Every finding on record at Windsor Nursing and Rehabilitation Center of Morga

Based on interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated with respect and dignity when CNA A used foul language towards her on 07/01/26.This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.Findings included:Record review of Resident #1's face sheet dated revealed a [AGE] year-old female admitted on [DATE] with an original admission date on 04/19/16. Diagnoses included heart failure, osteoporosis (a condition that weakens bones, making them brittle, fragile, and much more likely to break. It occurs when the body loses bone mass faster than it can replace it, turning the inside of the bones from a dense, strong structure into a porous, sponge-like one), hip replacement, skin disorder (unspecified), schizophrenia, dementia, depression, gait and mobility problems, malnutrition, low blood pressure, lung disease, and muscle wasting. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06 indicating severe cognitive impairment. Her speech was unclear and she could comprehend most conversation. At times she exhibited hallucinations, delusions, and verbal behavioral towards others. She had bilateral lower extremity impairment, was in a wheelchair, and required substantial assistance to propel. She was dependent on staff for footwear and transfers. She required substantial assistance with oral hygiene, toileting, showering, dressing, and positioning. She required partial assistance for eating and personal hygiene. She was always incontinent of bladder and bowel. Her active diagnosis was medically complex conditions.Record review of Resident #1's care plan dated 02/05/20 revealed a problem of limited physical mobility r/t hx of hip fracture, needs substantial assistance with ADLs and transfers. Revision on: 05/13/2026. Interventions included: Make sure call light is in reach and answer promptly. Revision on: 12/15/2022. Remind Resident #1 to ask for help and anticipate needs not made known by resident. Revision on: 03/17/2026. Problem: Resident #1 is at risk of self-care deficit: ADL deficits, impaired mobility, impaired cognition. Revision on: 06/10/2026. Goal: Resident's dignity, autonomy, and personal grooming preferences will be respected. Revision on: 06/01/2026. Resident #1 experienced alleged verbal abuse, placing her at risk for emotional distress and anxiety. Date Initiated: 07/01/2026. Resident #1 will remain free from emotional harm related to the incident. Date Initiated: 07/01/2026. Assess and document the resident's emotional status, mood, affect, and any signs of anxiety, fear, withdrawal, or depression. Date Initiated: 07/01/2026. Monitor the resident for changes in behavior, sleep, appetite, participation in activities, or interactions with staff. Date Initiated: 07/01/2026. Provide emotional support and allow the resident to express feelings and concerns in a private supportive environment. Date Initiated: 07/01/2026. Problem: Resident #1 experiences persistent delusions resulting in repeated allegations of harm that are inconsistent with objective findings, placing the resident at risk for anxiety and emotional distress. Date Initiated: 07/01/2026. Problem: Resident #1 is dependent on staff, etc. for meeting emotional, intellectual, physical, and social needs r/t physical limitations. Revision on: 04/30/2026. Problem: Resident #1 has an ADL self-care performance deficit r/t weakness, decreased mobility related to L4 compression fracture, Anemia, and schizophrenia. Revision on: 04/30/2026. Interventions: Resident#1 requires substantial/maximal assistance to roll from lying on back to left and right side, and return to lying on back on the bed. Revision on: 09/23/2024. Resident #1 requires (substantial/maximal assistance) to get on and off a toilet or commode. Revision on: 07/13/2026. Resident #1 requires (Substantial/maximal assistance) for toileting hygiene. Revision on: 07/13/2026. Resident #1 has bowel incontinence r/t dementia. Revision on: 04/30/2026. Interventions: Provide bedpan/bedside commode. Date Initiated: 07/13/2025. Provide peri care after each incontinent episode. Date Initiated: 07/13/2025. See care plans on Mobility, ADLs, Cognitive Deficit, Communication. Date Initiated: 07/13/2025. Resident #1 usually understands verbal content from staff and/or other resident's d/t dx cognitive communication deficit. Revision on: 07/13/2025.Record review of Resident #1's progress notes: 7/1/2026 8:01 pm Note Text: notified administrator and DON of verbal abuse incident.7/1/2026 9:39 pm Note Text: Total head-to-toe assessment done following a report that a nurse overheard a CNA speaking to resident in an inappropriate manner. Resident was interviewed privately regarding the interaction. Resident was alert and oriented to her baseline. Resident denies any physical abuse and did not express fear of staff. Resident was unable to recall the interaction and stated she did not hear anything. Asked resident how she felt, and she stated I'm fine, how are you?Psychosocial assessment completed; resident's mood was calm, affect appropriate, and behavior consistent with baseline. No signs of acute emotional distress, anxiety, tearfulness, or withdrawal observed during assessment. 9:30 pm MD on call notified of incident and monitoring in effect. 7/2/2026 9:04 am Note Text: Dr. notified of an alleged allegation of verbal abuse that occurred last night. No new orders at this time. Resident appears calm and content. No s/s of distress noted. Denies any s/s of depression at this time.Record review of the facility's incident report dated 07/01/26 at 8:00 pm revealed Resident #1 was the victim of an alleged abuse incident. Record review of LVN C's written statement revealed: This nurse (LVN C) was on the hall passing meds when CNA A walked down the hall and stated loudly, oooh it smells like shit and told Resident #1, Why you gotta smell like shit, [First name of Resident #1]. As she walked out of the room, she was asked what she was doing by another resident, and she stated, looking for a battery to put this fat ass to bed. The other resident just laughed. Attempted contact with LVN C on 07/15/26 at 2:00 pm. No response.Attempted contact with CNA A on 07/15/26 at 2:05 pm. No response.Attempted contact with LVN C via the ADM on 07/16/2026 at 10:00 am. No response.Attempted contact with CNA A on 07/16/26 at 10:05 am. No response.Attempted text and voice message with LVN C on 07/16/2026 at 8:00 pm and 9:15 pm. No response.Attempted text and voice message with CNA A on 07/16/2026 at 8:05 pm and 9:20 pm. No response.Record review of the monthly grievance log dated July 2026 revealed on 07/01/26 grievances were filed regarding the CNA (A) with blue hair being rude (CNA A).Record of the PIR (provider investigation report) dated 07/01/26 revealed a grievance, and witness statement dated 07/01/26 revealed a resident (unnamed) stated to the ADM, the CNA A with blue hair is rude. The C.N.A. with blue hair is very rude when she comes in the room. No actual harm occurred; I just don't want her in my room. A grievance and witness statement dated 07/01/26 revealed a resident (unnamed) told a CNA (unnamed) that a lady with blue hair was rude. Record review of CNA A's written statement dated 07/01/26 revealed 7.1.2025. Alleged allegations, I have been presented has been falsely accused, saying I called someone a 'fatass', when I didn't say those words at all, I had said a light was on and I already had answered but didn't know what to do further, because it was about a medic, so I told nurse and light was left on. In an interview with HR on 07/16/26 at 9:30 am, she said she acted as a witness when CNA A was terminated. She said CNA A was emotional, sporadic, and surprised she was being terminated. HR said CNA A never denied or defended herself against the allegation. She said CNA A's personnel file revealed a hire date of 02/26/26.Record review of CNA A's personnel file revealed:Acknowledgement of receipt of the employer-employee manual signed by CNA A on 02/26/26.Employee acknowledgement of safety program/Employee Handbook signed by CNA A on 02/26/26.A written and signed (illegible) statement dated 07/01/26 revealed CNA A is loud with everyone and rude to residents but most likely with everyone. Counseling forms 5/14/26 at 7:00 pm revealed CNA A was seen by a nurse (unnamed) lying down on the sofa downstairs on her cellphone. I asked her if she was on break, and she said she was waiting for someone. On-call nurse notified. Throughout shift, CNA A was observed by both nurses lying on the sofa near the nurses' station on her phone, not answering lights. CNA A made a comment that the call lights were bothering her, and the nurse told her to answer the call lights to make the noise stop. CNA A walked off the hall at 2330 without notifying any nurse. She told the other CNA she needed to step off the hall because she was pissed''.Only one CNA has been taking care of the patients herself and making rounds and stated she did not need orientation. On call nurse notified of 4th floor nurses sending CNA A home. Witness statement: Witnessed CNA A sitting on the couch on her phone while I did a round by myself. I went to the bathroom downstairs, and CNA A followed me and laid on the couch on her phone while waiting for me to get out the bathroom. Witness statement dated 05/15/26: CNA A was not doing rounds. She has been on the couch while everyone else was doing rounds on her phone. A one-on-one in-service dated 05/15/26 regarding cell phone use while on the clock and taking extended breaks, and CNA A must clock out for all breaks.An email from CNA A titled bullying dated 05/15/26 at 9:45 am: In all honestly I told them yesterday n the fact a nurse nitpicking n I did everything n she wants to always put me out there in criticize front of everyone n make me look bad saying I was just on my phone is absurd . I've tried n I tried n I feel like im never going win wit yall so I get it if yall don't want me anymore I don't blame u be I feel like if no one going to like nor respect me n im just an issue . I really did everything documentation when she kept complaining to do it even without my credentials be the password n used someone else's credentials. Did my rounds . Tidy the spot like just everything n still not enough n just be I told the Cna's I'm take a 15 min breather she starts calling on call phone n [NAME] up these crazy lies just to get rid of me be she likes me for no reason! She been pickin on me since my first day! N I never said nun be idc n I didn't think it was a problem n she just escalated herself. I decided to go home be she embarrassed me n I was just embarrassed all around . So uncomfortable in hostile environment when I was just simply existing ik I can't please others n ppl don't like me be the way I look n what not n I get that but bullying me just to do it is crazy. N I've tried really did everything to please but if yall don't want me it's ok. I just wanted to let u know be at this rate im losing n I've lost. N I can keep going but I forgot again bc I been crying for past hour hurting bc all im trying to do is survive n ppl like her always win n ruin it for me. So in sorry once again fr idk vhat I did so wrong for her to nitpick n not like me just sorry fr. What I told the DON so idk what to do anymore n I got sent home early 6 hours n idk she just was really mean n now I think I fr don't have a job anymore period here . Thank u for opportunity tho I just wish things were different.Record review of CNA A's termination document dated 07/09/26 revealed: On 7/2/26, written statements were obtained from fellow coworkers that CNA A had been observed engaging in unprofessional conduct towards residents and employees. Even though a recent allegation could not be substantiated, CNA A was reported for not following the code of conduct on multiple occasions in the workplace. Specifically, 2 residents (unnamed) reported that CNA A was rude and speaks loudly. Fellow CNA (unnamed) states that CNA A is rude with residents and employees, creating a hostile work environment.In an interview with the ADM on 07/16/2026 at 10:00 am, she said CNA A worked nights, and she hadn't heard anything until the day she was told about the allegation. The ADM stated CNA A told her she did not do any of that and she loved her residents. The ADM stated Safe Surveys brought to light several other complaints about CNA A. The ADM stated a couple of days later (when CNA A was due to come back), she had her come into her office for a conversation about the code of conduct and expectations of every employee. The ADM stated she felt CNA A did not meet those expectations because of the statements she received from other residents during safe surveys. She said CNA A told her she had a loud voice and loved her residents and started crying. The ADM stated CNA A said, I'm not rude, I'm just loud. The ADM stated CNA A denied the original statements reported. The ADM stated CNA A came in again for her termination (about 5 days after the original suspension), and she was kept off the schedule. The ADM stated CNA A called daily asking to come back to work. The ADM stated HR was witness to the termination and did not say anything. The ADM stated she spoke with LVN C and was told she did not feel like she was picking on anyone. The ADM stated LVN C did a 1:1 with CNA A about the allegation. The ADM stated she was notified by LVN C on 07/01/26 around 8 pm. The ADM stated she came to the facility, spoke with LVN C, got her written statement, then spoke with CNA A, got her written statement, and was told she would be suspended immediately pending investigation. The ADM stated CNA A said, ok, and left. The ADM told her she would call her back. The ADM stated there were cameras in the building, but they did not work and never have; there was no server for them, and they were useless other than being good decoys. She said she came into the facility at night every so often to check in with the night staff. She said HR was often in the building in the early evenings and checked on them too. The ADM stated the ADON also came to work around 4 am frequently and also checked on staff & residents. In an interview with LVN D on 07/15/26 at 4:10 pm, she said she had heard of two other residents (unnamed) that complained of CNA A's tone and her being rude. LVN D said she had not worked with CNA A.In an interview with the CMA on 07/15/26/at 4:12 pm, she said she had heard about CNA A speaking rudely to Resident #1, and it was never ok to speak to residents in a disrespectful manner.Record review of all staff in-services revealed the following: 07/01/26-Resident Rights. 07/01/26-Abuse and Neglect-Specifically to verbal. 07/02/26-Employee Conduct/Handbook Policy.Record review of the undated facility handout regarding nursing home residents revealed: Nursing home residents are guaranteed comprehensive protections under federal and state laws. These include the right to be free from abuse and neglect, to receive dignified treatment. to make personal choices about daily routines and medical care. to maintain privacy. and to live in a safe. respectful environment. These vital rights can be grouped into several core categories: Quality of Life & Dignity, Freedom from Abuse & Restraints.Record review of the undated facility Employee Expectations and Safety section of the Handbook Policy revealed under Employee Conduct: Employees are expected to accept certain responsibilities, follow acceptable business principles in matters of conduct, and exhibit a high degree of integrity at all times. This not only involves sincere respect for the rights and feelings of others, but also demands that employees refrain from any behavior that might be harmful to themselves, residents, co-workers, or that might be viewed unfavorably.Employee conduct reflects upon us all.The following are some examples of the kind of conduct that would warrant discipline, up to and including termination:.Use of obscene, abusive or threatening language.Record review of the signature page of the facility's Employee Handbook: This Acknowledgment confirms that I have received a copy of the Employee Handbook (Handbook). I agree to read and become familiar with its contents. If I do not understand any policy or procedure outlined in this Handbook, I will contact a human resources representative for clarification. I also understand that this Handbook has been drafted as a guideline for employees. I understand that the company reserves the right to revoke, change, or supplement these guidelines at any time, and this Handbook is not a contract nor does it create any guarantees. I recognize that neither this Handbook nor any other communication about company policies by a management representative, either written or verbal, is intended, in any way, to create an employment agreement or a guarantee of continued employment. Rather, this Handbook and related communications merely describe the company's general philosophy concerning policies and procedures. These policies and procedures are in effect unless otherwise preempted by applicable federal, state and local law. I also understand that my employment is at-will and may be terminated at any time by either myself or my employer without cause. I understand that the at-will nature of my employment cannot be altered or modified by a supervisor, manager or other company representative; rather, when the company seeks to alter at-will employment, it does so through a written agreement. I have read this Acknowledgment and understand its contents.Record review of the facility's policy dated 07/11/25, titled, Abuse, Neglect, and Exploitation Under Definitions Abuse means the willful infliction of injury. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, or others.Verbal Abuse'' means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend. or disability.

Based on observation, interview, and record review, the facility failed to ensure residents' environment remains as free of accidents and hazards as possible for 1 of 5 residents (Resident #3) reviewed for abuse, neglect, and exploitation.The facility failed to protect Resident #3 from neglect when the AA failed to apply her smoking apron, and Resident #3 received a cigarette burn on 03/19/2026.These failures could place residents at risk for physical and/or psychological harm or injury.The findings included:Record review of Resident #3's face sheet, dated 04/10/2026, revealed a [AGE] year-old female with an original admission date of 02/15/2024, and a current admission date of 06/11/2024. Resident #3's diagnoses included Type 2 Diabetes (a chronic condition which affects how your body metabolizes sugar [glucose], leading to high blood sugar levels and various health complications) and Dementia with other behavioral disturbances (a condition which affected memory, thinking, and the ability to perform daily activities, as well as could include symptoms such as agitation, aggression, delusions, and/or hallucinations).Record review of Resident #3's Quarterly MDS assessment, dated 03/04/2026, revealed a BIMS score of 09, which indicated moderately impaired cognition. Resident #3's MDS also revealed disorganized thinking which comes and goes and changes in severity.Record review of Resident #3's care plan, initiated 03/20/2026, revealed Resident #3 sustained a burn to her left thigh while smoking. Interventions included educate resident on safe smoking practices. Resident #3 also had a care plan, initiated 02/16/2025 and revised 03/20/2026, to use a smoking apron. Interventions included Resident #3 required a smoking apron while smoking, and Resident #3 required supervision while smoking. Record review of Resident #3's progress note, dated 03/19/2026, revealed Resident #3 had a partial thickness burn (a second degree burn which damages the outer and underlying layers of the skin) to the left front thigh, with an intact, fluid-filled blister with redness around the wound. In an interview on 04/10/2026 at 10:44 AM, the AA stated Resident #3 could be very impatient when wanting to smoke. The AA stated she was the one who gave and lit Resident #3's cigarette for her without first applying her apron. She stated not all the smokers wear aprons, but most typically do. The AA stated she never saw Resident #3 drop the cigarette, but Resident #3 stated she had dropped it, so the AA picked the cigarette up out of Resident #3's lap and handed it back to her. While putting Resident #3's smoking apron on, Resident #3 stated the area was still burning. The AA stated she saw the ember and knocked it off Resident #3's lap, but she had not noticed a hole in Resident #3's clothing. The AA stated Resident #3 continued to smoke, and after Resident #3 went back to her floor, the CNA performing peri-care noticed the burn on Resident #3, which was in the same location the ember had fallen. The AA stated the smoking aprons were used to prevent situations such as dropping cigarettes or embers and burning residents' clothing or skin. The AA stated she should have placed the apron on prior to lighting Resident #3's cigarette, and she received a counseling and a suspension for the incident. In an interview on 04/10/2026 at 11:48 AM, CNA-B stated she was putting Resident #3 to bed and got ready to change her when she noticed the burn to Resident #3's upper left thigh area. CNA-B stated the burn looked like a fresh burn with a blister and white-grey color to it. CNA-B reported the burn to the charge nurse. She stated after the incident, the staff were in-serviced over smoking safety and using smoking aprons, as well as abuse and neglect.Record review of the facility's Abuse, Neglect, and Exploitation policy, dated 07/11/2025, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Record review of the facility's Resident Smoking policy, dated 10/24/2022, revealed 6. Residents who smoke with be further assessed, using the Smoking Safety Screen to determine safety with smoking. 14. The IDT, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by: d. Developing a safe smoking plan.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the residents' medical, nursing, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for person-centered care plans:The facility failed to recognize, develop, and implement a care plan and care plan interventions with measurable timeframes and objectives to address Resident #1's aggressive behaviors prior to his physical aggression incident on 03/29/2026.These failures could affect residents by placing them at risk of not being provided with the necessary care and services to address their needs. The findings included:Record review of Resident #1's face sheet, dated 04/09/2026, revealed a [AGE] year-old male with an admission date of 06/28/2024. Resident #1's diagnoses included Unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities), and a history of Transient Ischemic Attack with Cerebral Infarction (a blockage or disruption of blood flow to the brain).Record review of Resident #1's Quarterly MDS assessment, dated 02/27/2026, revealed a BIMS score of 03, which indicated severely impaired cognition. Resident #1's MDS also revealed Resident #1 exhibited verbal behaviors toward others, as well as he utilized a cane as a mobility device.Record review of Resident #1's care plan, initiated 03/30/2026, revealed Resident #1 had the potential to be physically aggressive toward other residents. Interventions included Resident #1's behaviors were de-escalated by redirection and intervening, as well as monitor, document, and report as needed any signs or symptoms of Resident #1 posing a danger to himself or others. There were no other care plans prior to the physical aggression on 03/30/2026 which addressed Resident #1's verbally or physically aggressive behavior. Record review of Resident #1's progress note, written by the SW, dated 03/29/2026, revealed Resident #1 hit another resident in the face. Another progress note, written by the SW, dated 03/30/2026, revealed Resident #1 made another attempt to engage in physical contact with another resident, but nursing staff were able to intervene and prevented resident-to-resident contact. The SW noted a resident was in the elevator on his way to his floor when Resident #1 tried to engage with him. An activities progress note, dated 11/26/2025, revealed Resident #1 being very demanding and making rude comments toward another resident. A nursing progress note, dated 12/12/2025, revealed Resident #1 was upset with his girlfriend and stated, where the hell have you been and fuck you. A nursing progress note dated 01/04/2026 revealed Resident #1 yelled at his girlfriend's neighbor for going around in a brief. A progress note written by the SW, dated 01/05/2026, revealed Resident #1 was educated about other patient's rights after he made a gesture to try to hit another resident with his cane after becoming upset. Record review of Resident #1's change of condition assessment, dated 10/06/2025, revealed Resident #1 was angry with his roommate and was yelling at his roommate.Record review of the facility's incident reports revealed Resident #1 had a resident-to-resident incident on 03/29/2026.In an interview on 04/09/2026 at 11:16 AM, the Receptionist stated a resident was sitting at the front desk by the front door talking to her just looking around when Resident #1 started cursing from across the room at him. She stated Resident #1 thought the resident was looking at his girlfriend. She stated Resident #1 continued to curse at the resident while he crossed the room, and then he began to punch the other resident on the side and back of his head. The Receptionist tried telling him to stop as he was crossing the room and started to hit the other resident, but Resident #1 was not listening to her, so she ran to call for help. In an interview on 04/09/2026 at 1:50 PM, the SW stated she was called up to the facility after the altercation between Resident #1 and another resident. The SW stated Resident #1 recalled and admitted to the altercation, but stated he was defending himself. She stated Resident #1 had never really exhibited physical aggression previously other than an instance when he got agitated and threatened to hit another resident with his cane, and once when he became angry with a roommate over the television. She stated he had been verbally aggressive in the past, and she had previously educated him over his as well as other residents' rights. The SW stated if Resident #1 was having verbal aggression toward others, it should have been care planned. She also stated typically nursing would have care planned this. In an interview on 04/13/2026 at 9:15 AM, the Administrator stated she had never seen Resident #1 get physically aggressive with anyone in the past. She stated he had always been pleasant and polite to her. She stated Resident #1 had some issues with depression and anxiety, and had gotten upset before, but never had physical aggression which she knew of. In an interview on 04/14/2026 at 9:37 AM, the MDS nurse stated if Resident #1 had any type of physical or verbal aggression previously, it should have been care planned, and anyone on the IDT could have added it, but typically the SW added behavior care plans. The MDS nurse stated interventions would have included trying to determine what the triggers were or what set the resident off and attended to any needs they would have been having at the time.Record review of the facility's Comprehensive Care Plans policy, implemented 10/24/2022, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for of 5 residents (Resident #2) reviewed for abuse, neglect, and exploitation.The facility failed to protect Resident #2 from physical abuse when Resident #1 hit Resident #2 multiple times in the head and fell to the floor with him on 03/29/2026.These failures could place residents at risk for physical and/or psychological harm or injury.The findings included:1. Record review of Resident #1's face sheet, dated 04/09/2026, revealed a [AGE] year-old male with an admission date of 06/28/2024. Resident #1's diagnoses included Unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities) and a history of Transient Ischemic Attack with Cerebral Infarction (a blockage or disruption of blood flow to the brain).Record review of Resident #1's Quarterly MDS assessment, dated 02/27/2026, revealed a BIMS score of 03, which indicated severely impaired cognition. Resident #1's MDS also revealed Resident #1 exhibited verbal behaviors toward others, as well as he utilized a cane as a mobility device.Record review of Resident #1's care plan, initiated 03/30/2026, revealed Resident #1 had the potential to be physically aggressive toward other residents. Interventions included Resident #1's behaviors were de-escalated by redirection and intervening, as well as monitor, document, and report, as needed, any signs or symptoms of Resident #1 posing a danger to himself or others. Record review of an activities progress note, dated 11/26/2025, revealed Resident #1 was being very demanding and making rude comments toward another resident.Record review of a nursing progress note, dated 12/12/2025, revealed Resident #1 was upset with his girlfriend and stated, where the hell have you been and fuck you.Record review of a nursing progress note, dated 01/04/2026, revealed Resident #1 yelled at his girlfriend's neighbor for going around in a brief.Record review of a progress note, written by the SW, dated 01/05/2026, revealed Resident #1 was educated about other patients' rights after he made a gesture and tried to hit another resident with his cane after he became upset. Record review of Resident #1's progress note, written by the SW, dated 03/29/2026, revealed Resident #1 hit another resident in the face.Record review of Resident #1's progress note, written by the SW, dated 03/30/2026, revealed Resident #1 made another attempt to engage in physical contact with Resident #2, but nursing staff intervened and prevented resident-to-resident contact. The SW noted Resident #2 was in the elevator on his way to his floor when Resident #1 tried to engage with him. Record review of Resident #1's change of condition assessment, dated 10/06/2025, revealed Resident #1 was angry with his roommate and was yelling at his roommate.Record review of the facility's incident reports revealed Resident #1 and Resident #2 had a resident-to-resident incident on 03/29/2026.2. Record review of Resident #2's face sheet, dated 04/10/2026, revealed a [AGE] year-old male with an admission date of 03/13/2026. Resident #2's diagnoses included Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes) and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning).Record review of Resident #2's admission MDS assessment, dated 03/19/2026, revealed a BIMS score of 07, which indicated severely impaired cognition. Resident #2's MDS also revealed no physical or verbal behaviors directed toward others.Record review of Resident #2's care plan, initiated 03/29/2026, revealed Resident #2 was involved in a physical altercation with another resident. Interventions included assessing for feelings of fear, anxiety, and/or behavioral changes after the incident; assessing Resident #2 for injuries; encourage Resident #2 to report any concerns immediately without hesitation. Another care plan, initiated 04/02/2026, revealed Resident #2 had an actual fall from his wheelchair during the physical altercation on 03/29/2026 and had an acute left distal clavicular fracture (a fracture which typically occurred after a direct blow to the shoulder, such as a fall) with clavicular superior displacement (a condition in which the clavicle, or collarbone, was displaced) to left shoulder. Interventions included Resident #2 was to follow-up with an orthopedist, medicate for pain as needed, and a physical therapy consult for strength and mobility. Record review of the Provider Investigation Report, dated 04/02/2026, revealed the description of the allegation included Resident #2 was sitting in his wheelchair talking to the receptionist at the front desk when Resident #1 got up from across the lobby and walked toward Resident #2 while using foul language. The receptionist told Resident #1 to stop and ran to the phone to call for assistance. Resident #1 was punching Resident #2, and they both fell to the floor. Investigation summary revealed Resident #1 became upset and agitated when Resident #2 was talking to a female resident. Resident #2 was sent to the emergency room for an evaluation where he was noted to have sustained an ear injury. On 04/01/2026 Resident #2 complained of pain to the left shoulder, and an x-ray revealed an acute left distal clavicular fracture with clavicular superior displacement. The Provider Investigation Report concluded the facility unsubstantiated the incident as both residents have no prior history of this type of behavior. In an observation on 04/10/2026 at 9:55 AM, the chair Resident #1 was sitting in prior to walking over and punching Resident #2 on 03/29/2026 was approximately 25 feet away from where Resident #2 was sitting.In an interview on 04/09/2026 at 11:16 AM, the Receptionist stated Resident #2 was sitting at the front desk by the front door talking to her, and just looking around, when Resident #1 started cursing from across the room at him. She stated Resident #1 thought Resident #2 was looking at his girlfriend. She stated Resident #1 continued to curse at Resident #2 while he crossed the room, and then he began to punch Resident #2 in the side and back of his head. The Receptionist tried telling him to stop as he was crossing the room and started to hit Resident #2, but Resident #1 was not listening to her, so she ran to call for help. She stated Resident #2 was in his wheelchair when the altercation was occurring, and he cursed back and Resident #2 wrapped his arms around Resident #1, and they both fell to the floor while still punching each other. She stated the nurse, as well as another resident came and assisted with getting the residents separated, and she had not noted any obvious injuries to either resident after the altercation. In an interview on 04/09/2026 at 1:50 PM, the SW stated she was called up to the facility after the altercation between Resident #1 and Resident #2. The SW stated Resident #1 recalled and admitted to the altercation, but stated he was defending himself. She stated Resident #1 had never really exhibited physical aggression previously other than an instance when he got agitated and threatened to hit another resident with his cane. She stated she had previously educated Resident #1 over his, as well as other, resident's rights. In an interview on 04/10/2026 at 10:27 AM, LVN-A stated Resident #2 did not have any injuries from the altercation on 03/29/2026. She stated she did a complete head-to-toe assessment on Resident #2 after the altercation, and he was doing okay but had some redness and slight swelling to his head and was complaining of right ear pain, which was one of the areas he had been hit. LVN-A stated they sent Resident #2 to the ER to just be assessed, and he was monitored for approximately 2 hours, and he refused treatment, so the ER sent him back with no new orders. LVN-A stated Resident #2's redness had subsided before she left at the end of her shift, and she hadn't noticed any other issues or injuries with Resident #2. In an interview on 04/13/2026 at 9:13 AM, the RNC stated it was only approximately 15 feet from where Resident #1 was to Resident #2 prior to the altercation on 03/29/2026. The RNC stated the receptionist told Resident #1 to stop the altercation, and she ran to call for assistance. She stated the receptionist was the only one monitoring the residents on the first-floor lobby area during the time of the incident as there was no requirement for there to be any other staff in the lobby area to monitor the residents. In an interview on 04/13/2026 at 9:15 AM, the Administrator stated she had never seen Resident #1 get physically aggressive with anyone in the past. She stated he had always been pleasant and polite. She stated Resident #1 had some issues with depression and anxiety, but never with any physical aggression she knew of. The Administrator stated Resident #1 was very fast, even though he utilized a cane, he was very fast and hit Resident 2 before the Receptionist could stop him. The Administrator stated the receptionist told him to stop and ran to call for assistance. She stated Resident #2 did not have any serious injuries, and the staff were in-serviced over abuse and neglect, as well as resident-to-resident altercations after the incident.Record review of the facility's Abuse, Neglect, and Exploitation policy, dated 07/11/2025, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Record review of the facility's Resident Smoking policy, dated 10/24/2022, revealed 6. Residents who smoke with be further assessed, using the Smoking Safety Screen to determine safety with smoking. 14. The IDT, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by: d. Developing a safe smoking plan.

Based on interview and record review, the facility failed to manage the personal funds deposited by residents for 1 (Resident #4) of 5 residents reviewed for residents' rights.The facility failed to ensure Resident #4 had access to his personal funds upon request in a timely manner on 04/03/2026.This failure could place residents whose funds were managed by the facility without access to their funds deposited within the facility.The findings Included: Record review of Resident #4's face sheet dated 04/10/2026 revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] with a readmission on [DATE]. Resident #4's admitting diagnosis was Transient Cerebral Ischemic Attack (a mini stroke which occurred when there was a temporary interruption of blood flow to the brain).Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated intact cognition. Record review of Resident #4's care plan, initiated 08/13/2024, revealed Resident #4 was independent with meeting emotional, intellectual, physical, and social needs. Record review of Resident #4's Resident Statement, dated 04/13/2026, revealed Resident #4 had a balance of $1,250.37 in his personal trust fund through the facility.In an interview on 04/13/2026 at 10:00 AM, Resident #4 stated he could not recall the exact date, but there was a Friday when he had requested to get some of his money, but they (the facility) would not give it to him. He stated he was supposed have gotten $75.00 per month, but sometimes they did not give it to him when he wanted it.In an interview on 04/13/2026 at 10:50 AM, the BOM stated when a resident's check came through, their board and room were paid, and the rest got deposited into a resident trust fund account. She stated Medicaid applied money toward the resident's room and board plus $75.00 for spending on what they wanted and/or needed. She stated Resident #4 was under the assumption his entire check was supposed to be given to him, even though they have explained to him it did not work this way. The BOM stated when a resident wants to withdrawal money from their account, they fill out a form, and the money was then pulled from the petty cash box. If there was not enough money in the petty cash box, the Administrator would cash a check and replenish the box. The BOM stated they tried to always make sure they had the money on-site, and there was always someone there during business hours to honor the request, and the longest she thought Resident #4 ever had to wait for his money was maybe 2 hours. In an interview on 04/13/2026 at 2:30 PM, the ABOM stated Resident #4 came to the business office on the evening of Friday April 3rd, maybe around 3:00 or 4:00 PM, asking for his money, and he was told the BOM was gone for the day, and she would not be back until Monday. The ABOM stated she had a key and access to the petty cash, but she had forgotten her key at home on this day, so Resident #4 did not get any money this day. The ABOM stated Resident #4 was angry, yelling and cussing because he expected to get his money as soon as he requested it. The Administrator was already gone at this time as well on this day, and she could not remember if she had notified the administrator or not. Resident #4 did not end up getting his money until the following Monday on 04/06/2026. The ABOM stated they have always tried to get the residents their money the same day it was requested, unless it was an amount over $100.In an interview on 04/13/2026 at 3:00 PM, the Administrator stated they did not have a specific policy regarding keeping and giving residents their funds, but they have a procedure they followed. She also stated there was always someone there with a key during business hours (Monday - Friday 8:00 AM - 5:00 PM) to give residents access to their funds, and if a resident requests a reasonable amount of money it should be given as soon as possible. The Administrator also stated there was no one there on the weekends to give residents access to their funds if requested, but this was why they gave them out on Fridays.Record review of the facility's Resident Trust Fund Procedures, revised 01/13/2026, revealed Additional Review Items Required: Witnesses: Be aware of resident needs and status. Record Retention: B. Resident Trust Fund transactions should be recorded daily, as they happen. C. Resident Petty Cash: Petty cash box should be reconciled daily.Record review of the facility's updated Personal Funds and Resident Trust Fund policy revealed Residents have the right to select how personal funds will be handled.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 5 of 10 residents (Resident #23, Resident #47, Resident #66, Resident #74, and Resident #82) reviewed for medication errors. 1. The facility failed to ensure LVN C did not document NA in place of Resident #23's blood pressure and pulse when her blood pressure altering medication was administered on 06/03/25, 06/06/25, 06/07/25, 06/08/25, 06/16/25, 06/25/25, 06/26/26, 07/06/25, 07/07/25, and 07/08/25. The facility failed to ensure LVN C did not document NA in place of Resident #23's BP, temp, pulse, resp, and O2 sats on 06/07/25, 06/16/25, 06/25/25, 06/26/25, 07/04/25, 07/05/25, and 07/06/25 when vital signs were to be documented on every day shift on Saturday (04/12/25 to 06/09/25) then every shift (began 06/13/25) per the two physician's orders. The facility failed to ensure LVN P did not document X or NA in place of Resident #23's BP, temp, pulse, resp, and O2 sats on 06/13/25, 06/14/25, 06/23/25, 06/24/25, 06/27/25, 06/28/25, and 06/29/25 when vital signs were to be documented on every shift (began 06/13/25) per the physician's order. The facility failed to ensure LVN Q did not document X in place of Resident #23's BP, temp, pulse, resp, and O2 sats on 06/16/25, 06/17/25, 06/21/25, 06/22/25, 06/25/25, 06/26/2506/30/25, 07/01/25, 07/04/25, 07/05/25, and 07/06/25 when vital signs were to be documented on every shift (began 06/13/25) per the physician's order. 2. The facility failed to clarify the blood pressure parameters for Resident #47's Midodrine (a medication used to treat hypotension, or low blood pressure) orders for June and July of 2025. The facility failed to administer Resident #47's Midodrine per the recommended and prescribed blood pressure parameters in June and July of 2025. 3. The facility failed to ensure LVN C did not document NA in place of Resident #66's blood pressure when his blood pressure altering medications were administered on 06/06/25, 06/07/25, 06/25/25, 07/04/25, 07/05/25, and 07/06/25. The facility failed to ensure LVN C did not document NA in place of Resident #66's BP, temp, pulse, resp, and O2 sats on 06/07/25 and 07/05/25 when vital signs were to be documented every day shift, every 7 days per the physician's order. 4. The facility failed to ensure MA B did not administer Resident #74's blood pressure/pulse altering medications on 06/01/25 when his blood pressure was not within the required parameters per the two physician's orders. The facility failed to ensure MA B administered Resident #74's blood pressure/pulse altering medication on 06/10/25 when his blood pressure was within the required parameters per the physician's order. The facility failed to ensure LVN Q administered Resident #74's blood pressure/pulse altering medication on 06/16/25, 06/22/25, 06/26/2507/01/25, and 07/05/25 when his blood pressure was within the required parameters per the physician's order. The facility failed to ensure LNV R administered Resident #74's blood pressure/pulse altering medication on 06/18/25 when his blood pressure was within the required parameters per the physician's order. The facility failed to ensure LVN C did not document NA in place of Resident #74's blood pressure when his blood pressure/ pulse altering medications were administered on 07/04/25, 07/05/25, and 07/06/25. The facility failed to ensure LVN C did not document NA in place of Resident #74's BP, temp, pulse, resp, and O2 sats on 06/06/25 and 07/04/25 when vital signs were to be documented every day shift, every 7 days per the physician's order. 5. The facility failed to ensure MA D administered Resident #82's blood pressure altering medication on 06/02/25 and 06/11/25, when there were no required parameters per the physician's order. The facility failed to ensure MA D administered Resident #82's blood pressure altering medications on 06/03/25, 06/07/25, 06/12/25, 06/17/25, 06/21/25, and 06/21/25 per the physician's orders. The facility failed to ensure MA B did not administer Resident #82's blood pressure altering medication on 06/14/25 when her blood pressure was not within the required parameters per the physician's order. The facility failed to ensure MA B administered Resident #82's blood pressure altering medications on 07/08/25 per the physician's order. The facility failed to ensure LVN C did not document NA in place of Resident #82's BP, temp, pulse, resp, and O2 sats on 06/03/25, 06/07/25, 06/12/25, 06/17/25, 06/21/25, 06/26/25, 07/01/25, and 07/05/25 when vital signs were to be documented upon return from dialysis every Tue, Thu, and Sat per the physician's order. The facility failed to ensure LVN C did not document NA in place of Resident #82's blood pressure when her blood pressure altering medication was administered on 07/04/25, 07/05/25, and 07/06/25. These failures could place residents who receive blood pressure/pulse altering medications at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease process, and potential hospitalization.1. Record review of Resident #23's admission record revealed a [AGE] year-old female initially admitted to the facility on [DATE] and most recently admitted on [DATE]. Her diagnoses included cerebral infarction (stroke), essential hypertension (high blood pressure), type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), aphasia (an impairment in the ability to read, write, and speak), dysphagia (difficulty swallowing), moderate protein-calorie malnutrition (an imbalance between the nutrients needed to function and the nutrients received), and vascular dementia (problems with thought processes and memory caused by brain damage from impaired blood flow). Record review of Resident #23's quarterly MDS dated [DATE] revealed no BIMS score as she could not speak and her cognitive skills for daily decision making were severely impaired in that she rarely/never made decisions. Record review of Resident #23's physician's orders on 07/08/25 revealed the following orders: Vital signs q shift. Every shift. Start date 06/13/25. Lisinopril Oral Tablet 10 mg. Give 1 tablet via G-Tube one time a day for hypertension. Hold for BP <100/60. Start date 06/17/25. Record review of Resident #23's June 2025 and July 2025 blood pressure and pulse summaries and June 2025 and July 2025 eMARs reflected the following: 06/03/25, 06/06/25, 06/07/25, 06/08/25, 06/16/25, 06/25/25, 06/26/25, 07/04/25, 07/05/25, and 07/06/25 there was no documentation of Resident #23's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she checked Resident #23's 6:00 am vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. LVN C documented she administered Resident #23's 6:00 am dose of Lisinopril and documented NA in both the space for the blood pressure and the space for the pulse on the eMAR. 06/13/25 there was not documentation of Resident #23's blood pressure or pulse the blood pressure and pulse summaries. LVN P documented she checked Resident #23's 6:00 pm vital signs and documented X in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 06/16/25, 06/21/25, 06/22/25, 06/25/25, 06/26/25, 06/30/25, 07/01/25, 07/04/25, 07/05/25 and 07/06/25 there was no documentation of Resident #23's 6:00 pm blood pressure or pulse in the blood pressure and pulse summaries. LVN Q documented she checked Resident #23's 6:00 pm vital signs and documented X in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 2. Record review of Resident #47's face sheet, dated 07/08/2025, revealed a [AGE] year-old male with an original admission date of 09/30/2019, and a current admission date of 03/28/2025. Diagnoses included Alcoholic Cirrhosis of the Liver with Ascites (severe condition resulting from chronic alcohol abuse, leading to liver damage and fluid accumulation in the abdomen), Congestive Heart Failure (long term condition in which the heart cannot pump blood effectively, leading to fluid buildup in the lungs and legs), Hypotension (low blood pressure) and End Stage Renal Disease (end stage kidney disease in which the kidneys can no longer function adequately, resulting in accumulation of waste products, fluids, and electrolytes, requiring dialysis). Record review of Resident #47's care plan, initiated 08/21/2023, and revised on 10/03/2023, revealed a care plan related to hypotension. Interventions included give medications as ordered. Record review of Resident #47's Quarterly MDS assessment, dated 06/13/2025, revealed a BIMS score of 15, which revealed intact cognition. MDS also revealed an active diagnosis of Orthostatic Hypotension. Record review of Resident #47's active physician orders, started 06/12/2025, revealed an order for Midodrine 10 MG, give one tablet by mouth twice per day related to Hypotension; Hold for blood pressure greater than 120/60. Record review of Resident #47's June 2025 MAR revealed Midodrine 10 MG, give 1 tablet by mouth two times per day related to Hypotension. Administer for blood pressure less than 110/50, started 02/26/2025 and stopped 06/12/2025. Dates when Midodrine was held or given inappropriately included: 06/02/2025 9:00 AM B/P 118/62 Administered 06/02/2025 5:00 PM B/P 124/64 Administered06/03/2025 5:00 PM B/P 110/60 Administered06/08/2025 9:00 AM B/P 124/73 Administered06/08/2025 5:00 PM B/P 115/67 Administered06/11/2025 5:00 PM B/P 115/65 Administered Record review of Resident #47's June 2025 MAR revealed Midodrine 10 MG, give 1 tablet by mouth two times per day related to Hypotension. Hold for blood pressure greater than 120/60, started 06/12/2025. Dates when Midodrine was held or given inappropriately included: 06/14/2025 9:00 AM B/P 130/67 Administered06/16/2025 9:00 AM B/P 133/72 Administered06/18/2025 9:00 AM B/P 116/74 Held06/18/2025 5:00 PM B/P 119/71 Held06/19/2025 5:00 PM B/P 119/66 Held06/20/2025 9:00 AM B/P 122/62 Administered06/22/2025 9:00 AM B/P 117/73 Held06/23/2025 5:00 PM B/P 117/74 Held06/24/2025 5:00 PM B/P 120/62 Held06/25/2025 9:00 AM B/P 137/87 Administered06/27/2025 9:00 AM B/P 120/76 Held06/27/2025 5:00 PM B/P 119/71 Held06/28/2025 9:00 AM B/P 118/75 Held06/28/2025 5:00 PM B/P 116/61 Held Record review of Resident #47's July 2025 MAR revealed Midodrine 10 MG, give 1 tablet by mouth two times per day related to Hypotension. Hold for blood pressure greater than 120/60, started 06/12/2025. Dates when Midodrine was held or given inappropriately included: 07/01/2025 5:00 PM B/P 126/74 Administered07/02/2025 9:00 AM B/P 124/69 Administered07/03/2025 5:00 PM B/P 118/85 Held 3. Record review of Resident #66's admission record revealed an [AGE] year-old male initially admitted to the facility on [DATE] and most recently admitted on [DATE]. His diagnoses included chronic kidney disease stage 3 (when the kidneys are damaged and can't filter blood as well as they should), essential hypertension (high blood pressure), atrial fibrillation (an irregular, often fast heartbeat), vascular dementia (problems with thought processes and memory caused by brain damage from impaired blood flow), and cognitive communication deficit (difficulty with communication). Record review of Resident #66's quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Record review of Resident #66's order summary report on 07/07/25 revealed the following orders: Assess vital signs weekly every day shift every 7 days. Start date 02/25/23. Amlodipine Besylate Oral Tablet 5 mg. Give 2.5 mg by mouth one time a day. Hold if SBP <105. Start date 04/22/25. Lisinopril Oral Tablet 20 mg. Give 1 tablet by mouth one time a day related to essential hypertension. Hold for SBP <100. Start date 04/22/25. Record review of Resident #66's June 2025 and July 2025 blood pressure summary and June 2025 and July 2025 eMARs reflected the following: 06/06/25, 06/07/25, 06/25/25, 07/04/25, 07/05/25 and 07/06/25 there was no documentation of Resident #66's 9:00 am blood pressure in the blood pressure summary. LVN C documented she checked Resident #66's 9:00 am vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR (06/07/25 and 07/05/25). LVN C documented she administered Resident #23's 9:00am dose of Amlodipine and Lisinopril and documented NA in both spaces for the blood pressure on the eMAR. 4. Record review of Resident #74's admission record revealed a [AGE] year-old male initially admitted to the facility on [DATE] and most recently admitted [DATE]. His diagnoses included type 2 diabetes mellitus (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), primary hypertension, end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), and dependence on renal dialysis (process of filtering blood through a machine to remove excess water and toxins in the blood when the kidneys no longer function). Record review of Resident #74's quarterly MDS dated [DATE] revealed a BIMS score of 9 which indicated moderate cognitive impairment. Record review of Resident #74's order summary report on 07/07/25 revealed the following orders: Carvedilol Oral Tablet 6.25 mg. Give 1 tablet by mouth every 12 hours for HTN. Hold for BP <110/60 or pulse <60. Start date 01/02/24. End date 06/14/25. Lisinopril Oral Tablet 2.5 mg. Give 1 tablet by mouth one time a day for HTN. Hold for blood pressure <100/60 o pulse <60. Start date 01/02/24. Dialysis days M, W, F at 11:30am. Start date 04/11/25. Carvedilol Oral Tablet 6.25 mg. Give 1 tablet by mouth every 12 hours for HTN. Hold for SBP <90 or pulse <60. Start date 06/14/25. Record review of Resident #74's June 2025 and July 2025 blood pressure and pulse summaries, June 2025 and July 2025 eMAR, and progress notes dated 05/08/25 to 07/08/25 revealed the following: 06/01/25 at 9:00 am Resident #74's blood pressure was documented as 123/56 in the blood pressure summary. MA B documented she administered Resident #74's 8:00 am doses of Carvedilol and Lisinopril when his blood pressure was not within the required parameters per the two physician's orders. 06/06/25 there was no documentation of Resident #74's 6:00 am blood pressure in the blood pressure summary. LVN C documented she checked Resident #74's 6:00 am vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 06/08/25 at 7:32 am Resident #74's blood pressure was 98/54. MA D documented she did not administer Resident #74's 8:00 am dose of Carvedilol due to VS outside of parameters for administration but she did administer his 8:00 am dose of Lisinopril when his blood pressure was not within the required parameters per the physician's order. 06/09/25 at 8:35 am Resident #74's blood pressure was documented as 125/74. There was no pulse documented. MA B documented she did not administer Resident #74's 8:00 am dose of Carvedilol when his blood pressure was within the required parameters for administration, but did administer his Lisinopril. There was no documentation in the progress notes for the Carvedilol non-administration. 06/10/25 at 7:12 am Resident #74's blood pressure was documented as 121/69. There was no pulse documented. MA B documented she did not administer Resident #74's 8:00 am dose of Carvedilol when his blood pressure was within the required parameters for administration, but did administer his Lisinopril. There was no documentation in the progress notes for the Carvedilol non-administration. 06/16/25 at 7:09 pm Resident #74's blood pressure was documented as 109/58. There was no pulse documented. LVN Q documented she did not administer Resident #74's 8:00 pm dose of Carvedilol when his blood pressure was within the required parameters for administration. LVN Q did not document a comment in the Carvedilol medication administration note. 06/22/25 at 7:36 pm Resident #74's blood pressure was documented as 101/57. There was no pulse documented. LVN Q documented she did not administer Resident #74's 8:00 pm dose of Carvedilol when his blood pressure was within the required parameters for administration. LVN Q there was no documentation in the progress notes for Carvedilol non-administration. 06/26/29 at 6:39 pm Resident #74's blood pressure was documented as 111/58. There was no pulse documented. LVN Q documented she did not administer Resident #74's 8:00 pm dose of Carvedilol when his blood pressure was within the required parameters for administration. LVN Q did not document a comment in the Carvedilol medication administration note. 07/01/25 at 7:11 pm Resident #74's blood pressure was documented as 101/59. There was no pulse documented. LVN Q documented she did not administer Resident #74's 8:00 pm dose of Carvedilol when his blood pressure was within the required parameters for administration. LVN Q did not document a comment in the Carvedilol medication administration note. 07/04/25, 07/05/26 and 07/06/25 there was no documentation of Resident #74's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she checked Resident #74's 6:00 am vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. LVN C documented she administered Resident #74's 8:00 am doses of Carvedilol and Lisinopril and documented NA in both the spaces for the blood pressure on the eMAR. 07/05/25 at 7:04 pm Resident #74's blood pressure was documented as 101/58. There was no pulse documented. LVN Q documented she did not administer Resident #74's 8:00 pm dose of Carvedilol when his blood pressure was within the required parameters for administration. LVN Q did not document a comment in the Carvedilol medication administration note. 5. Record review of Resident #82's admission record revealed a [AGE] year-old female initially admitted to the facility on [DATE] and most recently admitted [DATE]. Her diagnoses included type 2 diabetes mellitus, vascular dementia, primary hypertension, end stage renal disease, dependence on renal dialysis, and cognitive communication deficit. Record review of Resident #82's quarterly MDS dated [DATE] revealed a BIMS score of 6 which indicated severe cognitive impairment. Record review of Resident #82's order summary report on 07/07/25 revealed the following orders: Dialysis: Tues/ Thurs/ Sat. Needs to be there by 11:00 am. Start date 10/30/23. Assess vital signs upon return from dialysis T, TH, SAT. Every day shift every Tue, Thu, Sat. Start date 01/23/24. Carvedilol Tablet 12.5 mg. Give 1 tablet by mouth two times a day related to hypertension. (No hold parameters) Start date 01/03/24. Stop date 06/13/25. Carvedilol Tablet 12.5 mg. Give 1 tablet by mouth two times a day related to hypertension. Hold medication for BP <100/60. Start date 06/13/25. Record review of Resident #82's June 2025 and July 2025 blood pressure and pulse summaries, June 2025 and July 2025 eMAR, and progress notes dated 05/08/25 to 07/08/25 revealed the following: 06/02/25 at 9:56 am Resident #82's blood pressure was documented as 122/57. There was no pulse documented. MA D documented she did not administer Resident #82's 9:00 am dose of Carvedilol with comment code 4 which meant, VS outside of parameters for admin, when there were no parameters for administration. MA D did not document a comment in the orders administration note. 06/03/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. MA D documented she did not administer Resident #84's 9:00am or 5:00 pm doses of Carvedilol with code 9 which meant, other/ see progress notes. MA D documented at 9:25 am in the orders administration progress note, Pt going to dialysis. MA D did not comment in the 5:00 pm orders administration note. 06/03/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she checked Resident #82's after dialysis vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 06/07/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. MA D documented she did not administer Resident #84's 9:00am or 5:00 pm doses of Carvedilol with code 9 which meant, other/ see progress notes. MA D documented at 1:31 pm in the orders administration progress note, Pt gone to dialysis. MA D did not comment in the 5:00 pm orders administration note. 06/07/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she checked Resident #82's after dialysis vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 06/11/25 at 1:42 pm Resident #82's blood pressure was documented as 113/54 and 106/58 at 4:34pm. There was no pulse documented. MA D documented she did not administer Resident #82's 9:00 am or 5:00 pm doses of Carvedilol with comment code 4 which meant, VS outside of parameters for admin, when there were no parameters for administration. MA D did not document a comment in the orders administration note. 06/12/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. MA D documented she did not administer Resident #84's 9:00am or 5:00 pm doses of Carvedilol with code 7 which meant, Sleeping- see progress note. MA D documented at 10:14 am in the orders administration progress note, Pt left to dialysis. MA D did not comment in the 5:00 pm orders administration note. 06/12/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she checked Resident #82's after dialysis vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 06/14/25 at 9:00 am Resident #82's blood pressure was documented as 108/51. MA B documented she administered Resident #82's 9:00 am dose of Carvedilol when her blood pressure was not within the required parameters for administration per the physician's order. 06/17/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. MA D documented she did not administer Resident #84's 9:00am or 5:00 pm doses of Carvedilol with code 9 which meant, other/ see progress note. MA D documented at 11:29 am in the orders administration progress note, Pt in dialysis. MA D did not comment in the 5:00 pm orders administration note. 06/17/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she checked Resident #82's after dialysis vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 06/21/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. MA D documented she did not administer Resident #84's 9:00am or 5:00 pm doses of Carvedilol with code 9 which meant, other/ see progress note. MA D documented at 1:11 pm in the orders administration progress note, Pt in dialysis. MA D did not comment in the 5:00 pm orders administration note. 06/21/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she checked Resident #82's after dialysis vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 06/26/25 LVN C documented she checked Resident #82's after dialysis vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 07/01/25 LVN C documented she checked Resident #82's after dialysis vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 07/04/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she administered Resident #82's 9:00 am and 5:00 pm doses of Carvedilol and documented NA in both the spaces for the blood pressure on the eMAR. 07/05/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she administered Resident #82's 9:00 am and 5:00 pm doses of Carvedilol and documented NA in both the spaces for the blood pressure on the eMAR. LVN C documented she checked Resident #82's after dialysis vital signs and documented NA in the space for BP, Temp, Pulse, Resp, and O2 sats on the eMAR. 07/06/25 there was no documentation of Resident #82's blood pressure or pulse in the blood pressure and pulse summaries. LVN C documented she administered Resident #82's 9:00 am and 5:00 pm doses of Carvedilol and documented NA in both the spaces for the blood pressure on the eMAR. 07/08/25 MA B documented she did not administer Resident #82's 9:00 am dose of Carvedilol with an X in the space for the blood pressure on the eMAR and with code, 5 which meant, Hold/ see progress notes. MA B documented at 8:41 am in the orders administration progress note, resident going to dialysis, medications held. In an interview on 07/08/25 at 2:23 pm LVN A stated it was important to check vital signs before giving blood pressure medications because if it was already low, it could drop it too low and if it was too high the doctor needed to be notified and asked if the medications needed to be changed. LVN A stated it was important to document the vital signs when a medication was given or held so the provider and/ or the next shift could look back to see how the BP had been trending. LVN A stated if it was not documented the provider did not have a way to know if medication changes were needed. LVN A stated it was important to follow the physician orders to achieve the therapeutic effect of the medication. LVN A stated they had in- services on mediation administration/ documentation about every month and the last one was about a month ago. LVN A stated before she gave any medication, she read the order, made sure it matched the medication on hand, and made sure it was the right person, right time, right dose, and right reason. In an interview on 07/08/25 at 2:40 pm, the DON stated they were going to have a Back to Basics Nursing 101 class for the nurses and the MAs since she had only been at the facility for two weeks. She stated the documentation of NA or X where vital signs were supposed to be in the eMAR was not acceptable and there was a reason for supplemental documentation on an order. The DON stated she would do a complete one by one audit on each of them the orders/ MARs to make sure everything was ordered and documented correctly. The DON stated nurses and MAs should have had reminders on medication documentation at least monthly and as needed and in-services would be at least every three months and as needed. In an interview with the ADON-K on 07/08/2025 at 3:13 pm, she stated Midodrine was used for residents with low blood pressure. She stated the nurses should be utilizing the parameters in the orders and on the MAR the Midodrine, and if they were not, then they were not following physician's orders. She stated if Midodrine was administered when a resident's blood pressure was already elevated, it could continue to rise, and the resident could possibly have had a stroke. In an interview with the DON on 07/08/2025 at 3:49 PM, she stated Midodrine was used for hypotension and the typical parameters were to hold the medication if the systolic blood pressure was greater than 110 and/or the diastolic blood pressure was greater than 60. She stated these parameters can vary depending on which physician writes the order. She stated if Midodrine was held when a resident's blood pressure was low, the blood pressure could continue to drop and the resident could have had a severe hypotensive crisis, and if it was administered when the residents blood pressure was already high, it could continue to rise and caused the resident to have had a stroke, or even possibly death. In an interview on 07/08/25 at 3:20 pm, MA B stated, it was important to check vital signs because the blood pressure might go lower, and you had to read the parameters to determine if you were allowed to give and it was important to document the vital signs to let the person who reads them know that I checked them. MA B stated if the vital signs were not documented, the provider would not know what the blood pressure was. MA B stated she did not think it was acceptable to put NA where the vital signs went. When asked why she held Resident #82's medication on the morning of 07/08/25, MA B stated there was not an order to hold her BP medications before dialysis but to her, everyone who went to dialysis should not have BP medications before they went because it would drop their blood pressure too low. MA B stated it was not acceptable to hold medications without a physician's order and if a medication was held, the provider needed to be notified. She stated in-services on medication administration were done, but she forgot how often. MA B stated if either of the numbers in a blood pressure was out of parameters, the medication was to be held. MA B stated she did not remember on 06/14/25 if she gave or held the Resident #82's blood pressure medication, but based off the blood pressure that was documented, she would have held it. MA B stated during skills checkoffs with the ADON O they went through the medications, made sure they had the right ones, and asked the physician about parameters if there were not any in the order. In an interview with the LVN-I on 07/08/2025 at 4:22 PM, she stated Midodrine was a blood pressure medicine used for hypotension. She stated she did not remember why she administered the medication outside of parameters, but stated she always took the blood pressure prior to administering the medications. She stated if the resident's blood pressure was already elevated, this medication could cause it to continue to rise, which could cause the resident to have had a stroke or even possibly cause death. Record review of the facility's Medication Administration policy, implemented 10/24/2022, revealed: 8. Obtain and record vital signs, when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview, and record review the facility failed to ensure residents who required dialysis received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #47) reviewed for Dialysis fistula assessment and care. The facility failed to ensure the nurses knew how and were performing the proper technique for assessing Resident #47's dialysis fistula (vascular access used in hemodialysis, which was a treatment for patients with kidney failure) for thrill (a vibration felt over the fistula or shunt) and bruit (swooshing sound cause by blood flow through the fistula or shunt). This deficient practice and failure could place residents at risk for a blockage and/or stenosis (narrowing of the veins and/or arteries) of the fistula site.Record review of Resident #47's face sheet, dated 07/08/2025, revealed a [AGE] year-old male with an original admission date of 09/30/2019, and a current admission date of 03/28/2025. Diagnoses included Alcoholic Cirrhosis of the Liver with Ascites (severe condition resulting from chronic alcohol abuse, leading to liver damage and fluid accumulation in the abdomen), Congestive Heart Failure (long term condition in which the heart cannot pump blood effectively, leading to fluid buildup in the lungs and legs), and End Stage Renal Disease (end stage kidney disease in which the kidneys can no longer function adequately, resulting in accumulation of waste products, fluids, and electrolytes, requiring dialysis). Record review of Resident #47's Quarterly MDS assessment, dated 06/13/2025, revealed a BIMS score of 15, which revealed intact cognition. MDS also revealed an active diagnosis of Dependence on Renal Dialysis. Record review of Resident #47's active physician orders, started 03/13/2024, revealed an order to assess fistula for thrill and bruit every shift. Record review of Resident #47's care plan, initiated 03/15/2024, revealed a care plan related to the need for dialysis due to End Stage Renal Disease with a goal to have no signs or symptoms of complications from dialysis. In an observation on 07/08/2025 at 10:30 AM, LVN-J was noted to have placed the stethoscope appropriately over Resident #47's fistula to listen for bruit, but LVN-J was noted to assess inaccurately above fistula for thrill. In an interview with LVN-J on 07/08/2025 at 10:35 AM, she stated the nurses were supposed to assess the dialysis fistulas each shift for thrill and bruit. She stated she had not done this because she just gets too busy or forgets. She stated she did not think any of the nurses had actually done this because Resident #47 went to dialysis, and the fistula was checked there. In an interview with Resident #47 on 07/08/2025 at 10:40 AM, he stated he was just going to be honest and tell the truth, none of the nurses ever checked his fistula. He stated he did not know they were supposed to check it at the facility since it was checked when he went to dialysis. In an interview with ADON-K on 07/08/2025 at 10:45 AM, she stated the nurses should have and were supposed to know how to assess the dialysis fistula since the orders were to assess it each shift. She stated Resident #47 had a BIMS of 15 and was intelligent, and if he stated it was not getting checked, then she knew it was not getting checked. She stated the nurses were supposed to check for the thrill and bruit because if there was not one, it could mean the fistula had a blockage. In an interview with the DON on 07/08/2025 at 3:50 PM, she stated the nurses knew how and should have been assessing Resident #47's fistula every shift for the thrill and bruit. She stated she was not sure why they had not done it, but it sounded like they were being lazy and just not taking the time to assess it. She stated if the fistula was not assessed appropriately, Resident #47 could have ended up with a blockage in the fistula, which could have stopped the blood flow through the area. She also stated she planned to in-service all the nurses over the importance of assessing the dialysis fistula every shift. Record review of the facility's policy for Writing/Obtaining Orders: Dialysis (AV shunts), no date listed, revealed Obtain orders for days of dialysis, where dialysis would be, Nephrologist name and phone number, to check for thrill and bruit each shift, and to monitor for bleeding upon return from dialysis every shift.

Based on interview and record review, the facility failed to ensure one (Resident #70) of one resident the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. The facility did not provide Resident #70 with a written notice prior to a room change or the right to refuse on 03/27/25. This deficient practice could place residents at risk for being displaced without notice and/or reason to accommodate other individuals.Record Review of Resident #70's Face Sheet dated 07/07/2025 revealed a [AGE] year-old male re-admitted [DATE] with diagnoses including Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves) Quadriplegia (is paralysis that affects the ability to voluntarily move the upper and lower body), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) adult failure to thrive generalized anxiety disorder, and major depressive disorder recurrent. Record Review of Resident #70's quarterly MDS dated [DATE] reflected a BIMS score was unable to be obtained due to the resident being rarely or never understood, indicating severe cognitive impairment for daily decision-making skills. Record Review of Resident #70's care plan 07/07/25 revealed Resident #70 enjoyed eating in his room and did not like to participate in activities, so he spent large amounts of time in his room. Resident #70 would become agitated when he was encouraged to participate in activities. The resident was dependent on staff for all activities of daily living. Record Review of Resident #70's progress notes dated 02/04/25 to 07/08/2025 indicated no documentation or notification to resident representative about why a room change was made. During an interview on 07/07/25 at 9:19 AM with Resident #70's family member and patient representative stated she was never notified about the room change that happened in March of 2025. The family member did not understand why Resident #70 had been moved. The family member recalled there was no problem with the roommate, Resident #70 felt comfortable with the roommate, and it was hard for him to deal with the change. The family member stated Resident #70 did not like to be in the new room as it was too cold for him. Resident #70 would spend a lot of time in the dining room and wanted to sleep there because the new roommate had the temperature too cold for him. The family member stated she got no phone call, letter or verbal explanation as to why Resident #70 was moved even though she asked the nurse who was attending him at the time. In an interview on 07/08/25 at 4:30 PM with the Social Worker who stated she was responsible for giving 30 day written notices to any resident or the patient representative for any type of room change per the Room Change, Transfer and Discharge policy. The Social Worker failed to find any type of documentation that indicated the reason why Resident #70 was relocated to another room on 03/26/25. The Social Worker stated either the nurse, or she was responsible for entering the documentation and could not say why the room change was not documented. During an interview on 07/08/25 at 5:00 PM, the Interim DON said Resident #70's room change occurred before she began her role as DON and could not say why exactly his room was changed but did describe the process of a room change for a resident. The DON said either the nurse, or the Social Worker began the process, but notifications were sent by the Social Worker. The DON stated there was a form filled out and the patient representatives or family member was notified with a 30-day notice unless the resident was moved in an emergency like the room being unlivable or an altercation had occurred, and safety was a concern for one of the residents sharing a room. The facility tried to not violate the resident's right to not be relocated except for the facility's regulations. During an interview on 07/08/25 at 5:15 PM, the Administrator stated the facility tried to follow its policy of a 30-day notice before a resident was relocated into another room by sending notification, speaking to a family member/ resident representative, or make a call. The Administrator could not give an answer as to why there was no documentation of the room change for Resident #70 but did say the Social Worker would usually send out the notice and filled out the form to begin the process and usually the nurses initiate the process. The Administrator was able to produce a copy of the policy and procedures and resident rights of the facility. Review of undated Policy titled, Room Change, Transfer & Discharge revealed Room change. Facility reserves the right to change Resident's room or roommate when Facility determines it is appropriate to do so. The ombudsman, resident, and responsible party will be notified 30 days prior to a change and will provide the reasons for transfer or discharge; the statement of a right to appeal in a language the resident or legal representative understands; the date the change will take place; and record the reasons in the resident's clinical record. The facility will comply in accordance with state and federal regulations.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff and public in 2 (Elevator 1 and Elevator 2) of 3 elevators reviewed for environment. The facility failed to maintain 2 elevators used by residents, staff, and visitors free from offensive odors. This failure could affect all residents that used common areas and place them at risk for diminished quality of life due to the lack of a well-kept environment. During an observation throughout the day beginning on 07/07/25 08:33 AM, this surveyor smelled a strong foul odor on both Elevator 1 and Elevator 2 most of the day. During an observation throughout the day beginning on 07/08/25 08:10 AM this surveyor smelled a strong foul odor on both Elevator 1 and Elevator 2. In an interview on 07/07/25 at 08:45 AM, a visitor who wished to remain anonymous stated the elevators always smelled foul and smelled of urine and feces. In an interview on 07/07/25 at 03:47 PM, the MDS Coordinator agreed that Elevator 1 and Elevator 2 smelled bad and stated they did not smell as bad as they used to. The MDS Coordinator did not elaborate on how long or what kind of foul odor was observed on Elevator 1 and Elevator 2. The MDS Coordinator stated staff have complained about the foul smells in the elevators. In an interview on 07/08/25 08:12 AM, the WCN stated both Elevator 1 and Elevator 2 smelled bad and believed it was because of the carpet that was installed in Elevator 1 and Elevator 2. The WCN stated the elevators were cleaned frequently, but they still had a foul odor. In an interview on 07/08/25 at 11:26 AM, the HS stated the carpets in Elevator 1 and Elevator 2 were shampooed daily in the morning and throughout the day as needed. The HS agreed the elevators have a foul order and stated it was because residents have accidents in them. The HS stated that the elevators are vacuumed and sprayed with shampoo cleaner throughout the day. The HS stated that staff and family members have complained about the foul odor. The HS stated there was no good reason to keep a log or keep record of when the elevators are vacuumed, cleaned, or shampooed but was going to start a log to track the cleaning. In an interview on 07/08/25 at 01:30 PM with the RD revealed the facility was working on getting an approved vendor to remove the carpet. The RD stated the elevators smelled like urine or old carpet. In an interview on 07/08/25 at 01:31 PM the ADM stated the elevators do have a foul odor and stated the elevators smelled of a combination of urine and old carpet. The ADM stated she has had a few family members complain about the foul odor. The ADM stated there was a resident that had a history of urinating in the elevator and housekeeping was cleaning the carpet daily and as needed to help with sanitation. In an interview on 07/08/25 01:32 PM, the MS stated he was aware of the elevators having a foul odor and had been working on getting a quote with an approved vendor to get the carpet taken out. In an interview on 07/08/25 02:55 PM the SW stated the previous ADM installed carpet in the elevators and there are a few residents that have a history of urinating in the elevators or are just unable to wait to go to the bathroom. The SW stated housekeeping was called over the intercom when such an incident occured. The SW stated housekeeping was seen approximately every other day, if not daily shampooing the carpets. Record review of the facility's General Housekeeping Policies not dated reflected: The facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. Nursing personnel are not assigned to routine housekeeping duties. All housekeeping personnel utilize the accepted practices and procedures to keep the facility free from offensive odors, accumulations of dirt, rubbish, dust, and hazards as well as participate in ongoing education and training to maintain or increase their competency. Deodorizers are not used to cover up doors caused by unsanitary conditions or poor housekeeping practices. Odor control is achieved by prompt cleansing of bedpans, urinals, and commodes by prompt and proper care of residents and soiled linens. by good housekeeping procedures, and by approved ventilation.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were labeled and stored in accordance with currently accepted professional principles for 3 of 6 medication carts (2nd Floor Nurse Med-Cart A, 2nd Floor Treatment Cart, 3rd Floor Nurse Med-Cart B, and 3rd Floor Treatment Cart) reviewed for labeling and storage. The facility failed to properly label from 2nd Floor Nurse-Med-Cart-A a vial of insulin Glargine (a long-acting insulin used to treat Type 1 or Type 2 Diabetes), with an open or expiration date. The facility failed to dispose of the medication from 2nd Floor Treatment Cart a container of Hemorrhoidal Pads (a pad used to treat hemorrhoids) 50% which had expired on 03/22/2025. The facility failed to dispose of the medication from 3rd Floor Nurse-Med-Cart-B a card of Promethazine (a medication used to treat nausea) 25 MG which had expired on 05/21/2025. The facility failed to keep the 3rd Floor Treatment Cart free from employee personal items on 07/07/2025 as evidenced by a large, personal, aluminum cup with a straw in it in the bottom drawer of the cart. These deficient practices could place residents at risk of receiving medications or supplies which were both expired and possibly cross-contaminated. In an observation on 07/07/2025 at 9:04 AM of the 2nd floor Nurse-Med-Cart-A it was revealed an approximately 3/4 full, discontinued, expired, and non-dated vial of insulin Glargine which had expired on 6/17/2025 and had never had an opened or expired by date written on it. In an observation on 07/07/25 at 9:13 AM of the 2nd Floor Treatment Cart it was revealed an approximately 1/2 full container of Hemorrhoidal Pads (a pad used to treat hemorrhoids) 50% which had expired on 03/22/2025. In an observation on 07/07/25 at 9:26 AM of the 3rd Floor Nurse-Med-Cart-B a card of Promethazine (a medication used to treat nausea) 25 MG tablet, with 26 tablets left, which had expired on 05/21/2025, as well as a card of Tramadol (a medication used to treat pain) 50 MG, with 9 tablets left, which had expired 06/11/2025. In an observation on 07/07/25 at 9:31 AM of the 3rd Floor Treatment Cart revealed it was not free from employee personal items on 07/07/2025 as evidenced by a large personal aluminum cup with a straw in it in the bottom drawer of the cart. In an interview with LVN-N on 07/07/2025 at 9:35 AM she stated the cup was hers in the treatment cart, and she knew that she was not supposed to have personal items in the cart with resident medications and supplies. She stated the cup could have caused cross-contamination and caused a resident or herself to be exposed to something they would not have been exposed to. In an interview with ADON-L on 07/08/25 at 9:14 AM, she stated the insulin was supposed to be dated when it was opened because it was only good for 28 days. If it was not dated, then it cannot be used because it could possibly be expired. She stated expired meds were removed from the med-carts by the floor nurses at night, as well as the ADONs checked for expired meds weekly. She stated the treatment nurse checked the treatment cart weekly for expired meds. She also stated if a resident was given an expired medication, it could have possibly made them sick, or it may be ineffective and not work. ADON-L stated the nurses' personal effects should not be in the med-carts or treatment carts because it could cause cross-contamination with the medication or the wound supplies. In an interview with LVN-M on 07/08/25 at 9:23 AM, she stated expired medications were removed from the med-carts by the floor nurses who should be checking them daily, and the narcotics were removed by the ADONs who checked the med-carts weekly. She stated if a resident was given an expired medication, it could make them sick or be ineffective and not work. In an interview with LVN-A on 07/08/25 at 9:27 AM, he stated expired medications were removed by the floor nurses who checked the carts daily, as well as by the ADONs who checked the cart weekly. He stated if the medication was a narcotic, it was removed by the ADON. He also stated if a resident was given an expired medication, it could possibly not work or possibly make them sick. Record review of the facility's Medication Administration, implemented 10/24/2022, revealed 1. Keep medication cart clean, organized, and stocked with adequate supplies; 12. Identify expiration date. If expired, notify nurse manager.

Based on observations, interview, and record reviews, the facility failed to provide the required 80 square feet per resident in 89 of 89 resident rooms (Room numbers: 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 312, 313, 314, 315, 316, 317, 318, 319, 320, 321, 322, 323, 324, 325, 326, 327, 328, 329, 330, 331, 401, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, 422, 423, 425, 426, 427, 428, 429, 430, 431) observed for room size requirement. All 89 rooms did not account for 80 square feet per resident.This failure could restrict the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms and limit the residents' ability to move about the room.Record review of Health and Human Services Form 3740 Bed Classifications, dated 07/07/25, reflected 89 rooms with 2 beds each.Observation beginning on 07/07/25 at 9:30 am during the facility's recertification survey, this surveyor used an agency laser measuring device, obtained measurements for all existing rooms. Rooms with 2 beds measured between 149 and 156.5 square feet.In an interview on 07/07/25 at 10:50 am, the Adm provided a letter requesting a room size waiver for rooms 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 312, 313, 314, 315, 316, 317, 318, 319, 320, 321, 322, 323, 324, 325, 326, 327, 328, 329, 330, 331, 401, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 414, 415, 416, 417, 418, 419, 420, 421, 422, 423, 425, 426, 427, 428, 429, 430, 431. The ADM stated there had been no changes to the rooms.

Based on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents for one 1 of 5 residents (Resident #9) reviewed for accident hazards. The facility failed to ensure that on 12/16/24 the PTA supervised and did not leave Resident #9 unattended in her wheelchair which allowed Resident #9 to fall out of the wheelchair onto the floor where she sustained a hematoma (a closed wound where blood collects and causes swelling because it cannot drain out) above and a laceration (cut) next to her left eyebrow. This failure could result in residents not receiving appropriate supervision leading to falls, injuries, or hospitalization . The findings included: Record review of Resident #9's admission record reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (a condition in which the blood flow to the brain is interrupted causing brain tissue to die), lack of coordination, muscle wasting, dementia (a term for several diseases that affect memory, thinking, and the ability to perform activities of daily living), cognitive communication deficit (difficulty understanding or producing language and non-verbal communication skills), and dysphagia (difficulty swallowing). Record review of Resident #9's admission MDS dated [DATE] reflected a BIMS score of 0 which indicated that Resident #9 was severely cognitively impaired. Resident #9 was dependent for ADL's including toileting, shower/bathing, dressing, and personal hygiene. Record review of Resident #9's initial nursing evaluation dated 11/12/24 reflected Resident #9 used a manual wheelchair and a walker prior to admission to the facility and required substantial/maximal assistance to stand up from a sitting position. Record review of Resident #9's fall risk evaluation dated 11/12/24 reflected she had a history of 3 or more falls in the previous 3 months, she required the use of assistive devices (wheelchair, walker), and her total score was 25 which indicated she was at high risk for falls. Record review of Resident #9's care plan dated 11/13/24 reflected a problem of a risk for falls related to confusion, incontinence, poor communication/comprehension, psychoactive drug use, and unaware of safety needs with a goal of resident would not sustain serious injury through the review date and the interventions included ensure the call light was within reach, encourage use, and respond promptly to requests for assistance, frequent rounding to ensure safety, and PT evaluate and treat as ordered or as needed. Resident #9's care plan also reflected a problem of an actual fall dated 11/18/24 (minor injury- bruising to right eyebrow), 12/16/24 (hematoma above left eyebrow with laceration on side of left eyebrow) and 02/15/25 (no injury). The goals included discoloration to right eyebrow would resolve with complication (initiated 11/18/24) and the resident's hematoma and laceration above left eyebrow would resolve without complication (initiated 12/16/24). The interventions included PT consult for strength and mobility (initiated 11/18/24), staff was to anticipate resident's needs, frequent rounds were to be done by staff (initiated 11/18/24), resident was to be supervised when in therapy room (initiated 12/16/24), and staff was to monitor/document/report PRN for 72 hours to MD for s/sx: pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture or agitation (initiated 12/16/24). Record review of Resident #9's progress notes dated 11/22/24 to 12/23/24 reflected the following entries: Effective date: 12/16/24 at 1:37pm, Type: Change of Condition by LVN C. Resident had an unwitnessed fall, hematoma to above left eyebrow and small laceration next to left eyebrow, started 12/16/24, since started it has gotten: stayed the same. Things that make the condition worse: leaning forward in chair. Things that make the condition better: repositioning and watching resident. Resident likes to reach out from w/c, she overreaches at times. Effective date: 12/16/24 at 1:32pm, Type: Nurse note by LVN C. Note text: Therapy called nurse into therapy room, therapist stated to nurse resident had fallen out of her wheelchair, they did not witness the fall but seen her laying down on the floor on her left side. While on the floor writer checked vitals and seen she had a small laceration near eyebrow and a hematoma forming above left eyebrow. Applied light pressure with gauze, called the NP and reported incident, given orders to send out d/t possible head injury. Writer kept resident in a supine position on the floor until ambulance arrival while supporting neck and head. EMS arrived and transferred to stretcher and taken to [the hospital]. Writer called family and spoke with [RP] and will meet at hospital. Effective date: 12/17/24 at 4:51am, Type: Nurse note by LVN D. Note text: Patient (Resident #9) returned from hospital at 6:40pm, patient was taken to room, no issues noted with patient, all vitals within baseline, patient remained asleep throughout the night. Record review of Resident #9's after visit summary from the ER dated 12/16/24 reflected that she was seen for a fall from chair, and she had no broken bones. Record review of Resident #9's radiology report for a CT scan of her head and face dated 12/16/24 reflected Resident #9 had a large left frontal (on the front) and periorbital (around the eye) soft tissue hematoma. Record review of the undated written statement by the COTA reflected, To whom it may concern, I was seated in the therapy breakroom with coworkers when I heard a thump and turned and witnessed the patient (Resident #9) on the floor. The therapist got up immediately to check on the patient who was laying on the ground in front of her wheelchair. Patient's nurse immediately came to assess patient with aid. Record review of the written statement by the OTR dated 12/16/24 reflected, I was eating lunch in the breakroom (unaware there was a patient was in the gym) when we heard a loud noise. [The COTA] look out of the break room door way to assess the source of the noise and said, Oh no!, immediately stood up and ran into the main gym room. [The DOR] and I immediately followed and observed the patient, [Resident #9] to be on the ground in front of her wheelchair. While [the COTA] and I remained with the patient, [the DOR] immediately reported to the nurse (LVN C) who entered the gym shortly after. Patient was directly handed off to nursing. [sic] Record review of the written statement by the DOR dated 12/16/24 reflected, I was in the copy room when I heard [the COTA] say patient (Resident #9) is on the floor. I immediately went to check on the patient. I went immediately to get the charge nurse, which nursing assessed patient and provided care. Patient was left in nursing care. In an interview on 03/26/25 at 10:04am CNA E stated a little after lunch, Resident #9's FM was pushing the resident in her wheelchair toward the nurse's station so they could speak with the nurse. CNA E stated when she asked Resident #9's FM if they would like for her to take Resident #9 to her room, the FM stated that therapy wanted to work with Resident #9, so she took her over to the therapy room. CNA E stated when she got to the therapy room, the OTR was sitting on the stool and the PTA was over in the corner area. CNA E stated the OTR was messing with the foot things and she left Resident #9 there in front of the OTR and went back to the hall and the next thing she knew, they said Resident #9 had fallen. CNA E stated Resident #9 was very active that day, moving around in her wheelchair and that they normally keep her wheelchair tilted back. In an interview on 03/26/25 at 2:20pm the DOR stated she was in the copy room when she heard the COTA say the patient was on the floor so she got up to help, and immediately went and got the nurse. The DOR stated she believed that a miscommunication between the PTA and the COTA is what lead to Resident #9's fall. The DOR stated that her understanding was the PTA had asked the COTA to watch Resident #9 while he took another resident out of the therapy area, but the COTA did not hear him. The DOR stated the COTA was in the gym documenting and that CNA E may have handed Resident #9 off to the OTR. The DOR stated normally when there were residents in therapy, if someone was going to step away, they handed off to another therapist. The DOR stated there had not been any incidents like that before or since Resident #9's fall and the staff was in-serviced on 12/16/24 on fall prevention and leaving residents unattended. The DOR stated they did in-services on ANE and fall prevention as often as needed through the facility and through the PT department and the last in-service was within the last month. In an interview on 03/26/25 at 2:32pm the COTA stated she was in the breakroom beginning lunch with the DOR and the OTR when she heard a thump, turned around and saw Resident #9 on the floor, went out of the breakroom to her and called out for the nurse to come see her. The COTA stated she had been in the gym but was focused on what she was doing so she did not know that Resident #9 was in the gym. The COTA stated the therapists normally went to get the resident at their allotted time and brought them to the gym for therapy. The COTA stated that hand off consisted of telling the person they were handing off to about the resident and making sure that the person receiving acknowledged the hand off. The COTA stated she saw the PTA while they were assessing the resident but did not know when he entered the gym. The COTA stated the PT staff was in-serviced that day (12/16/24) on hand off communication and fall prevention and their last ANE in-service was a few days ago on the computer through their on-line continuing education program. In an interview on 03/26/25 at 2:55pm the OTR stated she was on her lunchbreak in the breakroom part of the gym with the door open and heard a loud noise. The OTR stated the COTA who was sitting closest to the door looked out and said something like, oh no, so they all (the OTR, The COTA, and the DOR) got up and went out to the gym. The OTR stated she and the COTA stayed with Resident #9 who was awake and responding while the DOR went and got the nurse. When asked about the details of when the resident was brought to the therapy department, the OTR stated, I was sitting on a stool. The CNA walked in with the resident, asked who had her and the PTA said he had her. I said hi to her and was looking at her chair. When the PTA wheeled her over toward the parallel bars by the window, I went into the break room with the DOR and the COTA. There was no other staff in the gym with the PTA. The OTR stated they had never had an incident like that before and had not had one since. The OTR stated they were in-serviced by the regional person on proper hand offs and such and their las in-service on ANE was yesterday through their on-line continuing education program. The OTR stated. I feel like we do ANE and fall prevention in-services all the time. In a telephone interview on 03/26/25 at 3:18pm the PTA stated CNA E had put Resident #9 close to the doorway, so he moved her closer to the window and took off the leg rests from the wheelchair to get everything ready. The PTA stated, It was a miscommunication between me and my co-worker (the COTA). I thought she heard me say hey, can you watch my patient? I thought she said yes, but I guess she didn't hear me. I took my patient back to the dining room and when I got back, she (Resident #9) was on the floor. The PTA stated the COTA was in the lounge area, about 10 feet from the resident, not inside the lounge but facing it sitting sideways to Resident #9. The PTA stated the PT staff was in-serviced on 12/16/25 on proper hand off which meant in part to make sure that the resident was right next to the person taking hand off so that the resident could be properly supervised. The PTA stated he felt the reason Resident #9 fell was lack of communication and for sure lack of supervision and he had only seen her one time before and did not expect her to fall. The PTA stated the last in-service on ANE was last month. In an interview on 03/27/25 at 10:55am the DON stated as soon as she was informed that Resident #9 fell , she immediately went to give the resident a head-to-toe assessment. The DON stated Resident #9 had visible bruising and was sent to ER for further evaluation. The DON stated staff should have made sure the resident was visually handed off to another staff member so they could assume the care responsibilities and resident safety. The DON stated an in-service was conducted with all facility and rehabilitation staff on 12/16/24 about fall prevention and proper hand off of resident care as well as ANE. In an interview on 03/27/25 at 3:47pm the ADM stated, CNA E took Resident #9 to the gym and left her in the care of a therapist. That therapist took another resident out of the gym and he told another therapist to watch this resident. I think it was probably miscommunication. If someone is having to leave a resident for any reason, they should make sure that the person they are asking to help watch the resident hears them and understands what is being asked. If a resident, especially a fall risk resident, is left alone, they could fall which could lead to lacerations, broken bones, head injury, and/ or hospitalization . Staff was in serviced on effective communication about 2 months ago. It was not something that was regularly in-serviced, but it will be now, monthly. A supervision policy was requested from the facility on 03/26/25 but was not received. The facility's undated Fall Prevention Program policy reflected in part: A successful fall risk management program requires organizational commitment and an interdisciplinary team approach to prevent and minimize falls. This policy did not address supervision of fall risk residents.

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 2 of 3 Residents (Residents #62 and #61) reviewed for Abuse, and Injury of unknown source. 1. The facility did not report an allegation of abuse per facility policy to the Administrator regarding Resident #62 on 02/24/25 until 02/28/25. 2. The facility failed to ensure CNA ZZ reported an allegation of injury of unknown sources per facility policy to the Administrator regarding Resident #61 on 11/24/24 until 11/26/24. This deficient practice could affect any resident and could contribute to further neglect. The findings included: 1. Record review of Resident #62's face sheet dated 03/14/25 revealed an [AGE] year-old male with an original admitted [DATE]. Diagnoses included stroke with subsequent weakness to the right dominant side, dementia (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, high blood pressure, diabetes, heart disease, kidney disease, anxiety, insomnia (difficulty sleeping), aphasia (difficulty speaking), and depression. Record review of Resident #62's quarterly MDS Assessment, dated 02/26/25, reflected an [AGE] year-old male who readmitted on [DATE]. His BIMS score of 00 indicated the resident had severe cognitive impairment with inattention and disorganized thinking. He could not speak, was rarely/never understood, had short- and long-term memory problems, and he was severely cognitively impaired for decision making. He required set-up assistance with eating, moderate assistance with oral and personal hygiene, showering, and upper body dressing. He required substantial assistance with toileting, lower body dressing, and footwear. He required moderate assistance with transferring and positioning, and supervision to stand and walk. He did not utilize a wheelchair. He was frequently incontinent of urine and always incontinent of bowel. 2. Record review of Resident #61's face sheet revealed a [AGE] year-old male with an admitted [DATE]. Diagnoses included Alzheimer's Disease, dementia, depression, anorexia, and had a dependence on wheelchair due to a left knee contracture. Record Review of Resident #61's annual MDS Assessment, dated 10/30/24, reflected his BIMS score of 09 indicated the resident had moderate cognitive impairment with inattention and disorganized thinking. He required substantial assistance with eating, dressing, personal and oral hygiene. He was dependent for toileting, showering, transferring, and footwear. He utilized a manual wheelchair and required assistance to propel. He was always incontinent of bladder and bowel. He did not display any behaviors at the time (look back period) of the MDS assessment. He took antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. Record review of Resident #61's shower sheet dated 11/25/24 indicated bruising to the left shoulder and left hip. Record review of Resident #61's pain evaluation dated 11/26/24 at 7:21 am indicated the resident had no complaint of pain in the last 5 days. Record review of Resident #61's wound evaluation dated 11/26/24 at 8:14 am signed by the wound care nurse indicated a new left shoulder bruise acquired in-house. Area 140.46 cm 2, length 22.14 cm, width 7.49 cm. non-pitting edema extends < 4 cm around wound. Temperature normal. Cognitively impaired, Relaxed, pain score 0, denied pain when asked in Spanish. No dressing was applied. Intact bruising dark purple in color. Possible edema to the shoulder area, skin intact. Also indicated was a 5 x 9 inch bruise to the left hip. In an interview with CNA ZZ on 03/26/25 at 10:11 am, she said she knew Resident #61 and worked with him on 11/24/24 through 11/26/24. She said she did not report the bruising she saw on Sunday, 11/24/24, because she thought it had already been reported since it was a good size area and because he did not complain of pain. She said the bruise looked faded and old. She said it was purple, not red, not yellow, but already fading. She said Resident #61 had an old bruise on the left side of his hip on that day (Sunday). She said a couple of hours after the first time she saw the shoulder bruise, she told the DON. She said the DON asked Resident #61 if he had fallen during the night several times, but he never indicated yes or no. She said the DON performed a full body assessment and both bruises were there on the left. She said the bruising was bigger on Tuesday (11/26/24) compared to the day before. In an interview with the wound care nurse on 03/26/25 at 4:40 pm she said she knew Resident #61. She said she conducted the 11/26/24 wound evaluation for his shoulder and his hip. She said she was not informed about the bruising until the 26th. She said her understanding of the situation was he tripped in his room. She said she could not recall how she received that information. She said the resident's dementia had worsened and he had been having more falls lately. She said staff tried to keep him in a wheelchair close by when awake. She said his fall mat was in place, and his bed was low. She said his call light was within his reach, and he was wearing non-skid socks. She said any bruising should be reported immediately. She said she should have been made aware on Monday the 25th. She said her last ANE training was a week or two ago. She said the in-services taught how, what, and when to report any kind of abuse. She said the types of abuse were physical, verbal, exploitation, and neglect. In an interview with the DON on 03/27/25 at 10:37 am, she said Resident #61 could not speak. She said he has had multiple falls. She said she had the wound care nurse go with her to assess the resident. She said staff were trained to report immediately and show on their shower sheets any discolorations. In an interview with the DON on 03/27/25 at 1:24 pm, she said alleged abuse or neglect should be reported right away and the allegations were not reported timely. She said staff were trained often in abuse, neglect, and reporting. She said staff did not report the allegation of abuse for Resident #62 because he did not tell them, and the incident was unwitnessed. She said she did not know why staff did not report the allegation of injury of unknown sources regarding Resident #61. Interviews beginning on 3/25/25 at 8:30 am, five CNA's, five LVN's, and 1 housekeeper were all able to identify the different types of ANE and who to report it to if suspected. All staff stated they did not suspect ANE at the facility. They all said they had abuse, neglect and reporting in-services frequently either in-person or on the computer. They all said they had been trained within the last week to within the last month. Record review of Resident #61's Change of Condition form dated 11/24/24: Noted resident to have a 5x9 red/purple discoloration to Right lateral buttock; resident unable to clearly verbalize discomfort, however at this time no signs/symptoms of pain; no changes in ADL's; continues to ambulate independently with no issues at this time. Record review of the facility policy titled, Abuse, Neglect, and Exploitation dated 08/15/22 defines abuse as the willful infliction of injury or intimidation. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. VII. Reporting/Response A. 1. Reporting of all alleged violations to the Administrator, state agency .within specified timeframes: b. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegations involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse for one (Resident #62) of two residents reviewed for abuse. The facility failed to ensure Resident #62 was free from abuse. On 10/24/24, Resident #60 hit Resident #62 in the head with a grabber because Resident #62 would not stop touching it. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #60's face sheet revealed a [AGE] year-old male with an admitted d of 06/20/19. Diagnoses included dementia (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, high blood pressure, depression, mood disorder, and abnormalities of gait and balance. Record review of Resident #60's Annual MDS, dated [DATE], reflected a [AGE] year-old male who admitted on [DATE]. His BIMS score of 15 indicated the resident had no cognitive impairment with inattention and disorganized thinking. He required supervision for all ADL's. He could walk supervised with the use of a walker. He had a manual wheelchair and could self-propel. He was frequently incontinent of urine and frequently incontinent of bowel. Record review of Resident #60's Care Plan dated 06/21/19, reflected Resident #60 had potential to be physically aggressive with fell ow roommate (Resident #62). Resident #60 was in a resident-to-resident altercation when his roommate was touching his personal belongings. Interventions included on 10/24/24, Resident #60 was placed on 1:1, psyche services contacted, and new orders for medication were received and implemented. Record review of Resident #62's face sheet revealed a [AGE] year-old male with an admitted [DATE]. Diagnoses included Alzheimer's Disease, dementia, and depression, and had a dependence on wheelchair due to a left knee contracture. Record Review of Resident #62's annual MDS Assessment, dated 10/30/24, reflected his BIMS score of 09 indicated the resident had moderate cognitive impairment with inattention and disorganized thinking. He required substantial assistance with eating, dressing, personal and oral hygiene. He was dependent for toileting, showering, transferring, and footwear. He utilized a manual wheelchair and required assistance to propel. He was always incontinent of bladder and bowel. He did not display any behaviors at the time (look back period) of the MDS assessment. She took antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. Resident #62's quarterly care plan dated 02/19/25 reflected Resident #62 was involved in resident-to-resident altercation secondary to reaching for another resident belongings Date Initiated: 10/24/2024. Interventions included o 10/24/24 Room change made and placed on immediate one to one Date Initiated: 10/24/2024 o Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 10/24/2024. o Give the resident as many choices as possible about care and activities. Date Initiated: 10/24/2024. Record review of PIR dated 10/29/24 revealed R#60 hit R#62 with his grabber causing redness to his forehead that resolved immediately. Increased supervision (1:1) on R#60. R#62 moved to another room at his request. The PIR confirmed the findings. Resident #60 stated he did hit him after he would not leave his grabber alone. Police report done case #2410240122. Intervention: resident placed on immediate one to one and room change made. Record review of all staff in-services dated 10/24/24 for Resident-to-Resident Altercation and Abuse & Neglect. Observation and interview with Resident #60 on 03/26/25 at 3:04 pm revealed a well kempt cheerful male, lying in bed with eyes closed and TV on. He readily awoke to his name and said he was doing fine. He denied any kind of ever having an altercation with anyone. He said no one messes with him. He said he was tired of rules and wanted to get an apartment. He said 7 years was long enough.(Admission 06/19/21) He said everyone was good to him here. Observation and interview with Resident #62 on 03/26/25 at 3:16 pm he denied any altercations with any CNA. He said this surveyor was mistaken, even though he was reminded of the altercation he had with his roommate on 10/24/24. In an interview with the SW on 03/26/25 at 1:40 pm, she said Resident #60 did not like to bathe. Sometimes he would curse at others-he was grumpy. He will sit in his own urine until after I get my smoke break or other excuse. He had been through several roommates due to his lack of hygiene, this last time, he was now in a room by himself. She said she spoke to him and he did not have any issues or duress. She said his demeanor was calm and had been since the incident. He had not had any situations since then. She said she met with both residents for a 3 day follow up. She said Residents #60 and #62 were calm. She said Resident #60 was talkative, in a good mood and was around at activities downstairs. She said Resident #62 did not appear to be in distress at any time. She said no behavior incidents have been reported. In an interview with the DON on 03/27/25 at 8:45 am, she said she was familiar with both gentlemen. She said Resident #60 had behaviors and it was unfortunate it was not witnessed and was not sure how to prevent that. She said the quote in the PIR sounded like something Resident #60 would say. She said Resident #62 did not have any complications because of the altercation. She said they moved Resident #60 to a room by himself and have not had any further incidents since then. She said one of the interventions she requested was a medication review which the pharmacist and doctor did, (verified) and to keep monitoring him. She said someone was requesting assistance to the resident's room regarding a resident being hit on the forehead with another resident's grabber. She stated she was told by another resident it sounded like someone was arguing. She said she heard shouting and went to the room and found Resident #60 cursing at Resident #62. Resident #60 stated Resident #62 was getting his grabber and he has already stated over and over, don't touch it. Resident #60 said, I've already told this other m r o to quit touching my shit and he doesn't stop so I whacked him with it. The DON said Resident #62 was removed from the room immediately. She said he was unable to verbally give a description of what occurred but able to point to his left front forehead to indicate where he was hit with the grabber. Resident #60 was removed from the room and placed on immediate one to one as per facility protocol. She said a head-to-toe assessment was performed and a small, reddened area was noted to Resident #62's left front side of his forehead that disappeared over 5 mins. She said Resident #62 denied any pain, his vital signs were all normal, and there were no other areas noted. Neuros initiated. In an interview with the ADM on 03/27/25 at 3:07 pm, she said Resident #60 was intentional when he hit Resident #62 on the head. She said Resident #60 did not always get mad, and staff were using nursing judgement and placed him on 1:1 to protect others from him. She said they were roommates at the time. She said Resident #60 did not always have aggression daily and he could be very nice. She said since that incident, they moved Resident #60 to a room by himself and he had not had any incidents since. Record review of the facility policy titled, Abuse, Neglect, and Exploitation dated 08/15/22 defines abuse as the willful infliction of injury or intimidation. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Record review of all staff in-service/training dated 07/26/24 titled Abuse & Neglect: Resident to Resident altercation-how, when, why, and where with ANE policy dated 08/15/22. Resident Rights dated 07/26/24.

Based on interviews, and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for two residents (Resident #3 and Resident #61) of 20 residents whose care plans were reviewed, in that: 1) Resident #3's comprehensive care plan was not revised to reflect Resident #3 had a history of trying to give money to residents and staff. 2) Resident #61's comprehensive care plan was not revised to reflect interventions for Resident #61 who had a history of falls. These failures could place residents at risk for inadequate care, accidents, and injuries. The findings included: 1.Record review of Resident #3's face sheet dated 03/26/25 reflected an [AGE] year-old-female with an original admitted [DATE]. Diagnoses included Alzheimer's Disease (brain disorder that affects memory, thinking, behavior and everyday skills) and depression (mood disorder that causes persistent feelings of sadness and loss of interest). Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIM score of 6 (severe cognitive impairment). In an interview on 3/27/25 at 10:00 am the DON stated if Resident #3 had a change in condition, that behavior or change should have been care planned. The DON stated any resident changes were discussed in morning meetings. The DON stated care plans were a team effort and the MDS Coordinator as well as the nurses, the ADONs, the DON and social services can update the care plans. The DON stated Resident #3's care plan was overlooked and should have been care planned because care plans are an individualized plan of care that provide specific care residents need, and so staff can be aware of any changes or behaviors. The DON stated the policy stated the MDS Coordinator and ADON's were responsible for updating the care plan. The DON stated ultimately the responsibility of making sure the care plans were accurate and updated was the DON but was a team effort. In an interview on 3/27/25 at 2:10pm ADON A stated MDS Coordinator or nurses could update a care plan as soon as a new behavior or change of condition was noted. ADON A stated Resident #3's behaviors of trying to give money to residents and staff should have been care planned to let all staff know of Resident #3's history of behaviors and individualized plan of care. In an interview on 3/27/25 at 3:24pm the ADM stated the DON and MDS were ultimately responsible to ensure that resident care plans were accurate. In an interview on 3/27/25 at 4:03pm the MDS Coordinator stated behaviors such as trying to give residents or staff money should be care planned. The MDS Coordinator stated repetitive behavior that could lead to an issue and any repeated episodes from a resident should be care planned so staff were aware. The MDS Coordinator stated care plans were an individualized plan of care. The MDS Coordinator stated there was no reason Residents #3 and #61's behaviors were not care planned and was overlooked. 2.Record review of Resident #61's face sheet dated 03/14/25 revealed an [AGE] year-old male with an original admitted [DATE]. Diagnoses included stroke with subsequent weakness to the right dominant side, dementia (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, high blood pressure, diabetes, heart disease, kidney disease, anxiety, insomnia (difficulty sleeping), aphasia (difficulty speaking), and depression. Record review of Resident #61's quarterly MDS Assessment, dated 02/26/25, reflected an [AGE] year-old male who readmitted on [DATE]. His BIMS score of 00 indicated the resident had severe cognitive impairment with inattention and disorganized thinking. He could not speak, was rarely/never understood, had short- and long-term memory problems, and he was severely cognitively impaired for decision making. He required set-up assistance with eating, moderate assistance with oral and personal hygiene, showering, and upper body dressing. He required substantial assistance with toileting, lower body dressing, and footwear. He required moderate assistance with transferring and positioning, and supervision to stand and walk. He did not utilize a wheelchair. He was frequently incontinent of urine and always incontinent of bowel. Record review of Resident #61's Care Plans dated 01/18/23, 11/25/24, 08/21/24, and 03/08/25, reflected Resident #61 was o at risk for falls r/t Confusion, Unaware of safety needs Date Initiated: 01/16/2023 Revision on: 01/16/2023 o will be free of minor injury through the review date. Date Initiated: 01/16/2023 Revision on: 02/12/2025. o Anticipate and meet the resident's needs. Date Initiated: 01/16/2023. o Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 01/16/2023 Revision on: 01/16/2023 Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Date Initiated: 01/16/2023 Revision on: 01/16/2023. There were no further updates for fall preventions. In an interview with DON on 03/27/25 at 10:37 am, she said Resident #61 had a history of multiple falls. He had been progressively declining for some time, and he had been placed on hospice. She said fall preventions/interventions for Resident #61 included putting a helmet on him, fall mat, frequent rounding (meaning staff knew that Resident #61 was one of their focused, more likely fall risk residents), and monitored them a lot closer. She said they had to respect the residents' rights. She said they could not make the residents stay in their beds. She said the interventions she named were care planned. She said falls should be under falls. She said there were no interventions on his care plans related to helmet, low bed, or fall mat, or non-skid socks. She said IT tickets showed they were losing documentation, but that was 2 weeks ago. She said putting a helmet on Resident #61 was entered today, 03/27/25. She said the other interventions were not care-planned. She said the policy said MDS was responsible for updating care plans, but the unit manager (ADON), herself, and primary care nurses were supposed to be updating care plans as well. She said she was ultimately responsible for ensuring the care plans were updated, accurate, and done. She said management discussed person centered care planning in the daily morning meetings and the primary care nurse should update immediately, the ADON's monitor them on their unit, then she monitors them both. She said interventions were discussed for Resident #61 but they were never entered, and she did not know why. She said the interventions in Resident #61's care plans were not dated. She said his fall risks were high because his son did not want to have any surgery done. She said the son told her he did not want the resident going to the hospital anymore because it triggered Resident #61's PTSD. (PTSD not in medical records). She said a diagnosis of PTSD would be significant information and should be in his care plan. In an interview with the ADM on 03/27/25 at 3:13 pm, she said Resident #61 had PTSD (Post Traumatic Stress Disorder) from the Navy. She said she assumed PTSD needed to be in the care plan and diagnoses so staff could understand the resident's behaviors. She said she did not know why PTSD was not in Resident #61's care plan or diagnoses because she was not his nurse. She said the nurses were responsible for the care plans. She said her responsibility regarding care plans was making sure they were done and updated. She said she was under the impression the nurses were updating care plans during the daily morning meetings. She said the DON should be checking the nurses' updates. She said Resident #61 was one of her frequent fallers. She said interventions such as non-skid socks, floor mat, wheelchair, and placing him on 1:1 were listed in his care plan. She said she and regional administration started monthly audits in 01/2025 such as nutrition, infection control, dietary, etc., but did not know if care plans were on that list. She said MDS was part of the IDT, and the IDT team were responsible for updating care plans. She said MDS entered comprehensive care plans and nurses/ADON's entered the updates. Record Review of the facility's Care Plan Revisions Upon Status Change reflected: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. d. The care plan will be updated with the new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. 46038

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and under proper temperature controls on 2 of 6 treatment/medication carts and 3 of 3 medication storage rooms reviewed for storage of drugs. 1. The 200-floor treatment/medication cart was left unlocked by the nurse's station with the drawers facing outward. 2. 300 floor treatment/medication cart was left unlocked outside room [ROOM NUMBER] with its back against the wall and drawers facing the hallway. 3. The temperature log for the medication storage refrigerator in the 400 floor medication storage room did not have a temperature recorded for 06/15/24 or 06/16/24 and the refrigerator was not clean. 4. The temperature log for the medication storage refrigerator in the 300 floor medication storage room did not have a temperature recorded for 06/09/24 AM or 06/17/24 AM. 5. The temperature log for the medication storage refrigerator in the 200 floor medication storage room did not have a temperature recorded for 06/17/24 AM. These deficient practices could affect residents who have medications in the nurse's treatment/medication cart or in refrigerated storage and could result in lost medications, drug diversion, harm due to accidental ingestion of unprescribed medications, or medications that are ineffective and/or contaminated. Findings included: 1. Observation on 6/16/24 at 11:02am revealed an unlocked medication/treatment cart located by the 200-floor nurse's station. The medication/treatment cart was against a wall and one staff member (LVN A) located at the nurse's station. There were two residents by the nurse's station near the treatment/medication cart. This surveyor opened the top drawer recognizing the treatment/medication cart being unlocked. Multiple medications in bulk bottles were easily assessable and removable. This surveyor was able to open all drawers and go through various medications and treatment supplies. In an interview on 6/16/24 at 11:05am, LVN A stated she had been on shift since 6:00am and did not see the treatment/medication cart unlocked. LVN A stated the treatment/medication cart was closer to the nurse's station, but a resident had pushed it out the way to grab snacks that were located on the nurse's station counter. LVN A stated that was not her treatment/medication cart and she was not doing any treatments on residents. LVN A stated the treatment nurse was not working at that that time and had no idea of how long it had been unlocked. LVN A stated she was not in-serviced on making sure treatment/medication carts are to be locked when not in use. LVN A stated since the treatment/medication cart was unlocked, residents could gain access to the cart easily. 2. Observation on 06/16/24 at 11:16 AM revealed an unlocked medication cart unattended on the 3rd floor across from room [ROOM NUMBER]. All drawers on the medication cart could be opened with medication easily accessible. The surveyor was able to open all drawers and look inside the cart. The medication cart was unlocked and unattended for approximately 30 seconds before LVN D exited room [ROOM NUMBER] and locked the cart. In an interview with LVN D on 06/16/24 at 11:17 AM, LVN D stated that the unlocked cart was hers. LVN D stated that her cart had been unlocked for a few minutes while she went into room [ROOM NUMBER] to assist a resident. LVN D stated that she has received many in-services on keeping her medication cart locked when not actively in use. LVN D was unable to recall specifically when the last in-service she received on medication cart usage. LVN D stated any unauthorized person walking by could access the medications in the cart while it was unlocked. LVN D stated residents could steal medications from an unlocked cart and potentially ingest them causing harm. In an interview on 06/17/24 09:07am, the DON stated, sated the treatment/medication carts should be locked when not in use. The DON stated unauthorized people could gain access to medications and supplies within the cart. The DON stated there should not be any reason the treatment/medication cart was unlocked. The DON stated it is the charge nurses' job to ensure all carts are locked when not in use and the last in-service on locking all carts when not in use was sometime in May. In an interview on 6/16/24 at 12:02pm, the Regional Nurse Consultant stated all treatment/medication carts are supposed to be locked at all times when not in use for the safety and protection of residents, staff, and visitors. 3. Observation of 400 floor medication storage room on 06/16/24 at 11:30am revealed the temperature log for the medication refrigerator had columns for date, shift, temperature, initials, and Clean? Y/N. There were no temperatures recorded for 06/15/24 or 06/16/24, the clean column was marked with a Y for 06/01/24 - 06/14/24, and there was a brown sticky substance on the left side of the bottom shelf. Repeat observation of the 400 floor medication refrigerator and temperature log on 06/16/24 at 2:30pm revealed the temperature was recorded for 06/16/24; 1400 (2:00pm) was entered in the Shift column, 36 degrees was entered in the Temperature column, there were intials entered in the Initials column, and Y was entered in the Clean column. The brown sticky substance was still on the bottom shelf of the refrigerator. Repeat observation of the 400 floor medication storage refrigerator on 06/17/24 at 10:54am revealed the brown sticky substance on the bottom shelf of the refrigerator was still there and a Y was entered in the Clean column of the temperature log. In an interview on 06/17/24 at 10:55am, LVN E stated she did not know what the substance was on the bottom of the refrigerator, but she would clean it up. LVN E stated spills could cause contamination of resident medications that were stored in there which could cause illness. LVN E stated if the temperature was not kept track of the refrigerator may not be working properly and it could lead to medications not being stored at the proper temperatures. LVN E stated if medications were not stored at the proper temperature, it could lead to medication ineffectiveness or contamination, residents not receiving the medication benefits, such as insulin not working, and residents' blood sugar not being controlled. LVN E stated elevated blood sugar could result in illness and/ or death. LVN E stated the last in-service on medication storage was last month. In an interview on 06/17/24 at 11:10am, LVN F stated she had not seen the brown substance on the bottom of the refrigerator. LVN F stated it could cause contamination of medication which could lead to residents getting sick. LVN F stated the nurses were responsible for cleaning up messes and spills because they were the only ones allowed in the medication room. LVN F stated night shift was responsible for checking and logging temperature on the refrigerator and if the temperature was not checked or logged, the refrigerator could be too warm or too cold and could lead to medications not working like they were supposed to. LVN F stated residents could get sick or get hospitalized if their medications were not working properly. LVN F stated they got in-services on medication storage about once a month. In an interview on 06/17/24 at 11:22am, LVN G stated she was not aware of the substance at the bottom of the refrigerator. LVN G stated if a medication was to fall in it/on it, they would have to discard the medication and get a new one. LVN G stated if the medication was given to a resident after it touched the substance, it could cause harm to the resident if given. LVN G stated if someone contaminated a medication then put it back with all the other medications, it could contaminate all of the medications. LVN G stated whoever caused the mess was responsible for cleaning it, but if that did not happen, whoever saw it was responsible for cleaning it. LVN G stated nurses primarily on the night shift were responsible for checking the temperatures and logging them but if it was not filled out for the day, all nurses were responsible for checking and logging it. LVN G stated medications could go bad if the temperatures were out of range and no one noticed it and that could lead to residents getting sick or hospitalized . LVN G stated she thought the last in-service on medication storage was in May. 4. Observation of the 300 floor medication storage room on 06/17/24 at 12:10pm revealed the temperature log for the medication refrigerator had columns for Day, AM Temperature, Initials, PM Temperature, Initials, and Weekly Clean Initials. There was no temperature recorded for 06/09/24 AM or 06/17/24 AM. In an interview on 06/17/24 at 12:22pm, the DON stated that there should never be spilled substances of any kind in a medication refrigerator. The DON stated spilled substances could cause illness to residents if medication came into contact with them and it could contaminate the entire storage of the medication. The DON stated it is everyone's responsibility to clean up any spills or leaks in the refrigerators and the ADON and DON are responsible for making sure that they are kept clean. The DON stated the temperature logs had to be kept accurately to make sure that medications were stored at the correct temperatures to prevent issues such as medications becoming ineffective or contaminated. The DON stated nurses on both shifts were responsible for checking the temperature and recording it in the log, and it was every nurse's responsibility to make sure the refrigerators were functioning properly. The DON stated if the refrigerator was not functioning properly or there was no thermometer, the nurse should contact maintenance to get a new thermometer or refrigerator and contact the DON or ADON to remove the medications until a new refrigerator was acquired. The DON stated if there was an issue with a refrigerator, they would get a replacement as soon as they were notified. The DON stated if the refrigerators were not at the correct temperature and no one noticed, it could lead to medications becoming ineffective or contaminated and could cause resident illness or worsening of their medical condition which could lead to hospitalization or death. 5. Observation of the 200 floor medication storage room on 06/17/24 at 12:58pm revealed the temperature log had an AM block with columns for Date, Temperature, and Initials and a PM block with the same columns for the medication refrigerator. There was no temperature recorded for 06/17/24 AM. In an interview on 06/17/24 at 1:11pm, the ADON stated it was the responsibility of the nurses on both shifts to check and log the temperature of the medication refrigerator in the storage room. The ADON stated if the temperatures did not get checked, no one would know if the refrigerator was not functioning properly and medications could go bad which could lead to them not working properly and residents getting sick. The ADON stated she was going to do an in-service specifically on temperatures in the medication refrigerators. In an interview on 06/17/24 at 1:16pm, LVN H stated nurses on both shifts were supposed to check the temperature and record it as well as make sure the refrigerator and room were clean. LVN H stated if temperatures were out of range, medications could go bad and could make residents sick which could lead to hospitalization . LVN H stated depending on the medication, it could lead to resident death if medications were ineffective. Record review of Medication Carts and Supplies for Administering Meds dated 10/01/19 stated: Policy The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. 2. The medication cart is locked at all times when not in use. 3. Do not leave the medication cart unlocked or unattended in the resident care areas. Supplies: The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications. 2. A refrigerator and freezer with a thermometer for each section. 4. A temperature log with acceptable temperature ranges for each area should be maintained at all times. 49157 50039 FACILITY FTAGDIR

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. 1. The facility failed to ensure juice dispenser guns were sanitary. 2. The facility failed to ensure equipment was clean and sanitized. 3. The facility failed to ensure dry goods were sealed. 4. The facility failed to ensure spices and a freezer item were not left open to air. 6. The facility failed to ensure personal items were not in the prep area or refrigerator 7. The facility failed to ensure the kitchen was following their policies These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of the kitchen on 06/17/24 beginning at 11:05 am revealed 95 of 108 coffee cups, 27 of 61 juice glasses, and 28 of 84 plastic bowls were scratched and/or badly stained inside with a whitish powdery substance and/or dark brown-red stains. There were 8 drying mats of 22 needed for drying the cups, glasses, and bowls on the trays. The dishes on the trays without drying mats were wet inside. There were 2 of 2 juice guns hanging from the juice machine. There was only one holster on the juice machine table. The tip of one of the juice guns was touching the top of a cardboard box that had a thick, sticky red substance the nozzle of the juice gun was resting in. The other juice gun was hanging with the nozzle touching the outside of a cabinet and not in its holder, which was near the juice gun. There were gnats around the juice machine. Both juice guns had a similar thick, red sticky substance on the handles and in and around the dispense buttons. There was an open, partially full 16-ounce bottle of soda on the juice machine table. There was an open and partially full unlabeled 12 ounce can of soda on a tray labeled residents for Monday, June 17 in the refrigerator. There were 2 tape dispensers on a prep table. The sugar bin in the dry storage area did not have the lid sealed, leaving the sugar exposed to the air. There were 4 of 15, 16-ounce containers of spices open to the air. There was a large bag labeled breaded fish in the freezer that was open to the air. There was a large non-stick frying pan that was worn down to the metal and hanging on the pot hanger. The underside of the shelf above the steam table holding area had a brownish red substance the length of the holding table. The substance was formed in small droplets and potentially falling off into the food on the prep table. Observation of the juice guns and interview with the FSM on 06/17/24 at 11:35 am revealed the FSM removed the nozzles from the juice gun heads revealing a build-up of a red substance and a black substance. The FSM stated the black substance was the same as the red substance and neither substance should be there. The FSM stated she did not know about the underside of the holding table shelf. She stated the kitchen had a cleaning schedule that staff were responsible for and she was ultimately responsible for the kitchen. Observation of the cleaning schedule dated June 2024 revealed all spaces filled, as if the cleaning had been done regularly. An interview with COOK A on 06/17/24 at 11:08 am she stated the worn pan was in use, and they used it for making grilled cheese sandwiches. She stated they probably should not be using the pan because the non-stick surface could flake off even more and get into the food. She stated it could make residents sick. COOK A stated the spices should not have been open to air because the spices could clump, and it could affect the residents-maybe make them sick or cause some kind of reaction. She stated the stained and scratched cups, bowls, and glasses were on the clean racks, and in use. An interview with [NAME] B on 06/17/24 at 11:09 am she stated the stained and scratched cups, bowls, and glasses were on the clean rack, and about to go out on the carts for delivery to the residents. She did not know who was responsible for checking the dirty dishes. She stated she did not know the dishes looked the way they did and would not want to drink or eat from them because it would probably make her sick. She stated the dishes needed to be re-washed because whatever was in the dirty dishes on the clean rack could make the residents sick. An interview with the FSM on 06/17/24 at 11:30 am she stated the stained and scratched cups, bowls, and glasses were used every single shift. She stated there were no problems with the dishwasher and proceeded to check a chem strip, which was normal. She stated the stained and scratched cups, bowls, and glasses should not be used and the dishwasher was responsible for checking them. She stated they would not send the dishes out like that. When shown the dirty dishes, she stated, they're not washing them. She stated the dishwashers were trained to check every load. She stated she was ultimately responsible for the entire kitchen. Regarding the juice guns, the FSM stated they were not supposed to be hanging down and should be in the holsters. She stated the red sticky substance was old juice. She stated the juice guns were cleaned after each use. She stated she cleaned them herself last week. She stated they did not look like they had been cleaned after every use. The FSM stated if the nozzles got dirty, it could transfer germs into the glasses and it could make residents sick. The FSM stated cross contamination could occur with the juice guns in the condition they were in as well as the scratched and dirty dishes. The FSM stated the spices and sugar should not have been open to air because it could cause clumping. She stated the residents could get sick. The FSM stated staff should not be using the worn, non-stick pan for anything, and it should have been replaced. The FSM stated she was not sure what their policy said about cleaning, sanitation, and personal items. The FSM stated she did not know who the personal sodas belonged to, but they should not have been on the juice machine table or in the refrigerator. The FSM stated the tape dispensers on the prep table should not have been on the shelf above the prep table because kitchen staff used the prep table to place sandwiches and other snacks in bags or plastic wrap and used the tape to secure the bags and plastic wrap. An interview with the DW on 06/17/24 at 11:40 am she stated the stained and scratched cups, bowls, and glasses were typically not looked at after the wash cycle. She stated all of the stained and scratched cups, bowls, and glasses were on the clean rack and about to be used. She stated the stained and scratched cups, bowls, and glasses typically looked like that and they used them anyway. She stated she guessed the staff was moving too fast to notice. She stated cross contamination could occur, especially in the scratches and make the residents sick. She stated she tried to say something to the FSM, but nothing happened, and she was afraid she could get fired if she said anything more. She stated drying mats were needed for drying the cups, glasses, and bowls on the trays and that all of the drying trays should have had a drying mat on them so air could circulate and keep bacteria from growing, which could make the residents sick. She stated without the drying mats, the dishes did not dry properly. Record review of the facility policy, Food Storage revised 10/05/21: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes an HACCP (Hazard Analysis Critical Control Point-a management system in which food safety is addressed through the analysis and control of bilogical, chemical, and physical hazards from raw material production, procurement and handling, to manufacturing, distribution and consumption of the finished product) guidelines. Procedure: 1. Dry storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators d. Date, label, and tightly seal all refrigerated foods . Facility policies for cleaning and personal items were requested from the FSM on 06/17/24 at 11:45 am but not provided. In-services for kitchen staff was requested from the FSM on 06/17/24 at 11:45 am but not provided. References: TAC 554.1111 (b) The facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Service sanitation requirements.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 20 residents r(Resident #273), staff, and the public. -A facility staff member left an empty covered needle syringe on top of Resident #273's drawer in his room. This failure could place 20 residents who reside on the 200 floor at risk for injury or illness due to an unsafe environment. The Findings: Record review of Resident #273's face sheet dated 6/17/24 reflected a [AGE] year-old-male with an original admitted [DATE]. Diagnoses included type 2 diabetes (insufficient insulin production in the body), surgical aftercare following surgery, and end stage renal failure (kidney failure). Record review of Resident #273's MDS reflected a BIMS score of 15 (cognition intact). Record review of Resident #273's care plan reflected Resident #273 has the need for enhanced barrier precautions due to: (open wound, wound vacuum). Interventions included: -Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shield as indicated. -Assess the resident for risk factors or current injuries or treatments that could put the patient at risk for infection (wounds, central lines, drains, catheters, tracheostomy). -Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures. During an observation/interview on 6/16/24 at 03:19pm, this surveyor noticed a covered empty needle syringe on Resident #273's dresser approximately 5 to 6 feet away from Resident #273's bed. Resident #273 stated he did not know how long that needle had been there and could not say who could have left it there. Resident #273 denied getting an injection and did not know why the needle syringe would be in his room. Resident #273 denied touching it, stating he did not notice the needle syringe was even there. In an interview on 06/16/24 at 03:21pm, LVN B, stated she was not aware there was a covered needle on Resident 273's dresser. LVN B stated she got to work at 2:00pm and started her rounds in resident rooms around 2:00pm and stated she peeked into Resident #273's room and did not see the needle. LVN B stated all needles are to be disposed of in the sharp's container located on the nurse's cart. LVN B stated she had no idea who could have left the needle in Resident #273's room or if it even belonged to him. LVN B stated by the needle being in Resident's 273's room could possibly cause staff, visitors, or other residents to get injured by getting poked and could cause an infection control issue. LVN B stated she could not remember the last time she was in-serviced on placing sharps in the appropriate sharps container. In an interview on 6/17/24 at 9:12am the DON stated, she did not now who was responsible for leaving the needle syringe in Resident #273's room. The DON stated it could have been the previous night nurse (LVN C) and stated possibly when LVN C went into the Resident #273's room to monitor the wound care vac, LVN C could have placed the needle syringe down on the dresser to tend to the wound vac machine and forgot to dispose the needle. The DON stated all sharps containers are located on the nurse's medication carts. The DON stated by having a needle syringe in Resident #273's room, it was putting visitors, residents, and staff at risk for injury or harm. The DON stated rounding is done by staff at a minimum of every 2 hours and staff are supposed to look into the rooms, assess residents, and make sure everything is in order. The DON stated staff should be going into resident rooms and not just peeking in. The DON stated Crown Rounds are conducted every morning and throughout the day by administration to ensure residents do not have any concerns and to identify anything out of the ordinary. The DON stated on the weekends, the weekend supervisor should be conducting those rounds to ensure residents are checked but was unsure if rounds were conducted on 6/16/24. The DON stated she was unsure when the last in-service on rounding was. This surveyor called LVN C on 6/18/24 at 2:30pm, 6/18/24 at 2:40pm, and on 6/18/24 at 2:49pm with no answer, message left. Record review of Medication Administration- Injectable Administration Policy dated 10/01/19 stated: Policy To administer medications via subcutaneous, intradermal, and intramuscular routes in a safe, accurate and effective matter. Procedure Dispose of syringe in a sharps container and supplies in a appropriate waste container.

Based on observation, interview, and record review, the facility failed to have sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (Resident #272) of eight residents reviewed for medication administration. The facility failed to ensure that four nurses (LVN A, LVN H, LVN I, and LVN J) admistered medication that was ordered for Resident #272 as documented. This failure could place residents at risk for not receiving their medications, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. Findings included: Record review of Resident #272's admission record dated 06/18/24 revealed a [AGE] year old male admitted to the facility on [DATE]. Diagnoses included encounter for orthopedic aftercare following surgical amputation, iron deficiency anemia, gastrostomy (a tube inserted through the abdominal wall into the stomach that is used to give residents nutrition, medications, and/or fluids) status, congestive heart failure, type 2 diabetes, primary hypertension, history of skin cancer removal on nose, chronic kidney disease, and cerebral infarction (disrupted blood flow to the brain that causes brain cells to die). Record review of Resident #272's order summary report dated 06/18/24 revealed an order for Alkalol Saline Nasal Solution (Nasal Moisturizer Combination); 2 sprays in both nostrils one time a day for allergies. Order date: 06/11/24. Start date: 06/11/24. Observation of medication pass on 06/18/24 at 9:10am revealed that Resident #272's ordered nasal spray was not in the medication administration cart that was being used by the WCN, who was also the floor charge nurse that day, to administer medications. Record review of Resident #272's MAR on 06/18/24 revealed that Resident #272's nasal spray was administered on: 06/12/24 at 9:00am by LVN I 06/13/24 at 9:00am by LVN A 06/14/24 at 9:00am by LVN A 06/15/24 at 9:00am by LVN J 06/16/24 at 9:00am by LVN A 06/17/24 at 8:00am by LVN H In an interview on 06/18/24 at 10:15am, the WCN stated the nasal spray was not in the medication cart nor in the medication storage room. The WCN stated she contacted the nurse practitioner by phone who advised the WCN to try to get the nasal spray from the pharmacy. The WCN stated she contacted the pharmacy and was told the nasal spray is an over the counter medication and should be obtained by central supply. The WCN stated if a medication is not administered as prescribed, it could cause the resident to have medical issues, depending on the medication, such as high blood pressure for a hypertension medication or decreased wound healing for vitamins/minerals. The WCN stated she was not able to tell who the other nurses were that were on the MAR because it only showed initials or abbreviations, but that she would try to run a report to show who each nurse was. (She was not able to run that report). In an interview on 06/18/24 at 12:29pm in Resident #272's room, Resident #272's family member stated that she was at the facility with the resident every day and had observed his medication administration on 4 days out of 7 that she had been at the facility. The family member stated Resident #272 had not received nasal spray on any of the days that she observed him being given medications. The family member stated that Resident #272 got the nasal spray at home due to the cancer removed from the top of his nose on the right side. The family member stated the nasal spray was used at home as needed, not necessarily every day, to help prevent infections. Resident #272 also stated that he had not gotten the nasal spray since he had been in the facility. In an interview on 06/18/24 at 12:32pm, MA K stated that you should never document that you gave a medication that you did not give. MA K stated if the medication is not on the cart or in the medication room, she would tell the nurses so that they could get it. MA K stated it would be false documentation and could have adverse effects such as high blood pressure or high blood sugar due to the resident not getting prescribed medication. MA K stated if she saw that a medication was not administered, but was documented that it was, she would let the charge nurse know. In an interview on 06/18/24 at 12:35pm, the WCN stated she would not document that a medication was given if she did not have the medication. The WCN stated she would contact the pharmacy and/or the practitioner as needed to advise them of the situation and see if the order needed to be changed or what needed to be done. The WCN stated as charge nurse, if she knew about a medication being documented but not given, she would find out who that person was, find out the reason, and tell the DON. The WCN stated that she talked to central supply and now has the nasal spray for the resident and the nurse practitioner has updated the order to as needed instead of scheduled, per Resident #272 and family request. In an interview on 06/18/24 at 12:46pm, the DON stated, I'm working on the in-service now. The DON stated she would expect that if a medication was ordered and had not been available for over 24 hours, the nurse would notify the ADON, DON, pharmacy, and/or central supply to get the prescribed medication or over the counter medication. The DON stated she would also expect the nurse to notify the practitioner to let them know what was going on and see if they wanted to make any changes. The DON stated she would expect the nurse to NOT document that a medication had been given if it had not. The DON stated if a medication is not really given but documented as administered, it could cause complications such as a physician ordering another blood pressure medication because documentation showed that a resident had been receiving an anti-hypertensive medication but the blood pressure was still high which could have possibly lead to a resident having a critically low blood pressure due to the extra medication. The DON stated false documentation of medication administration could lead to resident complications up to and including death, depending on the medication. The DON stated that the nurses that falsified the documentation would be disciplined and re-trained on medication administration and documentation. The DON stated she had notified the family and was waiting on a call back from the doctor. Telephone contact was attempted on 06/18/24 with LVN A, LVN I, LVN H, and LVN J, two times each between 1:00pm and 3:00pm. Messages were left each time with surveyor's name and contact number with no call backs received. In an interview on 06/18/24 at 1:32pm, the ADMIN stated she would expect the nurse to contact the pharmacist or supply to get the medication, then to contact the ADON or DON if they still were not able to get it. The ADMIN stated if the medication was still not available after all that, the nurse would have to contact the prescriber to see if the order needed to be changed. The ADMIN stated she would expect all staff to follow physician orders and not just document that it was done. The ADMIN stated that all of the nurses who falsified the documentation would be disciplined by the facility and in-serviced/ retrained on medication administration and documentation. Record review of the facility's Medication Administration Policy and Procedure dated 10/01/19 states in part: D. 10 Rights of Medication Administration- 6. Right Documentation- Nurses need to document medications as they're given. Any medication documentation needs to be initialed yourself, never let anyone document for you. Chart the time, route, and any other specific information as necessary. E. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. K. If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. 2. Administration B. Medications are administered in accordance with written orders of the prescriber. 4. Documentation (including electronic) A. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering medications reviews the MAR to ensure necessary doses were administered and documented. D. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are cross referenced to a full signature in the space provided. G. If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters are described in the user's manual. These procedures should be followed and may differ slightly from the procedures for using paper MARs.

Based on observation, interview, and record review the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent deterioration of existing pressure ulcers, promote healing, and prevent development of new pressure ulcers, for one (Resident #46) of three residents reviewed for pressure ulcers, in that: -Wound care nurse did not pat dry Resident #46's pressure ulcer after cleaning the wound with wound cleanser as ordered. This failure could place residents with existing pressure ulcers receiving preventive skin care at risk for developing new pressure ulcers and/or a deterioration in existing pressure ulcers. The findings included: Record review of Resident #46's face sheet dated 6/18/24 reflected a [AGE] year-old-male originally admitted on [DATE]. Diagnoses included cerebral infarction (stroke, blood supply to part of the brain is blocked or reduced), contractures (shortening or hardening of the muscles) to the left and right hand, and muscle atrophy (wasting or thinning of muscle mass). Record review of Resident #46's physician orders stated: Dated 5/18/2024 Left posterior (closer to back of) ischium (hip bone) stage 3 (full thickness skin loss) pressure injury. Cleanse with wound cleanser and pat dry. Apply barrier cream over the site. Every day for aid in wound healing. Record review of Resident #46's care plan dated 5/7/24 stated Resident 46 had pain r/t contractures to bilateral (both) hands, pressure ulcer stage 3 to the ischium. Interventions included: Administer analgesia as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Respond timely to any complaint of pain. Observation of wound care on 06/17/24 at 02:37pm, the Wound Care nurse cleansed Resident #46's left posterior ischium with wound cleanser, removed gloves, washed hands for greater than 20 seconds, put on new gloves, and applied barrier cream. The - Wound Care nurse did not pat dry after cleansing Resident #46's left posterior ischium as ordered after cleansing wound with wound cleanser. Attempted an interview with Resident #46 however, Resident #46 was uninterviewable. In an interview on 06/17/24 at 02:56pm, the Wound Care nurse stated she did not pat dry Resident #46's wound after cleansing the wound with wound cleanser because she was nervous and missed a step. The Wound Care nurse stated after washing her hands, she felt the wound cleanser she applied to Resident #46's wound had enough time to dry. The Wound Care nurse stated it is important to follow doctor's orders because it is person centered and care that was ordered by a physician for Resident #46. The Wound Care nurse by not pat drying Resident #46's wound, the wound could become macerated (soften or become softened by soaking in liquid), and could delay healing. The Wound Care Nurse she usually pat dries the wound and could not stated when the last time she received in-service on wound care. In an interview on 06/18/24 at 11:01am, the DON stated it is important to follow all doctor orders because it is person centered. In-service was conducted yesterday on following doctors' orders and infection control. DON stated by the DON stated by not pat drying the Resident #46's wound, it could lead to infection, sepsis, hospitalization , and the wound not healing properly. The DON stated she and the ADON on the floor was in charge of overseeing the Wound Care nurse was following doctors' orders. The DON stated she had watched the Wound Care nurse perform wound care last week with no concerns noted. The DON stated the wound care doctor comes twice a week and watches the Wound Care nurse perform wound care on Resident #46 as well as other residents and stated the doctor has never had any issues with the Wound Care nurse's performance. The DON stated the Wound Care nurse was nervous and visibly upset about the mistake. Record review of Medication Administration dated 10/24/22 stated: Policy: Medications are administered by a licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents 1 (Resident #1) of 5 reviewed for elopement. The facility failed to ensure Resident #1 was supervised for elopement, Resident #1 eloped on 12/09/2023 and was found approximately 1.3 miles from facility. Failed to care plan Resident #1's wandering, pacing, trash digging, schizophrenia behaviors, and drug seeking behaviors. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 12/09/2023 and ended on 12/11/2023. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of not receiving individualized interventions to promote appropriate supervision that could cause injury/serious injury/ or death. Findings include: Record review of Resident #1's face sheet dated 12/15/2023, documented a [AGE] year-old male admitted on [DATE] with diagnoses of schizophrenia, psychoactive substance abuse with intoxication, dementia with mood disturbance. Record review of Resident #1's MDS dated [DATE], documented BIMS Score of 09 with moderate cognitive impairment. Coded within the Delirium portion as having inattention and disorganized thinking. Resident #1 was also coded within the potential indicators of psychosis as having delusions (misconceptions or beliefs that are firmly held, contrary to reality). Record review of Resident #1's Baseline Care Plan dated 11/22/2023, did not care plan: Resident #1's verbalized request to leave the facility, wandering, digging into trash, drug seeking behavior, or schizophrenic episodes of flight of ideas. The resident voiced on multiple occasions his desire to leave the facility, exhibited pacing and agitation. Record review of Resident #1's Wandering Evaluation dated 11/21/2023 documented score of 6 which indicated a moderate risk. Record review of Resident #1's Wandering Evaluation dated 12/06/2023 documented score of 7 which indicated a moderate risk. Record review of Resident #1's progress note dated 12/02/23 at 5:55 a.m., written by LVN A indicated, the resident was documented to be pacing throughout the hallways and digging through the trash. Resident became agitated. Yelling at nurse, I'm not doing anything, I'm just playing with this, it's nothing, upon closer inspection resident had a small bag with white powder like substance stuffed into the connection tubing. Questioned resident what he has, resident took out the small bag from the tubing and threw it in cup writer had in her hand. Record review of Resident #1's progress note dated 12/03/23 at 4:37 a.m., written by LVN B indicated the resident was documented to have come out of his room on the 2nd floor with all his belongings in his arms and stated he needed the front door open, and I'm going to leave to my friend's house for the night so I can get cigarettes and my lighter, I will be back He became agitated and started to yell out at nurse I just need a hit, I need to leave the f***ing place Record review of Resident #1's progress note dated 12/03/23 at 10:07 a.m., written by MDS Coordinator, indicated the resident was asking to leave the facility unsupervised to get fresh air and cigarettes. Noted delusions and flight of idea, consistent with schizophrenia dx. Record review of Resident #1's progress note dated 12/06/2023 at 3:06 a.m., written by LVN A indicated resident wandering most shift looking for food, resident noticed by staff digging in trashcan in kitchenette area, this nurse advised by staff that resident trying to leave out front door with visitors leaving facility. Record review of Resident #1's progress note dated 12/09/2023 at 8:11 a.m., written by LVN C, Approximately 7:30am I received a call from CNA stating that the resident was on [NAME] near the pawn shop by [a Restaurant] . I told her I would be right there, notified CMA and she followed me to the Del Mar Multiservice Center on Ayers. I saw resident walking on the sidewalk . Record review of Resident #1's Against Medical Advice Form dated 12/09/2023 documented, this is to certify that I, Resident #1, a patient at Windsor Nursing and Rehabilitation Center of Morngan, am refusing at my own insistence and without the authoirity of and against the advice of my attending physician [physician] request to leave against medical advice. The medical risks/benefits have been explained to me by a member of the medical staff and I understnad those risks. I hereby release the medical center, its administration, personnel, and my attending and/or resident physician(s) from any responsibility for all consequences, which may result by my leaving. Signed Resident #1 date:12/09/2023. Witness: facility staff member signature. Interview with Resident #1 was attempted on 12/16/2023 at 12:03p.m. but was unsuccessful. During an observation on 12/16/2023 at 12:10 p.m., observed the main entrance door's alarm engage at the 10 second mark when a wander guard crossed door threshold and entrance door was pushed , the alarm was loudly audible. Resident #1 discharged himself from facility on the morning of 12/09/2023 and against medical advice. During an observation on 12/16/2023 at 12:12p.m., observed three unidentified residents in the outside patio being supervised by a CNA. During an observation of resident #1, #2, #3, #4, #5 who were identified as high risk for elopement and wore wander guard devices on 12/16/2023 at 12:20p.m. revealed they were all located at the first floor lobby area being monitored by Administrator and DON. During an interview 12/15/2023 at 2:51 p.m., the MDS Coordinator stated Resident #1 was not at facility long, and was admitted on [DATE], discharged [DATE], and was there for approximately 19 days. Resident #1's verbalized requests to leave, to leave for cigarettes, request to sleep at friend's place, and frequent flight of ideas would be implemented into a comprehensive care plan on the 21st day per state regulations. When asked about what would happen in-between if an incident/or behavior occurred, the MDS Coordinator stated the event and behaviors would be on a 24hr report, and verbalized to the clinical staff a midst shift report, who would then use their nursing expertise to implement common interventions i.e., redirection, or activities. The MDS coordinator stated the verbalized previously mentioned requests would not be implemented into the baseline care plan due the attempt to understand Resident #1's wants and needs before prematurely care planning the behavioral events. MDS stated due to wander assessment, she did not find it appropriate to use wander guard on Resident #1 due to low-moderate score and because Resident #1 was his own RP. Referencing progress note on 12/03/23 at 10:07 a.m, MDS Coordinator stated, she de-escalated and redirected Resident #1, and offered donation cigarettes, Resident #1 was then okay after. MDS Coordinator stated she attended an in-service on 12/11 regarding procedure with a resident goes missing. The MDS Coordinator stated the baseline care plan is done with 48 hours and encompasses immediate needs, and reiterated she knows state regulation only requires a baseline care plan within 48hours, and a comprehensive care plan by the 21st day after admission, as well as reiterated she is not mandated to update care plan prior to the 21st day after admission. During an interview on 12/15/2023 at 3:31 p.m., LVN A stated she remembered taking care of Resident #1, and remembered he was confused. LVN A stated Resident #1 would wander and not remember where he was, like he had dementia. LVN A stated she recalled one evening CNA A notified her that Resident #1 was found downstairs trying to leave and was notified that his reason for trying to leave was to go to the store. LVN A stated on 12/6 she kept a closer eye on Resident #1 and when she questioned Resident #1 why he was trying to leave, Resident #1 stated he wanted to get cigarettes. LVN A stated she was notified Resident #1 left when visitors would leave. LVN A stated she implemented diversional activities of puzzles, and activities to keep him engaged, but nothing to keep him hostage. LVN A stated after the redirection Resident #1 did not attempt to leave. LVN A stated she does not recall being notified of Resident #1's attempts to leave the facility in nurse-to-nurse report and is not part of morning clinical meetings due to being a night shift nurse. LVN A stated when CNA A notified her of Resident #1's attempt to leave, that she had a plan in place if Resident #1 attempted to leave again she had a wander guard in the nurse's cart that she would use but did not have to use. LVN A stated nobody ever voiced to her any desire to leave. LVN A stated she verbalized when she was amongst a CNA and an unknown nurse, that if Resident #1 tried to leave, after his first attempt, that she would have retrieve a wander guard that is kept in the nurse's cart and apply it to Resident #1. LVN A stated had Resident #1 presented an elevated behavior, she was prepated to de-escalate the situation and redirect and re-educate resident on the importance of maintaing safety within the facility. During an interview on 12/15/2023 at 3:50 p.m., LVN B stated Resident #1 was his own responsible party, and on 12/03/2023 around 3am Resident #1 came out of his room with all his clothes and stated he wanted to go to his friend's house to get high and get cigarettes. LVN B stated Resident #1 had schizophrenia and may have been his cause of agitation on 12/03/2023. LVN B stated after Resident #1 made the additional issue of not feeling comfortable with living with his roommate, LVN B moved Resident #1 to a different room. LVN B stated Resident #1 was not actively trying to exit or get out. LVN B stated Resident #1 was wanting to leave to get a cigarette and wanted to get high and wasn't trying to physically leave just voiced that he wanted to leave. LVN B stated Resident #1 was in the middle of the second-floor dining area, and had a couple pants in hands, and voiced that he wanted to go right now, then began to yell, and just needed a hit around 3am in the morning. LVN B stated she was taught to first de-escalate the situation and redirected for Resident #1 to return to room, to which he did, and was okay after. LVN B stated she was not notified of Resident #1 wanting to leave previously any time before shift. LVN B stated had she been notified of Resident #1's desire to leave, it would have triggered her to read the progress notes and monitor him for trying to leave. LVN B stated she attended an in-service regarding procedure when a resident goes missing. During an interview on 12/15/2023 at 6:00 p.m., CNA A stated on 12/06/23 around 10-11PM, she heard the downstairs door alarm sounding off and went to go and investigate/turn off the alarm. CNA A stated once out of the elevator she was walking through to the main entrance door, and saw Resident #1 returning from outside, back to entrance door. CNA A stated she asked Resident #1 how he got outside, and he stated that he walked behind a visitor, and was coming back to get his cigarettes. CNA A stated she then escorted Resident #1 back upstairs and notified the nurse taking care of Resident #1. CNA A stated she observed Resident #1 in his room on the evening of 12/08/2023 at around 11:30p.m. and was the last time she saw the resident due to having other residents to attend to. During an interview on 12/16/2023 at 12:16p.m., the DON and Administrator both stated Resident #1 eloped between the night of Friday 12/08/2023 into Saturday 12/09/2023 morning. Both stated on the evening of Friday 12/08/2023 around 11:30p.m. a CNA offered Resident #1 a snack, and upon a midnight round around 12:40a.m on 12/09/2023, Resident #1 was noted to not be in his room nor facility. Both stated the facility notified the police department but were notified that the police department would not look for Resident #1 because he was of sound mind. Both stated, around 7am on 12/09/2023, two facility staff members located Resident #1 at the corner of a restaurant that was approximately 1.3miles away. Both stated, the two facility staff members attempted to persuade Resident #1 to return to the facility but were unsuccessful, and under the direction of the DON, Resident #1 was given an Against Medical Advice form to sign, which meant he was choosing to discharge against medical advice. Both stated, during a 24-hour clinical report clinical meeting, Resident #1's wandering and trash digging were discussed and were deemed as behaviors indicative of Resident #1's history of homelessness and planned to have snacks readily available for Resident #1 as well as have cigarettes for him. Both stated Resident #1's verbalized desire to sleep over at a friend's house, and leave were behaviors indicative of drug seeking but planned through redirection and re-education from facility staff to care for Resident #1. Both stated, Resident #1 did not have order to be out on pass due to drug seeking behavior. When the DON and Administrator were questioned about the plan of care for Resident #1, and what plan they had in place to ensure the safety of Resident #1's behaviors of drug seeking, sleeping over at a friend's house, wandering, and trash digging both replied, the staff would use in conjunction with the 24-hour report, redirection, and re-education to care for Resident #1. Both stated additionally, Resident #1's wander assessments were discussed within a morning clinical meeting, and with the MDS Coordinator, did not find it appropriate to implement a wander guard onto Resident #1's person, given that his assessment scores were low to moderate and was his own RP. The Administrator stated after Resident #1's successful elopement on 12/09/2023, they changed the door alarm system from 15seconds to a 10 second delay followed by alarm engagement. The DON and Administrator stated after 8p.m. all first floor exiting doors will alarm if engaged, and the alarm will continue to alarm until a staff member inputs a code. Both stated on 12/06/2023 during the day, Resident #1 did not exit the facility, and continued by stating, they were notified by staff that as a facility staff member was holding the door open for visitors to leave on 12/06/2023, the staff member caught Resident #1 attempting to leave behind the visitors but was kept from leaving by staff member. Both stated, the drug seeking behaviors, the verbalization to leave, the wandering and trash digging, would be on the comprehensive care plan, but reiterated that they knew the state legislation regarding care plans, and did not have to have a care plan before the 21 days. When the DON and Administrator were asked what their process would be if an event or issue occurred prior/ in between the 21 days, the Administrator stated they would monitor Resident #1, as well as stated the facility could actively have a working care plan but did not have, and again reiterated they knew state regulations, and knew the facility did not have to have a care plan till the 21st day after the admission of Resident #1. Record review of the facility's Elopement drill L code Green Missing Resident conducted 12/11/2023 Record review of the facility's in-service indicated If a residence presence is unknown, alert all personnel including the DON and Administrator. All the police, alert the administrator and designate staff to search for the resident in-service conducted on 12/09/2023. - Inservice Missing Resident: 1. Ensure resident is not on floor in another room, shower room, bathroom, etc . 2. Once sure resident not on floor or on downstairs lobby, page overhead Code green- (floor number) 3. Nurses immediately do head count of resident and ensure all resident accounted for 4. Call to floor with code and find out what resident missing 5. Initiate search party of neighborhood 6. Nurse to check medication list for life-saving medications 7. Notify Administrator and DON and on call of missing resident and time lifesaving medication is due to be administered 8. Notify physician, RP, and CCPD with description and picture of resident 9. Figure out how resident eloped from facility and ensure all doors closing and alarms sounding. Record review of the facility's AdHoc QAPI Meeting date 12/09/2023. Issue: Resident who exhibited wandering behavior x 2 eloped on 12/09/2023. Plan: Re-educated staff on elopement protocols, care planning and intervening if a resident is exhibiting wandering tendency Review nurses notes and 24hr report daily for any resident exhibiting wandering behaviors. Complete elopement drills per P&P Alarm on door to stairwell reactivated and will be monitored by maintenance director and administration. Wander guard system audit completed, alarm system in place and followed per protocol. Record review of the facility's How to check wander guard with tested to ensure its functioning properly in-service conducted 12/11/2023. Interviews with the following staff revealed they received in-service training re: Elopement drill L code Green Missing Resident, If a residence presence is unknown, alert all personnel including the DON and Administrator. All the police, alert the administrator and designate staff to search for the resident, How to check wander guard with tested to ensure its functioning properly , and Procedures for Elopements and Wandering Residents, and were knowledgable and able to verbalize the procedures correctly by: MDS Coordinator on 12/15/2023 at 2:51p.m., LVN A on 12/15/2023 at 3:31p.m., LVN B on 12/15/2023 at 3:50p.m., CNA A on 12/15/2023 at 6:00p.m., and DON and Administrator on 12/16/2023 at 12:16p.m. Record review of the facility's Elopements and Wandering Residents date implemented 11/21/2022 revealed, Monitoring and Managing Resident at Risk for Elopement Or Unsafe Wandering c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.

Based on interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 1 of 1 residents reviewed for abuse and neglect. The facility failed to ensure Resident #1 did not experience abuse from CNA B. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/25/23 and ended on 7/25/23. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of face sheet dated 7/28/2023 revealed Resident #1 is a [AGE] year-old male with a diagnosis of cerebellar ataxia, altered mental status, cognitive communication deficit, muscle wasting, dysphagia and a need or personal assistance. 2. Record review of Resident #1s quarterly MDS accessed on 7/28/2023 indicate he had a BIMS score of 6, which indicates severe mental impairment. 3. Record review of Resident #1s care plan initiated 7/25/2023 indicates he is sometimes sexually inappropriate and touches female staff related to impaired cognition and poor impulse control. 4. Resident #1s care plan indicates he is totally dependent on 1 staff for personal hygiene care, eating, dressing, toileting, bathing, and repositioning. During an interview on 7/28/2023 at 1:55 PM CNA A said CNA B told Resident #1 during breakfast on 7/25/2023, I heard you like to touch my sister's boobs and ass. How would you like it if I took your sister and fucked her over your bed?. CNA A said Resident #1 became mad. CNA A said she was afraid of CNA B and did not say anything to her. CNA A said she was supposed to report abuse to the charge nurse, and she was supposed to report it to the Administrator, but she did not report it to the Administrator. She said she told the charge nurse. CNA A said CNA B continued to work on the floor until approximately lunch time. During an interview on 7/28/2023 at 2:30 PM CNA C said she had finished feeding residents down the hall and came upon CNA B as she started talking to Resident #1 about touching her sister. CNA C said CNA B said to Resident #1, How would you like it if I did that to your sister?. CNA C said Resident #1 went off (became angry). CNA C told CNA B she shouldn't say that in front of Resident #1, but it was after he was taken away. CNA C said she was in shock a little bit. CNA C said it was the first time she had seen something like that. CNA C said she didn't realize CNA B was talking to Resident#1 until after CNA B started talking about fucking his sister. During an interview with the Administrator on 7/28/2023 at 2:49 PM she said breakfast was over at around 9:00 AM on 7/25/2023. She said the DON removed CNA B from the floor and suspended her at around 10:30 AM. CNA B was working on the floor an hour and a half after the abuse occurred. The Administrator said the staff knew they had to call her immediately if abuse occurred. The Administrator said she was notified of the abuse at the same time as the DON. The Administrator said she thought the staff made a conscious decision not to call her immediately, and it was the wrong decision. During an interview with the Administrator on 7/28/2023 at 2:49 PM she said she would make sure CNA B was reported to the Nurse Aid Registry. During an interview on 8/21/2023 the DON displayed evidence CNA B was reported to the Nurse Aid Registry on 7/8/2023. During an interview with resident #1 on 8/21/2023 at 10:45 he said he thought he remembered CNA B. Resident #1 did not remember CNA B being mean to him. Resident #1 said he was not afraid of anyone at the facility. During and interview with the ADON on 8/21/2023 at 1:00 PM she said she was told at around 8:45 AM on 7/25/2023 that Resident #1 was upset because the CNAs told him No and attempted to re direct Resident #1 when he tried to grab them inappropriately. ADON said he often gets upset when told no. ADON said she was not told at that time CNA B was abusive to Resident #1 and learned the full scope of the incident when CNA A texted them during morning meeting at around 10:30 AM. ADON learned the full scope of the incident at the same time as the DON and the administrator. During an interview with MDS LVN on 8/21/2023 11:45 AM she said Resident #1 hit CNA B a couple of times in the face. MDS LVN said she saw that but did not hear CNA B say anything disparaging to Resident #1. MDS LVN said she was at the nurse's station and heard Resident #1 screaming. MDS LVN said after Resident #1 hit CNA B , she told CNA B to back away, and MDS LVN took Resident #1 to the nurse's station, just to get him out of the dining room. MDS LVN said she did not know CNA B was the cause of Resident #1s anger. MDS LVN said she was very familiar with Resident #1. MDS LVN said she tried to calm Resident #1 down at the nurse's station and said he was calm in less than a minute but was still more riled up than he usually was. Resident #1 was still agitated, but he wasn't screaming or hitting. He was just agitated. MDS LVN said it is not unusual that he doesn't remember the event. MDS LVN said that later on 7/25/2023 when she interviewed him, he didn't seem to remember it either. During interviews conducted on 7/28/2023 10:30 AM - 5:30 PM with all residents in their rooms during inspection of the 4th floor revealed no complaints about facility or staff. During a record review of in-services for abuse and neglect it was revealed staff received training on 7/25/2023, 7/12/2023, 6/12/2023, 5/11/2023, and 1/11/2023. A transcript of training for CNA B indicates she completed training for preventing abuse and managing aggressive behaviors on 4/16/2023 and completed training for quality dementia care on 1/4/2023. Record review of facility's policy on abuse (revised December 2017) indicated Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of the facility's Abuse Policy dated 8/15/2022 indicated the facility will implement policies and procedures to prevent and prohibit all types of abuse that achieves: Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors Verification of the facility's response to the incident included: Record review: Facility staff training on abuse and neglect, notification of abuse prevention coordinator Investigation report and allegation of verbal abuse confirmed Alleged perpetrator reported to Nurse Aid registry 7/28/2023 Notification to police: case # 2307260117 Review of resident interviews CNA B employee record for completion of training 7/25/2023 Reviewed facility notes Resident abuse interview and observation. Resident #1 denies, (7) total residents all deny abuse. NAR of CNA B no issues searched 2/16/23 CNA A abuse training 7/10/23 Elder Abuse 7/21/23 Police report: Case # 2307260117 Nurse Aid B reported to Nurse Aid Registry 7/28/2023. Interviews: On 8/21/2023 between 2:30 PM and 3:00 PM interviews conducted across 2 shifts that included CNA A, CNA C, CNA D, CNA E, CNA F, CNA G, and CNA H to ensure training was completed. Responses were consistent with facility training and policy. Staff able to identify who the abuse prevention coordinator is and can find the number for the abuse prevention coordinator. Observations: Facility observations on 7/28/2023 revealed residents appeared content and no issues were noted. On 08/23/23 at 1:45 pm, the DON (Administrator not on duty) was notified of a Past Non-Compliance Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the DON at this time.

Based on observation, interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, for 1 of 3 residents (Resident#1) reviewed for abuse and neglect, in that: The facility failed to ensure CNA A and CNA C immediately reported any alleged incidents of abuse to the abuse prevention coordinator. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/25/23 and ended on 7/25/23. The facility corrected the non-compliance before the investigation began. These failures placed residents at risk of further abuse by leaving an alleged perpetrator remain in contact with facility residents. The findings were: During a record review of Resident #1's face sheet it was revealed he is a [AGE] year old male with a diagnosis of cerebellar ataxia, altered mental status, cognitive communication deficit, muscle wasting, dysphagia and a need or personal assistance. Record review of Resident #1's quarterly MDS assessment dated [DATE], he has a BIMS score of 6, which is considered a severe impairment to cognitive ability. Resident #1 was interviewed on the morning of 7/28/2023 with his sister present. He displayed no signs of distress. He nodded yes when asked if the staff treated him well. During a review of Resident #1's chart it was noted on 7/28/2023 at 11:25 AM Social Services interviewed Resident #1. Social Services note indicated all was good and that the resident did not mention an allegation. During an interview on 7/28/2023 at 1:55 PM CNA A said CNA B told Resident #1 during breakfast on 7/25/2023, I heard you like to touch my sister's boobs and ass. How would you like it if I took your sister and fucked her over your bed? CNA A said Resident #1 became upset. CNA A said she was afraid of CNA B and did not say anything to her. CNA A said she was supposed to report abuse to the charge nurse, and she was supposed to report it to the Administrator, but she did not report it to the Administrator. She said she told the charge nurse. CNA A said CNA B continued to work on the floor until approximately lunch time. During an interview on 8/21/2023 at 1:00 PM ADON said she was told at around 8:45 AM on 7/25/2023 that Resident #1 was upset because the CNAs told him No and attempted to re-direct Resident #1 when he tried to grab them inappropriately. ADON said he often gets upset when told no. ADON said she was not told at that time CNA B was abusive to Resident #1 and learned the full scope of the incident when CNA A texted them during morning meeting at around 10:30 AM. ADON learned the full scope of the incident at the same time as the DON and the administrator. During a record review dated 7/25/2023 at 8:45 AM late entry created on 7/25/2023 at 5:16 PM by the charge nurse it was charted she became aware of abuse after Resident #1 became calm and made ADON aware of abuse. During an interview with the charge nurse on 8/21/2023 at 11:30 AM indicates she was at the nurse's station and did not know why Resident #1 was upset. The charge nurse said there were already other staff there and the MDS nurse was trying to de-escalate Resident #1. During an interview with the MDS nurse on 8/21/2023 she said she used to be the ADON on the floor and knew Resident #1 well. MDS nurse said she was at the nurse's station and did not hear anything CNA B said but heard Resident #1 screaming. The nurse's station is about 20 feet from the dining area. MDS nurse said she witnessed Resident #1 hit CNA B and so told CNA B to back away. MDS nurse then took Resident #1 to the nurse's station. MDS nurse said she did not know CNA B was the cause of Resident #1s anger. During an observation on 7/28/2023 at 3:30 PM the nurse's station on the 4th floor revealed signage clearly displaying the abuse prevention coordinator's name and instructions on how to notify him/her. During an interview on 7/28/2023 at 2:30 PM CNA C said she had finished feeding residents down the hall and came upon CNA B as she started talking to Resident #1 about touching her sister. CNA C said CNA B said to Resident #1, How would you like it if I did that to your sister? CNA C said Resident #1 went off. CNA C told CNA B she shouldn't say that in front of Resident #1, but it was after he was taken away. CNA C said she was in shock a little bit. CNA C said it was the first time she had seen something like that. CNA C said she didn't realize CNA B was talking to Resident#1 until after CNA B started talking about fucking his sister. CNA C said she notified her charge nurse. CNA C said she knew now to report it to the Administrator. CNA C said In Colorado, we are supposed to report it to our ADON. During iterviews conducted on 7/28/2023 10:30 AM - 5:30 PM with all residents in their rooms during inspection of the 4th floor revealed no complaints with facility or staff. During an interview with the DON on 7/28/2023 at 10:45 it was revealed CNA B had a sister that also worked at the facility. During an interview on 7/28/2023 at 2:20 PM the DON said he found out on 7/25/2023 between 10:30 AM and 10:45 AM that the Resident #1 had been confronted by CNA B. During a review of in-services for abuse and neglect it was revealed staff received training on 7/25/2023, 7/12/2023, 6/12/2023, 5/11/2023, and 1/11/2023. A transcript of training for CNA B indicates she completed training for preventing abuse and managing aggressive behaviors on 4/16/2023 and completed training for quality dementia care on 1/4/2023. During an interview on 7/28/2023 at 2:49 PM the Administrator said breakfast was over at around 9:00 AM on 7/25/2023. She said the DON removed CNA B from the floor and suspended her at around 10:30 AM. CNA B was working on the floor an hour and a half after the abuse occurred. The Administrator said the staff knew they had to call her immediately if abuse occurred. The Administrator said she was notified of the abuse at the same time as the DON. The Administrator said she thought the staff made a conscious decision not to call her immediately, and it was the wrong decision. During an interview with the Administrator on 7/28/2023 at 2:49 PM she said she would make sure CNA B was reported to the Nurse Aid Registry. During an interview on 8/21/2023 the DON displayed evidence CNA B was reported to the Nurse Aid Registry on 7/8/2023. Record review of facility's policy on abuse (revised December 2017) indicated Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of the facility's Abuse Policy dated 8/15/2022 indicated the facility will implement policies and procedures to prevent and prohibit all types of abuse that achieves: Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors Verification of the facility's response to the incident included: Record review: Facility staff training on abuse and neglect, notification of abuse prevention coordinator Investigation report and allegation of verbal abuse confirmed Alleged perpetrator reported to Nurse Aid registry 7/28/2023 Notification to police: case # 2307260117 Review of resident interviews CNA B employee record for completion of training 7/25/2023 Reviewed facility notes Resident abuse interview and observation. Resident #1 denies, (7) total residents all deny abuse. NAR CNA B no issues searched 2/16/23 CNA A abuse training 7/10/23 Elder Abuse 7/21/23 CNA B reported to Nurse Aid Registry 7/28/2023 Interviews: On 8/21/2023 between 2:30 PM and 3:00 PM interviews conducted across 2 shifts that included CNA A, CNA C, CNA D, CNA E, CNA F, CNA G, and CNA H to ensure training was completed. Responses were consistent facility training and policy. Staff able to identify who the abuse prevention coordinator is and can find the number for the abuse prevention coordinator. Observations: Facility observations on 7/28/2023 revealed residents appeared content and no issues were noted On 08/23/23 at 1:45 pm, the DON (Administrator not on duty) was notified of a Past Non-Compliance Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the DON at this time.

Based on interview and record review it was determined for 7 (R#1, R#2, R#3, R#5, R#6, R#8 and R#9) of 10 sample residents that the facility failed to keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, neglect of goods and services occurred when staff were aware, or should have been aware, of residents' care needs, based on assessment, but were unable to meet the identified needs due to lack of training to perform the intervention and lack of staff knowledge of the needs of the resident. Additionally, facility administration failed to identify that an item purchased for a resident with the resident's personal funds and then not given to the resident to use was a misappropriation of resident property, resulting in the misappropriation not being reported to the State Survey Agency and not being investigated. The above failures resulted in an IJ situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures have the potential to result in a continued delay of treatment after a change in condition that could cause serious bodily injury or death. Findings include: Review of resident medical records revealed the following: 1. Resident 9 (R#9) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility staff failed to notify the physician regarding laboratory values obtained for R#9 and facility staff failed to send R#9 to the hospital in a timely manner despite R#9 experiencing a change in condition because the staff did not have the facility's Director of Nursing's permission to send the resident to the hospital even though staff felt the resident should have been sent. R#9 was sent to the hospital hours after the staff felt he should have been sent and where he was diagnosed with [REDACTED]. R#9 expired at the hospital 6 days after his admission to the hospital. 2. Resident 3 (R#3) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility staff did not call Emergency Medical Services for transport to the hospital after R#3 experienced a change in condition and after a family member requested the resident be sent to the hospital but instead called the facility Director of Nursing to get permission to send R#3 to the hospital thus causing the family member to call Emergency Medical Services herself to have the resident sent to the hospital. Additionally, facility staff stated that the facility Director of Nursing had to give staff permission to send residents to the hospital despite the Nursing staff assessments and judgements if they felt the residents needed to be sent. 3. Resident #1's Face Sheet revealed a [AGE] year old male initially admitted on [DATE] with [DIAGNOSES REDACTED]. body). The facility staff did not administer R#1's pain medication, as prescribed by the physician, after admission to the facility. Facility staff had documented on the Medication Administration Record that the medication was unavailable from the pharmacy. 4. Resident 2 (R#2) was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The facility staff did not administer R#2's prescribed medications, after admission to the facility, for his diagnosed mental health disorder. Facility staff had documented on the Medication Administration Record that the medications were unavailable from the pharmacy. 5. Resident 5 (R#5) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. After R#5 experienced a fall from her bed, sustaining a [MEDICAL CONDITION], facility staff administered Tylenol with [MEDICATION NAME] for R#5's reported pain despite R#5 having a physician's orders [REDACTED].#5 grimacing in pain and did not feel like the [MEDICATION NAME] would help with the pain R#5 was experiencing from the broken hip. 6. Resident #6's Face Sheet revealed a [AGE] year old male initially admitted on [DATE] with [DIAGNOSES REDACTED]. enough healthy red blood cells), and Vitamin Deficiency (lack of vitamins). Facility staff did not fill R#6's prescribed pain medication after admission to the facility. Facility staff were documenting on the Medication Administration Record that the medication was not available thus R#6 was in pain after undergoing a surgical procedure on his neck. 7. Resident 8 (R#8) was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Facility staff used R#8's personal funds to purchase an Over Bed Table for R#8's personal use. When the table was delivered, a facility staff member kept the table in her office for awhile before delivering the table to R#8 for use. The facility staff member stated that she did not know how to label the table sufficiently so the table would not be taken and used elsewhere in the facility. On [DATE] at approximately 5:15 PM, the Administrator was interviewed. The Administrator stated that the SSW was not utilizing the Over Bed Table that was purchased for R#8 but that the table was just sitting in the SSW's office. The Administrator failed to identify that the table not being available for R#8's use immediately after being delivered to the facility was a Misappropriation of Resident Property. On [DATE] at 5:12 PM, the facility Administrator and Director of Nursing were verbally notified of the Immediate Jeopardy in regards to a delay in treatment when a resident had experienced a change in condition. The Administrator was asked to begin an immediate plan to ensure the health and safety of the residents within the facility. On [DATE] at 2:20 PM, the facility Administrator submitted a Letter of Credible Allegation for Removal of the Immediate Jeopardy. The letter contained the following: Retama Manor Corpus North - RMCN respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on (MONTH) 28, (YEAR). Submitted on (MONTH) 29, (YEAR) at 10:30am. Immediate Action for entire population: Lab: The facility immediately began a review of all lab results that have been completed within the last 30 days, to ensure there were no critical lab values that have not been communicated to the physician and to ensure that all ordered interventions were carried out. The facility identified 5 residents who had critical lab results within the last 30 days within the facility. All residents with critical lab values were reviewed by an RN to ensure there was no delay in treatment. Completed [DATE] X-Ray: The facility immediately began a review of all residents with orders for X-Ray within the last 30 days to ensure the diagnostic test had been conducted and the result reported to the MD. The facility identified 32 residents with orders for X-Ray within the last 30 days. All abnormal X-Ray results were reviewed by an RN to ensure there was no delay in treatment. Completed [DATE] Change of Condition: The facility immediately began to review all residents to ensure there were no unidentified changes of condition or change of condition not appropriately addressed. All residents identified on the PCC 24 hour report as having an SBAR or otherwise High Risk Progress Note were reviewed by an RN to ensure there was no delay in treatment for [REDACTED]. Completed [DATE] Residents with the potential to be affected by the alleged deficient practice: 1. During the above thorough review of the entire facility population the facility identified 5 residents who had critical lab values within the last 30 days, 32 of residents who had MD orders for X-Ray studies within the last 30 days and 46 of residents who had a change of condition within the last 30 days. Systemic Measures: 1. Lab: Facility will contact Schryver Lab Company and set up a notification alert system for all critical labs. Any lab that has a Critical result will be called to the facility DON to ensure that all critical labs are reported to the MD timely and appropriate interventions are implemented. The lab will continue its process of faxing lab results to the facility as well. Upon notification that there has been a Critical result, facility DON will promptly contact the nurse assigned to that patient to ensure she has received the result and to ensure the MD has been contacted. This will be tracked on a Critical Lab Result Log and will be reviewed daily by the DON for no less than 90 days to ensure the interventions implemented were effective and that there was no delay in treatment. The Critical Lab Result Log will be utilized for reporting to the QAPI committee. Further, to address the issue of Broken Fax Machine on the 3rd floor the facility has implemented the following procedure: Schryver will continue to fax ALL results to ALL floors, however, until the 3rd floor fax is repaired, the nurses on floors 2 and 4 who receive faxes will be responsible to hand deliver all lab results for floor 3 to the nurse on shift. *Nurses will be trained on this temporary procedure* To address routine lab orders: The facility will implement a tracking system for ALL lab orders as follows: The DON/Designee will immediately implement a Lab Tracking System utilizing a Lab Log. Initially the DON/Designee will pull all lab orders from PCC and input them on the Lab Tracking Log with the corresponding due date, and daily the DON/Designee will pull all orders from PCC for Lab input in the last 24 hours to add on to the Lab Tracking Log. Daily the DON/Designee will reconcile the ordered labs entered on the Lab Tracking Log with the labs drawn and then the labs resulted each day. The DON/Designee will also review these results for Abnormal and Critical results and ensure there was MD notification and interventions implemented and no delay in care. X-Ray: When the facility receives an order for [REDACTED]. The DON and/or designee will review the 24 hour report and pull from PCC all orders for X-Rays daily to ensure those studies were completed and results reported to the MD and to ensure there is no delay in treatment. This will be tracked on a X-Ray Result Log for reporting to the QAPI committee for no less than 90 days. Change of Condition: When a nurse identifies a change of condition that is life threating, that nurse will call 911 immediately when assessment indicates that such action is necessary. For all other changes of condition that are not identified as life threating, the nurse will promptly notify the attending and/or on call physician. Documentation of changes of condition will be recorded on the SBAR UDA in the resident's medical record. The DON and/or designee will review all SBARs daily to ensure that the all residents who experienced a change in condition received effectively and timely interventions and reported to QAPI for no less than 90 days. 2. Training: Will be completed as follows: a. Lab: All licensed nursing staff will be trained on prompt notification of physician for Critical lab results and timely implementation of physician ordered interventions. All licensed nursing staff will be trained that the fax machine on the 3rd floor is not currently functioning. Each nurse who receives lab faxes on floor 2 and 4 will be responsible to hand deliver the 3rd floor faxes to the nurse on the 3rd floor. Will be completed [DATE] b. X-Ray: All licensed nursing staff will be trained on utilizing Christus Spohn when the physician orders [REDACTED]. Licensed nurses will be trained on clarifying with MD if he wants X-Ray STAT or routine time frame. If resident is having a Change of Condition requiring an X-Ray, nursing staff will be trained to request a STAT order from MD. Will be completed [DATE] c. Change of Condition: All licensed nursing staff will be trained on facility process for calling 911 first when a nurse identifies a life threating change of condition, and on prompt notification to the physician on all other changes of condition and completion of the SBAR UDA in the resident's medical record. Will be completed [DATE] d. Director of Nursing: Facility Director of Nursing will be trained on Critical Lab Result daily tracking, X-Ray result tracking and audits to ensure no delay in treatment. Further training on facility process for calling 911 first when a licensed nurse identifies a life threating change of condition and prompt notification of the physician for all other changes of condition. Training on audits of all SBARs to be reviewed daily for delay in treatment. This training will be completed by Mandi Schmitt, RN District Director of Clinical Services on [DATE]. e. Administrator: Facility administrator will be trained on reviewing the monitoring tools that will be utilized by the DON and/or designee to track and monitor compliance with this corrective action. This training will be provided by (name) District Director of Clinical Services on [DATE]. Quality Assurance Performance Improvement: On [DATE] the Quality Assessment and Assurance Committee members to include, the Medical Director, Administrator, and Director of Nursing, District Director of Clinical Services and Division VP of Operations met to review and approve this plan. The Committee will meet weekly until the findings of immediate jeopardy are abated. The results of the Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction: [DATE]. On [DATE], the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: -Interviews with nursing staff on what to do when a resident experiences a change in condition and who to call in the event a resident needed to be transferred to the hospital, the new procedure for obtaining STAT x-rays and the procedure for following up on laboratory values. Nurses were able to identify that the DON does not need to be called when a resident needs to be sent out and where residents go when a STAT x-ray was ordered. Additionally, nurses were able to identify the new process for following up on laboratory values. -Chart reviews were done on 3 residents that currently reside in the facility to show that the facility was following up on labs as stated in the plan of correction and calling the physician with a change in condition. On [DATE], the surveyors were able to verify through interview and record review that the plan, as stated above, had been implemented, by the facility staff, sufficiently to remove the Immediate Jeopardy. On [DATE] at approximately 10:00 AM, the facility Director of Nursing (DON) was interviewed. The DON was asked what structures were in place to ensure staff were sufficiently trained to meet the needs of the residents. The DON stated that she was in the process of completing Competency requirements for staff but had not been able to sign all staff off on competencies. The DON stated that training was ongoing and that she was trying to set up a Skills Fair for the staff to attend annually to ensure staff were appropriately trained. The DON stated that she tried to provide oversight to staff and that she was continuing to train staff but that she had several new nurses and employees that did not have sufficient experience in nursing with assessments and judgement calls. When the DON was asked about what Process she had in place for effective communication and ongoing assessments for a change in condition, the DON stated that staff should have been utilizing the 24 hour report form to communicate to other shifts but that she was continuing to do education because the staff did not utilize the form the way it was intended. The DON stated that the night shift was good about filling out the 24 hour report but that the day shift was not. The DON stated that she would need to provide more inservices to ensure staff communicated effectively and that she would need to provide more oversight to ensure the form was filled out appropriately. The DON stated that she had provided inservice training on communication and ordering medications from the pharmacy. The DON stated that staff should not be documenting that Medications are Unavailable from the pharmacy because there was always a way to get the medications. The DON stated that the facility had a Omnicycle machine that held pain medication that was accessible to all staff and that she had provided inservice education on the machine. The DON further stated that if staff had difficulty obtaining medications, the staff should have contacted her to get her assistance in getting the medication. The DON stated that she was attempting to institute the Interact tool within the facility to assist staff in assessments and when to call the physician and send a resident to the hospital but that it was a work in progress with the training because she had some new staff. On [DATE] at approximately 10:00 AM, the facility Administrator was interviewed. When asked why she felt the Immediate Jeopardy in Quality of Life and Quality of Care had occurred, the Administrator stated that she felt the faciltiy had had a failure in their systems resulting in the physician not being notified of laboratory values and residents not being sent to the hospital sooner. The Administrator further stated that the Social Services Worker (SSW) was not using the table purchased for a resident but just had the table sitting in her office. The above failures resulted in a pattern of Neglect to multiple residents at the facility. The facility remained out of substantial compliance with actual harm and the potential for more than minimal harm in the area of Quality of Life and Quality of Care. On [DATE], the facility's Policy and Procedure on Abuse and Neglect Prohibition was reviewed. Review of Policy and Procedure revealed the following: Policy Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Definitions . Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. . Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of unknown origin may occur as a result of neglect. . Procedure Screening . Training 1. The facility will train each employee on this policy during orientation, annually, and more often as determined by the facility. 2. The facility will provide training regarding related policies and procedures. 3. The facility will provide education for the resident and those additional individuals involved with the resident (i.e. family, responsible party or resident's representative, visitors). Prevention 1. The facility will address all concerns in accordance with Truly Listening to Our Customers (TLC) policy . Residents, families and staff will be able to report incidents and concerns without fear of retribution. (Cross Refer to F-602, F-607, F-675, F-684, F-697, F-755, and F-773)

Based on interview and record review it was determined that the facility failed to implement written policies and procedures that prohibit and prevent neglect and misappropriation of resident property and provide training as required to prevent the neglect. Specifically, the facility failed to implement their policy which included providing goods and services to a resident that were necessary to avoid physical harm, pain, mental anguich or emotional distress and failed to ensure that staff had adequate training to identify the neglect and that a resident's property was not deliberately misplaced, exploited or used without the resident's consent. The above failures resulted in an IJ situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures have the potential to result in a continued delay of treatment after a change in condition that could cause serious bodily injury or death. Findings include: On [DATE], the facility's Policy and Procedure on Abuse and Neglect Prohibition was reviewed. Review of Policy and Procedure revealed the following: Policy Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punichment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Definitions . Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. . Neglect means the failurer of tdhe facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of unknown origin may occur as a result of neglect. . Procedure Screening . Training 1. The facility will train each employee on this policy during orientation, annually, and more often as determined by the facility. 2. The facility will provide training regarding related policies and procedures. 3. The facility will provide education for the resident and those additional individuals involved with the resident (i.e. family, responsible party or resident's representative, visitors). Prevention 1. The facility will address all concerns in accordance with Truly Listening to Our Customers (TLC) policy . Residents, families and staff will be able to report incidents and concerns without fear of retribution. Review of resident medical records revealed the following: 1. Resident 9 (R#9) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility staff failed to notify the physician regarding laboratory values obtained for R#9 and facility staff failed to send R#9 to the hospital in a timely manner despite R#9 experiencing a change in condition because the staff did not have the facility's Director of Nursing's permission to send the resident to the hospital even though staff felt the resident should have been sent. R#9 was sent to the hospital hours after the staff felt he should have been sent and where he was diagnosed with [REDACTED]. R#9 expired at the hospital 6 days after his admission to the hospital. 2. Resident 3 (R#3) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility staff did not call Emergency Medical Services for transport to the hospital after R#3 experienced a change in condition and after a family member requested the resident be sent to the hospital but instead called the facility Director of Nursing to get permission to send R#3 to the hospital thus causing the family member to call Emergency Medical Services herself to have the resident sent to the hospital. Additionally, facility staff stated that the facility Director of Nursing had to give staff permission to send residents to the hospital despite the Nursing staff assessments and judgements if they felt the residents needed to be sent. 3. Resident #1's Face Sheet revealed a [AGE] year old male initially admitted on [DATE] with [DIAGNOSES REDACTED]. body). The facility staff did not administer R#1's pain medication, as prescribed by the physician, after admission to the facility. Facility staff had documented on the Medication Administration Record that the medication was unavailable from the pharmacy. 4. Resident 2 (R#2) was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The facility staff did not administer R#2's prescribed medications, after admission to the facility, for his diagnosed mental health disorder. Facility staff had documented on the Medication Administration Record that the medications were unavailable from the pharmacy. 5. Resident 5 (R#5) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. After R#5 experienced a fall from her bed, sustaining a [MEDICAL CONDITION], facility staff administered Tylenol with [MEDICATION NAME] for R#5's reported pain despite R#5 having a physician's orders [REDACTED].#5 grimacing in pain and did not feel like the [MEDICATION NAME] would help with the pain R#5 was experiencing from the broken hip. 6. Resident #6's Face Sheet revealed a [AGE] year old male initially admitted on [DATE] with [DIAGNOSES REDACTED]. enough healthy red blood cells), and Vitamin Deficiency (lack of vitamins). Facility staff did not fill R#6's prescribed pain medication after admission to the facility. Facility staff were documenting on the Medication Administration Record that the medication was not available thus R#6 was in pain after undergoing a surgical procedure on his neck. 7. Resident 8 (R#8) was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Facility staff used R#8's personal funds to purchase an Over Bed Table for R#8's personal use. When the table was delivered, a facility staff member kept the table in her office for awhile before delivering the table to R#8 for use. The facility staff member stated that she did not know how to label the table sufficiently so the table would not be taken and used elsewhere in the facility. On [DATE] at approximately 5:15 PM, the Administrator was interviewed. The Administrator stated that the SSW was not utilizing the Over Bed Table that was purchased for R#8 but that the table was just sitting in the SSW's office. The Administrator failed to identify that the table not being available for R#8's use immediately after being delivered to the facility was a Misappropriation of Resident Property. On [DATE] at 5:12 PM, the facility Administrator and Director of Nursing were verbally notified of the Immediate Jeopardy in regards to a delay in treatment when a resident had experienced a change in condition. The Administrator was asked to begin an immediate plan to ensure the health and safety of the residents within the facility. On [DATE] at 2:20 PM, the facility Administrator submitted a Letter of Credible Allegation for Removal of the Immediate Jeopardy. The letter contained the following: Retama Manor Corpus North - RMCN respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on (MONTH) 28, (YEAR). Submitted on (MONTH) 29, (YEAR) at 10:30am. Immediate Action for entire population: Lab: The facility immediately began a review of all lab results that have been completed within the last 30 days, to ensure there were no critical lab values that have not been communicated to the physician and to ensure that all ordered interventions were carried out. The facility identified 5 residents who had critical lab results within the last 30 days within the facility. All residents with critical lab values were reviewed by an RN to ensure there was no delay in treatment. Completed [DATE] X-Ray: The facility immediately began a review of all residents with orders for X-Ray within the last 30 days to ensure the diagnostic test had been conducted and the result reported to the MD. The facility identified 32 residents with orders for X-Ray within the last 30 days. All abnormal X-Ray results were reviewed by an RN to ensure there was no delay in treatment. Completed [DATE] Change of Condition: The facility immediately began to review all residents to ensure there were no unidentified changes of condition or change of condition not appropriately addressed. All residents identified on the PCC 24 hour report as having an SBAR or otherwise High Risk Progress Note were reviewed by an RN to ensure there was no delay in treatment for [REDACTED]. Completed [DATE] Residents with the potential to be affected by the alleged deficient practice: 1. During the above thorough review of the entire facility population the facility identified 5 residents who had critical lab values within the last 30 days, 32 of residents who had MD orders for X-Ray studies within the last 30 days and 46 of residents who had a change of condition within the last 30 days. Systemic Measures: 1. Lab: Facility will contact Schryver Lab Company and set up a notification alert system for all critical labs. Any lab that has a Critical result will be called to the facility DON to ensure that all critical labs are reported to the MD timely and appropriate interventions are implemented. The lab will continue its process of faxing lab results to the facility as well. Upon notification that there has been a Critical result, facility DON will promptly contact the nurse assigned to that patient to ensure she has received the result and to ensure the MD has been contacted. This will be tracked on a Critical Lab Result Log and will be reviewed daily by the DON for no less than 90 days to ensure the interventions implemented were effective and that there was no delay in treatment. The Critical Lab Result Log will be utilized for reporting to the QAPI committee. Further, to address the issue of Broken Fax Machine on the 3rd floor the facility has implemented the following procedure: Schryver will continue to fax ALL results to ALL floors, however, until the 3rd floor fax is repaired, the nurses on floors 2 and 4 who receive faxes will be responsible to hand deliver all lab results for floor 3 to the nurse on shift. *Nurses will be trained on this temporary procedure* To address routine lab orders: The facility will implement a tracking system for ALL lab orders as follows: The DON/Designee will immediately implement a Lab Tracking System utilizing a Lab Log. Initially the DON/Designee will pull all lab orders from PCC and input them on the Lab Tracking Log with the corresponding due date, and daily the DON/Designee will pull all orders from PCC for Lab input in the last 24 hours to add on to the Lab Tracking Log. Daily the DON/Designee will reconcile the ordered labs entered on the Lab Tracking Log with the labs drawn and then the labs resulted each day. The DON/Designee will also review these results for Abnormal and Critical results and ensure there was MD notification and interventions implemented and no delay in care. X-Ray: When the facility receives an order for [REDACTED]. The DON and/or designee will review the 24 hour report and pull from PCC all orders for X-Rays daily to ensure those studies were completed and results reported to the MD and to ensure there is no delay in treatment. This will be tracked on a X-Ray Result Log for reporting to the QAPI committee for no less than 90 days. Change of Condition: When a nurse identifies a change of condition that is life threating, that nurse will call 911 immediately when assessment indicates that such action is necessary. For all other changes of condition that are not identified as life threating, the nurse will promptly notify the attending and/or on call physician. Documentation of changes of condition will be recorded on the SBAR UDA in the resident's medical record. The DON and/or designee will review all SBARs daily to ensure that the all residents who experienced a change in condition received effectively and timely interventions and reported to QAPI for no less than 90 days. 2. Training: Will be completed as follows: a. Lab: All licensed nursing staff will be trained on prompt notification of physician for Critical lab results and timely implementation of physician ordered interventions. All licensed nursing staff will be trained that the fax machine on the 3rd floor is not currently functioning. Each nurse who receives lab faxes on floor 2 and 4 will be responsible to hand deliver the 3rd floor faxes to the nurse on the 3rd floor. Will be completed [DATE] b. X-Ray: All licensed nursing staff will be trained on utilizing Christus Spohn when the physician orders [REDACTED]. Licensed nurses will be trained on clarifying with MD if he wants X-Ray STAT or routine time frame. If resident is having a Change of Condition requiring an X-Ray, nursing staff will be trained to request a STAT order from MD. Will be completed [DATE] c. Change of Condition: All licensed nursing staff will be trained on facility process for calling 911 first when a nurse identifies a life threating change of condition, and on prompt notification to the physician on all other changes of condition and completion of the SBAR UDA in the resident's medical record. Will be completed [DATE] d. Director of Nursing: Facility Director of Nursing will be trained on Critical Lab Result daily tracking, X-Ray result tracking and audits to ensure no delay in treatment. Further training on facility process for calling 911 first when a licensed nurse identifies a life threating change of condition and prompt notification of the physician for all other changes of condition. Training on audits of all SBARs to be reviewed daily for delay in treatment. This training will be completed by Mandi Schmitt, RN District Director of Clinical Services on [DATE]. e. Administrator: Facility administrator will be trained on reviewing the monitoring tools that will be utilized by the DON and/or designee to track and monitor compliance with this corrective action. This training will be provided by (name) District Director of Clinical Services on [DATE]. Quality Assurance Performance Improvement: On [DATE] the Quality Assessment and Assurance Committee members to include, the Medical Director, Administrator, and Director of Nursing, District Director of Clinical Services and Division VP of Operations met to review and approve this plan. The Committee will meet weekly until the findings of immediate jeopardy are abated. The results of the Director of Nursing/designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction: [DATE]. On [DATE], the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with nursing staff on what to do when a resident experiences a change in condition and who to call in the event a resident needed to be transferred to the hospital, the new procedure for obtaining STAT x-rays and the procedure for following up on laboratory values. Nurses were able to identify that the DON does not need to be called when a resident needs to be sent out and where residents go when a STAT x-ray was ordered. Additionally, nurses were able to identify the new process for following up on laboratory values. Chart reviews were done on 3 residents that currently reside in the facility to show that the facility was following up on labs as stated in the plan of correction and calling the physician with a change in condition. On [DATE], the surveyors were able to verify through interview and record review that the plan, as stated above, had been implemented, by the facility staff, sufficiently to remove the Immediate Jeopardy. On [DATE] at approximately 10:00 AM, the facility Administrator was interviewed. When asked why she felt the Immediate Jeopardy in Quality of Life and Quality of Care had occurred, the Administrator stated that she felt the faciltiy had had a failure in a their systems resulting the physician not being notified of laboratory values and resident's not being sent to the hospital sooner. The Administrator further stated that the Social Services Worker (SSW) was not using the table purchased for a resident but just had the table sitting in her office. The facililty Administrator failed to identify the table being in the SSW's office for an extended time frame as a misappropriation of resident property per the facility's own Policy and Procedure definitions. The facility remained out of substantial compliance with actual harm and the potential for more than minimal harm in the area of Quality of Life and Quality of Care. (Cross refer to F-600 and F-602)

Based on interview and record review it was determined for 2 (R#9 and R#3) of 10 sample residents that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, facility nursing staff had been instructed, by the facility Director of Nursing (DON), to call the DON to get permission to send a resident to the hospital, despite the nursing staff's assessment and clinical judgement that the resident needed to be discharged . These calls to the DON resulted in a delay of treatment for [REDACTED]. 1.) Resident 9 (R#9) Facility staff failed to notify the physician regarding laboratory values obtained for R#9, on [DATE], and facility staff failed to send R#9 to the hosptial, on [DATE], in a timely manner despite R#9 experiencing a change in condition because the staff did not have the facility's Director of Nursing's permission to send the resident to the hospital even though staff felt the resident should have been sent. R#9 was sent to the hospital four hours after the staff felt he should have been sent, where he was diagnosed with [REDACTED]. R#9 expired at the hopital 5 days after his admission to the hospital. 2.) Resident 3 (R#3) Facility staff did not call Emergency Medical Services for transport to the hospital, on [DATE], after R#3 experienced a change in condition and after a family member requested the resident be sent to the hospital but instead called the facility Director of Nursing to get permission to send R#3 to the hospital thus causing the family member to call Emergency Medical Services herself to have the resident sent to the hospital. Additionally, facility staff stated that the facility Director of Nursing had to give staff permission to send residents to the hospital despite the Nursing staff assessments and judgements if they felt the residents needed to be sent. The above failures resulted in an IJ situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures have the potential to result in a continued delay of treatment after a change in condition that could cause serious bodily injury or death. Findings include: 1.) Resident 9 (R#9) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], R#9's medical record was reviewed. Review of the Progress Notes revealed the following entry: [DATE] 13:52 (1:52 PM): Vital Signs: BP (Blood Pressure) ,[DATE], P (Pulse) 110, . T (Temperature) 101.3, . resident looks uncomfortable Additional notes as applicable: STAT (immediate) chest x-ray 2 views, STAT BMP (Basic Metabolic Panel), CBC (Complete Blood Count), UA (Urinalysis) c&s (culture and sensitivity), [MEDICATION NAME] 4mg (milligrams) PO (by mouth) PRN (as needed). ([MEDICATION NAME] is a medication given for nausea.) On [DATE] at 11:15 AM, Licensed Vocational Nurse (LVN) A was interviewed. LVN A stated the laboratory values obtained on [DATE] had never been followed up on and reported to the physician. Review of the laboratory values obtained on [DATE] revealed the following: a. [DATE] -UA - sample not collected by facility. b. [DATE] - BMP: 1. Sodium 123 L (Low). Reference range of ,[DATE] mmol/L (millimoles per Liter). 2. Chloride 93 L. Reference range of ,[DATE] mmol/L. 3. CO2 (Carbon [MEDICATION NAME]) 21 L. Reference range of ,[DATE] mmol/L. 4. Glucose 174. H (High). Reference range of ,[DATE] mg/dl (milligrams per deciliter). 5. Calcium 7.6 L. Reference range of 8XXX,[DATE].0 mg/dl. c. [DATE] - CBC: 1. WBC (white blood cells) 17.8 H. Reference range of 4XXX,[DATE].8. No documentation could be found to show that facility staff notified R#9's physician regarding the above listed laboratory values. On [DATE], the facility Director of Nursing (DON) was interviewed. The DON confirmed that the facility staff should have followed up with the physician regarding the laboratory values obtained on [DATE]. The DON further stated that if the facility staff were unable to obtain the urinalysis for R#9 on [DATE], the physician should have been notified. Reveiw of the Progress Notes revealed the following entries: a. [DATE] 23:54 (11:54 PM): . Witnessed fall with skin tear to L (left) stump. According to the entry the doctor was notified of the fall and the skin tear to the Left stump. b. [DATE]: 9.5 X 3.5 Bruise noted to Left Buttock, skin dry and intact will cont. (continue) to monitor. No documentation could be found to show that the physician was notified regarding the bruise or injury of unknown origin. c. [DATE]: Resident day 3 follow-up fall. Refused dinner. Ate some lunch and breakfast. Refused to get out of bed. Denies pain. Neuros WNL (within normal limits). Will monitor. f. [DATE] 02:43 (2:43 AM): [MEDICATION NAME] tablet 4 mg Give 1 tablet by mouth every 8 hours as needed for nausea related to nausea. c/o (complaints of) nausea, had a small emesis of clear light pink liquid. Pink liquid was possible from candy that resident had eaten earlier. No documentation or evidence could be found to show that facility staff notified R#9's physician regarding R#9's emesis or refusal to get out of bed. g. [DATE] 07:40 (7:40 AM): Late entry for [DATE] Bruise to left buttock/Ishium) now presents as Stage 2 fluid filled blister skin dry intact area larger is size. Resident has had a decline in status . (The above entry was made on [DATE] after R#9 was transferred to the hospital) No documentation or evidence could be found to show that facility staff notified R#9's physician regarding the bruise presenting as a Stage 2 fluid filled blister on [DATE]. h. [DATE] 10:00 (10:00 AM): BP ,[DATE], P 91, . Resident was noted with increased confusion, bilateral lungs auscultated with upper congestion noted. O2 (oxygen) sats (saturations) 92 % RA (room air), speech noted with difficulty when trying to talk. oriented X 1. skin slightly jaundice. No acute distress noted at this time. On [DATE] at 11:15 AM, LVN A stated that she had reassessed R#9 at around 4:00 PM on [DATE] and had wanted to transfer R#9 to the hospital at that time but was told No by the facility Director of Nursing. LVN A stated that she felt that there had been a delay in treatment for [REDACTED].#9 to the hospital. LVN A stated that when she spoke to the DON at 4:00 PM on [DATE], the DON had told her that since the physician had not ordered R#9 to be sent to the hospital, the staff were not going to discharge him to the hospital. i. [DATE] 20:00: . Resident is semicomatose, O2 sats 74% on 2LPM (liter per minute) via N/C (nasal cannula). Was unable to get V/S (vital signs) until EMS (Emergency Medical Services) arrived first set of BP was ,[DATE], 2nd set was ,[DATE], Resident had. On [DATE] at 8:08 AM, LVN H was interviewed. LVN H stated that he was the nurse caring for R#9 the night R#9 was sent to the hospital. LVN H stated that after he received report, a facility CNA (Certified Nursing Assistant) came to tell him that something was wrong with R#9. LVN H stated that when he entered R#9's room, R#9 looked completely different than he had four days prior. LVN H stated that R#9 appeared to be actively dying. LVN H stated that he called the DON to tell her that he was sending R#9 out to the hospital. LVN H stated that the DON asked if the facility had received the results of the X-ray obtained earlier and he had told the DON that he did not have the results. LVN H stated that the DON told him that R#9 had received a [MEDICATION NAME] (antibiotic) shot earlier and he had responded that he did not care, that R#9 needed to be sent out. LVN H stated that the DON had told him that she was surprised that the day shift had not sent R#9 out earlier. LVN H stated there was a 15 minute time lapse between the time he assessed R#9 and called 911 because he was on the phone with the DON. LVN H stated that the facility protocol was to call the DON to get permission before sending residents to the hospital. LVN H stated that he did feel that there had been a delay in treatment for [REDACTED]. On [DATE], R#9's physician was interviewed via telephone. The physician stated that review of his call log for his practice revealed that one call had been logged on [DATE] for R#9. The physician stated that the call log showed that the facility staff had called his practice on [DATE] at around 8:30 PM. The physician stated that he was unaware that R#9 had expired after being discharged to the hospital. The physician further stated that his expectation of the staff would be for staff to send a resident to the hospital, if the Nurse's assessment determined the need for discharge, and then notify him. The physician stated that he did not expect for the staff to call the DON for permission to send the resident to the hospital if the nurse's assessment indicated that the resident needed to be sent. The physician further stated that a resident not eating or getting out of bed and confusion were signs of a change in conditon. The physician stated that based on the nursing entry documented in R#9's medical record on [DATE] at 10:00 AM, he would have requested that the resident be sent to the hospital then. On [DATE] at approximately 5:00 PM, the Nurse Practitioner that worked with R#9's physician was interviewed via telephone. The Nurse Practitioner stated that she recalled ordering [MEDICATION NAME] for R#9 on [DATE] but was ordering the [MEDICATION NAME] for chest congestion. The Nurse Practitioner did not recall being notified regarding R#9's jaundice and difficulty when trying to talk. The Nurse Practitioner stated that if the nurses felt like a resident had a change from their baseline, she would expect that the resident be sent to the hospital. The Nurse Practitioner stated that the resident population at the facility was a high risk population and the staff and practitioners needed to be very astute with resident's experiencing a change in condition. The Nurse Practitioner stated that she would prefer the staff err on the side of caution and send a resident to the hospital if they felt the resident needed more advanced medical care. On [DATE], R#9's medical record from the hospital was reviewed. Review of the medical record revealed that R#9 had expired on [DATE] from Preliminary Cause of Death - Septic Shock secondary to necrotizing myositis (rare disease in which the muscle fibers and skin are inflammed and damaged). Additionally, according to the hospital medical record, R#9's white blood cell count upon admission to the hospital was 30,800 and his sodium was 129. Reason for hospitalization was documented as [DIAGNOSES REDACTED] with [MEDICAL CONDITION]. According to rarediseases.org/rare-diseases/necrotizing-fasciitis, Necrotizing fasciites (NF) is a rare infection that mean 'decaying infection of the fascia' which is the soft tissue that is part of the connective tissue system that runs throughout the body. Early symptoms of NF are often mistaken for the flu. Diagnosing NF early and quickly is vital to improving survival. However, studies have shown that since it is so rare, mis[DIAGNOSES REDACTED]. Once at the hospital, patients will have laboratory testing performed. Often, patients will have a white blood cell counts greater that 15,400 cells/mm (millimeter) or a sodium level lower than 135 mmol/L 2.) Resident 3 (R#3) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], R#3's medical record was reviewed. Review of the medical record revealed the following Progress Notes: a. [DATE] 18:10 (6:10 PM): .O2 (Oxygen Saturations) 65% Room Air. resident is coughing and congested during dinner. resident laying bed with head of bed elevated. noted acute respiratory distress. oxygen started at 2 liters. suctioned numerous times with copious amounts of yellowish colored mucus. sucitoned effective but continues to sound congested with occasional coughing o2 sats at 97% went down to 91% with 2liters oxygen. resident taking off oxygen. resident sitting in wheel chair. (name of Nurse Practitioner) ordering stat (immediate) chest x-ray. monitor oxygen. suction resident as needed. (Note: Normal Oxygen Saturation is 90 - 100 % on Room Air). b. [DATE] 19:24 (7:24 PM): daughter arrived to nursing home was given update. saw mother coughing and continues to remove o2 cannula of 2liters. daughter upset and demanded resident be sent out per 911 call now. daughter called 911 herself DON notified, daughter demanded to speak to DON, spoke to DON on phone daughter very unhappy with conversation that took place. resident was brought to nurse station for observation during this time. oxygen sat (saturation) at 91%. Ems (Emergency Medical Services) arrived at 720pm resident continued with wet cough. continued to remove o2. resident restless unaware of daughter being here, coughing with productive cough ems X2 transferred from wheelchair to stretcher taken to (name of local acute care hospital). c. [DATE] 12:15: follow up for SBAR (Situation, Background, Assessment, Recommendation) from [DATE] some clarification and further documentation that had been left out. resident was not in acute respiratory distress at the time it was a typo. notification for doctor and daughter times were entered wrong. correct times see below. Resident yelled out that (R#3) was vomiting. (name) nurse and I went into room. resident coughing and congested during dinner laying in bed with HOB (head of bed) elevated. alert with no acute respiratory distress noted. sat up resident to edge of the bed and starting patting her back. resident telling us to stop padding her. resident was suctioned and copious amounts of yellowish colored mucus came out. resident resumed normal activity. her o2 was 97% then 91% resident was placed on o2 at 2liters. resident kept removing oxygen cannula. resident did not appear in distress. resident taken to nurses station. @ (at) 1813 (6:13 PM) notified doctor ((name)). @ 1822 (6:22 PM) called daughter to update on status of resident. (name) nurse spoke to doctor and stated STAT chest x-ray ordered suction as needed and o2 at 2liters. X-ray done, then changed resident because she had a BM (bowel movement). Daughter arrived at this time. resident started to sound girggly (sic) in her throat. resident brought back to nurse station with no signs or symptoms of distress and alert. DON notified and stated if she aspirated this is treatable with antibiotics. DON asked if doctor ordered resident to send out, I told her no. DON said we would wait on xray result. during this time nurse (name) was speaking to daughter about our protocol of calling doctor and DON. I was notified after hanging up phone with DON that the daughter wants us to call 911. during call back daughter spoke to DON and stated she was calling 911 herself and she was going to sue. Daughter called ems. ems arrived at 720pm resident continued with wet cough. resident continued to remove o2. resident restless/alert to self which is resident norm (normal) due to dementia. unaware of daughter being here, coughing with productive cough ems X2 transferred from wheelchair to stretcher taken to (name of local acute care hospital) at 725 accompanied by daughter. (Note: the above entry indicated that the resident was not in respiratory distress on [DATE] despite the nursing entry made by the facility staff that the resident was having respiratory distress on [DATE] at 6:10PM.) According to the above entries, the facility staff identified that R#3 had experienced a change in condition at approximately 6:15 PM, yet R#3 was not sent to the hospital until 7:25 PM, one hour and 15 minutes after the staff assessed the change in condition. On [DATE] at 10:20 AM, R#3's daughter was interviwed via the phone. R#3's daughter stated that she had received a call from the facility around 7:30 PM the night her mother was discharged to the hospital. R#3's daughter stated that facility staff had reported that her mother (R#3) had possibly aspirated on something at dinner. R#3's daughter stated that she did not know what aspirated meant and had to look the term up to discover that the term meant choked. R#3's daughter stated that the staff stated that they had been given the instructions to suction her mom but that the suction was not working. R#3's daughter stated that she left immediately for the facility. R#3's daughter stated that when she arrived at the facility her mother was at the nurse's station and that her mother did not look good and her mother had a lot of congestion and was coughing. R#3's daughter stated that she wanted her mother to be sent to the hospital and a staff nurse had responded that the staff would need to call the Director of Nursing (DON) to get permission to send R#3 to the hospital. R#3's daughter stated that the staff then called the DON to speak with her. R#3's daughter stated that she got on the phone with the DON and the DON told her that she would talk with the nurse. R#3's daughter stated that after the nurse hung up the phone with the DON, the nurse told the daughter that the DON had not given permission to send R#3 to the hospital. R#3's daughter stated that she then called 911 herself to have her mother sent to the hospital. On [DATE] at 11:15 AM, the nurse who made the medical record entries on [DATE] and [DATE], Licensed Vocational Nurse ((LVN A)) was interviewed. LVN A stated that after she had assessed R#3 and suctioned R#3, LVN A took R#3 to the nurses station and called the doctor to get orders. LVN A stated that the x-ray company showed up to do the X-ray quickly and that after the X-ray, R#3 had had a BM so she was taking R#3 down the hall to change R#3. LVN A stated that after R#3 had received incontinent care was when her daughter had come to the facility. LVN A stated that R#3's daughter was upset and the other nurse (LVN C) told the daughter that we needed to call the doctor and the DON regarding R#3's current condition. LVN A stated that she placed a call to the DON and reported to the DON that the resident had aspirated and the DON stated that the aspiration could be treated with antibiotics. LVN A stated that the daughter spoke with the DON via the phone and that after she (LVN A) hung up the phone the daughter stated that she wanted R#3 to be sent out to the hospital. LVN A stated that she then turned to call the DON back and R#3's daughter called 911. LVN A stated that she felt that R#3 needed more medical attention than the facility could provide but that she did not know if R#3 needed to be sent to the hospital emergently. LVN A stated that she did feel like there was a delay in treatment for [REDACTED]. On [DATE] at 9:23 AM, LVN C was interviewed. LVN C stated that she was the nurse that was assisting LVN A on the day that R#3 was sent to the hospital. LVN C stated that while LVN A was on the phone with the DON, she was talking with R#3's daughter about the process of calling the DON before a resident could be sent to the hospital. LVN C stated that she did not hear the conversation that LVN A had with the DON. LVN C stated that R#3's daughter spoke with the DON over the phone and then handed the phone back to LVN A. LVN C stated that R#3's daughter looked at her (LVN C) after giving the phone back to LVN A and told LVN C that she wanted R#3 to be sent to the hospital. LVN C stated that she tried to tell LVN A that R#3's daughter wanted R#3 sent to the hospital while she (LVN A) was finishing her call to the DON but that LVN A did not hear her. LVN C stated that after LVN A hung up the phone, she (LVN C) told LVN A that R#3's daughter wanted R#3 sent to the hospital. LVN C stated that LVN A then picked the phone back up to call the DON and that was when R#3's daughter pulled out her phone and dialed 911. LVN C stated that the facility's protocol was to call the DON to get permission to send residents to the hospital. LVN C stated that the staff did not like that protocol and felt like their judegement was not being utilized. LVN C stated that she felt like there had been a delay in treatment for [REDACTED]. On [DATE] at 6:35 AM, LVN D was interviewed. LVN D stated that the nursing staff was told that the DON needed to be called if a nurse wanted to send a resident out to the hospital. LVN D stated that she had butted heads with the DON a few times when the DON had told her not to send a resident out to the hospital. LVN D stated that she felt like there had been a delay in treatment for [REDACTED]. On [DATE], the facility DON was interviewed. The DON stated that facility staff would call her before calling the physician if a resident experienced a change in condition. The DON stated that the staff would call her to go over the SBAR form to ensure that the staff had the appropriate documentation before calling the physician. The DON stated that staff did not need to get her permission to send a resident to the hospital. On [DATE], the facility's Policy and Procedure for Changes in Resident Condition was reviewed. Review of the Policy revealed the following: The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. Guidelines 1. For life-threatening events, call 911 if initial assessment indicates that such action is necessary. 2. Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's attending physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. 3. If the attending physician cannot be reached, nursing attempts to contact the following providers in this order until a physician has been contacted: the physician on call, the facility Medical Director, the Division Medical Director and emergency services. 4. The SBAR (Situation Background, Assessment, Recommendation) Communication Form and the Progress Note are used to: a. Assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physician, and c. Provide clear comprehensive documentation. 3. (sic) Changes in condition are communicated from shift to shift through the 24 Hour Report. 4. (sic) Changes in the resident status that affect the problem (s) / goal (s) or approach (es) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers. On [DATE] at 5:12 PM, the facility Administrator and Director of Nursing were verbally notified of the Immediate Jeopardy in regards to a delay in treatment when a resident had experienced a change in condition. The Administrator was asked to begin an immediate plan to ensure the health and safety of the residents within the facility. On [DATE] at 2:20 PM, the facility Administrator submitted a Letter of Credible Allegation for Removal of the Immediate Jeopardy. The letter contained the following: Retama Manor Corpus North - RMCN respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on (MONTH) 28, (YEAR). Submitted on (MONTH) 29, (YEAR) at 10:30am. Immediate Action for entire population: Lab: The facility immediately began a review of all lab results that have been completed within the last 30 days, to ensure there were no critical lab values that have not been communicated to the physician and to ensure that all ordered interventions were carried out. The facility identified 5 residents who had critical lab results within the last 30 days within the facility. All residents with critical lab values were reviewed by an RN to ensure there was no delay in treatment. Completed [DATE] X-Ray: The facility immediately began a review of all residents with orders for X-Ray within the last 30 days to ensure the diagnostic test had been conducted and the result reported to the MD. The facility identified 32 residents with orders for X-Ray within the last 30 days. All abnormal X-Ray results were reviewed by an RN to ensure there was no delay in treatment. Completed [DATE] Change of Condition: The facility immediately began to review all residents to ensure there were no unidentified changes of condition or change of condition not appropriately addressed. All residents identified on the PCC 24 hour report as having an SBAR or otherwise High Risk Progress Note were reviewed by an RN to ensure there was no delay in treatment for [REDACTED]. Completed [DATE] Residents with the potential to be affected by the alleged deficient practice: 1. During the above thorough review of the entire facility population the facility identified 5 residents who had critical lab values within the last 30 days, 32 of residents who had MD orders for X-Ray studies within the last 30 days and 46 of residents who had a change of condition within the last 30 days. Systemic Measures: 1. Lab: Facility will contact Schryver Lab Company and set up a notification alert system for all critical labs. Any lab that has a Critical result will be called to the facility DON to ensure that all critical labs are reported to the MD timely and appropriate interventions are implemented. The lab will continue its process of faxing lab results to the facility as well. Upon notification that there has been a Critical result, facility DON will promptly contact the nurse assigned to that patient to ensure she has received the result and to ensure the MD has been contacted. This will be tracked on a Critical Lab Result Log and will be reviewed daily by the DON for no less than 90 days to ensure the interventions implemented were effective and that there was no delay in treatment. The Critical Lab Result Log will be utilized for reporting to the QAPI committee. Further, to address the issue of Broken Fax Machine on the 3rd floor the facility has implemented the following procedure: Schryver will continue to fax ALL results to ALL floors, however, until the 3rd floor fax is repaired, the nurses on floors 2 and 4 who receive faxes will be responsible to hand deliver all lab results for floor 3 to the nurse on shift. *Nurses will be trained on this temporary procedure* To address routine lab orders: The facility will implement a tracking system for ALL lab orders as follows: The DON/Designee will immediately implement a Lab Tracking System utilizing a Lab Log. Initially the DON/Designee will pull all lab orders from PCC and input them on the Lab Tracking Log with the corresponding due date, and daily the DON/Designee will pull all orders from PCC for Lab input in the last 24 hours to add on to the Lab Tracking Log. Daily the DON/Designee will reconcile the ordered labs entered on the Lab Tracking Log with the labs drawn and then the labs resulted each day. The DON/Designee will also review these results for Abnormal and Critical results and ensure there was MD notification and interventions implemented and no delay in care. X-Ray: When the facility receives an order for [REDACTED]. This will be tracked on a X-Ray Result Log for reporting to the QAPI committee for no less than 90 days. Change of Condition: When a nurse identifies a change of condition that is life threating, that nurse will call 911 immediately when assessment indicates that such action is necessary. For all other changes of condition that are not identified as life threating, the nurse will promptly notify the attending and/or on call physician. Documentation of changes of condition will be recorded on the SBAR UDA in the resident's medical record. The DON and/or designee will review all SBARs daily to ensure that the all residents who experienced a change in condition received effectively and timely interventions and reported to QAPI for no less than 90 days. 2. Training: Will be completed as follows: a. Lab: All licensed nursing staff will be trained on prompt notification of physician for Critical lab results and timely implementation of physician ordered interventions. All licensed nursing staff will be trained that the fax machine on the 3rd floor is not currently functioning. Each nurse who receives lab faxes on floor 2 and 4 will be responsible to hand deliver the 3rd floor faxes to the nurse on the 3rd floor. Will be completed [DATE] b. X-Ray: All licensed nursing staff will be trained on utilizing Christus Spohn when the physician orders [REDACTED]. Licensed nurses will be trained on clarifying with MD if he wants X-Ray STAT or routine time frame. If resident is having a Change of Condition requiring an X-Ray, nursing staff will be trained to request a STAT order from MD. Will be completed [DATE] c. Change of Condition: All licensed nursing staff will be trained on facility process for calling 911 first when a nurse identifies a life threating change of condition, and on prompt notification to the physician on all other changes of condition and completion of the SBAR UDA in the resident's medical record. Will be completed [DATE] d. Director of Nursing: Facility Director of Nursing will be trained on Critical Lab Result daily tracking, X-Ray result tracking and audits to ensure no delay in treatment. Further training on facility process for calling 911 first when a licensed nurse identifies a life threating change of condition and prompt notification of the physician for all other changes of condition. Training on audits of all SBARs to be reviewed daily for delay in treatment. This training will be completed by Mandi Schmitt, RN District Director of Clinical Services on [DATE]. e. Administrator: Facility administrator will be trained on reviewing the monitoring tools that will be utilized by the DON and/or d

Based on interview and record review it was determined for 2 (R#3 and R#9) of 10 sample residents that the facility failed to provide care and treatment in accordance with professional standards of practice, the person centered care plan, and the residents' choices. Specifically, facility nursing staff had been instructed, by the facility Director of Nursing (DON), to call the DON to get permission to send a resident to the hospital, despite the nursing staff's assessment and clinical judgement that the resident needed to be discharged . These calls to the DON resulted in a delay of treatment for [REDACTED]. Additionally, staff were waiting for extended periods of time to contact the DON when a change in condition had been identified further delaying medical treatment. 1.) Resident 9 (R#9) Facility staff failed to notify the physician regarding laboratory values obtained for R#9, on [DATE], and facility staff failed to send R#9 to the hosptial, on [DATE], in a timely manner despite R#9 experiencing a change in condition because the staff did not have the facility's Director of Nursing's permission to send the resident to the hospital even though staff felt the resident should have been sent. R#9 was sent to the hospital four hours after the staff felt he should have been sent, where he was diagnosed with [REDACTED]. R#9 expired at the hopital 5 days after his admission to the hospital. 2.) Resident 3 (R#3) Facility staff did not call Emergency Medical Services for transport to the hospital, on [DATE], after R#3 experienced a change in condition and after a family member requested the resident be sent to the hospital but instead called the facility Director of Nursing to get permission to send R#3 to the hospital thus causing the family member to call Emergency Medical Services herself to have the resident sent to the hospital. Additionally, facility staff stated that the facility Director of Nursing had to give staff permission to send residents to the hospital despite the Nursing staff assessments and judgements if they felt the residents needed to be sent. The above failures resulted in an IJ situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures have the potential to result in a continued delay of treatment after a change in condition that could cause serious bodily injury or death. Findings include: 1.) Resident 9 (R#9) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], R#9's medical record was reviewed. Review of the Progress Notes revealed the following entry: [DATE] 13:52 (1:52 PM): Vital Signs: BP (Blood Pressure) ,[DATE], P (Pulse) 110, . T (Temperature) 101.3, . resident looks uncomfortable Additional notes as applicable: STAT (immediate) chest x-ray 2 views, STAT BMP (Basic Metabolic Panel), CBC (Complete Blood Count), UA (Urinalysis) c&s (culture and sensitivity), [MEDICATION NAME] 4mg (milligrams) PO (by mouth) PRN (as needed). ([MEDICATION NAME] is a medication given for nausea.) On [DATE] at 11:15 AM, Licensed Vocational Nurse (LVN) A was interviewed. LVN A stated the laboratory values obtained on [DATE] had never been followed up on and reported to the physician. Review of the laboratory values obtained on [DATE] revealed the following: a. [DATE] -UA - sample not collected by facility. b. [DATE] - BMP: 1. Sodium 123 L (Low). Reference range of ,[DATE] mmol/L (millimoles per Liter). 2. Chloride 93 L. Reference range of ,[DATE] mmol/L. 3. CO2 (Carbon [MEDICATION NAME]) 21 L. Reference range of ,[DATE] mmol/L. 4. Glucose 174. H (High). Reference range of ,[DATE] mg/dl (milligrams per deciliter). 5. Calcium 7.6 L. Reference range of 8XXX,[DATE].0 mg/dl. c. [DATE] - CBC: 1. WBC (white blood cells) 17.8 H. Reference range of 4XXX,[DATE].8. No documentation could be found to show that facility staff notified R#9's physician regarding the above listed laboratory values. On [DATE], the facility Director of Nursing (DON) was interviewed. The DON confirmed that the facility staff should have followed up with the physician regarding the laboratory values obtained on [DATE]. The DON further stated that if the facility staff were unable to obtain the urinalysis for R#9 on [DATE], the physician should have been notified. Reveiw of the Progress Notes revealed the following entries: a. [DATE] 23:54 (11:54 PM): . Witnessed fall with skin tear to L (left) stump. According to the entry the doctor was notified of the fall and the skin tear to the Left stump. b. [DATE]: 9.5 X 3.5 Bruise noted to Left Buttock, skin dry and intact will cont. (continue) to monitor. No documentation could be found to show that the physician was notified regarding the bruise or injury of unknown origin. c. [DATE]: Resident day 3 follow-up fall. Refused dinner. Ate some lunch and breakfast. Refused to get out of bed. Denies pain. Neuros WNL (within normal limits). Will monitor. f. [DATE] 02:43 (2:43 AM): [MEDICATION NAME] tablet 4 mg Give 1 tablet by mouth every 8 hours as needed for nausea related to nausea. c/o (complaints of) nausea, had a small emesis of clear light pink liquid. Pink liquid was possible from candy that resident had eaten earlier. No documentation or evidence could be found to show that facility staff notified R#9's physician regarding R#9's emesis or refusal to get out of bed. g. [DATE] 07:40 (7:40 AM): Late entry for [DATE] Bruise to left buttock/Ishium) now presents as Stage 2 fluid filled blister skin dry intact area larger is size. Resident has had a decline in status . (The above entry was made on [DATE] after R#9 was transferred to the hospital) No documentation or evidence could be found to show that facility staff notified R#9's physician regarding the bruise presenting as a Stage 2 fluid filled blister on [DATE]. h. [DATE] 10:00 (10:00 AM): BP ,[DATE], P 91, . Resident was noted with increased confusion, bilateral lungs auscultated with upper congestion noted. O2 (oxygen) sats (saturations) 92 % RA (room air), speech noted with difficulty when trying to talk. oriented X 1. skin slightly jaundice. No acute distress noted at this time. On [DATE] at 11:15 AM, LVN A stated that she had reassessed R#9 at around 4:00 PM on [DATE] and had wanted to transfer R#9 to the hospital at that time but was told No by the facility Director of Nursing. LVN A stated that she felt that there had been a delay in treatment for [REDACTED].#9 to the hospital. LVN A stated that when she spoke to the DON at 4:00 PM on [DATE], the DON had told her that since the physician had not ordered R#9 to be sent to the hospital, the staff were not going to discharge him to the hospital. i. [DATE] 20:00: . Resident is semicomatose, O2 sats 74% on 2LPM (liter per minute) via N/C (nasal cannula). Was unable to get V/S (vital signs) until EMS (Emergency Medical Services) arrived first set of BP was ,[DATE], 2nd set was ,[DATE], Resident had. On [DATE] at 8:08 AM, LVN H was interviewed. LVN H stated that he was the nurse caring for R#9 the night R#9 was sent to the hospital. LVN H stated that after he received report, a facility CNA (Certified Nursing Assistant) came to tell him that something was wrong with R#9. LVN H stated that when he entered R#9's room, R#9 looked completely different than he had four days prior. LVN H stated that R#9 appeared to be actively dying. LVN H stated that he called the DON to tell her that he was sending R#9 out to the hospital. LVN H stated that the DON asked if the facility had received the results of the X-ray obtained earlier and he had told the DON that he did not have the results. LVN H stated that the DON told him that R#9 had received a [MEDICATION NAME] (antibiotic) shot earlier and he had responded that he did not care, that R#9 needed to be sent out. LVN H stated that the DON had told him that she was surprised that the day shift had not sent R#9 out earlier. LVN H stated there was a 15 minute time lapse between the time he assessed R#9 and called 911 because he was on the phone with the DON. LVN H stated that the facility protocol was to call the DON to get permission before sending residents to the hospital. LVN H stated that he did feel that there had been a delay in treatment for [REDACTED]. On [DATE], R#9's physician was interviewed via telephone. The physician stated that review of his call log for his practice revealed that one call had been logged on [DATE] for R#9. The physician stated that the call log showed that the facility staff had called his practice on [DATE] at around 8:30 PM. The physician stated that he was unaware that R#9 had expired after being discharged to the hospital. The physician further stated that his expectation of the staff would be for staff to send a resident to the hospital, if the Nurse's assessment determined the need for discharge, and then notify him. The physician stated that he did not expect for the staff to call the DON for permission to send the resident to the hospital if the nurse's assessment indicated that the resident needed to be sent. The physician further stated that a resident not eating or getting out of bed and confusion were signs of a change in conditon. The physician stated that based on the nursing entry documented in R#9's medical record on [DATE] at 10:00 AM, he would have requested that the resident be sent to the hospital then. On [DATE] at approximately 5:00 PM, the Nurse Practitioner that worked with R#9's physician was interviewed via telephone. The Nurse Practitioner stated that she recalled ordering [MEDICATION NAME] for R#9 on [DATE] but was ordering the [MEDICATION NAME] for chest congestion. The Nurse Practitioner did not recall being notified regarding R#9's jaundice and difficulty when trying to talk. The Nurse Practitioner stated that if the nurses felt like a resident had a change from their baseline, she would expect that the resident be sent to the hospital. The Nurse Practitioner stated that the resident population at the facility was a high risk population and the staff and practitioners needed to be very astute with resident's experiencing a change in condition. The Nurse Practitioner stated that she would prefer the staff err on the side of caution and send a resident to the hospital if they felt the resident needed more advanced medical care. On [DATE], R#9's medical record from the hospital was reviewed. Review of the medical record revealed that R#9 had expired on [DATE] from Preliminary Cause of Death - Septic Shock secondary to necrotizing myositis (rare disease in which the muscle fibers and skin are inflammed and damaged). Additionally, according to the hospital medical record, R#9's white blood cell count upon admission to the hospital was 30,800 and his sodium was 129. Reason for hospitalization was documented as [DIAGNOSES REDACTED] with [MEDICAL CONDITION]. According to rarediseases.org/rare-diseases/necrotizing-fasciitis, Necrotizing fasciites (NF) is a rare infection that mean 'decaying infection of the fascia' which is the soft tissue that is part of the connective tissue system that runs throughout the body. Early symptoms of NF are often mistaken for the flu. Diagnosing NF early and quickly is vital to improving survival. However, studies have shown that since it is so rare, mis[DIAGNOSES REDACTED]. Once at the hospital, patients will have laboratory testing performed. Often, patients will have a white blood cell counts greater that 15,400 cells/mm (millimeter) or a sodium level lower than 135 mmol/L 2.) Resident 3 (R#3) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], R#3's medical record was reviewed. Review of the medical record revealed the following Progress Notes: a. [DATE] 18:10 (6:10 PM): .O2 (Oxygen Saturations) 65% Room Air. resident is coughing and congested during dinner. resident laying bed with head of bed elevated. noted acute respiratory distress. oxygen started at 2 liters. suctioned numerous times with copious amounts of yellowish colored mucus. sucitoned effective but continues to sound congested with occasional coughing o2 sats at 97% went down to 91% with 2liters oxygen. resident taking off oxygen. resident sitting in wheel chair. (name of Nurse Practitioner) ordering stat (immediate) chest x-ray. monitor oxygen. suction resident as needed. (Note: Normal Oxygen Saturation is 90 - 100 % on Room Air). b. [DATE] 19:24 (7:24 PM): daughter arrived to nursing home was given update. saw mother coughing and continues to remove o2 cannula of 2liters. daughter upset and demanded resident be sent out per 911 call now. daughter called 911 herself DON notified, daughter demanded to speak to DON, spoke to DON on phone daughter very unhappy with conversation that took place. resident was brought to nurse station for observation during this time. oxygen sat (saturation) at 91%. Ems (Emergency Medical Services) arrived at 720pm resident continued with wet cough. continued to remove o2. resident restless unaware of daughter being here, coughing with productive cough ems X2 transferred from wheelchair to stretcher taken to (name of local acute care hospital). c. [DATE] 12:15: follow up for SBAR (Situation, Background, Assessment, Recommendation) from [DATE] some clarification and further documentation that had been left out. resident was not in acute respiratory distress at the time it was a typo. notification for doctor and daughter times were entered wrong. correct times see below. Resident yelled out that (R#3) was vomiting. (name) nurse and I went into room. resident coughing and congested during dinner laying in bed with HOB (head of bed) elevated. alert with no acute respiratory distress noted. sat up resident to edge of the bed and starting patting her back. resident telling us to stop padding her. resident was suctioned and copious amounts of yellowish colored mucus came out. resident resumed normal activity. her o2 was 97% then 91% resident was placed on o2 at 2liters. resident kept removing oxygen cannula. resident did not appear in distress. resident taken to nurses station. @ (at) 1813 (6:13 PM) notified doctor ((name)). @ 1822 (6:22 PM) called daughter to update on status of resident. (name) nurse spoke to doctor and stated STAT chest x-ray ordered suction as needed and o2 at 2liters. X-ray done, then changed resident because she had a BM (bowel movement). Daughter arrived at this time. resident started to sound girggly (sic) in her throat. resident brought back to nurse station with no signs or symptoms of distress and alert. DON notified and stated if she aspirated this is treatable with antibiotics. DON asked if doctor ordered resident to send out, I told her no. DON said we would wait on xray result. during this time nurse (name) was speaking to daughter about our protocol of calling doctor and DON. I was notified after hanging up phone with DON that the daughter wants us to call 911. during call back daughter spoke to DON and stated she was calling 911 herself and she was going to sue. Daughter called ems. ems arrived at 720pm resident continued with wet cough. resident continued to remove o2. resident restless/alert to self which is resident norm (normal) due to dementia. unaware of daughter being here, coughing with productive cough ems X2 transferred from wheelchair to stretcher taken to (name of local acute care hospital) at 725 accompanied by daughter. (Note: the above entry indicated that the resident was not in respiratory distress on [DATE] despite the nursing entry made by the facility staff that the resident was having respiratory distress on [DATE] at 6:10PM.) According to the above entries, the facility staff identified that R#3 had experienced a change in condition at approximately 6:15 PM, yet R#3 was not sent to the hospital until 7:25 PM, one hour and 15 minutes after the staff assessed the change in condition. On [DATE] at 10:20 AM, R#3's daughter was interviwed via the phone. R#3's daughter stated that she had received a call from the facility around 7:30 PM the night her mother was discharged to the hospital. R#3's daughter stated that facility staff had reported that her mother (R#3) had possibly aspirated on something at dinner. R#3's daughter stated that she did not know what aspirated meant and had to look the term up to discover that the term meant choked. R#3's daughter stated that the staff stated that they had been given the instructions to suction her mom but that the suction was not working. R#3's daughter stated that she left immediately for the facility. R#3's daughter stated that when she arrived at the facility her mother was at the nurse's station and that her mother did not look good and her mother had a lot of congestion and was coughing. R#3's daughter stated that she wanted her mother to be sent to the hospital and a staff nurse had responded that the staff would need to call the Director of Nursing (DON) to get permission to send R#3 to the hospital. R#3's daughter stated that the staff then called the DON to speak with her. R#3's daughter stated that she got on the phone with the DON and the DON told her that she would talk with the nurse. R#3's daughter stated that after the nurse hung up the phone with the DON, the nurse told the daughter that the DON had not given permission to send R#3 to the hospital. R#3's daughter stated that she then called 911 herself to have her mother sent to the hospital. On [DATE] at 11:15 AM, the nurse who made the medical record entries on [DATE] and [DATE], Licensed Vocational Nurse ((LVN A)) was interviewed. LVN A stated that after she had assessed R#3 and suctioned R#3, LVN A took R#3 to the nurses station and called the doctor to get orders. LVN A stated that the x-ray company showed up to do the X-ray quickly and that after the X-ray, R#3 had had a BM so she was taking R#3 down the hall to change R#3. LVN A stated that after R#3 had received incontinent care was when her daughter had come to the facility. LVN A stated that R#3's daughter was upset and the other nurse told the daughter that we needed to call the doctor and the DON regarding R#3's current condition. LVN A stated that she placed a call to the DON and reported to the DON that the resident had aspirated and the DON stated that the aspiration could be treated with antibiotics. LVN A stated that the daughter spoke with the DON via the phone and that after she (LVN A) hung up the phone the daughter stated that she wanted R#3 to be sent out to the hospital. LVN A stated that she then turned to call the DON back and R#3's daughter called 911. LVN A stated that she felt that R#3 needed more medical attention than the facility could provide but that she did not know if R#3 needed to be sent to the hospital emergently. LVN A stated that she did feel like there was a delay in treatment for [REDACTED]. On [DATE] at 9:23 AM, LVN C was interviewed. LVN C stated that she was the nurse that was assisting LVN A on the day that R#3 was sent to the hospital. LVN C stated that while LVN A was on the phone with the DON, she was talking with R#3's daughter about the process of calling the DON before a resident could be sent to the hospital. LVN C stated that she did not hear the conversation that LVN A had with the DON. LVN C stated that R#3's daughter spoke with the DON over the phone and then handed the phone back to LVN A. LVN C stated that R#3's daughter looked at her (LVN C) after giving the phone back to LVN A and told LVN C that she wanted R#3 to be sent to the hospital. LVN C stated that she tried to tell LVN A that R#3's daughter wanted R#3 sent to the hospital while she (LVN A) was finishing her call to the DON but that LVN A did not hear her. LVN C stated that after LVN A hung up the phone, she (LVN C) told LVN A that R#3's daughter wanted R#3 sent to the hospital. LVN C stated that LVN A then picked the phone back up to call the DON and that was when R#3's daughter pulled out her phone and dialed 911. LVN C stated that the facility's protocol was to call the DON to get permission to send residents to the hospital. LVN C stated that the staff did not like that protocol and felt like their judegement was not being utilized. LVN C stated that she felt like there had been a delay in treatment for [REDACTED]. On [DATE] at 6:35 AM, LVN D was interviewed. LVN D stated that the nursing staff was told that the DON needed to be called if a nurse wanted to send a resident out to the hospital. LVN D stated that she had butted heads with the DON a few times when the DON had told her not to send a resident out to the hospital. LVN D stated that she felt like there had been a delay in treatment for [REDACTED]. On [DATE], the facility DON was interviewed. The DON stated that facility staff would call her before calling the physician if a resident experienced a change in condition. The DON stated that the staff would call her to go over the SBAR form to ensure that the staff had the appropriate documentation before calling the physician. The DON stated that staff did not need to get her permission to send a resident to the hospital. On [DATE], the facility's Policy and Procedure for Changes in Resident Condition was reviewed. Review of the Policy revealed the following: The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. Guidelines 1. For life-threatening events, call 911 if initial assessment indicates that such action is necessary. 2. Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's attending physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. 3. If the attending physician cannot be reached, nursing attempts to contact the following providers in this order until a physician has been contacted: the physician on call, the facility Medical Director, the Division Medical Director and emergency services. 4. The SBAR (Situation Background, Assessment, Recommendation) Communication Form and the Progress Note are used to: a. Assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physician, and c. Provide clear comprehensive documentation. 3. (sic) Changes in condition are communicated from shift to shift through the 24 Hour Report. 4. (sic) Changes in the resident status that affect the problem (s) / goal (s) or approach (es) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers. On [DATE] at 5:12 PM, the facility Administrator and Director of Nursing were verbally notified of the Immediate Jeopardy in regards to a delay in treatment when a resident had experienced a change in condition. The Administrator was asked to begin an immediate plan to ensure the health and safety of the residents within the facility. On [DATE] at 2:20 PM, the facility Administrator submitted a Letter of Credible Allegation for Removal of the Immediate Jeopardy. The letter contained the following: Retama Manor Corpus North - RMCN respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on (MONTH) 28, (YEAR). Submitted on (MONTH) 29, (YEAR) at 10:30am. Immediate Action for entire population: Lab: The facility immediately began a review of all lab results that have been completed within the last 30 days, to ensure there were no critical lab values that have not been communicated to the physician and to ensure that all ordered interventions were carried out. The facility identified 5 residents who had critical lab results within the last 30 days within the facility. All residents with critical lab values were reviewed by an RN to ensure there was no delay in treatment. Completed [DATE] X-Ray: The facility immediately began a review of all residents with orders for X-Ray within the last 30 days to ensure the diagnostic test had been conducted and the result reported to the MD. The facility identified 32 residents with orders for X-Ray within the last 30 days. All abnormal X-Ray results were reviewed by an RN to ensure there was no delay in treatment. Completed [DATE] Change of Condition: The facility immediately began to review all residents to ensure there were no unidentified changes of condition or change of condition not appropriately addressed. All residents identified on the PCC 24 hour report as having an SBAR or otherwise High Risk Progress Note were reviewed by an RN to ensure there was no delay in treatment for [REDACTED]. Completed [DATE] Residents with the potential to be affected by the alleged deficient practice: 1. During the above thorough review of the entire facility population the facility identified 5 residents who had critical lab values within the last 30 days, 32 of residents who had MD orders for X-Ray studies within the last 30 days and 46 of residents who had a change of condition within the last 30 days. Systemic Measures: 1. Lab: Facility will contact Schryver Lab Company and set up a notification alert system for all critical labs. Any lab that has a Critical result will be called to the facility DON to ensure that all critical labs are reported to the MD timely and appropriate interventions are implemented. The lab will continue its process of faxing lab results to the facility as well. Upon notification that there has been a Critical result, facility DON will promptly contact the nurse assigned to that patient to ensure she has received the result and to ensure the MD has been contacted. This will be tracked on a Critical Lab Result Log and will be reviewed daily by the DON for no less than 90 days to ensure the interventions implemented were effective and that there was no delay in treatment. The Critical Lab Result Log will be utilized for reporting to the QAPI committee. Further, to address the issue of Broken Fax Machine on the 3rd floor the facility has implemented the following procedure: Schryver will continue to fax ALL results to ALL floors, however, until the 3rd floor fax is repaired, the nurses on floors 2 and 4 who receive faxes will be responsible to hand deliver all lab results for floor 3 to the nurse on shift. *Nurses will be trained on this temporary procedure* To address routine lab orders: The facility will implement a tracking system for ALL lab orders as follows: The DON/Designee will immediately implement a Lab Tracking System utilizing a Lab Log. Initially the DON/Designee will pull all lab orders from PCC and input them on the Lab Tracking Log with the corresponding due date, and daily the DON/Designee will pull all orders from PCC for Lab input in the last 24 hours to add on to the Lab Tracking Log. Daily the DON/Designee will reconcile the ordered labs entered on the Lab Tracking Log with the labs drawn and then the labs resulted each day. The DON/Designee will also review these results for Abnormal and Critical results and ensure there was MD notification and interventions implemented and no delay in care. X-Ray: When the facility receives an order for [REDACTED]. This will be tracked on a X-Ray Result Log for reporting to the QAPI committee for no less than 90 days. Change of Condition: When a nurse identifies a change of condition that is life threating, that nurse will call 911 immediately when assessment indicates that such action is necessary. For all other changes of condition that are not identified as life threating, the nurse will promptly notify the attending and/or on call physician. Documentation of changes of condition will be recorded on the SBAR UDA in the resident's medical record. The DON and/or designee will review all SBARs daily to ensure that the all residents who experienced a change in condition received effectively and timely interventions and reported to QAPI for no less than 90 days. 2. Training: Will be completed as follows: a. Lab: All licensed nursing staff will be trained on prompt notification of physician for Critical lab results and timely implementation of physician ordered interventions. All licensed nursing staff will be trained that the fax machine on the 3rd floor is not currently functioning. Each nurse who receives lab faxes on floor 2 and 4 will be responsible to hand deliver the 3rd floor faxes to the nurse on the 3rd floor. Will be completed [DATE] b. X-Ray: All licensed nursing staff will be trained on utilizing Christus Spohn when the physician orders [REDACTED]. Licensed nurses will be trained on clarifying with MD if he wants X-Ray STAT or routine time frame. If resident is having a Change of Condition requiring an X-Ray, nursing staff will be trained to request a STAT order from MD. Will be completed [DATE] c. Change of Condition: All licensed nursing staff will be trained on facility process for calling 911 first when a nurse identifies a life threating change of condition, and on prompt notification to the physician on all other changes of condition and completion of the SBAR UDA in the resident's medical record. Will be completed [DATE] d. Director of Nursing: Facility Director of Nursing will be trained on Critical Lab Result daily tracking, X-Ray result tracking and audits to ensure no delay in treatment. Further training on facility process for calling 911 first when a licensed nurse identifies a life threating change of condition and prompt notification of the physician for all other changes of condition. Training on audits of all SBARs to be reviewed daily for delay in treatment. This training will be completed by Mandi Schmitt, RN District Director of Clinical Services on [DATE]. e. Administrator: Facility admini

Based on interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the comprehensive person-centered care plan for 3 (Resident #5, #1, #6) of 10 sample residents. The facility did not provide effective pain relief for R #1 for almost 24 hours after admission. The facility did not provide effective pain relief for Resident #5 after sustaining a [MEDICAL CONDITION]. The facility failed to ensure nursing staff filled Resident #6's prescribed [MEDICATION NAME] and [MEDICATION NAME]. This failure could place the residents at risk for not having effective pain control. Findings included: 1. Resident 5 (R#5) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/28/18, R#5's medical record was reviewed. Review of R#5's care plan revealed a Focus area dated 03/14/18 of (R#5) is at risk for pain r/t recent LAKA (left above the knee amputation) and L femur fracture. The goals listed for the Focus area were; . (R#5)'s pain will be managed to the greatest extent possible so it does not effect day to day activities. The interventions listed to help R#5 achieve the stated goals were; Administer pain medication as ordered., Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition., Notify physician if interventions are unsuccessful or if current complaints is a significant change from residents past experience of pain., . Review of the physician's orders [REDACTED]. a. 03/13/18 - Tylenol with [MEDICATION NAME] #3 Tablet 300-30 MG. Given 1 tablet by mouth every 04 hours as needed for Pain - for pain scale 5-10 related to Pain. b. 04/19/18 - [MEDICATION NAME] (Concentrate) Solution 20 mg/ml (milligrams per milliliter) Give 0.25 ml by mouth every 2 hours as needed for pain - Moderate 1-5 and SOB (Shortness of Breath). c. 04/19/18 - [MEDICATION NAME] (Concentrate) Solution 20 mg/ml Give 0.5 ml sublingually every 2 hours as needed for Pain - Severe 6-10 and SOB. Review of the medical record revealed the following Progress Notes entries: a. 11/06/18 19:57 (7:57 PM): . Resident appears to have fallen of (sic) bed during incontinent care. I assessed her for injury. After assisting her back to bed, I medicated her with APAP#3 (Tylenol with [MEDICATION NAME]) for c/o (complaints of) pain to r. (right) hip. This was reported to Dr. (name) on call for Dr. (name) at this time he ordered xray as indicated above. b. 11/06/18 20:00 (8:00 PM) Administration Note: Tylenol with [MEDICATION NAME] #3 tablet 300 - 30 mg. Give 1 tablet by mouth every 04 hours as needed for Pain - for pain scale 5-10 related to Pain, . d/t (due to) complaining of right hip pain. (Note: the staff member did not document a number to indicate what level of pain R#5 was experiencing.) c. 11/06/18 23:05 (11:05 PM): Received Xray of right shoulder and clavicle and right hip, right hip shows acute fracture of hip. Notified (name of Hospice company) Nurse (name) and stated what does family want done. I told her will call niece and ask her. d. 11/06/18 23:07 (11:07 PM): Called Dr. on call for Dr. (name) spoke with Dr. (name) and made him aware of resident's abnormal right hip xray shows acute right [MEDICAL CONDITION] and as per niece would like her aunt sent out to hospital for further pain evaluation which I told her I had given her APAP#3 she wanted something stronger given to her. e. 11/06/18 23:09 (11:09 PM): Called (name) and made her aware of aunts abnormal right hip findings show acute fracture she stated Oh my god, I ask her what she wanted for us to do as far as tx (treatment) she wants her aunt sent out to hospital for stronger pain management due to fracture I told her I had already given her apap #3 she stated she needed something stronger than that. f. 11/07/18 00:00 (12:00 AM): Administration Note: Tylenol with [MEDICATION NAME] #3 Tablet 300-30 mg . Administration was: Ineffective. The above entry was made in regards to the administration of the Tylenol #3 being ineffective when it was administered at 8:00 PM. On 11/29/18 at approximately 10:00 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that her expectation was that staff completed a pre and post pain score when administering pain medication. The DON stated that staff should be obtaining a number, in regards to level of pain, prior to administering pain medication and then staff should evaluate the effectiveness of the medication after they have administered the medication by obtaining another number, in regards to the level of pain. On 11/30/18 at 6:30 AM, Licensed Vocational Nurse (LVN) B was interviewed. LVN B stated that she was the nurse caring for R#5 on 11/06/18. LVN B stated that after R#5 sustained the fall from bed, it took her and two CNAs (Certified Nursing Assistants) to transfer R#5 back into bed. LVN B stated that R#5 was complaining of hip pain. LVN stated that she had administered Tylenol #3 to R#5 for the complaints of pain. LVN B stated that the Tylenol #3 was not effective in controlling R#5's pain. LVN B stated that she did not administer the [MEDICATION NAME] to R#5 because she did not think that the [MEDICATION NAME] would control the pain and that [MEDICATION NAME] was not something that was given for a fracture. LVN B stated that R#5 only stated that she had pain and LVN B did not see R#5 grimacing with pain. LVN B stated that she had given R#5 an additional Tylenol #3 before discharging R#5 to the hospital at midnight. 2. Resident #1's Face Sheet revealed a [AGE] year old male initially admitted on [DATE] with [DIAGNOSES REDACTED]. body). Record review of R #1's Hospital records dated 8/22/18 revealed R #1 had an Aortic Valve Replacement Surgery on 08/28/18. Additionally, when R#1 was discharged from the hospital on [DATE], R#1 was receiving [MEDICATION NAME] for pain. Review of the physician's orders [REDACTED].#1 for pain every shift. No documentation could be found to show that facility staff were assessing R#1 each shift for pain. Physician orders [REDACTED]. Record review of R #1's Nursing Admission Data Collection dated 09/06/18 revealed, Surgical Incision at Mid Chest and at Left Upper Quadrant. The MARs from (MONTH) (YEAR) indicated Resident #1 received no pain medication after admission on 09/06/18 at 3:22 PM. Record review of R #1's Nursing Progress Notes dated 9/06/18 at 6:35 PM revealed Resident came to the facility at 3:22 PM via stretcher accompanied by spouse and 2 EMTs (Emergency Medical Technician). Resident was taken to room [ROOM NUMBER] and EMT transfer resident from stretcher to bed. Resident is able to stand with assistance, but has trouble walking. Resident was oriented to surroundings and to bed functions and call light resident demonstrated usage of call light and bed. We were not able to obtain weight from resident due to him not being able to push himself or get on Hoyer lift due to recent Surgery. Resident was requesting to get out of bed therefore therapy came and help resident out of bed into bed side chair. Resident had a large bowel movement during dinner time he was cleaned and change, but he was demanding a shower. Resident was educated that we were in the middle of passing dinner trays and that he needed to wait in order for us to pass trays. Resident agreed to sit on chair and wait for his dinner tray. Will continue to monitor resident sitting on chair eating dinner with call light within reach. Record review of R #1's Nursing Progress Notes dated 09/07/18 at 7:05 AM revealed, Met for 72 hour care plan on 09/07/18 in R #1's room. R #1 voiced that he was unhappy at facility and did not feel we could care for him. R #1 insisted he did not want to stay. Record review of R #1's Nursing Progress Notes dated 09/08/18 3:36 AM revealed R #1 was not happy here and we promised him a lot of things and didn't deliver. I called director of nurses and she tried to talk to R #1 but he still decided to leave. 3. Resident #6's Face Sheet revealed a [AGE] year old male initially admitted on [DATE] with [DIAGNOSES REDACTED]. enough healthy red blood cells), and Vitamin Deficiency (lack of vitamins). Record review of R #6's Admission MDS dated [DATE] facility staff assessed this resident manual as receiving prn medication, having pain almost constantly in last 5 days. Over the last 5 days the intensity of resident's pain was an 8 on a scale of 1 to 10. Additionally on care area assessment or CAA pain was triggered and facility staff indicated it would be care planned. Record review of R #6's Care Plan revealed, Resident prefers pain controlled by: Medication. Record review of R #6's Hospital records admission date of [DATE] revealed R #6 had a Posterior Cervical Fusion surgery (joining of 2 or more bones in the neck together) due to a fracture of R #6's cervical spine (C1) sustained from a fall at R #6's home. Physician orders [REDACTED]. -[MEDICATION NAME] Tablet 30 MG Give 1 tablet by mouth every 12 hours related to other nondisplaced fracture of first cervical vertebra order date: 06/22/18. - [MEDICATION NAME] Tablet 10-325 MG (Hydrocarbon-[MEDICATION NAME]) Give 1 tablet by mouth every 6 hours as needed for pain - for pain scale 5-10 related to pain order date: 06/23/18. Record review of R #6's 2 hand written scripts dated 06/22/18 revealed, -[MEDICATION NAME] 10MG/325MG take 1 tab by mouth every 6 hours as needed for pain. - [MEDICATION NAME] 30MG 2 tab by mouth every 12 hours as needed for pain. Record review of R #6's Nursing Progress Notes dated 06/22/18 at 5:16 PM revealed, Patient arrived by stretcher with EMS (Emergency Medical services) & has a cervical collar on. R #6 rated pain as a constant 8 from neck. Record review of R #6's Nursing Progress Notes dated 06/22/18 at 9:16 PM revealed, Medical not available from pharmacy at this time. Attempted to call LVN Y on 11/28/18 at 3:42 PM revealed, not a working number. According to the documentation, R#6 received none of the prescribed pain medication until 6/23/18 at 4:21 PM, almost 24 hours after R#6's admission to the facility despite the resident reporting a pain score of 8 upon admission Record review of R #6's Nurses Progress notes dated 7/20/18 at 4:12 PM revealed, Met for discharge planning 7/19/18. R#6 had went without pain meds . Interview on 11/29/18 at 1:40 PM with LVN Z revealed, I don't remember much about R #6 as to what he got when he was admitted . If we don't have the medication, we call the doctor back and obtain a new order. Our Omnicare pharmacy is based out of San Antonio and we call a 1-800 number and have them call in an order for [REDACTED]. On 11/29/18, the DON was interviewed. The DON stated that facility staff should never document that medications are not available. The DON stated that if the facility staff were unable to obtain medication then the staff should have contacted her to get assistance in aquiring the medications. The DON stated that pain was whatever the resident reported it to be and that the staff should have been treating resident's pain. The DON stated that the facility had an Omnicycle that contained pain medication that all staff had access to. On 11/28/18, the facility's Pain Mangement policy and procedure were reviewed. Review of the Pain Mangement policy revealed the following: Policy .Residents who experience a change in condition or have a suspected new onset of pain are evaluated for pain. Residents are also evaluated for pain regularly by inquiring if they have pain and observing the resident for signs and symptoms of pain. The goal of the Pain Management System is to effectively and consistently identify and treat pain. Definitions . Acute Pain Also known as warning pain, this pain is the discomfort or signal that alerts you something is wrong in your body. Pain results from any condition that stimulates the body's sensors, such as infections, injuries, . Acute pain usually abates as the underlying problem is treated. Early management of acute pain may hasten the recovery of the causative problem and reduce the length of treatment. . Basic Overview of Pain Mangement Step 1: . Step 2: Evaluation of Pain For those residents who screen positive for pain, an in-depth evaluation of their pain is conducted, including such things as the intensity and characteristics of pain, and the effectiveness of prior treatments. An evaluation of pain should be completed when the resident has a new complaint of pain or when pain is suspected to be present. . Step 5: Regular Re-evaluation Regular re-evaluation occurs when a non-pharmacological intervention is attempted or pain medication is administered to the resident. Effectiveness of the intervention or medication is evaluated, and changes are made if the medication or approach is determined to be ineffective. -

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for two (R #1 and R #2) of three residents reviewed for pressure ulcers. -The facility failed to clarify and implement R #1's pressure ulcer physician's wound care orders upon admission. Upon admission R #1 entered the facility with two red open areas and currently acquired 39 separate ulcers throughout his body. -The facility allowed R #1's draining pressure ulcers to remain uncovered and untreated for [REDACTED]. -The facility failed to clarify, and implement R #2's pressure ulcer physician's wound care orders. R #2's community acquired Buttock/Sacral/Coccyx Stage 4 pressure ulcer deteriorated, and had a foul odor and necrotic tissue. -The facility failed to accurately describe, document measurements, and stage R #1 and R #2's pressure ulcers. -The facility's documentation of R #1 and R #2's pressure ulcers was conflicting on separate forms making it difficult to track the progress of the pressure ulcers. -The facility did not consistently identify all of R #2's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. -The facility failed to inform R #2's physician of any changes in his Buttock/Sacral/Coccyx Stage 4 pressure ulcer and the development of a new ulcer on his Left Ischial Tuberosity. R #2's Buttock/Sacral/Coccyx ulcer developed 95% necrotic tissue and foul odorous drainage. The facility failed to ensure the licensed staff providing wound care were trained and competent in the identification, assessment, and treatment of [REDACTED]. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 13 residents with pressure ulcers and 37 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: Interview with the Director of Nurses (DON) on entrance conference on [DATE] at 2:15 p.m. revealed the facility had not had a Treatment Nurse since [DATE]. The DON mentioned she was made aware of assessment and documentation issues regarding wounds/pressure ulcers while the facility was last revisited by a different surveyor approximately ,[DATE] weeks ago. The DON said she had been trying to assess every resident's skin from head to toe since then but had not completed 100%. When asked for a current pressure ulcer log, the DON stated she did not have a current log but was working on one. R #1: R #1's Admission Record dated [DATE] revealed R #1 was a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. of onset for both left and right hip blisters was [DATE]). R #1's Braden Scale dated [DATE] revealed R #1 risk for Pressure Ulcers was at 9=high risk. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (admission) revealed R #1 had R (Right) Lateral Heel 5 CM Size Purplish Colored Intact Blister .R Lateral Back 5 CM Size Redden Area. R #1's History and Physical dated [DATE] revealed R #1 had no Decubitus Ulcers. R #1's admission MDS dated [DATE] revealed R #1 had severely impaired vision, R #1 did not have speech, rarely/never understood by others and rarely/never understood others. R #1 Cognitive skills for daily decision making and vision was severely impaired. R #1 was totally dependent with bed mobility, bathing and dressing requiring the assistance of two people. R #1 was assessed as having an indwelling urinary catheter and was frequently incontinent of bowel. R #1 was assessed as having a Feeding Tube and received 51% or more calories and 501 cc/day or more fluid intake through feeding tube. R #1 was assessed at risk for Pressure Ulcers and had two Deep Tissue Injuries present on admission. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had left heel has purple blister intact. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had two blood blisters to right and left heel. R #1 had not been sent out to the hospital after [DATE]. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] revealed R #1 had 2 blood blisters R&L (Left) heel. R #1's Skin-Head to Toe Skin Checks assessments and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 Was assessed as having a new pressure ulcer the description was Excoriation right buttock, DTI (Deep Tissue Injury) Lt. buttock. BI (bilateral) heels blood blisters. BI hip blanchable redness .Right buttock Length 1.1 cm Width 0.7 excoriation .Left buttock Length 4.5 cm Width 1.5 cm Suspected Deep Tissue Injury .LT hip blanchable redness .RT hip blanchable redness .Specialty Interventions Air Mattress . The Skin Weekly Pressure Ulcer Record provided definitions of the stages of pressure ulcers that included: -Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure ulcer and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3: Fill thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or broom) and/or eschar (tan, brown or black) in the wound bed. R #1's NP XX Initial Consultation dated [DATE] revealed R #1 was assessed as having the following wounds and treatment recommendations: left heel unstageable heel L-2 cm x W-1 cm the wound bed was dark purple discoloration, unstageable. Right elbow fluid filled blister L-2.1 cm x L-1.5 cm stage 2 pressure ulcer Rt. Heel L-1cm x 1 cm 100% discoloration Unstageable. Right Ear had non blanchable redness Stage 1, Anterior neck L-0.7 cm x W-1 cm x D- 0.1 cm, Right buttock pressure ulcer L-5 cm x 6 cm x unknown unstageable wound bed with dark purple/black discoloration. Treatment recommendation for heel wounds was to cleanse with NS pat dry with gauze apply Sure Prep leave OTA. Recommended float heels on pillow. treatment for [REDACTED]. Right ear recommendation was to monitor for proper placement of N/C every shift. treatment for [REDACTED]. R #1's Care Plan dated [DATE] revealed (R #1) has unstageable pressure ulcer to right buttock or potential for pressure ulcer development r/t Immobility XXX[DATE] Consult with Regional Wound Care to evaluate and treat .Administer treatments as ordered and observe for effectiveness . NP XX followed up on [DATE], [DATE], and [DATE] and assessed R #1's wounds and provided recommendations each visit. (The assessments and recommendations were not legible.) R #1's Skin-Head to Toe Skin Checks assessment and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 was assessed as having a neck pressure ulcer Length 0.7 cm Width 1 cm Depth 0.1 red wound bed Stage III .Right heel pressure ulcer Length 1 cm Width 1 cm Stage I red DTI .Right elbow Pressure ulcer Length 2.5 cm Width 1.5 cm Stage II fluid filled blister .Left heel Pressure Ulcer Length 2 cm Width 1 cm Unstageable DTI .R Buttock Pressure ulcer Length 5 cm Width 6 cm Stage I reddened DTI .R ear Pressure ulcer stage I Length 1 cm Width 1 cm Suspected Deep Tissue Injury .R ankle Pressure ulcer Unstageable .Specialty Interventions Positioning Device .Wedge Cushions . R #1's Care Plan dated [DATE] revealed (R #1) has Potential/ Actual Skin Issues related to: Pressure Ulcer related to history of ulcers, Pressure Ulcer related to Mobility .(R #1) will remain without signs of breakdown by next review .(R #1) wound will show signs of healing with area decreasing in overall size and depth by next review . Notify MD in changes in wound or emerging wounds .observe wound healing . place on air loss mattress .provide would care/preventative skin care per order .Skin checks weekly per facility protocol, document findings . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip, DTI L heel .Right Trochanter (hip) Blister Length 10.5 cm Width 8.5 cm Stage N/A .Left Trochanter (hip) Blister Length 8.5 cm Width 5 cm Stage N/A .Right buttock excoriation .Left buttock excoriation .Left heel Length 1 cm Width 1 cm Suspected Deep Tissue Injury .Specialty Interventions Positioning devices pillows other interventions turn frequently . Left Trochanter was described as having red wound bed, small amount of serosanguineous drainage, blister getting bigger and wound edges Dark Red/Purple . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Right ear pressure ulcer Stage II .Left ear Pressure Ulcer Stage I .Right buttock Suspected Deep Tissue Injury DTI . Right heel pressure ulcer .Left heel pressure ulcer .Right Knee #2 Length 1.0 cm Width 1.5 cm Depth 0.1 cm Stage II open blister . red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Right Knee #1 Length 3.0 cm Width 2.5 cm Depth 0.1 cm Stage II open blister .red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Knee Length 3.0 cm Width 3.5 cm Depth 0.1 cm Stage II open blister . red wound bed, .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Hip Pressure Ulcer Unstageable .Right Hip Unstageable R #1's Skin-Head to Toe Skin Checks dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip R/L medial knees .see noted measurements [DATE] R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Non-Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having intact blister to left flank back .Length 6.2 cm Width 3 cm .Specialty Interventions .Wedge Cushion . R #1's Skin-Head to Toe Skin Checks dated [DATE] Existing blood blister to left heel, DTI's, continues with ruptured blisters to L/R knee .Coccyx Pressure Ulcer Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III . Right Trochanter (hip) Pressure Ulcer Length 3.6 cm Width 2.2 cm Unstageable .Left Trochanter (hip) Pressure Ulcer Length 9.4 cm Width 6.3 cm Unstageable .Left ear Pressure Ulcer Length 1.2 cm Width 1.2 cm Depth 0.1 cm Stage II .Left heel Length 1.3 cm Width 1.2 cm Healing Blood Blister .Left flank Length 10.2 cm Width 2.3 cm .Right Medial Knee Blister Length 2.5 cm Width 2.0 cm .Left Medial Knee Pressure Pressure Ulcer Length 2.9 cm Width 2.2 cm Suspected deep tissue injury .Right Calcaneous Pressure Ulcer Length 0.9 cm width 0.8 cm Suspected deep tissue injury .LT Lat. Lower Extremity. Pressure Ulcer Length 3.4 cm Width 2.0 cm .Ruptured blister to right medial heel dry, healing, and intact, left and right medial blisters with beefy wound bed, minimal serosanguinous drainage, L/R unstageable hip ulcers with 100% eschar to wound bed, dried blister to left flank intact and scab-like, stage 3 to coccyx with boggy slough, foul odor . R #1's Skin Head to Toe Skin Check and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] (late entry) revealed R #1 was assessed as having Coccyx Pressure Ulcer date of onset [DATE] Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III .wound bed yellow scant amount of serous drainage .Odor Not Present Specialty Interventions LAL Bed .Positioning devices Pillows .Notes to apply santyl oint to wound bed and cover with adhesive foam dressing daily until resolved .Left Medial Lateral Foot date of onset [DATE] Length 2.0 cm Width 0.9 cm Depth 0 cm Stage I Nonblanchable .wound bed red Specialty Interventions Bed LAL positioning pillows .Left Calcaneous date of onset [DATE] Length 2.2 cm Width 1.2 cm Depth 0 cm Stage I Nonblanchable Redden area wound bed red Specialty Interventions Bed LAL positioning devices Keen, pillows .Right Lateral Foot Date of onset [DATE] Length 1.4 cm Width 1.6 cm Depth 0 cm Suspected Deep Tissue Injury Redden Skin Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows .Ordered skin prep area Q shift until resolved .Right Medial Foot Date of Onset [DATE] Length 3.5 cm Width 2.5 cm Depth 0 cm Stage I .Wound Bed Red .ordered to off load feet and monitor for any changes Q shift until resolved .Right Calcaneous date of onset [DATE] Length 1.2 cm Width 0.9 cm Depth 0 cm Stage I reddened Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows . Skin-Weekly Non-Pressure Condition Record .Right Anterior Foot date of onset [DATE] bruising Length 1.3 cm Width 1.0 cm Depth 0 cm Wound Bed Red . R #1's Skin-Head to Toe Skin Checks dated and Skin-Weekly Pressure Condition Record both dated [DATE] assessment revealed blisters L/R hip RL medial knees, Stage III R buttock . Right Trochanter (hip) Blister Length 85 cm Width 3.5 cm Depth 0 cm .Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 .Right buttock Pressure Ulcer Length 8 cm Width 7 cm Depth 3 cm Stage III .L medial knee Blister Length 2.5 cm Width 2.5 cm Depth 0 cm .R medial knee Blister Length 3 cm Width 2 cm Depth 0 cm . Ruptured blisters to L/R medial knees dry and healing, L/R unstageable blisters to hips that appear as ulcers now (with) 100% eschar to wound bed, stage III to right buttock (with) boggy slough, foul odor .Skin-Weekly Pressure Condition Record Right Buttock wound date of onset [DATE] Length 8 cm Width 7 cm Depth 3 cm Stage III .Drainage Moderate amount Color Purulent Wound Edges White/Gray/Pallor .Response to treatment Deteriorated area getting bigger Treatment plan Continue . Skin-Weekly Non- Pressure Condition Record L medial knee blister date of Length 2.5 cm Width 2.5 cm Depth 0 cm ruptured blister that is drying out .R medial knee date of onset [DATE] Length 3 cm Width 2 cm Depth 0 cm ruptured blister that is drying out . L medial knee Blister date of onset [DATE] Length 2.5 cm Width 2.5 cm Depth 0 cm . ruptured blister that is drying out .Right Trochanter (hip) blister date of onset [DATE] Length 5 cm Width 3.5 cm Depth 0 cm unstageable Wound bed Black Eschar Drainage small amount Color serosanguinous Wound edges Black Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 unstageable Wound bed Black Drainage scant amount Color serosanguinous Wound edges Black Response to Treatment No Change Treatment Plan Continue. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) revealed L/R hip R/L medial knees, pressure R buttock, multiple wounds .Left hand wound (palm) .Left hand (back) Blister .Left shoulder (rear) pressure ulcer Length 1.6 cm Width 2.5 cm Depth 0 cm. Unstageable . Rt medi lower leg B Blister Length 2.0 cm Width 1.5 cm .Rt medi lower leg A blister Length 3.0 cm Width 2.0 cm .Left medial knee pressure ulcer Length 1.0 cm Width 1.3 cm Depth 0.1 cm Stage II . Lt medial upper back Pressure ulcer Length 1.5 cm Width 1.0 cm Unstageable .Left back Pressure ulcer Length 2.0 cm Width 2.5 cm Unstageable .Left lateral ankle Pressure Ulcer Length 2.5 cm Width 0.5 cm Depth 0.1 cm Stage II .Left Hip Pressure Ulcer Length 8.0 cm Width 6.5 cm Unstageable .Right hip Pressure Ulcer .Stage N/A .Rt Knee pressure Ulcer Stage N/A .Skin-Weekly Non- Pressure Condition Record dated [DATE] . date of onset [DATE] L. ring finger Blister Length 2.3 cm Width 2.3 cm Depth 0 cm. fluid filled blister . L hand thumb Blister Length 7 cm Width 1 cm Depth 0 cm fluid filled blister .Left hand pinky finger Blister Length 1.7 cm Width 2 cm Depth 0cm Fluid filled blister .Left hand palm blister Length 8.5 cm Width 2.3 cm Depth 0 cm Fluid filled blister .Left hand (back) Blister Length 8 cm Width 5 cm Depth 0 cm Fluid filled blister with dark purple with clear fluid .L hand middle finger blister Length 3 cm Width 2.5 cm Depth 0 cm Fluid filled blister .Left hand index finger Length 7 cm Width .5 cm Depth 0 cm Clear fluid filled blister . R #1's Care Plan dated [DATE] revealed (R #1) is on (Hospice for dysphagia following cerebral infarction .do not initial CPR . On [DATE] at 2:18 p.m., observation accompanied by LVN C revealed R #1 was lying in bed on his back with his left hand swollen with draining blisters without a dressing. Left and right hip wounds with black eschar, left lateral ankle wound, left lateral lower leg wound, Right and left medial knee wounds, left posterior shoulder wound, left and right ear wounds, left medial tibial wound, right medial heel wound, Left coccyx wound and left buttock wound open without dressings. R #1 had an adult brief on and his linens were soiled with drainage from open wounds. LVN C said NP XX was in the facility today and removed R #1's dressings, at approximately 11:00 a.m. On [DATE] at 3:15 p.m., observation revealed LVN B and C were in R #1's room providing wound care. LVN B had gloves on, applied skin prep to Left malleolus and left lateral leg wounds, then applied a foam dressing, doffed gloves picked up foam dressing with her bare hands cut dressing to fit wound then placed foam dressing on the outer dressing packaging. LVN B donned clean gloves. LVN B did not wash hands in between glove changes. LVN B said NP XX had removed R #1's dressings at approximately 10:30 a.m.-11:00 a.m. during wound care rounds. LVN B said when she conducted rounds with NP XX, they go from patient to patient for wound care recommendations. Then the nurses have to go back and dress resident's wounds when all residents have been seen by NP XX. On [DATE] at 3:55 p.m. LVN B and C said leaving R #1's wounds open without dressings could place R #1 at risk for infection. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) Sacral/Bil/ Buttock/Coccyx Pressure ulcer date of onset [DATE] Length 8 cm Width 8 cm Depth 4 cm unstageable wound bed Red with slough Moderate amount of serous drainage odor present wound edges pink . Response to treatment Deteriorated Treatment Plan Continue . On [DATE] at 10:35 a.m., observation revealed on entering R #1's room LVN B was applying a foam dressing to R #1's Left hip wound. LVN B said she had to dress the Coccyx wound dressing. Surveyor requested wound care measurements on the right buttock/coccyx wound. LVN B said the wound was staged at 4 and that she was not a wound care nurse and had no formal training but would do the best she could do. LVN B cleansed the Right buttock/coccyx wound with wound cleanser and measured the wound L-7.0 cm x W-4.0 cm x D-4 cm, tunneling at 12:00 was at 5 cm. Surveyor observed wound was 60% yellow gray colored slough tissue with a foul odor. LVN B doffed dirty gloves after measuring wound coughed into left hand, donned a clean pair of gloves and applied foam dressing to right buttock/coccyx wound. LVN B did not wash her hands between glove changes. On [DATE] at 12:40 p.m., Surveyor requested copies of written MD orders. DON said they were waiting for order clarification on NP XX's orders. On [DATE] at 12:55 p.m., interview with LVN B revealed she did not know if wound care orders were verified by the attending Physician or NP XX. LVN B said she had not been given direction form the ADON or the DON if wound care orders are accepted from NP XX. LVN B said she has never been trained on wound staging. LVN B said if she did not wash hands in between glove changes when performing would care that could place the resident at risk for infection. LVN B said by leaving R #1's wound open without dressings could place the resident at risk of infection. On [DATE] at 1:15 p.m., interview with LVN A revealed she had training in wound care last year in 2016 but was never taught how to measure wounds. LVN A said wound orders are initially given from attending Physician, then the Physician refers NP XX for consultation, then NP XX changes the orders accordingly. The nurse that conducts rounds with NP XX obtains the verbal orders from NP XX and places the orders in the computer. LVN A said the consequences of leaving wounds open to air would be infection. On [DATE] at 2:05 p.m., interview with the DON said leaving wounds open to air without a dressing would place the resident at risk for infection. The DON said she would expect the nurse to provide the wound care when the order is received by the Physician. On [DATE] at 10:00 a.m., interview with NP XX said she had seen R #1 prior to admission to the facility and he only had two small reddened areas, last time she came to the facility to see R #1 he had 14 wounds. NP XX said the facility never had adequate supplies, and did not implement the wound orders or recommendations. NP XX recommended the facility obtain an air mattress for R #1 because of his high risk of skin breakdown and from week to week he developed more wounds. NP XX said R #1 developed pressure ulcers between his knees when the nurses could have just used a pillow between his knees to prevent the wounds. NP XX said she was horrified and that most of R #1's wounds were avoidable. NP XX said R #1's hand wounds looked as if they were caused by the resident was positioned on top of his hand resulting in a pressure ulcer. NP XX said she received a call on [DATE], from the facility for the first time since the wound care nurse left on [DATE] to clarify orders. NP XX said she makes wound care prevention and recommendations to the facility and does not provide wound care unless it is for debridement. NP XX said that when the facility had a wound care nurse he would always call and clarify orders. NP XX said when she makes recommendations for wound care, the next visit she finds her recommendations were never followed. NP XX said she was not surprised this surveyor found R #1 with no dressings applied to his open wounds. On [DATE] R #1's wound care observation beginning at 11:45 a.m. and resumed at 5:35 p.m., revealed R #1 had a total of 39 wounds treated and measured by LVN D and DON. On [DATE] at 11:00 a.m. interview with MD PP revealed R #1's wounds will not heal now, MD PP said a wound VAC could help. MD PP said R #1 was terminal and was placed on Hospice this week. MD PP said in regards to R #1's wound care he would expect the nurses to follow physician's orders [REDACTED]. Interview with the DON on [DATE] at 3:09 p.m. revealed after she thoroughly assessed R #1's skin from head to toe on [DATE], she found that he had 39 separate pressure ulcers throughout his body. The DON acknowledged that some of the ulcers had not been identified or documented prior to the skin sweep. R #2: R #2's Face Sheet dated [DATE] documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted to the facility on [DATE], and discharged back to the hospital on [DATE]. R #2's [DIAGNOSES REDACTED]. R #2's Admission Nursing Admission Data Collection dated [DATE] documented Note all skin issues: Stage 2 to coccyx/buttock. Resident alert and oriented to person, time, and place, cognition intact. Oxygen at 2 lpm (liters per minute) via ns (nasal cannula) continuous. Foley catheter in place for [MEDICAL CONDITION] with lower urinary tract symptoms. Contractures present. Skin Issues: Coccyx Stage 2- open area with pink/red wound bed, no drainage noted (there were no measurements documented in the measurement section of this assessment). R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 15- at risk. R #2's Care Plan dated [DATE] documented: -(R #2) has venous stasis ulcer to right lower leg medial aspect. Also has pressure ulcer to right 4 and 5 digit he was admitted with .Interventions: Notify MD (Medical Doctor) of changes in wound or emerging wounds. Observe wound healing. Provide wound care per order. Skin checks weekly per facility protocol, document findings. Turn and reposition frequently to decrease pressure. -(R #2) has an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and limited mobility. Interventions: Encourage active participation in tasks. Provide cuing with tasks as needed. Bathing/Showering: the resident is totally dependent on ,[DATE] staff to provide bath/shower. Bed Mobility: the resident requires extensive assistance by ,[DATE] staff to turn and reposition in bed. Dressing: the resident requires extensive assistance by ,[DATE] staff for dressing. Personal Hygiene: the resident requires extensive assistance by ,[DATE] staff for personal hygiene and oral care Transfer: the resident is totally dependent on 2 staff for transferring. Encourage the resident to use bell to call for assistance. -(R #2) has impaired cognitive function . -(R #2) has DTI to left 4, 5, and 6th digit and surgical wound to abdomen he was admitted with. Interventions: Assess/record/observe wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Complete full body check weekly and document. Inform resident/family of new areas of skin breakdown. Low air loss mattress. Observe/document/report prn any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage. Reposition frequently. R #2's Skin-Head to Toe Skin Check dated [DATE] documented: -Left foot 4th digit: DTI 0.3 cm X 0.8 cm. -Left foot 5th digit: DTI 0.4 X 0.4 cm. -Left foot 3rd digit: DTI 1.5 cm X 2.0 cm. -Left Heel: DTI 2.5 cm X 4.5 cm . --R #2's Bilateral Buttocks/Coccyx/Sacrum ulcer was not documented on this record. R #2's Skin-Weekly Pressure Ulcer Record dated [DATE] Left Heel: Date of Onset: [DATE], existing pressure ulcer, admitted with pressure ulcer. 1.5 cm X 2.0 cm DTI, area resembles scab, no signs/symptoms (s/s) of infection. Wound bed appearance yellow, odor not present, wound edges normal for skin, area with yellow scab. Description of resident's response to current treatment: no change. --The documentation on this assessment of the description of the wound provided did not meet the definition of a DTI. R #2's Skin- Weekly Pressure Ulcer Record dated [DATE] documented Date of Onset: [DATE], existing pressure ulcer, admitted with. Location: Bilateral Buttock/Coccyx/Sacrum: Unstageable 20.0 cm X 12.0 cm. large area with partial red beefy tissue, partial yellow moist tissue. Wound bed description: other, Drainage: small serosanguineous, no odor present, no s/s of infection, wound edges: pink without maceration, surrounding skin: normal for skin. Response to Treatment: no change. R #2's Wound Care Specialist Consultation Note dated [DATE] documented: -Left Heel: Unstageable Pressure Ulcer/DTI 1.5 cm X 2.0 cm, wound bed 100% dark scab, periwound dry, scaly, sluggish, blanchable redness, boggy. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, cover with foam dressing every other day. -Bilateral Buttocks/Sacrum/Coccyx Unstageable Pressure Injury 20 cm X 12 cm X unknown depth, 75% moist necrotic tissue, 25% scattered granulation, periwound denuded, mild odor, moderate drainage. Treatment: cleanse with vashe (intended for use in cleansing, irrigating, moistening and [MEDICATION NAME] acute and chronic wounds) wound cleanser (blue bottle), pat dry with gauze, apply Triad cream, place ABD to glut fold . -Left 3rd Toe Suspected DTI (SDTI) 0.4 cm X 0.4 cm dark maroon discoloration, no redness, no drainage. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave open to air (OTA) QOD (every other day). -Left 4th Toe SDTI 0.3 cm X 0.4 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. - Left 5th Toe SDTI 0.3 cm X 0.8 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. --The facility's description of R #2's sacral ulcer on the Weekly Pressure Ulcer Record dated [DATE] did not include necrotic or black tissue. The description of the facility's measurements of the toes on the Weekly Pressure Ulcer Record dated [DATE] were significantly different than that of the NP XX's measurements. R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 10- High risk. R #2's Admission MDS dated [DATE] documented R #2 entered from acute hospital and had a BIMS score of 2 (severely impaired cognitive skills). R #2 required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. R #2 had an indwelling catheter and was always incontinent of bowel. R #2 was 73 inches tall, 208 pounds and had a feeding tube. R #2 was assessed to be at risk of developing pressure ulcers; R #2 had one Stage 3 pressure ulcer that was present upon admission/entry or reentry, one unstageable pressure ulcer present upon admission/entry or reentry, and four unstageable pressure ulcers with suspected deep tissue injury present upon admission/entry or reentry. The Stage 3 or unstageable pressure ulcer with the largest surface area measured 1.0 X 0.5 X 0.2 cm. The most severe type of tissue present in any pressure ulcer bed is slough. Skin and ulcer treatments: Pressure ulcer care, application of nonsurgical dressings, and applications of ointments/medications. R #2 w(TRUNCATED)

Based on observation, interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, for two (R #1 and R #2) of four residents with pressure ulcers/wounds reviewed for physician consultation issues, in that: -The facility did not consult with the Physician when R #1 and R #2 had a change of wound status. -The facility did not consult with R #2's Wound Care Specialist to clarify illegible orders, or when R #2 was transferred to the hospital. -The facility did not consult R #2's physician for care of R #2's abdominal incision with staples that had been in place for over a month. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This failure could place four residents with surgical incisions and 13 residents with pressure ulcers at risk for worsening of condition. The findings included: Interview with the Director of Nurses (DON) on entrance conference on [DATE] at 2:15 p.m. revealed the facility had not had a Treatment Nurse since [DATE]. The DON mentioned she was made aware of assessment and documentation issues regarding wounds/pressure ulcers while the facility was last revisited by a different surveyor approximately ,[DATE] weeks ago. The DON said she had been trying to assess every resident's skin from head to toe since then but had not completed 100%. When asked for a current pressure ulcer log, the DON stated she did not have a current log but was working on one. R #1: R #1's Admission Record dated [DATE] revealed R #1 was a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. of onset for both left and right hip blisters was [DATE]). R #1's Braden Scale dated [DATE] revealed R #1 risk for Pressure Ulcers was at 9=high risk. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (admission) revealed R #1 had R (Right) Lateral Heel 5 CM Size Purplish Colored Intact Blister .R Lateral Back 5 CM Size Redden Area. R #1's History and Physical dated [DATE] revealed R #1 had no Decubitus Ulcers. R #1's admission MDS dated [DATE] revealed R #1 had severely impaired vision, R #1 did not have speech, rarely/never understood by others and rarely/never understood others. R #1 Cognitive skills for daily decision making and vision was severely impaired. R #1 was totally dependent with bed mobility, bathing and dressing requiring the assistance of two people. R #1 was assessed as having an indwelling urinary catheter and was frequently incontinent of bowel. R #1 was assessed as having a Feeding Tube and received 51% or more calories and 501 cc/day or more fluid intake through feeding tube. R #1 was assessed at risk for Pressure Ulcers and had two Deep Tissue Injuries present on admission. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had left heel has purple blister intact. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had two blood blisters to right and left heel. R #1 had not been sent out to the hospital after [DATE]. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] revealed R #1 had 2 blood blisters R&L (Left) heel. R #1's Skin-Head to Toe Skin Checks assessments and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 Was assessed as having a new pressure ulcer the description was Excoriation right buttock, DTI (Deep Tissue Injury) Lt. buttock. BI (bilateral) heels blood blisters. BI hip blanchable redness .Right buttock Length 1.1 cm Width 0.7 excoriation .Left buttock Length 4.5 cm Width 1.5 cm Suspected Deep Tissue Injury .LT hip blanchable redness .RT hip blanchable redness .Specialty Interventions Air Mattress . The Skin Weekly Pressure Ulcer Record provided definitions of the stages of pressure ulcers that included: -Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure ulcer and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3: Fill thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or broom) and/or eschar (tan, brown or black) in the wound bed. R #1's NP XX Initial Consultation dated [DATE] revealed R #1 was assessed as having the following wounds and treatment recommendations: left heel unstageable heel L-2 cm x W-1 cm the wound bed was dark purple discoloration, unstageable. Right elbow fluid filled blister L-2.1 cm x L-1.5 cm stage 2 pressure ulcer Rt. Heel L-1cm x 1 cm 100% discoloration Unstageable. Right Ear had non blanchable redness Stage 1, Anterior neck L-0.7 cm x W-1 cm x D- 0.1 cm, Right buttock pressure ulcer L-5 cm x 6 cm x unknown unstageable wound bed with dark purple/black discoloration. Treatment recommendation for heel wounds was to cleanse with NS pat dry with gauze apply Sure Prep leave OTA. Recommended float heels on pillow. treatment for [REDACTED]. Right ear recommendation was to monitor for proper placement of N/C every shift. treatment for [REDACTED]. R #1's Care Plan dated [DATE] revealed (R #1) has unstageable pressure ulcer to right buttock or potential for pressure ulcer development r/t Immobility XXX[DATE] Consult with Regional Wound Care to evaluate and treat .Administer treatments as ordered and observe for effectiveness . NP XX followed up on [DATE], [DATE], and [DATE] and assessed R #1's wounds and provided recommendations each visit. (The assessments and recommendations were not legible.) R #1's Skin-Head to Toe Skin Checks assessment and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 was assessed as having a neck pressure ulcer Length 0.7 cm Width 1 cm Depth 0.1 red wound bed Stage III .Right heel pressure ulcer Length 1 cm Width 1 cm Stage I red DTI .Right elbow Pressure ulcer Length 2.5 cm Width 1.5 cm Stage II fluid filled blister .Left heel Pressure Ulcer Length 2 cm Width 1 cm Unstageable DTI .R Buttock Pressure ulcer Length 5 cm Width 6 cm Stage I reddened DTI .R ear Pressure ulcer stage I Length 1 cm Width 1 cm Suspected Deep Tissue Injury .R ankle Pressure ulcer Unstageable .Specialty Interventions Positioning Device .Wedge Cushions . R #1's Care Plan dated [DATE] revealed (R #1) has Potential/ Actual Skin Issues related to: Pressure Ulcer related to history of ulcers, Pressure Ulcer related to Mobility .(R #1) will remain without signs of breakdown by next review .(R #1) wound will show signs of healing with area decreasing in overall size and depth by next review . Notify MD in changes in wound or emerging wounds .observe wound healing . place on air loss mattress .provide would care/preventative skin care per order .Skin checks weekly per facility protocol, document findings . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip, DTI L heel .Right Trochanter (hip) Blister Length 10.5 cm Width 8.5 cm Stage N/A .Left Trochanter (hip) Blister Length 8.5 cm Width 5 cm Stage N/A .Right buttock excoriation .Left buttock excoriation .Left heel Length 1 cm Width 1 cm Suspected Deep Tissue Injury .Specialty Interventions Positioning devices pillows other interventions turn frequently . Left Trochanter was described as having red wound bed, small amount of serosanguineous drainage, blister getting bigger and wound edges Dark Red/Purple . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Right ear pressure ulcer Stage II .Left ear Pressure Ulcer Stage I .Right buttock Suspected Deep Tissue Injury DTI . Right heel pressure ulcer .Left heel pressure ulcer .Right Knee #2 Length 1.0 cm Width 1.5 cm Depth 0.1 cm Stage II open blister . red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Right Knee #1 Length 3.0 cm Width 2.5 cm Depth 0.1 cm Stage II open blister .red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Knee Length 3.0 cm Width 3.5 cm Depth 0.1 cm Stage II open blister . red wound bed, .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Hip Pressure Ulcer Unstageable .Right Hip Unstageable R #1's Skin-Head to Toe Skin Checks dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip R/L medial knees .see noted measurements [DATE] R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Non-Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having intact blister to left flank back .Length 6.2 cm Width 3 cm .Specialty Interventions .Wedge Cushion . R #1's Skin-Head to Toe Skin Checks dated [DATE] Existing blood blister to left heel, DTI's, continues with ruptured blisters to L/R knee .Coccyx Pressure Ulcer Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III . Right Trochanter (hip) Pressure Ulcer Length 3.6 cm Width 2.2 cm Unstageable .Left Trochanter (hip) Pressure Ulcer Length 9.4 cm Width 6.3 cm Unstageable .Left ear Pressure Ulcer Length 1.2 cm Width 1.2 cm Depth 0.1 cm Stage II .Left heel Length 1.3 cm Width 1.2 cm Healing Blood Blister .Left flank Length 10.2 cm Width 2.3 cm .Right Medial Knee Blister Length 2.5 cm Width 2.0 cm .Left Medial Knee Pressure Pressure Ulcer Length 2.9 cm Width 2.2 cm Suspected deep tissue injury .Right Calcaneous Pressure Ulcer Length 0.9 cm width 0.8 cm Suspected deep tissue injury .LT Lat. Lower Extremity. Pressure Ulcer Length 3.4 cm Width 2.0 cm .Ruptured blister to right medial heel dry, healing, and intact, left and right medial blisters with beefy wound bed, minimal serosanguinous drainage, L/R unstageable hip ulcers with 100% eschar to wound bed, dried blister to left flank intact and scab-like, stage 3 to coccyx with boggy slough, foul odor . R #1's Skin Head to Toe Skin Check and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] (late entry) revealed R #1 was assessed as having Coccyx Pressure Ulcer date of onset [DATE] Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III .wound bed yellow scant amount of serous drainage .Odor Not Present Specialty Interventions LAL Bed .Positioning devices Pillows .Notes to apply santyl oint to wound bed and cover with adhesive foam dressing daily until resolved .Left Medial Lateral Foot date of onset [DATE] Length 2.0 cm Width 0.9 cm Depth 0 cm Stage I Nonblanchable .wound bed red Specialty Interventions Bed LAL positioning pillows .Left Calcaneous date of onset [DATE] Length 2.2 cm Width 1.2 cm Depth 0 cm Stage I Nonblanchable Redden area wound bed red Specialty Interventions Bed LAL positioning devices Keen, pillows .Right Lateral Foot Date of onset [DATE] Length 1.4 cm Width 1.6 cm Depth 0 cm Suspected Deep Tissue Injury Redden Skin Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows .Ordered skin prep area Q shift until resolved .Right Medial Foot Date of Onset [DATE] Length 3.5 cm Width 2.5 cm Depth 0 cm Stage I .Wound Bed Red .ordered to off load feet and monitor for any changes Q shift until resolved .Right Calcaneous date of onset [DATE] Length 1.2 cm Width 0.9 cm Depth 0 cm Stage I reddened Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows . Skin-Weekly Non-Pressure Condition Record .Right Anterior Foot date of onset [DATE] bruising Length 1.3 cm Width 1.0 cm Depth 0 cm Wound Bed Red . R #1's Skin-Head to Toe Skin Checks dated and Skin-Weekly Pressure Condition Record both dated [DATE] assessment revealed blisters L/R hip RL medial knees, Stage III R buttock . Right Trochanter (hip) Blister Length 85 cm Width 3.5 cm Depth 0 cm .Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 .Right buttock Pressure Ulcer Length 8 cm Width 7 cm Depth 3 cm Stage III .L medial knee Blister Length 2.5 cm Width 2.5 cm Depth 0 cm .R medial knee Blister Length 3 cm Width 2 cm Depth 0 cm . Ruptured blisters to L/R medial knees dry and healing, L/R unstageable blisters to hips that appear as ulcers now (with) 100% eschar to wound bed, stage III to right buttock (with) boggy slough, foul odor .Skin-Weekly Pressure Condition Record Right Buttock wound date of onset [DATE] Length 8 cm Width 7 cm Depth 3 cm Stage III .Drainage Moderate amount Color Purulent Wound Edges White/Gray/Pallor .Response to treatment Deteriorated area getting bigger Treatment plan Continue . Skin-Weekly Non- Pressure Condition Record L medial knee blister date of Length 2.5 cm Width 2.5 cm Depth 0 cm ruptured blister that is drying out .R medial knee date of onset [DATE] Length 3 cm Width 2 cm Depth 0 cm ruptured blister that is drying out . L medial knee Blister date of onset [DATE] Length 2.5 cm Width 2.5 cm Depth 0 cm . ruptured blister that is drying out .Right Trochanter (hip) blister date of onset [DATE] Length 5 cm Width 3.5 cm Depth 0 cm unstageable Wound bed Black Eschar Drainage small amount Color serosanguinous Wound edges Black Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 unstageable Wound bed Black Drainage scant amount Color serosanguinous Wound edges Black Response to Treatment No Change Treatment Plan Continue. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) revealed L/R hip R/L medial knees, pressure R buttock, multiple wounds .Left hand wound (palm) .Left hand (back) Blister .Left shoulder (rear) pressure ulcer Length 1.6 cm Width 2.5 cm Depth 0 cm. Unstageable . Rt medi lower leg B Blister Length 2.0 cm Width 1.5 cm .Rt medi lower leg A blister Length 3.0 cm Width 2.0 cm .Left medial knee pressure ulcer Length 1.0 cm Width 1.3 cm Depth 0.1 cm Stage II . Lt medial upper back Pressure ulcer Length 1.5 cm Width 1.0 cm Unstageable .Left back Pressure ulcer Length 2.0 cm Width 2.5 cm Unstageable .Left lateral ankle Pressure Ulcer Length 2.5 cm Width 0.5 cm Depth 0.1 cm Stage II .Left Hip Pressure Ulcer Length 8.0 cm Width 6.5 cm Unstageable .Right hip Pressure Ulcer .Stage N/A .Rt Knee pressure Ulcer Stage N/A .Skin-Weekly Non- Pressure Condition Record dated [DATE] . date of onset [DATE] L. ring finger Blister Length 2.3 cm Width 2.3 cm Depth 0 cm. fluid filled blister . L hand thumb Blister Length 7 cm Width 1 cm Depth 0 cm fluid filled blister .Left hand pinky finger Blister Length 1.7 cm Width 2 cm Depth 0cm Fluid filled blister .Left hand palm blister Length 8.5 cm Width 2.3 cm Depth 0 cm Fluid filled blister .Left hand (back) Blister Length 8 cm Width 5 cm Depth 0 cm Fluid filled blister with dark purple with clear fluid .L hand middle finger blister Length 3 cm Width 2.5 cm Depth 0 cm Fluid filled blister .Left hand index finger Length 7 cm Width .5 cm Depth 0 cm Clear fluid filled blister . R #1's Care Plan dated [DATE] revealed (R #1) is on (Hospice for dysphagia following cerebral infarction .do not initial CPR . On [DATE] at 2:18 p.m., observation accompanied by LVN C revealed R #1 was lying in bed on his back with his left hand swollen with draining blisters without a dressing. Left and right hip wounds with black eschar, left lateral ankle wound, left lateral lower leg wound, Right and left medial knee wounds, left posterior shoulder wound, left and right ear wounds, left medial tibial wound, right medial heel wound, Left coccyx wound and left buttock wound open without dressings. R #1 had an adult brief on and his linens were soiled with drainage from open wounds. LVN C said NP XX was in the facility today and removed R #1's dressings, at approximately 11:00 a.m. R #1's Urinary Catheter was not anchored. On [DATE] at 3:15 p.m., observation revealed LVN B and C were in R #1's room providing wound care. LVN B had gloves on, applied skin prep to Left malleolus and left lateral leg wounds, then applied a foam dressing, doffed gloves picked up foam dressing with her bare hands cut dressing to fit wound then placed foam dressing on the outer dressing packaging. LVN B donned clean gloves. LVN B did not wash hands in between glove changes. LVN B said NP XX had removed R #1's dressings at approximately 10:30 a.m.-11:00 a.m. during wound care rounds. LVN B said when she conducted rounds with NP XX, they go from patient to patient for wound care recommendations. Then the nurses have to go back and dress resident's wounds when all residents have been seen by NP XX. On [DATE] at 3:55 p.m. LVN B and C said leaving R #1's wounds open without dressings could place R #1 at risk for infection. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) Sacral/Bil/ Buttock/Coccyx Pressure ulcer date of onset [DATE] Length 8 cm Width 8 cm Depth 4 cm unstageable wound bed Red with slough Moderate amount of serous drainage odor present wound edges pink . Response to treatment Deteriorated Treatment Plan Continue . On [DATE] at 10:35 a.m., observation revealed on entering R #1's room LVN B was applying a foam dressing to R #1's Left hip wound. LVN B said she had to dress the Coccyx wound dressing. Surveyor requested wound care measurements on the right buttock/coccyx wound. LVN B said the wound was staged at 4 and that she was not a wound care nurse and had no formal training but would do the best she could do. LVN B cleansed the Right buttock/coccyx wound with wound cleanser and measured the wound L-7.0 cm x W-4.0 cm x D-4 cm, tunneling at 12:00 was at 5 cm. Surveyor observed wound was 60% yellow gray colored slough tissue with a foul odor. LVN B doffed dirty gloves after measuring wound coughed into left hand, donned a clean pair of gloves and applied foam dressing to right buttock/coccyx wound. LVN B did not wash her hands between glove changes. R #1's Urinary Catheter was not anchored. During would care CNA P lifted R #1's urinary catheter above R #1's bladder and surveyor observed urine back flow towards insertion site. On [DATE] at 12:40 p.m., Surveyor requested copies of written MD orders. DON said they were waiting for order clarification on NP XX's orders. On [DATE] at 12:55 p.m., interview with LVN B revealed she did not know if wound care orders were verified by the attending Physician or NP XX. LVN B said she had not been given direction form the ADON or the DON if wound care orders are accepted from NP XX. LVN B said she has never been trained on wound staging. LVN B said if she did not wash hands in between glove changes when performing would care that could place the resident at risk for infection. LVN B said by leaving R #1's wound open without dressings could place the resident at risk of infection. LVN B said if a resident's F/C was not anchored it could pull and cause injury. The DON said if a resident has a Urinary catheter it should not touch the floor and always be anchored and held below the bladder to prevent infection, dislodgement, trauma and other complications. On [DATE] at 1:15 p.m., interview with LVN A revealed she had training in wound care last year in 2016 but was never taught how to measure wounds. LVN A said wound orders are initially given from attending Physician, then the Physician refers NP XX for consultation, then NP XX changes the orders accordingly. The nurse that conducts rounds with NP XX obtains the verbal orders from NP XX and places the orders in the computer. LVN A said the consequences of leaving wounds open to air would be infection. On [DATE] at 2:05 p.m., interview with the DON said leaving wounds open to air without a dressing would place the resident at risk for infection. The DON said she would expect the nurse to provide the wound care when the order is received by the Physician. On [DATE] at 10:00 a.m., interview with NP XX said she had seen R #1 prior to admission to the facility and he only had two small reddened areas, last time she came to the facility to see R #1 he had 14 wounds. NP XX said the facility never had adequate supplies, and did not implement the wound orders or recommendations. NP XX recommended the facility obtain an air mattress for R #1 because of his high risk of skin breakdown and from week to week he developed more wounds. NP XX said R #1 developed pressure ulcers between his knees when the nurses could have just used a pillow between his knees to prevent the wounds. NP XX said she was horrified and that most of R #1's wounds were avoidable. NP XX said R #1's hand wounds looked as if they were caused by the resident was positioned on top of his hand resulting in a pressure ulcer. NP XX said she received a call on [DATE], from the facility for the first time since the wound care nurse left on [DATE] to clarify orders. NP XX said she makes wound care prevention and recommendations to the facility and does not provide wound care unless it is for debridement. NP XX said that when the facility had a wound care nurse he would always call and clarify orders. NP XX said when she makes recommendations for wound care, the next visit she finds her recommendations were never followed. NP XX said she was not surprised this surveyor found R #1 with no dressings applied to his open wounds. On [DATE] R #1's wound care observation beginning at 11:45 a.m. and resumed at 5:35 p.m., revealed R #1 had a total of 39 wounds treated and measured by LVN D and DON. On [DATE] at 11:00 a.m. interview with MD PP revealed R #1's wounds will not heal, MD PP said a wound VAC could help. MD PP said R #1 was terminal and was placed on Hospice this week. MD PP said in regards to R #1's wound care he would expect the nurses to follow physician's orders [REDACTED]. Interview with the DON on [DATE] at 3:09 p.m. revealed after she thoroughly assessed R #1's skin from head to toe on [DATE], she found that he had 39 separate pressure ulcers throughout his body. The DON acknowledged that some of the ulcers had not been identified or documented prior to the skin sweep. R #2: R #2's Face Sheet dated [DATE] documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted to the facility on [DATE], and discharged back to the hospital on [DATE]. R #2's [DIAGNOSES REDACTED]. R #2's Admission Nursing Admission Data Collection dated [DATE] documented Note all skin issues: Stage 2 to coccyx/buttock. Resident alert and oriented to person, time, and place, cognition intact. Oxygen at 2 lpm (liters per minute) via ns (nasal cannula) continuous. Foley catheter in place for [MEDICAL CONDITION] with lower urinary tract symptoms. Contractures present. Skin Issues: Coccyx Stage 2- open area with pink/red wound bed, no drainage noted (there were no measurements documented in the measurement section of this assessment). R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 15- at risk. R #2's Care Plan dated [DATE] documented: -(R #2) has venous stasis ulcer to right lower leg medial aspect. Also has pressure ulcer to right 4 and 5 digit he was admitted with .Interventions: Notify MD (Medical Doctor) of changes in wound or emerging wounds. Observe wound healing. Provide wound care per order. Skin checks weekly per facility protocol, document findings. Turn and reposition frequently to decrease pressure. -(R #2) has an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and limited mobility. Interventions: Encourage active participation in tasks. Provide cuing with tasks as needed. Bathing/Showering: the resident is totally dependent on ,[DATE] staff to provide bath/shower. Bed Mobility: the resident requires extensive assistance by ,[DATE] staff to turn and reposition in bed. Dressing: the resident requires extensive assistance by ,[DATE] staff for dressing. Personal Hygiene: the resident requires extensive assistance by ,[DATE] staff for personal hygiene and oral care Transfer: the resident is totally dependent on 2 staff for transferring. Encourage the resident to use bell to call for assistance. -(R #2) has impaired cognitive function . -(R #2) has DTI to left 4, 5, and 6th digit and surgical wound to abdomen he was admitted with. Interventions: Assess/record/observe wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Complete full body check weekly and document. Inform resident/family of new areas of skin breakdown. Low air loss mattress. Observe/document/report prn any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage. Reposition frequently. R #2's Skin-Head to Toe Skin Check dated [DATE] documented: -Left foot 4th digit: DTI 0.3 cm X 0.8 cm. -Left foot 5th digit: DTI 0.4 X 0.4 cm. -Left foot 3rd digit: DTI 1.5 cm X 2.0 cm. -Left Heel: DTI 2.5 cm X 4.5 cm . --R #2's Bilateral Buttocks/Coccyx/Sacrum ulcer was not documented on this record. R #2's Skin-Weekly Pressure Ulcer Record dated [DATE] Left Heel: Date of Onset: [DATE], existing pressure ulcer, admitted with pressure ulcer. 1.5 cm X 2.0 cm DTI, area resembles scab, no signs/symptoms (s/s) of infection. Wound bed appearance yellow, odor not present, wound edges normal for skin, area with yellow scab. Description of resident's response to current treatment: no change. --The documentation on this assessment of the description of the wound provided did not meet the definition of a DTI. R #2's Skin- Weekly Pressure Ulcer Record dated [DATE] documented Date of Onset: [DATE], existing pressure ulcer, admitted with. Location: Bilateral Buttock/Coccyx/Sacrum: Unstageable 20.0 cm X 12.0 cm. large area with partial red beefy tissue, partial yellow moist tissue. Wound bed description: other, Drainage: small serosanguineous, no odor present, no s/s of infection, wound edges: pink without maceration, surrounding skin: normal for skin. Response to Treatment: no change. R #2's Wound Care Specialist Consultation Note dated [DATE] documented: -Left Heel: Unstageable Pressure Ulcer/DTI 1.5 cm X 2.0 cm, wound bed 100% dark scab, periwound dry, scaly, sluggish, blanchable redness, boggy. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, cover with foam dressing every other day. -Bilateral Buttocks/Sacrum/Coccyx Unstageable Pressure Injury 20 cm X 12 cm X unknown depth, 75% moist necrotic tissue, 25% scattered granulation, periwound denuded, mild odor, moderate drainage. Treatment: cleanse with vashe (intended for use in cleansing, irrigating, moistening and [MEDICATION NAME] acute and chronic wounds) wound cleanser (blue bottle), pat dry with gauze, apply Triad cream, place ABD to glut fold . -Left 3rd Toe Suspected DTI (SDTI) 0.4 cm X 0.4 cm dark maroon discoloration, no redness, no drainage. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave open to air (OTA) QOD (every other day). -Left 4th Toe SDTI 0.3 cm X 0.4 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. - Left 5th Toe SDTI 0.3 cm X 0.8 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. --The facility's description of R #2's sacral ulcer on the Weekly Pressure Ulcer Record dated [DATE] did not include necrotic or black tissue. The description of the facility's measurements of the toes on the Weekly Pressure Ulcer Record dated [DATE] were significantly different than that of the NP XX's measurements. R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 10- High risk. R #2's Admission MDS dated [DATE] documented R #2 entered from acute hospital and had a BIMS score of 2 (severely impaired cognitive skills). R #2 required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. R #2 had an indwelling catheter and was always incontinent of bowel. R #2 was 73 inches tall, 208 pounds and had a feeding tube. R #2 was assessed to be at risk of developing pressure ulcers; R #2 had one Stage 3 pressure ulcer that was present upon admission/entry or reentry, one unstageable pressure ulcer present upon admission/entry or reentry, and four unstageable pressure ulcers with suspected deep tissue injury present upon admission/entry or reentry. The Stage 3 or unstageable pressure ulcer with the largest surface area measured 1.0 X 0.5 X 0.2 cm. The most severe type of tissue present in any pressure ulcer bed is slough. Skin and ulcer treatments: Pressure ulcer care, application of nonsurgical dressings, and applications of ointments/medications. R #2 was on oxygen therapy while not a resident and while a resident. R #2's Wound Care Specialist Consultation Note dated [DATE] documented: -Left Heel: Unstageable Pressure Ulcer/DTI 1.5 cm X 2.0 cm, wound bed 100% dark scab, periwound dry, scaly, sluggish, blanchable redness, boggy. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, cover with foam dressing every other day. -Bilateral Buttocks/Sacrum/Coccyx Unstageable Pressure Injury 14 cm X 15 cm X unknown depth, 90% moist necrotic tissue, 10% scattered granulation, periwound mild foul odor, minimal bleeding. Treatment: cleanse with vashe wound cleanser, pat dry with gauze, apply Triad cream, leave OTA, place ABD to glut fold .air mattress, no diapers in bed, 100% off back side, turn side to side. -Left 3rd Toe Suspected DTI (SDTI) 0.5 cm X 0.5 cm dark (TRUNCATED)

Based on record review and interview, the facility failed to ensure residents have the right to be free from neglect for two (R #1 and R #2) of two residents reviewed for abuse/neglect. -The facility failed to clarify, and implement R #1's physician's wound care orders for his pressure ulcers. R #1 entered the facility with two red open areas yet, currently acquired 39 separate ulcers throughout his body. -The facility allowed R #1's draining pressure ulcers to remain uncovered and untreated for [REDACTED]. -The facility failed to clarify, and implement R #2's physician's wound care orders for his pressure ulcers. R #2's community acquired Buttock/Sacral/Coccyx Stage 4 pressure ulcer deteriorated, after being debrided. -The facility failed to accurately describe, document measurements, and stage R #1 and R #2's pressure ulcers. -The facility's documentation of R #1 and R #2's pressure ulcers was conflicting on separate forms making it difficult to track the progress of the pressure ulcers. -The facility did not consistently identify all of R #2's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. -The facility failed to inform R #2's physician of any changes in his Buttock/Sacral/Coccyx Stage 4 pressure ulcer and the development of a new ulcer on his Left Ischial Tuberosity. R #2's Buttock/Sacral/Coccyx ulcer developed 95% necrotic tissue and foul odorous drainage. -The facility did not make attempt to receive orders for treatment of [REDACTED]. R #2 arrived to the hospital with embedded staples in place. The facility failed to ensure the licensed staff providing wound care were trained and competent in the identification, assessment, and treatment of [REDACTED]. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 13 residents with pressure ulcers and 37 residents receiving preventative skin care, four residents with surgical wounds and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers and risk for infection [MEDICAL CONDITION]. The findings included: Interview with the Director of Nurses (DON) on entrance conference on [DATE] at 2:15 p.m. revealed the facility had not had a Treatment Nurse since [DATE]. The DON mentioned she was made aware of assessment and documentation issues regarding wounds/pressure ulcers while the facility was last revisited by a different surveyor approximately ,[DATE] weeks ago. The DON said she had been trying to assess every resident's skin from head to toe since then but had not completed 100%. When asked for a current pressure ulcer log, the DON stated she did not have a current log but was working on one. R #1: R #1's Admission Record dated [DATE] revealed R #1 was a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. of onset for both left and right hip blisters was [DATE]). R #1's Braden Scale dated [DATE] revealed R #1 risk for Pressure Ulcers was at 9=high risk. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (admission) revealed R #1 had R (Right) Lateral Heel 5 CM Size Purplish Colored Intact Blister .R Lateral Back 5 CM Size Redden Area. R #1's History and Physical dated [DATE] revealed R #1 had no Decubitus Ulcers. R #1's admission MDS dated [DATE] revealed R #1 had severely impaired vision, R #1 did not have speech, rarely/never understood by others and rarely/never understood others. R #1 Cognitive skills for daily decision making and vision was severely impaired. R #1 was totally dependent with bed mobility, bathing and dressing requiring the assistance of two people. R #1 was assessed as having an indwelling urinary catheter and was frequently incontinent of bowel. R #1 was assessed as having a Feeding Tube and received 51% or more calories and 501 cc/day or more fluid intake through feeding tube. R #1 was assessed at risk for Pressure Ulcers and had two Deep Tissue Injuries present on admission. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had left heel has purple blister intact. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had two blood blisters to right and left heel. R #1 had not been sent out to the hospital after [DATE]. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] revealed R #1 had 2 blood blisters R&L (Left) heel. R #1's Skin-Head to Toe Skin Checks assessments and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 Was assessed as having a new pressure ulcer the description was Excoriation right buttock, DTI (Deep Tissue Injury) Lt. buttock. BI (bilateral) heels blood blisters. BI hip blanchable redness .Right buttock Length 1.1 cm Width 0.7 excoriation .Left buttock Length 4.5 cm Width 1.5 cm Suspected Deep Tissue Injury .LT hip blanchable redness .RT hip blanchable redness .Specialty Interventions Air Mattress . The Skin Weekly Pressure Ulcer Record provided definitions of the stages of pressure ulcers that included: -Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure ulcer and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3: Fill thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or broom) and/or eschar (tan, brown or black) in the wound bed. R #1's NP XX Initial Consultation dated [DATE] revealed R #1 was assessed as having the following wounds and treatment recommendations: left heel unstageable heel L-2 cm x W-1 cm the wound bed was dark purple discoloration, unstageable. Right elbow fluid filled blister L-2.1 cm x L-1.5 cm stage 2 pressure ulcer Rt. Heel L-1cm x 1 cm 100% discoloration Unstageable. Right Ear had non blanchable redness Stage 1, Anterior neck L-0.7 cm x W-1 cm x D- 0.1 cm, Right buttock pressure ulcer L-5 cm x 6 cm x unknown unstageable wound bed with dark purple/black discoloration. Treatment recommendation for heel wounds was to cleanse with NS pat dry with gauze apply Sure Prep leave OTA. Recommended float heels on pillow. treatment for [REDACTED]. Right ear recommendation was to monitor for proper placement of N/C every shift. treatment for [REDACTED]. R #1's Care Plan dated [DATE] revealed (R #1) has unstageable pressure ulcer to right buttock or potential for pressure ulcer development r/t Immobility XXX[DATE] Consult with Regional Wound Care to evaluate and treat .Administer treatments as ordered and observe for effectiveness . NP XX followed up on [DATE], [DATE], and [DATE] and assessed R #1's wounds and provided recommendations each visit. (The assessments and recommendations were not legible.) R #1's Skin-Head to Toe Skin Checks assessment and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 was assessed as having a neck pressure ulcer Length 0.7 cm Width 1 cm Depth 0.1 red wound bed Stage III .Right heel pressure ulcer Length 1 cm Width 1 cm Stage I red DTI .Right elbow Pressure ulcer Length 2.5 cm Width 1.5 cm Stage II fluid filled blister .Left heel Pressure Ulcer Length 2 cm Width 1 cm Unstageable DTI .R Buttock Pressure ulcer Length 5 cm Width 6 cm Stage I reddened DTI .R ear Pressure ulcer stage I Length 1 cm Width 1 cm Suspected Deep Tissue Injury .R ankle Pressure ulcer Unstageable .Specialty Interventions Positioning Device .Wedge Cushions . R #1's Care Plan dated [DATE] revealed (R #1) has Potential/ Actual Skin Issues related to: Pressure Ulcer related to history of ulcers, Pressure Ulcer related to Mobility .(R #1) will remain without signs of breakdown by next review .(R #1) wound will show signs of healing with area decreasing in overall size and depth by next review . Notify MD in changes in wound or emerging wounds .observe wound healing . place on air loss mattress .provide would care/preventative skin care per order .Skin checks weekly per facility protocol, document findings . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip, DTI L heel .Right Trochanter (hip) Blister Length 10.5 cm Width 8.5 cm Stage N/A .Left Trochanter (hip) Blister Length 8.5 cm Width 5 cm Stage N/A .Right buttock excoriation .Left buttock excoriation .Left heel Length 1 cm Width 1 cm Suspected Deep Tissue Injury .Specialty Interventions Positioning devices pillows other interventions turn frequently . Left Trochanter was described as having red wound bed, small amount of serosanguineous drainage, blister getting bigger and wound edges Dark Red/Purple . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Right ear pressure ulcer Stage II .Left ear Pressure Ulcer Stage I .Right buttock Suspected Deep Tissue Injury DTI . Right heel pressure ulcer .Left heel pressure ulcer .Right Knee #2 Length 1.0 cm Width 1.5 cm Depth 0.1 cm Stage II open blister . red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Right Knee #1 Length 3.0 cm Width 2.5 cm Depth 0.1 cm Stage II open blister .red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Knee Length 3.0 cm Width 3.5 cm Depth 0.1 cm Stage II open blister . red wound bed, .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Hip Pressure Ulcer Unstageable .Right Hip Unstageable R #1's Skin-Head to Toe Skin Checks dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip R/L medial knees .see noted measurements [DATE] R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Non-Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having intact blister to left flank back .Length 6.2 cm Width 3 cm .Specialty Interventions .Wedge Cushion . R #1's Skin-Head to Toe Skin Checks dated [DATE] Existing blood blister to left heel, DTI's, continues with ruptured blisters to L/R knee .Coccyx Pressure Ulcer Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III . Right Trochanter (hip) Pressure Ulcer Length 3.6 cm Width 2.2 cm Unstageable .Left Trochanter (hip) Pressure Ulcer Length 9.4 cm Width 6.3 cm Unstageable .Left ear Pressure Ulcer Length 1.2 cm Width 1.2 cm Depth 0.1 cm Stage II .Left heel Length 1.3 cm Width 1.2 cm Healing Blood Blister .Left flank Length 10.2 cm Width 2.3 cm .Right Medial Knee Blister Length 2.5 cm Width 2.0 cm .Left Medial Knee Pressure Pressure Ulcer Length 2.9 cm Width 2.2 cm Suspected deep tissue injury .Right Calcaneous Pressure Ulcer Length 0.9 cm width 0.8 cm Suspected deep tissue injury .LT Lat. Lower Extremity. Pressure Ulcer Length 3.4 cm Width 2.0 cm .Ruptured blister to right medial heel dry, healing, and intact, left and right medial blisters with beefy wound bed, minimal serosanguinous drainage, L/R unstageable hip ulcers with 100% eschar to wound bed, dried blister to left flank intact and scab-like, stage 3 to coccyx with boggy slough, foul odor . R #1's Skin Head to Toe Skin Check and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] (late entry) revealed R #1 was assessed as having Coccyx Pressure Ulcer date of onset [DATE] Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III .wound bed yellow scant amount of serous drainage .Odor Not Present Specialty Interventions LAL Bed .Positioning devices Pillows .Notes to apply santyl oint to wound bed and cover with adhesive foam dressing daily until resolved .Left Medial Lateral Foot date of onset [DATE] Length 2.0 cm Width 0.9 cm Depth 0 cm Stage I Nonblanchable .wound bed red Specialty Interventions Bed LAL positioning pillows .Left Calcaneous date of onset [DATE] Length 2.2 cm Width 1.2 cm Depth 0 cm Stage I Nonblanchable Redden area wound bed red Specialty Interventions Bed LAL positioning devices Keen, pillows .Right Lateral Foot Date of onset [DATE] Length 1.4 cm Width 1.6 cm Depth 0 cm Suspected Deep Tissue Injury Redden Skin Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows .Ordered skin prep area Q shift until resolved .Right Medial Foot Date of Onset [DATE] Length 3.5 cm Width 2.5 cm Depth 0 cm Stage I .Wound Bed Red .ordered to off load feet and monitor for any changes Q shift until resolved .Right Calcaneous date of onset [DATE] Length 1.2 cm Width 0.9 cm Depth 0 cm Stage I reddened Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows . Skin-Weekly Non-Pressure Condition Record .Right Anterior Foot date of onset [DATE] bruising Length 1.3 cm Width 1.0 cm Depth 0 cm Wound Bed Red . R #1's Skin-Head to Toe Skin Checks dated and Skin-Weekly Pressure Condition Record both dated [DATE] assessment revealed blisters L/R hip RL medial knees, Stage III R buttock . Right Trochanter (hip) Blister Length 85 cm Width 3.5 cm Depth 0 cm .Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 .Right buttock Pressure Ulcer Length 8 cm Width 7 cm Depth 3 cm Stage III .L medial knee Blister Length 2.5 cm Width 2.5 cm Depth 0 cm .R medial knee Blister Length 3 cm Width 2 cm Depth 0 cm . Ruptured blisters to L/R medial knees dry and healing, L/R unstageable blisters to hips that appear as ulcers now (with) 100% eschar to wound bed, stage III to right buttock (with) boggy slough, foul odor .Skin-Weekly Pressure Condition Record Right Buttock wound date of onset [DATE] Length 8 cm Width 7 cm Depth 3 cm Stage III .Drainage Moderate amount Color Purulent Wound Edges White/Gray/Pallor .Response to treatment Deteriorated area getting bigger Treatment plan Continue . Skin-Weekly Non- Pressure Condition Record L medial knee blister date of Length 2.5 cm Width 2.5 cm Depth 0 cm ruptured blister that is drying out .R medial knee date of onset [DATE] Length 3 cm Width 2 cm Depth 0 cm ruptured blister that is drying out . L medial knee Blister date of onset [DATE] Length 2.5 cm Width 2.5 cm Depth 0 cm . ruptured blister that is drying out .Right Trochanter (hip) blister date of onset [DATE] Length 5 cm Width 3.5 cm Depth 0 cm unstageable Wound bed Black Eschar Drainage small amount Color serosanguinous Wound edges Black Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 unstageable Wound bed Black Drainage scant amount Color serosanguinous Wound edges Black Response to Treatment No Change Treatment Plan Continue. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) revealed L/R hip R/L medial knees, pressure R buttock, multiple wounds .Left hand wound (palm) .Left hand (back) Blister .Left shoulder (rear) pressure ulcer Length 1.6 cm Width 2.5 cm Depth 0 cm. Unstageable . Rt medi lower leg B Blister Length 2.0 cm Width 1.5 cm .Rt medi lower leg A blister Length 3.0 cm Width 2.0 cm .Left medial knee pressure ulcer Length 1.0 cm Width 1.3 cm Depth 0.1 cm Stage II . Lt medial upper back Pressure ulcer Length 1.5 cm Width 1.0 cm Unstageable .Left back Pressure ulcer Length 2.0 cm Width 2.5 cm Unstageable .Left lateral ankle Pressure Ulcer Length 2.5 cm Width 0.5 cm Depth 0.1 cm Stage II .Left Hip Pressure Ulcer Length 8.0 cm Width 6.5 cm Unstageable .Right hip Pressure Ulcer .Stage N/A .Rt Knee pressure Ulcer Stage N/A .Skin-Weekly Non- Pressure Condition Record dated [DATE] . date of onset [DATE] L. ring finger Blister Length 2.3 cm Width 2.3 cm Depth 0 cm. fluid filled blister . L hand thumb Blister Length 7 cm Width 1 cm Depth 0 cm fluid filled blister .Left hand pinky finger Blister Length 1.7 cm Width 2 cm Depth 0cm Fluid filled blister .Left hand palm blister Length 8.5 cm Width 2.3 cm Depth 0 cm Fluid filled blister .Left hand (back) Blister Length 8 cm Width 5 cm Depth 0 cm Fluid filled blister with dark purple with clear fluid .L hand middle finger blister Length 3 cm Width 2.5 cm Depth 0 cm Fluid filled blister .Left hand index finger Length 7 cm Width .5 cm Depth 0 cm Clear fluid filled blister . R #1's Care Plan dated [DATE] revealed (R #1) is on (Hospice for dysphagia following cerebral infarction .do not initial CPR . On [DATE] at 2:18 p.m., observation accompanied by LVN C revealed R #1 was lying in bed on his back with his left hand swollen with draining blisters without a dressing. Left and right hip wounds with black eschar, left lateral ankle wound, left lateral lower leg wound, Right and left medial knee wounds, left posterior shoulder wound, left and right ear wounds, left medial tibial wound, right medial heel wound, Left coccyx wound and left buttock wound open without dressings. R #1 had an adult brief on and his linens were soiled with drainage from open wounds. LVN C said NP XX was in the facility today and removed R #1's dressings, at approximately 11:00 a.m. R #1's Urinary Catheter was not anchored. On [DATE] at 3:15 p.m., observation revealed LVN B and C were in R #1's room providing wound care. LVN B had gloves on, applied skin prep to Left malleolus and left lateral leg wounds, then applied a foam dressing, doffed gloves picked up foam dressing with her bare hands cut dressing to fit wound then placed foam dressing on the outer dressing packaging. LVN B donned clean gloves. LVN B did not wash hands in between glove changes. LVN B said NP XX had removed R #1's dressings at approximately 10:30 a.m.-11:00 a.m. during wound care rounds. LVN B said when she conducted rounds with NP XX, they go from patient to patient for wound care recommendations. Then the nurses have to go back and dress resident's wounds when all residents have been seen by NP XX. On [DATE] at 3:55 p.m. LVN B and C said leaving R #1's wounds open without dressings could place R #1 at risk for infection. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) Sacral/Bil/ Buttock/Coccyx Pressure ulcer date of onset [DATE] Length 8 cm Width 8 cm Depth 4 cm unstageable wound bed Red with slough Moderate amount of serous drainage odor present wound edges pink . Response to treatment Deteriorated Treatment Plan Continue . On [DATE] at 10:35 a.m., observation revealed on entering R #1's room LVN B was applying a foam dressing to R #1's Left hip wound. LVN B said she had to dress the Coccyx wound dressing. Surveyor requested wound care measurements on the right buttock/coccyx wound. LVN B said the wound was staged at 4 and that she was not a wound care nurse and had no formal training but would do the best she could do. LVN B cleansed the Right buttock/coccyx wound with wound cleanser and measured the wound L-7.0 cm x W-4.0 cm x D-4 cm, tunneling at 12:00 was at 5 cm. Surveyor observed wound was 60% yellow gray colored slough tissue with a foul odor. LVN B doffed dirty gloves after measuring wound coughed into left hand, donned a clean pair of gloves and applied foam dressing to right buttock/coccyx wound. LVN B did not wash her hands between glove changes. R #1's Urinary Catheter was not anchored. During would care CNA P lifted R #1's urinary catheter above R #1's bladder and surveyor observed urine back flow towards insertion site. On [DATE] at 12:40 p.m., Surveyor requested copies of written MD orders. DON said they were waiting for order clarification on NP XX's orders. On [DATE] at 12:55 p.m., interview with LVN B revealed she did not know if wound care orders were verified by the attending Physician or NP XX. LVN B said she had not been given direction form the ADON or the DON if wound care orders are accepted from NP XX. LVN B said she has never been trained on wound staging. LVN B said if she did not wash hands in between glove changes when performing would care that could place the resident at risk for infection. LVN B said by leaving R #1's wound open without dressings could place the resident at risk of infection. LVN B said if a resident's F/C was not anchored it could pull and cause injury. The DON said if a resident has a Urinary catheter it should not touch the floor and always be anchored and held below the bladder to prevent infection, dislodgement, trauma and other complications. On [DATE] at 1:15 p.m., interview with LVN A revealed she had training in wound care last year in 2016 but was never taught how to measure wounds. LVN A said wound orders are initially given from attending Physician, then the Physician refers NP XX for consultation, then NP XX changes the orders accordingly. The nurse that conducts rounds with NP XX obtains the verbal orders from NP XX and places the orders in the computer. LVN A said the consequences of leaving wounds open to air would be infection. On [DATE] at 2:05 p.m., interview with the DON said leaving wounds open to air without a dressing would place the resident at risk for infection. The DON said she would expect the nurse to provide the wound care when the order is received by the Physician. On [DATE] at 10:00 a.m., interview with NP XX said she had seen R #1 prior to admission to the facility and he only had two small reddened areas, last time she came to the facility to see R #1 he had 14 wounds. NP XX said the facility never had adequate supplies, and did not implement the wound orders or recommendations. NP XX recommended the facility obtain an air mattress for R #1 because of his high risk of skin breakdown and from week to week he developed more wounds. NP XX said R #1 developed pressure ulcers between his knees when the nurses could have just used a pillow between his knees to prevent the wounds. NP XX said she was horrified and that most of R #1's wounds were avoidable. NP XX said R #1's hand wounds looked as if they were caused by the resident was positioned on top of his hand resulting in a pressure ulcer. NP XX said she received a call on [DATE], from the facility for the first time since the wound care nurse left on [DATE] to clarify orders. NP XX said she makes wound care prevention and recommendations to the facility and does not provide wound care unless it is for debridement. NP XX said that when the facility had a wound care nurse he would always call and clarify orders. NP XX said when she makes recommendations for wound care, the next visit she finds her recommendations were never followed. NP XX said she was not surprised this surveyor found R #1 with no dressings applied to his open wounds. On [DATE] R #1's wound care observation beginning at 11:45 a.m. and resumed at 5:35 p.m., revealed R #1 had a total of 39 wounds treated and measured by LVN D and DON. On [DATE] at 11:00 a.m. interview with MD PP revealed R #1's wounds will not heal, MD PP said a wound VAC could help. MD PP said R #1 was terminal and was placed on Hospice this week. MD PP said in regards to R #1's wound care he would expect the nurses to follow physician's orders [REDACTED]. Interview with the DON on [DATE] at 3:09 p.m. revealed after she thoroughly assessed R #1's skin from head to toe on [DATE], she found that he had 39 separate pressure ulcers throughout his body. The DON acknowledged that some of the ulcers had not been identified or documented prior to the skin sweep. R #2: R #2's Face Sheet dated [DATE] documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted to the facility on [DATE], and discharged back to the hospital on [DATE]. R #2's [DIAGNOSES REDACTED]. R #2's Admission Nursing Admission Data Collection dated [DATE] documented Note all skin issues: Stage 2 to coccyx/buttock. Resident alert and oriented to person, time, and place, cognition intact. Oxygen at 2 lpm (liters per minute) via ns (nasal cannula) continuous. Foley catheter in place for [MEDICAL CONDITION] with lower urinary tract symptoms. Contractures present. Skin Issues: Coccyx Stage 2- open area with pink/red wound bed, no drainage noted (there were no measurements documented in the measurement section of this assessment). R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 15- at risk. R #2's Care Plan dated [DATE] documented: -(R #2) has venous stasis ulcer to right lower leg medial aspect. Also has pressure ulcer to right 4 and 5 digit he was admitted with .Interventions: Notify MD (Medical Doctor) of changes in wound or emerging wounds. Observe wound healing. Provide wound care per order. Skin checks weekly per facility protocol, document findings. Turn and reposition frequently to decrease pressure. -(R #2) has an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and limited mobility. Interventions: Encourage active participation in tasks. Provide cuing with tasks as needed. Bathing/Showering: the resident is totally dependent on ,[DATE] staff to provide bath/shower. Bed Mobility: the resident requires extensive assistance by ,[DATE] staff to turn and reposition in bed. Dressing: the resident requires extensive assistance by ,[DATE] staff for dressing. Personal Hygiene: the resident requires extensive assistance by ,[DATE] staff for personal hygiene and oral care Transfer: the resident is totally dependent on 2 staff for transferring. Encourage the resident to use bell to call for assistance. -(R #2) has impaired cognitive function . -(R #2) has DTI to left 4, 5, and 6th digit and surgical wound to abdomen he was admitted with. Interventions: Assess/record/observe wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Complete full body check weekly and document. Inform resident/family of new areas of skin breakdown. Low air loss mattress. Observe/document/report prn any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage. Reposition frequently. R #2's Skin-Head to Toe Skin Check dated [DATE] documented: -Left foot 4th digit: DTI 0.3 cm X 0.8 cm. -Left foot 5th digit: DTI 0.4 X 0.4 cm. -Left foot 3rd digit: DTI 1.5 cm X 2.0 cm. -Left Heel: DTI 2.5 cm X 4.5 cm . --R #2's Bilateral Buttocks/Coccyx/Sacrum ulcer was not documented on this record. R #2's Skin-Weekly Pressure Ulcer Record dated [DATE] Left Heel: Date of Onset: [DATE], existing pressure ulcer, admitted with pressure ulcer. 1.5 cm X 2.0 cm DTI, area resembles scab, no signs/symptoms (s/s) of infection. Wound bed appearance yellow, odor not present, wound edges normal for skin, area with yellow scab. Description of resident's response to current treatment: no change. --The documentation on this assessment of the description of the wound provided did not meet the definition of a DTI. R #2's Skin- Weekly Pressure Ulcer Record dated [DATE] documented Date of Onset: [DATE], existing pressure ulcer, admitted with. Location: Bilateral Buttock/Coccyx/Sacrum: Unstageable 20.0 cm X 12.0 cm. large area with partial red beefy tissue, partial yellow moist tissue. Wound bed description: other, Drainage: small serosanguineous, no odor present, no s/s of infection, wound edges: pink without maceration, surrounding skin: normal for skin. Response to Treatment: no change. R #2's Wound Care Specialist Consultation Note dated [DATE] documented: -Left Heel: Unstageable Pressure Ulcer/DTI 1.5 cm X 2.0 cm, wound bed 100% dark scab, periwound dry, scaly, sluggish, blanchable redness, boggy. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, cover with foam dressing every other day. -Bilateral Buttocks/Sacrum/Coccyx Unstageable Pressure Injury 20 cm X 12 cm X unknown depth, 75% moist necrotic tissue, 25% scattered granulation, periwound denuded, mild odor, moderate drainage. Treatment: cleanse with vashe (intended for use in cleansing, irrigating, moistening and [MEDICATION NAME] acute and chronic wounds) wound cleanser (blue bottle), pat dry with gauze, apply Triad cream, place ABD to glut fold . -Left 3rd Toe Suspected DTI (SDTI) 0.4 cm X 0.4 cm dark maroon discoloration, no redness, no drainage. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave open to air (OTA) QOD (every other day). -Left 4th Toe SDTI 0.3 cm X 0.4 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. - Left 5th Toe SDTI 0.3 cm X 0.8 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. --The facility's description of R #2's sacral ulcer on the Weekly Pressure Ulcer Record dated [DATE] did not include necrotic or black tissue. The description of the facility's measurements of the toes on the Weekly Pressure Ulcer Record dated [DATE] were significantly different than that of the NP XX's measurements. R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 10- High risk. R #2's Admission MDS dated [DATE] documented R #2 entered from acute hospital and had a BIMS score of 2 (severely impaired cognitive skills). R #2 required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. R #2 had an indwelling catheter and was always incontinent of bowel. R #2 was 73 inches tall, 208 pounds and had a feeding tube. R #2 was assessed to be at risk of developing pressure ulcers; R #2 had one Stage 3 pressure ulcer that was present upon admission/entry or reentry, one unstageable pr(TRUNCATED)

Based on interview and record review, the facility failed to implement their written policies that prohibit mistreatment, neglect, and abuse of residents, for two (R #1 and R #2) of two residents reviewed for abuse/neglect. -The facility failed to clarify, and implement R #1's physician's wound care orders for his pressure ulcers. R #1 entered the facility with two red open areas yet, currently acquired 39 separate ulcers throughout his body. -The facility allowed R #1's draining pressure ulcers to remain uncovered and untreated for [REDACTED]. -The facility failed to clarify, and implement R #2's physician's wound care orders for his pressure ulcers. R #2's community acquired Buttock/Sacral/Coccyx Stage 4 pressure ulcer deteriorated, after being debrided. -The facility failed to accurately describe, document measurements, and stage R #1 and R #2's pressure ulcers. -The facility's documentation of R #1 and R #2's pressure ulcers was conflicting on separate forms making it difficult to track the progress of the pressure ulcers. -The facility did not consistently identify all of R #2's pressure ulcers in their Skin-Weekly Pressure Ulcer Record or the Skin Head to Toe Check. -The facility failed to inform R #2's physician of any changes in his Buttock/Sacral/Coccyx Stage 4 pressure ulcer and the development of a new ulcer on his Left Ischial Tuberosity. R #2's Buttock/Sacral/Coccyx ulcer developed 95% necrotic tissue and foul odorous drainage. -The facility did not make attempt to receive orders for treatment of [REDACTED]. R #2 arrived to the hospital with embedded staples in place. The facility failed to ensure the licensed staff providing wound care were trained and competent in the identification, assessment, and treatment of [REDACTED]. The above failures resulted in an Immediate Jeopardy (IJ) situation on 09/23/17. While the IJ was removed on 09/27/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 13 residents with pressure ulcers, 37 residents receiving preventative skin care, four residents with surgical wounds and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers and risk of infection [MEDICAL CONDITION]. The findings included: The facility's Abuse and Neglect Prohibition Policy and Procedure dated August 2017 documented Each resident has the right to be free from abuse, neglect, mistreatment .to help ensure a resident's right to a safe and healthy environment. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Injuries of an unknown origin may occur as a result of neglect The facility's Change in Resident Condition Policy and Procedure dated 02/2017 documented The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident;s condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. Guidelines: 1. For life-threatening events, call 911 if initial assessment indicates that such action is necessary. 2. Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention: a significant change in the resident's attending physical, mental or psychological status in either life threatening conditions or clinical complications; or a need to alter treatment significantly . 4. The SBAR Communication Form and the Progress Note are used to: a. Assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physician, and c. Provide clear comprehensive documentation. 3. Changes in condition are communicated from shift to shift through the 24 Hour Report. 4. Changes in the resident status that affect the problem(s)/goal(s) pr approach(es) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers. The facility's Skin Management Policy, Revision Date July 2017 documented: Policy: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. Fundamental Information: A pressure ulcer is defined as any [MEDICAL CONDITION] caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually over bony prominences and are staged to determine the degree of tissue damage observed. Unavoidable Pressure Ulcers In accordance with CMS guidelines, unavoidable means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. All of this must be clearly documented in the resident's medical record. (Important: Unavoidable pressure ulcers are not excluded from the Monthly Clinical Key Indicators. Staging Classification The following Staging Classification is consistent with the National Pressure Ulcer Advisory Panel (NPUAP). Stage 1 An observable pressure area is present on intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Stage 2 Partial-thickness loss of skin with exposed dermis is present. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI) or traumatic wounds, (skin tears, burns, abrasions). Partial thickness of skin loss involving epidermis and/or dermis, the ulcer is superficial and presents clinically as abrasion, blister, or shallow crater. (Note: Granulation tissue, slough, and eschar are not found on Stage 2 ulcers. In addition, a Stage 2 blister may be intact or open serum filled. A blood blister is considered to be a suspected Deep Tissue Injury (DTI). Stage 3 Full-thickness loss of skin, in which adipose tissue (fat) is visible in the wound and granulation tissue and epibole (rolled wound edges) are often present. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Small amounts of slough or eschar may be visible, but if slough or eschar obscures in depth of tissue loss this is staged as an Unstageable Pressure Ulcer. The Stage 3 pressure ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. (Note: A Stage 3 may include tunneling or undermining. Ulcers to the bridge of the nose, ear, occiput and malleolus may be a Stage 3 wound, but may appear shallow due to lack of large amounts of adipose tissue. Stage 4 Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer are present. Epibole (rolled edges), undermining and/or tunneling beneath the surface of the ulcer often occur. Depth varies by anatomical location. Even if slough or eschar is visible in the wound, if there is fascia, muscle, tendon, ligament, cartilage and/or bone exposed or palpable, this ulcer is still classified as a Stage 4 pressure ulcer. (Note: Tunneling and sinus tracts may also be associated with Stage 4 pressure ulcers. Unstageable Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the depth is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer may be revealed. Stable eschar (i.e., dry, adherent, intact, without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. When eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has bene debrided. Identify/document as eschar covered area, unable to determine depth and stage, etc. Eschar in the wound bed may be tan, brown, or black in color. Unstageable wounds may be covered by yellow, tan, gray, green, ore brown slough. When the slough and/or eschar covering an Unstageable pressure ulcer has been debrided or removed, the ulcer should be reassessed for appropriate staging. Suspected Deep Tissue Injury Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister is present. Pain and temperature change often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. This wound results from intense and/or prolonged pressure and shear forces as the bon-muscle interface. The area may be preceded by tissue that is firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss even with optimal treatment. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (Unstageable, Stage 3, or Stage 4). Do not use Deep Tissue Injury to describe vascular, traumatic, neuropathic, or dermatologic conditions. Practice Guidelines 1. Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale For Predicting Pressure sore Risk User Defined Assessment (UDA) in conjunction with the Nursing Admission Data Collection Set (UDA). 2. Following admission, the Braden Scale for Predicting Pressure Sore Risk (UDA) will be completed weekly for 3 additional weeks (for a total of 4 weeks, including admission), quarterly, annually, and with a significant change of status to determine the risk for development of pressure ulcers. 3. Appropriate preventive surfaces (e.g., beds, wheelchairs, etc.) will be implemented for residents identified as risk. Interventions are documented on the Care Plan. (Note: Best practice is to place a cushion in all wheelchairs. 4. Residents admitted with skin impairments will have: a. Interventions implemented to promote healing; b. A physician's orders [REDACTED].>c. Wound location and characteristics documented in the Nursing Admission Data Collection Set (UDA); d. Referral to rehabilitation services, as indicated, or consideration of appropriate assistive devices and/or additional treatment modalities; e. Notification of the presence of skin impairment to the resident's representative and attending physician and documentation in the Nursing Admission Data Collection Set (UDA) or Progress Notes; f. Completion of the Weekly Pressure Ulcer Record for pressure ulcers; and g. Completion of the Weekly Non-Pressure Condition Record for non-pressure areas such as vascular, diabetic or arterial ulcers, wounds, skin tears, and/or other significant skin impairments. 5. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The Care Plan should address, but is not limited to the following: a. Hydration; b. Nutrition; c. Preventive devices; d. Physical activity; e. Pain management; f. Positioning requirements; g. Proper body alignment, and h. Psychosocial adjustment to skin impairment. 7. If a new pressure ulcer is identified, either upon admission, readmission, or during the resident's stay, the wound is, assessed and documented on the Weekly Pressure Ulcer Record (UDA). 8. The Licensed nurse will document daily monitoring of pressure ulcers on the Treatment Administration Record (TAR). 9. A physician's orders [REDACTED]. a. The licensed nurse will record observations and initial. b. A plus sign (+) is noted if there are no observed abnormalities or changes to the dressing, skin or pain associated with the wound. c. A minus sign (-) is noted if abnormalities or changes to the dressing, skin, or pain associated with the wound are present/observed. d. If any abnormalities are observed, a descriptive note of findings and the licensed nurses' response are documented in the Progress Notes section of the resident's medical record. 10. A nutritional evaluation using the Nutrition Data Collection (UDA) will be completed within seven (7) days of admission for residents identified at risk or with compromised skin integrity. 11. A registered dietitian will timely assess residents identified with skin impairment for nutritional status and document recommendations, as indicated. 12. At-Risk Review Meetings will be conducted to review/discuss: a. New Admissions: b. Residents identified at risk or with skin integrity compromise; c. Treatment modalities and interventions; and d. Recommendations based on interdisciplinary evaluation. (Important: No photographs of wound conditions are to be taken without the expressed consent and direction of the legal department. 13. The Director of Nursing or designee will distribute follow up assignments to the IDT following the At Risk Review Meeting. 14. The Assigned IDT member will communicate the results of the review and any recommended changes to the Care Plan to the resident and/or resident's representative. 15. The assigned IDT member will communicate any implemented Care Plan changes to appropriate staff. Ongoing Skin Assessments 1. A Weekly Skin Check will be completed in the resident's record using the Head To Toe Skin Check (UDA). (Note: Alterations or change(s) in skin integrity, breaks in the residents' skin including skin tear, bruises, abrasions, ulcers, rash, surgical wounds, etc., are recorded on the Head to Toe Skin Check UDA. 2. An SBAR Communication Form and Progress Notes (UDA) is completed and a new physician's orders [REDACTED]. 3. The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines. 4. Pressure ulcers are measured and staged in accordance with the Practice Guidelines. Bed Bound Resident Management of Tissue Loads through Positioning 1. Avoid positioning a resident directly on a pressure ulcer whenever possible. 2. Use Positioning devices. Devices (pillows, wedges, blanket rolls, etc.) should be used to completely raise the pressure area, i.e., heel and back of the head, completely off of the support surface. Use of these devices may reduce the need for a pressure reducing mattress or overlay. Avoid the use of donut-type devices. 3. Establish an individualized turning and positioning schedule based on the resident's clinical condition. 4. Assess for risk of developing additional pressure ulcers. a. Totally relieve heel pressure by elevation of the heel completely off of the bed surface. For example, placing a pillow beneath the calves with pressure evenly distributed across the posterior lower extremity. b. Prevent direct contact between bony prominences and support surface. Management of Tissue Loads through selection of a Support Surface Factors to consider when choosing a support surface: -Therapeutic benefit associated with the product; and -Resident's Clinical condition Measurement of Pressure Ulcers (Note: Assess the resident for pain before measurement begins. 1. Using disposable measurement devices, measure the length of the wound from the direction of the head to the foot at the longest point. 2. Measure the width of the wound from side to side at the widest point. Wound tracings are very effective. 3. Depth should be measured for Stage III and Stage IV ulcers. a. Place a sterile Q-Tip, moistened with NS (Normal Saline) gently into the wound perpendicular to the surface at the deepest point. b. Mark the point at which the skin would cover the wound if it were intact. c. Compare the mark with the ruler to give the measurement in centimeters (cm). 4. Measure undermining/tunneling by: a. Gently inserting a sterile Q-Tip moistened with NS into the area of undermining and marking the point at which the skin would be cover the wound if it were intact. b. Compare this mark with the ruler to give the measurement in centimeters (cm). c. Be sure to note the location of the undermining using a clock face diagram as a guide. The resident's head will be 12:00 o'clock, feet will be 6:00 o'clock. If possible, it is recommended to measure two (2) positions related to the location of the undermining, referencing the same two time positions with each subsequent measurement(see example). d. Tunneling: Use a new sterile, moistened Q-Tip, measure the length of the tunneling, document the position of the tunneling as you would undermining, using a clock face diagram as a guide. Pressure Reduction 1. Assist the resident to change position in bed periodically as indicated by the nursing assessment, or as requested by the resident. 2. Use a turn sheet/draw sheet for repositioning. This will help prevent shearing. 3. Utilize a pressure reducing mattress or pressure reducing overlay. 4. Provide a pressure-reducing device on wheelchair/chair/recliner. Avoid use of donut type devices. 5. Consider elevating heel(s) off of the bed with pillow or use of heel protectors. 6. Utilize minimal linen under prone skin areas i.e., only one (1) incontinent pad at a time. Stage 3 Pressure Ulcer Suggested Interventions Care Interventions 1. The resident, resident's representative and the attending physician are notified of development of a Stage 3 pressure ulcer. 2. Avoid pressure over the wound as much as possible, especially during position changes. Thirty-degree (30 ) oblique positioning, (rolled partially to the side and supported by pillows or wedge) of the resident may be effective to help relieve pressure, if tolerated. 3. The Care Plan and Care Kardex are updated to reflect the wound status and interventions. 4. Licensed nurse should assess weekly and document progress. 5. Resident is added to the 24- Hour Report via Progress Note. 6. Care Plan interventions are implemented and discussed during shift report. 7. Assess the resident for pain related to at pressure ulcer(s) during turning, positioning, dressing changes, and debridement. Provide [MEDICATION NAME] as needed. 8. Use a turn sheet/draw sheet for repositioning. This will help prevent shearing. 9. Consult with rehabilitation services for evaluation and options for treatment interventions, if indicated. 10. Consultation with CW/(NAME)N nurse consultant, wound consultant, or surgeon as appropriate. Pressure Reduction/Relief 1. Evaluate for pressure reduction/relief support surfaces, as indicated. 2. The IDT may make a referral to rehabilitation services for positioning recommendations and appropriate seating surface, if the resident is able to be out of bed. 3. Implement an individualized schedule for turning and repositioning. 4. Residents with a wound(s) to the lower trunk should limit time up in a chair, unless using specialized support surface appropriate to the wound if the activity is not contraindicated. Mobility/Exercise 1. Rehabilitation services may evaluate for additional interventions such as, mobility/positioning exercise schedule, positioning devices, range of motion, ambulation programs or orthotic devices. 2. Encourage the resident to participate in exercise programs offered by the activity department or restorative nursing. 3. Use caution during transfers and use of lifting devices. Stage 4 Pressure Ulcer Suggested Interventions Care Interventions 1. The resident, resident's representative, and the attending physician are notified of development of a Stage 4 pressure ulcer. 2. Avoid pressure over the wound as much as possible, especially during position changes. Thirty-degree (30 ) oblique positioning, (rolled partially to the side and supported by pillows or wedge) of the resident may be effective to help relieve pressure. 3. The nurse will assess weekly and document progress. 4. Resident is added to the 24- Hour Report via Progress Note. Care Plan interventions are implemented and discussed during shift report. 5. Assess the resident for pain related to at pressure ulcer(s) during turning, positioning, dressing changes, and debridement. Provide [MEDICATION NAME] as needed. 6. Use a turn sheet/draw sheet for repositioning. This will help prevent shearing. 7. Consult with rehabilitation services for evaluation and options for treatment interventions. 8. Consultation with CW/(NAME)N nurse consultant, wound consultant, or surgeon as appropriate. Pressure Reduction/Relief 1. Evaluate for pressure reduction/relief support surfaces, as indicated. 2. The IDT may make a referral to rehabilitation services for positioning recommendations and appropriate seating surface, if the resident is able to be out of bed. 3. Implement an individualized schedule for turning and repositioning. 4. Residents with a wound(s) to the lower trunk should limit time up in a chair, unless using specialized support surface appropriate to the wound if the activity is not contraindicated. Mobility/Exercise 1. Rehabilitation services may evaluate for additional interventions such as, mobility/positioning exercise schedule, positioning devices, range of motion, ambulation programs or orthotic devices. 2. Encourage the resident to participate in exercise programs offered by the activity department or restorative nursing. 3. Use caution during transfers and use of lifting devices . According to the National Pressure Ulcer Advisory Panel website (http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/) searched on 09/23/17 revealed: Pressure Injury Prevention Points: Risk Assessment: 1 Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2 Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within 8 hours after admission). 3 Refine the assessment by including these additional risk factors: A. Fragile skin B. Existing pressure injury of any stage, including those ulcers that have healed or are closed C. Impairments in blood flow to the extremities from vascular disease, diabetes or tobacco use D. Pain in areas of the body exposed to pressure . 5 Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Skin Care: .Avoid positioning an individual on an area of [DIAGNOSES REDACTED] or pressure injury Repositioning and Mobilization: 1 Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 2 Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. 3 Consider lengthening t/e turning schedule during the night to allow for uninterrupted sleep/ 4 Turn the individual into a 30-degree side lying position, and use your hand to determine if the sacrum is off the bed 5 Avoid positioning the individual on body areas with pressure injury. 6 Ensure that the heels are free from the bed. 7 Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface. 8 Continue to reposition an individual when placed on any support surface. 9 Use a breathable incontinence pad when using microclimate management surfaces. 10 Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs. 11 Reposition weak or immobile individuals in chairs hourly Interview with the Director of Nurses (DON) on entrance conference on 09/22/17 at 2:15 p.m. revealed the facility had not had a Treatment Nurse since 07/19/17. The DON mentioned she was made aware of assessment and documentation issues regarding wounds/pressure ulcers while the facility was last revisited by a different surveyor approximately 3-4 weeks ago. The DON said she had been trying to assess every resident's skin from head to toe since then but had not completed 100%. When asked for a current pressure ulcer log, the DON stated she did not have a current log but was working on one. R #1: R #1's Admission Record dated 07/24/17 revealed R #1 was a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. of onset for both left and right hip blisters was 08/10/17). R #1's Braden Scale dated 06/28/17 revealed R #1 risk for Pressure Ulcers was at 9=high risk. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (admission) revealed R #1 had R (Right) Lateral Heel 5 CM Size Purplish Colored Intact Blister .R Lateral Back 5 CM Size Redden Area. R #1's History and Physical dated 06/30/17 revealed R #1 had no Decubitus Ulcers. R #1's admission MDS dated [DATE] revealed R #1 had severely impaired vision, R #1 did not have speech, rarely/never understood by others and rarely/never understood others. R #1 Cognitive skills for daily decision making and vision was severely impaired. R #1 was totally dependent with bed mobility, bathing and dressing requiring the assistance of two people. R #1 was assessed as having an indwelling urinary catheter and was frequently incontinent of bowel. R #1 was assessed as having a Feeding Tube and received 51% or more calories and 501 cc/day or more fluid intake through feeding tube. R #1 was assessed at risk for Pressure Ulcers and had two Deep Tissue Injuries present on admission. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had left heel has purple blister intact. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had two blood blisters to right and left heel. R #1 had not been sent out to the hospital after 07/21/17. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] revealed R #1 had 2 blood blisters R&L (Left) heel. R #1's Skin-Head to Toe Skin Checks assessments and Skin-Weekly Pressure Ulcer Record both dated 07/27/17 revealed R #1 Was assessed as having a new pressure ulcer the description was Excoriation right buttock, DTI (Deep Tissue Injury) Lt. buttock. BI (bilateral) heels blood blisters. BI hip blanchable redness .Right buttock Length 1.1 cm Width 0.7 excoriation .Left buttock Length 4.5 cm Width 1.5 cm Suspected Deep Tissue Injury .LT hip blanchable redness .RT hip blanchable redness .Specialty Interventions Air Mattress . The Skin Weekly Pressure Ulcer Record provided definitions of the stages of pressure ulcers that included: -Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure ulcer and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3: Fill thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or broom) and/or eschar (tan, brown or black) in the wound bed. R #1's NP XX Initial Consultation dated 07/28/17 revealed R #1 was assessed as having the following wounds and treatment recommendations: left heel unstageable heel L-2 cm x W-1 cm the wound bed was dark purple discoloration, unstageable. Right elbow fluid filled blister L-2.1 cm x L-1.5 cm stage 2 pressure ulcer Rt. Heel L-1cm x 1 cm 100% discoloration Unstageable. Right Ear had non blanchable redness Stage 1, Anterior neck L-0.7 cm x W-1 cm x D- 0.1 cm, Right buttock pressure ulcer L-5 cm x 6 cm x unknown unstageable wound bed with dark purple/black discoloration. Treatment recommendation for heel wounds was to cleanse with NS pat dry with gauze apply Sure Prep leave OTA. Recommended float heels on pillow. treatment for [REDACTED]. Right ear recommendation was to monitor for proper placement of N/C every shift. treatment for [REDACTED]. R #1's Care Plan dated 07/28/17 revealed (R #1) has unstageable pressure ulcer to right buttock or potential for pressure ulcer development r/t Immobility .07/27/17 Consult with Regional Wound Care to evaluate and treat .Administer treatments as ordered and observe for effectiveness . NP XX followed up on 08/11/17, 09/15/17, and 09/22/17 and assessed R #1's wounds and provided recommendations each visit. (The assessments and recommendations were not legible.) R #1's Skin-Head to Toe Skin Checks assessment and Skin-Weekly Pressure Ulcer Record both dated 08/01/17 revealed R #1 was assessed as having a neck pressure ulcer Length 0.7 cm Width 1 cm Depth 0.1 red wound bed Stage III .Right heel pressure ulcer Length 1 cm Width 1 cm Stage I red DTI .Right elbow Pressure ulcer Length 2.5 cm Width 1.5 cm Stage II flui

Based on observation, interview, and record review the facility failed to follow the care plan and provide services in accordance with the Physician's Plan of Care (physician's orders [REDACTED].# 1 and R #2) of four residents reviewed for plans of care. -The facility failed to clarify, and implement R #1's pressure ulcer physician's wound care orders. R #1 entered the facility with two red open areas yet, currently acquired 39 separate ulcers throughout his body. -The facility allowed R #1's draining pressure ulcers to remain uncovered and untreated for [REDACTED]. -The facility failed to clarify, and implement R #2's pressure ulcer physician's wound care orders. R #2's community acquired Buttock/Sacral/Coccyx Stage 4 pressure ulcer deteriorated, after being debrided. -The facility failed to inform R #2's physician of any changes in his Buttock/Sacral/Coccyx Stage 4 pressure ulcer and the development of a new ulcer on his Left Ischial Tuberosity. R #2's Buttocks/Sacral/Coccyx ulcer developed necrotic tissue and foul odorous drainange. -The facility did not make attempt to request orders for treatment of [REDACTED]. When the facility recived order for R #2's surgical incision on [DATE], the orders were not inplemented. R #2 arrived to the hospital on [DATE] with embedded staples in place. The above failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This failure could place four residents with surgical incisions and 13 residents with pressure ulcers at risk for worsening of condition. The findings included: Interview with the Director of Nurses (DON) on entrance conference on [DATE] at 2:15 p.m. revealed the facility had not had a Treatment Nurse since [DATE]. The DON mentioned she was made aware of assessment and documentation issues regarding wounds/pressure ulcers while the facility was last revisited by a different surveyor approximately ,[DATE] weeks ago. The DON said she had been trying to assess every resident's skin from head to toe since then but had not completed 100%. When asked for a current pressure ulcer log, the DON stated she did not have a current log but was working on one. R #1: R #1's Admission Record dated [DATE] revealed R #1 was a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. of onset for both left and right hip blisters was [DATE]). R #1's Braden Scale dated [DATE] revealed R #1 risk for Pressure Ulcers was at 9=high risk. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (admission) revealed R #1 had R (Right) Lateral Heel 5 CM Size Purplish Colored Intact Blister .R Lateral Back 5 CM Size Redden Area. R #1's History and Physical dated [DATE] revealed R #1 had no Decubitus Ulcers. R #1's admission MDS dated [DATE] revealed R #1 had severely impaired vision, R #1 did not have speech, rarely/never understood by others and rarely/never understood others. R #1 Cognitive skills for daily decision making and vision was severely impaired. R #1 was totally dependent with bed mobility, bathing and dressing requiring the assistance of two people. R #1 was assessed as having an indwelling urinary catheter and was frequently incontinent of bowel. R #1 was assessed as having a Feeding Tube and received 51% or more calories and 501 cc/day or more fluid intake through feeding tube. R #1 was assessed at risk for Pressure Ulcers and had two Deep Tissue Injuries present on admission. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had left heel has purple blister intact. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had two blood blisters to right and left heel. R #1 had not been sent out to the hospital after [DATE]. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] revealed R #1 had 2 blood blisters R&L (Left) heel. R #1's Skin-Head to Toe Skin Checks assessments and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 Was assessed as having a new pressure ulcer the description was Excoriation right buttock, DTI (Deep Tissue Injury) Lt. buttock. BI (bilateral) heels blood blisters. BI hip blanchable redness .Right buttock Length 1.1 cm Width 0.7 excoriation .Left buttock Length 4.5 cm Width 1.5 cm Suspected Deep Tissue Injury .LT hip blanchable redness .RT hip blanchable redness .Specialty Interventions Air Mattress . The Skin Weekly Pressure Ulcer Record provided definitions of the stages of pressure ulcers that included: -Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure ulcer and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3: Fill thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or broom) and/or eschar (tan, brown or black) in the wound bed. R #1's NP XX Initial Consultation dated [DATE] revealed R #1 was assessed as having the following wounds and treatment recommendations: left heel unstageable heel L-2 cm x W-1 cm the wound bed was dark purple discoloration, unstageable. Right elbow fluid filled blister L-2.1 cm x L-1.5 cm stage 2 pressure ulcer Rt. Heel L-1cm x 1 cm 100% discoloration Unstageable. Right Ear had non blanchable redness Stage 1, Anterior neck L-0.7 cm x W-1 cm x D- 0.1 cm, Right buttock pressure ulcer L-5 cm x 6 cm x unknown unstageable wound bed with dark purple/black discoloration. Treatment recommendation for heel wounds was to cleanse with NS pat dry with gauze apply Sure Prep leave OTA. Recommended float heels on pillow. treatment for [REDACTED]. Right ear recommendation was to monitor for proper placement of N/C every shift. treatment for [REDACTED]. R #1's Care Plan dated [DATE] revealed (R #1) has unstageable pressure ulcer to right buttock or potential for pressure ulcer development r/t Immobility XXX[DATE] Consult with Regional Wound Care to evaluate and treat .Administer treatments as ordered and observe for effectiveness . NP XX followed up on [DATE], [DATE], and [DATE] and assessed R #1's wounds and provided recommendations each visit. (The assessments and recommendations were not legible.) R #1's Skin-Head to Toe Skin Checks assessment and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 was assessed as having a neck pressure ulcer Length 0.7 cm Width 1 cm Depth 0.1 red wound bed Stage III .Right heel pressure ulcer Length 1 cm Width 1 cm Stage I red DTI .Right elbow Pressure ulcer Length 2.5 cm Width 1.5 cm Stage II fluid filled blister .Left heel Pressure Ulcer Length 2 cm Width 1 cm Unstageable DTI .R Buttock Pressure ulcer Length 5 cm Width 6 cm Stage I reddened DTI .R ear Pressure ulcer stage I Length 1 cm Width 1 cm Suspected Deep Tissue Injury .R ankle Pressure ulcer Unstageable .Specialty Interventions Positioning Device .Wedge Cushions . R #1's Care Plan dated [DATE] revealed (R #1) has Potential/ Actual Skin Issues related to: Pressure Ulcer related to history of ulcers, Pressure Ulcer related to Mobility .(R #1) will remain without signs of breakdown by next review .(R #1) wound will show signs of healing with area decreasing in overall size and depth by next review . Notify MD in changes in wound or emerging wounds .observe wound healing . place on air loss mattress .provide would care/preventative skin care per order .Skin checks weekly per facility protocol, document findings . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip, DTI L heel .Right Trochanter (hip) Blister Length 10.5 cm Width 8.5 cm Stage N/A .Left Trochanter (hip) Blister Length 8.5 cm Width 5 cm Stage N/A .Right buttock excoriation .Left buttock excoriation .Left heel Length 1 cm Width 1 cm Suspected Deep Tissue Injury .Specialty Interventions Positioning devices pillows other interventions turn frequently . Left Trochanter was described as having red wound bed, small amount of serosanguineous drainage, blister getting bigger and wound edges Dark Red/Purple . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Right ear pressure ulcer Stage II .Left ear Pressure Ulcer Stage I .Right buttock Suspected Deep Tissue Injury DTI . Right heel pressure ulcer .Left heel pressure ulcer .Right Knee #2 Length 1.0 cm Width 1.5 cm Depth 0.1 cm Stage II open blister . red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Right Knee #1 Length 3.0 cm Width 2.5 cm Depth 0.1 cm Stage II open blister .red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Knee Length 3.0 cm Width 3.5 cm Depth 0.1 cm Stage II open blister . red wound bed, .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Hip Pressure Ulcer Unstageable .Right Hip Unstageable R #1's Skin-Head to Toe Skin Checks dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip R/L medial knees .see noted measurements [DATE] R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Non-Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having intact blister to left flank back .Length 6.2 cm Width 3 cm .Specialty Interventions .Wedge Cushion . R #1's Skin-Head to Toe Skin Checks dated [DATE] Existing blood blister to left heel, DTI's, continues with ruptured blisters to L/R knee .Coccyx Pressure Ulcer Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III . Right Trochanter (hip) Pressure Ulcer Length 3.6 cm Width 2.2 cm Unstageable .Left Trochanter (hip) Pressure Ulcer Length 9.4 cm Width 6.3 cm Unstageable .Left ear Pressure Ulcer Length 1.2 cm Width 1.2 cm Depth 0.1 cm Stage II .Left heel Length 1.3 cm Width 1.2 cm Healing Blood Blister .Left flank Length 10.2 cm Width 2.3 cm .Right Medial Knee Blister Length 2.5 cm Width 2.0 cm .Left Medial Knee Pressure Pressure Ulcer Length 2.9 cm Width 2.2 cm Suspected deep tissue injury .Right Calcaneous Pressure Ulcer Length 0.9 cm width 0.8 cm Suspected deep tissue injury .LT Lat. Lower Extremity. Pressure Ulcer Length 3.4 cm Width 2.0 cm .Ruptured blister to right medial heel dry, healing, and intact, left and right medial blisters with beefy wound bed, minimal serosanguinous drainage, L/R unstageable hip ulcers with 100% eschar to wound bed, dried blister to left flank intact and scab-like, stage 3 to coccyx with boggy slough, foul odor . R #1's Skin Head to Toe Skin Check and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] (late entry) revealed R #1 was assessed as having Coccyx Pressure Ulcer date of onset [DATE] Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III .wound bed yellow scant amount of serous drainage .Odor Not Present Specialty Interventions LAL Bed .Positioning devices Pillows .Notes to apply santyl oint to wound bed and cover with adhesive foam dressing daily until resolved .Left Medial Lateral Foot date of onset [DATE] Length 2.0 cm Width 0.9 cm Depth 0 cm Stage I Nonblanchable .wound bed red Specialty Interventions Bed LAL positioning pillows .Left Calcaneous date of onset [DATE] Length 2.2 cm Width 1.2 cm Depth 0 cm Stage I Nonblanchable Redden area wound bed red Specialty Interventions Bed LAL positioning devices Keen, pillows .Right Lateral Foot Date of onset [DATE] Length 1.4 cm Width 1.6 cm Depth 0 cm Suspected Deep Tissue Injury Redden Skin Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows .Ordered skin prep area Q shift until resolved .Right Medial Foot Date of Onset [DATE] Length 3.5 cm Width 2.5 cm Depth 0 cm Stage I .Wound Bed Red .ordered to off load feet and monitor for any changes Q shift until resolved .Right Calcaneous date of onset [DATE] Length 1.2 cm Width 0.9 cm Depth 0 cm Stage I reddened Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows . Skin-Weekly Non-Pressure Condition Record .Right Anterior Foot date of onset [DATE] bruising Length 1.3 cm Width 1.0 cm Depth 0 cm Wound Bed Red . R #1's Skin-Head to Toe Skin Checks dated and Skin-Weekly Pressure Condition Record both dated [DATE] assessment revealed blisters L/R hip RL medial knees, Stage III R buttock . Right Trochanter (hip) Blister Length 85 cm Width 3.5 cm Depth 0 cm .Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 .Right buttock Pressure Ulcer Length 8 cm Width 7 cm Depth 3 cm Stage III .L medial knee Blister Length 2.5 cm Width 2.5 cm Depth 0 cm .R medial knee Blister Length 3 cm Width 2 cm Depth 0 cm . Ruptured blisters to L/R medial knees dry and healing, L/R unstageable blisters to hips that appear as ulcers now (with) 100% eschar to wound bed, stage III to right buttock (with) boggy slough, foul odor .Skin-Weekly Pressure Condition Record Right Buttock wound date of onset [DATE] Length 8 cm Width 7 cm Depth 3 cm Stage III .Drainage Moderate amount Color Purulent Wound Edges White/Gray/Pallor .Response to treatment Deteriorated area getting bigger Treatment plan Continue . Skin-Weekly Non- Pressure Condition Record L medial knee blister date of Length 2.5 cm Width 2.5 cm Depth 0 cm ruptured blister that is drying out .R medial knee date of onset [DATE] Length 3 cm Width 2 cm Depth 0 cm ruptured blister that is drying out . L medial knee Blister date of onset [DATE] Length 2.5 cm Width 2.5 cm Depth 0 cm . ruptured blister that is drying out .Right Trochanter (hip) blister date of onset [DATE] Length 5 cm Width 3.5 cm Depth 0 cm unstageable Wound bed Black Eschar Drainage small amount Color serosanguinous Wound edges Black Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 unstageable Wound bed Black Drainage scant amount Color serosanguinous Wound edges Black Response to Treatment No Change Treatment Plan Continue. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) revealed L/R hip R/L medial knees, pressure R buttock, multiple wounds .Left hand wound (palm) .Left hand (back) Blister .Left shoulder (rear) pressure ulcer Length 1.6 cm Width 2.5 cm Depth 0 cm. Unstageable . Rt medi lower leg B Blister Length 2.0 cm Width 1.5 cm .Rt medi lower leg A blister Length 3.0 cm Width 2.0 cm .Left medial knee pressure ulcer Length 1.0 cm Width 1.3 cm Depth 0.1 cm Stage II . Lt medial upper back Pressure ulcer Length 1.5 cm Width 1.0 cm Unstageable .Left back Pressure ulcer Length 2.0 cm Width 2.5 cm Unstageable .Left lateral ankle Pressure Ulcer Length 2.5 cm Width 0.5 cm Depth 0.1 cm Stage II .Left Hip Pressure Ulcer Length 8.0 cm Width 6.5 cm Unstageable .Right hip Pressure Ulcer .Stage N/A .Rt Knee pressure Ulcer Stage N/A .Skin-Weekly Non- Pressure Condition Record dated [DATE] . date of onset [DATE] L. ring finger Blister Length 2.3 cm Width 2.3 cm Depth 0 cm. fluid filled blister . L hand thumb Blister Length 7 cm Width 1 cm Depth 0 cm fluid filled blister .Left hand pinky finger Blister Length 1.7 cm Width 2 cm Depth 0cm Fluid filled blister .Left hand palm blister Length 8.5 cm Width 2.3 cm Depth 0 cm Fluid filled blister .Left hand (back) Blister Length 8 cm Width 5 cm Depth 0 cm Fluid filled blister with dark purple with clear fluid .L hand middle finger blister Length 3 cm Width 2.5 cm Depth 0 cm Fluid filled blister .Left hand index finger Length 7 cm Width .5 cm Depth 0 cm Clear fluid filled blister . R #1's Care Plan dated [DATE] revealed (R #1) is on (Hospice for dysphagia following cerebral infarction .do not initial CPR . On [DATE] at 2:18 p.m., observation accompanied by LVN C revealed R #1 was lying in bed on his back with his left hand swollen with draining blisters without a dressing. Left and right hip wounds with black eschar, left lateral ankle wound, left lateral lower leg wound, Right and left medial knee wounds, left posterior shoulder wound, left and right ear wounds, left medial tibial wound, right medial heel wound, Left coccyx wound and left buttock wound open without dressings. R #1 had an adult brief on and his linens were soiled with drainage from open wounds. LVN C said NP XX was in the facility today and removed R #1's dressings, at approximately 11:00 a.m. R #1's Urinary Catheter was not anchored. On [DATE] at 3:15 p.m., observation revealed LVN B and C were in R #1's room providing wound care. LVN B had gloves on, applied skin prep to Left malleolus and left lateral leg wounds, then applied a foam dressing, doffed gloves picked up foam dressing with her bare hands cut dressing to fit wound then placed foam dressing on the outer dressing packaging. LVN B donned clean gloves. LVN B did not wash hands in between glove changes. LVN B said NP XX had removed R #1's dressings at approximately 10:30 a.m.-11:00 a.m. during wound care rounds. LVN B said when she conducted rounds with NP XX, they go from patient to patient for wound care recommendations. Then the nurses have to go back and dress resident's wounds when all residents have been seen by NP XX. On [DATE] at 3:55 p.m. LVN B and C said leaving R #1's wounds open without dressings could place R #1 at risk for infection. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) Sacral/Bil/ Buttock/Coccyx Pressure ulcer date of onset [DATE] Length 8 cm Width 8 cm Depth 4 cm unstageable wound bed Red with slough Moderate amount of serous drainage odor present wound edges pink . Response to treatment Deteriorated Treatment Plan Continue . On [DATE] at 10:35 a.m., observation revealed on entering R #1's room LVN B was applying a foam dressing to R #1's Left hip wound. LVN B said she had to dress the Coccyx wound dressing. Surveyor requested wound care measurements on the right buttock/coccyx wound. LVN B said the wound was staged at 4 and that she was not a wound care nurse and had no formal training but would do the best she could do. LVN B cleansed the Right buttock/coccyx wound with wound cleanser and measured the wound L-7.0 cm x W-4.0 cm x D-4 cm, tunneling at 12:00 was at 5 cm. Surveyor observed wound was 60% yellow gray colored slough tissue with a foul odor. LVN B doffed dirty gloves after measuring wound coughed into left hand, donned a clean pair of gloves and applied foam dressing to right buttock/coccyx wound. LVN B did not wash her hands between glove changes. R #1's Urinary Catheter was not anchored. During would care CNA P lifted R #1's urinary catheter above R #1's bladder and surveyor observed urine back flow towards insertion site. On [DATE] at 12:40 p.m., Surveyor requested copies of written MD orders. DON said they were waiting for order clarification on NP XX's orders. On [DATE] at 12:55 p.m., interview with LVN B revealed she did not know if wound care orders were verified by the attending Physician or NP XX. LVN B said she had not been given direction form the ADON or the DON if wound care orders are accepted from NP XX. LVN B said she has never been trained on wound staging. LVN B said if she did not wash hands in between glove changes when performing would care that could place the resident at risk for infection. LVN B said by leaving R #1's wound open without dressings could place the resident at risk of infection. LVN B said if a resident's F/C was not anchored it could pull and cause injury. The DON said if a resident has a Urinary catheter it should not touch the floor and always be anchored and held below the bladder to prevent infection, dislodgement, trauma and other complications. On [DATE] at 1:15 p.m., interview with LVN A revealed she had training in wound care last year in 2016 but was never taught how to measure wounds. LVN A said wound orders are initially given from attending Physician, then the Physician refers NP XX for consultation, then NP XX changes the orders accordingly. The nurse that conducts rounds with NP XX obtains the verbal orders from NP XX and places the orders in the computer. LVN A said the consequences of leaving wounds open to air would be infection. On [DATE] at 2:05 p.m., interview with the DON said leaving wounds open to air without a dressing would place the resident at risk for infection. The DON said she would expect the nurse to provide the wound care when the order is received by the Physician. On [DATE] at 10:00 a.m., interview with NP XX said she had seen R #1 prior to admission to the facility and he only had two small reddened areas, last time she came to the facility to see R #1 he had 14 wounds. NP XX said the facility never had adequate supplies, and did not implement the wound orders or recommendations. NP XX recommended the facility obtain an air mattress for R #1 because of his high risk of skin breakdown and from week to week he developed more wounds. NP XX said R #1 developed pressure ulcers between his knees when the nurses could have just used a pillow between his knees to prevent the wounds. NP XX said she was horrified and that most of R #1's wounds were avoidable. NP XX said R #1's hand wounds looked as if they were caused by the resident was positioned on top of his hand resulting in a pressure ulcer. NP XX said she received a call on [DATE], from the facility for the first time since the wound care nurse left on [DATE] to clarify orders. NP XX said she makes wound care prevention and recommendations to the facility and does not provide wound care unless it is for debridement. NP XX said that when the facility had a wound care nurse he would always call and clarify orders. NP XX said when she makes recommendations for wound care, the next visit she finds her recommendations were never followed. NP XX said she was not surprised this surveyor found R #1 with no dressings applied to his open wounds. On [DATE] R #1's wound care observation beginning at 11:45 a.m. and resumed at 5:35 p.m., revealed R #1 had a total of 39 wounds treated and measured by LVN D and DON. On [DATE] at 11:00 a.m. interview with MD PP revealed R #1's wounds will not heal, MD PP said a wound VAC could help. MD PP said R #1 was terminal and was placed on Hospice this week. MD PP said in regards to R #1's wound care he would expect the nurses to follow physician's orders [REDACTED]. Interview with the DON on [DATE] at 3:09 p.m. revealed after she thoroughly assessed R #1's skin from head to toe on [DATE], she found that he had 39 separate pressure ulcers throughout his body. The DON acknowledged that some of the ulcers had not been identified or documented prior to the skin sweep. R #2: R #2's Face Sheet dated [DATE] documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted to the facility on [DATE], and discharged back to the hospital on [DATE]. R #2's [DIAGNOSES REDACTED]. R #2's Admission Nursing Admission Data Collection dated [DATE] documented Note all skin issues: Stage 2 to coccyx/buttock. Resident alert and oriented to person, time, and place, cognition intact. Oxygen at 2 lpm (liters per minute) via ns (nasal cannula) continuous. Foley catheter in place for [MEDICAL CONDITION] with lower urinary tract symptoms. Contractures present. Skin Issues: Coccyx Stage 2- open area with pink/red wound bed, no drainage noted (there were no measurements documented in the measurement section of this assessment). R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 15- at risk. R #2's Care Plan dated [DATE] documented: -(R #2) has venous stasis ulcer to right lower leg medial aspect. Also has pressure ulcer to right 4 and 5 digit he was admitted with .Interventions: Notify MD (Medical Doctor) of changes in wound or emerging wounds. Observe wound healing. Provide wound care per order. Skin checks weekly per facility protocol, document findings. Turn and reposition frequently to decrease pressure. -(R #2) has an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and limited mobility. Interventions: Encourage active participation in tasks. Provide cuing with tasks as needed. Bathing/Showering: the resident is totally dependent on ,[DATE] staff to provide bath/shower. Bed Mobility: the resident requires extensive assistance by ,[DATE] staff to turn and reposition in bed. Dressing: the resident requires extensive assistance by ,[DATE] staff for dressing. Personal Hygiene: the resident requires extensive assistance by ,[DATE] staff for personal hygiene and oral care Transfer: the resident is totally dependent on 2 staff for transferring. Encourage the resident to use bell to call for assistance. -(R #2) has impaired cognitive function . -(R #2) has DTI to left 4, 5, and 6th digit and surgical wound to abdomen he was admitted with. Interventions: Assess/record/observe wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Complete full body check weekly and document. Inform resident/family of new areas of skin breakdown. Low air loss mattress. Observe/document/report prn any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage. Reposition frequently. R #2's Skin-Head to Toe Skin Check dated [DATE] documented: -Left foot 4th digit: DTI 0.3 cm X 0.8 cm. -Left foot 5th digit: DTI 0.4 X 0.4 cm. -Left foot 3rd digit: DTI 1.5 cm X 2.0 cm. -Left Heel: DTI 2.5 cm X 4.5 cm . --R #2's Bilateral Buttocks/Coccyx/Sacrum ulcer was not documented on this record. R #2's Skin-Weekly Pressure Ulcer Record dated [DATE] Left Heel: Date of Onset: [DATE], existing pressure ulcer, admitted with pressure ulcer. 1.5 cm X 2.0 cm DTI, area resembles scab, no signs/symptoms (s/s) of infection. Wound bed appearance yellow, odor not present, wound edges normal for skin, area with yellow scab. Description of resident's response to current treatment: no change. --The documentation on this assessment of the description of the wound provided did not meet the definition of a DTI. R #2's Skin- Weekly Pressure Ulcer Record dated [DATE] documented Date of Onset: [DATE], existing pressure ulcer, admitted with. Location: Bilateral Buttock/Coccyx/Sacrum: Unstageable 20.0 cm X 12.0 cm. large area with partial red beefy tissue, partial yellow moist tissue. Wound bed description: other, Drainage: small serosanguineous, no odor present, no s/s of infection, wound edges: pink without maceration, surrounding skin: normal for skin. Response to Treatment: no change. R #2's Wound Care Specialist Consultation Note dated [DATE] documented: -Left Heel: Unstageable Pressure Ulcer/DTI 1.5 cm X 2.0 cm, wound bed 100% dark scab, periwound dry, scaly, sluggish, blanchable redness, boggy. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, cover with foam dressing every other day. -Bilateral Buttocks/Sacrum/Coccyx Unstageable Pressure Injury 20 cm X 12 cm X unknown depth, 75% moist necrotic tissue, 25% scattered granulation, periwound denuded, mild odor, moderate drainage. Treatment: cleanse with vashe (intended for use in cleansing, irrigating, moistening and [MEDICATION NAME] acute and chronic wounds) wound cleanser (blue bottle), pat dry with gauze, apply Triad cream, place ABD to glut fold . -Left 3rd Toe Suspected DTI (SDTI) 0.4 cm X 0.4 cm dark maroon discoloration, no redness, no drainage. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave open to air (OTA) QOD (every other day). -Left 4th Toe SDTI 0.3 cm X 0.4 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. - Left 5th Toe SDTI 0.3 cm X 0.8 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. --The facility's description of R #2's sacral ulcer on the Weekly Pressure Ulcer Record dated [DATE] did not include necrotic or black tissue. The description of the facility's measurements of the toes on the Weekly Pressure Ulcer Record dated [DATE] were significantly different than that of the NP XX's measurements. R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 10- High risk. R #2's Admission MDS dated [DATE] documented R #2 entered from acute hospital and had a BIMS score of 2 (severely impaired cognitive skills). R #2 required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. R #2 had an indwelling catheter and was always incontinent of bowel. R #2 was 73 inches tall, 208 pounds and had a feeding tube. R #2 was assessed to be at risk of developing pressure ulcers; R #2 had one Stage 3 pressure ulcer that was present upon admission/entry or reentry, one unstageable pressure ulcer present upon admission/entry or reentry, and four unstageable pressure ulcers with suspected deep tissue injury present upon admission/entry or reentry. The Stage 3 or unstageable pressure ulcer with the largest surface area measured 1.0 X 0.5 X 0.2 cm. The most severe type of tissue present in any pressure ulcer bed is slough. Skin and ulcer treatments: Pressure ulcer care, application of nonsurgical dressings, and applications of ointments/medications. R #2 was on oxygen therapy while not a resident and while a resident. R #2's Wound Care Sp(TRUNCATED)

Based on observation, interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of: The Administrator failed to: -ensure nurses were competent on skin management guidelines -supervise the leadership of the Director of Nurses (DON) -ensure the DON followed up to make sure weekly skin assessments were done correctly -ensure there was a weekly at risk meeting to address pressure ulcers -implement policies and procedures related to neglect. The DON failed to: -Follow up to ensure weekly skin assessments were done correctly -Implement policies and procedures related to neglect -Put effective measures into place to ensure staff obtained and clarified physician's orders [REDACTED].>-Supervise and monitor the nursing staff to ensure that the nursing staff followed the facility's Skin Management and Neglect policies and procedures correctly. The above failure resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect four residents with surgical wounds, 13 residents with pressure ulcers, and 37 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: Interview with the Director of Nurses (DON) on entrance conference on [DATE] at 2:15 p.m. revealed the facility had not had a Treatment Nurse since [DATE]. The DON mentioned she was made aware of assessment and documentation issues regarding wounds/pressure ulcers while the facility was last revisited by a different surveyor approximately ,[DATE] weeks ago. The DON said she had been trying to assess every resident's skin from head to toe since then but had not completed 100%. When asked for a current pressure ulcer log, the DON stated she did not have a current log but was working on one. R #1: R #1's Admission Record dated [DATE] revealed R #1 was a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. of onset for both left and right hip blisters was [DATE]). R #1's Braden Scale dated [DATE] revealed R #1 risk for Pressure Ulcers was at 9=high risk. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (admission) revealed R #1 had R (Right) Lateral Heel 5 CM Size Purplish Colored Intact Blister .R Lateral Back 5 CM Size Redden Area. R #1's History and Physical dated [DATE] revealed R #1 had no Decubitus Ulcers. R #1's admission MDS dated [DATE] revealed R #1 had severely impaired vision, R #1 did not have speech, rarely/never understood by others and rarely/never understood others. R #1 Cognitive skills for daily decision making and vision was severely impaired. R #1 was totally dependent with bed mobility, bathing and dressing requiring the assistance of two people. R #1 was assessed as having an indwelling urinary catheter and was frequently incontinent of bowel. R #1 was assessed as having a Feeding Tube and received 51% or more calories and 501 cc/day or more fluid intake through feeding tube. R #1 was assessed at risk for Pressure Ulcers and had two Deep Tissue Injuries present on admission. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had left heel has purple blister intact. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] (readmission) revealed R #1 had two blood blisters to right and left heel. R #1 had not been sent out to the hospital after [DATE]. R #1's Skin-Head to Toe Skin Checks assessment dated [DATE] revealed R #1 had 2 blood blisters R&L (Left) heel. R #1's Skin-Head to Toe Skin Checks assessments and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 Was assessed as having a new pressure ulcer the description was Excoriation right buttock, DTI (Deep Tissue Injury) Lt. buttock. BI (bilateral) heels blood blisters. BI hip blanchable redness .Right buttock Length 1.1 cm Width 0.7 excoriation .Left buttock Length 4.5 cm Width 1.5 cm Suspected Deep Tissue Injury .LT hip blanchable redness .RT hip blanchable redness .Specialty Interventions Air Mattress . The Skin Weekly Pressure Ulcer Record provided definitions of the stages of pressure ulcers that included: -Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure ulcer and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3: Fill thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or broom) and/or eschar (tan, brown or black) in the wound bed. R #1's NP XX Initial Consultation dated [DATE] revealed R #1 was assessed as having the following wounds and treatment recommendations: left heel unstageable heel L-2 cm x W-1 cm the wound bed was dark purple discoloration, unstageable. Right elbow fluid filled blister L-2.1 cm x L-1.5 cm stage 2 pressure ulcer Rt. Heel L-1cm x 1 cm 100% discoloration Unstageable. Right Ear had non blanchable redness Stage 1, Anterior neck L-0.7 cm x W-1 cm x D- 0.1 cm, Right buttock pressure ulcer L-5 cm x 6 cm x unknown unstageable wound bed with dark purple/black discoloration. Treatment recommendation for heel wounds was to cleanse with NS pat dry with gauze apply Sure Prep leave OTA. Recommended float heels on pillow. treatment for [REDACTED]. Right ear recommendation was to monitor for proper placement of N/C every shift. treatment for [REDACTED]. R #1's Care Plan dated [DATE] revealed (R #1) has unstageable pressure ulcer to right buttock or potential for pressure ulcer development r/t Immobility XXX[DATE] Consult with Regional Wound Care to evaluate and treat .Administer treatments as ordered and observe for effectiveness . NP XX followed up on [DATE], [DATE], and [DATE] and assessed R #1's wounds and provided recommendations each visit. (The assessments and recommendations were not legible.) R #1's Skin-Head to Toe Skin Checks assessment and Skin-Weekly Pressure Ulcer Record both dated [DATE] revealed R #1 was assessed as having a neck pressure ulcer Length 0.7 cm Width 1 cm Depth 0.1 red wound bed Stage III .Right heel pressure ulcer Length 1 cm Width 1 cm Stage I red DTI .Right elbow Pressure ulcer Length 2.5 cm Width 1.5 cm Stage II fluid filled blister .Left heel Pressure Ulcer Length 2 cm Width 1 cm Unstageable DTI .R Buttock Pressure ulcer Length 5 cm Width 6 cm Stage I reddened DTI .R ear Pressure ulcer stage I Length 1 cm Width 1 cm Suspected Deep Tissue Injury .R ankle Pressure ulcer Unstageable .Specialty Interventions Positioning Device .Wedge Cushions . R #1's Care Plan dated [DATE] revealed (R #1) has Potential/ Actual Skin Issues related to: Pressure Ulcer related to history of ulcers, Pressure Ulcer related to Mobility .(R #1) will remain without signs of breakdown by next review .(R #1) wound will show signs of healing with area decreasing in overall size and depth by next review . Notify MD in changes in wound or emerging wounds .observe wound healing . place on air loss mattress .provide would care/preventative skin care per order .Skin checks weekly per facility protocol, document findings . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip, DTI L heel .Right Trochanter (hip) Blister Length 10.5 cm Width 8.5 cm Stage N/A .Left Trochanter (hip) Blister Length 8.5 cm Width 5 cm Stage N/A .Right buttock excoriation .Left buttock excoriation .Left heel Length 1 cm Width 1 cm Suspected Deep Tissue Injury .Specialty Interventions Positioning devices pillows other interventions turn frequently . Left Trochanter was described as having red wound bed, small amount of serosanguineous drainage, blister getting bigger and wound edges Dark Red/Purple . R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having Right ear pressure ulcer Stage II .Left ear Pressure Ulcer Stage I .Right buttock Suspected Deep Tissue Injury DTI . Right heel pressure ulcer .Left heel pressure ulcer .Right Knee #2 Length 1.0 cm Width 1.5 cm Depth 0.1 cm Stage II open blister . red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Right Knee #1 Length 3.0 cm Width 2.5 cm Depth 0.1 cm Stage II open blister .red wound bed .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Knee Length 3.0 cm Width 3.5 cm Depth 0.1 cm Stage II open blister . red wound bed, .scant Amount of serosanguineous drainage .Specialty Interventions Bed Air mattress .Left Hip Pressure Ulcer Unstageable .Right Hip Unstageable R #1's Skin-Head to Toe Skin Checks dated [DATE] revealed R #1 was assessed as having Excoriation L/R buttocks, blisters L/R hip R/L medial knees .see noted measurements [DATE] R #1's Skin-Head to Toe Skin Checks and Skin-Weekly Non-Pressure Ulcer Record both assessments dated [DATE] revealed R #1 was assessed as having intact blister to left flank back .Length 6.2 cm Width 3 cm .Specialty Interventions .Wedge Cushion . R #1's Skin-Head to Toe Skin Checks dated [DATE] Existing blood blister to left heel, DTI's, continues with ruptured blisters to L/R knee .Coccyx Pressure Ulcer Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III . Right Trochanter (hip) Pressure Ulcer Length 3.6 cm Width 2.2 cm Unstageable .Left Trochanter (hip) Pressure Ulcer Length 9.4 cm Width 6.3 cm Unstageable .Left ear Pressure Ulcer Length 1.2 cm Width 1.2 cm Depth 0.1 cm Stage II .Left heel Length 1.3 cm Width 1.2 cm Healing Blood Blister .Left flank Length 10.2 cm Width 2.3 cm .Right Medial Knee Blister Length 2.5 cm Width 2.0 cm .Left Medial Knee Pressure Pressure Ulcer Length 2.9 cm Width 2.2 cm Suspected deep tissue injury .Right Calcaneous Pressure Ulcer Length 0.9 cm width 0.8 cm Suspected deep tissue injury .LT Lat. Lower Extremity. Pressure Ulcer Length 3.4 cm Width 2.0 cm .Ruptured blister to right medial heel dry, healing, and intact, left and right medial blisters with beefy wound bed, minimal serosanguinous drainage, L/R unstageable hip ulcers with 100% eschar to wound bed, dried blister to left flank intact and scab-like, stage 3 to coccyx with boggy slough, foul odor . R #1's Skin Head to Toe Skin Check and Skin-Weekly Pressure Ulcer Record both assessments dated [DATE] (late entry) revealed R #1 was assessed as having Coccyx Pressure Ulcer date of onset [DATE] Length 6.9 cm Width 3.8 cm Depth 1.2 cm Stage III .wound bed yellow scant amount of serous drainage .Odor Not Present Specialty Interventions LAL Bed .Positioning devices Pillows .Notes to apply santyl oint to wound bed and cover with adhesive foam dressing daily until resolved .Left Medial Lateral Foot date of onset [DATE] Length 2.0 cm Width 0.9 cm Depth 0 cm Stage I Nonblanchable .wound bed red Specialty Interventions Bed LAL positioning pillows .Left Calcaneous date of onset [DATE] Length 2.2 cm Width 1.2 cm Depth 0 cm Stage I Nonblanchable Redden area wound bed red Specialty Interventions Bed LAL positioning devices Keen, pillows .Right Lateral Foot Date of onset [DATE] Length 1.4 cm Width 1.6 cm Depth 0 cm Suspected Deep Tissue Injury Redden Skin Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows .Ordered skin prep area Q shift until resolved .Right Medial Foot Date of Onset [DATE] Length 3.5 cm Width 2.5 cm Depth 0 cm Stage I .Wound Bed Red .ordered to off load feet and monitor for any changes Q shift until resolved .Right Calcaneous date of onset [DATE] Length 1.2 cm Width 0.9 cm Depth 0 cm Stage I reddened Area .Wound Bed Red . Specialty Interventions Bed LAL positioning devices, pillows . Skin-Weekly Non-Pressure Condition Record .Right Anterior Foot date of onset [DATE] bruising Length 1.3 cm Width 1.0 cm Depth 0 cm Wound Bed Red . R #1's Skin-Head to Toe Skin Checks dated and Skin-Weekly Pressure Condition Record both dated [DATE] assessment revealed blisters L/R hip RL medial knees, Stage III R buttock . Right Trochanter (hip) Blister Length 85 cm Width 3.5 cm Depth 0 cm .Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 .Right buttock Pressure Ulcer Length 8 cm Width 7 cm Depth 3 cm Stage III .L medial knee Blister Length 2.5 cm Width 2.5 cm Depth 0 cm .R medial knee Blister Length 3 cm Width 2 cm Depth 0 cm . Ruptured blisters to L/R medial knees dry and healing, L/R unstageable blisters to hips that appear as ulcers now (with) 100% eschar to wound bed, stage III to right buttock (with) boggy slough, foul odor .Skin-Weekly Pressure Condition Record Right Buttock wound date of onset [DATE] Length 8 cm Width 7 cm Depth 3 cm Stage III .Drainage Moderate amount Color Purulent Wound Edges White/Gray/Pallor .Response to treatment Deteriorated area getting bigger Treatment plan Continue . Skin-Weekly Non- Pressure Condition Record L medial knee blister date of Length 2.5 cm Width 2.5 cm Depth 0 cm ruptured blister that is drying out .R medial knee date of onset [DATE] Length 3 cm Width 2 cm Depth 0 cm ruptured blister that is drying out . L medial knee Blister date of onset [DATE] Length 2.5 cm Width 2.5 cm Depth 0 cm . ruptured blister that is drying out .Right Trochanter (hip) blister date of onset [DATE] Length 5 cm Width 3.5 cm Depth 0 cm unstageable Wound bed Black Eschar Drainage small amount Color serosanguinous Wound edges Black Left Trochanter (hip) Blister Length 9.5 Width 7 cm Depth 0 unstageable Wound bed Black Drainage scant amount Color serosanguinous Wound edges Black Response to Treatment No Change Treatment Plan Continue. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) revealed L/R hip R/L medial knees, pressure R buttock, multiple wounds .Left hand wound (palm) .Left hand (back) Blister .Left shoulder (rear) pressure ulcer Length 1.6 cm Width 2.5 cm Depth 0 cm. Unstageable . Rt medi lower leg B Blister Length 2.0 cm Width 1.5 cm .Rt medi lower leg A blister Length 3.0 cm Width 2.0 cm .Left medial knee pressure ulcer Length 1.0 cm Width 1.3 cm Depth 0.1 cm Stage II . Lt medial upper back Pressure ulcer Length 1.5 cm Width 1.0 cm Unstageable .Left back Pressure ulcer Length 2.0 cm Width 2.5 cm Unstageable .Left lateral ankle Pressure Ulcer Length 2.5 cm Width 0.5 cm Depth 0.1 cm Stage II .Left Hip Pressure Ulcer Length 8.0 cm Width 6.5 cm Unstageable .Right hip Pressure Ulcer .Stage N/A .Rt Knee pressure Ulcer Stage N/A .Skin-Weekly Non- Pressure Condition Record dated [DATE] . date of onset [DATE] L. ring finger Blister Length 2.3 cm Width 2.3 cm Depth 0 cm. fluid filled blister . L hand thumb Blister Length 7 cm Width 1 cm Depth 0 cm fluid filled blister .Left hand pinky finger Blister Length 1.7 cm Width 2 cm Depth 0cm Fluid filled blister .Left hand palm blister Length 8.5 cm Width 2.3 cm Depth 0 cm Fluid filled blister .Left hand (back) Blister Length 8 cm Width 5 cm Depth 0 cm Fluid filled blister with dark purple with clear fluid .L hand middle finger blister Length 3 cm Width 2.5 cm Depth 0 cm Fluid filled blister .Left hand index finger Length 7 cm Width .5 cm Depth 0 cm Clear fluid filled blister . R #1's Care Plan dated [DATE] revealed (R #1) is on (Hospice for dysphagia following cerebral infarction .do not initial CPR . On [DATE] at 2:18 p.m., observation accompanied by LVN C revealed R #1 was lying in bed on his back with his left hand swollen with draining blisters without a dressing. Left and right hip wounds with black eschar, left lateral ankle wound, left lateral lower leg wound, Right and left medial knee wounds, left posterior shoulder wound, left and right ear wounds, left medial tibial wound, right medial heel wound, Left coccyx wound and left buttock wound open without dressings. R #1 had an adult brief on and his linens were soiled with drainage from open wounds. LVN C said NP XX was in the facility today and removed R #1's dressings, at approximately 11:00 a.m. R #1's Urinary Catheter was not anchored. On [DATE] at 3:15 p.m., observation revealed LVN B and C were in R #1's room providing wound care. LVN B had gloves on, applied skin prep to Left malleolus and left lateral leg wounds, then applied a foam dressing, doffed gloves picked up foam dressing with her bare hands cut dressing to fit wound then placed foam dressing on the outer dressing packaging. LVN B donned clean gloves. LVN B did not wash hands in between glove changes. LVN B said NP XX had removed R #1's dressings at approximately 10:30 a.m.-11:00 a.m. during wound care rounds. LVN B said when she conducted rounds with NP XX, they go from patient to patient for wound care recommendations. Then the nurses have to go back and dress resident's wounds when all residents have been seen by NP XX. On [DATE] at 3:55 p.m. LVN B and C said leaving R #1's wounds open without dressings could place R #1 at risk for infection. R #1's Skin-Head to Toe Skin Checks dated [DATE] (late entry) Sacral/Bil/ Buttock/Coccyx Pressure ulcer date of onset [DATE] Length 8 cm Width 8 cm Depth 4 cm unstageable wound bed Red with slough Moderate amount of serous drainage odor present wound edges pink . Response to treatment Deteriorated Treatment Plan Continue . On [DATE] at 10:35 a.m., observation revealed on entering R #1's room LVN B was applying a foam dressing to R #1's Left hip wound. LVN B said she had to dress the Coccyx wound dressing. Surveyor requested wound care measurements on the right buttock/coccyx wound. LVN B said the wound was staged at 4 and that she was not a wound care nurse and had no formal training but would do the best she could do. LVN B cleansed the Right buttock/coccyx wound with wound cleanser and measured the wound L-7.0 cm x W-4.0 cm x D-4 cm, tunneling at 12:00 was at 5 cm. Surveyor observed wound was 60% yellow gray colored slough tissue with a foul odor. LVN B doffed dirty gloves after measuring wound coughed into left hand, donned a clean pair of gloves and applied foam dressing to right buttock/coccyx wound. LVN B did not wash her hands between glove changes. R #1's Urinary Catheter was not anchored. During would care CNA P lifted R #1's urinary catheter above R #1's bladder and surveyor observed urine back flow towards insertion site. On [DATE] at 12:40 p.m., Surveyor requested copies of written MD orders. DON said they were waiting for order clarification on NP XX's orders. On [DATE] at 12:55 p.m., interview with LVN B revealed she did not know if wound care orders were verified by the attending Physician or NP XX. LVN B said she had not been given direction form the ADON or the DON if wound care orders are accepted from NP XX. LVN B said she has never been trained on wound staging. LVN B said if she did not wash hands in between glove changes when performing would care that could place the resident at risk for infection. LVN B said by leaving R #1's wound open without dressings could place the resident at risk of infection. LVN B said if a resident's F/C was not anchored it could pull and cause injury. The DON said if a resident has a Urinary catheter it should not touch the floor and always be anchored and held below the bladder to prevent infection, dislodgement, trauma and other complications. On [DATE] at 1:15 p.m., interview with LVN A revealed she had training in wound care last year in 2016 but was never taught how to measure wounds. LVN A said wound orders are initially given from attending Physician, then the Physician refers NP XX for consultation, then NP XX changes the orders accordingly. The nurse that conducts rounds with NP XX obtains the verbal orders from NP XX and places the orders in the computer. LVN A said the consequences of leaving wounds open to air would be infection. On [DATE] at 2:05 p.m., interview with the DON said leaving wounds open to air without a dressing would place the resident at risk for infection. The DON said she would expect the nurse to provide the wound care when the order is received by the Physician. On [DATE] at 10:00 a.m., interview with NP XX said she had seen R #1 prior to admission to the facility and he only had two small reddened areas, last time she came to the facility to see R #1 he had 14 wounds. NP XX said the facility never had adequate supplies, and did not implement the wound orders or recommendations. NP XX recommended the facility obtain an air mattress for R #1 because of his high risk of skin breakdown and from week to week he developed more wounds. NP XX said R #1 developed pressure ulcers between his knees when the nurses could have just used a pillow between his knees to prevent the wounds. NP XX said she was horrified and that most of R #1's wounds were avoidable. NP XX said R #1's hand wounds looked as if they were caused by the resident was positioned on top of his hand resulting in a pressure ulcer. NP XX said she received a call on [DATE], from the facility for the first time since the wound care nurse left on [DATE] to clarify orders. NP XX said she makes wound care prevention and recommendations to the facility and does not provide wound care unless it is for debridement. NP XX said that when the facility had a wound care nurse he would always call and clarify orders. NP XX said when she makes recommendations for wound care, the next visit she finds her recommendations were never followed. NP XX said she was not surprised this surveyor found R #1 with no dressings applied to his open wounds. On [DATE] R #1's wound care observation beginning at 11:45 a.m. and resumed at 5:35 p.m., revealed R #1 had a total of 39 wounds treated and measured by LVN D and DON. On [DATE] at 11:00 a.m. interview with MD PP revealed R #1's wounds will not heal, MD PP said a wound VAC could help. MD PP said R #1 was terminal and was placed on Hospice this week. MD PP said in regards to R #1's wound care he would expect the nurses to follow physician's orders [REDACTED]. Interview with the DON on [DATE] at 3:09 p.m. revealed after she thoroughly assessed R #1's skin from head to toe on [DATE], she found that he had 39 separate pressure ulcers throughout his body. The DON acknowledged that some of the ulcers had not been identified or documented prior to the skin sweep. R #2: R #2's Face Sheet dated [DATE] documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted to the facility on [DATE], and discharged back to the hospital on [DATE]. R #2's [DIAGNOSES REDACTED]. R #2's Admission Nursing Admission Data Collection dated [DATE] documented Note all skin issues: Stage 2 to coccyx/buttock. Resident alert and oriented to person, time, and place, cognition intact. Oxygen at 2 lpm (liters per minute) via ns (nasal cannula) continuous. Foley catheter in place for [MEDICAL CONDITION] with lower urinary tract symptoms. Contractures present. Skin Issues: Coccyx Stage 2- open area with pink/red wound bed, no drainage noted (there were no measurements documented in the measurement section of this assessment). R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 15- at risk. R #2's Care Plan dated [DATE] documented: -(R #2) has venous stasis ulcer to right lower leg medial aspect. Also has pressure ulcer to right 4 and 5 digit he was admitted with .Interventions: Notify MD (Medical Doctor) of changes in wound or emerging wounds. Observe wound healing. Provide wound care per order. Skin checks weekly per facility protocol, document findings. Turn and reposition frequently to decrease pressure. -(R #2) has an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and limited mobility. Interventions: Encourage active participation in tasks. Provide cuing with tasks as needed. Bathing/Showering: the resident is totally dependent on ,[DATE] staff to provide bath/shower. Bed Mobility: the resident requires extensive assistance by ,[DATE] staff to turn and reposition in bed. Dressing: the resident requires extensive assistance by ,[DATE] staff for dressing. Personal Hygiene: the resident requires extensive assistance by ,[DATE] staff for personal hygiene and oral care Transfer: the resident is totally dependent on 2 staff for transferring. Encourage the resident to use bell to call for assistance. -(R #2) has impaired cognitive function . -(R #2) has DTI to left 4, 5, and 6th digit and surgical wound to abdomen he was admitted with. Interventions: Assess/record/observe wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Complete full body check weekly and document. Inform resident/family of new areas of skin breakdown. Low air loss mattress. Observe/document/report prn any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage. Reposition frequently. R #2's Skin-Head to Toe Skin Check dated [DATE] documented: -Left foot 4th digit: DTI 0.3 cm X 0.8 cm. -Left foot 5th digit: DTI 0.4 X 0.4 cm. -Left foot 3rd digit: DTI 1.5 cm X 2.0 cm. -Left Heel: DTI 2.5 cm X 4.5 cm . --R #2's Bilateral Buttocks/Coccyx/Sacrum ulcer was not documented on this record. R #2's Skin-Weekly Pressure Ulcer Record dated [DATE] Left Heel: Date of Onset: [DATE], existing pressure ulcer, admitted with pressure ulcer. 1.5 cm X 2.0 cm DTI, area resembles scab, no signs/symptoms (s/s) of infection. Wound bed appearance yellow, odor not present, wound edges normal for skin, area with yellow scab. Description of resident's response to current treatment: no change. --The documentation on this assessment of the description of the wound provided did not meet the definition of a DTI. R #2's Skin- Weekly Pressure Ulcer Record dated [DATE] documented Date of Onset: [DATE], existing pressure ulcer, admitted with. Location: Bilateral Buttock/Coccyx/Sacrum: Unstageable 20.0 cm X 12.0 cm. large area with partial red beefy tissue, partial yellow moist tissue. Wound bed description: other, Drainage: small serosanguineous, no odor present, no s/s of infection, wound edges: pink without maceration, surrounding skin: normal for skin. Response to Treatment: no change. R #2's Wound Care Specialist Consultation Note dated [DATE] documented: -Left Heel: Unstageable Pressure Ulcer/DTI 1.5 cm X 2.0 cm, wound bed 100% dark scab, periwound dry, scaly, sluggish, blanchable redness, boggy. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, cover with foam dressing every other day. -Bilateral Buttocks/Sacrum/Coccyx Unstageable Pressure Injury 20 cm X 12 cm X unknown depth, 75% moist necrotic tissue, 25% scattered granulation, periwound denuded, mild odor, moderate drainage. Treatment: cleanse with vashe (intended for use in cleansing, irrigating, moistening and [MEDICATION NAME] acute and chronic wounds) wound cleanser (blue bottle), pat dry with gauze, apply Triad cream, place ABD to glut fold . -Left 3rd Toe Suspected DTI (SDTI) 0.4 cm X 0.4 cm dark maroon discoloration, no redness, no drainage. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave open to air (OTA) QOD (every other day). -Left 4th Toe SDTI 0.3 cm X 0.4 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. - Left 5th Toe SDTI 0.3 cm X 0.8 cm dark maroon discoloration, no redness, no drainage, no odor. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, leave OTA QOD. --The facility's description of R #2's sacral ulcer on the Weekly Pressure Ulcer Record dated [DATE] did not include necrotic or black tissue. The description of the facility's measurements of the toes on the Weekly Pressure Ulcer Record dated [DATE] were significantly different than that of the NP XX's measurements. R #2's Admission Braden Scale for Predicting Pressure Sore Risk dated [DATE] documented a risk score of 10- High risk. R #2's Admission MDS dated [DATE] documented R #2 entered from acute hospital and had a BIMS score of 2 (severely impaired cognitive skills). R #2 required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. R #2 had an indwelling catheter and was always incontinent of bowel. R #2 was 73 inches tall, 208 pounds and had a feeding tube. R #2 was assessed to be at risk of developing pressure ulcers; R #2 had one Stage 3 pressure ulcer that was present upon admission/entry or reentry, one unstageable pressure ulcer present upon admission/entry or reentry, and four unstageable pressure ulcers with suspected deep tissue injury present upon admission/entry or reentry. The Stage 3 or unstageable pressure ulcer with the largest surface area measured 1.0 X 0.5 X 0.2 cm. The most severe type of tissue present in any pressure ulcer bed is slough. Skin and ulcer treatments: Pressure ulcer care, application of nonsurgical dressings, and applications of ointments/medications. R #2 was on oxygen therapy while not a resident and while a resident. R #2's Wound Care Specialist Consultation Note dated [DATE] documented: -Left Heel: Unstageable Pressure Ulcer/DTI 1.5 cm X 2.0 cm, wound bed 100% dark scab, periwound dry, scaly, sluggish, blanchable redness, boggy. Treatment: cleanse with normal saline, pat dry with gauze, sure prep, cover with foam dressing every other day. -Bilateral Buttocks/Sacrum/Coccyx(TRUNCATED)

Based on observation, interview, and record review the facility failed to provide the necessary care and services for one (R#2) of two Residents reviewed for surgical incisions, and three (R #1, R #2, and R #3) of three Residents reviewed for Indwelling Urinary Catheters to attain the highest practicable physical, mental and psychosocial well-being consistent with his quality of care. -The facility did not make attempt to request orders for treatment of [REDACTED]. When the facility recived order for R #2's surgical incision on 09/15/17, the orders were not inplemented. R #2 arrived to the hospital on [DATE] with embedded staples in place. -The facility did not ensure R #2's indwelling catheter and catheter drainage bag was in place for over a month. R #2's catheter drainage bag was not changed on 09/15/17 as ordered. R #2 arrived to the hospital with strong foul smelling urine and sediment deposited throughout the inner catheter tubing. -The facility did not ensure R #1's indwelling catheter tubing was secured to his leg and the catheter drainage bag was raised above R #1's bladder causing his urine to backflow, while receiving personal care. -The facility did not ensure R #3's indwelling catheter drainage bag was kept off the floor. This failure could affect four residents identified as having a surgical incision and six residents with indwelling urinary catheters at risk for pain, infections, [MEDICAL CONDITION]. The findings included: R #2: R #2's Face Sheet dated 09/19/17 documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted to the facility on [DATE], and discharged back to the hospital on [DATE]. R #2's [DIAGNOSES REDACTED]. R #2's Care Plan dated 07/17/17 documented: -(#2) has an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and limited mobility. -(R #2) has impaired cognitive function . -(R #2) has indwelling catheter for [MEDICAL CONDITION] and skin breakdown .Interventions: Anchor catheter to prevent excess tension, The resident has #16 french Foley Catheter. Position catheter bag and tubing below the level of the bladder, Check tubing for kinks, Observe/record/report to MD for signs/symptoms: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior . R #2's August 2017 Treatment Administration Record revealed R #2's Foley catheter drainage bag was changed on 08/16/17 as evidenced by an initialed entry. The record did not include instructions for R #2's surgical abdominal incision or staples. R #2's SBAR (Situation Background Assessment Request) Communication Form and Progress Note dated 08/07/17 documented The change in condition, symptoms, or signs: short of breath, O2 (oxygen) saturation low at 75% on 2 lpm (liters per minute), elevated blood pressure: 163/145. Transfer to hospital for evaluation and treat. R #2's Hospital Discharge Summary Report dated 08/23/17 documented admitted with recurrence diabetic ketoacidosis, septic shock. Previous admission had been for the same and he was discharged to (the nursing home) .His Stage 4 sacral decubitus ulcer present at last hospitalization was noted to have deteriorated. Plastic surgeon was consulted and patient underwent debridement on 08/13/17. He underwent diverting [MEDICAL CONDITION] on 08/18/17 to allow healing of his sacral ulcer, 12 staples intact . R #2's Admission Nursing Admission Data Collection dated 08/24/17 documented: Note all skin issues: Abdomen surgical incision- 12 cm X 1.0 cm; Right Iliac Crest (front) surgical incision- 3 cm X 2.0 cm. Notes: there is a surgery area to the abdomen wall and [MEDICAL CONDITION] area. The area has 12 staples. The area is pink in color .(No other skin conditions were identified on this assessment). R #2's 5-Day MDS dated [DATE] documented a BIMS score of 11. R #2 was totally dependent with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. R #2 had an indwelling catheter and a [MEDICAL CONDITION]. R #2 was 73 inches tall, 187 pounds and had a feeding tube. R #2 was assessed to be at risk of developing pressure ulcers; R #2 had one Stage 3 pressure ulcer that was present upon admission/entry or reentry, one unstageable pressure ulcer present upon admission/entry or reentry, and four unstageable pressure ulcers with suspected deep tissue injury present upon admission/entry or reentry. The Stage 3 or unstageable pressure ulcer with the largest surface area measured 10.0 X 8.0 X 6.0 cm. The most severe type of tissue present in any pressure ulcer bed is slough. Skin and ulcer treatments: Pressure reducing device for bed, Pressure ulcer care, application of nonsurgical dressings, applications of ointments/medications, application of dressing to feet. R #2 was on oxygen therapy while not a resident and while a resident. R #2's Order Summary Report dated September 2017 did not include any orders for monitoring or treatment of [REDACTED]. Catheter care with soap and water every shift related to [MEDICAL CONDITION] with lower Urinary Tract Symptoms. Change Foley catheter drainage bag every 15th of every month .Replace 16 french (fr)/ 10 ml foley cath as needed for to maintain patency . R #2's September 2017 Treatment Administration Record revealed R #2's Foley catheter drainage bag was changed on 09/15/17 as evidenced by an initialed entry. The record did not include instructions for R #2's surgical abdominal incision or staples. R #2's Skin-Head to Toe Skin Check dated 09/13/17 documented .Abdomen: Surgical incision 12.0 cm X 1.0 cm . --There was no mention of the staples in the documentation. R #2's Wound Care Specialist Consultation Note dated 09/15/17 documented Treatment/Recommendation: Remove all staples (abdomen 9 cm/9 staples, cleanse with wound cleanser, apply no sting skin prep .Air mattress, Pro-Mod 30 ml per [DEVICE] . --This order was not transferred to R #2's consolidated computerized orders or current Treatment Administration Record therefore R #2's staples were not removed. R #2's Transfer to hospital Note dated 09/19/17 at 11:43 a.m. documented Resident seemed very lethargic and was not responding in normal manner. Blood glucose was 546. Foley catheter . Attending Physician NP in the facility and made decision based on recent lab results and general look of resident that he would benefit from trip to the emergency room for further evaluation .Preparations made for transfer to hospital . R #2's Hospital Admission Consultation Report dated 09/19/17 documented Patient is a [AGE] year-old male unable to communicate and simply moans. He was found in the nursing home to have altered mental status and low blood pressure. In the Emergency Department (ED) he was found to be septic with [MEDICAL CONDITION](rapid heart rate), tachypnea (rapid respiratory rate), hypotensive (low blood pressure), and an elevated sodium level. There was an unstageable decubitus ulcer that the patient received a wound vac for on last admission. Review of his last hospital admission records indicated a recent admission in August [MEDICAL CONDITION] and [MEDICAL CONDITION] (high blood sodium levels). He has an unstageable decubitus ulcer that was debrided and was placed on a vac during last admission .His decubitus ulcer is worse now and has a very foul smell. The sacral wound culture specimen collected on admission grew five different organisms: [DIAGNOSES REDACTED] Pneumoniae, Pseudomonas Aeruginosa, Proteus Mirabilis, [MEDICAL CONDITION] Resistant Staphaureus, and [MEDICATION NAME] Avium. This source, along with his urine infection, being the source of [MEDICAL CONDITION] this admission. R #2's Hospital Urine Culture Speciman Report dated 09/19/17 revealed the culture grew Proteus Mirabilis. R #2's Hospital History and Physical dated 09/19/17 documented [AGE] year-old male found with altered mental status .He also has embedded surgical staples, presumably from the diverting [MEDICAL CONDITION] in August that were still in place.Of note, the patient came in with a Foley in place that was inserted/dated 08/16/17 placing patient in Intensive Care Unit (ICU) . Interview with MD NM on 09/22/17 at 10:35 a.m. revealed he assessed R #2 upon arrival to the hospital. MD NM said he recalled R #2 after assessing him and reading his last admission to the hospital in August. MD NM said R #2 had a bad urine infection and is septic from urine and sacral ulcer pressure ulcer infections. MD NM stated upon R #2's arrival to the hospital, his catheter was dated 08/16/17. MD NM said the nurses at the facility should have monitored the catheter, If they had been monitoring then they would have known he had an infection with the amount of sediment in the urine, the color of the urine, and the strong foul odor of the urine. When a nurse see's those symptoms, they should immediatly call the patient's physician for a urine culture, an antibiotic, and change of the catheter. MD NM stated R #2 underwent a diverting [MEDICAL CONDITION] on 08/18/17 and as a result had a abdominal incision with staples. MD NM stated R #2 returned to the hospital on [DATE] with the same staples in place, embedded in his skin with old dry crusted blood over each staple. It was difficult for the nurse to remove them because they were so embedded in the skin. Of course, trying to remove them caused him pain. MD NM said usually staples stay in place for approximately 10 days then removed. MD NM stated the facility should have followed up with R #2's surgeon or even his attending doctor for orders to remove the staples This is absolutely neglect and this definitely could have been avoidable if the ulcers had been treated properly and he had gotten his staples removed before skin started growing over them. Observation of R #2 on 09/22/17 at 10:45 a.m., in the hospital, revealed R #1 layed in the hospital bed with his eyes closed. R #2 had oxygen at 2 lpnc, the cannula tubing was padded behind the ears. R #2 had two seperate intravenous antibiotics infusing via his right intajugular central line. R #2 had a catheter drainage bag dated 09/19/17 with amber colored urine collected in the bag. Several attempts were made to engage R #2 into conversation but attempts were unsuccessful. R #2's nurse (RN NL) entered the hospital room and said R #2 minimally spoke words but the words were usually incomprehensible. RN NL stated she provided R #2 with pain medication rountinely every four hours due to R #2 moaning most of the time, especially when care was rendered or when repositioning. RN NL said she observed R #2 when he was admitted to the Intensive Care Unit (ICU) on 09/20/17 and he looked bad. RN NL said R #2 looked unclean and smelled of foul urine and rotten flesh. RN NL said his sacral pressure ulcer was almost completely black, grey, and yellow in color and was draining thick yellow/green/grey/red foul drainage. On 09/22/17 at 2:30 p.m., LVN A stated she cared for R #2 on 09/18/17 and 09/19/17, until he was transferred to the hospital at approximately noon. LVN A said she could not recall if R #2 had staples to his abdomen. The surveyor informed LVN A that R #2 arrived to the hospital with staples to his surgical abdominal incision. LVN A said she did not recall seeing any orders for treatment for [REDACTED]. Then LVN A said Oh yea, he did have staples. When asked at what point does she, being R #2's nurse, consult with the physician about the treatment of [REDACTED]. LVN A said she did not make an attempt to consult with the physician about R #2's abdominal incsion or staples. Interview with NP XX on 09/22/17 at 3:37 p.m. revealed she last saw R #2 on 09/15/17 in the facility. NP XX said she was a consultant for R #2's pressure ulcers, not for his surgical incsion. NP XX said she documented the site because that was what she saw when she assessed his skin. NP XX said she could not clearly recall but said she wrote an order for [REDACTED].#2's attending physician or surgeon for instructions to care for the site. On 09/22/17 at 5:05 p.m., interview with the DON revealed she was not aware of R #2 having abdominal staples. The DON was informed of R #2's staples being in place for a month. The DON responded I have seen, in some occassions, staples in place for a couple of weeks, it all depends on the physician. When asked what should happen if a resident entered the facility with no orders addressing the surgical site or staples, the DON said The nurse monitors it. Yes, a nurse should ask the physician if there were any orders for the site and staples on admission. The DON proceeded to say that NP XX was the wound care specialist and she did not say anything about the abdominal staples. The DON was informed of an order written [REDACTED]. The DON said staff should have implemented the order and did not know what happened that the order was not implemented. R #3: R #3's Admission Record dated 09/27/17 revealed R #3 was an [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. R #3's quarterly MDS dated [DATE] revealed R #3 had severely impaired cognition. R #3 required extensive assistance of one person for bed mobility and extensive assistance of two people for transfers. R #3 was frequently incontinent of bowel and had a urinary catheter. R #3's Care Plan date initiated 04/18/17 revealed I have problems with my bladder and use a foley catheter .Clean Foley with soap and water per orders .Change foley monthly per orders .Notify MD of signs ans symptoms of infection . R #3's Order Summary dated 09/27/17 revealed Foley Catheter as needed related to retention of urine .change Foley Cath and bag every 15th of every month On 09/22/17 at 2:50 p.m., during initial rounds accompanied by LVN C observation revealed R #3 lying in a low bed with his foley catheter on the floor. On 09/22/17 at 6:05 p.m. interview with LVN C said the consequences of R #3 having his foley catheter bag on the floor was that he could pull out his catheter and he should have a privacy bag. When Surveyor asked what else could happen with the foley bag on the floor LVN C said Infection? Surveyor said yes and LVN C said really? LVN C said she would change out the bag and figure out a way to keep the foley bag off the floor. R #1: R #1's Admission Record dated 07/24/17 revealed R #1 was a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. of onset for both left and right hip blisters was 08/10/17). R #1's admission MDS dated [DATE] revealed R #1 had severely impaired vision, R #1 did not have speech, rarely/never understood by others and rarely/never understood others. R #1 Cognitive skills for daily decision making and vision was severely impaired. R #1 was totally dependent with bed mobility, bathing and dressing requiring the assistance of two people. R #1 was assessed as having an indwelling urinary catheter and was frequently incontinent of bowel. R #1 was assessed as having a Feeding Tube and received 51% or more calories and 501 cc/day or more fluid intake through feeding tube. R #1 was assessed at risk for Pressure Ulcers and had two Deep Tissue Injuries present on admission. R #1's Care Plan dated 07/28/17 revealed (R #1) has unstageable pressure ulcer to right buttock or potential for pressure ulcer development r/t Immobility .07/27/17 Consult with Regional Wound Care to evaluate and treat .Administer treatments as ordered and observe for effectiveness . Has a foley catheter .Clean Foley with soap and water per orders .Change foley monthly per orders .Notify MD of signs ans symptoms of infection . On 09/22/17 at 2:18 p.m., observation accompanied by LVN C revealed R #1 was lying in bed on his back with his left hand swollen with draining blisters without a dressing. LVN C said NP XX was in the facility today and removed R #1's dressings, at approximately 11:00 a.m. R #1's Urinary Catheter was not anchored. On 09/23/17 at 10:35 a.m., observation revealed on entering R #1's room LVN B was applying a foam dressing to R #1's Left hip wound. R #1's Urinary Catheter was not anchored. During would care CNA P lifted R #1's urinary catheter above R #1's bladder and surveyor observed urine back flow towards insertion site. On 09/23/17 at 12:40 p.m., Surveyor requested copies of written MD orders. DON said they were waiting for order clarification on NP XX's orders. On 09/23/17 at 12:55 p.m., interview with LVN B revealed she did not know if wound care orders were verified by the attending Physician or NP XX. LVN B said if a resident's F/C was not anchored it could pull and cause injury. The DON said if a resident has a Urinary catheter it should not touch the floor and always be anchored and held below the bladder to prevent infection, dislodgement, trauma and other complications. The facility's Change in Resident Condition Policy and Procedure dated 02/2017 documented The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident;s condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. Guidelines: 1. For life-threatening events, call 911 if initial assessment indicates that such action is necessary. 2. Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention: a significant change in the resident's attending physical, mental or psychological status in either life threatening conditions or clinical complications; or a need to alter treatment significantly . 4. The SBAR Communication Form and the Progress Note are used to: a. Assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physician, and c. Provide clear comprehensive documentation. 3. Changes in condition are communicated from shift to shift through the 24 Hour Report. 4. Changes in the resident status that affect the problem(s)/goal(s) pr approach(es) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers. The facility's Centers for Medicare and Medicaid Services Form 672 dated 09/22/17 identified four residents with surgical incisions and six residents with catheters.

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for three (R #1, R #2, and R #3) of three Residents reviewed for Indwelling Urinary Catheters. -R #1's indwelling catheter tubing was not secured to his leg and the catheter drainage bag was raised above R #1's bladder causing his urine to backflow, while receiving personal care. -R #3's indwelling catheter drainage bag was on the floor. -R #2's indwelling catheter and catheter drainage bag was in place over a month. R #2's catheter drainage bag was not changed on 09/15/17 as ordered. R #2 arrived to the hospital with strong foul smelling urine and sediment deposited throughout the inner catheter tubing. These failures could place six residents with indwelling urinary catheters at risk for infections [MEDICAL CONDITION]. The findings included: R #2: R #2's Face Sheet dated 09/19/17 documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted to the facility on [DATE], and discharged back to the hospital on [DATE]. R #2's [DIAGNOSES REDACTED]. R #2's Admission Nursing Admission Data Collection dated 07/16/17 documented Note all skin issues: Stage 2 to coccyx/buttock. Resident alert and oriented to person, time, and place, cognition intact. Oxygen at 2 lpm (liters per minute) via ns (nasal cannula) continuous. Foley catheter in place for [MEDICAL CONDITION] with lower urinary tract symptoms. Contractures present. Skin Issues: Coccyx Stage 2- open area with pink/red wound bed, no drainage noted (there were no measurements documented in the measurement section of this assessment). R #2's Care Plan dated 07/17/17 documented: -(#2) has an ADL (Activities of Daily Living) self-care performance deficit related to fatigue and limited mobility. -(R #2) has impaired cognitive function . -(R #2) has indwelling catheter for [MEDICAL CONDITION] and skin breakdown .Interventions: Anchor catheter to prevent excess tension, The resident has #16 french Foley Catheter. Position catheter bag and tubing below the level of the bladder, Check tubing for kinks, Observe/record/report to MD for signs/symptoms: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior . R #2's August 2017 Treatment Administration Record revealed R #2's Foley catheter drainage bag was changed on 08/16/17 as evidenced by an initialed entry. R #2's Order Summary Report dated September 2017 documented Catheter care with soap and water every shift related to [MEDICAL CONDITION] with lower Urinary Tract Symptoms. Change Foley catheter drainage bag every 15th of every month .Replace 16 french (fr)/ 10 ml foley cath as needed for to maintain patency . R #2's September 2017 Treatment Administration Record revealed R #2's Foley catheter drainage bag was changed on 09/15/17 as evidenced by an initialed entry. R #2's Transfer to hospital Note dated 09/19/17 at 11:43 a.m. documented Resident seemed very lethargic and was not responding in normal manner. Blood glucose was 546. Foley catheter. Attending Physician NP in the facility and made decision based on recent lab results and general look of resident that he would benefit from trip to the emergency room for further evaluation .Preparations made for transfer to hospital . R #2's SBAR Communication Form and Progress Note dated 09/19/17 at 12:38 p.m. documented The change in condition, symptom, or signs: increased lethargy, not responding in a normal manner, elevated WBC (White Blood Cells) .Other pertinent history: Diabetes, Stage 4 sacral wound .Blood Pressure:112/82, Pulse: 98, Respirations: 14, oxygen saturation 96%, oxygen via nasal cannula .Transfer to hospital. R #2's Hospital Admission Consultation Report dated 09/19/17 documented Patient is a [AGE] year-old male unable to communicate and simply moans. He was found in the nursing home to have altered mental status and low blood pressure. In the Emergency Department (ED) he was found to be septic with [MEDICAL CONDITION](rapid heart rate), tachypnea (rapid respiratory rate), hypotensive (low blood pressure), and an elevated sodium level. Thick amber colored urine with sediment attached in tubing and strong foul odor. There was an unstageable decubitus ulcer that the patient received a wound vac for on last admission. Review of his last hospital admission records indicated a recent admission in August [MEDICAL CONDITION] and [MEDICAL CONDITION] (high blood sodium levels). He has an unstageable decubitus ulcer that was debrided and was placed on a vac during last admission .His decubitus ulcer is worse now and has a very foul smell. The sacral wound culture specimen collected on admission grew five different organisms: [DIAGNOSES REDACTED] Pneumoniae, Pseudomonas Aeruginosa, Proteus Mirabilis, [MEDICAL CONDITION] Resistant Staphaureus, and [MEDICATION NAME] Avium. This source, along with his urine infection, being the source of [MEDICAL CONDITION] this admission. R #2's Hospital Urine Culture Speciman Report dated 09/19/17 revealed the culture grew Proteus Mirabilis. R #2's Hospital History and Physical dated 09/19/17 documented [AGE] year-old male found with altered mental status .His decubitus ulcer to sacrum/buttocks is worse now (compared to his last discharge on 08/23/17) and has a very foul odor. This is the source [MEDICAL CONDITION]. The sacral ulcer was packed with dry gauze and pads that were foul smelling and appear to be at least many days old. After removal of packed dry dressings, attempted to perform wound care however, unsuccessful due to excessive bleeding of wound due to trauma from removal of dressings .Of note, the patient came in with a Foley in place that was inserted/dated 08/16/17 . placing patient in Intensive Care Unit (ICU) . Interview with MD NM on 09/22/17 at 10:35 a.m. revealed he assessed R #2 upon arrival to the hospital. MD NM said he recalled R #2 after assessing him and reading his last admission to the hospital in August. MD NM said R #2 had a bad urine infection and is septic from urine and sacral ulcer pressure ulcer infections. MD NM stated upon R #2's arrival to the hospital, his catheter was dated 08/16/17. MD NM said the nurses at the facility should have monitored the catheter, If they had been monitoring then they would have known he had an infection with the amount of sediment in the urine, the color of the urine, and the strong foul odor of the urine. When a nurse see's those symptoms, they should immediatly call the patient's physician for a urine culture, an antibiotic, and change of the catheter. This is absolutely neglect . Observation of R #2 on 09/22/17 at 10:45 a.m., in the hospital, revealed R #1 layed in the hospital bed with his eyes closed. R #2 had oxygen at 2 lpnc, the cannula tubing was padded behind the ears. R #2 had two seperate intravenous antibiotics infusing via his right intajugular central line. R #2 had a catheter drainage bag dated 09/19/17 with amber colored urine collected in the bag. Several attempts were made to engage R #2 into conversation but attempts were unsuccessful. R #2's nurse (RN NL) entered the hospital room and said R #2 minimally spoke words but the words were usually incomprehensible. RN NL stated she provided R #2 with pain medication rountinely every four hours due to R #2 moaning most of the time, especially when care was rendered or when repositioning. RN NL said she observed R #2 when he was admitted to the Intensive Care Unit (ICU) on 09/20/17 and he looked bad. RN NL said R #2 looked unclean and smelled of foul urine and rotten flesh. RN NL said his sacral pressure ulcer was almost completely black, grey, and yellow in color and was draining thick yellow/green/grey/red foul drainage. R #3: R #3's Admission Record dated 09/27/17 revealed R #3 was an [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. R #3's quarterly MDS dated [DATE] revealed R #3 had severely impaired cognition. R #3 required extensive assistance of one person for bed mobility and extensive assistance of two people for transfers. R #3 was frequently incontinent of bowel and had a urinary catheter. R #3's Care Plan date initiated 04/18/17 revealed I have problems with my bladder and use a foley catheter .Clean Foley with soap and water per orders .Change foley monthly per orders .Notify MD of signs ans symptoms of infection . R #3's Order Summary dated 09/27/17 revealed Foley Catheter as needed related to retention of urine .change Foley Cath and bag every 15th of every month On 09/22/17 at 2:50 p.m., during initial rounds accompanied by LVN C observation revealed R #3 lying in a low bed with his foley catheter on the floor. On 09/22/17 at 6:05 p.m. interview with LVN C said the consequences of R #3 having his foley catheter bag on the floor was that he could pull out his catheter and he should have a privacy bag. When Surveyor asked what else could happen with the foley bag on the floor LVN C said Infection? Surveyor said yes and LVN C said really? LVN C said she would change out the bag and figure out a way to keep the foley bag off the floor. R #1: R #1's Admission Record dated 07/24/17 revealed R #1 was a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. of onset for both left and right hip blisters was 08/10/17). R #1's admission MDS dated [DATE] revealed R #1 had severely impaired vision, R #1 did not have speech, rarely/never understood by others and rarely/never understood others. R #1 Cognitive skills for daily decision making and vision was severely impaired. R #1 was totally dependent with bed mobility, bathing and dressing requiring the assistance of two people. R #1 was assessed as having an indwelling urinary catheter and was frequently incontinent of bowel. R #1 was assessed as having a Feeding Tube and received 51% or more calories and 501 cc/day or more fluid intake through feeding tube. R #1 was assessed at risk for Pressure Ulcers and had two Deep Tissue Injuries present on admission. R #1's Care Plan dated 07/28/17 revealed (R #1) has unstageable pressure ulcer to right buttock or potential for pressure ulcer development r/t Immobility .07/27/17 Consult with Regional Wound Care to evaluate and treat .Administer treatments as ordered and observe for effectiveness . Has a foley catheter .Clean Foley with soap and water per orders .Change foley monthly per orders .Notify MD of signs ans symptoms of infection . On 09/22/17 at 2:18 p.m., observation accompanied by LVN C revealed R #1 was lying in bed on his back with his left hand swollen with draining blisters without a dressing. LVN C said NP XX was in the facility today and removed R #1's dressings, at approximately 11:00 a.m. R #1's Urinary Catheter was not anchored. On 09/23/17 at 10:35 a.m., observation revealed on entering R #1's room LVN B was applying a foam dressing to R #1's Left hip wound. R #1's Urinary Catheter was not anchored. During would care CNA P lifted R #1's urinary catheter above R #1's bladder and surveyor observed urine back flow towards insertion site. On 09/23/17 at 12:40 p.m., Surveyor requested copies of written MD orders. DON said they were waiting for order clarification on NP XX's orders. On 09/23/17 at 12:55 p.m., interview with LVN B revealed she did not know if wound care orders were verified by the attending Physician or NP XX. LVN B said if a resident's F/C was not anchored it could pull and cause injury. The DON said if a resident has a Urinary catheter it should not touch the floor and always be anchored and held below the bladder to prevent infection, dislodgement, trauma and other complications. The facility's Centers for Medicare and Medicaid Services Form 672 dated 09/22/17 identified six residents with catheters.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents, for one Resident (R#6) of six residents reviewed for accidents and hazards. -The facility did not supervise R #6 while in the Shower Room on 08/01/16, she fell , sustained a laceration to her head, and was hospitalized ; -The facility did not implement the safety measures of locking the Shower Room/Restroom/Dressing Room doors after R #6's fall; and -The facility did not identify R #6, her wheelchair or room as her being on the Falling Star Program as of 08/02/16. R #6 was paranoid and afraid of falling to the point of not wanting to ambulate and use her walker, as she previously did. This failure could place all 72 residents who were identified by the facility as being independently mobile and three residents identified as independent in bathing at risk for serious injuries. The findings included: R #6's Face Sheet dated 08/24/16 documented an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #6's Quarterly Minimum Date Set ((MDS) dated [DATE] documented R #6 -had adequate hearing and vision; -made self understood and understood others; -had a Brief Interview of Mental Status (BIMS) score of zero (no staff assessment of mental status was conducted); -her self-performance for bathing/shower was totally dependent with one person physical assistance; and -was not steady, but able to stabilize without staff assistance during walking and transitions. Used a walker. R #6's Situation Background Assessment Request (SBAR) Communication Form dated 04/29/16 documented Found resident sitting on floor, next to her bed, resident stated she was getting up to go to bedroom, resident also stated she was very weak to lower extremities, and she unable to stand, she sit herself on floor, resident disconnected her bed alarm, head to toe assessment done, no head injuries, no c/o (complaints of) pain, continue to redirect on bed alarm and call light, time and place. R #6's physician's orders [REDACTED]. R #6's most current ADL (Activities of Daily Living) Care Plan revised 07/13/16 documented (R #6) has an ADL self-care performance deficit related to fatigue and disease process. (R #6) will maintain current level of function in ADL's through 10/12/16. Interventions: .Bathing/Showering: The resident requires extensive assistance by one staff with bathing/showering three times per week and as necessary- date initiated 03/25/16. Dressing: The resident requires limited assistance by one staff to dress- date initiated 03/25/16 . R #6's Cognitive Care Plan revised 07/13/16 documented (R #6) has impaired cognitive function/dementia or impaired thought processes. Interventions: .Cue, reorient and supervise as needed .The resident needs assistance with all decision making- date initiated 02/29/16. R #6's Risk for Fall Care Plan revised 07/13/16 documented (R #6) is moderate risk for falls related to psychoactive drug use/Parkinson's. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance- date initiated: 03/01/16. On the Falling Star Program- date initiated 08/02/16. R #6's Fall Risk assessment dated [DATE] documented a score of 13. The assessment documented a score of 10 or higher indicates at risk. R #6's SBAR Communication Form dated 08/01/16 documented Observed resident on floor in shower room at approximately 4:30 p.m. This nurse and CNA (Certified Nurse Aide) from (local hospice company) heard a yell and thump from the shower. Resident found alert, awake laying on her right side. Resident with large deep laceration to upper right eyebrow with moderate amount of blood on floor and bruising to right shoulder. Resident denied pain to right lower extremity and was able to stand with two person assistance. Resident transferred to (local hospital) via ambulance. R #6's Hospital History and Physical dated 08/02/16 documented History of Present Illness: This patient is an [AGE] year-old female .who states that she was not feeling well today felt somewhat dizzy, was standing in the shower and loss of balance approximately sometime before 5:00 p.m. Apparently, there was an aide somewhere behind her that came to help, but could not sustain her and she fell forward causing a laceration above her right eyebrow and presents to the emergency room for further workup and recommendations .Physical Examination: Neurological: She was alert to self, did not know time and place. She did speak appropriately. She did have good word usage and finding. There were no other gross neurological deficits. Speech was clear .Assessment and Plan: Fall, likely secondary to urinary tract infection. Sutures to laceration. We will admit for observation . R #6's Fall Risk assessment dated [DATE] documented a score of 15. The assessment documented a score of 10 or higher indicates at risk. R #6's Incident/Accident Investigation Follow-Up Report dated 08/02/16 documented: Description of Incident/Accident: Resident observed on floor in Shower Room at 4:30 p.m. A yell and thump were heard. Resident alert, laying on right side, head to toe done, large deep laceration to upper right eyebrow, bruise right shoulder. Summary of Investigation/Reasonable Conclusion: Resident slipped in shower, received a laceration to upper right eyebrow, bruised right shoulder. No complaints of pain, stood up with assist. Sent to emergency room for evaluation. Past Interventions Attempted: 04/29/16- had a fall. Anticipate and meet resident needs. Be sure call light in reach. Resident placed on Fall Prevention Program. Recommendations/New Interventions: Fall Prevention Program. The report did not indicate if there were any witnesses. R #6's Fall Risk Care Plan revised 08/10/16 documented (R #6) has actual safety and /or fall risk related to actual fall and/or history of falls. Resident will be free of falls or fall related injury thru next review 10/12/16. Interventions: Falling Star Program- date initiated 08/02/16 and Initiate safety checks as indicated- date initiated 08/02/16. R #6's Progress Note dated 08/04/16 at 12:20 p.m. documented Received resident via stretcher per ambulance. No family accompanied. Resident awake and alert. Resident right eye sutures above eyebrow and large bruise to entire right eye and temple area back beyond hair, 9 sutures noted at this time. Large bruise to right shoulder, elbow and ribs . R #6's Incident/Accident Report dated 08/11/16 documented Resident was using her walker after being instructed to stay in her bed. She got out of bed, went to the sink and fell on her left side. R #6's Incident/Accident Investigation Follow-Up dated 08/11/16 conducted by the Assistant Director of Nurses (ADON) documented Description of Incident/Accident: Resident was using her walker after being instructed to stay in her bed. She got out of bed, went to the sink and fell on her left side. Summary of Investigation: Resident fell going from bed to sink with her walker. Resident was laying on floor on her left side. No apparent injuries at this time. Past Interventions Attempted: PT/OT (Physical Therapy/Occupational Therapy) five times a week. Fall prevention program. Falling Star Program, Initiate Safety Checks, Bed Alarm. Recommendations/New Interventions: Ordered larger bed alarm pad for bed. The Incident/Accident Report or Investigation Follow-Up did not document whether R #6's bed alarm was functioning or in place when she sustained her fall. R #6's Actual Fall Care Plan dated 08/02/16 and revised 08/24/16 revealed (R #6) has had an actual fall (08/01/16) with minor injury related to unsteady gait. Interventions: Fall Prevention Program- date initiated 08/02/16. Environmental rounds conducted on 08/24/16 at 10:14 a.m. revealed the fourth floor Dressing Room door was unlocked. The Dressing Room was connected and led to the Restroom which connected to and led to the Shower Room. The Shower Room revealed a small floor tile that was cracked and missing broken pieces causing an uneven surface located beneath the shower head. A cracked tile was located to the left of the shower's drain and two more cracked tiles were located at each doorway of the Shower Room. The Shower Room contained a white two drawer container filled with washcloths and bathing toiletries (shaving cream, body wash, and shavers) positioned in front of the Shower Room door blocking access to the door entrance/exit. Observation of R #6 on 08/24/16 at 10:55 a.m. revealed R #6 sat in a wheelchair on the fourth floor dining room then propelled herself to her bedroom; R #6 held each arm rest of her wheelchair tightly. R #6 was alert and able to correctly state her name and location. R #6 was not able to correctly state the day, date or time. R #6's right upper eyebrow had a scar approximately three centimeters in length. R #6 stated she received the scar on her eyebrow a couple of weeks ago from a fall. R #6 said her shower days were Monday, Wednesday, and Friday's between 6:00 a.m. to 2:00 p.m. R #6 said she was supposed to receive her shower in the morning of the day of her fall but did not get one. R #6 said she asked staff on a couple of occasions if she could take her shower but staff kept telling her to wait. R #6 said the second shift staff came in and she asked the nurse and a Certified Nurse Aide (CNA) for permission to shower and she was told maybe later. R #6 said she was in her room and then a female CNA entered her room and asked her if she was ready for her shower. R #6 stated she used her rolling walker to follow the CNA to the shower room. R #6 said once she entered the shower room, the CNA said she would be right back but never returned. R #6 said she remembered she began to shower herself then everything went black. R #6 said she did not recall how or why she fell . R #6 said she was sure a female staff entered the shower room with her. R #6 said she currently had pain to her right arm and her right temple and rated the pain at a 5 on a pain scale of 1 (least)-10 (most). R #6 said she was in constant fear of falling. R #6 said she no longer used her walker because she was afraid to fall. R #6 said she was afraid of falling just sitting in her wheelchair. R #6 said she did not think she was going to ever walk again because of her fear of falling due to the fall she sustained in the shower room. R #6 said she fell again in her room approximately one week ago. R #6 said she needed to go to the restroom and no one would come to help her so she attempted to get up from bed then fell . R #6 began crying and said she felt anxious and helpless not being able to walk because of fear of falling. R #6 was not able to identify or describe the person who entered the shower room with her nor the staff she asked to take a shower. R #6 could not recall if she received assistance or supervision with her showers prior to her fall but said she showered herself. Record review of the facility's Fourth Floor Shower Schedule dated 08/24/16 revealed R #6's shower days were Monday, Wednesday, and Friday on the 6:00 a.m.-2:00 p.m. shift. Interview with the ADON on 08/24/16 at 11:28 a.m. revealed R #6 had three falls in the last year- 04/29/16, 08/01/16, and 08/11/16. The ADON stated R #6 went to the shower room alone to take a shower and fell . The ADON said interventions placed after R #6's fall on 08/01/16 were: placing a bed alarm on her bed, beginning physical and occupational therapy, and keeping all access to the shower rooms locked at all times. The ADON explained prior to R #6's fall on 08/01/16, the fourth floor shower room was not required to be locked. The ADON said the shower room door automatically locked when closed and the key was hanging on the door frame beside the door knob and could be unlocked without removing the key from the hook because the beaded string was long enough to reach the lock. The ADON said the key was removed from the door frame and the charge nurse was responsible for holding the key. The ADON said all showers were supervised. The ADON said all the fourth floor staff were verbally told to ensure any door with access to the Shower Room was to remain locked at all times. At 11:40 a.m., the surveyor followed the ADON to the fourth floor shower room. The ADON opened the door to the Dressing Room that was not latched closed nor locked. The ADON said all access to the Shower Room including the Dressing Room should have been locked. The ADON closed the door to the Dressing Room and showed the surveyor the door locked when properly closed. The ADON and the surveyor observed the fourth floor Shower Room which revealed a small floor tile that was cracked and missing broken pieces causing an uneven surface located beneath the shower head. A cracked tile was located to the left of the shower's drain and two more cracked tiles were located at each doorway of the Shower Room. The ADON said the Maintenance Supervisor (MS) was made aware and was waiting for the replacement tiles to arrive. Interview with CNA B on 08/24/16 at 11:45 a.m. revealed she frequently cared for R #6. CNA B said she worked on 08/01/16 on the 6:00 a.m.-2:00 p.m. shift. CNA B said she could not recall if she or another CNA cared for R #6 on 08/01/16. CNA B confirmed R #6 should have had a shower the morning of 08/01/16 and recalled R #6 asking to take her shower. CNA B stated after returning from the hospital, R #6 told her someone took her to the shower room and then left her there. CNA B said prior to 08/01/16, R #6 was independent and used her rolling walker for mobility. CNA B stated R #6 would independently go to the shower room and if the shower was being used, she would wait in the Dressing Room for her turn. CNA B said R #6 showered herself and staff just supervised her. CNA B said R #6 was currently using a wheelchair. CNA B said R #6 was scared of falling. CNA B explained R #6 tensed and hesitated whenever a transfer occurred. CNA B said R #6 tensed up and put her feet on the floor when staff steered her wheelchair because she was afraid of falling out of the wheelchair. Interview with CNA C on 08/24/16 at 3:41 p.m. revealed she frequently cared for R #6 on the 2:00 p.m.-10:00 p.m. shift. CNA C stated she worked on 08/01/16 but could not recall if she was responsible for caring for R #6 that day. CNA C said she was providing care for another resident when she heard R #6 fell in the Shower Room. CNA C said at approximately 4:00 p.m., R #6 told her she was still waiting for her shower. CNA C said she did not observe R #6 enter the shower room. CNA C explained R #6 no longer used her rolling walker because she was afraid of falling. CNA C said R #6 currently used a wheelchair but was even afraid of falling out of the wheelchair. Interview with Licensed Vocational Nurse (LVN) D on 08/24/16 at 3:58 p.m. revealed she cared for R #6 on 08/01/16 from 2:00 p.m.-10:00 p.m. LVN D said she only had two CNAs for the shift to care for approximately 50 residents, which made providing care for the residents, very difficult. LVN D said at the beginning of her shift, R #6 asked to take a shower. LVN D said she told R #6 staff would have to try to shower her later. LVN D said at approximately 4:30 p.m., she and a CNA from a hospice agency (CNA E) were at the nurses station. LVN D said she and CNA E heard a yell and thump coming from the Shower Room located across from the nurses station. LVN D said she and CNA E entered the Shower Room through the unlocked door of the Dressing Room and found R #6 naked on the floor of the Shower Room. LVN D said R #6 was positioned on her right side with her head towards the Shower Room door and her feet towards the shower head. LVN D stated R #6 had an open laceration on the right side of her forehead that was bleeding. LVN D said R #6 was alert and oriented and stated she fell , as she cried. LVN D said CNA E applied pressure to R #6's laceration while she assessed R #6. LVN D stated she sent R #6 to the hospital for treatment to her laceration. LVN D said she did not see R #6 walk by the nurses station or enter the Shower Room. Interview with the Maintenance Supervisor (MS) on 08/25/16 at 9:29 a.m. revealed the surveyor followed the MS to the fourth floor Shower Room. The MS stated he was made aware of the cracked and broken floor tile approximately a couple of days after R #6 was found in the Shower Room. The MS said he found out about the cracked and broken tile via a morning meeting. The MS said he could not replace the tile if staff were going to continue to use the Shower Room because the floor needed to be dry and remain dry after the tile was replaced. The MS said staff continued to use the shower daily so he had to plan to replace the tile on a Sunday. The MS said he would attempt to place something on the uneven floor surface for the mean time. The MS said each floor had a Maintenance Log which he presented to the surveyor. The Surveyor and the MS reviewed the fourth floor Maintenance Log from 12/2015-08/25/16 which had no documentation of any cracked or broken Shower Room floor tile. The MS stated all Shower Room doors were meant to lock automatically once they closed. The MS stated the doors were kept locked to limit access to the Shower Room from the residents and visitors. Interview with the Director of Nurses (DON) on 08/25/16 at 9:48 a.m. revealed since R #6's fall, she implemented access to the Shower Room was to remain locked with the key removed from the door and held by the nurse. The DON said R #6 was started on PT/OT, and placed on the Falling Star Program. After presenting R #6's Fall Risk Care Plan revised 08/10/16 that documented safety checks to the DON, the DON stated That was no longer in place. That was the 15 minute neurological checks she would have had if she had remained in the facility but she was sent out to the hospital and did not return until 08/04/16. That should have indicated completed on her Care Plan. The DON said R #6 already had a bed alarm in place. Interview with CNA E on 08/25/16 at 9:54 a.m. revealed she did not work for the facility but did see certain residents residing in the facility receiving hospice services. CNA E said R #6 was not a residents she cared for. CNA E stated on 08/01/16 between 4:00 p.m.-4:30 p.m. she was standing at the nurse's station documenting and LVN D was sitting at the nurse's station also documenting. CNA E stated she heard a thump and then a yell coming from the Shower Room. CNA E said she and LVN D entered the unlocked door of the Dressing Room and found R #6 on the floor on her right side with her head towards the Shower Room door, bleeding from her right forehead area. CNA E said R #6's body was all soapy and suds throughout her hair. CNA E said she did not see R #6 walking toward or entering the Shower Room. CNA E stated approximately 10 minutes prior to R #6's discovery, CNA E entered the Dressing Room to throw a bag of dirty linen in the dirty linen barrel and heard the water running from the shower. CNA E said the curtain was pulled for privacy so she assumed staff was assisting someone to shower and then walked out. CNA E said she had been visiting residents of the facility for several years and said she assisted residents with showers at least two-three times a week. CNA E said the Dressing Room door was always left open or barely closed so the door would not lock for easy access. CNA E said the doors automatically lock but staff did not close the door entirely shut. CNA E said the Shower Room floors were usually slippery and toiletries were usually kept in the Shower Room. Interview with the Administrator on 08/25/16 at 10:39 a.m. revealed the facility did not have a policy and procedure in regards to whether access to the Shower/Restroom/Dressing Rooms should remain locked. The Administrator said slippery floors, cracked/broken floor tiles, and access to bathing supplies (shaving cream, body wash, and shavers) could be a fall hazard for some residents and staff. The Administrator said since R #6's fall, all access to Shower Rooms were to remain locked at all times. Interview with Rehabilitation Program Manager (RPM) on 08/25/16 at 10:43 a.m. revealed her department began therapy with R #6 since her return from the hospital. The RPM said R #6 was ambulating using a rolling walker prior to her fall but now used a wheelchair. The RPM said R #6 was Very fearful to fall. She is hesitant and paranoid that she id going to fall. The RPM said R #6's therapy would continue for a total of 30 days in attempt to achieve her goal to ambulate with her rolling walker as she did prior to her fall. Interview with R #6's Family Member (FM) H on 08/25/16 at 10:58 a.m. revealed on the day of 08/01/16, she/he was a witness to R #6 asking a CNA and the nurse for a shower. The FM stated staff responded with we will do it later. FM H stated R #6's fall could have been prevented if staff would have bathed R #6 as she was scheduled. FM H said she/he also asked LVN A the afternoon of 08/01/16 when R #6 was going to have her bath because R #6 was getting frustrated but received no definite answer. FM H said it was possible that R #6 may have lost her balance by stepping in the uneven broken tile in the Shower Room. FM H stated R #6 had said staff usually left her alone in the Shower Room. FM H said R #6 said staff frequently escorted her to the Shower Room, assisted with water temperature regulation, and then left her alone as R #6 showered herself. FM H said R #6 had expressed, in the past, that she was scared to fall in the Shower Room because it was slippery. FM H stated R #6 had another fall on 08/11/16 due to staff not responding to R #6 in a timely manner. FM H said R #6 stated she needed to go to the restroom and was tired of waiting for staff to assist her. FM H stated a meeting with the DON on 08/02/16 revealed the facility would put safety measures in place to prevent a future fall such as keeping the shower rooms locked and fixing the shower room broken tiles to avoid unevenness. Interview with CNA F on 8/25/16 at 11:46 a.m. revealed she no longer worked on the fourth floor caring for residents and her current position was scheduling. CNA F said when she worked on the floor over a month ago, R #6 used to walk using her walker to the Shower Room and wait there to be showered. CNA F said R #6 would not wait to be called or escorted to the Shower Room but would wait for staff to regulate the water for her and provide her with towels and washcloths. Additional observation of R #6 on 08/25/16 at 12:09 p.m. revealed R #6 did not have any visual identifier on her person or her wheelchair identifying that she was on the Falling Star Program or recognizing she was a fall risk. CNA G said she recalled R #6 being a fall risk because she knew she had fallen a couple of times. CNA G said if a resident was on the Falling Star Program, their room name plate, bed overhead light, wheelchair, walker or wrist band would have a Falling Star sticker. CNA G inspected R #6 and her wheelchair and said she does not have a sticker. CNA G then walked to R #6's room and inspected R #6's room name plate, bed overhead light, and walker and said she does not have a Falling Star sticker. CNA G walked back to the dining room and approached R #6 and asked LVN A if R #6 was on the Falling Star Program. LVN A replied I think so, I'm not sure, check the Kardex. CNA G walked to the computer and showed the surveyor R #6's Care Plan that revealed she was on the Falling Star Program. CNA G approached LVN A and informed LVN A that R #6 was on the Falling Star Program. LVN A asked CNA G to find a Falling Star sticker and provide R #6 with one. Interview with the DON on 08/25/16 at 4:02 p.m. revealed she was informed of the surveyor's findings of the unlocked Shower/Restroom/Dressing Room on the fourth floor, R #6 not having a Falling Star identifier, and the fourth floor Shower Room floor with broken tile. The DON said she would immediately Get that taken care of. The DON admitted she did not follow-up to ensure the interventions remained in effect. The facility's Fall Management Policy and Procedure dated 08/2012 documented If a fall occurs, the IDT (Interdisciplinary Team) conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .When a resident is found on the floor, the facility is obligated to investigate to determine how he or she got there and put place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred .Event of a fall the Plan of Care for the resident will address this outcome. Fall Event: 1. When a fall occurs, assess resident for injury. 2. The Licensed Nurse will complete and Incident/Accident Report, 24 Hour Report, and initiate the Post Fall Review . 4. The nurse will communicate the resident fall to the IDT via the 24 Hour Report. 5. The IDT will review all resident falls within 24-72 hours at the morning IDT meeting to evaluate circumstances and probable cause of fall . 7. The IDT modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. 8. The IDT will be responsible for placing and removing residents on/off the Falling Star Program. Falling Star Program: 1. The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. 2. Visual identifiers will assist the facility staff as well as family and visitors to identify those residents that are at risk for falls, ad to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall. 3. Placement on the Falling Star Program a. Newly admitted residents b. Residents identified at risk c. IDT determination If a resident is identified for the program, a falling star symbol will be placed on any or all of the locations below: a. over the bed b. On assistive devices- wheelchair, walker c. Identification Band . 5. Each facility is responsible for implementing individualized interventions related to/for each resident's fall risks. 6. Residents that experience actual falls will be reviewed each week during the At-Risk Review Meeting. 7. The At-Risk Review Committee members will review weekly all residents with falls for documentation, compliance, and interventions. 8. After the At-Risk Review Meeting, the IDT will perform the follow-up items assigned as indicated by the review. Fall Management Program: Complete Fall Risk Assessment, Institute Falling Star, IDT Review, if Resident Identified at Risk, Refer to Rehab Services, Continue Fall Management, Program/Falling Star, Educate resident, family. and staff. If resident fall: Complete Documentation: Incident/Accident Report, Start Post Fall Review, Change of Condition, 24 Hour Report, ECMB. Notification to: Physician, Family/Responsible Party, IDT via 24-Hour Report. Institute Falling Star, Update Fall Care Plan, and Resident Care Specialist Assignment Sheet/Care Kardex. According to a list provided by the DON on 08/25/16, the facility identified 72 residents as independently mobile and the facility's Centers for Medicare and Medicaid Services 672 Form dated 07/24/16 identified three residents independent in bathing.

Based on observation, interview, and record review, the facility failed to implement their policies and procedures that prohibit neglect for one Resident (R #6), of six residents reviewed for neglect. -The facility did not supervise R #6 while in the Shower Room on 08/01/16, she fell , sustained a laceration to her head, and was hospitalized ; -The facility did not implement the safety measures of locking the Shower Room/Restroom/Dressing Room doors after R #6's fall; and -The facility did not identify R #6, her wheelchair or room as her being on the Falling Star Program as of 08/02/16. R #6 was paranoid and afraid of falling to the point of not wanting to ambulate and use her walker, as she previously did. These failures could place all 72 residents who were identified by the facility as being independently mobile and three residents identified as independent in bathing at risk for serious injuries. The findings included: R #6's Face Sheet dated 08/24/16 documented an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #6's Quarterly Minimum Date Set ((MDS) dated [DATE] documented R #6 -had adequate hearing and vision; -made self understood and understood others; -had a Brief Interview of Mental Status (BIMS) score of zero (no staff assessment of mental status was conducted); -her self-performance for bathing/shower was totally dependent with one person physical assistance; and -was not steady, but able to stabilize without staff assistance during walking and transitions. Used a walker. R #6's Situation Background Assessment Request (SBAR) Communication Form dated 04/29/16 documented Found resident sitting on floor, next to her bed, resident stated she was getting up to go to bedroom, resident also stated she was very weak to lower extremities, and she unable to stand, she sit herself on floor, resident disconnected her bed alarm, head to toe assessment done, no head injuries, no c/o (complaints of) pain, continue to redirect on bed alarm and call light, time and place. R #6's physician's orders [REDACTED]. R #6's most current ADL (Activities of Daily Living) Care Plan revised 07/13/16 documented (R #6) has an ADL self-care performance deficit related to fatigue and disease process. (R #6) will maintain current level of function in ADL's through 10/12/16. Interventions: .Bathing/Showering: The resident requires extensive assistance by one staff with bathing/showering three times per week and as necessary- date initiated 03/25/16. Dressing: The resident requires limited assistance by one staff to dress- date initiated 03/25/16 . R #6's Cognitive Care Plan revised 07/13/16 documented (R #6) has impaired cognitive function/dementia or impaired thought processes. Interventions: .Cue, reorient and supervise as needed .The resident needs assistance with all decision making- date initiated 02/29/16. R #6's Risk for Fall Care Plan revised 07/13/16 documented (R #6) is moderate risk for falls related to psychoactive drug use/[MEDICAL CONDITION]. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance- date initiated: 03/01/16. On the Falling Star Program- date initiated 08/02/16. R #6's Fall Risk assessment dated [DATE] documented a score of 13. The assessment documented a score of 10 or higher indicates at risk. R #6's SBAR Communication Form dated 08/01/16 documented Observed resident on floor in shower room at approximately 4:30 p.m. This nurse and CNA (Certified Nurse Aide) from (local hospice company) heard a yell and thump from the shower. Resident found alert, awake laying on her right side. Resident with large deep laceration to upper right eyebrow with moderate amount of blood on floor and bruising to right shoulder. Resident denied pain to right lower extremity and was able to stand with two person assistance. Resident transferred to (local hospital) via ambulance. R #6's Hospital History and Physical dated 08/02/16 documented History of Present Illness: This patient is an [AGE] year-old female .who states that she was not feeling well today felt somewhat dizzy, was standing in the shower and loss of balance approximately sometime before 5:00 p.m. Apparently, there was an aide somewhere behind her that came to help, but could not sustain her and she fell forward causing a laceration above her right eyebrow and presents to the emergency room for further workup and recommendations .Physical Examination: Neurological: She was alert to self, did not know time and place. She did speak appropriately. She did have good word usage and finding. There were no other gross neurological deficits. Speech was clear .Assessment and Plan: Fall, likely secondary to urinary tract infection. Sutures to laceration. We will admit for observation . R #6's Fall Risk assessment dated [DATE] documented a score of 15. The assessment documented a score of 10 or higher indicates at risk. R #6's Incident/Accident Investigation Follow-Up Report dated 08/02/16 documented: Description of Incident/Accident: Resident observed on floor in Shower Room at 4:30 p.m. A yell and thump were heard. Resident alert, laying on right side, head to toe done, large deep laceration to upper right eyebrow, bruise right shoulder. Summary of Investigation/Reasonable Conclusion: Resident slipped in shower, received a laceration to upper right eyebrow, bruised right shoulder. No complaints of pain, stood up with assist. Sent to emergency room for evaluation. Past Interventions Attempted: 04/29/16- had a fall. Anticipate and meet resident needs. Be sure call light in reach. Resident placed on Fall Prevention Program. Recommendations/New Interventions: Fall Prevention Program. The report did not indicate if there were any witnesses. R #6's Fall Risk Care Plan revised 08/10/16 documented (R #6) has actual safety and /or fall risk related to actual fall and/or history of falls. Resident will be free of falls or fall related injury thru next review 10/12/16. Interventions: Falling Star Program- date initiated 08/02/16 and Initiate safety checks as indicated- date initiated 08/02/16. R #6's Progress Note dated 08/04/16 at 12:20 p.m. documented Received resident via stretcher per ambulance. No family accompanied. Resident awake and alert. Resident right eye sutures above eyebrow and large bruise to entire right eye and temple area back beyond hair, 9 sutures noted at this time. Large bruise to right shoulder, elbow and ribs . R #6's Incident/Accident Report dated 08/11/16 documented Resident was using her walker after being instructed to stay in her bed. She got out of bed, went to the sink and fell on her left side. R #6's Incident/Accident Investigation Follow-Up dated 08/11/16 conducted by the Assistant Director of Nurses (ADON) documented Description of Incident/Accident: Resident was using her walker after being instructed to stay in her bed. She got out of bed, went to the sink and fell on her left side. Summary of Investigation: Resident fell going from bed to sink with her walker. Resident was laying on floor on her left side. No apparent injuries at this time. Past Interventions Attempted: PT/OT (Physical Therapy/Occupational Therapy) five times a week. Fall prevention program. Falling Star Program, Initiate Safety Checks, Bed Alarm. Recommendations/New Interventions: Ordered larger bed alarm pad for bed. The Incident/Accident Report or Investigation Follow-Up did not document whether R #6's bed alarm was functioning or in place when she sustained her fall. R #6's Actual Fall Care Plan dated 08/02/16 and revised 08/24/16 revealed (R #6) has had an actual fall (08/01/16) with minor injury related to unsteady gait. Interventions: Fall Prevention Program- date initiated 08/02/16. Environmental rounds conducted on 08/24/16 at 10:14 a.m. revealed the fourth floor Dressing Room door was unlocked. The Dressing Room was connected and led to the Restroom which connected to and led to the Shower Room. The Shower Room revealed a small floor tile that was cracked and missing broken pieces causing an uneven surface located beneath the shower head. A cracked tile was located to the left of the shower's drain and two more cracked tiles were located at each doorway of the Shower Room. The Shower Room contained a white two drawer container filled with washcloths and bathing toiletries (shaving cream, body wash, and shavers) positioned in front of the Shower Room door blocking access to the door entrance/exit. Observation of R #6 on 08/24/16 at 10:55 a.m. revealed R #6 sat in a wheelchair on the fourth floor dining room then propelled herself to her bedroom; R #6 held each arm rest of her wheelchair tightly. R #6 was alert and able to correctly state her name and location. R #6 was not able to correctly state the day, date or time. R #6's right upper eyebrow had a scar approximately three centimeters in length. R #6 stated she received the scar on her eyebrow a couple of weeks ago from a fall. R #6 said her shower days were Monday, Wednesday, and Friday's between 6:00 a.m. to 2:00 p.m. R #6 said she was supposed to receive her shower in the morning of the day of her fall but did not get one. R #6 said she asked staff on a couple of occasions if she could take her shower but staff kept telling her to wait. R #6 said the second shift staff came in and she asked the nurse and a Certified Nurse Aide (CNA) for permission to shower and she was told maybe later. R #6 said she was in her room and then a female CNA entered her room and asked her if she was ready for her shower. R #6 stated she used her rolling walker to follow the CNA to the shower room. R #6 said once she entered the shower room, the CNA said she would be right back but never returned. R #6 said she remembered she began to shower herself then everything went black. R #6 said she did not recall how or why she fell . R #6 said she was sure a female staff entered the shower room with her. R #6 said she currently had pain to her right arm and her right temple and rated the pain at a 5 on a pain scale of 1 (least)-10 (most). R #6 said she was in constant fear of falling. R #6 said she no longer used her walker because she was afraid to fall. R #6 said she was afraid of falling just sitting in her wheelchair. R #6 said she did not think she was going to ever walk again because of her fear of falling due to the fall she sustained in the shower room. R #6 said she fell again in her room approximately one week ago. R #6 said she needed to go to the restroom and no one would come to help her so she attempted to get up from bed then fell . R #6 began crying and said she felt anxious and helpless not being able to walk because of fear of falling. R #6 was not able to identify or describe the person who entered the shower room with her nor the staff she asked to take a shower. R #6 could not recall if she received assistance or supervision with her showers prior to her fall but said she showered herself. Record review of the facility's Fourth Floor Shower Schedule dated 08/24/16 revealed R #6's shower days were Monday, Wednesday, and Friday on the 6:00 a.m.-2:00 p.m. shift. Interview with the ADON on 08/24/16 at 11:28 a.m. revealed R #6 had three falls in the last year- 04/29/16, 08/01/16, and 08/11/16. The ADON stated R #6 went to the shower room alone to take a shower and fell . The ADON said interventions placed after R #6's fall on 08/01/16 were: placing a bed alarm on her bed, beginning physical and occupational therapy, and keeping all access to the shower rooms locked at all times. The ADON explained prior to R #6's fall on 08/01/16, the fourth floor shower room was not required to be locked. The ADON said the shower room door automatically locked when closed and the key was hanging on the door frame beside the door knob and could be unlocked without removing the key from the hook because the beaded string was long enough to reach the lock. The ADON said the key was removed from the door frame and the charge nurse was responsible for holding the key. The ADON said all showers were supervised. The ADON said all the fourth floor staff were verbally told to ensure any door with access to the Shower Room was to remain locked at all times. At 11:40 a.m., the surveyor followed the ADON to the fourth floor shower room. The ADON opened the door to the Dressing Room that was not latched closed nor locked. The ADON said all access to the Shower Room including the Dressing Room should have been locked. The ADON closed the door to the Dressing Room and showed the surveyor the door locked when properly closed. The ADON and the surveyor observed the fourth floor Shower Room which revealed a small floor tile that was cracked and missing broken pieces causing an uneven surface located beneath the shower head. A cracked tile was located to the left of the shower's drain and two more cracked tiles were located at each doorway of the Shower Room. The ADON said the Maintenance Supervisor (MS) was made aware and was waiting for the replacement tiles to arrive. Interview with CNA B on 08/24/16 at 11:45 a.m. revealed she frequently cared for R #6. CNA B said she worked on 08/01/16 on the 6:00 a.m.-2:00 p.m. shift. CNA B said she could not recall if she or another CNA cared for R #6 on 08/01/16. CNA B confirmed R #6 should have had a shower the morning of 08/01/16 and recalled R #6 asking to take her shower. CNA B stated after returning from the hospital, R #6 told her someone took her to the shower room and then left her there. CNA B said prior to 08/01/16, R #6 was independent and used her rolling walker for mobility. CNA B stated R #6 would independently go to the shower room and if the shower was being used, she would wait in the Dressing Room for her turn. CNA B said R #6 showered herself and staff just supervised her. CNA B said R #6 was currently using a wheelchair. CNA B said R #6 was scared of falling. CNA B explained R #6 tensed and hesitated whenever a transfer occurred. CNA B said R #6 tensed up and put her feet on the floor when staff steered her wheelchair because she was afraid of falling out of the wheelchair. Interview with CNA C on 08/24/16 at 3:41 p.m. revealed she frequently cared for R #6 on the 2:00 p.m.-10:00 p.m. shift. CNA C stated she worked on 08/01/16 but could not recall if she was responsible for caring for R #6 that day. CNA C said she was providing care for another resident when she heard R #6 fell in the Shower Room. CNA C said at approximately 4:00 p.m., R #6 told her she was still waiting for her shower. CNA C said she did not observe R #6 enter the shower room. CNA C explained R #6 no longer used her rolling walker because she was afraid of falling. CNA C said R #6 currently used a wheelchair but was even afraid of falling out of the wheelchair. Interview with Licensed Vocational Nurse (LVN) D on 08/24/16 at 3:58 p.m. revealed she cared for R #6 on 08/01/16 from 2:00 p.m.-10:00 p.m. LVN D said she only had two CNAs for the shift to care for approximately 50 residents, which made providing care for the residents, very difficult. LVN D said at the beginning of her shift, R #6 asked to take a shower. LVN D said she told R #6 staff would have to try to shower her later. LVN D said at approximately 4:30 p.m., she and a CNA from a hospice agency (CNA E) were at the nurses station. LVN D said she and CNA E heard a yell and thump coming from the Shower Room located across from the nurses station. LVN D said she and CNA E entered the Shower Room through the unlocked door of the Dressing Room and found R #6 naked on the floor of the Shower Room. LVN D said R #6 was positioned on her right side with her head towards the Shower Room door and her feet towards the shower head. LVN D stated R #6 had an open laceration on the right side of her forehead that was bleeding. LVN D said R #6 was alert and oriented and stated she fell , as she cried. LVN D said CNA E applied pressure to R #6's laceration while she assessed R #6. LVN D stated she sent R #6 to the hospital for treatment to her laceration. LVN D said she did not see R #6 walk by the nurses station or enter the Shower Room. Interview with the Maintenance Supervisor (MS) on 08/25/16 at 9:29 a.m. revealed the surveyor followed the MS to the fourth floor Shower Room. The MS stated he was made aware of the cracked and broken floor tile approximately a couple of days after R #6 was found in the Shower Room. The MS said he found out about the cracked and broken tile via a morning meeting. The MS said he could not replace the tile if staff were going to continue to use the Shower Room because the floor needed to be dry and remain dry after the tile was replaced. The MS said staff continued to use the shower daily so he had to plan to replace the tile on a Sunday. The MS said he would attempt to place something on the uneven floor surface for the mean time. The MS said each floor had a Maintenance Log which he presented to the surveyor. The Surveyor and the MS reviewed the fourth floor Maintenance Log from 12/2015-08/25/16 which had no documentation of any cracked or broken Shower Room floor tile. The MS stated all Shower Room doors were meant to lock automatically once they closed. The MS stated the doors were kept locked to limit access to the Shower Room from the residents and visitors. Interview with the Director of Nurses (DON) on 08/25/16 at 9:48 a.m. revealed since R #6's fall, she implemented access to the Shower Room was to remain locked with the key removed from the door and held by the nurse. The DON said R #6 was started on PT/OT, and placed on the Falling Star Program. After presenting R #6's Fall Risk Care Plan revised 08/10/16 that documented safety checks to the DON, the DON stated That was no longer in place. That was the 15 minute neurological checks she would have had if she had remained in the facility but she was sent out to the hospital and did not return until 08/04/16. That should have indicated completed on her Care Plan. The DON said R #6 already had a bed alarm in place. Interview with CNA E on 08/25/16 at 9:54 a.m. revealed she did not work for the facility but did see certain residents residing in the facility receiving hospice services. CNA E said R #6 was not a residents she cared for. CNA E stated on 08/01/16 between 4:00 p.m.-4:30 p.m. she was standing at the nurse's station documenting and LVN D was sitting at the nurse's station also documenting. CNA E stated she heard a thump and then a yell coming from the Shower Room. CNA E said she and LVN D entered the unlocked door of the Dressing Room and found R #6 on the floor on her right side with her head towards the Shower Room door, bleeding from her right forehead area. CNA E said R #6's body was all soapy and suds throughout her hair. CNA E said she did not see R #6 walking toward or entering the Shower Room. CNA E stated approximately 10 minutes prior to R #6's discovery, CNA E entered the Dressing Room to throw a bag of dirty linen in the dirty linen barrel and heard the water running from the shower. CNA E said the curtain was pulled for privacy so she assumed staff was assisting someone to shower and then walked out. CNA E said she had been visiting residents of the facility for several years and said she assisted residents with showers at least two-three times a week. CNA E said the Dressing Room door was always left open or barely closed so the door would not lock for easy access. CNA E said the doors automatically lock but staff did not close the door entirely shut. CNA E said the Shower Room floors were usually slippery and toiletries were usually kept in the Shower Room. Interview with the Administrator on 08/25/16 at 10:39 a.m. revealed the facility did not have a policy and procedure in regards to whether access to the Shower/Restroom/Dressing Rooms should remain locked. The Administrator said slippery floors, cracked/broken floor tiles, and access to bathing supplies (shaving cream, body wash, and shavers) could be a fall hazard for some residents and staff. The Administrator said since R #6's fall, all access to Shower Rooms were to remain locked at all times. Interview with Rehabilitation Program Manager (RPM) on 08/25/16 at 10:43 a.m. revealed her department began therapy with R #6 since her return from the hospital. The RPM said R #6 was ambulating using a rolling walker prior to her fall but now used a wheelchair. The RPM said R #6 was Very fearful to fall. She is hesitant and paranoid that she id going to fall. The RPM said R #6's therapy would continue for a total of 30 days in attempt to achieve her goal to ambulate with her rolling walker as she did prior to her fall. Interview with R #6's Family Member (FM) H on 08/25/16 at 10:58 a.m. revealed on the day of 08/01/16, she/he was a witness to R #6 asking a CNA and the nurse for a shower. The FM stated staff responded with we will do it later. FM H stated R #6's fall could have been prevented if staff would have bathed R #6 as she was scheduled. FM H said she/he also asked LVN A the afternoon of 08/01/16 when R #6 was going to have her bath because R #6 was getting frustrated but received no definite answer. FM H said it was possible that R #6 may have lost her balance by stepping in the uneven broken tile in the Shower Room. FM H stated R #6 had said staff usually left her alone in the Shower Room. FM H said R #6 said staff frequently escorted her to the Shower Room, assisted with water temperature regulation, and then left her alone as R #6 showered herself. FM H said R #6 had expressed, in the past, that she was scared to fall in the Shower Room because it was slippery. FM H stated R #6 had another fall on 08/11/16 due to staff not responding to R #6 in a timely manner. FM H said R #6 stated she needed to go to the restroom and was tired of waiting for staff to assist her. FM H stated a meeting with the DON on 08/02/16 revealed the facility would put safety measures in place to prevent a future fall such as keeping the shower rooms locked and fixing the shower room broken tiles to avoid unevenness. Further interview with the DON on 08/25/16 at 11:35 a.m. revealed the surveyor asked the DON how she ruled out neglect in regards to R #6's fall. The DON said R #6 was assessed and sent to the hospital for treatment. When asked if R #6 had alleged a staff person assisted her to the Shower Room and then left her alone; the DON replied she did not know R #6 alleged a staff person left her in the Shower Room. The DON verified she met with R #6's Family Member and discussed ensuring all Shower Room doors remained locked and fixing the Shower Room broken tiles to prevent any other falls. The DON said she did not include the interventions in R #6's Care Plan. The DON stated she did not document the meeting with R #6's Family Member or the interventions promised during the meeting. Interview with CNA F on 8/25/16 at 11:46 a.m. revealed she no longer worked on the fourth floor caring for residents and her current position was scheduling. CNA F said when she worked on the floor over a month ago, R #6 used to walk using her walker to the Shower Room and wait there to be showered. CNA F said R #6 would not wait to be called or escorted to the Shower Room but would wait for staff to regulate the water for her and provide her with towels and washcloths. Additional observation of R #6 on 08/25/16 at 12:09 p.m. revealed R #6 did not have any visual identifier on her person or her wheelchair identifying that she was on the Falling Star Program or recognizing she was a fall risk. CNA G said she recalled R #6 being a fall risk because she knew she had fallen a couple of times. CNA G said if a resident was on the Falling Star Program, their room name plate, bed overhead light, wheelchair, walker or wrist band would have a Falling Star sticker. CNA G inspected R #6 and her wheelchair and said she does not have a sticker. CNA G then walked to R #6's room and inspected R #6's room name plate, bed overhead light, and walker and said she does not have a Falling Star sticker. CNA G walked back to the dining room and approached R #6 and asked LVN A if R #6 was on the Falling Star Program. LVN A replied I think so, I'm not sure, check the Kardex. CNA G walked to the computer and showed the surveyor R #6's Care Plan that revealed she was on the Falling Star Program. CNA G approached LVN A and informed LVN A that R #6 was on the Falling Star Program. LVN A asked CNA G to find a Falling Star sticker and provide R #6 with one. Interview with the DON on 08/25/16 at 4:02 p.m. revealed she was informed of the surveyor's findings of the unlocked Shower/Restroom/Dressing Room on the fourth floor, R #6 not having a Falling Star identifier, and the fourth floor Shower Room floor with broken tile. The DON said she would immediately Get that taken care of. The DON admitted she did not follow-up to ensure the interventions remained in effect. The facility's Fall Management Policy and Procedure dated 08/2012 documented If a fall occurs, the IDT (Interdisciplinary Team) conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .When a resident is found on the floor, the facility is obligated to investigate to determine how he or she got there and put place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred .Event of a fall the Plan of Care for the resident will address this outcome. Fall Event: 1. When a fall occurs, assess resident for injury. 2. The Licensed Nurse will complete and Incident/Accident Report, 24 Hour Report, and initiate the Post Fall Review . 4. The nurse will communicate the resident fall to the IDT via the 24 Hour Report. 5. The IDT will review all resident falls within 24-72 hours at the morning IDT meeting to evaluate circumstances and probable cause of fall . 7. The IDT modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. 8. The IDT will be responsible for placing and removing residents on/off the Falling Star Program. Falling Star Program: 1. The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. 2. Visual identifiers will assist the facility staff as well as family and visitors to identify those residents that are at risk for falls, ad to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall. 3. Placement on the Falling Star Program a. Newly admitted residents b. Residents identified at risk c. IDT determination If a resident is identified for the program, a falling star symbol will be placed on any or all of the locations below: a. over the bed b. On assistive devices- wheelchair, walker c. Identification Band . 5. Each facility is responsible for implementing individualized interventions related to/for each resident's fall risks. 6. Residents that experience actual falls will be reviewed each week during the At-Risk Review Meeting. 7. The At-Risk Review Committee members will review weekly all residents with falls for documentation, compliance, and interventions. 8. After the At-Risk Review Meeting, the IDT will perform the follow-up items assigned as indicated by the review. Fall Management Program: Complete Fall Risk Assessment, Institute Falling Star, IDT Review, if Resident Identified at Risk, Refer to Rehab Services, Continue Fall Management, Program/Falling Star, Educate resident, family. and staff. If resident fall: Complete Documentation: Incident/Accident Report, Start Post Fall Review, Change of Condition, 24 Hour Report, ECMB. Notification to: Physician, Family/Responsible Party, IDT via 24-Hour Report. Institute Falling Star, Update Fall Care Plan, and Resident Care Specialist Assignment Sheet/Care Kardex. The facility's Abuse and Neglect Prohibition Policy and Procedure dated 07/2016 documented Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect .Investigation: 1. The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state within 24 hours 4. The facility will investigate all patterns/trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property, identified through analysis conducted by the Quality Assurance Committee, with intervention, reporting, or policy/procedure modification conducted as appropriate According to a list provided by the DON on 08/25/16, the facility identified 72 residents as independently mobile and the facility's Centers for Medicare and Medicaid Services 672 Form dated 07/24/16 identified three residents independent in bathing.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit neglect and abuse, for one Resident (R#6), of six residents reviewed for neglect. -The facility did not supervise R #6 while in the Shower Room on 08/01/16, she fell , sustained a laceration to her head, and was hospitalized ; -The facility did not implement the safety measures of locking the Shower Room/Restroom/Dressing Room doors after R #6's fall; and -The facility did not identify R #6, her wheelchair or room as her being on the Falling Star Program as of 08/02/16. R #6 was paranoid and afraid of falling to the point of not wanting to ambulate and use her walker, as she previously did. 2.) The facility did not thoroughly investigate to determine how or the cause of R #6's fall. 3.) The facility did not report the fall R #6 sustained to the Department of Aging and Disability Services (DADS) for possible neglect. These failures could place all 72 residents who were identified by the facility as being independently mobile and three residents identified as independent in bathing at risk for serious injuries. The findings included: The facility's Fall Management Policy and Procedure dated 08/2012 documented If a fall occurs, the IDT (Interdisciplinary Team) conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .When a resident is found on the floor, the facility is obligated to investigate to determine how he or she got there and put place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred .Event of a fall the Plan of Care for the resident will address this outcome. Fall Event: 1. When a fall occurs, assess resident for injury. 2. The Licensed Nurse will complete and Incident/Accident Report, 24 Hour Report, and initiate the Post Fall Review . 4. The nurse will communicate the resident fall to the IDT via the 24 Hour Report. 5. The IDT will review all resident falls within 24-72 hours at the morning IDT meeting to evaluate circumstances and probable cause of fall. 6. Optional: Fall information may be added to the Electronic Care Management Board- ECMB if so desired for tracking purposes. 7. The IDT modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. 8. The IDT will be responsible for placing and removing residents on/off the Falling Star Program. Falling Star Program: 1. The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. 2. Visual identifiers will assist the facility staff as well as family and visitors to identify those residents that are at risk for falls, and to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall. 3. Placement on the Falling Star Program a. Newly admitted residents b. Residents identified at risk c. IDT determination If a resident is identified for the program, a falling star symbol will be placed on any or all of the locations below: a. over the bed b. On assistive devices- wheelchair, walker c. Identification Band . 5. Each facility is responsible for implementing individualized interventions related to/for each resident's fall risks. 6. Residents that experience actual falls will be reviewed each week during the At-Risk Review Meeting. 7. The At-Risk Review Committee members will review weekly all residents with falls for documentation, compliance, and interventions. 8. After the At-Risk Review Meeting, the IDT will perform the follow-up items assigned as indicated by the review. Fall Management Program: Complete Fall Risk Assessment, Institute Falling Star, IDT Review, if Resident Identified at Risk, Refer to Rehab Services, Continue Fall Management, Program/Falling Star, Educate resident, family. and staff. If resident fall: Complete Documentation: Incident/Accident Report, Start Post Fall Review, Change of Condition, 24 Hour Report, ECMB. Notification to: Physician, Family/Responsible Party, IDT via 24-Hour Report. Institute Falling Star, Update Fall Care Plan, and Resident Care Specialist Assignment Sheet/Care Kardex. The facility's Abuse and Neglect Prohibition Policy and Procedure dated 07/2016 documented Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect .Investigation: 1. The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state within 24 hours 4. The facility will investigate all patterns/trends, or incidents that suggest the possible presence of abuse, neglect, injuries of unknown origin, or misappropriation of property, identified through analysis conducted by the Quality Assurance Committee, with intervention, reporting, or policy/procedure modification conducted as appropriate R #6's Face Sheet dated 08/24/16 documented an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #6's Quarterly Minimum Date Set ((MDS) dated [DATE] documented R #6 -had adequate hearing and vision; -made self understood and understood others; -had a Brief Interview of Mental Status (BIMS) score of zero (no staff assessment of mental status was conducted); -her self-performance for bathing/shower was totally dependent with one person physical assistance; and -was not steady, but able to stabilize without staff assistance during walking and transitions. Used a walker. R #6's Situation Background Assessment Request (SBAR) Communication Form dated 04/29/16 documented Found resident sitting on floor, next to her bed, resident stated she was getting up to go to bedroom, resident also stated she was very weak to lower extremities, and she unable to stand, she sit herself on floor, resident disconnected her bed alarm, head to toe assessment done, no head injuries, no c/o (complaints of) pain, continue to redirect on bed alarm and call light, time and place. R #6's physician's orders [REDACTED]. R #6's most current ADL (Activities of Daily Living) Care Plan revised 07/13/16 documented (R #6) has an ADL self-care performance deficit related to fatigue and disease process. (R #6) will maintain current level of function in ADL's through 10/12/16. Interventions: .Bathing/Showering: The resident requires extensive assistance by one staff with bathing/showering three times per week and as necessary- date initiated 03/25/16. Dressing: The resident requires limited assistance by one staff to dress- date initiated 03/25/16 . R #6's Cognitive Care Plan revised 07/13/16 documented (R #6) has impaired cognitive function/dementia or impaired thought processes. Interventions: .Cue, reorient and supervise as needed .The resident needs assistance with all decision making- date initiated 02/29/16. R #6's Risk for Fall Care Plan revised 07/13/16 documented (R #6) is moderate risk for falls related to psychoactive drug use/[MEDICAL CONDITION]. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance- date initiated: 03/01/16. On the Falling Star Program- date initiated 08/02/16. R #6's Fall Risk assessment dated [DATE] documented a score of 13. The assessment documented a score of 10 or higher indicates at risk. R #6's SBAR Communication Form dated 08/01/16 documented Observed resident on floor in shower room at approximately 4:30 p.m. This nurse and CNA (Certified Nurse Aide) from (local hospice company) heard a yell and thump from the shower. Resident found alert, awake laying on her right side. Resident with large deep laceration to upper right eyebrow with moderate amount of blood on floor and bruising to right shoulder. Resident denied pain to right lower extremity and was able to stand with two person assistance. Resident transferred to (local hospital) via ambulance. R #6's Hospital History and Physical dated 08/02/16 documented History of Present Illness: This patient is an [AGE] year-old female .who states that she was not feeling well today felt somewhat dizzy, was standing in the shower and loss of balance approximately sometime before 5:00 p.m. Apparently, there was an aide somewhere behind her that came to help, but could not sustain her and she fell forward causing a laceration above her right eyebrow and presents to the emergency room for further workup and recommendations .Physical Examination: Neurological: She was alert to self, did not know time and place. She did speak appropriately. She did have good word usage and finding. There were no other gross neurological deficits. Speech was clear .Assessment and Plan: Fall, likely secondary to urinary tract infection. Sutures to laceration. We will admit for observation . R #6's Fall Risk assessment dated [DATE] documented a score of 15. The assessment documented a score of 10 or higher indicates at risk. R #6's Incident/Accident Investigation Follow-Up Report dated 08/02/16 documented: Description of Incident/Accident: Resident observed on floor in Shower Room at 4:30 p.m. A yell and thump were heard. Resident alert, laying on right side, head to toe done, large deep laceration to upper right eyebrow, bruise right shoulder. Summary of Investigation/Reasonable Conclusion: Resident slipped in shower, received a laceration to upper right eyebrow, bruised right shoulder. No complaints of pain, stood up with assist. Sent to emergency room for evaluation. Past Interventions Attempted: 04/29/16- had a fall. Anticipate and meet resident needs. Be sure call light in reach. Resident placed on Fall Prevention Program. Recommendations/New Interventions: Fall Prevention Program. The report did not indicate if there were any witnesses. R #6's Fall Risk Care Plan revised 08/10/16 documented (R #6) has actual safety and /or fall risk related to actual fall and/or history of falls. Resident will be free of falls or fall related injury thru next review 10/12/16. Interventions: Falling Star Program- date initiated 08/02/16 and Initiate safety checks as indicated- date initiated 08/02/16. R #6's Progress Note dated 08/04/16 at 12:20 p.m. documented Received resident via stretcher per ambulance. No family accompanied. Resident awake and alert. Resident right eye sutures above eyebrow and large bruise to entire right eye and temple area back beyond hair, 9 sutures noted at this time. Large bruise to right shoulder, elbow and ribs . R #6's Incident/Accident Report dated 08/11/16 documented Resident was using her walker after being instructed to stay in her bed. She got out of bed, went to the sink and fell on her left side. R #6's Incident/Accident Investigation Follow-Up dated 08/11/16 conducted by the Assistant Director of Nurses (ADON) documented Description of Incident/Accident: Resident was using her walker after being instructed to stay in her bed. She got out of bed, went to the sink and fell on her left side. Summary of Investigation: Resident fell going from bed to sink with her walker. Resident was laying on floor on her left side. No apparent injuries at this time. Past Interventions Attempted: PT/OT (Physical Therapy/Occupational Therapy) five times a week. Fall prevention program. Falling Star Program, Initiate Safety Checks, Bed Alarm. Recommendations/New Interventions: Ordered larger bed alarm pad for bed. The Incident/Accident Report or Investigation Follow-Up did not document whether R #6's bed alarm was functioning or in place when she sustained her fall. R #6's Actual Fall Care Plan dated 08/02/16 and revised 08/24/16 revealed (R #6) has had an actual fall (08/01/16) with minor injury related to unsteady gait. Interventions: Fall Prevention Program- date initiated 08/02/16. Environmental rounds conducted on 08/24/16 at 10:14 a.m. revealed the fourth floor Dressing Room door was unlocked. The Dressing Room was connected and led to the Restroom which connected to and led to the Shower Room. The Shower Room revealed a small floor tile that was cracked and missing broken pieces causing an uneven surface located beneath the shower head. A cracked tile was located to the left of the shower's drain and two more cracked tiles were located at each doorway of the Shower Room. The Shower Room contained a white two drawer container filled with washcloths and bathing toiletries (shaving cream, body wash, and shavers) positioned in front of the Shower Room door blocking access to the door entrance/exit. Observation of R #6 on 08/24/16 at 10:55 a.m. revealed R #6 sat in a wheelchair on the fourth floor dining room then propelled herself to her bedroom; R #6 held each arm rest of her wheelchair tightly. R #6 was alert and able to correctly state her name and location. R #6 was not able to correctly state the day, date or time. R #6's right upper eyebrow had a scar approximately three centimeters in length. R #6 stated she received the scar on her eyebrow a couple of weeks ago from a fall. R #6 said her shower days were Monday, Wednesday, and Friday's between 6:00 a.m. to 2:00 p.m. R #6 said she was supposed to receive her shower in the morning of the day of her fall but did not get one. R #6 said she asked staff on a couple of occasions if she could take her shower but staff kept telling her to wait. R #6 said the second shift staff came in and she asked the nurse and a Certified Nurse Aide (CNA) for permission to shower and she was told maybe later. R #6 said she was in her room and then a female CNA entered her room and asked her if she was ready for her shower. R #6 stated she used her rolling walker to follow the CNA to the shower room. R #6 said once she entered the shower room, the CNA said she would be right back but never returned. R #6 said she remembered she began to shower herself then everything went black. R #6 said she did not recall how or why she fell . R #6 said she was sure a female staff entered the shower room with her. R #6 said she currently had pain to her right arm and her right temple and rated the pain at a 5 on a pain scale of 1 (least)-10 (most). R #6 said she was in constant fear of falling. R #6 said she no longer used her walker because she was afraid to fall. R #6 said she was afraid of falling just sitting in her wheelchair. R #6 said she did not think she was going to ever walk again because of her fear of falling due to the fall she sustained in the shower room. R #6 said she fell again in her room approximately one week ago. R #6 said she needed to go to the restroom and no one would come to help her so she attempted to get up from bed then fell . R #6 began crying and said she felt anxious and helpless not being able to walk because of fear of falling. R #6 was not able to identify or describe the person who entered the shower room with her nor the staff she asked to take a shower. R #6 could not recall if she received assistance or supervision with her showers prior to her fall but said she showered herself. Record review of the facility's Fourth Floor Shower Schedule dated 08/24/16 revealed R #6's shower days were Monday, Wednesday, and Friday on the 6:00 a.m.-2:00 p.m. shift. Interview with the ADON on 08/24/16 at 11:28 a.m. revealed R #6 had three falls in the last year- 04/29/16, 08/01/16, and 08/11/16. The ADON stated R #6 went to the shower room alone to take a shower and fell . The ADON said interventions placed after R #6's fall on 08/01/16 were: placing a bed alarm on her bed, beginning physical and occupational therapy, and keeping all access to the shower rooms locked at all times. The ADON explained prior to R #6's fall on 08/01/16, the fourth floor shower room was not required to be locked. The ADON said the shower room door automatically locked when closed and the key was hanging on the door frame beside the door knob and could be unlocked without removing the key from the hook because the beaded string was long enough to reach the lock. The ADON said the key was removed from the door frame and the charge nurse was responsible for holding the key. The ADON said all showers were supervised. The ADON said all the fourth floor staff were verbally told to ensure any door with access to the Shower Room was to remain locked at all times. At 11:40 a.m., the surveyor followed the ADON to the fourth floor shower room. The ADON opened the door to the Dressing Room that was not latched closed nor locked. The ADON said all access to the Shower Room including the Dressing Room should have been locked. The ADON closed the door to the Dressing Room and showed the surveyor the door locked when properly closed. The ADON and the surveyor observed the fourth floor Shower Room which revealed a small floor tile that was cracked and missing broken pieces causing an uneven surface located beneath the shower head. A cracked tile was located to the left of the shower's drain and two more cracked tiles were located at each doorway of the Shower Room. The ADON said the Maintenance Supervisor (MS) was made aware and was waiting for the replacement tiles to arrive. Interview with CNA B on 08/24/16 at 11:45 a.m. revealed she frequently cared for R #6. CNA B said she worked on 08/01/16 on the 6:00 a.m.-2:00 p.m. shift. CNA B said she could not recall if she or another CNA cared for R #6 on 08/01/16. CNA B confirmed R #6 should have had a shower the morning of 08/01/16 and recalled R #6 asking to take her shower. CNA B stated after returning from the hospital, R #6 told her someone took her to the shower room and then left her there. CNA B said prior to 08/01/16, R #6 was independent and used her rolling walker for mobility. CNA B stated R #6 would independently go to the shower room and if the shower was being used, she would wait in the Dressing Room for her turn. CNA B said R #6 showered herself and staff just supervised her. CNA B said R #6 was currently using a wheelchair. CNA B said R #6 was scared of falling. CNA B explained R #6 tensed and hesitated whenever a transfer occurred. CNA B said R #6 tensed up and put her feet on the floor when staff steered her wheelchair because she was afraid of falling out of the wheelchair. Interview with CNA C on 08/24/16 at 3:41 p.m. revealed she frequently cared for R #6 on the 2:00 p.m.-10:00 p.m. shift. CNA C stated she worked on 08/01/16 but could not recall if she was responsible for caring for R #6 that day. CNA C said she was providing care for another resident when she heard R #6 fell in the Shower Room. CNA C said at approximately 4:00 p.m., R #6 told her she was still waiting for her shower. CNA C said she did not observe R #6 enter the shower room. CNA C explained R #6 no longer used her rolling walker because she was afraid of falling. CNA C said R #6 currently used a wheelchair but was even afraid of falling out of the wheelchair. Interview with Licensed Vocational Nurse (LVN) D on 08/24/16 at 3:58 p.m. revealed she cared for R #6 on 08/01/16 from 2:00 p.m.-10:00 p.m. LVN D said she only had two CNAs for the shift to care for approximately 50 residents, which made providing care for the residents, very difficult. LVN D said at the beginning of her shift, R #6 asked to take a shower. LVN D said she told R #6 staff would have to try to shower her later. LVN D said at approximately 4:30 p.m., she and a CNA from a hospice agency (CNA E) were at the nurses station. LVN D said she and CNA E heard a yell and thump coming from the Shower Room located across from the nurses station. LVN D said she and CNA E entered the Shower Room through the unlocked door of the Dressing Room and found R #6 naked on the floor of the Shower Room. LVN D said R #6 was positioned on her right side with her head towards the Shower Room door and her feet towards the shower head. LVN D stated R #6 had an open laceration on the right side of her forehead that was bleeding. LVN D said R #6 was alert and oriented and stated she fell , as she cried. LVN D said CNA E applied pressure to R #6's laceration while she assessed R #6. LVN D stated she sent R #6 to the hospital for treatment to her laceration. LVN D said she did not see R #6 walk by the nurses station or enter the Shower Room. Interview with the Maintenance Supervisor (MS) on 08/25/16 at 9:29 a.m. revealed the surveyor followed the MS to the fourth floor Shower Room. The MS stated he was made aware of the cracked and broken floor tile approximately a couple of days after R #6 was found in the Shower Room. The MS said he found out about the cracked and broken tile via a morning meeting. The MS said he could not replace the tile if staff were going to continue to use the Shower Room because the floor needed to be dry and remain dry after the tile was replaced. The MS said staff continued to use the shower daily so he had to plan to replace the tile on a Sunday. The MS said he would attempt to place something on the uneven floor surface for the mean time. The MS said each floor had a Maintenance Log which he presented to the surveyor. The Surveyor and the MS reviewed the fourth floor Maintenance Log from 12/2015-08/25/16 which had no documentation of any cracked or broken Shower Room floor tile. The MS stated all Shower Room doors were meant to lock automatically once they closed. The MS stated the doors were kept locked to limit access to the Shower Room from the residents and visitors. Interview with the Director of Nurses (DON) on 08/25/16 at 9:48 a.m. revealed she was responsible for the investigation of R #6's fall on 08/01/16. The DON stated her investigation included figuring out what we were going to do to prevent another fall. The DON said she was made aware of R #6's fall immediately after R #6 was found. The DON said she entered the Shower Room and found blood only on the floor and not anywhere else in the room. The DON said R #6 was found with her head on the tile floor so she must have cut her head on the floor. The DON said R #6 had a habit of going into the Shower Room by herself. The DON said she concluded (R #6) walked into the Shower Room independently, without anyone seeing her, began to shower herself, slipped, and fell . The surveyor asked the DON for her investigation documentation; the DON provided R #6's SBAR Communication Form dated 08/01/16 and R #6's Incident/Accident Investigation Follow-Up Report dated 08/02/16. The DON said she did not have any other witness statements other than the statement of LVN D on the SBAR. The DON said she did not interview R #6 because she was taken to the hospital. The DON said she did not investigate why R #6 did not receive a shower on 08/01/16 and confirmed R #6's bathing needs was not met on 08/01/16. The DON said R #6 had a habit of going into the Shower Room because she was told so by CNA F. The DON said she had not witnessed R #6 enter the Shower Room independently. The DON confirmed R #6 did not have a Care Plan to reflect her habit of independently entering the shower room alone but said she would immediately make up a Care Plan. The DON said since R #6's fall, she implemented access to the Shower Room was to remain locked with the key removed from the door and held by the nurse. The DON said R #6 was started on PT/OT, and placed on the Falling Star Program. After presenting R #6's Fall Risk Care Plan revised 08/10/16 that documented safety checks to the DON, the DON stated That was no longer in place. That was the 15 minute neurological checks she would have had if she had remained in the facility but she was sent out to the hospital and did not return until 08/04/16. That should have indicated completed on her Care Plan. The DON said R #6 already had a bed alarm in place. Interview with CNA E on 08/25/16 at 9:54 a.m. revealed she did not work for the facility but did provide care for certain residents residing in the facility receiving hospice services. CNA E said R #6 was not a resident she cared for. CNA E stated on 08/01/16 between 4:00 p.m.-4:30 p.m. she was standing at the nurse's station documenting and LVN D was sitting at the nurse's station also documenting. CNA E stated she heard a thump and then a yell coming from the Shower Room. CNA E said she and LVN D entered the unlocked door of the Dressing Room and found R #6 on the floor on her right side with her head towards the Shower Room door, bleeding from her right forehead area. CNA E said R #6's body was all soapy and suds throughout her hair. CNA E said she did not see R #6 walking toward or entering the Shower Room. CNA E stated approximately 10 minutes prior to R #6's discovery, CNA E entered the Dressing Room to throw a bag of dirty linen in the dirty linen barrel and heard the water running from the shower. CNA E said the curtain was pulled for privacy so she assumed staff was assisting someone to shower and then walked out. CNA E said she had been visiting residents of the facility for several years and said she assisted residents with showers at least two-three times a week. CNA E said the Dressing Room door was always left open or barely closed so the door would not lock for easy access. CNA E said the doors automatically lock but staff did not close the door entirely shut. CNA E said the Shower Room floors were usually slippery and toiletries were usually kept in the Shower Room. Interview with the Administrator on 08/25/16 at 10:39 a.m. revealed the facility did not have a policy and procedure in regards to whether access to the Shower Rooms should remain locked. The Administrator said slippery floors, cracked/broken floor tiles, and personal hygiene supplies could be a fall hazard for some residents and staff. The Administrator said since R #6's fall, access to Shower Rooms were to remain locked at all times. Interview with Rehabilitation Program Manager (RPM) on 08/25/16 at 10:43 a.m. revealed her department began therapy with R #6 since her return from the hospital. The RPM said R #6 was ambulating using a rolling walker prior to her fall but now used a wheelchair. The RPM said R #6 was Very fearful to fall. She is hesitant and paranoid that she id going to fall. The RPM said R #6's therapy would continue for a total of 30 days in attempt to achieve her goal to ambulate with her rolling walker as she did prior to her fall. Interview with R #6's Family Member (FM) H on 08/25/16 at 10:58 a.m. revealed on the day of 08/01/16, she/he was a witness to R #6 asking a CNA and the nurse for a shower. FM H stated staff responded with we will do it later. FM H stated R #6's fall could have been prevented if staff would have bathed R #6 as she was scheduled. FM H said she/he also asked LVN A the afternoon of 08/01/16 when R #6 was going to have her bath because R #6 was getting frustrated but received no definite answer. FM H said it was possible that R #6 may have lost her balance by stepping on the uneven broken tile in the Shower Room. FM H stated R #6 had said staff usually left her alone in the Shower Room. FM H said R #6 said staff frequently escorted her to the Shower Room, assisted with water temperature regulation, and then left her alone as R #6 showered herself. FM H said R #6 had expressed, in the past, that she was scared to fall in the Shower Room because it was slippery. FM H stated R #6 had another fall on 08/11/16 due to staff not responding to R #6 in a timely manner. FM H said R #6 stated she needed to go to the restroom and was tired of waiting for staff to assist her. FM H stated a meeting with the DON on 08/02/16 revealed the facility would put safety measures in place to prevent a future fall such as keeping the shower rooms locked and fixing the shower room broken tiles to avoid unevenness. Further interview with the DON on 08/25/16 at 11:35 a.m. verified she had no other documentary evidence of a thorough investigation of R #6's fall. The surveyor asked the DON how she ruled out neglect in regards to R #6's fall. The DON said R #6 was assessed and sent to the hospital for treatment. When asked if R #6 had alleged a staff person assisted her to the Shower Room and then left her alone; the DON replied she did not know R #6 alleged a staff person left her in the Shower Room. The DON verified she met with R #6's Family Member and discussed ensuring all Shower Room doors remained locked and fixing the Shower Room broken tiles to prevent any other falls. The DON said she did not include the interventions in R #6's Care Plan. The DON stated she did not document the meeting with R #6's Family Member or the interventions promised during the meeting. Interview with CNA F on 8/25/16 at 11:46 a.m. revealed she no longer worked on the fourth floor caring for residents and her current position was scheduling. CNA F said when she worked on the floor over a month ago, R #6 used to walk using her walker to the Shower Room and wait to be showered. CNA F said R #6 would not wait to be called or escorted to the Shower Room but would wait for staff to regulate the water for her and provide her with towels and washcloths. Additional observation of R #6, accompanied by CNA G, on 08/25/16 at 12:09 p.m. revealed R #6 did not have any visual identifier on her person or her wheelchair identifying that she was on the Falling Star Program or recognizing she was a fall risk. CNA G said she recalled R #6 being a fall risk because she knew she had fallen a couple of times. CNA G said if a resident was on the Falling Star Program, their room name plate, bed overhead light, wheelchair, walker or wrist band would have a Falling Star sticker. CNA G and the surveyor inspected R #6 and her wheelchair and said she does not have a sticker. CNA G and the surveyor then walked to R #6's room and inspected R #6's room name plate, bed overhead light, and walker and said she does not have a Falling Star sticker. CNA G and the surveyor walked back to the dining room and approached R #6 and asked LVN A if R #6 was on the Falling Star Program. LVN A replied I think so, I'm not sure, check the Kardex. CNA G and the surveyor walked to the computer and showed the surveyor R #6's Care Plan that revealed she was on the Falling Star Program. CNA G and the surveyor approached LVN A and CNA G informed LVN A that R #6 was on the Falling Star Program. LVN A asked CNA G to find a Falling Star sticker and provide R #6 with one. Interview with the DON on 08/25/16 at 4:02 p.m. revealed she did not have any other investigative documentation regarding R #6's 08/11/16 fall other than the Incident Report and the Incident/Accident Investigation Follow-Up. The DON verified that R #6's fall was not documented on her current Care Plan. The DON said the facility policy for a fall was To investigate/review the fall, make revisions to the Care Plan to include the date of fall and any interventions placed to prevent a future fall. The DON was informed of the surveyor's findings of the unlocked Shower Room, R #6 not having a Falling Star identifier, and the fourth floor Shower Room floor with broken tile. The DON said she would immediately Get that taken care of. The DON admitted she did not follow-up to ensure the interventions remained in effect. Interview with the Administrator on 08/25/16 at 4:30 p.m. revealed she stated she was not made aware of R #6's 08/01/16 fall until the surveyor asked questions about it. The Administrator explained she was on vacation when R #6's fall happened and was not told of the fall by the DON upon her arrival back to work on 08/22/16. The Administrator said if she had known of the incident, she would have ensured an in

Based on observation, interview and record review. The facility failed to implement its policies and procedures the prohibit neglect of residents for one Resident (R#1) of Five Residents reviewed for neglect. -R#1 was admitted to the the facility without a "pressure ulcer/necrotic flap". R#1 had a history of [REDACTED]. -The facility did not conduct weekly skin assessments according to R#1's care plan. -R#1 was admitted to the hospital on [DATE] with an unstageable "pressure ulcer" to the penis. The facility was not aware that R#1 had an "unstageable pressure ulcer" to his penis until the Surveyor brought it to their attention. This deficient practice resulted placed seven residents with behavioral symptoms at risk of skin breakdown due to not receiving assessments, care and services needed to prevent delay in treatment, complications and hospitalization . The Findings were: R#1's face sheet revealed admitted [DATE], [AGE] year old male, with the following Diagnoses: [REDACTED]. "Own Responsible Party." R#1's History and Physical dated 02/01/13 revealed current [DIAGNOSES REDACTED]. R#1's Care Plan- "Non-Pressure Ulcer Skin Impairment" dated 02/01/13 revealed "Problem ...Skin Impairment: actual, related to: sensory perception ...other. Goal: (R #1) skin impairment: Stasis ulcer Right anterior heel will heal without complications by 03/01/13 or next review 05/01/13. Approach: Observe skin weekly and document findings as indicated, Document observation of any non-pressure related skin impairments on facility Non-pressure Ulcer Wound documentation form. " (There was no date that Care Plan reviewed for weekly skin observations after 02/01/13.) R#1's Care Plan- " Behavioral Symptoms " dated 04/16/13, last date reviewed 04/18/13, 05/23/13 and 08/08/13 revealed " Problem ...Verbal Abuse ...Socially Inappropriate. Target Behaviors indicated include: Resident refuses his bath and care to change clothes. Goal: (R #1) will have decreased episodes of identified behaviors with to no more than 2 times per week through the next review: 90 days. Approach: Use firm, gentle voice, identify self to individual prior to initiating care. Give simple clear directions, repeat as needed. Ignore verbal outbursts, check for discomfort, pain, allow choices within individual's decision making abilities, and modify environment, situations, and / or treatment to minimize external stressors. Redirect as needed. Be alert for triggers of potential evidence of pending behavioral episodes. Notify M.D. as needed. Administer medications as ordered." R#1's Braden Scale assessment (tool used for predicting Pressure Sore Risk) dated 07/31/13 total score was 21. (Total score 12 or less represents a high risk). -There was no further evidence in documentation revealing additional Braden Scales were done on R#1 after 07/31/13. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed rejection of care one to three days; makes self understood, able to express ideas and wants, able to understand others with clear comprehension; one person physical assist for locomotion off unit and toileting, and bathing; no pressure ulcers or skin conditions, continent of bowel and bladder. R#1's Head to Toe Skin Checks revealed (dated) 09/03/13, 09/10/13, 10/21/13, 11/05/13, 11/12/13, 11/19/13 and 11/26/13. It was documented on 11/19/13 that R#1 had a peri- rash and that A&D ointment was applied. On 11/26/13 it was documented that resident "refused." - There was no further evidence by documentation that R #1 received skin assessments or staff attempted to perform weekly skin checks after 11/26/13. There was no documentation that R#1 received any teaching or instruction regarding consequences of refusal of care. -In the Month of October there was only one skin assessment documented. -In the month of September there were only two skin assessments documented. R #1's November 2013 Resident Bathing Type by Day Chart revealed resident took a shower the following dates in the month of November. 11/02/13, 11/05/13, 11/07/13, 11/09/13, 11/12/13, 11/13/13, 11/14/13, 11/16/13, 11/19/13, 11/21/13, 11/23/13, 11/29/13, and 11/30/13. It was documented on 11/16/13 that R#1 did take a shower. R #1's Nursing Notes dated 11/16/13 (2:00 p.m.-10:00 p.m.) revealed that the resident refused to take a shower."Resident refusing to take a bath, resident smells very bad. He was asked six times this shift to take a bath, resident stated, no. will continue to monitor." R #1's Nurses note dated 11/17/13 (2:00 p.m.-10:00 p.m.) revealed "Resident was asked to take a shower. Resident asked why? This nurse told resident that he smelled very bad. Resident replied that this nurse smells not him. Resident was re-directed and was asked to please take a shower and change his clothes. Resident said the hell with all of you! I am not taking a bath. Resident went to his room. Will continue to monitor." *There was no further documentation on nursing interventions that were attempted by staff to encourage R#1 to take a shower. R #1's Change of Condition form dated 12/01/13 at 8:00 a.m. revealed resident was found in his room with absent vital signs, non-responsive, and blue in color. 911 was dispatched and resident was sent to Hospital. On 12/05/13, review of Hospital emergency room (ER) electronic records dated 12/01/13 at 8:47 a.m. revealed R #1's penis had "necrotic tissue" (dead skin) "unstageable pressure ulcer" that measured 3(cm) centimeters by 4cm on the end of his penis, surrounding skin was "yellow slough tissue" (non-viable tissue). R #1's hospital laboratory results indicated an infection with the elevated White Blood Cell (WBC) count and a Kidney function impairment with an elevated Blood Urea Nitrogen (BUN) an elevated Creatinine and low Glomerular Filtration Rate (GFR). When placing the Urinary Catheter there was no urine output. emergency room Lab values; WBC= 14.8 Normal Values= (5-10) BUN=55 Normal Values= (8-23) Creatinine= 2.1 Normal Values= (0.7-1.3) GFR= 34 Normal Values= (>90-100) Confidential interviewee (CI) "LL" said, that it was impossible for R#1 to have had such an advanced "pressure sore" occur over the weekend. The end of his penis was a "necrotic flap" (dead tissue). The extent of the tissue damage on R #1's penis took a long time to advance to an "unstageable wound." CI "LL" said that a call was placed to the facility to ask if the staff knew that R#1 had a "pressure ulcer." CI "LL" said that staff at facility reported that R#1 received peri-care on 11/29/13 and that there were no reports of a skin change by staff. Review of Facility Policy and Procedure titled Skin Management (revision) dated: August 2012 revealed; -"Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." ....2. " Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with significant change of status for their risk for development of pressure sores. ....6. " Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address but is not limited to: *Hydration *Nutrition * Preventative devices * Physical Activity * Pain * Positioning requirements * Proper Body Alignment ....16. c. Skin assessment findings will be documented weekly on the Head to Toe Check form." On 12/06/13 at 9:00 a.m., the Director of Nurses (DON) said he was unaware of the "pressure ulcer" on R #1. The DON said, "I did not know that (R #1) had a "pressure ulcer." He was non-compliant with bathing and that is when we would have noticed the necrotic tissue. Skin assessments are done on all residents monthly. On 12/06/13 at 9:10 a.m., an interview was conducted with License Vocational Nurse (LVN) "C." LVN "C" reported that skin assessments were done on all residents in the facility one time a week and documented on the Head to Toe assessment record. LVN "C" said that she was on duty the day R#1 was sent to the hospital and that Medication Aide (MA) "H" discovered R#1 unresponsive and without a pulse. MA "H "called LVN "C" to the resident's room and Cardio-Pulmonary-Resuscitation was initiated. R #1 was sent to the hospital. LVN "C" said that she was unaware that R #1 had a "pressure ulcer" on his penis. R #1 received a bath on 11/29/13 by Certified Nurse's Aide (CNA) "I "and that the CNAs were supposed to report skin changes to the nurse. LVN"C" said that R #1 was non-compliant with care and the Physician was aware, but the facility was not given further instruction from the Physician on how to manage R #1's behavior. On 12/06/13 at 9:30 a.m. an interview was conducted with CNA "I.". CNA "I" said that all skin changes were reported to the charge nurse on duty. CNA "I" said she did not see any changes to R#1's skin during his shower on 11/29/13. CNA "I" said that R#1 provided his own Peri-care and that she would wash R#1's back and bottom. If R#1 refused a shower CNA "I" would report to the nurse and the nurse would talk the resident into a shower. R #1's November 2013 Resident Bathing Type by Day Chart revealed no evidence of documentation of a shower taken for five days: 11/24/13 through 11/28/13 and no documentation in Nursing Notes to reflect R#1's omission of a shower. On 12/05/13 at 3:25 p.m., an interview with CNA "K" revealed all skin changes found on residents during care were always reported to the Nurse on duty. On 12/05/13 at 4:00 p.m., an interview with CNA "J" revealed all skin changes found on residents during care were always reported directly to the Charge Nurse. On 12/05/13 at 5:35 p.m., an interview was conducted with the Director of Nurses (DON). The surveyor asked the DON what the facility did to address R #1's behavioral issues and where the updated care plan on R #1 regarding behavior was (Last update was 08/08/13). The DON said, "Some people call it behavioral issues but I call it that is just the way he is R #1 wanted to do what he wanted to do, he did not like rules. He was a nice guy but preferred to be alone. That was R#1's personality, he did not like to take a bath every day, if he wanted to smoke a cigarette or drink water he would do it. I don't think he cared about taking care of his health. R #1 was that way his entire life. We missed the Quarterly Care Plan on R#1 it should have been done." Review of Facility Job Description for CNAs revealed; consistently and promptly reporting resident changes of condition ... Review of Facility Job description for LVNs revealed; .....Communicates with Physicians regarding changes in resident's conditions, ....etc. Documents assessments and care in compliance with standards of care and company policy. Educates patients ...on health care issues. On 12/06/13 at 11:00 a.m. an observation was conducted to observe skin checks with LVN "D. " LVN "D" did a head to toe assessment on R#3 and documented findings on the facility Head to Toe Assessment Sheet. LVN "D" said all residents in the facility had a weekly Head to Toe assessment and it was documented on a skin sheet. LVN "D" said if a resident refused a skin assessment LVN "D" would try to talk the resident into the assessment and if they continued to refuse then she would notify the Doctor. The facility's Policy and Procedure titled Abuse & Neglect Prohibition dated (revision date) March 2009 under "Prevention #2 Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. #3 stated; Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect or misappropriation of resident property, and intervene as appropriate. Definitions: Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... The facility's Centers for Medicare and Medicaid Services form 802 identified seven residents with behavioral symptoms. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R #1's "pressure ulcer." As of exit on 12/06/13 at 2:00 p.m., the facility provided no further information.

Based on observation, interview and record review. The facility failed to implement written policies and procedures the prohibit neglect of residents provide services for two Residents (R#1 and R#2) of five Residents reviewed for neglect. R #1 -R#1 was admitted to the the facility without a "pressure ulcer/necrotic flap". R#1 had a history of [REDACTED]. -The facility did not conduct weekly skin assessments according to R#1's care plan. -R#1 was admitted to the hospital on [DATE] with an unstageable "pressure ulcer" to the penis. The facility was not aware that R#1 had an "unstageable pressure ulcer" to his penis until the Surveyor brought it to their attention. This deficient practice placed seven residents with behavioral symptoms at risk of skin breakdown due to not receiving assessments, care and services needed to prevent delay in treatment, complications and hospitalization . R #2 -Three staff members were aware of R#2's reported abuse allegation of being slapped by Family Member (FM) "P", and failed to report the allegation to the Administrator (Admin.). - The facility did not report the allegation to Department of Aging and Disability Services (DADS) - The facility did not have evidence the allegation was investigated. This deficient practice could affect 53 residents residing on the third floor and place them at risk for abuse. Findings were: The facility's Policy and Procedure titled Abuse & Neglect Prohibition dated (revision date) March 2009 under "Prevention #2 Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. #3 stated; Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect or misappropriation of resident property, and intervene as appropriate. Definitions:Physical Abuse includes hitting, slapping, pinching, and kicking...Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... Investigation: The facility will report all allegations to the State, as per state regulations. .....Investigation 1) The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance to law. 2) the facility will report such allegations to the state, as per state regulations. 3) The facility will report all investigative findings to the state as per state regulations." Texas Department of Aging and Disability Services Provider Letter #06-43 - Guidelines for Reporting Incidents, dated January 3, 2007 includes: The facility or facility staff member must report the following incidents (1-10) to the Consumer Rights and Services Section, DADS State Office, Austin, Texas, immediately (within 24 hours) upon learning of the incident... 1. ABUSE (as defined in 40 TAC ?19.101(1)) - For allegations of resident-to-resident abuse, refer to Attachment 2 and the accompanying flowchart. -For all other allegations of abuse, report to DADS. R#1 R#1's face sheet revealed admitted [DATE], [AGE] year old male, with the following Diagnoses: [REDACTED]. "Own Responsible Party." R#1's History and Physical dated 02/01/13 revealed current [DIAGNOSES REDACTED]. R#1's Care Plan- "Non-Pressure Ulcer Skin Impairment" dated 02/01/13 revealed "Problem ...Skin Impairment: actual, related to: sensory perception ...other. Goal: (R #1) skin impairment: Stasis ulcer Right anterior heel will heal without complications by 03/01/13 or next review 05/01/13. Approach: Observe skin weekly and document findings as indicated, Document observation of any non-pressure related skin impairments on facility Non-pressure Ulcer Wound documentation form. " (There was no date that Care Plan reviewed for weekly skin observations after 02/01/13.) R#1's Care Plan- " Behavioral Symptoms " dated 04/16/13, last date reviewed 04/18/13, 05/23/13 and 08/08/13 revealed " Problem ...Verbal Abuse ...Socially Inappropriate. Target Behaviors indicated include: Resident refuses his bath and care to change clothes. Goal: (R #1) will have decreased episodes of identified behaviors with to no more than 2 times per week through the next review: 90 days. Approach: Use firm, gentle voice, identify self to individual prior to initiating care. Give simple clear directions, repeat as needed. Ignore verbal outbursts, check for discomfort, pain, allow choices within individual's decision making abilities, and modify environment, situations, and / or treatment to minimize external stressors. Redirect as needed. Be alert for triggers of potential evidence of pending behavioral episodes. Notify M.D. as needed. Administer medications as ordered." R#1's Braden Scale assessment (tool used for predicting Pressure Sore Risk) dated 07/31/13 total score was 21. (Total score 12 or less represents a high risk). -There was no further evidence in documentation revealing additional Braden Scales were done on R#1 after 07/31/13. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed rejection of care one to three days; makes self understood, able to express ideas and wants, able to understand others with clear comprehension; one person physical assist for locomotion off unit and toileting, and bathing; no pressure ulcers or skin conditions, continent of bowel and bladder. R#1's Head to Toe Skin Checks revealed (dated) 09/03/13, 09/10/13, 10/21/13, 11/05/13, 11/12/13, 11/19/13 and 11/26/13. It was documented on 11/19/13 that R#1 had a peri- rash and that A&D ointment was applied. On 11/26/13 it was documented that resident "refused." - There was no further evidence by documentation that R #1 received skin assessments or staff attempted to perform weekly skin checks after 11/26/13. There was no documentation that R#1 received any teaching or instruction regarding consequences of refusal of care. -In the Month of October there was only one skin assessment documented. -In the month of September there were only two skin assessments documented. R #1's November 2013 Resident Bathing Type by Day Chart revealed resident took a shower the following dates in the month of November. 11/02/13, 11/05/13, 11/07/13, 11/09/13, 11/12/13, 11/13/13, 11/14/13, 11/16/13, 11/19/13, 11/21/13, 11/23/13, 11/29/13, and 11/30/13. It was documented on 11/16/13 that R#1 did take a shower. R #1's Nursing Notes dated 11/16/13 (2:00 p.m.-10:00 p.m.) revealed that the resident refused to take a shower."Resident refusing to take a bath, resident smells very bad. He was asked six times this shift to take a bath, resident stated, no. will continue to monitor." R #1's Nurses note dated 11/17/13 (2:00 p.m.-10:00 p.m.) revealed "Resident was asked to take a shower. Resident asked why? This nurse told resident that he smelled very bad. Resident replied that this nurse smells not him. Resident was re-directed and was asked to please take a shower and change his clothes. Resident said the hell with all of you! I am not taking a bath. Resident went to his room. Will continue to monitor." *There was no further documentation on nursing interventions that were attempted by staff to encourage R#1 to take a shower. R #1's Change of Condition form dated 12/01/13 at 8:00 a.m. revealed resident was found in his room with absent vital signs, non-responsive, and blue in color. 911 was dispatched and resident was sent to Hospital. On 12/05/13, review of Hospital emergency room (ER) electronic records dated 12/01/13 at 8:47 a.m. revealed R #1's penis had "necrotic tissue" (dead skin) "unstageable pressure ulcer" that measured 3(cm) centimeters by 4cm on the end of his penis, surrounding skin was "yellow slough tissue" (non-viable tissue). R #1's hospital laboratory results indicated an infection with the elevated White Blood Cell (WBC) count and a Kidney function impairment with an elevated Blood Urea Nitrogen (BUN) an elevated Creatinine and low Glomerular Filtration Rate (GFR). When placing the Urinary Catheter there was no urine output. emergency room Lab values; WBC= 14.8 Normal Values= (5-10) BUN=55 Normal Values= (8-23) Creatinine= 2.1 Normal Values= (0.7-1.3) GFR= 34 Normal Values= (>90-100) Confidential interviewee (CI) "LL" said, that it was impossible for R#1 to have had such an advanced "pressure sore" occur over the weekend. The end of his penis was a "necrotic flap" (dead tissue). The extent of the tissue damage on R #1's penis took a long time to advance to an "unstageable wound." CI "LL" said that a call was placed to the facility to ask if the staff knew that R#1 had a "pressure ulcer." CI "LL" said that staff at facility reported that R#1 received peri-care on 11/29/13 and that there were no reports of a skin change by staff. Review of Facility Policy and Procedure titled Skin Management (revision) dated: August 2012 revealed; -"Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." ....2. " Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with significant change of status for their risk for development of pressure sores. ....6. " Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address but is not limited to: *Hydration *Nutrition * Preventative devices * Physical Activity * Pain * Positioning requirements * Proper Body Alignment ....16. c. Skin assessment findings will be documented weekly on the Head to Toe Check form." On 12/06/13 at 9:00 a.m., the Director of Nurses (DON) said he was unaware of the "pressure ulcer" on R #1. The DON said, "I did not know that (R #1) had a "pressure ulcer." He was non-compliant with bathing and that is when we would have noticed the necrotic tissue. Skin assessments are done on all residents monthly. On 12/06/13 at 9:10 a.m., an interview was conducted with License Vocational Nurse (LVN) "C." LVN "C" reported that skin assessments were done on all residents in the facility one time a week and documented on the Head to Toe assessment record. LVN "C" said that she was on duty the day R#1 was sent to the hospital and that Medication Aide (MA) "H" discovered R#1 unresponsive and without a pulse. MA "H "called LVN "C" to the resident's room and Cardio-Pulmonary-Resuscitation was initiated. R #1 was sent to the hospital. LVN "C" said that she was unaware that R #1 had a "pressure ulcer" on his penis. R #1 received a bath on 11/29/13 by Certified Nurse's Aide (CNA) "I "and that the CNAs were supposed to report skin changes to the nurse. LVN"C" said that R #1 was non-compliant with care and the Physician was aware, but the facility was not given further instruction from the Physician on how to manage R #1's behavior. On 12/06/13 at 9:30 a.m. an interview was conducted with CNA "I.". CNA "I" said that all skin changes were reported to the charge nurse on duty. CNA "I" said she did not see any changes to R#1's skin during his shower on 11/29/13. CNA "I" said that R#1 provided his own Peri-care and that she would wash R#1's back and bottom. If R#1 refused a shower CNA "I" would report to the nurse and the nurse would talk the resident into a shower. R #1's November 2013 Resident Bathing Type by Day Chart revealed no evidence of documentation of a shower taken for five days: 11/24/13 through 11/28/13 and no documentation in Nursing Notes to reflect R#1's omission of a shower. On 12/05/13 at 3:25 p.m., an interview with CNA "K" revealed all skin changes found on residents during care were always reported to the Nurse on duty. On 12/05/13 at 4:00 p.m., an interview with CNA "J" revealed all skin changes found on residents during care were always reported directly to the Charge Nurse. On 12/05/13 at 5:35 p.m., an interview was conducted with the Director of Nurses (DON). The surveyor asked the DON what the facility did to address R #1's behavioral issues and where the updated care plan on R #1 regarding behavior was (Last update was 08/08/13). The DON said, "Some people call it behavioral issues but I call it that is just the way he is R #1 wanted to do what he wanted to do, he did not like rules. He was a nice guy but preferred to be alone. That was R#1's personality, he did not like to take a bath every day, if he wanted to smoke a cigarette or drink water he would do it. I don't think he cared about taking care of his health. R #1 was that way his entire life. We missed the Quarterly Care Plan on R#1 it should have been done." Review of Facility Job Description for CNAs revealed; consistently and promptly reporting resident changes of condition ... Review of Facility Job description for LVNs revealed; .....Communicates with Physicians regarding changes in resident's conditions, ....etc. Documents assessments and care in compliance with standards of care and company policy. Educates patients ...on health care issues. On 12/06/13 at 11:00 a.m. an observation was conducted to observe skin checks with LVN "D. " LVN "D" did a head to toe assessment on R#3 and documented findings on the facility Head to Toe Assessment Sheet. LVN "D" said all residents in the facility had a weekly Head to Toe assessment and it was documented on a skin sheet. LVN "D" said if a resident refused a skin assessment LVN "D" would try to talk the resident into the assessment and if they continued to refuse then she would notify the Doctor. The facility's Centers for Medicare and Medicaid Services form 802 identified seven residents with behavioral symptoms. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R #1's "pressure ulcer." As of exit on 12/06/13 at 2:00 p.m., the facility provided no further information. R#2 R #2's Face Sheet dated 08/19/13 revealed a [AGE] year old female admitted on [DATE] with the following diagnoses; Diabetes Type II, Coronary Artery Bypass, Generalized Pain, [MEDICAL CONDITION] (high cholesterol), [MEDICAL CONDITION] Pectoris (chest pain), and [MEDICAL CONDITION] Reflux (acid comes up to esophagus). R#2's Physician Telephone order dated 8/19/13 revealed, "Admit to LTC (Long Term Care) with Professional Hospice under ... DX (diagnosis): [MEDICAL CONDITION]." R#2's MDS dated [DATE] revealed active [DIAGNOSES REDACTED]. R #2's physician progress notes [REDACTED]. R#2's Minimum Data Set (MDS) dated ,[DATE] 13 revealed no cognitive, behavioral or mood problems; required one person assist for transfers, and was never married. Observation of R#2 on 12/04/13 at 2:12 p.m., 12/05/13 at 3:10 p.m. and 12/06/13 at 10:05 a.m., revealed R was wheelchair bound, had right sided weakness, was awake and able to converse with Surveyor. On 12/05/13 at 3:10 p.m., interview with R#2 revealed FM "P" assaulted her on 12/01/13. Resident said that FM "P" slapped her across the face because R#2 made FM "P" mad, and that FM "P" was only playing around. R #2's Nurse's Notes dated 12/03/13 at 7:30 a.m. revealed: "Hospice Chaplin informed nurse resident stated (FM "P") slapped resident. Chaplin stated he will call Adult Protective Services, (FM "P") not allowed to be alone in resident's room." R #2's Nurses Notes dated 12/04/13 through 12/05/13 revealed there was no further documentation of nursing intervention regarding the abuse allegation. The facility's Incident /Accident Log for November 2013 through December 2013 revealed no record of incident regarding R #2 on 12/01/13 being hit by FM "P" at the facility. On 12/04/13 at 3:55 p.m., interview with the Administrator (Admin.) revealed the Facility did not have any reportable incidents in the months of November or December. The Admin. said, "The only incident I heard of was that (R#2's FM "P"), threatened License Vocational Nurse (LVN "E") 12/02/13 and I was informed of this just yesterday by the Social Worker (SW)." On 12/04/13 at 4:10 p.m., an interview with LVN "E" revealed, she read on the 24 Hour nursing report on 12/02/13 at 9:00 a.m., R#2 was slapped in the face by FM "P." The Hospice Chaplin had reported the incident to LVN "G." LVN "E "said, she went to R #2 and questioned her about the allegation and R #2 denied that FM "P" had intentionally hit her. R#2 said FM "P" was only playing around. R#2's FM "P" showed up at the facility on 12/02/13 at 11:00 a.m. and wanted to take R#2 out on pass. LVN "E" consulted with the Facility SW and the SW said it was OK for the Resident to leave with FM "P." The SW was aware that FM "P" had slapped R#2. When R#2 returned to the Facility with FM "P", LVN "E" consulted with the SW a second time because FM "P" and R#2 went into R#2's room alone. SW relayed they could not be in the room alone together because the roommate needed privacy. When FM "P" came out of the room, LVN "E" told him that he could only have visitation in the Day Area. R#2's FM "P" went back into R#2's room with the door open. The SW went to R#2's room and told FM "P" he would have to visit in the Day Area. R #2 and FM "P" left the room and went to the downstairs lobby. At 5:00 p.m. FM "P" came back upstairs and went into R#2's room and came back out and walked toward the elevator. FM "P" turned and said to LVN "E", "Wuera, Who snitched me out?" LVN "E" told FM "P" that she didn't know what he was talking about. FM "P"said, "You don't [***] ing know me, I will [***] you up." On 12/04/13 at 4:50 p.m., an interview with the SW revealed that she was informed of the abuse allegation made by R #2 against FM "P." SW said that LVN "E" informed her on 12/02/13 in the afternoon. SW reported that LVN "E "wanted the SW to speak to FM "P" visiting in R #2's room. This was the second time the SW had to speak with FM "P"; the first time was when the Hospice Nurse reported that FM "P" was making sexual comments in front of other residents towards R#2. The SW said that she did not think R#2 would tell the SW the truth about FM "P" slapping R#2, and if R#2 would have told the SW directly about the abuse allegation then the SW would have reported it to the Admin. The SW said she would normally ask the resident about the abuse allegation however since FM "P" was in the room the SW didn't ask R#2 about the abuse allegation. On 12/04/13 at 5:20 p.m., an interview with LVN "G" revealed that she was told by the Hospice Chaplin on 12/02/13 at 7:30 a.m. that R#2 was hit by FM "P" the previous day and asked if she knew anything about the incident. LVN "G" said that was her first knowledge of the assault. LVN "G" said she reported the incident to the oncoming nurse (LVN "E"), SW and the Admin. LVN "G" said she filled out an incident report. LVN "G" said she reported the incident to the Admin. at 9:00 a.m. or 10:00 a.m. on 12/02/13. On 12/04/13 at 5:30 p.m. an interview with the facility Admin. revealed, he was not aware of the abuse allegation. The Admin. said he was never informed until a couple of minutes ago. The Admin. said, that either the Director of Nurses (DON) or the Assistant Director of Nurses (ADON) had the incident report. The Admin. said, he started to in service all employees on Abuse/ Neglect Policy and Procedures. The Admin. said, that after he completed his investigation he would call the police. On 12/04/13 at 6:10 p.m., an interview with LVN "G" revealed that she had told the SW and LVN "E" about the abuse allegation and said, "Maybe I didn't tell the Administrator about (R #2), I was really busy that morning trying to transfer another resident out to the hospital." On 12/04/13 at 1:35 p.m., the DON said, "I don't know why any of the staff did not report this incident to me, they all know if they cannot reach the Administrator they should report to me." According to facility's Centers of Medicare and Medicaid Services form 802, 53 residents resided on the third floor. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R#2's abuse allegation. As of exit on 12/06/13 at 2:00 p.m., the facility provided no further information.

Based on interview and record review the Facility failed to provide care in accordance with each resident's plan of care for one Resident (R #1) of five residents reviewed for care plans. -The facility did not conduct weekly skin assessments according to R#1's care plan. -R#1 was admitted to the the facility without a "pressure ulcer/necrotic flap". R#1 had a history of [REDACTED]. -R#1 was admitted to the hospital on [DATE] with an unstageable "pressure ulcer" to the penis. The facility was not aware that R#1 had an "unstageable pressure ulcer" to his penis until the Surveyor brought it to their attention. This deficient practice could affect seven residents residing in the facility with behavior symptoms and place them at risk of skin breakdown, due to not receiving proper assessments and care and services needed to prevent a delay in treatment, complications and hospitalization . The Findings were: R#1's face sheet revealed admitted [DATE], [AGE] year old male, with the following Diagnoses: [REDACTED]. "Own Responsible Party." R#1's History and Physical dated 02/01/13 revealed current [DIAGNOSES REDACTED]. R#1's Care Plan- "Non-Pressure Ulcer Skin Impairment" dated 02/01/13 revealed "Problem ...Skin Impairment: actual, related to: sensory perception ...other. Goal: (R #1) skin impairment: Stasis ulcer Right anterior heel will heal without complications by 03/01/13 or next review 05/01/13. Approach: Observe skin weekly and document findings as indicated, Document observation of any non-pressure related skin impairments on facility Non-pressure Ulcer Wound documentation form. " (There was no date that Care Plan reviewed for weekly skin observations after 02/01/13.) R#1's Care Plan- " Behavioral Symptoms " dated 04/16/13, last date reviewed 04/18/13, 05/23/13 and 08/08/13 revealed " Problem ...Verbal Abuse ...Socially Inappropriate. Target Behaviors indicated include: Resident refuses his bath and care to change clothes. Goal: (R #1) will have decreased episodes of identified behaviors with to no more than 2 times per week through the next review: 90 days. Approach: Use firm, gentle voice, identify self to individual prior to initiating care. Give simple clear directions, repeat as needed. Ignore verbal outbursts, check for discomfort, pain, allow choices within individual's decision making abilities, and modify environment, situations, and / or treatment to minimize external stressors. Redirect as needed. Be alert for triggers of potential evidence of pending behavioral episodes. Notify M.D. as needed. Administer medications as ordered." R#1's Braden Scale assessment (tool used for predicting Pressure Sore Risk) dated 07/31/13 total score was 21. (Total score 12 or less represents a high risk). -There was no further evidence in documentation revealing additional Braden Scales were done on R#1 after 07/31/13. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed rejection of care one to three days; makes self understood, able to express ideas and wants, able to understand others with clear comprehension; one person physical assist for locomotion off unit and toileting, and bathing; no pressure ulcers or skin conditions, continent of bowel and bladder. R#1's Head to Toe Skin Checks revealed (dated) 09/03/13, 09/10/13, 10/21/13, 11/05/13, 11/12/13, 11/19/13 and 11/26/13. It was documented on 11/19/13 that R#1 had a peri- rash and that A&D ointment was applied. On 11/26/13 it was documented that resident "refused." - There was no further evidence by documentation that R #1 received skin assessments or staff attempted to perform weekly skin checks after 11/26/13. There was no documentation that R#1 received any teaching or instruction regarding consequences of refusal of care. -In the Month of October there was only one skin assessment documented. -In the month of September there were only two skin assessments documented. R #1's November 2013 Resident Bathing Type by Day Chart revealed resident took a shower the following dates in the month of November. 11/02/13, 11/05/13, 11/07/13, 11/09/13, 11/12/13, 11/13/13, 11/14/13, 11/16/13, 11/19/13, 11/21/13, 11/23/13, 11/29/13, and 11/30/13. It was documented on 11/16/13 that R#1 did take a shower. R #1's Nursing Notes dated 11/16/13 (2:00 p.m.-10:00 p.m.) revealed that the resident refused to take a shower."Resident refusing to take a bath, resident smells very bad. He was asked six times this shift to take a bath, resident stated, no. will continue to monitor." R #1's Nurses note dated 11/17/13 (2:00 p.m.-10:00 p.m.) revealed "Resident was asked to take a shower. Resident asked why? This nurse told resident that he smelled very bad. Resident replied that this nurse smells not him. Resident was re-directed and was asked to please take a shower and change his clothes. Resident said the hell with all of you! I am not taking a bath. Resident went to his room. Will continue to monitor." *There was no further documentation on nursing interventions that were attempted by staff to encourage R#1 to take a shower. R #1's Change of Condition form dated 12/01/13 at 8:00 a.m. revealed resident was found in his room with absent vital signs, non-responsive, and blue in color. 911 was dispatched and resident was sent to Hospital. On 12/05/13, review of Hospital emergency room (ER) electronic records dated 12/01/13 at 8:47 a.m. revealed R #1's penis had "necrotic tissue" (dead skin) "unstageable pressure ulcer" that measured 3(cm) centimeters by 4cm on the end of his penis, surrounding skin was "yellow slough tissue" (non-viable tissue). R #1's hospital laboratory results indicated an infection with the elevated White Blood Cell (WBC) count and a Kidney function impairment with an elevated Blood Urea Nitrogen (BUN) an elevated Creatinine and low Glomerular Filtration Rate (GFR). When placing the Urinary Catheter there was no urine output. emergency room Lab values; WBC= 14.8 Normal Values= (5-10) BUN=55 Normal Values= (8-23) Creatinine= 2.1 Normal Values= (0.7-1.3) GFR= 34 Normal Values= (>90-100) Confidential interviewee (CI) "LL" said, that it was impossible for R#1 to have had such an advanced "pressure sore" occur over the weekend. The end of his penis was a "necrotic flap" (dead tissue). The extent of the tissue damage on R #1's penis took a long time to advance to an "unstageable wound." CI "LL" said that a call was placed to the facility to ask if the staff knew that R#1 had a "pressure ulcer." CI "LL" said that staff at facility reported that R#1 received peri-care on 11/29/13 and that there were no reports of a skin change by staff. Review of Facility Policy and Procedure titled Skin Management (revision) dated: August 2012 revealed; -"Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." ....2. " Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with significant change of status for their risk for development of pressure sores. ....6. " Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address but is not limited to: *Hydration *Nutrition * Preventative devices * Physical Activity * Pain * Positioning requirements * Proper Body Alignment ....16. c. Skin assessment findings will be documented weekly on the Head to Toe Check form." On 12/06/13 at 9:00 a.m., the Director of Nurses (DON) said he was unaware of the "pressure ulcer" on R #1. The DON said, "I did not know that (R #1) had a "pressure ulcer." He was non-compliant with bathing and that is when we would have noticed the necrotic tissue. Skin assessments are done on all residents monthly. On 12/06/13 at 9:10 a.m., an interview was conducted with License Vocational Nurse (LVN) "C." LVN "C" reported that skin assessments were done on all residents in the facility one time a week and documented on the Head to Toe assessment record. LVN "C" said that she was on duty the day R#1 was sent to the hospital and that Medication Aide (MA) "H" discovered R#1 unresponsive and without a pulse. MA "H "called LVN "C" to the resident's room and Cardio-Pulmonary-Resuscitation was initiated. R #1 was sent to the hospital. LVN "C" said that she was unaware that R #1 had a "pressure ulcer" on his penis. R #1 received a bath on 11/29/13 by Certified Nurse's Aide (CNA) "I "and that the CNAs were supposed to report skin changes to the nurse. LVN"C" said that R #1 was non-compliant with care and the Physician was aware, but the facility was not given further instruction from the Physician on how to manage R #1's behavior. On 12/06/13 at 9:30 a.m. an interview was conducted with CNA "I.". CNA "I" said that all skin changes were reported to the charge nurse on duty. CNA "I" said she did not see any changes to R#1's skin during his shower on 11/29/13. CNA "I" said that R#1 provided his own Peri-care and that she would wash R#1's back and bottom. If R#1 refused a shower CNA "I" would report to the nurse and the nurse would talk the resident into a shower. R #1's November 2013 Resident Bathing Type by Day Chart revealed no evidence of documentation of a shower taken for five days: 11/24/13 through 11/28/13 and no documentation in Nursing Notes to reflect R#1's omission of a shower. On 12/05/13 at 3:25 p.m., an interview with CNA "K" revealed all skin changes found on residents during care were always reported to the Nurse on duty. On 12/05/13 at 4:00 p.m., an interview with CNA "J" revealed all skin changes found on residents during care were always reported directly to the Charge Nurse. On 12/05/13 at 5:35 p.m., an interview was conducted with the Director of Nurses (DON). The surveyor asked the DON what the facility did to address R #1's behavioral issues and where the updated care plan on R #1 regarding behavior was (Last update was 08/08/13). The DON said, "Some people call it behavioral issues but I call it that is just the way he is #1 wanted to do what he wanted to do, he did not like rules. He was a nice guy but preferred to be alone. That was R#1's personality, he did not like to take a bath every day, if he wanted to smoke a cigarette or drink water he would do it. I don't think he cared about taking care of his health. R #1 was that way his entire life. We missed the Quarterly Care Plan on R#1 it should have been done." Review of Facility Job Description for CNAs revealed; consistently and promptly reporting resident changes of condition ... Review of Facility Job description for LVNs revealed; .....Communicates with Physicians regarding changes in resident's conditions, ....etc. Documents assessments and care in compliance with standards of care and company policy. Educates patients ...on health care issues. On 12/06/13 at 11:00 a.m. an observation was conducted to observe skin checks with LVN "D. " LVN "D" did a head to toe assessment on R#3 and documented findings on the facility Head to Toe Assessment Sheet. LVN "D" said all residents in the facility had a weekly Head to Toe assessment and it was documented on a skin sheet. LVN "D" said if a resident refused a skin assessment LVN "D" would try to talk the resident into the assessment and if they continued to refuse then she would notify the Doctor. The facility's Centers for Medicare and Medicaid Services form 802 identified seven residents with behavioral symptoms. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to failure to conduct skin assessments per the care plan As of exit on 12/06/13 at 2:00 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and care plan for one Resident (R#1) of four residents reviewed for pressure ulcers. -R#1 was admitted to the the facility without a "pressure ulcer/necrotic flap". R#1 had a history of [REDACTED]. -The facility did not conduct weekly skin assessments according to R#1's care plan. -R#1 was admitted to the hospital on [DATE] with an unstageable "pressure ulcer" to the penis. The facility was not aware that R#1 had an "unstageable pressure ulcer" to his penis until the Surveyor brought it to their attention. This deficient practice resulted placed seven residents with behavioral symptoms at risk of skin breakdown due to not receiving assessments, care and services needed to prevent delay in treatment, complications and hospitalization . The Findings were: R#1's face sheet revealed admitted [DATE], [AGE] year old male, with the following Diagnoses: [REDACTED]. "Own Responsible Party." R#1's History and Physical dated 02/01/13 revealed current [DIAGNOSES REDACTED]. R#1's Care Plan- "Non-Pressure Ulcer Skin Impairment" dated 02/01/13 revealed "Problem ...Skin Impairment: actual, related to: sensory perception ...other. Goal: (R #1) skin impairment: Stasis ulcer Right anterior heel will heal without complications by 03/01/13 or next review 05/01/13. Approach: Observe skin weekly and document findings as indicated, Document observation of any non-pressure related skin impairments on facility Non-pressure Ulcer Wound documentation form. " (There was no date that Care Plan reviewed for weekly skin observations after 02/01/13.) R#1's Care Plan- " Behavioral Symptoms " dated 04/16/13, last date reviewed 04/18/13, 05/23/13 and 08/08/13 revealed " Problem ...Verbal Abuse ...Socially Inappropriate. Target Behaviors indicated include: Resident refuses his bath and care to change clothes. Goal: (R #1) will have decreased episodes of identified behaviors with to no more than 2 times per week through the next review: 90 days. Approach: Use firm, gentle voice, identify self to individual prior to initiating care. Give simple clear directions, repeat as needed. Ignore verbal outbursts, check for discomfort, pain, allow choices within individual's decision making abilities, and modify environment, situations, and / or treatment to minimize external stressors. Redirect as needed. Be alert for triggers of potential evidence of pending behavioral episodes. Notify M.D. as needed. Administer medications as ordered." R#1's Braden Scale assessment (tool used for predicting Pressure Sore Risk) dated 07/31/13 total score was 21. (Total score 12 or less represents a high risk). -There was no further evidence in documentation revealing additional Braden Scales were done on R#1 after 07/31/13. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed rejection of care one to three days; makes self understood, able to express ideas and wants, able to understand others with clear comprehension; one person physical assist for locomotion off unit and toileting, and bathing; no pressure ulcers or skin conditions, continent of bowel and bladder. R#1's Head to Toe Skin Checks revealed (dated) 09/03/13, 09/10/13, 10/21/13, 11/05/13, 11/12/13, 11/19/13 and 11/26/13. It was documented on 11/19/13 that R#1 had a peri- rash and that A&D ointment was applied. On 11/26/13 it was documented that resident "refused." - There was no further evidence by documentation that R #1 received skin assessments or staff attempted to perform weekly skin checks after 11/26/13. There was no documentation that R#1 received any teaching or instruction regarding consequences of refusal of care. -In the Month of October there was only one skin assessment documented. -In the month of September there were only two skin assessments documented. R #1's November 2013 Resident Bathing Type by Day Chart revealed resident took a shower the following dates in the month of November. 11/02/13, 11/05/13, 11/07/13, 11/09/13, 11/12/13, 11/13/13, 11/14/13, 11/16/13, 11/19/13, 11/21/13, 11/23/13, 11/29/13, and 11/30/13. It was documented on 11/16/13 that R#1 did take a shower. R #1's Nursing Notes dated 11/16/13 (2:00 p.m.-10:00 p.m.) revealed that the resident refused to take a shower."Resident refusing to take a bath, resident smells very bad. He was asked six times this shift to take a bath, resident stated, no. will continue to monitor." R #1's Nurses note dated 11/17/13 (2:00 p.m.-10:00 p.m.) revealed "Resident was asked to take a shower. Resident asked why? This nurse told resident that he smelled very bad. Resident replied that this nurse smells not him. Resident was re-directed and was asked to please take a shower and change his clothes. Resident said the hell with all of you! I am not taking a bath. Resident went to his room. Will continue to monitor." *There was no further documentation on nursing interventions that were attempted by staff to encourage R#1 to take a shower. R #1's Change of Condition form dated 12/01/13 at 8:00 a.m. revealed resident was found in his room with absent vital signs, non-responsive, and blue in color. 911 was dispatched and resident was sent to Hospital. On 12/05/13, review of Hospital emergency room (ER) electronic records dated 12/01/13 at 8:47 a.m. revealed R #1's penis had "necrotic tissue" (dead skin) "unstageable pressure ulcer" that measured 3(cm) centimeters by 4cm on the end of his penis, surrounding skin was "yellow slough tissue" (non-viable tissue). R #1's hospital laboratory results indicated an infection with the elevated White Blood Cell (WBC) count and a Kidney function impairment with an elevated Blood Urea Nitrogen (BUN) an elevated Creatinine and low Glomerular Filtration Rate (GFR). When placing the Urinary Catheter there was no urine output. emergency room Lab values; WBC= 14.8 Normal Values= (5-10) BUN=55 Normal Values= (8-23) Creatinine= 2.1 Normal Values= (0.7-1.3) GFR= 34 Normal Values= (>90-100) Confidential interviewee (CI) "LL" said, that it was impossible for R#1 to have had such an advanced "pressure sore" occur over the weekend. The end of his penis was a "necrotic flap" (dead tissue). The extent of the tissue damage on R #1's penis took a long time to advance to an "unstageable wound." CI "LL" said that a call was placed to the facility to ask if the staff knew that R#1 had a "pressure ulcer." CI "LL" said that staff at facility reported that R#1 received peri-care on 11/29/13 and that there were no reports of a skin change by staff. Review of Facility Policy and Procedure titled Skin Management (revision) dated: August 2012 revealed; -"Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." ....2. " Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with significant change of status for their risk for development of pressure sores. ....6. " Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address but is not limited to: *Hydration *Nutrition * Preventative devices * Physical Activity * Pain * Positioning requirements * Proper Body Alignment ....16. c. Skin assessment findings will be documented weekly on the Head to Toe Check form." On 12/06/13 at 9:00 a.m., the Director of Nurses (DON) said he was unaware of the "pressure ulcer" on R #1. The DON said, "I did not know that (R #1) had a "pressure ulcer." He was non-compliant with bathing and that is when we would have noticed the necrotic tissue. Skin assessments are done on all residents monthly. On 12/06/13 at 9:10 a.m., an interview was conducted with License Vocational Nurse (LVN) "C." LVN "C" reported that skin assessments were done on all residents in the facility one time a week and documented on the Head to Toe assessment record. LVN "C" said that she was on duty the day R#1 was sent to the hospital and that Medication Aide (MA) "H" discovered R#1 unresponsive and without a pulse. MA "H "called LVN "C" to the resident's room and Cardio-Pulmonary-Resuscitation was initiated. R #1 was sent to the hospital. LVN "C" said that she was unaware that R #1 had a "pressure ulcer" on his penis. R #1 received a bath on 11/29/13 by Certified Nurse's Aide (CNA) "I "and that the CNAs were supposed to report skin changes to the nurse. LVN"C" said that R #1 was non-compliant with care and the Physician was aware, but the facility was not given further instruction from the Physician on how to manage R #1's behavior. On 12/06/13 at 9:30 a.m. an interview was conducted with CNA "I.". CNA "I" said that all skin changes were reported to the charge nurse on duty. CNA "I" said she did not see any changes to R#1's skin during his shower on 11/29/13. CNA "I" said that R#1 provided his own Peri-care and that she would wash R#1's back and bottom. If R#1 refused a shower CNA "I" would report to the nurse and the nurse would talk the resident into a shower. R #1's November 2013 Resident Bathing Type by Day Chart revealed no evidence of documentation of a shower taken for five days: 11/24/13 through 11/28/13 and no documentation in Nursing Notes to reflect R#1's omission of a shower. On 12/05/13 at 3:25 p.m., an interview with CNA "K" revealed all skin changes found on residents during care were always reported to the Nurse on duty. On 12/05/13 at 4:00 p.m., an interview with CNA "J" revealed all skin changes found on residents during care were always reported directly to the Charge Nurse. On 12/05/13 at 5:35 p.m., an interview was conducted with the Director of Nurses (DON). The surveyor asked the DON what the facility did to address R #1's behavioral issues and where the updated care plan on R #1 regarding behavior was (Last update was 08/08/13). The DON said, "Some people call it behavioral issues but I call it that is just the way he is #1 wanted to do what he wanted to do, he did not like rules. He was a nice guy but preferred to be alone. That was R#1's personality, he did not like to take a bath every day, if he wanted to smoke a cigarette or drink water he would do it. I don't think he cared about taking care of his health. R #1 was that way his entire life. We missed the Quarterly Care Plan on R#1 it should have been done." Review of Facility Job Description for CNAs revealed; consistently and promptly reporting resident changes of condition ... Review of Facility Job description for LVNs revealed; .....Communicates with Physicians regarding changes in resident's conditions, ....etc. Documents assessments and care in compliance with standards of care and company policy. Educates patients ...on health care issues. On 12/06/13 at 11:00 a.m. an observation was conducted to observe skin checks with LVN "D. " LVN "D" did a head to toe assessment on R#3 and documented findings on the facility Head to Toe Assessment Sheet. LVN "D" said all residents in the facility had a weekly Head to Toe assessment and it was documented on a skin sheet. LVN "D" said if a resident refused a skin assessment LVN "D" would try to talk the resident into the assessment and if they continued to refuse then she would notify the Doctor. The facility's Centers for Medicare and Medicaid Services form 802 identified seven residents with behavioral symptoms. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R #1's "pressure ulcer." As of exit on 12/06/13 at 2:00 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to ensure a resident who enters the facility without pressure ulcers does not develop pressure ulcers for one Resident (R#1) of four residents reviewed for pressure ulcers. -R#1 was admitted to the the facility without a "pressure ulcer/necrotic flap". R#1 had a history of [REDACTED]. -The facility did not conduct weekly skin assessments according to R#1's care plan. -R#1 was admitted to the hospital on [DATE] with an unstageable "pressure ulcer" to the penis. The facility was not aware that R#1 had an "unstageable pressure ulcer" to his penis until the Surveyor brought it to their attention. This deficient practice placed seven residents with behavioral symptoms at risk of skin breakdown due to not receiving assessments, care and services needed to prevent delay in treatment, complications and hospitalization . The Findings were: R#1's face sheet revealed admitted [DATE], [AGE] year old male, with the following Diagnoses: [REDACTED]. "Own Responsible Party." R#1's History and Physical dated 02/01/13 revealed current [DIAGNOSES REDACTED]. R#1's Care Plan- "Non-Pressure Ulcer Skin Impairment" dated 02/01/13 revealed "Problem ...Skin Impairment: actual, related to: sensory perception ...other. Goal: (R #1) skin impairment: Stasis ulcer Right anterior heel will heal without complications by 03/01/13 or next review 05/01/13. Approach: Observe skin weekly and document findings as indicated, Document observation of any non-pressure related skin impairments on facility Non-pressure Ulcer Wound documentation form. " (There was no date that Care Plan reviewed for weekly skin observations after 02/01/13.) R#1's Care Plan- " Behavioral Symptoms " dated 04/16/13, last date reviewed 04/18/13, 05/23/13 and 08/08/13 revealed " Problem ...Verbal Abuse ...Socially Inappropriate. Target Behaviors indicated include: Resident refuses his bath and care to change clothes. Goal: (R #1) will have decreased episodes of identified behaviors with to no more than 2 times per week through the next review: 90 days. Approach: Use firm, gentle voice, identify self to individual prior to initiating care. Give simple clear directions, repeat as needed. Ignore verbal outbursts, check for discomfort, pain, allow choices within individual's decision making abilities, and modify environment, situations, and / or treatment to minimize external stressors. Redirect as needed. Be alert for triggers of potential evidence of pending behavioral episodes. Notify M.D. as needed. Administer medications as ordered." R#1's Braden Scale assessment (tool used for predicting Pressure Sore Risk) dated 07/31/13 total score was 21. (Total score 12 or less represents a high risk). -There was no further evidence in documentation revealing additional Braden Scales were done on R#1 after 07/31/13. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed rejection of care one to three days; makes self understood, able to express ideas and wants, able to understand others with clear comprehension; one person physical assist for locomotion off unit and toileting, and bathing; no pressure ulcers or skin conditions, continent of bowel and bladder. R#1's Head to Toe Skin Checks revealed (dated) 09/03/13, 09/10/13, 10/21/13, 11/05/13, 11/12/13, 11/19/13 and 11/26/13. It was documented on 11/19/13 that R#1 had a peri- rash and that A&D ointment was applied. On 11/26/13 it was documented that resident "refused." - There was no further evidence by documentation that R #1 received skin assessments or staff attempted to perform weekly skin checks after 11/26/13. There was no documentation that R#1 received any teaching or instruction regarding consequences of refusal of care. -In the Month of October there was only one skin assessment documented. -In the month of September there were only two skin assessments documented. R #1's November 2013 Resident Bathing Type by Day Chart revealed resident took a shower the following dates in the month of November. 11/02/13, 11/05/13, 11/07/13, 11/09/13, 11/12/13, 11/13/13, 11/14/13, 11/16/13, 11/19/13, 11/21/13, 11/23/13, 11/29/13, and 11/30/13. It was documented on 11/16/13 that R#1 did take a shower. R #1's Nursing Notes dated 11/16/13 (2:00 p.m.-10:00 p.m.) revealed that the resident refused to take a shower."Resident refusing to take a bath, resident smells very bad. He was asked six times this shift to take a bath, resident stated, no. will continue to monitor." R #1's Nurses note dated 11/17/13 (2:00 p.m.-10:00 p.m.) revealed "Resident was asked to take a shower. Resident asked why? This nurse told resident that he smelled very bad. Resident replied that this nurse smells not him. Resident was re-directed and was asked to please take a shower and change his clothes. Resident said the hell with all of you! I am not taking a bath. Resident went to his room. Will continue to monitor." *There was no further documentation on nursing interventions that were attempted by staff to encourage R#1 to take a shower. R #1's Change of Condition form dated 12/01/13 at 8:00 a.m. revealed resident was found in his room with absent vital signs, non-responsive, and blue in color. 911 was dispatched and resident was sent to Hospital. On 12/05/13, review of Hospital emergency room (ER) electronic records dated 12/01/13 at 8:47 a.m. revealed R #1's penis had "necrotic tissue" (dead skin) "unstageable pressure ulcer" that measured 3(cm) centimeters by 4cm on the end of his penis, surrounding skin was "yellow slough tissue" (non-viable tissue). R #1's hospital laboratory results indicated an infection with the elevated White Blood Cell (WBC) count and a Kidney function impairment with an elevated Blood Urea Nitrogen (BUN) an elevated Creatinine and low Glomerular Filtration Rate (GFR). When placing the Urinary Catheter there was no urine output. emergency room Lab values; WBC= 14.8 Normal Values= (5-10) BUN=55 Normal Values= (8-23) Creatinine= 2.1 Normal Values= (0.7-1.3) GFR= 34 Normal Values= (>90-100) Confidential interviewee (CI) "LL" said, that it was impossible for R#1 to have had such an advanced "pressure sore" occur over the weekend. The end of his penis was a "necrotic flap" (dead tissue). The extent of the tissue damage on R #1's penis took a long time to advance to an "unstageable wound." CI "LL" said that a call was placed to the facility to ask if the staff knew that R#1 had a "pressure ulcer." CI "LL" said that staff at facility reported that R#1 received peri-care on 11/29/13 and that there were no reports of a skin change by staff. Review of Facility Policy and Procedure titled Skin Management (revision) dated: August 2012 revealed; -"Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." ....2. " Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with significant change of status for their risk for development of pressure sores. ....6. " Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address but is not limited to: *Hydration *Nutrition * Preventative devices * Physical Activity * Pain * Positioning requirements * Proper Body Alignment ....16. c. Skin assessment findings will be documented weekly on the Head to Toe Check form." On 12/06/13 at 9:00 a.m., the Director of Nurses (DON) said he was unaware of the "pressure ulcer" on R #1. The DON said, "I did not know that (R #1) had a "pressure ulcer." He was non-compliant with bathing and that is when we would have noticed the necrotic tissue. Skin assessments are done on all residents monthly. On 12/06/13 at 9:10 a.m., an interview was conducted with License Vocational Nurse (LVN) "C." LVN "C" reported that skin assessments were done on all residents in the facility one time a week and documented on the Head to Toe assessment record. LVN "C" said that she was on duty the day R#1 was sent to the hospital and that Medication Aide (MA) "H" discovered R#1 unresponsive and without a pulse. MA "H "called LVN "C" to the resident's room and Cardio-Pulmonary-Resuscitation was initiated. R #1 was sent to the hospital. LVN "C" said that she was unaware that R #1 had a "pressure ulcer" on his penis. R #1 received a bath on 11/29/13 by Certified Nurse's Aide (CNA) "I "and that the CNAs were supposed to report skin changes to the nurse. LVN"C" said that R #1 was non-compliant with care and the Physician was aware, but the facility was not given further instruction from the Physician on how to manage R #1's behavior. On 12/06/13 at 9:30 a.m. an interview was conducted with CNA "I.". CNA "I" said that all skin changes were reported to the charge nurse on duty. CNA "I" said she did not see any changes to R#1's skin during his shower on 11/29/13. CNA "I" said that R#1 provided his own Peri-care and that she would wash R#1's back and bottom. If R#1 refused a shower CNA "I" would report to the nurse and the nurse would talk the resident into a shower. R #1's November 2013 Resident Bathing Type by Day Chart revealed no evidence of documentation of a shower taken for five days: 11/24/13 through 11/28/13 and no documentation in Nursing Notes to reflect R#1's omission of a shower. On 12/05/13 at 3:25 p.m., an interview with CNA "K" revealed all skin changes found on residents during care were always reported to the Nurse on duty. On 12/05/13 at 4:00 p.m., an interview with CNA "J" revealed all skin changes found on residents during care were always reported directly to the Charge Nurse. On 12/05/13 at 5:35 p.m., an interview was conducted with the Director of Nurses (DON). The surveyor asked the DON what the facility did to address R #1's behavioral issues and where the updated care plan on R #1 regarding behavior was (Last update was 08/08/13). The DON said, "Some people call it behavioral issues but I call it that is just the way he is R #1 wanted to do what he wanted to do, he did not like rules. He was a nice guy but preferred to be alone. That was R#1's personality, he did not like to take a bath every day, if he wanted to smoke a cigarette or drink water he would do it. I don't think he cared about taking care of his health. R #1 was that way his entire life. We missed the Quarterly Care Plan on R#1 it should have been done." Review of Facility Job Description for CNAs revealed; consistently and promptly reporting resident changes of condition ... Review of Facility Job description for LVNs revealed; .....Communicates with Physicians regarding changes in resident's conditions, ....etc. Documents assessments and care in compliance with standards of care and company policy. Educates patients ...on health care issues. On 12/06/13 at 11:00 a.m. an observation was conducted to observe skin checks with LVN "D. " LVN "D" did a head to toe assessment on R#3 and documented findings on the facility Head to Toe Assessment Sheet. LVN "D" said all residents in the facility had a weekly Head to Toe assessment and it was documented on a skin sheet. LVN "D" said if a resident refused a skin assessment LVN "D" would try to talk the resident into the assessment and if they continued to refuse then she would notify the Doctor. The facility's Centers for Medicare and Medicaid Services form 802 identified seven residents with behavioral symptoms. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R #1's "pressure ulcer." As of exit on 12/06/13 at 2:00 p.m., the facility provided no further information.

Based on observation, interview and record review. The facility failed to provide services that met professional standards for two Residents (R#1 and R#2) of five Residents reviewed for standards of care. R #1 -R#1 was admitted to the the facility without a "pressure ulcer/necrotic flap". R#1 had a history of [REDACTED]. -The facility did not conduct weekly skin assessments according to R#1's care plan. -R#1 was admitted to the hospital on [DATE] with an unstageable "pressure ulcer" to the penis. The facility was not aware that R#1 had an "unstageable pressure ulcer" to his penis until the Surveyor brought it to their attention. This deficient practice placed seven residents with behavioral symptoms at risk of skin breakdown due to not receiving assessments, care and services needed to prevent delay in treatment, complications and hospitalization . R #2 -Three staff members were aware of R#2's reported abuse allegation of being slapped by Family Member (FM) "P", and failed to report the allegation to the Administrator (Admin.). - The facility did not report the allegation to Department of Aging and Disability Services (DADS) - The facility did not have evidence the allegation was investigated. This deficient practice could affect 53 residents residing on the third floor and place them at risk for abuse. Findings were: According to Texas Administrative Code Title 22 Part II Chapter 217 Rule 217.11 (1) Standards Applicable to all Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ....(B) Implement measures to promote a safe environment for clients and others; ....(D) Accurately and completely report and document: ....(vi) contacts with other heath care team members concerning significant events regarding client's status. ....(F) Promote and participate in education and counseling to a client (s) and, where applicable, the family/significant other(s) based on heath needs; According to Texas State Board of Social Worker Examiner Title 22, Texas Administrative Code, Chapter 781.221 ....(f) A licensee shall report information if required by any of the following statues: ....(2) Texas Human Resources Code, Chapter 48, concerning abuse, neglect,or exploitation or disabled persons; HUMAN RESOURCES CODE TITLE 2. DEPARTMENT OF HUMAN SERVICES AND DEPARTMENT OF PROTECTIVE AND REGULATORY SERVICES SUBTITLE D. DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES; CHILD WELFARE AND PROTECTIVE SERVICES CHAPTER 48. INVESTIGATIONS AND PROTECTIVE SERVICES FOR ELDERLY AND DISABLED PERSONS SUBCHAPTER A. GENERAL PROVISIONS Sec. 48.001. PURPOSE. The purpose of this chapter is to provide for the authority to investigate the abuse, neglect, or exploitation of an elderly or disabled person and to provide protective services to that person. R#1 R#1's face sheet revealed admitted [DATE], [AGE] year old male, with the following Diagnoses: [REDACTED]. "Own Responsible Party." R#1's History and Physical dated 02/01/13 revealed current [DIAGNOSES REDACTED]. R#1's Care Plan- "Non-Pressure Ulcer Skin Impairment" dated 02/01/13 revealed "Problem ...Skin Impairment: actual, related to: sensory perception ...other. Goal: (R #1) skin impairment: Stasis ulcer Right anterior heel will heal without complications by 03/01/13 or next review 05/01/13. Approach: Observe skin weekly and document findings as indicated, Document observation of any non-pressure related skin impairments on facility Non-pressure Ulcer Wound documentation form. " (There was no date that Care Plan reviewed for weekly skin observations after 02/01/13.) R#1's Care Plan- " Behavioral Symptoms " dated 04/16/13, last date reviewed 04/18/13, 05/23/13 and 08/08/13 revealed " Problem ...Verbal Abuse ...Socially Inappropriate. Target Behaviors indicated include: Resident refuses his bath and care to change clothes. Goal: (R #1) will have decreased episodes of identified behaviors with to no more than 2 times per week through the next review: 90 days. Approach: Use firm, gentle voice, identify self to individual prior to initiating care. Give simple clear directions, repeat as needed. Ignore verbal outbursts, check for discomfort, pain, allow choices within individual's decision making abilities, and modify environment, situations, and / or treatment to minimize external stressors. Redirect as needed. Be alert for triggers of potential evidence of pending behavioral episodes. Notify M.D. as needed. Administer medications as ordered." R#1's Braden Scale assessment (tool used for predicting Pressure Sore Risk) dated 07/31/13 total score was 21. (Total score 12 or less represents a high risk). -There was no further evidence in documentation revealing additional Braden Scales were done on R#1 after 07/31/13. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed rejection of care one to three days; makes self understood, able to express ideas and wants, able to understand others with clear comprehension; one person physical assist for locomotion off unit and toileting, and bathing; no pressure ulcers or skin conditions, continent of bowel and bladder. R#1's Head to Toe Skin Checks revealed (dated) 09/03/13, 09/10/13, 10/21/13, 11/05/13, 11/12/13, 11/19/13 and 11/26/13. It was documented on 11/19/13 that R#1 had a peri- rash and that A&D ointment was applied. On 11/26/13 it was documented that resident "refused." - There was no further evidence by documentation that R #1 received skin assessments or staff attempted to perform weekly skin checks after 11/26/13. There was no documentation that R#1 received any teaching or instruction regarding consequences of refusal of care. -In the Month of October there was only one skin assessment documented. -In the month of September there were only two skin assessments documented. R #1's November 2013 Resident Bathing Type by Day Chart revealed resident took a shower the following dates in the month of November. 11/02/13, 11/05/13, 11/07/13, 11/09/13, 11/12/13, 11/13/13, 11/14/13, 11/16/13, 11/19/13, 11/21/13, 11/23/13, 11/29/13, and 11/30/13. It was documented on 11/16/13 that R#1 did take a shower. R #1's Nursing Notes dated 11/16/13 (2:00 p.m.-10:00 p.m.) revealed that the resident refused to take a shower."Resident refusing to take a bath, resident smells very bad. He was asked six times this shift to take a bath, resident stated, no. will continue to monitor." R #1's Nurses note dated 11/17/13 (2:00 p.m.-10:00 p.m.) revealed "Resident was asked to take a shower. Resident asked why? This nurse told resident that he smelled very bad. Resident replied that this nurse smells not him. Resident was re-directed and was asked to please take a shower and change his clothes. Resident said the hell with all of you! I am not taking a bath. Resident went to his room. Will continue to monitor." *There was no further documentation on nursing interventions that were attempted by staff to encourage R#1 to take a shower. R #1's Change of Condition form dated 12/01/13 at 8:00 a.m. revealed resident was found in his room with absent vital signs, non-responsive, and blue in color. 911 was dispatched and resident was sent to Hospital. On 12/05/13, review of Hospital emergency room (ER) electronic records dated 12/01/13 at 8:47 a.m. revealed R #1's penis had "necrotic tissue" (dead skin) "unstageable pressure ulcer" that measured 3(cm) centimeters by 4cm on the end of his penis, surrounding skin was "yellow slough tissue" (non-viable tissue). R #1's hospital laboratory results indicated an infection with the elevated White Blood Cell (WBC) count and a Kidney function impairment with an elevated Blood Urea Nitrogen (BUN) an elevated Creatinine and low Glomerular Filtration Rate (GFR). When placing the Urinary Catheter there was no urine output. emergency room Lab values; WBC= 14.8 Normal Values= (5-10) BUN=55 Normal Values= (8-23) Creatinine= 2.1 Normal Values= (0.7-1.3) GFR= 34 Normal Values= (>90-100) Confidential interviewee (CI) "LL" said, that it was impossible for R#1 to have had such an advanced "pressure sore" occur over the weekend. The end of his penis was a "necrotic flap" (dead tissue). The extent of the tissue damage on R #1's penis took a long time to advance to an "unstageable wound." CI "LL" said that a call was placed to the facility to ask if the staff knew that R#1 had a "pressure ulcer." CI "LL" said that staff at facility reported that R#1 received peri-care on 11/29/13 and that there were no reports of a skin change by staff. Review of Facility Policy and Procedure titled Skin Management (revision) dated: August 2012 revealed; -"Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." ....2. " Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with significant change of status for their risk for development of pressure sores. ....6. " Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address but is not limited to: *Hydration *Nutrition * Preventative devices * Physical Activity * Pain * Positioning requirements * Proper Body Alignment ....16. c. Skin assessment findings will be documented weekly on the Head to Toe Check form." On 12/06/13 at 9:00 a.m., the Director of Nurses (DON) said he was unaware of the "pressure ulcer" on R #1. The DON said, "I did not know that (R #1) had a "pressure ulcer." He was non-compliant with bathing and that is when we would have noticed the necrotic tissue. Skin assessments are done on all residents monthly. On 12/06/13 at 9:10 a.m., an interview was conducted with License Vocational Nurse (LVN) "C." LVN "C" reported that skin assessments were done on all residents in the facility one time a week and documented on the Head to Toe assessment record. LVN "C" said that she was on duty the day R#1 was sent to the hospital and that Medication Aide (MA) "H" discovered R#1 unresponsive and without a pulse. MA "H "called LVN "C" to the resident's room and Cardio-Pulmonary-Resuscitation was initiated. R #1 was sent to the hospital. LVN "C" said that she was unaware that R #1 had a "pressure ulcer" on his penis. R #1 received a bath on 11/29/13 by Certified Nurse's Aide (CNA) "I "and that the CNAs were supposed to report skin changes to the nurse. LVN"C" said that R #1 was non-compliant with care and the Physician was aware, but the facility was not given further instruction from the Physician on how to manage R #1's behavior. On 12/06/13 at 9:30 a.m. an interview was conducted with CNA "I.". CNA "I" said that all skin changes were reported to the charge nurse on duty. CNA "I" said she did not see any changes to R#1's skin during his shower on 11/29/13. CNA "I" said that R#1 provided his own Peri-care and that she would wash R#1's back and bottom. If R#1 refused a shower CNA "I" would report to the nurse and the nurse would talk the resident into a shower. R #1's November 2013 Resident Bathing Type by Day Chart revealed no evidence of documentation of a shower taken for five days: 11/24/13 through 11/28/13 and no documentation in Nursing Notes to reflect R#1's omission of a shower. On 12/05/13 at 3:25 p.m., an interview with CNA "K" revealed all skin changes found on residents during care were always reported to the Nurse on duty. On 12/05/13 at 4:00 p.m., an interview with CNA "J" revealed all skin changes found on residents during care were always reported directly to the Charge Nurse. On 12/05/13 at 5:35 p.m., an interview was conducted with the Director of Nurses (DON). The surveyor asked the DON what the facility did to address R #1's behavioral issues and where the updated care plan on R #1 regarding behavior was (Last update was 08/08/13). The DON said, "Some people call it behavioral issues but I call it that is just the way he is R #1 wanted to do what he wanted to do, he did not like rules. He was a nice guy but preferred to be alone. That was R#1's personality, he did not like to take a bath every day, if he wanted to smoke a cigarette or drink water he would do it. I don't think he cared about taking care of his health. R #1 was that way his entire life. We missed the Quarterly Care Plan on R#1 it should have been done." Review of Facility Job Description for CNAs revealed; consistently and promptly reporting resident changes of condition ... Review of Facility Job description for LVNs revealed; .....Communicates with Physicians regarding changes in resident's conditions, ....etc. Documents assessments and care in compliance with standards of care and company policy. Educates patients ...on health care issues. On 12/06/13 at 11:00 a.m. an observation was conducted to observe skin checks with LVN "D. " LVN "D" did a head to toe assessment on R#3 and documented findings on the facility Head to Toe Assessment Sheet. LVN "D" said all residents in the facility had a weekly Head to Toe assessment and it was documented on a skin sheet. LVN "D" said if a resident refused a skin assessment LVN "D" would try to talk the resident into the assessment and if they continued to refuse then she would notify the Doctor. The facility's Centers for Medicare and Medicaid Services form 802 identified seven residents with behavioral symptoms. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R #1's "pressure ulcer." As of exit on 12/06/13 at 2:00 p.m., the facility provided no further information. R#2 R #2's Face Sheet dated 08/19/13 revealed a [AGE] year old female admitted on [DATE] with the following diagnoses; Diabetes Type II, Coronary Artery Bypass, Generalized Pain, [MEDICAL CONDITION] (high cholesterol), [MEDICAL CONDITION] Pectoris (chest pain), and [MEDICAL CONDITION] Reflux (acid comes up to esophagus). R#2's Physician Telephone order dated 8/19/13 revealed, "Admit to LTC (Long Term Care) with Professional Hospice under ... DX (diagnosis): [MEDICAL CONDITION]." R#2's MDS dated [DATE] revealed active [DIAGNOSES REDACTED]. R #2's physician progress notes [REDACTED]. R#2's Minimum Data Set (MDS) dated ,[DATE] 13 revealed no cognitive, behavioral or mood problems; required one person assist for transfers, and was never married. Observation of R#2 on 12/04/13 at 2:12 p.m., 12/05/13 at 3:10 p.m. and 12/06/13 at 10:05 a.m., revealed R was wheelchair bound, had right sided weakness, was awake and able to converse with Surveyor. On 12/05/13 at 3:10 p.m., interview with R#2 revealed FM "P" assaulted her on 12/01/13. Resident said that FM "P" slapped her across the face because R#2 made FM "P" mad, and that FM "P" was only playing around. R #2's Nurse's Notes dated 12/03/13 at 7:30 a.m. revealed: "Hospice Chaplin informed nurse resident stated (FM "P") slapped resident. Chaplin stated he will call Adult Protective Services, (FM "P") not allowed to be alone in resident's room." R #2's Nurses Notes dated 12/04/13 through 12/05/13 revealed there was no further documentation of nursing intervention regarding the abuse allegation. The facility's Incident /Accident Log for November 2013 through December 2013 revealed no record of incident regarding R #2 on 12/01/13 being hit by FM "P" at the facility. On 12/04/13 at 3:55 p.m., interview with the Administrator (Admin.) revealed the Facility did not have any reportable incidents in the months of November or December. The Admin. said, "The only incident I heard of was that (R#2's FM "P"), threatened License Vocational Nurse (LVN "E") 12/02/13 and I was informed of this just yesterday by the Social Worker (SW)." On 12/04/13 at 4:10 p.m., an interview with LVN "E" revealed, she read on the 24 Hour nursing report on 12/02/13 at 9:00 a.m., R#2 was slapped in the face by FM "P." The Hospice Chaplin had reported the incident to LVN "G." LVN "E "said, she went to R #2 and questioned her about the allegation and R #2 denied that FM "P" had intentionally hit her. R#2 said FM "P" was only playing around. R#2's FM "P" showed up at the facility on 12/02/13 at 11:00 a.m. and wanted to take R#2 out on pass. LVN "E" consulted with the Facility SW and the SW said it was OK for the Resident to leave with FM "P." The SW was aware that FM "P" had slapped R#2. When R#2 returned to the Facility with FM "P", LVN "E" consulted with the SW a second time because FM "P" and R#2 went into R#2's room alone. SW relayed they could not be in the room alone together because the roommate needed privacy. When FM "P" came out of the room, LVN "E" told him that he could only have visitation in the Day Area. R#2's FM "P" went back into R#2's room with the door open. The SW went to R#2's room and told FM "P" he would have to visit in the Day Area. R #2 and FM "P" left the room and went to the downstairs lobby. At 5:00 p.m. FM "P" came back upstairs and went into R#2's room and came back out and walked toward the elevator. FM "P" turned and said to LVN "E", "Wuera, Who snitched me out?" LVN "E" told FM "P" that she didn't know what he was talking about. FM "P"said, "You don't [***] ing know me, I will [***] you up." On 12/04/13 at 4:50 p.m., an interview with the SW revealed that she was informed of the abuse allegation made by R #2 against FM "P." SW said that LVN "E" informed her on 12/02/13 in the afternoon. SW reported that LVN "E "wanted the SW to speak to FM "P" visiting in R #2's room. This was the second time the SW had to speak with FM "P"; the first time was when the Hospice Nurse reported that FM "P" was making sexual comments in front of other residents towards R#2. The SW said that she did not think R#2 would tell the SW the truth about FM "P" slapping R#2, and if R#2 would have told the SW directly about the abuse allegation then the SW would have reported it to the Admin. The SW said she would normally ask the resident about the abuse allegation however since FM "P" was in the room the SW didn't ask R#2 about the abuse allegation. On 12/04/13 at 5:20 p.m., an interview with LVN "G" revealed that she was told by the Hospice Chaplin on 12/02/13 at 7:30 a.m. that R#2 was hit by FM "P" the previous day and asked if she knew anything about the incident. LVN "G" said that was her first knowledge of the assault. LVN "G" said she reported the incident to the oncoming nurse (LVN "E"), SW and the Admin. LVN "G" said she filled out an incident report. LVN "G" said she reported the incident to the Admin. at 9:00 a.m. or 10:00 a.m. on 12/02/13. On 12/04/13 at 5:30 p.m. an interview with the facility Admin. revealed, he was not aware of the abuse allegation. The Admin. said he was never informed until a couple of minutes ago. The Admin. said, that either the Director of Nurses (DON) or the Assistant Director of Nurses (ADON) had the incident report. The Admin. said, he started to in service all employees on Abuse/ Neglect Policy and Procedures. The Admin. said, that after he completed his investigation he would call the police. On 12/04/13 at 6:10 p.m., an interview with LVN "G" revealed that she had told the SW and LVN "E" about the abuse allegation and said, "Maybe I didn't tell the Administrator about (R #2), I was really busy that morning trying to transfer another resident out to the hospital." On 12/04/13 at 1:35 p.m., the DON said, "I don't know why any of the staff did not report this incident to me, they all know if they cannot reach the Administrator they should report to me." The facility's Policy and Procedure titled Abuse & Neglect Prohibition dated (revision date) March 2009 under "Prevention #2 Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. #3 stated; Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect or misappropriation of resident property, and intervene as appropriate. Definitions:Physical Abuse includes hitting, slapping, pinching, and kicking...Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... Investigation: The facility will report all allegations to the State, as per state regulations. .....Investigation 1) The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance to law. 2) the facility will report such allegations to the state, as per state regulations. 3) The facility will report all investigative findings to the state as per state regulations." Texas Department of Aging and Disability Services Provider Letter #06-43 - Guidelines for Reporting Incidents, dated January 3, 2007 includes: The facility or facility staff member must report the following incidents (1-10) to the Consumer Rights and Services Section, DADS State Office, Austin, Texas, immediately (within 24 hours) upon learning of the incident... 1. ABUSE (as defined in 40 TAC ?19.101(1)) - For allegations of resident-to-resident abuse, refer to Attachment 2 and the accompanying flowchart. -For all other allegations of abuse, report to DADS. According to facility's Centers of Medicare and Medicaid Services form 802, 53 residents resided on the third floor. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to R#2's abuse allegation. As of exit on 12/06/13 at 2:00 p.m., the facility provided no further information.

Based on observation, record review, and interview, the facility failed to provide adequate supervision and monitor the use of an assistive device to prevent falls and injury (antithrust cushion) for one Resident (R#3) of one resident with an anti thrust cushion. Incident/Accident Report dated 01/03/12 indicated at approximately 7:30 a.m., in the 4th floor dining room, R#3 was found lying on the floor, infront of his wheelchair with his head leaning against the left wheel in the dining room. The Tab alarm was not attached to his shirt and the Anti thrust cushion was not on his wheelchair. R#3 sustained a pubic fracture from the fall. (Anti thrust Wheelchair Cushion is designed to prevent pelvis from thrusting forward - Tab Alarm -- A Tab alarm is a patient safety device that when activated alerts staff when a patient attempts to rise out of the chair or bed. The pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the caregiver). Failure to implement their policy to prevent neglect by not ensuring safety positioning devices were in place, resulted in R#3 a double amputee, and required an antithrust cushion sustained a fractured pelvis. 14 residents with Tab alarms could be affected. The findings were: R#3's Incident/Accident Report dated 11/02/11 indicated at approximately 5:00 p.m., in the 4th floor dining room, R#3 was sitting at the dining room table during meal. R#3 slipped out of the wheelchair onto the floor. R#3 had a reddened area to the left eye. R#3,s care plan was revised, first aid done and an anti thrust cushion was initiated. R#3's Face Sheet dated 01/03/12 indicated R#3 was admitted to the facility on [DATE]. R#3 was [AGE] years old with [DIAGNOSES REDACTED]. R#3's History and Physical dated 02/14/11 indicated R#3 had a Right Below Knee Amputation and Left Above Knee Amputation (R) BKA and (L) AKA. R#3's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R#3: -had long and short term memory problems, -had cognitive skills for daily decision making was severely impaired (never/rarely made decisions) -was never /rarely understands or was understood, -was totally dependent on staff for activities of daily living (ADLs) bed mobility, transfers, bathing, and toilet use, locomotion,dressing and personal hygiene, -had impairment on both sides lower extremities (knee, ankle and foot) -was not steady moving on and off the toilet, only able to stabilize with human assistance, -was incontinent of bowel and bladder, -had no falls since the previous assessment and -had additional [DIAGNOSES REDACTED]. 1. R#3's Care Plan dated 12/22/11 indicated R#3 was at risk for Falls/Injury due to (R) BKA and (L) AKA. The Goal was R#3's dignity would be maintained and no occurrence of falls/injury would occur. One of the approaches was to assist with ADLs (Activities of daily living) and transfers using mechanical lift with two person assist at all times. R#3 was in a restraint free environment by using a bed and chair alarm. The approach was to monitor R#3 to ensure safety. 2. R#3's Care Plan dated 12/22/11 revised on 01/03/12 indicated R#3 was at risk for Falls related to a recent fall. The Goal was : -R#3 was sent to the ER (emergency room ), -had Physical and Occupational therapy evaluation -was placed on a low bed with a floor mat. The approaches that were put in place on 01/03/12: R#3 was placed on the Falling Star Program, Mechanical Lift x 2 persons and Anti Thrust Cushion to wheelchair A bed and chair alarm , The bed and chair alarm was discontinued on 01/20/12. Resident Care Cardex Worksheet undated indicated R#3: -was transferred with a hoyer lift x 2 persons, -was on a restorative program, -was on Falling Star Program, -had a bed and chair alarm and -had an anti thrust cushion. R#3's Incident/Accident Report dated 01/03/12 indicated at approximately 7:30 a.m., in the 4th floor dining room, R#3 was found lying on the floor, infront of his wheelchair with his head leaning against the left wheel. The Tab alarm was not attached to his shirt. X-ray of the pelvis was done by X-ray on wheels at the facility. R#3 was taken to a local hospital ER. X-ray of Pelvis dated 01/03/12 indicated R#3 sustained a fracture of the pelvis R#3 Telephone physician's orders [REDACTED]. Hospital Visit Information dated 01/03/12 indicated R#3 was seen for nondisplaced left inferior ischiopubic ramus fracture. On 01/03/12, R#3 was sent back to the facility on bedrest or in wheelchair if he tolerated a sitting position until cleared by his physician. R#3 was given Tylenol, Ice, Rest for pain with instructions was to be followed up with the Orthopedist (ortho-bone specialist) in 2-3 days. Surveyor observed R#3 on 01/19/12 at 11:10 a.m., lying on a low bed with a mat on the floor. RP was sitting at his bedside. She stated she was the RP. On 01/19/12 at 1:55 p.m., RP stated she visited R#3 once to twice weekly. RP stated the facility called to inform her that R#3 fell on [DATE], an X-ray revealed R#3 had a pelvic fracture and he would be transferred to a local hospital. On 01/19/12 at 3:15 p.m. DON "C" said she was at the facility on 01/03/12 until 8:30 p.m that night. DON "C" said she was informed of R#3's incident the next day 01/04/12, during the staff morning meeting. DON "C" said Licensed Vocational Nurse (LVN "F") was informed of R#3's incident on 01/03/12, but LVN "F" did not inform the ADM or DON "C". DON "C" said the staff members who were involved in the incident, Certified Nurse Aide/Restorative Aide (CNA/RA "B"), CNA "D", CNA "E" and Licensed Vocational Nurse (LVN "A") failed to check all of the safety measures were in place, including the anti thrust cushion when R#3 was transferred to the wheelchair "therefore, R#3 fell and fractured his pelvis". DON "C" said LVN "A" and CNA "E" worked on the 10:00 p.m - 6:00 a.m. shift. On 01/03/12, CNA "E" transferred R#3 from the bed to the wheelchair without the anti thrust cushion in place. LVN "A" was the charge nurse on the 6:00 a.m. - 2:00 p.m and failed to monitor that R#3's anti thrust cushion was in place. CNA/RA "B" was assigned to the 4th floor. DON "C" said CNA/RA "B" admitted to the ADM and DON "C" that R#3 did not have the anti thrust cushion for approximately two weeks prior to the fall on 01/03/12. DON "C" stated all the staff involved in the incident were terminated. On 01/19/12 at 4:00 p.m., LVN "F" said LVN "A" reported R#3's incident to LVN "F". LVN "F" assessed R#3 and found "negative findings". LVN "F" informed RP and R#3's physician. R#3's physician gave new orders for X-rays. X-ray indicated a fractured pelvis. R#3's Physician gave orders to transfer R#3 to a local hospital for evaluation and treatment. LVN "F" stated she could not remember if she reported the incident to DON "C". LVN "F" said CNA/RA "B" informed LVN "F" that R#3 did not have the anti thrust cushion on the wheelchair the day of the incident. LVN "F" denied that CNA/RA reported R#3 's ill fitted anti thrust cushion. LVN "F" stated she was familiar with the facility's protocol on Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. On 01/19/12 at 4:40 p.m., the ADM said she was informed of R#3's incident the next day 01/04/12, during the staff morning meeting. LVN "F" did not report R#3's incident with abnormal pelvic X-ray to her. The ADM stated when she received the information, she initiated an internal investigation and immediately suspended the four staff that were involved in the incident because they failed to follow the facility's abuse/neglect policy. The ADM stated during the investigation on 01/04/12, CNA/RA "B" informed the ADM that that the wheelchairs were washed approximately one week ago, and the anti thrust cushion was not replaced on R#3's wheelchair. The ADM said after R#3's incident the ADM implemented "The Falling Star Program". Family and staff were inserviced on the Falling Star Program. The DON said the DON monitored the licensed and certified staff. On 01/23/12 at 8:25 a.m., LVN "G" denied that CNA/RA reported R#3 's ill fitted anti thrust cushion to LVN "G" . LVN "G"said she was familiar with facility's protocol in Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. On 01/23/12 at 9:55 a.m.,The Rehabilitation Manager (RM) said the anti thrust cushion assists with positioning of residents. The RM said an anti thrust cushion would be beneficial for Residents with bilateral lower extremities amputation. The anti thrust cushion position the hips and this could prevent a resident from falling. No physicians order was required because it was only wheelchair positioning device. The RM said that was a nursing judgement and nursing informed PT. During a phone interview,on 01/23/12 at 10:45 a.m., CNA/RA "B" said approximately two weeks before R#3's incident on 01/03/12, she had reported to LVN "G", LVN "F" and Physical Therapist that R#3 slid off the cushion approximately four to five times a day, because the cushion was longer than the wheelchair. CNA/RA "B" said PT stated they would order a new anti thrust cushion, but up to the last day she worked 01/04/12, PT did not order the new anti thrust cushion. CNA/RA "B" said approximately one week before R#3's incident, the maintenance department washed down the wheelchairs and the cushions. The maintenance staff got R#3's cushion mixed up. CNA/RA "B" stated she looked for SR#3's anti thrust cushion and she could not find the cushion. CNA/RA "B" said she put another cushion on R#3's wheelchair. It was not an anti thrust cushion but, it fitted the wheelchair. CNA/RA "B" stated she informed LVN "F" that she had put another cushion instead of the anti thrust cushion on R#3's wheelchair. CNA/RA "B" stated The charge nurse LVN "G" PT and LVN "F" were aware of the ill fitting anti thrust cushion. CNA/RA "B" PT stated he would order a new anti thrust cushion, but up to 01/04/12, PT did not order the anti thrust cushion. CNA/RA "B" worked she was familiar with facility's protocol in Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. Surveyor observed R#3 on 01/19/12 at 11:10 a.m., lying on a low bed with mat on floor,breathing was labored with gurgling sounds, O2 was on at 2.5 L/M continuously per nasal canula, bilateral LE amputation. R#3 was non responsive. RP was sitting at his bedside. She stated she was the RP. Review of the undated Falling Star Program indicated : "A program used to help identify if a resident is at a high risk of falling to help determine how to care for a resident and reduce the risk of fall and /or injuries due to falls". "The purpose of the falling Star Program is to promote resident safety and have decrease in the amount of resident falls in the facility". Review of Physician's telephone Order dated 01/20/12 indicated: -DC bed alarm -DC pin alarm Sign in sheets indicated staff inservices on: 10/02/11- Understanding Abuse 11/04/11- Understanding Abuse 11/18/11- Fall Prevention 12/11/11- Understanding Abuse 01/17/11- Change in Condition 01/04/12- Abuse Facility policy, Abuse and Neglect Prohibition release date February 2010 defined Neglect as a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On 01/27/12 at 3:10 p.m., the Administrator was given the opportunity to provide any additional information regarding the anti thrust cushion. No additional information was provided. The Administrator informed surveyor that there was only one Resident with an anti thrust cushion on the 4th floor. The LVN "G"informed surveyor, that there were 14 residents with Tab Alarms on the 4th floor.

Based on observation, record review, and interview, the facility failed to implement their policy to prevent neglect by not ensuring safety positioning devices were in place for one Resident (R#3) of one resident reviewed for the effectiveness and use of safety/positioning device. Incident/Accident Report dated 01/03/12 indicated at approximately 7:30 a.m., in the 4th floor dining room, R#3 was found lying on the floor, infront of his wheelchair with his head leaning against the left wheel in the dining room. The Tab alarm was not attached to his shirt and the Anti thrust cushion was not on his wheelchair. R#3 sustained a pubic fracture from the fall. (Anti thrust Wheelchair Cushion is designed to prevent pelvis from thrusting forward - Tab Alarm -- A Tab alarm is a patient safety device that when activated alerts staff when a patient attempts to rise out of the chair or bed. The pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the caregiver). Failure to implement their policy to prevent neglect by not ensuring safety positioning devices were in place, resulted in R#3 a double [MEDICAL CONDITION], and required an antithrust cushion sustained a fractured pelvis. 14 residents with Tab alarms could be affected. The findings were: R#3's Incident/Accident Report dated 11/02/11 indicated at approximately 5:00 p.m., in the 4th floor dining room, R#3 was sitting at the dining room table during meal. R#3 slipped out of the wheelchair onto the floor. R#3 had a reddened area to the left eye. R#3,s care plan was revised, first aid done and an anti thrust cushion was initiated. R#3's Face Sheet dated 01/03/12 indicated R#3 was admitted to the facility on [DATE]. R#3 was [AGE] years old with [DIAGNOSES REDACTED]. R#3's History and Physical dated 02/14/11 indicated R#3 had a Right Below Knee Amputation and Left Above Knee Amputation (R) BKA and (L) AKA. R#3's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R#3: -had long and short term memory problems, -had cognitive skills for daily decision making was severely impaired (never/rarely made decisions) -was never /rarely understands or was understood, -was totally dependent on staff for activities of daily living (ADLs) bed mobility, transfers, bathing, and toilet use, locomotion,dressing and personal hygiene, -had impairment on both sides lower extremities (knee, ankle and foot) -was not steady moving on and off the toilet, only able to stabilize with human assistance, -was incontinent of bowel and bladder, -had no falls since the previous assessment and -had additional [DIAGNOSES REDACTED]. 1. R#3's Care Plan dated 12/22/11 indicated R#3 was at risk for Falls/Injury due to (R) BKA and (L) AKA. The Goal was R#3's dignity would be maintained and no occurrence of falls/injury would occur. One of the approaches was to assist with ADLs (Activities of daily living) and transfers using mechanical lift with two person assist at all times. R#3 was in a restraint free environment by using a bed and chair alarm. The approach was to monitor R#3 to ensure safety. 2. R#3's Care Plan dated 12/22/11 revised on 01/03/12 indicated R#3 was at risk for Falls related to a recent fall. The Goal was : -R#3 was sent to the ER (emergency room ), -had Physical and Occupational therapy evaluation -was placed on a low bed with a floor mat. The approaches that were put in place on 01/03/12: R#3 was placed on the Falling Star Program, Mechanical Lift x 2 persons and Anti Thrust Cushion to wheelchair A bed and chair alarm , The bed and chair alarm was discontinued on 01/20/12. Resident Care Cardex Worksheet undated indicated R#3: -was transferred with a hoyer lift x 2 persons, -was on a restorative program, -was on Falling Star Program, -had a bed and chair alarm and -had an anti thrust cushion. R#3's Incident/Accident Report dated 01/03/12 indicated at approximately 7:30 a.m., in the 4th floor dining room, R#3 was found lying on the floor, infront of his wheelchair with his head leaning against the left wheel. The Tab alarm was not attached to his shirt. X-ray of the pelvis was done by X-ray on wheels at the facility. R#3 was taken to a local hospital ER. X-ray of Pelvis dated 01/03/12 indicated R#3 sustained a [MEDICAL CONDITION] R#3 Telephone physician's orders [REDACTED]. Hospital Visit Information dated 01/03/12 indicated R#3 was seen for nondisplaced left inferior ischiopubic ramus fracture. On 01/03/12, R#3 was sent back to the facility on bedrest or in wheelchair if he tolerated a sitting position until cleared by his physician. R#3 was given Tylenol, Ice, Rest for pain with instructions was to be followed up with the Orthopedist (ortho-bone specialist) in 2-3 days. Surveyor observed R#3 on 01/19/12 at 11:10 a.m., lying on a low bed with a mat on the floor. RP was sitting at his bedside. She stated she was the RP. On 01/19/12 at 1:55 p.m., RP stated she visited R#3 once to twice weekly. RP stated the facility called to inform her that R#3 fell on [DATE], an X-ray revealed R#3 had a pelvic fracture and he would be transferred to a local hospital. On 01/19/12 at 3:15 p.m. DON "C" said she was at the facility on 01/03/12 until 8:30 p.m that night. DON "C" said she was informed of R#3's incident the next day 01/04/12, during the staff morning meeting. DON "C" said Licensed Vocational Nurse (LVN "F") was informed of R#3's incident on 01/03/12, but LVN "F" did not inform the ADM or DON "C". DON "C" said the staff members who were involved in the incident, Certified Nurse Aide/Restorative Aide (CNA/RA "B"), CNA "D", CNA "E" and Licensed Vocational Nurse (LVN "A") failed to check all of the safety measures were in place, including the anti thrust cushion when R#3 was transferred to the wheelchair "therefore, R#3 fell and fractured his pelvis". DON "C" said LVN "A" and CNA "E" worked on the 10:00 p.m - 6:00 a.m. shift. On 01/03/12, CNA "E" transferred R#3 from the bed to the wheelchair without the anti thrust cushion in place. LVN "A" was the charge nurse on the 6:00 a.m. - 2:00 p.m and failed to monitor that R#3's anti thrust cushion was in place. CNA/RA "B" was assigned to the 4th floor. DON "C" said CNA/RA "B" admitted to the ADM and DON "C" that R#3 did not have the anti thrust cushion for approximately two weeks prior to the fall on 01/03/12. DON "C" stated all the staff involved in the incident were terminated. On 01/19/12 at 4:00 p.m., LVN "F" said LVN "A" reported R#3's incident to LVN "F". LVN "F" assessed R#3 and found "negative findings". LVN "F" informed RP and R#3's physician. R#3's physician gave new orders for X-rays. X-ray indicated a fractured pelvis. R#3's Physician gave orders to transfer R#3 to a local hospital for evaluation and treatment. LVN "F" stated she could not remember if she reported the incident to DON "C". LVN "F" said CNA/RA "B" informed LVN "F" that R#3 did not have the anti thrust cushion on the wheelchair the day of the incident. LVN "F" denied that CNA/RA reported R#3 's ill fitted anti thrust cushion. LVN "F" stated she was familiar with the facility's protocol on Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. On 01/19/12 at 4:40 p.m., the ADM said she was informed of R#3's incident the next day 01/04/12, during the staff morning meeting. LVN "F" did not report R#3's incident with abnormal pelvic X-ray to her. The ADM stated when she received the information, she initiated an internal investigation and immediately suspended the four staff that were involved in the incident because they failed to follow the facility's abuse/neglect policy. The ADM stated during the investigation on 01/04/12, CNA/RA "B" informed the ADM that that the wheelchairs were washed approximately one week ago, and the anti thrust cushion was not replaced on R#3's wheelchair. The ADM said after R#3's incident the ADM implemented "The Falling Star Program". Family and staff were inserviced on the Falling Star Program. The DON said the DON monitored the licensed and certified staff. On 01/23/12 at 8:25 a.m., LVN "G" denied that CNA/RA reported R#3 's ill fitted anti thrust cushion to LVN "G" . LVN "G"said she was familiar with facility's protocol in Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. On 01/23/12 at 9:55 a.m.,The Rehabilitation Manager (RM) said the anti thrust cushion assists with positioning of residents. The RM said an anti thrust cushion would be beneficial for Residents with bilateral lower extremities amputation. The anti thrust cushion position the hips and this could prevent a resident from falling. No physicians order was required because it was only wheelchair positioning device. The RM said that was a nursing judgement and nursing informed PT. During a phone interview,on 01/23/12 at 10:45 a.m., CNA/RA "B" said approximately two weeks before R#3's incident on 01/03/12, she had reported to LVN "G", LVN "F" and Physical Therapist that R#3 slid off the cushion approximately four to five times a day, because the cushion was longer than the wheelchair. CNA/RA "B" said PT stated they would order a new anti thrust cushion, but up to the last day she worked 01/04/12, PT did not order the new anti thrust cushion. CNA/RA "B" said approximately one week before R#3's incident, the maintenance department washed down the wheelchairs and the cushions. The maintenance staff got R#3's cushion mixed up. CNA/RA "B" stated she looked for SR#3's anti thrust cushion and she could not find the cushion. CNA/RA "B" said she put another cushion on R#3's wheelchair. It was not an anti thrust cushion but, it fitted the wheelchair. CNA/RA "B" stated she informed LVN "F" that she had put another cushion instead of the anti thrust cushion on R#3's wheelchair. CNA/RA "B" stated The charge nurse LVN "G" PT and LVN "F" were aware of the ill fitting anti thrust cushion. CNA/RA "B" PT stated he would order a new anti thrust cushion, but up to 01/04/12, PT did not order the anti thrust cushion. CNA/RA "B" worked she was familiar with facility's protocol in Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. Surveyor observed R#3 on 01/19/12 at 11:10 a.m., lying on a low bed with mat on floor,breathing was labored with gurgling sounds, O2 was on at 2.5 L/M continuously per nasal canula, bilateral LE amputation. R#3 was non responsive. RP was sitting at his bedside. She stated she was the RP. Review of the undated Falling Star Program indicated : "A program used to help identify if a resident is at a high risk of falling to help determine how to care for a resident and reduce the risk of fall and /or injuries due to falls". "The purpose of the falling Star Program is to promote resident safety and have decrease in the amount of resident falls in the facility". Review of Physician's telephone Order dated 01/20/12 indicated: -DC bed alarm -DC pin alarm Sign in sheets indicated staff inservices on: 10/02/11- Understanding Abuse 11/04/11- Understanding Abuse 11/18/11- Fall Prevention 12/11/11- Understanding Abuse 01/17/11- Change in Condition 01/04/12- Abuse Facility policy, Abuse and Neglect Prohibition release date February 2010 defined Neglect as a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On 01/27/12 at 3:10 p.m., the Administrator was given the opportunity to provide any additional information regarding the anti thrust cushion. No additional information was provided. The Administrator informed surveyor that there was only one Resident with an anti thrust cushion on the 4th floor. The LVN "G"informed surveyor, that there were 14 residents with Tab Alarms on the 4th floor.

Based on observation, record review, and interview, the facility failed to implement written policies and procedures to prohibit neglect for one Resident (R#3) of one resident with an anti thrust cushion by not identifying, developing, and implementing measures to ensure the anti thrust cushion was monitored for effectiveness in the prevention of falls. Incident/Accident Report dated 01/03/12 indicated at approximately 7:30 a.m., in the 4th floor dining room, R#3 was found lying on the floor, infront of his wheelchair with his head leaning against the left wheel in the dining room. The Tab alarm was not attached to his shirt and the Anti thrust cushion was not on his wheelchair. R#3 sustained a pubic fracture from the fall. (Anti thrust Wheelchair Cushion is designed to prevent pelvis from thrusting forward - Tab Alarm -- A Tab alarm is a patient safety device that when activated alerts staff when a patient attempts to rise out of the chair or bed. The pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the caregiver). Failure to implement their policy to prevent neglect by not ensuring safety positioning devices were in place, resulted in R#3 a double [MEDICAL CONDITION], and required an antithrust cushion sustained a fractured pelvis. 14 residents with Tab alarms could be affected. The findings were: R#3's Incident/Accident Report dated 11/02/11 indicated at approximately 5:00 p.m., in the 4th floor dining room, R#3 was sitting at the dining room table during meal. R#3 slipped out of the wheelchair onto the floor. R#3 had a reddened area to the left eye. R#3,s care plan was revised, first aid done and an anti thrust cushion was initiated. R#3's Face Sheet dated 01/03/12 indicated R#3 was admitted to the facility on [DATE]. R#3 was [AGE] years old with [DIAGNOSES REDACTED]. R#3's History and Physical dated 02/14/11 indicated R#3 had a Right Below Knee Amputation and Left Above Knee Amputation (R) BKA and (L) AKA. R#3's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R#3: -had long and short term memory problems, -had cognitive skills for daily decision making was severely impaired (never/rarely made decisions) -was never /rarely understands or was understood, -was totally dependent on staff for activities of daily living (ADLs) bed mobility, transfers, bathing, and toilet use, locomotion,dressing and personal hygiene, -had impairment on both sides lower extremities (knee, ankle and foot) -was not steady moving on and off the toilet, only able to stabilize with human assistance, -was incontinent of bowel and bladder, -had no falls since the previous assessment and -had additional [DIAGNOSES REDACTED]. 1. R#3's Care Plan dated 12/22/11 indicated R#3 was at risk for Falls/Injury due to (R) BKA and (L) AKA. The Goal was R#3's dignity would be maintained and no occurrence of falls/injury would occur. One of the approaches was to assist with ADLs (Activities of daily living) and transfers using mechanical lift with two person assist at all times. R#3 was in a restraint free environment by using a bed and chair alarm. The approach was to monitor R#3 to ensure safety. 2. R#3's Care Plan dated 12/22/11 revised on 01/03/12 indicated R#3 was at risk for Falls related to a recent fall. The Goal was : -R#3 was sent to the ER (emergency room ), -had Physical and Occupational therapy evaluation -was placed on a low bed with a floor mat. The approaches that were put in place on 01/03/12: R#3 was placed on the Falling Star Program, Mechanical Lift x 2 persons and Anti Thrust Cushion to wheelchair A bed and chair alarm , The bed and chair alarm was discontinued on 01/20/12. Resident Care Cardex Worksheet undated indicated R#3: -was transferred with a hoyer lift x 2 persons, -was on a restorative program, -was on Falling Star Program, -had a bed and chair alarm and -had an anti thrust cushion. R#3's Incident/Accident Report dated 01/03/12 indicated at approximately 7:30 a.m., in the 4th floor dining room, R#3 was found lying on the floor, infront of his wheelchair with his head leaning against the left wheel. The Tab alarm was not attached to his shirt. X-ray of the pelvis was done by X-ray on wheels at the facility. R#3 was taken to a local hospital ER. X-ray of Pelvis dated 01/03/12 indicated R#3 sustained a [MEDICAL CONDITION] R#3 Telephone physician's orders [REDACTED]. Hospital Visit Information dated 01/03/12 indicated R#3 was seen for nondisplaced left inferior ischiopubic ramus fracture. On 01/03/12, R#3 was sent back to the facility on bedrest or in wheelchair if he tolerated a sitting position until cleared by his physician. R#3 was given Tylenol, Ice, Rest for pain with instructions was to be followed up with the Orthopedist (ortho-bone specialist) in 2-3 days. Surveyor observed R#3 on 01/19/12 at 11:10 a.m., lying on a low bed with a mat on the floor. RP was sitting at his bedside. She stated she was the RP. On 01/19/12 at 1:55 p.m., RP stated she visited R#3 once to twice weekly. RP stated the facility called to inform her that R#3 fell on [DATE], an X-ray revealed R#3 had a pelvic fracture and he would be transferred to a local hospital. On 01/19/12 at 3:15 p.m. DON "C" said she was at the facility on 01/03/12 until 8:30 p.m that night. DON "C" said she was informed of R#3's incident the next day 01/04/12, during the staff morning meeting. DON "C" said Licensed Vocational Nurse (LVN "F") was informed of R#3's incident on 01/03/12, but LVN "F" did not inform the ADM or DON "C". DON "C" said the staff members who were involved in the incident, Certified Nurse Aide/Restorative Aide (CNA/RA "B"), CNA "D", CNA "E" and Licensed Vocational Nurse (LVN "A") failed to check all of the safety measures were in place, including the anti thrust cushion when R#3 was transferred to the wheelchair "therefore, R#3 fell and fractured his pelvis". DON "C" said LVN "A" and CNA "E" worked on the 10:00 p.m - 6:00 a.m. shift. On 01/03/12, CNA "E" transferred R#3 from the bed to the wheelchair without the anti thrust cushion in place. LVN "A" was the charge nurse on the 6:00 a.m. - 2:00 p.m and failed to monitor that R#3's anti thrust cushion was in place. CNA/RA "B" was assigned to the 4th floor. DON "C" said CNA/RA "B" admitted to the ADM and DON "C" that R#3 did not have the anti thrust cushion for approximately two weeks prior to the fall on 01/03/12. DON "C" stated all the staff involved in the incident were terminated. On 01/19/12 at 4:00 p.m., LVN "F" said LVN "A" reported R#3's incident to LVN "F". LVN "F" assessed R#3 and found "negative findings". LVN "F" informed RP and R#3's physician. R#3's physician gave new orders for X-rays. X-ray indicated a fractured pelvis. R#3's Physician gave orders to transfer R#3 to a local hospital for evaluation and treatment. LVN "F" stated she could not remember if she reported the incident to DON "C". LVN "F" said CNA/RA "B" informed LVN "F" that R#3 did not have the anti thrust cushion on the wheelchair the day of the incident. LVN "F" denied that CNA/RA reported R#3 's ill fitted anti thrust cushion. LVN "F" stated she was familiar with the facility's protocol on Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. On 01/19/12 at 4:40 p.m., the ADM said she was informed of R#3's incident the next day 01/04/12, during the staff morning meeting. LVN "F" did not report R#3's incident with abnormal pelvic X-ray to her. The ADM stated when she received the information, she initiated an internal investigation and immediately suspended the four staff that were involved in the incident because they failed to follow the facility's abuse/neglect policy. The ADM stated during the investigation on 01/04/12, CNA/RA "B" informed the ADM that that the wheelchairs were washed approximately one week ago, and the anti thrust cushion was not replaced on R#3's wheelchair. The ADM said after R#3's incident the ADM implemented "The Falling Star Program". Family and staff were inserviced on the Falling Star Program. The DON said the DON monitored the licensed and certified staff. On 01/23/12 at 8:25 a.m., LVN "G" denied that CNA/RA reported R#3 's ill fitted anti thrust cushion to LVN "G" . LVN "G"said she was familiar with facility's protocol in Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. On 01/23/12 at 9:55 a.m.,The Rehabilitation Manager (RM) said the anti thrust cushion assists with positioning of residents. The RM said an anti thrust cushion would be beneficial for Residents with bilateral lower extremities amputation. The anti thrust cushion position the hips and this could prevent a resident from falling. No physicians order was required because it was only wheelchair positioning device. The RM said that was a nursing judgement and nursing informed PT. During a phone interview,on 01/23/12 at 10:45 a.m., CNA/RA "B" said approximately two weeks before R#3's incident on 01/03/12, she had reported to LVN "G", LVN "F" and Physical Therapist that R#3 slid off the cushion approximately four to five times a day, because the cushion was longer than the wheelchair. CNA/RA "B" said PT stated they would order a new anti thrust cushion, but up to the last day she worked 01/04/12, PT did not order the new anti thrust cushion. CNA/RA "B" said approximately one week before R#3's incident, the maintenance department washed down the wheelchairs and the cushions. The maintenance staff got R#3's cushion mixed up. CNA/RA "B" stated she looked for SR#3's anti thrust cushion and she could not find the cushion. CNA/RA "B" said she put another cushion on R#3's wheelchair. It was not an anti thrust cushion but, it fitted the wheelchair. CNA/RA "B" stated she informed LVN "F" that she had put another cushion instead of the anti thrust cushion on R#3's wheelchair. CNA/RA "B" stated The charge nurse LVN "G" PT and LVN "F" were aware of the ill fitting anti thrust cushion. CNA/RA "B" PT stated he would order a new anti thrust cushion, but up to 01/04/12, PT did not order the anti thrust cushion. CNA/RA "B" worked she was familiar with facility's protocol in Residents change in condition, The Fall Management Program and Abuse/Neglect Policy. Surveyor observed R#3 on 01/19/12 at 11:10 a.m., lying on a low bed with mat on floor,breathing was labored with gurgling sounds, O2 was on at 2.5 L/M continuously per nasal canula, bilateral LE amputation. R#3 was non responsive. RP was sitting at his bedside. She stated she was the RP. Review of the undated Falling Star Program indicated : "A program used to help identify if a resident is at a high risk of falling to help determine how to care for a resident and reduce the risk of fall and /or injuries due to falls". "The purpose of the falling Star Program is to promote resident safety and have decrease in the amount of resident falls in the facility". Review of Physician's telephone Order dated 01/20/12 indicated: -DC bed alarm -DC pin alarm Sign in sheets indicated staff inservices on: 10/02/11- Understanding Abuse 11/04/11- Understanding Abuse 11/18/11- Fall Prevention 12/11/11- Understanding Abuse 01/17/11- Change in Condition 01/04/12- Abuse Facility policy, Abuse and Neglect Prohibition release date February 2010 defined Neglect as a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On 01/27/12 at 3:10 p.m., the Administrator was given the opportunity to provide any additional information regarding the anti thrust cushion. No additional information was provided. The Administrator informed surveyor that there was only one Resident with an anti thrust cushion on the 4th floor. The LVN "G"informed surveyor, that there were 14 residents with Tab Alarms on the 4th floor.