 had a BIMS score of 99, indicating the resident was unable to complete the interview. It also reflected Resident #1 exhibited rejection of care 1 to 3 days per week in comparison to: Record Review of Resident #1's quarterly MDS assessment, dated [DATE], resident did not exhibit rejection of care. Record Review of the Provider Investigation Report, dated [DATE] and authored by the ADM reflected, Date/Time you first learned of incident: [DATE], 11:00AM Date/Time the incident occurred: [DATE], 10:45PM Brief narrative summary of the reportable incident: [CNA B] called this administrator to report physical abuse to [resident #1] by [HA A]. [CNA B] witnessed [HA A] slap [Resident #1] on the shoulder twice. .On [DATE], this administrator initiated resident questionnaires, which residents expressed to have been treated with respect, dignity, and no one has hurt them. On [DATE], [HA A] is terminated . I have concluded this allegation is confirmed because new injuries shown in new skin assessment completed on [DATE]. Record review of Nurse's Note, dated [DATE] at 11:27 AM and authored by the DON, reflected Resident skin noted to be clean dry and intact. Three small circular bruises noted to left posterior forearm. #1 2.5 x 2.0 cm, #2 0.3 x 0.3 cm, and #3 0.4x 0.3 cm. During an interview on [DATE] at 02:48 PM, the Administrator confirmed there were missing signatures on the in-services for this incident. During an interview on [DATE] at 03:13 PM, HA A could not recall Resident #1. During an interview on [DATE] at 11:01 AM, CNA B revealed she heard a loud thump when she was in the hallway 2 rooms away from Resident #1's room. She revealed she saw the AP in the process of hitting Resident #1 on the shoulder. CNA B witnessed the AP holding Resident #1's forearm while hitting Resident #1 once on the shoulder. She further revealed the AP hit Resident #1 hard enough to produce a loud sound. CNA B described Resident #1 as so small, fragile, and nonverbal. CNA B further revealed a red mark was visible on Resident #1's shoulder because her shirt was hanging off. CNA B could not see any other marks on her body. Resident #1 was not crying but Resident #1 flinched and looked at the AP in shock as if Resident #1 knew something happened to her. CNA B described the incident as an uncomfortable situation. CNA B revealed she told the AP to leave. CNA B stated she told Resident #1 that she would be okay. CNA B revealed the roommate was present in the room, but the curtain was closed. CNA B further revealed Resident #1's roommate was bedbound and had to have heard these thumps, but the roommate was observed sleeping. The administrator revealed in an email correspondence, dated [DATE] at 01:32 PM, Resident #1 never received psych services in the months of November and [DATE], after this incident of alleged abuse. During an interview on [DATE] at 02:11 PM, the Administrator revealed she educated all the staff the next 2 days after the incident, and she knew she educated everyone even though the [DATE] in-service was missing signatures. During an interview on [DATE] at 05:21 PM, the [Medical Doctor] revealed he was contacted when he heard about this incident of abuse. He did not contact or order psych services because he did not think the resident would need or benefit from these services because resident was nonverbal and was not responding to other care. When told about the MDS assessment findings of Resident #1 exhibiting behaviors of rejection of care after this incident of abuse, the [Medical Doctor] revealed he did not know about Resident #1 having new behaviors of rejection of care and would have wanted to know this. He further revealed if he was made aware of this, he would assess the situation, and prodder psychiatric services accordingly. Record Review of HA A's personnel file revealed her employee misconduct registry was clean. Record review of the [DATE] in-service titled Abuse/Neglect/Misappropriation/Reporting reflected 39 out of 104 (37.5%) did not sign that they received this training. Out of the staff members present during this shift 6 out of 12 (50%) did not sign this training. (At the time of this template the Administrator was verifying names.) Record review of facility's policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised [DATE], 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. 8. Investigate and report any allegations within timeframes required by federal requirements. Record review of the facility's policy, revised [DATE], titled Abuse and Neglect-Clinical Protocol reflected: The physician will order measures required to address the consequences of an abuse situation, such as psychological evaluation . Record review of the Texas HHSC Long-Term Care Regulatory Provider Letter, issues [DATE], reflected for an abuse incident the facility was to report immediately, but not later than two hours after the incident occurs or is suspected. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 03:52 PM. The Administrator was notified. The following Plan of Removal submitted by the facility was accepted on [DATE] at 05:02 PM. Date: [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes: On [DATE], an abbreviated survey was initiated at [Facility]. On [DATE] at 03:52PM, A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F600 The facility failed to keep Resident #1 free from abuse and neglect by employees not reporting abuse to the abuse coordinator when abuse occurred. This administrator did not report abuse within the two-hour requirement and in-services were not 100% signed. Identify residents who could be affected: All Residents have the potential to be affected. The Facility census on [DATE] was 88. Identify responsible staff/ what action taken: . DON, ADONS and MDS nurses will conduct 100% skin assessments to all residents by [DATE]. Skin assessments completed. Social Worker, MDS nurses, Activities Director, Admission Coordinator and Human Resources Director will conduct resident questionnaires to all cognitive residents by [DATE]. In-Service conducted: On [DATE], abuse, neglect and notification of abuse and neglect to the abuse coordinator to all current team members prior to their shift by [DATE]. The in-services indicate verbal notification to the abuse coordinator. The in-service specifically states allegations need to be verbally and immediate, which includes day, nights, weekends, holidays, vacation, and the abuse coordinator is available ,d+[DATE]. If the abuse coordinator is not available, staff are directed to call the DON. This administrator and DON will be responsible for ensuring staff receive in-service. A current staff roster is printed, and staff will sign off next to their name. Any PRN or Agency staff will be trained in abuse, neglect and notification of Abuse and Neglect prior to their shift and they will sign next to their name or add their name and sign. Implementation of Changes Conduct daily rounds prior to morning meetings, which includes speaking to residents regarding any of their concerns. For non-verbal residents, residents will be monitored for changes in demeanor, changes to their baseline and communicate with family for any noticeable changes. The daily rounds will begin [DATE] (Monday through Friday), manager on duty will round on the weekends and will continue with no end date. Department managers will complete rounds in their assigned resident rooms to rule out abuse and neglect. If any concerns arise it will be addressed immediately per HHSC guidelines. The manager on duty will round on the weekends and will notify this administrator of any concerns of abuse and neglect. The administrator will follow HHSC guidelines. The round of excellence sheet will be completed by department managers and the manager on duty. The administrator will request to be part of resident council to be made aware of any current concerns. If this administrator is not approved to join resident council then the activity director will document any concerns on a grievance form and will provide document to this administrator. Abuse, neglect and reporting protocol to be given during orientation process. This will confirm all staff members will be aware of the Abuse, Neglect and notification of Abuse and Neglect protocol. Any staff member who is an alleged perpetrator for any ANE allegation will be suspended pending investigation and will be advised to leave the premises at that time. The residents who are identified as experiencing abuse or neglect will be referred to psych services by the social worker. Any potential concern of weekly skin observations will be reviewed in morning meetings to ensure residents are not at risk of any type of abuse. Monitoring Administrator/DON/Designee will monitor this process. Any negative outcomes will be reported to QAPI Committee. Involvement of Medical Director The [Medical Director] was notified about the immediate Jeopardy on [DATE]. Involvement of QA Any issues will be brought to the QA meeting. This plan will be added to QAPI. Who is responsible for implementation of process? [Administrator] The POR verification was accepted on [DATE] at 09:15 PM as follows: Record review reflected the Facility Census on [DATE] was 88 residents. Record review reflected daily care round forms were completed for 88 of 88 residents. Record review reflected skin assessments were completed for 86 of 88 residents (one resident declined to be assessed; one resident was in the hospital) on [DATE]. Record review of resident questionnaires reflected 28 of 28 cognitive residents received interviews by staff [DATE]. In an interview on [DATE] at 7:30 PM, the Regional RN stated all cognitive residents received safe surveys interviews, with no findings that required follow-up. In-Service conducted: Record review reflected In-Services on Abuse/Neglect, Reporting time constraints, and protocols to protect to residents, completed on [DATE], included all staff, on duty, with a plan to in-service all PRN and staff on leave prior to working with any residents. Interviews conducted between [DATE] and [DATE], with staff who worked ,d+[DATE]p, ,d+[DATE]p, ,d+[DATE]a, along with ,d+[DATE] shift, and ,d+[DATE]pm shift; 28 interdisciplinary staff (RNs, LVNs, CNAs, MAs, PTA, Dietary Aides, Social Services/Activity Aides, Maintenance, Administrative). [The facility currently has 105 staff]. Interviews indicated in-servicing topics included Abuse/Neglect that included definitions and examples; immediate interventions; reporting time constraints; and reporting entity requirements. Record review reflected In-Services on Abuse/Neglect, Reporting time constraints, protocols to protect to residents, completed on [DATE] included all agency staff on duty, with a plan to in-service all future agency staff prior to working with residents. Implementation of Changes Record review reflected daily care round forms were completed for 88 of 88 residents on [DATE]. Record review reflected daily care round forms were completed for 90 of 90 (current census) residents on [DATE]. Record review reflect Morning Meeting- Stand Up process template now includes agenda item to include discussion of daily care rounds, which are completed prior to the Morning Meeting. Record review of email dated [DATE] reflected the ADM requested invitation to future resident council meetings; with the caveat that if invitation request is declined, the activities director will document any concerns and provide the resulting grievance form to the administrator. Record review of the Facility Orientation Outline reflected a checklist that included: policy manual review of resident rights and resident abuse. Record review of facility Orientation In Service document with the topic of Abuse/Neglect, included definitions, examples, and reporting guidelines. Record review of sample personnel file revealed blank forms that required new employee signatures related to receipt and adherence to employee handbook with details related to resident rights including abuse and neglect prohibition. Record review of sample personnel file revealed new employee signature requirements for Senate [NAME] 9 Acknowledgement related to staff liabilities and penalties related to resident rights impingement specific to abuse/neglect. Record review of facility Orientation In-Service document with the topic of Abuse/Neglect, included statement that Nurses were to direct the alleged perpetrator to clock out and leave the premises. In an interview on [DATE] at 6:28 PM, the Regional RN stated that residents experiencing abuse or neglect would be identified in the Daily Care Rounds. The Regional RN stated this information was included in the new Morning Meeting process template. The SW would then make the psychological services referrals as necessary. Record review of Clinical Alerts Skin Observation reflected 13 observations discussed in morning meeting on [DATE]. Record review of Clinical Alerts Skin Observation reflected 13 observations discussed in morning meeting on [DATE]. Monitoring In an interview on [DATE] at 6:36 PM, the Regional RN stated that any negative outcomes would be identified in the Daily Care Rounds. The Regional RN stated this information was included in the new Morning Meeting process template. The ADM/DON/Designee would then update the pending QAPI agenda template at each instance. In an interview on [DATE] at 6:40 PM, the Regional RN stated that the MD was notified via telephone on [DATE] at approximately 6:00 PM regarding the Immediate Jeopardy being called on [DATE]. In an interview on [DATE] at 6:40 PM, the Regional RN stated that any issues would be identified in the Daily Care Rounds. The Regional RN stated this information was included in the new Morning Meeting process template. The ADM/DON/Designee would then update the pending QAPI agenda template at each instance for follow up at the next regularly scheduled QAPI meeting. In an interview on [DATE] at 6:46 PM, the Regional RN stated that the ADM of the facility is responsible for implementation of process. On [DATE] at 03:52 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed prior to exit on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 (Resident #3) reviewed for quality of care. Resident #3 had signs and symptoms of a stroke and was not sent to the hospital for evaluation for approximately 6 hours after a change of condition was reported. The non-compliance was identified as past non-compliance. The immediate jeopardy began on 2/23/2024 and ended on 2/28/2024. The facility corrected the non-compliance before the investigation began. This deficient practice placed all residents at risk of experiencing a delay in treatment that could have resulted in harm or potentially death. The findings included: Record review of the admission record revealed Resident #3 was a [AGE] year-old male, originally admitted on [DATE]. Diagnosis information revealed positive for gastrostomy status with an onset date of 3/04/2024 [date of return from hospitalization after stroke like symptoms reported on 2/23/2024]. Record review of comprehensive MDS assessment dated [DATE], revealed Resident #3 had a BIMS summary score of 15, indicative of intact cognition. Resident #3 had active diagnoses that included heart failure, hypertension [high blood pressure], and high cholesterol [diagnoses indicative of higher risk for stroke or heart attack]. Record review of an email from COTA K dated 2/26/2024 at 12:26 PM, reflected that COTA K observed on 2/23/2024 at approximately 12:50 PM, Resident #3 was unable to use his left side as per his normal. COTA K informed RN M, who stated the resident was fine. COTA K and PTA L returned to Resident #3 at approximately 2:45 PM, and observed continued left sided weakness, incontinence of bowel and bladder, and reported findings to the DOR . Record review of an email from PTA L dated 2/23/2024 at 8:09 PM, revealed PTA L observed Resident #3 on 2/23/2024 after COTA K had informed PTA L of Resident #3's condition some time shortly after 12:00 PM. PTA L observed Resident #3 being unable to move his left arm and slurring speech. Further record review reflected that PTA L informed RN M of the resident's condition. When PTA L informed RN M of his findings, PTA L was told RN M had assessed Resident #3 and he seemed fine. PTA L returned to Resident #3's room around 3:00 PM, to provide incontinence care, and noticed Resident #3 was more pronounced in being unable to effectively use his left arm, and his voice was weaker than his normal self. PTA L reported the findings to the DOR. Record review of a typed note signed by the DOR revealed the DOR informed RN N on 2/23/2024 at approximately 3:30 PM of the changes in Resident #3 as slurred speech, having to repeat sentences multiple times, unable to lift LUE [left upper extremity], unable to grasp or make a fist with LUE, and overall fatigue. Record review of Nurses Note, authored by RN N on 2/23/2024 at 6:33 PM, reflected that Resident #3 was leaving via contracted service company for transport to ER for further evaluation. The hospital record revealed Resident #3 had an MRI done at the hospital, which found a stroke. The resident was also assessed for dysphagia that resulted in the placement of a gastrostomy tube for hydration, nutrition, and medications. Record review of the Care Plan revealed, Resident #3 .wears a Life Vest [wearable defibrillator for those at risk of sudden cardiac arrest], with a date initiated of 3/05/2024 [day after Resident #3 returned from hospital after stroke like symptoms on 2/23/2024]; additional problem area, .new feeding tube . with a date initiated 3/04/2024. In an observation on 5/20/2024 at 12:46 PM, Resident #3 was laying supine in bed, with the head of bed elevated approximately 60 degrees. Resident #3 had the over head lights off, but the television was playing softly. Resident #3 had his eyes closed but opened them when spoken to. Resident #3 declined to be interviewed stating that he was tired right now. In an interview on 5/24/2024 at 2:35 PM, RN M stated she was not very familiar with any of the residents at the time of the incident with Resident #3 (2/23/2024), as she had only worked at the facility for about a month. RN M stated she was informed by a member of the therapy staff that Resident #3 was not acting his usual self, by declining to attend his therapy session, and had complaints of shoulder pain. RN M stated this occurred just before or during lunch that day [approximately 11:30 AM-12:00 PM]. RN M stated she assessed the resident and recalled that his blood sugar was 77, and therefore he did not require a sliding scale dose of insulin before he could eat the lunch tray that had been delivered. RN M stated that Resident #3 did complain of his shoulder bothering him, and she administered Tylenol in response. RN M stated she felt that many other staff did not like Resident #3 due to him sometimes being mean spirited, and staff avoided taking the time to work with him. RN M stated she felt she had a good rapport with Resident #3, as they had similar back grounds and were jovial with each other in their conversations. RN M stated she did not document the findings of her informal assessment of him, because she, just did not see anything wrong with him. RN M stated at shift change the oncoming nurse (RN N) was running late and was flustered and out of breath when she arrived. RN M stated she reported to RN N about the new admissions they had received, the condition of another resident who had fallen earlier in the day. RN M stated that the unit was notorious for having a lot of stuff going on. RN M explained that the unit where this incident occurred was typically very busy. RN M stated that when the incident occurred the ADON, and the DON were both out. RN M stated no staff ever revisited their concerns that day about Resident #3 to her. RN M stated she observed him throughout the remaining afternoon before the end of her shift. RN M stated she never did see any thing that would have said possible stroke symptoms. RN M stated that looking back on the situation, that she really wished those staff that knew him better than she had at the time, had escalated the issue with her. RN M stated she was devastated by the whole thing. RN M stated that if she had run in to him as a stranger on the street, she would not have thought anything was wrong with Resident #3. RN M stated she was surprised and saddened to hear that Resident #3 had a stroke that day . In an interview on 5/24/2024 at 2:56 PM, NP O stated he was notified just after 3:00 PM by RN N, regarding a change in condition for Resident #3 with stroke like symptoms. NP O stated he was informed by RN N that it had been an ongoing concern since around lunch time. NP O stated he gave orders to send Resident #3 to the ER for further evaluation and treatment. NP O stated he felt that any resident with new onset stroke like symptoms should be sent immediately to the ER via 911/EMS before any further decline. In an interview on 5/24/2024 at 3:15 PM, RN N stated she did not receive any concerning information from RN M regarding Resident #3 during shift change report the day of the incident (2/23/2024). RN N stated she was not told that staff had raised concerns earlier in the day, or that Tylenol had been administered to Resident #3 for shoulder pain by RN M. RN N stated that the DOR came to her at about 3:15 PM, requesting an assessment of Resident #3 due to changes in his condition. RN N stated she was told the changes had been on-going since before lunch. RN N stated she recognized Resident #3 was not his normal self, he appeared fatigued, had some slurred speech, and one-sided weakness. RN N stated the most concerning symptom was that he was really slow to form words and really slow to respond to questions. RN N immediately notified the physician services group and received orders to send Resident #3 to the emergency room . RN N contacted the facility's contracted transportation and Resident #3 was picked up around 6:30 PM to be taken to the emergency room . [approximately 3 hours after she first assessed him for change in condition, and approximately 6 hours after the changes were first reported .] RN N stated she did not send him via EMS because her understanding was that the symptoms had been on-going since early morning, and by the time she assessed Resident #3, it would have been outside the window for the typical treatment associated with stroke. In an interview on 5/24/2024 at 3:32 PM, the DOR stated that two of her staff, COTA K and PTA L reported to her at approximately 2:45 PM on 2/23/2024, that they had concerns regarding Resident #3. The DOR assessed him and noted, slurred speech, unable to reach across his body. The DOR stated Resident #3 reported a headache to her. The DOR stated she requested the oncoming nurse assess Resident #3 right away . In an interview on 5/24/2024 at 3:43 PM, PTA L stated that his co-worker [COTA K] reported to him that she did not like the response the nurse gave when she reported a possible change in condition in Resident #3. PTA L stated he assessed Resident #3 before lunch on 2/23/2024 and then again near shift change [approximately 3:00 PM]. PTA L stated he observed the same changes his co-worker [COTA K] reported: different from his normal self, something off. PTA L stated that closer to shift change, around 2:45 PM, he took the issue to his DOR to escalate the findings. PTA L stated there were no significant changes from what he saw in Resident #3 before lunch and then again near shift change at 2:45 PM. PTA L stated Resident #3 was not any better, but not really any worse either. In an interview on 5/24/2024 at 5:15 PM, the DON stated her expectation was that assessments [NAME] documented as soon as completed, change of conditions were reported to the primary care provider, and that when the primary care provider issued new orders to send a resident with stroke like symptoms to the emergency room for further evaluation and treatment, that was done so via 911 and EMS transportation. The DON stated that in-servicing was initiated immediately in the wake of this event that included the signs and symptoms of a stroke, documenting, and reporting change of conditions. The DON stated Nurse M was suspended and ultimately terminated from employment at the facility upon completion of the internal investigation . The DON stated Resident #3 returned from the hospital with a PEG tube and was in therapy to see if he could return to intake by mouth. The DON stated Resident #3 was not as talkative now after the stroke as he used to be. Record review of In-Service topic, 911 Transfers, dated 2/23/2024, reflected that medical emergencies are any acute onset of a life-threating medical problems that cannot be managed in house. Further, signs and symptoms of a stroke include facial drooping, arm weakness, and speech difficulty. Record review of In-Service topic, Change in Condition, undated, reflected includes major decline, unknown injuries, and change in mental status. Anything out of the ordinary with the resident's baseline. Record review of Change in Residents Condition or Status policy, revised February 2021, reflected policy statement of promptly notifies the resident, attending physician, resident representative of changes in the residents medical or mental condition or status. Further review reflected a significant change in the residents physical .condition is a major decline .that a.) will not normally resolve itself without intervention; the nurse will record in the resident's medical record information relative to changes in the residents' condition or status. Record review of in-service topic, Stroke Signs and Symptoms, dated 2/23/2024, listed as: numbness or weakness in the face, arm, or leg, especially on one side of the body. Confusion or trouble speaking or understanding speech and severe headache with no known cause. Record review of in-service topic, Change in Condition Reporting, dated 2/23/2024, reflected change of conditions needs to be reported as soon as change is notice. If you report a change of condition or status to a charge nurse and nothing is done, the individual reporting needs to report the change to the DON or Administrator. The facility required immediate action to ensure that changes in condition and emergencies were recognized as such and an appropriate response was initiated. The facility initiated the following training with 100% compliance: Topic - 911 Transfers; target audience: RN and LVNs; started 2/23/2024; no dates next to signatures. Topic - Abuse/Neglect; target audience: all team members; started 2/23/2024; last signature dated 2/26/2024. Topic - Change of Condition; target audience: all team members; started 2/23/2024; last signature dated 2/26/2024. Topic - Change in Conditions: Stroke signs & symptoms; target audience: nursing; started 2/23/2024; no dates next to signatures. Topic - Change of Condition Reporting; target audience: all team members; started 2/23/2024; last signature dated 2/28/2024. Interviews included 20 staff members, across all shifts, confirming they received and understood the topics during the in-servicing (LVNs, RNs, CNAs, SW, PTAs, DOR, ADON/Infection Preventionist, Dietary Mgr, and [NAME] ).

Based on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #1), in that: The facility failed to ensure Resident #1's injury on her right knee was identified and assessed in a timely manner. This failure could place residents at risk for not a decline in physical and psychosocial wellbeing. Findings included: Record review of Resident #1's face sheet dated 05/24/2023 revealed an [AGE] year-old female initially admitted on [DATE], readmitted on [DATE], and discharged on [DATE]. Her diagnoses included fracture of left femur (break of the bone that runs from the hip to the knee), fracture of the shaft of the left arm humerus (break in the center section of the bone that runs from the shoulder to the elbow), and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's Significant Change MDS assessment dated [DATE] revealed the resident had a BIMS score of 00 (out of 15) indicating severely impaired cognition, required extensive assistance to total dependance with one-to-two-person physical assist for activities of daily living including toilet use and bathing, and had a history of one fall with a major injury during her admission. Record review of Resident #1's care plan, latest revision date 05/09/2023, revealed a problem of Acute Care Plan: Actual Fall, date initiated 05/09/2023, with goal of no major injuries from a fall over the next 90 days. Interventions included Monitor for changes in condition, document and report to MD/NP: localized swelling, c/o pain, increased lethargy, abnormal neuro vital signs, change in functional ability such as endurance, transfers, ambulation, etc. Further review revealed a problem of resident is on anticoagulant therapy r/t status post fracture to left hip and arm, date initiated 04/04/2023, with an intervention of Daily skin inspection. Report abnormalities to the nurse. Record review of Resident #1's Task: Monitor- Skin Observation dated 04/26/2023 to 05/22/2023 revealed on 05/10/2023 at 9:58 p.m. red area and discoloration were selected with no selected for if this was a new skin condition. The remainder of entries revealed none of the above observed or not applicable selected and response not required. Record review of Resident #1's Nursing MAR dated 05/01/2023 to 05/31/2023 revealed a scheduled weekly skin assessment for every Tuesday evening. Further review indicated a skin assessment was completed on 05/02/2023, 05/09/2023, and 05/16/2023. Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) dated 05/11/2023 at 8:38 a.m. revealed skin issue at right thigh (front). Record review of Resident #1's Nurse's note on 05/11/2023 at 6:24 p.m. revealed Resident has witnessed fall in lobby while attempting to stand. Lost balance and went to bottom. Witnesses report she did not strike her head . No signs of distress or pain however stated her 'hip hurt.' Resident has past injury to left hip from previous fall. PCP made aware and xray ordered to rule out injury. Record review of Resident #1's Nurse's note on 05/12/2023 at 11:06 a.m. revealed Reported left hip xray results to [resident #1's PCP], no new orders. Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) dated 05/11/2023 at 6:26 p.m. revealed no skin issues. Record review of Resident #1's Nurse's note on 05/12/2023 at 1:49 a.m. revealed .Resident moan and will say NO NO NO when repositioning her, Bruising remain slight visible but fading . Record review of Resident #1's Nurse's note dated 05/12/2023 at 11:04 a.m. revealed Pharmacy recommendation to review use of Celebrex, [PCP] reviewed and stated to continue due to 'patient with chronic pain.' Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) dated 05/12/2023 at 01:13 p.m. revealed no skin issues. Record review of Resident #1's progress notes revealed no notes regarding pain, bruising, or falls after 05/14/2023 or before 05/22/2023. Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) revealed no documentation for the week of 05/15/2023. Record review of Task: ADL- Bathing dated 04/29/2023 to 05/22/2023 revealed Resident #1 was bathed on 05/18/2023 at 9:07 p.m. with no selected for resident having something on their skin requiring a protective dressing or nurse notified before or after for other skin issue. Bathing task documentation for 05/16/2023 and 5/20/2023 revealed question selections for bathing self-performance and support provided as not applicable and question selections for protective dressing and skin issues as response not required. Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) dated 05/22/2023 at 12:35 p.m. revealed skin issue at right thigh (front) as surgical incision, right knee (front) as bruising, left shoulder (rear) as bruising, left forearm as bruising, and right forearm as bruising. Record review of Resident #1 Nurse's note dated 05/22/2023 at 1:45 p.m. revealed nurse's note text: Noted while doing weekly skin check resident had bruising being monitored from previous falls. Noted discoloration purple and yellow to right knee and lower thigh this nurse had not see before. Area to knee is swollen slightly and warm to touch . Pending STAT x-ray to the area. Record review of Resident #1's Nurse's note dated 05/22/2023 at 1:58 p.m. revealed Notified RP he stated he saw that on Saturday but did not mention it to anyone. Record review of Resident #1's x-ray fracture evaluation dated 05/22/2023 revealed findings of an acute transverse proximal tibial fracture [break straight across the upper part of the larger leg bone below the knee] as well as a fracture to the fibular neck [break in the upper portion of the smaller leg bone below the knee] .Osteopenic bones [bones are weaker than normal] . Record review of Resident #1's Nurse's note dated 05/22/2023 at 4:58 p.m. revealed proximal tibia/fibula fractures [break in the upper part of the leg bones below the knee] with mild displacement. Mild soft tissue swelling. Results from right knee x-ray. Interview with Resident #1's RP on 05/24/2023 at 3:58 p.m. revealed a concern that Resident #1's bruise was observed by himself on Saturday, 05/20/2023, but was not identified by the facility until Monday, 05/22/2023. He revealed that he did not report the bruise to facility staff. He revealed a concern that there was not a corresponding report from the facility of a fall or incident since 05/11/2023 and the possibility of Resident #1 having had an untreated fracture for 11 days. He revealed a nurse at the hospital stated the injury appeared 5-7 days old with the bruise going yellow and changing color. Interview with Resident #1's NP on 05/24/2023 at 4:59 p.m. revealed Resident #1 had multiple falls and her bruises took time to fade. The NP revealed Resident #1 took Aspirin which may delay bruising from fading. The NP revealed Resident #1's scheduled pain medications may have masked the pain. The NP revealed she was unaware of Resident #1 having a fall or injury occurring after Resident #1's fall on 05/11/2023 and before the knee bruise was identified on 05/22/2023. The NP revealed she did not know when or the circumstances that resulted in the knee fractures. Interview with Resident #1's PCP on 05/25/2023 at 09:39 a.m. revealed Resident #1 was on a blood thinner which would cause a bruise to form within a few hours after an injury. The PCP revealed he was not notified of Resident #1 having a fall or injury occurring after Resident #1's fall on 05/11/2023 and before the knee bruise was identified on 05/22/2023. The PCP revealed he did not know when or the circumstances that resulted in the knee fractures. Interview with LVN A on 05/25/2023 at 10:30 a.m. revealed there should have been a skin assessment completed for the week of 05/15/2023 and either the skin assessment or a progress note should have been completed if the resident refused. LVN A revealed a change in condition note should have been entered into the EMR if anything was found to be unusual or new for a resident. Interview with the DON on 05/25/2023 at 11:51 a.m. revealed if scheduled assessments were missed or late the EMR would trigger an alert and the ADONs monitor for those triggers. The DON revealed that she assumed the skin assessment was triggered for Resident #1 since the ADON completed the skin assessment on 05/22/2023. The DON revealed showers are scheduled for residents three times per week. The DON revealed a part of the CNA documentation for showers are notations for skin changes. The DON revealed staff had not reported Resident #1 indicating any unusual pain prior to the finding of the bruise and subsequent fractures. The DON revealed she would interpret a bruise described as purple and yellow as having been several days old. The DON revealed an injury not being identified for several days would result in a lot of consequences: including injury, delay of treatment, an even death.

Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse for 3 of 5 residents (Residents #4, #2 and #5) reviewed for abuse. The facility failed to ensure Resident #4 was subjected to abuse/neglect after making a grievance regarding CNA #1's care. CNA #1 made rude and offensive comments and refused to provide care for Resident #4. The facility failed to ensure Resident #2 was not feeling threatened and verbally abused by CNA #1 to the point where she would ask for assistance from other staff to avoid contact with CNA #1. The facility failed to ensure Resident #5 was able to feel comfortable requesting assistanace from staff. Resident #5 dreaded when CNA #1 was assigned to assist her due to CNA #1 attitude. Resident #5 would go with her needs unmet rather than have CNA #1 assist her. These failures affected 3 residents and placed them at risk of abuse, harm, pain, mental anguish and or emotional distress. Findings included: Intake # 8 Resident #4 Record review of Resident #4's Face Sheet dated 4/18/19 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's Significant Change MDS dated [DATE] revealed a BIMS score of 15 indicating the resident had intact cognition. She was coded as needing limited assistance of one staff for walking, dressing, and personal hygiene. The resident was coded as needing extensive assistance of one staff for bed mobility and transfers. Cancer was checked as an active diagnoses. Record review of Resident #4's Care Plan dated 4/18/19 revealed Resident has a behavior problem r/t (left blank). Interventions included if reasonable discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Caregivers to provide opportunity for positive interaction, attention. Stop and talk to him/her as passing by. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Further review revealed the resident required limited assistance of one staff for dressing. During an interview on 4/18/19 at 9:20 am, Resident #4 said the treatment was good up until recently. She said she told the Administrator about an incident with CNA #1, and the aide was talked to. After that, CNA #1 had been mean and rude to her. She said CNA #1 used to be nice to her when she was in a different room, but ever since Monday (4/15/19) after the incident, her attitude changed. She said CNA #1 made remarks such as You don't have to look at me, I know what I'm doing and I don't know why you're here you need to go home. She said it made her feel sad when she was treated that way and began crying hysterically. She said she was supposed to be ready yesterday for her 4 pm [MEDICAL CONDITION] appointment and CNA #1 told her the next shift would change her. Her family had to get her dressed and they were really upset. She said everyone knew about the incident including LVN #1 and the people in the office. She said she told her family member I don't want to be here and the family member reported it to administration. During an interview on 4/18/19 at 9:25 am, LVN #1 said yesterday CNA #1's shift was over, and she left the building. An activities personnel alerted him that Resident #4 was crying so he went into her room to see what was wrong. Resident #4 told him she needed to be changed and CNA #1 told her the next shift would have to do it. He said, I don't think she gets along with CNA #1 well. When LVN #1 was asked why Resident #4 did not get along well with CNA #1 he said, I'm not sure. He then said basically Resident #4 was concerned with the aspect that CNA #1 did not change her knowing she had a doctor's appointment. He said, You don't tell a resident you have to wait until the next shift without letting someone else know. He said She was in tears and very upset. She still is kind of upset today which is why he kept checking on her to let her know there was protection. When asked if not changing a resident was neglectful he said Resident #4 had only been wet 15-20 minutes. When asked how he knew that he said, I'm not sure. He said neglect would be if a resident was saturated wet with a brown ring on the sheet. When asked the different types of abuse he said physical and verbal. He said verbal included threatening and foul language. He said he was unaware of any inappropriate remarks made by CNA #1 to Resident #4 or any other residents, but if he was aware he would have reported the allegation to the Administrator and DON. During an interview on 4/18/19 at 9:30 am, the Administrator identified herself as the Abuse Prohibition Coordinator. She said she was unaware of any problems between CNA #1 and Resident #4. A few moments later the DON walked in and introduced herself. She said LVN #2 called her Monday night and informed her of an incident between Resident #4 and CNA #1 and she then called the Administrator and told her Resident #4 was upset with the aide. She said Resident #4 had a doctor's appointment and felt she was being rushed by CNA #1. She also said CNA #1 made a comment that Resident #4 was getting too fat and eating too much. The DON said Resident #4 was thinner when she was admitted and asked her Could she have been joking? She said she spoke with CNA #1 and told her she needed to watch what she said. She said she was just informed by LVN #1 of the incident yesterday when Resident #4 pushed her call button at 2:50 pm to be changed and CNA #1 informed her she had to wait until the next shift. She said shift change was at 3:00 pm. She said LVN #1 just informed her Resident #4 was crying and I don't want her upset/crying so I swapped CNAs and got her somebody that will make her comfortable. She said the proper protocol would have been to change Resident #4 right then. During an interview on 4/18/19 at 10:05 am, CNA #1 said she had between 11-20 residents on different days and felt like walking out sometimes because she was frustrated. She said there had been no allegations of abuse directed at her. She said, when I'm accused of something, I always take a staff member in there. She said Resident #4 did complain about her and she was talked to about it but, I don't treat her any different. My supervisor told me to bring somebody in there whenever she went into her room. She asked, If the situation was a big deal why wouldn't they remove me from Resident #4's room? When asked if she made a remark about Resident #4 not needing to be in the facility she said, It was said yesterday but it wasn't me who said it. She said it was another staff member talking in the hallway. When asked if she called Resident #4 fat she said she only asked how much she weighed. She denied making any inappropriate remarks. She said, During rounds on 4/17/19 Resident #4 said she was dry, but when she got her bags to go she said she was wet. She said she did tell Resident #4 she would have to be changed on the next shift. She said, I can't change her every time she's wet I just have to do my round. She said the oncoming aide was with her when she rounded and knew she needed to be changed. She said there have been numerous times where resident beds were soaked with urine due to the night shift not changing them. She said she had to change 4-5 beds before on several occasions. She said, It's neglect too when we report to the nurses that the whole bed is wet, and they do nothing about it. She said the DON told her don't say too much in there refering to the interview with the state surveyor. Record review of In-service dated 4/17/19 revealed training for CNA #1 only. The in-service said Speaking to residents with kindness and respect. Professional verbal conversations with residents at all times. Be cognizant not to hurt feelings. It was signed by CNA #1. During a follow-up interview on 4/18/19 at 12:05 pm, the Administrator said she spoke with Resident #4 and had a lengthy conversation within the past hour. She said the first incident was when CNA #1 was rushing to get her dressed for a doctor's appointment. The Administrator said CNA #1 was trying to put on the resident's orthotic leg and was doing so incorrectly causing Resident #4 pain. She said after two other staff members came in they were finally able to put it on. When asked if the CNAs were provided training regarding orthotics she replied, Resident #4 knows how to put it on herself and can tell you how to put it on. She said LVN #2 reached out to the DON and said, I just want you to know CNA #1 was rushing Resident #4. The DON then called the Administrator Monday night and told the DON that if she alleged any abuse to call her back, which never happened. When asked if calling a resident fat was appropriate she said, I think it depends on how it's said and the resident it was said to. The Administrator said, You see it as a professional setting we're here every day and some of these aides are viewed as family. She said it was not unusual for Resident #4 to cry and she got tearful several times during the interview she just conducted. She said when she asked Resident #4 if she felt CNA #1 was being rude she said yes and that it hurt her feelings. Resident #4 pushed the call light at 2:50 pm requesting that she be put in street clothes for her 4:00 pm appointment on 4/1719 and CNA #1 told her I'm already leaving the next shift will change you. She asked Resident #4 if she felt CNA #1 was intentionally being ugly or playing to which Resident #4 said she did not take it as a joke During a confidential interview on 4/18/19 with a staff member, she said she heard from Resident #2, Resident #5, and Resident #4 that CNA #1 was quite mean. She said, I don't know what's going on with CNA #1, but all of the residents aren't going to lie on one person. She said CNA #1 had a bully mentality and spoke rough. She said CNA #1 was one way in the hallways but another person behind closed doors. During a follow-up interview on 4/18/19 at 12:40 pm, when Resident #4 was asked if she was comfortable working with CNA #1, Resident #4 said I don't want to work with her. She said CNA #1 told her You're getting heavy for me and going to make me hurt my back. She said she always talks ugly when it was just the two of them behind closed doors. During the interview CNA #1 walked up alone and said, Oh I was going to change her. Resident #4 said when staff came to talk to her she told them she did not want to be in the facility anymore. During an observation on 4/18/19 at 12:50 pm, CNA #1 was observed walking out of Resident #4's room with an unidentified worker. During a follow-up interview on 4/18/19 at 4:40 pm, the DON said she informed CNA #1 if she was going in Resident #4's room to have a second person go with her. During a returned phone call interview on 4/22/19 at 9:30 am Resident #4's family member said about 2 weeks ago Resident #4 told her CNA #1 was verbally and physically abusive. She said Resident #4 told her CNA #1 kept calling her fat and told her she did not belong in the facility and to stop pretending to be sick. She said CNA #1 was attempting to put on Resident #4's orthotic leg and Resident #4 told CNA #1 how to do it. She said CNA #1 got upset and threw the orthotic leg, which had metal on it, and it hit Resident #4's other leg which was painful. When the allegation was brought to LVN #2, the family member was instructed to inform the Administrator. She said she had not had time to inform the Administrator due to several ongoing personal problems. On 4/22/19 at 9:50 am, an interview with LVN #2 was attempted by phone. LVN #2 did not answer or return the call. Resident #2 Record review of Resident #2's Face Sheet dated 4/18/19 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed a BIMS score of 14 indicating intact cognition. The MDS revealed the resident required total assistance of two staff for bathing, Record review of Resident #2's care plan date revised on 3/1/2019 revealed the resident required one stafff extensive assistance with showering. During an interview on 4/18/19 at 2:45pm, Resident #2 was asked if there were any CNAs that she had issues with Resident #2 said CNA #1. She said CNA #1 was very rude and carried her feelings with her. She said if she did or said something CNA #1 did not like she got real ugly. She said she was very mouthy and made nasty remarks like I'll never send my parents to a place like this. She said whenever CNA #1 was assigned to her she had to have another staff member assist her with showers. When asked if she had reported CNA #1 to administration she said, They know. Their response was Well she does her work to which Resident #2 responded, but she's not nice to us. She said CNA #1 would make remarks to her roommate like Your side of the room is so pretty, opposite of the one next to you. Resident #2 said around Christmas time CNA #1 said, Me and my mom are going to cook and I'm going bring you and my friends a lot of food. She said CNA #1 made her feel uncomfortable and threatened. She said whenever CNA #1 was to her she had to be very careful what she said and did. She said she told administration she did not want CNA #1 working with her but she continued to care for her. Resident #2 said whenever CNA #1 provided her showers she was accompanied by another staff member. Resident #5 Record review of Resident #5's Face Sheet dated 4/18/19 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Further review revealed she required extensive assistance of one staff for transfers and extensive assistance of two staff for bed mobility, dressing, and toilet use. Bathing was coded as physical help limited to transfer only with the assistance of one staff member. She was coded as total dependence of one staff member for personal hygiene. She was coded as not walking in the room, corridor, or locomotion off unit. Record review of Resident #5's care plan revised on 3/7/2019 concerning the problem of the resident had a tendency to refuse ADL care the interventions documented Resident #5 specifically informed the ADON that If I don't want the person assigned to my room to do my bath I will refuse. Listed on the same problem was the intervention to promote comfort with ADLs, and maintain consistancy with caregivers and routine. Interview on 4/18/19 at 3:00 pm, Resident #5 said CNA #1 was rude, but she had not mentioned it because it would cause a bigger strain on scheduling. She said she called CNA #1 irritating. She said she felt dread whenever she was assigned to her as her aide and noticed she did not use her call light as often. Resident #5 said she asked other staff members (medication aides and nurses) for what she needed whenever they entered her room. She said CNA #1 was obnoxious and hard to deal with and has that type of reputation and all the staff were aware of CNA #1. Continued interview with Resident #5 on 4/18/19 at 3:20 pm, when asked if the concerns regarding CNA #1 were brought to the Administrator's attention Resident #5 said if she did tell the Administrator, the Administrator would suspend CNA #1 and start an investigation which would then make the staff fewer. During an interview on 4/18/19 at 4:20 pm, the Social Worker said she had not had any complaints regarding CNA #1 recently. The only complaint she had was from a former resident who did not like her personality. She said she had not worked with her much but she does her job and took care of the residents. Record review of the grievance log on 4/18/19 revealed no documented grievances for the above incidents. Record review of Facility's undated Abuse and Neglect Policy revealed Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, unreasonable confinement, intimidation, neglect, psychological harm related to unauthorized photos or willful infliction of injury or punishment with resulting physical or emotional harm, mental anguish or pain to a resident . Further review revealed It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Although abuse comes in different types, the facility has one common goal and that is to protect each and every resident.

Based on observations, interviews, and record reviews, the facility failed to develop and implement its written policies and procedures that prohibit and prevent neglect for 3 of 8 residents (Resident #s, 2, 3, and 5) whose care was reviewed in that: 1. The facility failed to implement individualized interventions for Resident #2 to prevent further falls. Resident #2 sustained 18 falls within a month and a half, 4 of which involved hitting her head. Fall risk evaluations were not completed after each fall as per facility policy. Resident #2 was sent to out to the hospital for a hematoma to her forehead with swelling on 2/22/18 and passed away at the facility on 2/26/18. 2. The facility failed to implement individualized interventions for Resident #5 to prevent further falls. She sustained 4 falls within a month and a half, one resulting in the need for staples to her head. Fall risk evaluations were not completed after each fall as per facility policy. 3. The facility failed to implement individualized interventions for Resident #3 to prevent further falls. Resident #3 sustained 6 falls within 2 months. Fall risk evaluations were not completed after each fall as per facility policy. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 2/23/18. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. This deficient practice could affect 14 residents with recent falls by placing them at risk for recurrent falls with/without injury. The findings were: Record review of the facility's policy to prohibit the mistreatment, neglect, and abuse of residents and the misappropriation of resident property (not dated) revealed Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, unreasonable confinement, intimidation, neglect . No resident will be deprived by any individual of goods and services necessary to attain or maintain physical, mental and psychosocial well-being. Record review of the facility's fall prevention policy (not dated) revealed A fall risk assessment should be completed . after each fall. As part of the initial assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling . A care plan for fall risk management and injury prevention should be implemented. Effectiveness of the interventions identified in the care plan are evaluated for effectiveness. 1. Record review of Resident #2's facesheet (dated 1/24/18) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS assessment (ARD 1/16/18) revealed that she scored a 3 on the BIMS (indicating severe cognitive impairment); had delusions; had physical and verbal behaviors directed toward others, and rejected care; needed the extensive assistance of 1 staff for bed mobility and transfers; needed the extensive assistance of 1 staff for walking in the room and in the corridor and for locomotion on the unit; and was unsteady. A walker and wheelchair were checked as mobility devices. She was not on a toileting program and was frequently incontinent of bladder and occasionally incontinent of bowel. She was on as-needed pain medication. She had 2 or more falls since the previous assessment - none with injury. She received antidepressants 7 days during the lookback period, antianxiety medications 5 days during the lookback period, and opioid medications 2 days within the lookback period. Speech therapy services were provided. Record review of Resident #2's care plan (undated; printed and provided by MDS RN V on 2/27/18) revealed that her fall risk was addressed with interventions of Assess orthostatic blood pressure to rule out orthostatic [MEDICAL CONDITION], as ordered/needed; Assess for prior history of falls; Assess mental status as needed, Document changes in mental status and notify MD; Ensure that resident is wearing appropriate footwear when ambulating or in wheelchair; If receiving diuretics, schedule administration time so resident won't have to use the bathroom at bedtime, as ordered; PT, OT evaluation and follow-up as indicated; Provide a safe environment with floors that are even and free from spills or clutter, adequate glare-free light, call light within reach; Use mobility monitor or pressure-sensitive pads while in bed/chair, as ordered, to alert staff to resident's movements and self-transfer attempts; Evaluate medications that are potential risk factors - refer to pharmacy consultant as appropriate/indicated; Check brief and restroom/fluids when agitated/restless, Problem solve for other needs, Offer prn (as needed) meds as ordered/appropriate for restlessness/agitation. Record review of Resident #2's fall risk evaluations revealed that she scored a 14 on 1/1/18 with scores of 10 or above indicating high fall risk. Record review of Resident #2's incident/accident reports revealed: 1/1/18 - unwitnessed fall in the bathroom - resident noted sitting up on floor next to commode - resident stated My legs are weak - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/1/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/1/18 - Past Interventions Attempted (include dates): frequent monitoring, assist with ADLs, provide wheelchair as needed and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/2/18 - witnessed fall in the hallway - resident stood up from wheelchair and grabbed on to the med cart trash can and then fell straight down to sitting position - resident complained of pain, and x-ray was ordered - action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/2/18 - fall resulting in minor injury - hips - modify the at-risk plan; x-ray to area of concern Record review of Resident #2's investigation follow-ups revealed: 1/2/18 - Past Interventions Attempted (include dates): patient encouraged to use call light, call for help, nonskid socks and Recommendations/New Interventions: staff hourly checks to ensure resident has safe walkway and access to wheelchair Record review of Resident #2's incident/accident reports revealed: 1/2/18 - unwitnessed fall in resident room - resident found on floor on right side holding head and crying - had been up in wheelchair and watching television - hematoma to right side of head - action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/2/18 - fall resulting in minor injury - hematoma to right head - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/2/18 - Past Interventions Attempted (include dates): frequent monitoring, assist with ADLs, provide wheelchair and Recommendations/New Interventions: [MEDICATION NAME] discontinued, [MEDICATION NAME] discontinued, continue all other current interventions, transferred to room in front of desk Record review of Resident #2's incident/accident reports revealed: 1/5/18 - witnessed fall in hallway - resident sitting up in wheelchair across from desk; attempted to stand; when redirected to sit, resident sat at edge of seat and slid down to floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/5/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/5/18 - Past Interventions Attempted (include dates): assist with ADLs, offer wheelchair, frequent monitoring and Recommendations/New Interventions: [MEDICATION NAME] 14 milligrams discontinued, [MEDICATION NAME] decreased to 50 milligrams every day, [MEDICATION NAME] decreased to 500 milligrams every day, continue all current interventions Record review of Resident #2's incident/accident reports revealed: 1/10/18 - witnessed fall in hallway - resident sitting up in wheelchair at nurses' desk; noted to stand; nurse instructed her to sit down; when she sat back down, she missed the chair and sat on the floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/10/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/10/18 - Past Interventions Attempted (include dates): monitoring, assist with ADLs and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/10/18 - witnessed fall in resident room - resident attempted to self-transfer from wheelchair to bed; nurse witnessed resident lower herself to the floor while holding on to the bed and wheelchair - no injury; action taken was care plan update and resident education However, Resident #2 had severe cognitive impairment. Record review of Resident #2's immediate needs care plans revealed: 1/10/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/10/18 - Past Interventions Attempted (include dates): wheelchair, assist with transfers and Recommendations/New Interventions: continue past interventions, reeducation on help with transfers However, Resident #2 had severe cognitive impairment. Record review of Resident #2's therapy notes revealed that she received speech therapy from 1/11/18 through 1/31/18 (when progress ceased) and physical therapy from 1/17/18 through 1/31/18 (when her short-term goals of safely transferring from bed to wheelchair with minimal assistance and propelling her wheelchair 75 feet down the hallway with supervision were met). Record review of Resident #2's incident/accident reports revealed: 1/14/18 - unwitnessed fall in bathroom - resident found sitting up on bathroom floor - no injury; action taken was staff reeducation However, it was not clear as to what staff were reeducated on. Record review of Resident #2's immediate needs care plans revealed: 1/14/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/14/18 - Past Interventions Attempted (include dates): assisted device at all times and Recommendations/New Interventions: patient up at nurses' station, continue to redirect as needed There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/15/18 - unwitnessed fall in hallway - resident was observed lying on the floor in hallway on left side - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/15/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/15/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: check on resident every 30 minutes to 1 hour to ensure safety and proper use of assistive devices Record review of Resident #2's incident/accident reports revealed: 1/18/18 - witnessed fall in hallway - resident stood up from wheelchair and attempted to sit back down and slipped off wheelchair seat; landed on right side - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/18/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/18/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: slip resistant wheelchair seat Record review of Resident #2's incident/accident reports revealed: 1/22/18 - witnessed fall in resident room - resident began yelling and swinging at hospice CNA while in wheelchair; she kicked night stand, causing her to fall back; unsure if she hit head - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/22/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/22/18 - Past Interventions Attempted (include dates): staff supervision and Recommendations/New Interventions: continue staff monitoring, prn meds, previous interventions Record review of Resident #2's 1/22/18 physician telephone order [MEDICATION NAME] mg by mouth twice daily for 10 days for treatment of [REDACTED]. Record review of Resident #2's 1/25/18 physician telephone order revealed [MEDICATION NAME] 5/325 mg 1 tab po TID scheduled for pain. Record review of Resident #2's incident/accident reports revealed: 1/30/18 - witnessed fall in hallway - resident noted to stand up from wheelchair when hospice nurse instructed her to sit down (although Resident #2 required extensive assistance with transfers according to her quarterly MDS assessment); due to unsteady balance, resident missed the chair and fell to the floor, hitting back of head on door frame - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/30/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/30/18 - Past Interventions Attempted (include dates): frequent monitoring and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/31/18 - unwitnessed fall in resident room - resident found on floor in room in sitting position in front of wheelchair, resident noted grabbing or reaching for things that aren't there, [MEDICAL CONDITION] noted - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/31/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/31/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: have possible [MEDICAL CONDITION] assessed by hospice Record review of Resident #2's incident/accident reports revealed: 2/1/18 - witnessed fall in resident room - resident noted reaching forward while sitting in wheelchair when she fell forward on to the floor, resident landed on left side, hematoma to left forehead - minor injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/1/18 - fall resulting in minor injury - hematoma to head - cranichecks x 72 hours Record review of Resident #2's investigation follow-ups revealed: 2/1/18 - Past Interventions Attempted (include dates): resident redirection, staff hourly checks and Recommendations/New Interventions: ensure safe passageway, monitor frequently due to high fall risk, utilize wheelchair due to unsteady gait Record review of Resident #2's 2/1/18 physician telephone order revealed Continue to monitor the welt to upper left forehead, continue fall precautions, call hospice with concerns or changes in status, DME: high-back wheelchair with foot rests x 2 Record review of Resident #2's incident/accident reports revealed: 2/6/18 - witnessed fall in hallway - resident sitting up in wheelchair when she leaned forward and fell out of wheelchair - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/6/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/6/18 - Past Interventions Attempted (include dates): high-back wheelchair and Recommendations/New Interventions: nonskid wheelchair pad There were no new interventions. The nonskid wheelchair pad was supposed to be implemented as an intervention after the 1/18/18 fall. Record review of Resident #2's incident/accident reports revealed: 2/6/18 - witnessed fall at nurses' station - resident was sitting up in the wheelchair at nurses' station when she slid off the wheelchair and on to the floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/6/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/6/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: put to bed when falling asleep in wheelchair Record review of Resident #2's incident/accident reports revealed: 2/9/18 - unwitnessed fall in resident room - resident heard falling and hitting self against room door, observed resident in sitting position with legs extended out, hematoma to the back of head - minor injury; action taken was care plan update, staff reeducation, resident education However, it was not clear as to what staff were to be reeducated on and Resident #2 had severe cognitive impairment. Record review of Resident #2's immediate needs care plans revealed: 2/9/18 - fall resulting in minor injury - hematoma to back of head - cranichecks x 72 hours, treatment as ordered Record review of Resident #2's investigation follow-ups revealed: 2/9/18 - Past Interventions Attempted (include dates): staff hourly checks, incontinent care done frequently and Recommendations/New Interventions: continue hourly checks and resident in view for safety Record review of Resident #2's 2/9/18 physician telephone order revealed Discontinue 1/4 siderails - scoop mattress to prevent falls. Record review of Resident #2's fall risk evaluations revealed that she scored a 24 on 2/14/18 with scores of 10 or above indicating high fall risk. Record review of Resident #2's incident/accident reports revealed: 2/14/18 - witnessed fall in the dining room - resident noted to be sitting on floor, nurse said resident slid out of chair and sat on floor - no injury Record review of Resident #2's immediate needs care plans revealed: 2/14/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/14/18 - Past Interventions Attempted (include dates): frequent monitoring and Recommendations/New Interventions: continue all current interventions There were no new interventions. Observation of Resident #2 in her room at 4:15 p.m. on 2/22/18 revealed that she was sitting in her high-back wheelchair. The back was reclined so that her head was below her seat. There was no non-slip cushion in her wheelchair. She had a moccasin-type house shoe on her left foot and had no sock or shoe on her right foot. Resident #2 was pulling her legs up and leaning forward with her body, fidgeting with her hands. During an interview with LVN A at this time, she reported that Resident #2 could not recline her high-back wheelchair into the position it was in and confirmed that staff put her wheelchair in this position. Observation of Resident #2 in the hallway outside of the nursing station at 4:23 p.m. on 2/22/18 revealed that there was no non-slip cushion on her wheelchair. She had a moccasin-type house shoe on her left foot and had no sock or shoe on her right foot. She was rocking her upper body back and forth. Observation of Resident #2 sleeping in bed at 10:45 a.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with LVN B at 10:48 a.m. on 2/23/18, she reported that she thought Resident #2 fell last night. LVN B checked Resident #2's clinical record at this time and confirmed that Resident #2 fell at 9:30 p.m. on 2/22/18, hit her head, and was sent to the hospital. LVN B reported that Resident #2's nursing notes did not specify where the fall occurred but did say that she was found on the floor and that the fall was unwitnessed. During an interview with LVNs B and D at 10:53 a.m. on 2/23/18, they reported LVN C was Resident #2's charge nurse. However, because LVN C was in the conference room doing paperwork, they were covering her residents. At 10:55 a.m. on 2/23/18, the investigator asked the DON for Resident #2's 2/22/18 fall incident/accident report. The DON reported that she had not received it yet and that LVN C was Resident #2's charge nurse. During an interview with LVN C at 10:59 a.m. on 2/23/18, she reported that she was not working on the floor today and that she had no idea where Resident #2's 2/22/18 fall occurred. LVN C reported that LVNs B and D were covering as charge nurses for Resident #2 since she was in the conference room doing paperwork. During an interview with the DON at 11:01 a.m. on 2/23/18, when asked if the facility had their morning meeting already, she stated Kinda sorta. The nurses are trying to cover for each other because we're having that training - the (electronic records) one. (ADON R) is trying to find the incident/accident report. Record review of Resident #2's 2/22/18 incident/accident report (given to the investigator by ADON R at 11:04 a.m. on 2/23/18) revealed that she had an unwitnessed fall in her room at 9:30 p.m. Hematoma/Bruise, Major Injury, and Joint Dislocation were checked. Handwritten next to the Joint Dislocation box was possible. Summary of incident was Resident found on floor by (LVN E). This nurse was notified of incident. Head to toe assessment performed. Hematoma to mid-forehead 7.5 centimeters x 6.0 centimeters noted with swelling. Possible right shoulder injury also noted . Resident showed signs of distress. Resident placed by nurse station. Called and notified (hospice) of incident. Treatment was Sent to Hospital. Action taken was Assistive Device, Care Plan Update, and Resident Education. Record review of Resident #2's 2/22/18 immediate needs care plan revealed a fall resulting in minor injury to hematoma mid-forehead and a fall resulting in serious injury to possible right shoulder injury - crani checks x 72 hours, vital signs every shift x 72 hours, check range of motion daily x 72 hours, treatment as ordered, continue interventions on the at-risk plan. Record review of Resident #2's 2/22/18 investigation follow-up revealed Past Interventions Attempted (include dates): supervision, place next to nursing station, frequent rounds on resident and Recommendations/New Interventions: Implement floor mats next to resident's bed. Implement bedside railing. Maintain bed at lowest position with call bell within reach. Check resident every 2 hours. Observation of Resident #2 sleeping in bed at 11:24 a.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with LVN D at 11:31 a.m. on 2/23/18, when asked if any information had been given to her about new fall interventions for Resident #2, she reported that hospice came and that a new bed was to be delivered today. When asked about fall mats, LVN D stated (LVN C) said no - they would be more of a fall hazard. When asked about bedrails, LVN D stated LVN C said no because she would get trapped in them in the past. When asked if Resident #2's 2/22/18 fall was out of her bed or out of her chair, LVN D reviewed the incident/accident report and stated I don't know. You'll have to ask the nurse who wrote this. The nurse who wrote this put in the interventions. During an interview with Resident #2's hospice nurse at 12:15 p.m. on 2/23/18, she reported that she ordered a low bed and fall mats for Resident #2 after the 2/22/18 fall. She stated I don't think the fall mats are going to help, but we'll try. Residents have the right to fall. We can't restrain them. Resident #2's hospice nurse reported that Resident #2's medications had been adjusted and that they had put her in a high-back wheelchair. She stated I don't know what else to do. The hospice nurse reported that she did not know whether or not Resident #2's 2/22/18 fall was out of bed or out of the wheelchair. She confirmed that the high-back wheelchair should not have been positioned in such a way that Resident #2's head was below her seat. She stated (Resident #2) and (an unidentified resident) are both one fall away from dying. Observation of Resident #2 sleeping in bed at 1:10 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. Observation of Resident #2 sleeping in bed at 1:45 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with the DON at 2:45 p.m. on 2/23/18, she was asked if she knew whether Resident #2's 2/22/18 fall was out of her bed or out of her wheelchair. The DON responded with No. You have the incident report. You got it before I did. Observation of Resident #2 sleeping in bed at 4:33 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. Her call light was on the floor at the foot of her bed. During an interview with LVN F at 11:31 a.m. on 2/23/18, she reported that she was familiar with Resident #2's needs. She reported that Resident #2 had a wheelchair with a long back. LVN F stated She likes to stand and walk but she is unsteady and needs constant redirection. When asked to define constant redirection, LVN F stated We definitely have to round on her every hour and keep her in plain view as much as possible. LVN F reported that she was unsure if Resident #2 was supposed to have any special wheelchair cushion. During an interview with LVN E at 4:34 p.m. on 2/23/18, she reported that she was the nurse who found Resident #2 in her room on 2/22/18. She reported that she was in the room next door and heard yelling from Resident #2's room. When she went in to check on Resident #2, she found Resident #2 in a fetal position with her head near the corner of the wall. LVN E reported that she had checked on Resident #2 5-10 minutes before and that Resident #2 was calm and in bed. LVN E reported that the scoop mattress was on the bed, that there were no sheets around Resident #2's feet, and that there were no floor mats. She could not remember whether or not Resident #2 was wearing shoes and reported that she could not figure out what happened. During an interview with CNAs O and P at 10:21 a.m. on 2/27/17, when asked what kind of fall prevention measures Resident #2 had in place prior to her last fall, they reported that she had a high-back wheelchair that leaned back and that she was always kept at the nurses station. CNA P reported that she did not think Resident #2 had any kind of cushion in her chair, but CNA O reported that when the high-back wheelchair was provided by hospice, it came with a non-slip cushion. CNAs O and P reported that Resident #2 did not require any special shoes and that they weren't really monitoring her to ensure that she was wearing non-skid socks. They reported that she kept her shoes on when walking. During an interview with LVN C at 11:11 a.m. on 2/27/18, when asked what interventions were in place for Resident #2 prior to the investigator's visit, LVN C reported that they had adjusted her psych medications. They had noticed that she had orthostatic [MEDICAL CONDITION] and discontinued her hypertensive medications. They moved her to a room across from the nursing station. Hospice ordered medications to calm her agitation and provided her with a high-back wheelchair with leg rests to prevent swelling and a scoop mattress. Staff tried to keep her in eyesight. She was put on scheduled pain and anxiety medications. When asked if Resident #2 was supposed to have a low bed or fall mats prior to investigator entrance, LVN C stated I want to say that was after Friday (2/22/18 fall). When asked if Resident #2 was supposed to have a non-slip cushion on her wheelchair prior to investigator entrance, LVN C stated I don't think she had a specific cushion for her chair. LVN C reported that activities were a hit or miss for Resident #2. She reported that staff turned the television in her room on but that it was ineffective and that music sometimes calmed her. When asked about wheelchair brakes, LVN C stated Me personally - it depends on the resident. (Resident #2) was a wheelchair brake person. They should have been locked. I would try to sit her up against the wall so that, if she stood up, the wall would stop her chair from moving back. When asked if Resident #2 was capable of unlocking her wheelchair brakes, LVN C stated I don't think she knew what she was doing but she would fidget with him. I think that caused some of her falls. During an interview with LVN B at 11:36 a.m. on 2/27/18, she reported that Resident #2 could not self-propel her wheelchair, that Resident #2 needed constant supervision, and that wheelchair brakes were not appropriate for her. She reported that she was unsure about whether or not Resident #2 was supposed to have a non-slip cushion in her wheelchair or a fall mat prior to her 2/22/18 fall. During an interview with ADON R at 2:37 p.m. on 2/27/18, when asked if Resident #2 was supposed to have a fall mat in place at the time of her 2/22/18 fall, ADON R stated I don't remember. I'd have to look. I think that she didn't. Most of her falls were not in her room. When asked what interventions Resident #2 did have in place prior to her 2/22/18 fall, ADON R reported that she had a special chair with foot rests, a scoop mattress, scheduled pain medications, antitippers on her wheelchair, psych medication adjustments and discontinuations, non-skid socks, check and change every 2 hours, and a bed in a low position. ADON R reported that staff was to let her ambulate but that she wasn't on a scheduled walking program. She reported that staff had tried a toileting program but that Resident #2 then became incontinent. She reported that a helmet had not been tried because she would get violent and throw it. She reported that a lap belt had not been tried because the facility considered it a restraint. ADON R stated We lock her wheelchair brakes, but there's no order for that. It's just common sense. ADON R reported that the facility had tried a wedge cushion and stated It must have worked because we didn't take it away, I don't think. Maybe when we got the new chair, we took it away because the new chair reclined back? ADON R reported Resident #2 did not have a non-slip cushion on her chair because she really didn't slide out and stated I don't think we needed to try that. She would slip off the edge when she would stand up and try to sit back down. At that point, non-slip wouldn't help because she was too close to the edge. ADON R reported that most of Resident #2's falls occurred when she w (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment was as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 8 residents (Resident #s 2, 3, and 5) whose care was reviewed in that: 1. The facility failed to implement individualized interventions for Resident #2 to prevent further falls. Resident #2 sustained 18 falls within a month and a half, 4 of which involved hitting her head. Fall risk evaluations were not completed after each fall as per facility policy. Resident #2 was sent to out to the hospital for a hematoma to her forehead with swelling on 2/22/18 and passed away at the facility on 2/26/18. 2. The facility failed to implement individualized interventions for Resident #5 to prevent further falls. She sustained 4 falls within a month and a half, one resulting in the need for staples to her head. Fall risk evaluations were not completed after each fall as per facility policy. 3. The facility failed to implement individualized interventions for Resident #3 to prevent further falls. Resident #3 sustained 6 falls within 2 months. Fall risk evaluations were not completed after each fall as per facility policy. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 2/23/18. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. This deficient practice could affect 14 residents with recent falls by placing them at risk for recurrent falls with/without injury. The findings were: 1. Record review of Resident #2's facesheet (dated 1/24/18) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS assessment (ARD 1/16/18) revealed that she scored a 3 on the BIMS (indicating severe cognitive impairment); had delusions; had physical and verbal behaviors directed toward others, and rejected care; needed the extensive assistance of 1 staff for bed mobility and transfers; needed the extensive assistance of 1 staff for walking in the room and in the corridor and for locomotion on the unit; and was unsteady. A walker and wheelchair were checked as mobility devices. She was not on a toileting program and was frequently incontinent of bladder and occasionally incontinent of bowel. She was on as-needed pain medication. She had 2 or more falls since the previous assessment - none with injury. She received antidepressants 7 days during the lookback period, antianxiety medications 5 days during the lookback period, and opioid medications 2 days within the lookback period. Speech therapy services were provided. Record review of Resident #2's care plan (undated; printed and provided by MDS RN V on 2/27/18) revealed that her fall risk was addressed with interventions of Assess orthostatic blood pressure to rule out orthostatic [MEDICAL CONDITION], as ordered/needed; Assess for prior history of falls; Assess mental status as needed, Document changes in mental status and notify MD; Ensure that resident is wearing appropriate footwear when ambulating or in wheelchair; If receiving diuretics, schedule administration time so resident won't have to use the bathroom at bedtime, as ordered; PT, OT evaluation and follow-up as indicated; Provide a safe environment with floors that are even and free from spills or clutter, adequate glare-free light, call light within reach; Use mobility monitor or pressure-sensitive pads while in bed/chair, as ordered, to alert staff to resident's movements and self-transfer attempts; Evaluate medications that are potential risk factors - refer to pharmacy consultant as appropriate/indicated; Check brief and restroom/fluids when agitated/restless, Problem solve for other needs, Offer prn (as needed) meds as ordered/appropriate for restlessness/agitation. Record review of Resident #2's fall risk evaluations revealed that she scored a 14 on 1/1/18 with scores of 10 or above indicating high fall risk. Record review of Resident #2's incident/accident reports revealed: 1/1/18 - unwitnessed fall in the bathroom - resident noted sitting up on floor next to commode - resident stated My legs are weak - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/1/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/1/18 - Past Interventions Attempted (include dates): frequent monitoring, assist with ADLs, provide wheelchair as needed and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/2/18 - witnessed fall in the hallway - resident stood up from wheelchair and grabbed on to the med cart trash can and then fell straight down to sitting position - resident complained of pain, and x-ray was ordered - action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/2/18 - fall resulting in minor injury - hips - modify the at-risk plan; x-ray to area of concern Record review of Resident #2's investigation follow-ups revealed: 1/2/18 - Past Interventions Attempted (include dates): patient encouraged to use call light, call for help, nonskid socks and Recommendations/New Interventions: staff hourly checks to ensure resident has safe walkway and access to wheelchair Record review of Resident #2's incident/accident reports revealed: 1/2/18 - unwitnessed fall in resident room - resident found on floor on right side holding head and crying - had been up in wheelchair and watching television - hematoma to right side of head - action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/2/18 - fall resulting in minor injury - hematoma to right head - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/2/18 - Past Interventions Attempted (include dates): frequent monitoring, assist with ADLs, provide wheelchair and Recommendations/New Interventions: [MEDICATION NAME] discontinued, [MEDICATION NAME] discontinued, continue all other current interventions, transferred to room in front of desk Record review of Resident #2's incident/accident reports revealed: 1/5/18 - witnessed fall in hallway - resident sitting up in wheelchair across from desk; attempted to stand; when redirected to sit, resident sat at edge of seat and slid down to floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/5/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/5/18 - Past Interventions Attempted (include dates): assist with ADLs, offer wheelchair, frequent monitoring and Recommendations/New Interventions: [MEDICATION NAME] 14 milligrams discontinued, [MEDICATION NAME] decreased to 50 milligrams every day, [MEDICATION NAME] decreased to 500 milligrams every day, continue all current interventions Record review of Resident #2's incident/accident reports revealed: 1/10/18 - witnessed fall in hallway - resident sitting up in wheelchair at nurses' desk; noted to stand; nurse instructed her to sit down; when she sat back down, she missed the chair and sat on the floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/10/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/10/18 - Past Interventions Attempted (include dates): monitoring, assist with ADLs and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/10/18 - witnessed fall in resident room - resident attempted to self-transfer from wheelchair to bed; nurse witnessed resident lower herself to the floor while holding on to the bed and wheelchair - no injury; action taken was care plan update and resident education However, Resident #2 had severe cognitive impairment. Record review of Resident #2's immediate needs care plans revealed: 1/10/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/10/18 - Past Interventions Attempted (include dates): wheelchair, assist with transfers and Recommendations/New Interventions: continue past interventions, reeducation on help with transfers However, Resident #2 had severe cognitive impairment. Record review of Resident #2's therapy notes revealed that she received speech therapy from 1/11/18 through 1/31/18 (when progress ceased) and physical therapy from 1/17/18 through 1/31/18 (when her short-term goals of safely transferring from bed to wheelchair with minimal assistance and propelling her wheelchair 75 feet down the hallway with supervision were met). Record review of Resident #2's incident/accident reports revealed: 1/14/18 - unwitnessed fall in bathroom - resident found sitting up on bathroom floor - no injury; action taken was staff reeducation However, it was not clear as to what staff were reeducated on. Record review of Resident #2's immediate needs care plans revealed: 1/14/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/14/18 - Past Interventions Attempted (include dates): assisted device at all times and Recommendations/New Interventions: patient up at nurses' station, continue to redirect as needed There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/15/18 - unwitnessed fall in hallway - resident was observed lying on the floor in hallway on left side - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/15/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/15/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: check on resident every 30 minutes to 1 hour to ensure safety and proper use of assistive devices Record review of Resident #2's incident/accident reports revealed: 1/18/18 - witnessed fall in hallway - resident stood up from wheelchair and attempted to sit back down and slipped off wheelchair seat; landed on right side - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/18/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/18/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: slip resistant wheelchair seat Record review of Resident #2's incident/accident reports revealed: 1/22/18 - witnessed fall in resident room - resident began yelling and swinging at hospice CNA while in wheelchair; she kicked night stand, causing her to fall back; unsure if she hit head - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/22/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/22/18 - Past Interventions Attempted (include dates): staff supervision and Recommendations/New Interventions: continue staff monitoring, prn meds, previous interventions Record review of Resident #2's 1/22/18 physician telephone order [MEDICATION NAME] mg by mouth twice daily for 10 days for treatment of [REDACTED]. Record review of Resident #2's 1/25/18 physician telephone order revealed [MEDICATION NAME] 5/325 mg 1 tab po TID scheduled for pain. Record review of Resident #2's incident/accident reports revealed: 1/30/18 - witnessed fall in hallway - resident noted to stand up from wheelchair when hospice nurse instructed her to sit down (although Resident #2 required extensive assistance with transfers according to her quarterly MDS assessment); due to unsteady balance, resident missed the chair and fell to the floor, hitting back of head on door frame - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/30/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/30/18 - Past Interventions Attempted (include dates): frequent monitoring and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/31/18 - unwitnessed fall in resident room - resident found on floor in room in sitting position in front of wheelchair, resident noted grabbing or reaching for things that aren't there, [MEDICAL CONDITION] noted - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/31/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/31/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: have possible [MEDICAL CONDITION] assessed by hospice Record review of Resident #2's incident/accident reports revealed: 2/1/18 - witnessed fall in resident room - resident noted reaching forward while sitting in wheelchair when she fell forward on to the floor, resident landed on left side, hematoma to left forehead - minor injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/1/18 - fall resulting in minor injury - hematoma to head - cranichecks x 72 hours Record review of Resident #2's investigation follow-ups revealed: 2/1/18 - Past Interventions Attempted (include dates): resident redirection, staff hourly checks and Recommendations/New Interventions: ensure safe passageway, monitor frequently due to high fall risk, utilize wheelchair due to unsteady gait Record review of Resident #2's 2/1/18 physician telephone order revealed Continue to monitor the welt to upper left forehead, continue fall precautions, call hospice with concerns or changes in status, DME: high-back wheelchair with foot rests x 2 Record review of Resident #2's incident/accident reports revealed: 2/6/18 - witnessed fall in hallway - resident sitting up in wheelchair when she leaned forward and fell out of wheelchair - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/6/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/6/18 - Past Interventions Attempted (include dates): high-back wheelchair and Recommendations/New Interventions: nonskid wheelchair pad There were no new interventions. The nonskid wheelchair pad was supposed to be implemented as an intervention after the 1/18/18 fall. Record review of Resident #2's incident/accident reports revealed: 2/6/18 - witnessed fall at nurses' station - resident was sitting up in the wheelchair at nurses' station when she slid off the wheelchair and on to the floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/6/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/6/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: put to bed when falling asleep in wheelchair Record review of Resident #2's incident/accident reports revealed: 2/9/18 - unwitnessed fall in resident room - resident heard falling and hitting self against room door, observed resident in sitting position with legs extended out, hematoma to the back of head - minor injury; action taken was care plan update, staff reeducation, resident education However, it was not clear as to what staff were to be reeducated on and Resident #2 had severe cognitive impairment. Record review of Resident #2's immediate needs care plans revealed: 2/9/18 - fall resulting in minor injury - hematoma to back of head - cranichecks x 72 hours, treatment as ordered Record review of Resident #2's investigation follow-ups revealed: 2/9/18 - Past Interventions Attempted (include dates): staff hourly checks, incontinent care done frequently and Recommendations/New Interventions: continue hourly checks and resident in view for safety Record review of Resident #2's 2/9/18 physician telephone order revealed Discontinue 1/4 siderails - scoop mattress to prevent falls. Record review of Resident #2's fall risk evaluations revealed that she scored a 24 on 2/14/18 with scores of 10 or above indicating high fall risk. Record review of Resident #2's incident/accident reports revealed: 2/14/18 - witnessed fall in the dining room - resident noted to be sitting on floor, nurse said resident slid out of chair and sat on floor - no injury Record review of Resident #2's immediate needs care plans revealed: 2/14/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/14/18 - Past Interventions Attempted (include dates): frequent monitoring and Recommendations/New Interventions: continue all current interventions There were no new interventions. Observation of Resident #2 in her room at 4:15 p.m. on 2/22/18 revealed that she was sitting in her high-back wheelchair. The back was reclined so that her head was below her seat. There was no non-slip cushion in her wheelchair. She had a moccasin-type house shoe on her left foot and had no sock or shoe on her right foot. Resident #2 was pulling her legs up and leaning forward with her body, fidgeting with her hands. During an interview with LVN A at this time, she reported that Resident #2 could not recline her high-back wheelchair into the position it was in and confirmed that staff put her wheelchair in this position. Observation of Resident #2 in the hallway outside of the nursing station at 4:23 p.m. on 2/22/18 revealed that there was no non-slip cushion on her wheelchair. She had a moccasin-type house shoe on her left foot and had no sock or shoe on her right foot. She was rocking her upper body back and forth. Observation of Resident #2 sleeping in bed at 10:45 a.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with LVN B at 10:48 a.m. on 2/23/18, she reported that she thought Resident #2 fell last night. LVN B checked Resident #2's clinical record at this time and confirmed that Resident #2 fell at 9:30 p.m. on 2/22/18, hit her head, and was sent to the hospital. LVN B reported that Resident #2's nursing notes did not specify where the fall occurred but did say that she was found on the floor and that the fall was unwitnessed. During an interview with LVNs B and D at 10:53 a.m. on 2/23/18, they reported LVN C was Resident #2's charge nurse. However, because LVN C was in the conference room doing paperwork, they were covering her residents. At 10:55 a.m. on 2/23/18, the investigator asked the DON for Resident #2's 2/22/18 fall incident/accident report. The DON reported that she had not received it yet and that LVN C was Resident #2's charge nurse. During an interview with LVN C at 10:59 a.m. on 2/23/18, she reported that she was not working on the floor today and that she had no idea where Resident #2's 2/22/18 fall occurred. LVN C reported that LVNs B and D were covering as charge nurses for Resident #2 since she was in the conference room doing paperwork. During an interview with the DON at 11:01 a.m. on 2/23/18, when asked if the facility had their morning meeting already, she stated Kinda sorta. The nurses are trying to cover for each other because we're having that training - the (electronic records) one. (ADON R) is trying to find the incident/accident report. Record review of Resident #2's 2/22/18 incident/accident report (given to the investigator by ADON R at 11:04 a.m. on 2/23/18) revealed that she had an unwitnessed fall in her room at 9:30 p.m. Hematoma/Bruise, Major Injury, and Joint Dislocation were checked. Handwritten next to the Joint Dislocation box was possible. Summary of incident was Resident found on floor by (LVN E). This nurse was notified of incident. Head to toe assessment performed. Hematoma to mid-forehead 7.5 centimeters x 6.0 centimeters noted with swelling. Possible right shoulder injury also noted . Resident showed signs of distress. Resident placed by nurse station. Called and notified (hospice) of incident. Treatment was Sent to Hospital. Action taken was Assistive Device, Care Plan Update, and Resident Education. Record review of Resident #2's 2/22/18 immediate needs care plan revealed a fall resulting in minor injury to hematoma mid-forehead and a fall resulting in serious injury to possible right shoulder injury - crani checks x 72 hours, vital signs every shift x 72 hours, check range of motion daily x 72 hours, treatment as ordered, continue interventions on the at-risk plan. Record review of Resident #2's 2/22/18 investigation follow-up revealed Past Interventions Attempted (include dates): supervision, place next to nursing station, frequent rounds on resident and Recommendations/New Interventions: Implement floor mats next to resident's bed. Implement bedside railing. Maintain bed at lowest position with call bell within reach. Check resident every 2 hours. Observation of Resident #2 sleeping in bed at 11:24 a.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with LVN D at 11:31 a.m. on 2/23/18, when asked if any information had been given to her about new fall interventions for Resident #2, she reported that hospice came and that a new bed was to be delivered today. When asked about fall mats, LVN D stated (LVN C) said no - they would be more of a fall hazard. When asked about bedrails, LVN D stated LVN C said no because she would get trapped in them in the past. When asked if Resident #2's 2/22/18 fall was out of her bed or out of her chair, LVN D reviewed the incident/accident report and stated I don't know. You'll have to ask the nurse who wrote this. The nurse who wrote this put in the interventions. During an interview with Resident #2's hospice nurse at 12:15 p.m. on 2/23/18, she reported that she ordered a low bed and fall mats for Resident #2 after the 2/22/18 fall. She stated I don't think the fall mats are going to help, but we'll try. Residents have the right to fall. We can't restrain them. Resident #2's hospice nurse reported that Resident #2's medications had been adjusted and that they had put her in a high-back wheelchair. She stated I don't know what else to do. The hospice nurse reported that she did not know whether or not Resident #2's 2/22/18 fall was out of bed or out of the wheelchair. She confirmed that the high-back wheelchair should not have been positioned in such a way that Resident #2's head was below her seat. She stated (Resident #2) and (an unidentified resident) are both one fall away from dying. Observation of Resident #2 sleeping in bed at 1:10 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. Observation of Resident #2 sleeping in bed at 1:45 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with the DON at 2:45 p.m. on 2/23/18, she was asked if she knew whether Resident #2's 2/22/18 fall was out of her bed or out of her wheelchair. The DON responded with No. You have the incident report. You got it before I did. Observation of Resident #2 sleeping in bed at 4:33 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. Her call light was on the floor at the foot of her bed. During an interview with LVN F at 11:31 a.m. on 2/23/18, she reported that she was familiar with Resident #2's needs. She reported that Resident #2 had a wheelchair with a long back. LVN F stated She likes to stand and walk but she is unsteady and needs constant redirection. When asked to define constant redirection, LVN F stated We definitely have to round on her every hour and keep her in plain view as much as possible. LVN F reported that she was unsure if Resident #2 was supposed to have any special wheelchair cushion. During an interview with LVN E at 4:34 p.m. on 2/23/18, she reported that she was the nurse who found Resident #2 in her room on 2/22/18. She reported that she was in the room next door and heard yelling from Resident #2's room. When she went in to check on Resident #2, she found Resident #2 in a fetal position with her head near the corner of the wall. LVN E reported that she had checked on Resident #2 5-10 minutes before and that Resident #2 was calm and in bed. LVN E reported that the scoop mattress was on the bed, that there were no sheets around Resident #2's feet, and that there were no floor mats. She could not remember whether or not Resident #2 was wearing shoes and reported that she could not figure out what happened. During an interview with CNAs O and P at 10:21 a.m. on 2/27/17, when asked what kind of fall prevention measures Resident #2 had in place prior to her last fall, they reported that she had a high-back wheelchair that leaned back and that she was always kept at the nurses station. CNA P reported that she did not think Resident #2 had any kind of cushion in her chair, but CNA O reported that when the high-back wheelchair was provided by hospice, it came with a non-slip cushion. CNAs O and P reported that Resident #2 did not require any special shoes and that they weren't really monitoring her to ensure that she was wearing non-skid socks. They reported that she kept her shoes on when walking. During an interview with LVN C at 11:11 a.m. on 2/27/18, when asked what interventions were in place for Resident #2 prior to the investigator's visit, LVN C reported that they had adjusted her psych medications. They had noticed that she had orthostatic [MEDICAL CONDITION] and discontinued her hypertensive medications. They moved her to a room across from the nursing station. Hospice ordered medications to calm her agitation and provided her with a high-back wheelchair with leg rests to prevent swelling and a scoop mattress. Staff tried to keep her in eyesight. She was put on scheduled pain and anxiety medications. When asked if Resident #2 was supposed to have a low bed or fall mats prior to investigator entrance, LVN C stated I want to say that was after Friday (2/22/18 fall). When asked if Resident #2 was supposed to have a non-slip cushion on her wheelchair prior to investigator entrance, LVN C stated I don't think she had a specific cushion for her chair. LVN C reported that activities were a hit or miss for Resident #2. She reported that staff turned the television in her room on but that it was ineffective and that music sometimes calmed her. When asked about wheelchair brakes, LVN C stated Me personally - it depends on the resident. (Resident #2) was a wheelchair brake person. They should have been locked. I would try to sit her up against the wall so that, if she stood up, the wall would stop her chair from moving back. When asked if Resident #2 was capable of unlocking her wheelchair brakes, LVN C stated I don't think she knew what she was doing but she would fidget with him. I think that caused some of her falls. During an interview with LVN B at 11:36 a.m. on 2/27/18, she reported that Resident #2 could not self-propel her wheelchair, that Resident #2 needed constant supervision, and that wheelchair brakes were not appropriate for her. She reported that she was unsure about whether or not Resident #2 was supposed to have a non-slip cushion in her wheelchair or a fall mat prior to her 2/22/18 fall. During an interview with ADON R at 2:37 p.m. on 2/27/18, when asked if Resident #2 was supposed to have a fall mat in place at the time of her 2/22/18 fall, ADON R stated I don't remember. I'd have to look. I think that she didn't. Most of her falls were not in her room. When asked what interventions Resident #2 did have in place prior to her 2/22/18 fall, ADON R reported that she had a special chair with foot rests, a scoop mattress, scheduled pain medications, antitippers on her wheelchair, psych medication adjustments and discontinuations, non-skid socks, check and change every 2 hours, and a bed in a low position. ADON R reported that staff was to let her ambulate but that she wasn't on a scheduled walking program. She reported that staff had tried a toileting program but that Resident #2 then became incontinent. She reported that a helmet had not been tried because she would get violent and throw it. She reported that a lap belt had not been tried because the facility considered it a restraint. ADON R stated We lock her wheelchair brakes, but there's no order for that. It's just common sense. ADON R reported that the facility had tried a wedge cushion and stated It must have worked because we didn't take it away, I don't think. Maybe when we got the new chair, we took it away because the new chair reclined back? ADON R reported Resident #2 did not have a non-slip cushion on her chair because she really didn't slide out and stated I don't think we needed to try that. She would slip off the edge when she would stand up and try to sit back down. At that point, non-slip wouldn't help because she was too close to the edge. ADON R reported that most of Resident #2's falls occurred when she would stand up from her wheelchair. During an interview with CNA T at 2:59 p.m. on 2/27/18, he reported that Resident #2 was a resident for whom wheelchair brakes should be locked. 2. Record review of Resident #5's facesheet (dated 1/9/18) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] (after a hospital stay from 1/7/18 to 1/8/18) with [DIAGNOSES REDACTED]. Record review of Resident #5's significant change MDS assessment (ARD 1/9/18) revealed that she was unable to complete the BIMS and had severe cognitive impairment; wandered daily; and had behaviors that put herself and others at risk for injury; needed the extensive assistance of 1 staff for bed mobility and transfers; need (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to be administrered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 3 of 8 residents (Resident #s 2, 3, and 5) whose care was reviewed in that: 1. The administrator and DON failed to monitor staff to ensure that appropriate interventions were put in place for prevention of falls and fall reoccurrence. Resident #s 2, 3, and 5 continued to fall without effective interventions. 2. The administrator and DON failed to ensure that the facility's fall prevention policy was followed. Fall risk evaluations were not completed after each resident fall and interventions identified in the care plan were not evaluated for effectiveness. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 2/23/18. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. This deficient practice could affect 14 residents at the facility with recent falls by contributing to recurrent falls with/without injury. The findings were: Record review of the facility's administrator job description (not dated) revealed Essential Functions: To assure resident safety; Directs the location staff to provide high quality in daily care which meets/exceeds all internal/external standards within budget parameters, including but not limited to nursing services, physical plant and environment. During an interview with the administrator at 1:16 p.m. on 2/27/18, she reported that she did not agree with the IJ because she felt that the facility had fall prevention processes in place. She reported that she did not feel the facility had an issues with falls and stated This is a large facility. We also have a memory care unit. As the disease progresses, falls happen. It's harder. Those residents are more prone to frequent falls. There are varying degrees of residents that you get. If a resident fell 6 times at home before coming here, we're not going to get that to stop. The administrator reported that she ensured company policies and procedures were followed. She reported that, prior to the IJ, nurses filled out an incident/accident report after a fall and came to the morning meeting the next morning to discuss what happened. She reported that the nurse turned in the incident/accident report to the DON and that the DON logged the incident/accident on a corporate form. She reported that the charge nurses, ADONs, and DON tried to figure out what caused the fall and, as a team, discussed what interventions could be tried. Then the nurses would get orders for needed interventions and relay the information to direct care staff by word of mouth. The administrator reported that the ADONs checked to make sure needed interventions were in place during rounds, that therapy staff were also on the floors to monitor, and that department heads all made quality of life rounds. When asked how the process changed after the IJ, the administrator reported that resident-specific fall care plans were put in a care plan book for aides to look at and that these books were kept at the nursing stations. She confirmed that there was nothing similar to this being used prior to the IJ. She reported that, in addition to the care plan books, fall interventions were being monitored through the MARs and that nurses were having to initial for needed interventions being in place. When asked how she monitored staff (for example, the DON) to ensure the systems they monitored were being done sufficiently, the administrator reported that she and the DON had all-day-long communication and that she asked questions based on complaints. She reported that, at WAR (weekly at risk) meetings, administrative staff talked about what was done during the week. She reported that, as part of QA (quality assurance), administrative staff reviewed incident/accident reports. The administrator reported that she signed off on incident/accident reports for completion. She reported that she reviewed them primarily to make sure that none of them were [MEDICATION NAME] and had not noticed a trend with other interventions besides Care plan update and Continue interventions on the at-risk plan not being checked. When asked what Care plan update on the incident/accident reports meant, the administrator stated The MDS people are in the meeting. I am assuming that means the care plan will be updated. I'm not sure what is meant by 'Modify the at-risk plan'. Record review of the facility's DON job description (not dated) revealed Responsibilities: Participates as a member of the facilities management team in planning and administrative decision making with particular reference to the role, functions and operations of the facilities nursing services within the framework of the objectives and policies established by Senior Care Centers plans and coordinated nursing services. In summary, is responsible for patient care, management, resource management, and fiscal management and Essential Functions: To assure resident safety; Responsible for managing, directing and supervising nursing services; . Assesses the quality of care rendered . Responsible for staff performance . During an interview with the DON at 2:02 p.m. on 2/27/18, she reported that she did not agree with the IJ and stated Honestly, I don't think you felt like there was enough documentation to support things we were already doing. When asked if she felt the facility had issues with their fall process, the DON stated Yes, there are issues in every building. Do I think our issues were IJ level? No. When asked if she felt the facility had a problem with reoccurring falls, the DON stated No. Based on our numbers, no. We have certain people with lots of falls, but that's in every building - nothing unusual. We are below the State average on falls. We might not have been as formal as we should have been on documenting care plans but are now. Our falls weren't out of hand. When asked what kind of plan was in place for residents with frequent falls prior to the IJ being called, the DON reported that the charge nurse would call her whenever a fall occurred and that, the next morning, the charge nurse would bring the incident/accident report to the morning meeting. She reported that the charge nurses and administrative nurses would discuss the fall and that she would make notes to take to the WAR meeting on Friday. The DON reported that, on Fridays, the falls were looked at more thoroughly and interventions that the team came up with would be relayed to the floor staff by word of mouth. When asked how the process changed after the IJ, the DON reported that all staff were reeducated on care plans, the facility's fall prevention/management program, assessments after a fall, and looking at outcomes to ensure that the facility's plans were working. She reported that a root cause analysis form had been added to the incident/accident report packets so that, when nurses called her, they would thoroughly review the fall together. The DON reported that the falls care plan had been altered to look more like the traditional care plan - with problem, goals, interventions, etc. - and had replaced the immediate needs care plan that was part of the packet. The DON stated Before, the call to me would not be as thorough. We would discuss the fall more at the morning meeting. The DON reported that there was now a fall intervention resource book at every nursing station and that the resident-specific fall care plans were being kept in a binder at every nursing station as well. She reported that, prior to the care plan binder, the kardex was used to inform staff of residents at risk for falls and that immediate needs care plans were kept in resident charts. She confirmed that the immediate needs care plans that had been kept in resident charts were not usually specific. The DON stated It's basically the same system we were doing. Instead of on WAR meeting notes, information is now in the care plan binder. It's the same information - it's just out there now for the staff to refer to. Instead of just telling them, now it's on paper. 1. Record review of Resident #2's facesheet (dated 1/24/18) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS assessment (ARD 1/16/18) revealed that she scored a 3 on the BIMS (indicating severe cognitive impairment); had delusions; had physical and verbal behaviors directed toward others, and rejected care; needed the extensive assistance of 1 staff for bed mobility and transfers; needed the extensive assistance of 1 staff for walking in the room and in the corridor and for locomotion on the unit; and was unsteady. A walker and wheelchair were checked as mobility devices. She was not on a toileting program and was frequently incontinent of bladder and occasionally incontinent of bowel. She was on as-needed pain medication. She had 2 or more falls since the previous assessment - none with injury. She received antidepressants 7 days during the lookback period, antianxiety medications 5 days during the lookback period, and opioid medications 2 days within the lookback period. Speech therapy services were provided. Record review of Resident #2's care plan (undated; printed and provided by MDS RN V on 2/27/18) revealed that her fall risk was addressed with interventions of Assess orthostatic blood pressure to rule out orthostatic [MEDICAL CONDITION], as ordered/needed; Assess for prior history of falls; Assess mental status as needed, Document changes in mental status and notify MD; Ensure that resident is wearing appropriate footwear when ambulating or in wheelchair; If receiving diuretics, schedule administration time so resident won't have to use the bathroom at bedtime, as ordered; PT, OT evaluation and follow-up as indicated; Provide a safe environment with floors that are even and free from spills or clutter, adequate glare-free light, call light within reach; Use mobility monitor or pressure-sensitive pads while in bed/chair, as ordered, to alert staff to resident's movements and self-transfer attempts; Evaluate medications that are potential risk factors - refer to pharmacy consultant as appropriate/indicated; Check brief and restroom/fluids when agitated/restless, Problem solve for other needs, Offer prn (as needed) meds as ordered/appropriate for restlessness/agitation. Record review of Resident #2's fall risk evaluations revealed that she scored a 14 on 1/1/18 with scores of 10 or above indicating high fall risk. Record review of Resident #2's incident/accident reports revealed: 1/1/18 - unwitnessed fall in the bathroom - resident noted sitting up on floor next to commode - resident stated My legs are weak - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/1/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/1/18 - Past Interventions Attempted (include dates): frequent monitoring, assist with ADLs, provide wheelchair as needed and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/2/18 - witnessed fall in the hallway - resident stood up from wheelchair and grabbed on to the med cart trash can and then fell straight down to sitting position - resident complained of pain, and x-ray was ordered - action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/2/18 - fall resulting in minor injury - hips - modify the at-risk plan; x-ray to area of concern Record review of Resident #2's investigation follow-ups revealed: 1/2/18 - Past Interventions Attempted (include dates): patient encouraged to use call light, call for help, nonskid socks and Recommendations/New Interventions: staff hourly checks to ensure resident has safe walkway and access to wheelchair Record review of Resident #2's incident/accident reports revealed: 1/2/18 - unwitnessed fall in resident room - resident found on floor on right side holding head and crying - had been up in wheelchair and watching television - hematoma to right side of head - action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/2/18 - fall resulting in minor injury - hematoma to right head - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/2/18 - Past Interventions Attempted (include dates): frequent monitoring, assist with ADLs, provide wheelchair and Recommendations/New Interventions: [MEDICATION NAME] discontinued, [MEDICATION NAME] discontinued, continue all other current interventions, transferred to room in front of desk Record review of Resident #2's incident/accident reports revealed: 1/5/18 - witnessed fall in hallway - resident sitting up in wheelchair across from desk; attempted to stand; when redirected to sit, resident sat at edge of seat and slid down to floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/5/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/5/18 - Past Interventions Attempted (include dates): assist with ADLs, offer wheelchair, frequent monitoring and Recommendations/New Interventions: [MEDICATION NAME] 14 milligrams discontinued, [MEDICATION NAME] decreased to 50 milligrams every day, [MEDICATION NAME] decreased to 500 milligrams every day, continue all current interventions Record review of Resident #2's incident/accident reports revealed: 1/10/18 - witnessed fall in hallway - resident sitting up in wheelchair at nurses' desk; noted to stand; nurse instructed her to sit down; when she sat back down, she missed the chair and sat on the floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/10/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/10/18 - Past Interventions Attempted (include dates): monitoring, assist with ADLs and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/10/18 - witnessed fall in resident room - resident attempted to self-transfer from wheelchair to bed; nurse witnessed resident lower herself to the floor while holding on to the bed and wheelchair - no injury; action taken was care plan update and resident education However, Resident #2 had severe cognitive impairment. Record review of Resident #2's immediate needs care plans revealed: 1/10/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/10/18 - Past Interventions Attempted (include dates): wheelchair, assist with transfers and Recommendations/New Interventions: continue past interventions, reeducation on help with transfers However, Resident #2 had severe cognitive impairment. Record review of Resident #2's therapy notes revealed that she received speech therapy from 1/11/18 through 1/31/18 (when progress ceased) and physical therapy from 1/17/18 through 1/31/18 (when her short-term goals of safely transferring from bed to wheelchair with minimal assistance and propelling her wheelchair 75 feet down the hallway with supervision were met). Record review of Resident #2's incident/accident reports revealed: 1/14/18 - unwitnessed fall in bathroom - resident found sitting up on bathroom floor - no injury; action taken was staff reeducation However, it was not clear as to what staff were reeducated on. Record review of Resident #2's immediate needs care plans revealed: 1/14/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/14/18 - Past Interventions Attempted (include dates): assisted device at all times and Recommendations/New Interventions: patient up at nurses' station, continue to redirect as needed There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/15/18 - unwitnessed fall in hallway - resident was observed lying on the floor in hallway on left side - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/15/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/15/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: check on resident every 30 minutes to 1 hour to ensure safety and proper use of assistive devices Record review of Resident #2's incident/accident reports revealed: 1/18/18 - witnessed fall in hallway - resident stood up from wheelchair and attempted to sit back down and slipped off wheelchair seat; landed on right side - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/18/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/18/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: slip resistant wheelchair seat Record review of Resident #2's incident/accident reports revealed: 1/22/18 - witnessed fall in resident room - resident began yelling and swinging at hospice CNA while in wheelchair; she kicked night stand, causing her to fall back; unsure if she hit head - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/22/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/22/18 - Past Interventions Attempted (include dates): staff supervision and Recommendations/New Interventions: continue staff monitoring, prn meds, previous interventions Record review of Resident #2's 1/22/18 physician telephone order [MEDICATION NAME] mg by mouth twice daily for 10 days for treatment of [REDACTED]. Record review of Resident #2's 1/25/18 physician telephone order revealed [MEDICATION NAME] 5/325 mg 1 tab po TID scheduled for pain. Record review of Resident #2's incident/accident reports revealed: 1/30/18 - witnessed fall in hallway - resident noted to stand up from wheelchair when hospice nurse instructed her to sit down (although Resident #2 required extensive assistance with transfers according to her quarterly MDS assessment); due to unsteady balance, resident missed the chair and fell to the floor, hitting back of head on door frame - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/30/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/30/18 - Past Interventions Attempted (include dates): frequent monitoring and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/31/18 - unwitnessed fall in resident room - resident found on floor in room in sitting position in front of wheelchair, resident noted grabbing or reaching for things that aren't there, [MEDICAL CONDITION] noted - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/31/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/31/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: have possible [MEDICAL CONDITION] assessed by hospice Record review of Resident #2's incident/accident reports revealed: 2/1/18 - witnessed fall in resident room - resident noted reaching forward while sitting in wheelchair when she fell forward on to the floor, resident landed on left side, hematoma to left forehead - minor injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/1/18 - fall resulting in minor injury - hematoma to head - cranichecks x 72 hours Record review of Resident #2's investigation follow-ups revealed: 2/1/18 - Past Interventions Attempted (include dates): resident redirection, staff hourly checks and Recommendations/New Interventions: ensure safe passageway, monitor frequently due to high fall risk, utilize wheelchair due to unsteady gait Record review of Resident #2's 2/1/18 physician telephone order revealed Continue to monitor the welt to upper left forehead, continue fall precautions, call hospice with concerns or changes in status, DME: high-back wheelchair with foot rests x 2 Record review of Resident #2's incident/accident reports revealed: 2/6/18 - witnessed fall in hallway - resident sitting up in wheelchair when she leaned forward and fell out of wheelchair - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/6/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/6/18 - Past Interventions Attempted (include dates): high-back wheelchair and Recommendations/New Interventions: nonskid wheelchair pad There were no new interventions. The nonskid wheelchair pad was supposed to be implemented as an intervention after the 1/18/18 fall. Record review of Resident #2's incident/accident reports revealed: 2/6/18 - witnessed fall at nurses' station - resident was sitting up in the wheelchair at nurses' station when she slid off the wheelchair and on to the floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/6/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/6/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: put to bed when falling asleep in wheelchair Record review of Resident #2's incident/accident reports revealed: 2/9/18 - unwitnessed fall in resident room - resident heard falling and hitting self against room door, observed resident in sitting position with legs extended out, hematoma to the back of head - minor injury; action taken was care plan update, staff reeducation, resident education However, it was not clear as to what staff were to be reeducated on and Resident #2 had severe cognitive impairment. Record review of Resident #2's immediate needs care plans revealed: 2/9/18 - fall resulting in minor injury - hematoma to back of head - cranichecks x 72 hours, treatment as ordered Record review of Resident #2's investigation follow-ups revealed: 2/9/18 - Past Interventions Attempted (include dates): staff hourly checks, incontinent care done frequently and Recommendations/New Interventions: continue hourly checks and resident in view for safety Record review of Resident #2's 2/9/18 physician telephone order revealed Discontinue 1/4 siderails - scoop mattress to prevent falls. Record review of Resident #2's fall risk evaluations revealed that she scored a 24 on 2/14/18 with scores of 10 or above indicating high fall risk. Record review of Resident #2's incident/accident reports revealed: 2/14/18 - witnessed fall in the dining room - resident noted to be sitting on floor, nurse said resident slid out of chair and sat on floor - no injury Record review of Resident #2's immediate needs care plans revealed: 2/14/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/14/18 - Past Interventions Attempted (include dates): frequent monitoring and Recommendations/New Interventions: continue all current interventions There were no new interventions. Observation of Resident #2 in her room at 4:15 p.m. on 2/22/18 revealed that she was sitting in her high-back wheelchair. The back was reclined so that her head was below her seat. There was no non-slip cushion in her wheelchair. She had a moccasin-type house shoe on her left foot and had no sock or shoe on her right foot. Resident #2 was pulling her legs up and leaning forward with her body, fidgeting with her hands. During an interview with LVN A at this time, she reported that Resident #2 could not recline her high-back wheelchair into the position it was in and confirmed that staff put her wheelchair in this position. Observation of Resident #2 in the hallway outside of the nursing station at 4:23 p.m. on 2/22/18 revealed that there was no non-slip cushion on her wheelchair. She had a moccasin-type house shoe on her left foot and had no sock or shoe on her right foot. She was rocking her upper body back and forth. Observation of Resident #2 sleeping in bed at 10:45 a.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with LVN B at 10:48 a.m. on 2/23/18, she reported that she thought Resident #2 fell last night. LVN B checked Resident #2's clinical record at this time and confirmed that Resident #2 fell at 9:30 p.m. on 2/22/18, hit her head, and was sent to the hospital. LVN B reported that Resident #2's nursing notes did not specify where the fall occurred but did say that she was found on the floor and that the fall was unwitnessed. During an interview with LVNs B and D at 10:53 a.m. on 2/23/18, they reported LVN C was Resident #2's charge nurse. However, because LVN C was in the conference room doing paperwork, they were covering her residents. At 10:55 a.m. on 2/23/18, the investigator asked the DON for Resident #2's 2/22/18 fall incident/accident report. The DON reported that she had not received it yet and that LVN C was Resident #2's charge nurse. During an interview with LVN C at 10:59 a.m. on 2/23/18, she reported that she was not working on the floor today and that she had no idea where Resident #2's 2/22/18 fall occurred. LVN C reported that LVNs B and D were covering as charge nurses for Resident #2 since she was in the conference room doing paperwork. During an interview with the DON at 11:01 a.m. on 2/23/18, when asked if the facility had their morning meeting already, she stated Kinda sorta. The nurses are trying to cover for each other because we're having that training - the (electronic records) one. (ADON R) is trying to find the incident/accident report. Record review of Resident #2's 2/22/18 incident/accident report (given to the investigator by ADON R at 11:04 a.m. on 2/23/18) revealed that she had an unwitnessed fall in her room at 9:30 p.m. Hematoma/Bruise, Major Injury, and Joint Dislocation were checked. Handwritten next to the Joint Dislocation box was possible. Summary of incident was Resident found on floor by (LVN E). This nurse was notified of incident. Head to toe assessment performed. Hematoma to mid-forehead 7.5 centimeters x 6.0 centimeters noted with swelling. Possible right shoulder injury also noted . Resident showed signs of distress. Resident placed by nurse station. Called and notified (hospice) of incident. Treatment was Sent to Hospital. Action taken was Assistive Device, Care Plan Update, and Resident Education. Record review of Resident #2's 2/22/18 immediate needs care plan revealed a fall resulting in minor injury to hematoma mid-forehead and a fall resulting in serious injury to possible right shoulder injury - crani checks x 72 hours, vital signs every shift x 72 hours, check range of motion daily x 72 hours, treatment as ordered, continue interventions on the at-risk plan. Record review of Resident #2's 2/22/18 investigation follow-up revealed Past Interventions Attempted (include dates): supervision, place next to nursing station, frequent rounds on resident and Recommendations/New Interventions: Implement floor mats next to resident's bed. Implement bedside railing. Maintain bed at lowest position with call bell within reach. Check resident every 2 hours. Observation of Resident #2 sleeping in bed at 11:24 a.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with LVN D at 11:31 a.m. on 2/23/18, when asked if any information had been given to her about new fall interventions for Resident #2, she reported that hospice came and that a new bed was to be delivered today. When asked about fall mats, LVN D stated (LVN C) said no - they would be more of a fall hazard. When asked about bedrails, LVN D stated LVN C said no because she would get trapped in them in the past. When asked if Resident #2's 2/22/18 fall was out of her bed or out of her chair, LVN D reviewed the incident/accident report and stated I don't know. You'll have to ask the nurse who wrote this. The nurse who wrote this put in the interventions. During an interview with Resident #2's hospice nurse at 12:15 p.m. on 2/23/18, she reported that she ordered a low bed and fall mats for Resident #2 after the 2/22/18 fall. She stated I don't think the fall mats are going to help, but we'll try. Residents have the right to fall. We can't restrain them. Resident #2's hospice nurse reported that Resident #2's medications had been adjusted and that they had put her in a high-back wheelchair. She stated I don't know what else to do. The hospice nurse reported that she did not know whether or not Resident #2's 2/22/18 fall was out of bed or out of the wheelchair. She confirmed that the high-back wheelchair should not have been positioned in such a way that Resident #2's head was below her seat. She stated (Resident #2) and (an unidentified resident) are both one fall away from dying. Observation of Resident #2 sleeping in bed at 1:10 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. Observation of Resident #2 sleeping in bed at 1:45 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with the DON at 2:45 p.m. on 2/23/18, she was asked if she knew whether Resident #2's 2/22/18 fall was out of her bed or out of her wheelchair. The DON responded with No. You have the incident report. You got it before I did. Observation of Resident #2 sleeping in bed at 4:33 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. Her call light was on the floor at the foo (TRUNCATED)

Based on observations, interviews, and record reviews, the facility failed to ensure that 3 of 8 residents (Resident #s, 2, 3, and 5) whose care was reviewed had the right to be free from neglect related to falls in that: 1. The facility failed to implement individualized interventions for Resident #2 to prevent further falls. Resident #2 sustained 18 falls within a month and a half, 4 of which involved hitting her head. Fall risk evaluations were not completed after each fall as per facility policy. Resident #2 was sent to out to the hospital for a hematoma to her forehead with swelling on 2/22/18 and passed away at the facility on 2/26/18. 2. The facility failed to implement individualized interventions for Resident #5 to prevent further falls. She sustained 4 falls within a month and a half, one resulting in the need for staples to her head. Fall risk evaluations were not completed after each fall as per facility policy. 3. The facility failed to implement individualized interventions for Resident #3 to prevent further falls. Resident #3 sustained 6 falls within 2 months. Fall risk evaluations were not completed after each fall as per facility policy. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 2/23/18. While the IJ was removed on 2/26/18, the facility remained out of compliance at a severity level of actual harm with a scope identified as pattern until all staff were in-serviced. This deficient practice could affect 14 residents with recent falls by placing them at risk for recurrent falls with/without injury. The findings were: 1. Record review of Resident #2's facesheet (dated 1/24/18) revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS assessment (ARD 1/16/18) revealed that she scored a 3 on the BIMS (indicating severe cognitive impairment); had delusions; had physical and verbal behaviors directed toward others, and rejected care; needed the extensive assistance of 1 staff for bed mobility and transfers; needed the extensive assistance of 1 staff for walking in the room and in the corridor and for locomotion on the unit; and was unsteady. A walker and wheelchair were checked as mobility devices. She was not on a toileting program and was frequently incontinent of bladder and occasionally incontinent of bowel. She was on as-needed pain medication. She had 2 or more falls since the previous assessment - none with injury. She received antidepressants 7 days during the lookback period, antianxiety medications 5 days during the lookback period, and opioid medications 2 days within the lookback period. Speech therapy services were provided. Record review of Resident #2's care plan (undated; printed and provided by MDS RN V on 2/27/18) revealed that her fall risk was addressed with interventions of Assess orthostatic blood pressure to rule out orthostatic [MEDICAL CONDITION], as ordered/needed; Assess for prior history of falls; Assess mental status as needed, Document changes in mental status and notify MD; Ensure that resident is wearing appropriate footwear when ambulating or in wheelchair; If receiving diuretics, schedule administration time so resident won't have to use the bathroom at bedtime, as ordered; PT, OT evaluation and follow-up as indicated; Provide a safe environment with floors that are even and free from spills or clutter, adequate glare-free light, call light within reach; Use mobility monitor or pressure-sensitive pads while in bed/chair, as ordered, to alert staff to resident's movements and self-transfer attempts; Evaluate medications that are potential risk factors - refer to pharmacy consultant as appropriate/indicated; Check brief and restroom/fluids when agitated/restless, Problem solve for other needs, Offer prn (as needed) meds as ordered/appropriate for restlessness/agitation. Record review of Resident #2's fall risk evaluations revealed that she scored a 14 on 1/1/18 with scores of 10 or above indicating high fall risk. Record review of Resident #2's incident/accident reports revealed: 1/1/18 - unwitnessed fall in the bathroom - resident noted sitting up on floor next to commode - resident stated My legs are weak - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/1/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/1/18 - Past Interventions Attempted (include dates): frequent monitoring, assist with ADLs, provide wheelchair as needed and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/2/18 - witnessed fall in the hallway - resident stood up from wheelchair and grabbed on to the med cart trash can and then fell straight down to sitting position - resident complained of pain, and x-ray was ordered - action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/2/18 - fall resulting in minor injury - hips - modify the at-risk plan; x-ray to area of concern Record review of Resident #2's investigation follow-ups revealed: 1/2/18 - Past Interventions Attempted (include dates): patient encouraged to use call light, call for help, nonskid socks and Recommendations/New Interventions: staff hourly checks to ensure resident has safe walkway and access to wheelchair Record review of Resident #2's incident/accident reports revealed: 1/2/18 - unwitnessed fall in resident room - resident found on floor on right side holding head and crying - had been up in wheelchair and watching television - hematoma to right side of head - action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/2/18 - fall resulting in minor injury - hematoma to right head - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/2/18 - Past Interventions Attempted (include dates): frequent monitoring, assist with ADLs, provide wheelchair and Recommendations/New Interventions: [MEDICATION NAME] discontinued, [MEDICATION NAME] discontinued, continue all other current interventions, transferred to room in front of desk Record review of Resident #2's incident/accident reports revealed: 1/5/18 - witnessed fall in hallway - resident sitting up in wheelchair across from desk; attempted to stand; when redirected to sit, resident sat at edge of seat and slid down to floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/5/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/5/18 - Past Interventions Attempted (include dates): assist with ADLs, offer wheelchair, frequent monitoring and Recommendations/New Interventions: [MEDICATION NAME] 14 milligrams discontinued, [MEDICATION NAME] decreased to 50 milligrams every day, [MEDICATION NAME] decreased to 500 milligrams every day, continue all current interventions Record review of Resident #2's incident/accident reports revealed: 1/10/18 - witnessed fall in hallway - resident sitting up in wheelchair at nurses' desk; noted to stand; nurse instructed her to sit down; when she sat back down, she missed the chair and sat on the floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/10/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/10/18 - Past Interventions Attempted (include dates): monitoring, assist with ADLs and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/10/18 - witnessed fall in resident room - resident attempted to self-transfer from wheelchair to bed; nurse witnessed resident lower herself to the floor while holding on to the bed and wheelchair - no injury; action taken was care plan update and resident education However, Resident #2 had severe cognitive impairment. Record review of Resident #2's immediate needs care plans revealed: 1/10/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/10/18 - Past Interventions Attempted (include dates): wheelchair, assist with transfers and Recommendations/New Interventions: continue past interventions, reeducation on help with transfers However, Resident #2 had severe cognitive impairment. Record review of Resident #2's therapy notes revealed that she received speech therapy from 1/11/18 through 1/31/18 (when progress ceased) and physical therapy from 1/17/18 through 1/31/18 (when her short-term goals of safely transferring from bed to wheelchair with minimal assistance and propelling her wheelchair 75 feet down the hallway with supervision were met). Record review of Resident #2's incident/accident reports revealed: 1/14/18 - unwitnessed fall in bathroom - resident found sitting up on bathroom floor - no injury; action taken was staff reeducation However, it was not clear as to what staff were reeducated on. Record review of Resident #2's immediate needs care plans revealed: 1/14/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/14/18 - Past Interventions Attempted (include dates): assisted device at all times and Recommendations/New Interventions: patient up at nurses' station, continue to redirect as needed There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/15/18 - unwitnessed fall in hallway - resident was observed lying on the floor in hallway on left side - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/15/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/15/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: check on resident every 30 minutes to 1 hour to ensure safety and proper use of assistive devices Record review of Resident #2's incident/accident reports revealed: 1/18/18 - witnessed fall in hallway - resident stood up from wheelchair and attempted to sit back down and slipped off wheelchair seat; landed on right side - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/18/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/18/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: slip resistant wheelchair seat Record review of Resident #2's incident/accident reports revealed: 1/22/18 - witnessed fall in resident room - resident began yelling and swinging at hospice CNA while in wheelchair; she kicked night stand, causing her to fall back; unsure if she hit head - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/22/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/22/18 - Past Interventions Attempted (include dates): staff supervision and Recommendations/New Interventions: continue staff monitoring, prn meds, previous interventions Record review of Resident #2's 1/22/18 physician telephone order [MEDICATION NAME] mg by mouth twice daily for 10 days for treatment of [REDACTED]. Record review of Resident #2's 1/25/18 physician telephone order revealed [MEDICATION NAME] 5/325 mg 1 tab po TID scheduled for pain. Record review of Resident #2's incident/accident reports revealed: 1/30/18 - witnessed fall in hallway - resident noted to stand up from wheelchair when hospice nurse instructed her to sit down (although Resident #2 required extensive assistance with transfers according to her quarterly MDS assessment); due to unsteady balance, resident missed the chair and fell to the floor, hitting back of head on door frame - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/30/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/30/18 - Past Interventions Attempted (include dates): frequent monitoring and Recommendations/New Interventions: continue all current interventions There were no new interventions. Record review of Resident #2's incident/accident reports revealed: 1/31/18 - unwitnessed fall in resident room - resident found on floor in room in sitting position in front of wheelchair, resident noted grabbing or reaching for things that aren't there, [MEDICAL CONDITION] noted - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 1/31/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 1/31/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: have possible [MEDICAL CONDITION] assessed by hospice Record review of Resident #2's incident/accident reports revealed: 2/1/18 - witnessed fall in resident room - resident noted reaching forward while sitting in wheelchair when she fell forward on to the floor, resident landed on left side, hematoma to left forehead - minor injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/1/18 - fall resulting in minor injury - hematoma to head - cranichecks x 72 hours Record review of Resident #2's investigation follow-ups revealed: 2/1/18 - Past Interventions Attempted (include dates): resident redirection, staff hourly checks and Recommendations/New Interventions: ensure safe passageway, monitor frequently due to high fall risk, utilize wheelchair due to unsteady gait Record review of Resident #2's 2/1/18 physician telephone order revealed Continue to monitor the welt to upper left forehead, continue fall precautions, call hospice with concerns or changes in status, DME: high-back wheelchair with foot rests x 2 Record review of Resident #2's incident/accident reports revealed: 2/6/18 - witnessed fall in hallway - resident sitting up in wheelchair when she leaned forward and fell out of wheelchair - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/6/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/6/18 - Past Interventions Attempted (include dates): high-back wheelchair and Recommendations/New Interventions: nonskid wheelchair pad There were no new interventions. The nonskid wheelchair pad was supposed to be implemented as an intervention after the 1/18/18 fall. Record review of Resident #2's incident/accident reports revealed: 2/6/18 - witnessed fall at nurses' station - resident was sitting up in the wheelchair at nurses' station when she slid off the wheelchair and on to the floor - no injury; action taken was care plan update Record review of Resident #2's immediate needs care plans revealed: 2/6/18 - fall with no apparent injury - modify the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/6/18 - Past Interventions Attempted (include dates): nonskid socks and Recommendations/New Interventions: put to bed when falling asleep in wheelchair Record review of Resident #2's incident/accident reports revealed: 2/9/18 - unwitnessed fall in resident room - resident heard falling and hitting self against room door, observed resident in sitting position with legs extended out, hematoma to the back of head - minor injury; action taken was care plan update, staff reeducation, resident education However, it was not clear as to what staff were to be reeducated on and Resident #2 had severe cognitive impairment. Record review of Resident #2's immediate needs care plans revealed: 2/9/18 - fall resulting in minor injury - hematoma to back of head - cranichecks x 72 hours, treatment as ordered Record review of Resident #2's investigation follow-ups revealed: 2/9/18 - Past Interventions Attempted (include dates): staff hourly checks, incontinent care done frequently and Recommendations/New Interventions: continue hourly checks and resident in view for safety Record review of Resident #2's 2/9/18 physician telephone order revealed Discontinue 1/4 siderails - scoop mattress to prevent falls. Record review of Resident #2's fall risk evaluations revealed that she scored a 24 on 2/14/18 with scores of 10 or above indicating high fall risk. Record review of Resident #2's incident/accident reports revealed: 2/14/18 - witnessed fall in the dining room - resident noted to be sitting on floor, nurse said resident slid out of chair and sat on floor - no injury Record review of Resident #2's immediate needs care plans revealed: 2/14/18 - fall with no apparent injury - continue interventions on the at-risk plan Record review of Resident #2's investigation follow-ups revealed: 2/14/18 - Past Interventions Attempted (include dates): frequent monitoring and Recommendations/New Interventions: continue all current interventions There were no new interventions. Observation of Resident #2 in her room at 4:15 p.m. on 2/22/18 revealed that she was sitting in her high-back wheelchair. The back was reclined so that her head was below her seat. There was no non-slip cushion in her wheelchair. She had a moccasin-type house shoe on her left foot and had no sock or shoe on her right foot. Resident #2 was pulling her legs up and leaning forward with her body, fidgeting with her hands. During an interview with LVN A at this time, she reported that Resident #2 could not recline her high-back wheelchair into the position it was in and confirmed that staff put her wheelchair in this position. Observation of Resident #2 in the hallway outside of the nursing station at 4:23 p.m. on 2/22/18 revealed that there was no non-slip cushion on her wheelchair. She had a moccasin-type house shoe on her left foot and had no sock or shoe on her right foot. She was rocking her upper body back and forth. Observation of Resident #2 sleeping in bed at 10:45 a.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with LVN B at 10:48 a.m. on 2/23/18, she reported that she thought Resident #2 fell last night. LVN B checked Resident #2's clinical record at this time and confirmed that Resident #2 fell at 9:30 p.m. on 2/22/18, hit her head, and was sent to the hospital. LVN B reported that Resident #2's nursing notes did not specify where the fall occurred but did say that she was found on the floor and that the fall was unwitnessed. During an interview with LVNs B and D at 10:53 a.m. on 2/23/18, they reported LVN C was Resident #2's charge nurse. However, because LVN C was in the conference room doing paperwork, they were covering her residents. At 10:55 a.m. on 2/23/18, the investigator asked the DON for Resident #2's 2/22/18 fall incident/accident report. The DON reported that she had not received it yet and that LVN C was Resident #2's charge nurse. During an interview with LVN C at 10:59 a.m. on 2/23/18, she reported that she was not working on the floor today and that she had no idea where Resident #2's 2/22/18 fall occurred. LVN C reported that LVNs B and D were covering as charge nurses for Resident #2 since she was in the conference room doing paperwork. During an interview with the DON at 11:01 a.m. on 2/23/18, when asked if the facility had their morning meeting already, she stated Kinda sorta. The nurses are trying to cover for each other because we're having that training - the (electronic records) one. (ADON R) is trying to find the incident/accident report. Record review of Resident #2's 2/22/18 incident/accident report (given to the investigator by ADON R at 11:04 a.m. on 2/23/18) revealed that she had an unwitnessed fall in her room at 9:30 p.m. Hematoma/Bruise, Major Injury, and Joint Dislocation were checked. Handwritten next to the Joint Dislocation box was possible. Summary of incident was Resident found on floor by (LVN E). This nurse was notified of incident. Head to toe assessment performed. Hematoma to mid-forehead 7.5 centimeters x 6.0 centimeters noted with swelling. Possible right shoulder injury also noted . Resident showed signs of distress. Resident placed by nurse station. Called and notified (hospice) of incident. Treatment was Sent to Hospital. Action taken was Assistive Device, Care Plan Update, and Resident Education. Record review of Resident #2's 2/22/18 immediate needs care plan revealed a fall resulting in minor injury to hematoma mid-forehead and a fall resulting in serious injury to possible right shoulder injury - crani checks x 72 hours, vital signs every shift x 72 hours, check range of motion daily x 72 hours, treatment as ordered, continue interventions on the at-risk plan. Record review of Resident #2's 2/22/18 investigation follow-up revealed Past Interventions Attempted (include dates): supervision, place next to nursing station, frequent rounds on resident and Recommendations/New Interventions: Implement floor mats next to resident's bed. Implement bedside railing. Maintain bed at lowest position with call bell within reach. Check resident every 2 hours. Observation of Resident #2 sleeping in bed at 11:24 a.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with LVN D at 11:31 a.m. on 2/23/18, when asked if any information had been given to her about new fall interventions for Resident #2, she reported that hospice came and that a new bed was to be delivered today. When asked about fall mats, LVN D stated (LVN C) said no - they would be more of a fall hazard. When asked about bedrails, LVN D stated LVN C said no because she would get trapped in them in the past. When asked if Resident #2's 2/22/18 fall was out of her bed or out of her chair, LVN D reviewed the incident/accident report and stated I don't know. You'll have to ask the nurse who wrote this. The nurse who wrote this put in the interventions. During an interview with Resident #2's hospice nurse at 12:15 p.m. on 2/23/18, she reported that she ordered a low bed and fall mats for Resident #2 after the 2/22/18 fall. She stated I don't think the fall mats are going to help, but we'll try. Residents have the right to fall. We can't restrain them. Resident #2's hospice nurse reported that Resident #2's medications had been adjusted and that they had put her in a high-back wheelchair. She stated I don't know what else to do. The hospice nurse reported that she did not know whether or not Resident #2's 2/22/18 fall was out of bed or out of the wheelchair. She confirmed that the high-back wheelchair should not have been positioned in such a way that Resident #2's head was below her seat. She stated (Resident #2) and (an unidentified resident) are both one fall away from dying. Observation of Resident #2 sleeping in bed at 1:10 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. Observation of Resident #2 sleeping in bed at 1:45 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. During an interview with the DON at 2:45 p.m. on 2/23/18, she was asked if she knew whether Resident #2's 2/22/18 fall was out of her bed or out of her wheelchair. The DON responded with No. You have the incident report. You got it before I did. Observation of Resident #2 sleeping in bed at 4:33 p.m. on 2/23/18 revealed that she had a scoop mattress. There was no mat on the floor, and her bed was not in a low position. Her call light was on the floor at the foot of her bed. During an interview with LVN F at 11:31 a.m. on 2/23/18, she reported that she was familiar with Resident #2's needs. She reported that Resident #2 had a wheelchair with a long back. LVN F stated She likes to stand and walk but she is unsteady and needs constant redirection. When asked to define constant redirection, LVN F stated We definitely have to round on her every hour and keep her in plain view as much as possible. LVN F reported that she was unsure if Resident #2 was supposed to have any special wheelchair cushion. During an interview with LVN E at 4:34 p.m. on 2/23/18, she reported that she was the nurse who found Resident #2 in her room on 2/22/18. She reported that she was in the room next door and heard yelling from Resident #2's room. When she went in to check on Resident #2, she found Resident #2 in a fetal position with her head near the corner of the wall. LVN E reported that she had checked on Resident #2 5-10 minutes before and that Resident #2 was calm and in bed. LVN E reported that the scoop mattress was on the bed, that there were no sheets around Resident #2's feet, and that there were no floor mats. She could not remember whether or not Resident #2 was wearing shoes and reported that she could not figure out what happened. During an interview with CNAs O and P at 10:21 a.m. on 2/27/17, when asked what kind of fall prevention measures Resident #2 had in place prior to her last fall, they reported that she had a high-back wheelchair that leaned back and that she was always kept at the nurses station. CNA P reported that she did not think Resident #2 had any kind of cushion in her chair, but CNA O reported that when the high-back wheelchair was provided by hospice, it came with a non-slip cushion. CNAs O and P reported that Resident #2 did not require any special shoes and that they weren't really monitoring her to ensure that she was wearing non-skid socks. They reported that she kept her shoes on when walking. During an interview with LVN C at 11:11 a.m. on 2/27/18, when asked what interventions were in place for Resident #2 prior to the investigator's visit, LVN C reported that they had adjusted her psych medications. They had noticed that she had orthostatic [MEDICAL CONDITION] and discontinued her hypertensive medications. They moved her to a room across from the nursing station. Hospice ordered medications to calm her agitation and provided her with a high-back wheelchair with leg rests to prevent swelling and a scoop mattress. Staff tried to keep her in eyesight. She was put on scheduled pain and anxiety medications. When asked if Resident #2 was supposed to have a low bed or fall mats prior to investigator entrance, LVN C stated I want to say that was after Friday (2/22/18 fall). When asked if Resident #2 was supposed to have a non-slip cushion on her wheelchair prior to investigator entrance, LVN C stated I don't think she had a specific cushion for her chair. LVN C reported that activities were a hit or miss for Resident #2. She reported that staff turned the television in her room on but that it was ineffective and that music sometimes calmed her. When asked about wheelchair brakes, LVN C stated Me personally - it depends on the resident. (Resident #2) was a wheelchair brake person. They should have been locked. I would try to sit her up against the wall so that, if she stood up, the wall would stop her chair from moving back. When asked if Resident #2 was capable of unlocking her wheelchair brakes, LVN C stated I don't think she knew what she was doing but she would fidget with him. I think that caused some of her falls. During an interview with LVN B at 11:36 a.m. on 2/27/18, she reported that Resident #2 could not self-propel her wheelchair, that Resident #2 needed constant supervision, and that wheelchair brakes were not appropriate for her. She reported that she was unsure about whether or not Resident #2 was supposed to have a non-slip cushion in her wheelchair or a fall mat prior to her 2/22/18 fall. During an interview with ADON R at 2:37 p.m. on 2/27/18, when asked if Resident #2 was supposed to have a fall mat in place at the time of her 2/22/18 fall, ADON R stated I don't remember. I'd have to look. I think that she didn't. Most of her falls were not in her room. When asked what interventions Resident #2 did have in place prior to her 2/22/18 fall, ADON R reported that she had a special chair with foot rests, a scoop mattress, scheduled pain medications, antitippers on her wheelchair, psych medication adjustments and discontinuations, non-skid socks, check and change every 2 hours, and a bed in a low position. ADON R reported that staff was to let her ambulate but that she wasn't on a scheduled walking program. She reported that staff had tried a toileting program but that Resident #2 then became incontinent. She reported that a helmet had not been tried because she would get violent and throw it. She reported that a lap belt had not been tried because the facility considered it a restraint. ADON R stated We lock her wheelchair brakes, but there's no order for that. It's just common sense. ADON R reported that the facility had tried a wedge cushion and stated It must have worked because we didn't take it away, I don't think. Maybe when we got the new chair, we took it away because the new chair reclined back? ADON R reported Resident #2 did not have a non-slip cushion on her chair because she really didn't slide out and stated I don't think we needed to try that. She would slip off the edge when she would stand up and try to sit back down. At that point, non-slip wouldn't help because she was too close to the edge. ADON R reported that most of Resident #2's falls occurred when she would stand up from her wheelchair. During an interview with CNA T at 2:59 p.m. on 2/27/18, he reported that Resident #2 was a resident for whom wheelchair brakes should be locked. 2. Record review of Resident #5's facesheet (dated 1/9/18) revealed that she was admitted to the facility on [DATE] and readmitted on [DATE] (after a hospital stay from 1/7/18 to 1/8/18) with [DIAGNOSES REDACTED]. Record review of Resident #5's significant change MDS assessment (ARD 1/9/18) revealed that she was unable to complete the BIMS and had severe cognitive impairment; wandered daily; and had behaviors that put herself and others at risk for injury; needed the extensive assistance of 1 staff for bed mobility and transfers; needed the extensive assistance of 1 staff for walking in the room and in the corridor and for locomotion on and off the un (TRUNCATED)