Every finding on record at Windsor Quail Valley Post-Acute Healthcare

Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 (Resident #2) reviewed for PASARR. The facility failed to ensure Resident #2 who had a diagnosis of mental illness, received a positive PASARR Level I and PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Record review of Resident #2's face sheet reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnosis included depression (serious mood disorder that causes persistent sadness, and loss of interest in activities), mood disorder due to known physiological condition with mixed features (symptoms of depression and mania or hypomania), memory deficit following cerebral infarction other symptoms and signs involving cognitive functions following cerebral infarction (difficulty maintaining, creating and recalling memories), paranoid schizophrenia (delusions, and hallucinations), other impulse disorders (repeated inability to resist intense urges or impulses that may harm oneself or others), and drug induced secondary parkinsonism (reversible condition where medications cause Parkinson's-like symptoms by blocking dopamine receptors in the brain). Record review of Resident #2's Quarterly MDS dated [DATE], reflected resident had readmitted from an inpatient psychiatric facility. The resident had a BIMS score of 04 reflecting the resident had sever cognitive impairment. Resident #2's diagnoses were listed as depression, bipolar disorder, and schizophrenia, drug induced secondary parkinsonism, impulsive disorder, and insomnia. Record review of Resident #2's care plan undated, reflected the following: The resident was physically aggressive; he was kicking at staff r/t poor impulse control. The resident had a behavior of screaming outburst and swinging at staff, date initiated on 09/17/2025 and revised on 01/09/2026. The resident had impaired cognitive function or impaired thought processes r/t neurological symptoms (CVA) date initiated on 08/27/2025 and revised on 09/16/2025. The resident had used antidepressant medication Trazodone r/t depression and insomnia, date initiated on 09/16/2025 and revised on 05/12/2026. The resident had used psychotropic medications Risperdal r/t behavior management, date initiated on 02/21/2026 and revised on 02/21/2026. The resident had mood problems r/t depression and mood disorder, date Initiated: 09/16/2025 Revision on: 09/16/2025. Record review of Resident #2's PASARR Level I dated 02/26/2025 reflected the resident had a dx of MI only. Record review of Resident #2's PASARR Level I dated 08/26/2025 reflected the resident had a dx of MI only. Record review of Resident #2's Change of Condition Communication dated 02/24/2026 at 10:47 a.m., reflected, s/sx were reported of resident having a behavior of throwing personal foods and personal items throughout the room creating a safety hazard for roommate and self. The resident was allowed to express his feelings, and medication was increased to help the behavior. These conditions, symptoms, or signs had occurred before. Treatment for last episode required changes to medication changes and an inpatient psych stay. Record review of Resident #2's progress note dated 02/26/2026 at 09:31 p.m., reflected MD attempted to have a discussion with resident related to his behavior of throwing personal items, the resident declined. During an interview on 05/13/2026 at 02:12 p.m., the MDS Nurse stated Resident #2 had an inpatient stay at a psychiatric hospital from [DATE] to /202/2026 due his schizophrenia diagnosis. She stated that inpatient stay should have qualified the resident for PASARR services. She stated she was unaware what disqualified him from services and had not questioned the PASARR evaluated. She stated that she receives the evaluation results and adds the information to Resident #2's clinicals. During an interview on 05/13/2026 at 04:03 p.m., the PASARR Evaluator stated Resident #2 had been admitted to the facility in 2025 with a MI diagnosis of schizophrenia. She stated on 01/27/2026 to 02/20/2026 the resident had an inpatient stay with a psychiatric hospital. She stated that inpatient stay initiated the need for a new PASARR Level I evaluation. She stated on 03/25/2026 she completed the resident's latest PASARR Level I evaluation. She stated during the completion, she missed keyed that the resident had not had an inpatient stay at a psychiatric hospital which resulted in the resident having a negative PASARR Level I and not making him eligible for additional MI services. She stated on this date, MDS Nurse called questioning how the resident had become negative, when she found her error. She stated on 05/14/2026, she would have revaluated the resident, and he would have been found positive. She stated once the evaluation was submitted to the facility and an IDT meeting was scheduled with the resident, resident's RP, MDS Nurse, SW, MD, and DON to discuss what additional MI services could be provided and accepted by the resident and generate the PASARR Level II evaluation. She stated she was apologetically regretful for the error that was completely her fault. During an interview on 05/13/2026 at 04:13 p.m., the MDS Nurse stated she had worked for the facility for 3 years and had been an MDS Nurse for 15 years. She stated during that time as an MDS Nurse it had been her understanding that residents who had MI diagnosis and a psychiatric inpatient stay received a positive PASARR Level I evaluation and were eligible for PASARR Level II services. She stated the resident admitted with an MI diagnosis. She stated on 01/27/2026 to 02/20/2026, the resident had an inpatient stay with a psychiatric hospital and prompted a new PASARR Level I evaluation that was performed by the PASARR Evaluator on 03/25/2026. She stated Resident #2's results were received on 04/01/2026. She stated when she received results, she looked to see if positive or negative results were received and went with whatever the evaluator's decision concluded because the PASARR Evaluator was responsible for the evaluation. During an interview on 05/13/2026 at 04:31 p.m., with the ADM and DON, the DON stated that it was the PASARR Evaluator's responsibility to perform and determine when a resident was PASARR positive or negative. She stated the importance of a PASARR evaluation was to determine if residents qualify for additional services designed or their MI diagnosis. The DON stated that Resident #2 had received multiple psychiatric service visits, psychiatric medication monitoring to include GDR since admittance to the facility. The DON stated the MDS Nurse was responsible for ensuring resident's PASARR evaluations were scheduled, received, and the specialized services offered to the PASARR positive residents. The DON stated the resident's behaviors had improved since his inpatient psychiatric stay. The DON stated the facility used the RAI manual for PASARR policy and procedure guidance.

Based on observations, interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Residents #21) and 1 of 3 (CMA Q) staff observed during medication administration. The facility failed to ensure staff clarified the order for Resident #21's Miralax prior to administering the medication on 05/13/2026. The failure could place residents at risk of not receiving the intended therapeutic benefit. Findings included: Record review of Resident #21's undated admission record revealed a [AGE] year-old female with an admission date of 05/31/2024. Resident #21 diagnoses included dysphagia (trouble swallowing), gastro-esophageal reflux disease (a chronic digestive condition where stomach acid or bile repeatedly flows back into the food pipe, irritating its lining), muscle wasting, and cerebral infarction (blockage in blood vessels supplying the brain, resulting in tissue death). Record review of Resident #21's annual MDS dated [DATE] revealed a BIMS (a score is interpreted by assessing cognitive function, ranging from 0 to 15, with higher scores indicating better cognition. A score of 13-15 suggests intact cognition, 8-12 indicates moderate impairment, and 0-7 indicates severe impairment) score of 14 meaning the resident was cognitively intact. The resident often required assistance with toileting hygiene. Record review of Resident #21's Care Plan initiated on 05/13/2024 and last revised on 04/28/2026 read, resident had constipation r/t decreased mobility. The intervention read, give Miralax (a powder used to relieve constipation) as ordered. Record review of Resident #21's Physician Orders, dated 02/28/2025, revealed an active order of polyethylene glycol 3350 (the generic name for Miralax) oral (by mouth) powder 17 gm/scoop. Give 1 scoop by mouth daily for constipation. The order did not specify how much fluid to mix the powder with. During observation on 05/13/2026 at 8:55 a.m., CMA Q poured and mixed polyethylene glycol powder with an unmeasured amount of water and gave it to Resident #21. In an interview on 05/13/2026 at 9:00 a.m., CMA Q stated she should have held Resident #21's medication administration and contacted the provider for clarification on the polyethylene order. CMA Q stated she checked orders for instructions on how to administer medications. She stated she did not follow the proper procedure this time. CMA Q stated the order was incomplete and that could cause Resident #21 to receive a medication that was ineffective. CMA Q stated she received training on medication administration last month. In an interview on 05/13/2026 at 9:30 a.m., the DON stated he expected CMA Q to call the provider to request medication verifications on all incomplete orders when those orders missed instructions on how to administer them. She stated CMAs should have sought clarification about the amount of fluid required to mix the powder with before each administration. The DON stated the amount of fluids should have been 4-8 oz., she stated using the wrong amount of fluids to mix the powder could prevent the medication from working as prescribed and could cause fluid overload for residents with fluid restrictions. The DON stated the ADON performed reviews on residents' medication orders two times daily. The DON stated CMA Q last received in-service training on medication administration in December of last year. In an interview on 05/13/2026 at 9:45 a.m., the ADON stated using the wrong amount of water to mix the powder could prevent the medication from working as it was supposed to and could cause fluid overload for residents with fluid restrictions. The ADON stated she performed reviews on residents' medication orders two times daily and spot checked as well. She stated the incomplete Miralax order must have been missed during the review. In an interview on 05/13/2026 at 10:02 a.m., the MD stated polyethylene glycol orders should have included between 4 and 8 oz. of fluids to mix the powder with. The MD stated, ideally, the prescribing provider; who was not available to interview; should have included the amount of fluid required to mix the powder with. The MD stated he expected nurses and CMAs to contact the provider for clarification about medication orders when those orders missed instructions on how to use them. He stated mixing the MiraLAX powder with fluids without specifying the amount could not cause harm if residents required fluid restrictions. Record review of Miralax manufacturer's recommendations dated 2026, revealed, .Take 17 gram of powder once a day. Use the Miralax bottle top to measure 17gram by filling to the indicated line (white section in cap). Mix and dissolve into 4-8 ounces of any beverage (hot, cold or room temperature). Record review of the facility's Medication Administration Policy dated 10/24/2022, revealed, .14. Administer medications as ordered in accordance with manufacturer specifications.a. provide appropriate amount of fluids or food. Record review of the facility's Prescriber Medication Orders Policy dated 10/01/2019, revealed, Policy: medications are administered only upon the clear complete and signed order of a person lawfully authorized to prescribe. Record review of In-service training titled The 10 Rights of Medication Administration dated 12/03/2025, revealed, RNs, LVNs and CMAs received the training.The training included. Clarify unclear or questionable orders .The list of staff names who received the training included CMA Q.

Based on observations, interviews and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (WCN) staff observed for infection control practices. The facility failed to ensure WCN followed proper infection control procedures after she completed a wound care procedure on 05/14/2026. The failure could place residents and staff at risk of infections. Findings included:During an observation on 05/14/2026 at 9:12 a.m., the WCN completed wound care, and while she still had her yellow gown on, and held a trash bag that contained the soiled supplies and dressings. The WCN left the room and went to the treatment cart, she logged in to her computer that was on top of the cart, opened the treatment cart using the cart key, and grabbed a red trash bag (used to dispose trash from isolation rooms) out of the treatment cart and disposed the regular trash bag inside the red trash bag and placed it on the floor. The yellow gown and the regular trash bag both rubbed against the treatment cart . The resident's room had signage of EBP (an infection-control measure used in nursing homes and skilled nursing facilities to prevent the spread of multidrug-resistant organisms ) posted outside. In an interview on 05/14/2026 at 9:24 a.m., the WCN stated she should have made sure she had the red trash bag that was ready to use, before she started the wound care for the resident. She stated she should have disposed of the trash bag while her gloves were still on, and then took her gloves off, the yellow gown, performed hand hygiene, and then proceeded to perform any other activities she needed to do, afterward. She stated she received training on EBP and PPE use recently. She stated she had been working as the facility's WCN since 2024. She stated not following the proper procedures for taking off PPE and not performing hand hygiene could put residents at risk of infections. In an interview on 05/14/2026 at 9:30 a.m., the facility's ICPN stated she expected the WCN to ensure she completed wound care and did not engage in any other activity until she took off her PPE, performed hand hygiene, and made sure trash was disposed properly. She stated not following the proper infection control protocols could put residents and staff at risk of infection. The ICPN stated she completed random infection control audits to ensure proper infection control practices in the facility. The audit included PPE use and hand washing. The ICPN stated the WCN received in-service training on infection control recently. In an interview on 05/14/2026 at 9:36 a.m., the DON stated she expected the WCN to follow the proper infection control procedures in taking off PPE and performing hand hygiene. The DON stated not following the proper infection control procedures could put residents and staff at risk of infections. The DON stated the WCN received in-service training on infection control in May of this year. The DON stated she performed random audits on infection control practices to ensure staff followed those practices. The audit contained PPE use and hand hygiene. Record review of the facility's Enhanced Barrier Precautions Policy dated 11/24/2025, revealed .Definitions: Enhance Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .Initiation of Enhanced Barrier Precautions: .b. An order for Enhanced Barrier Precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers.3. Implementation of Enhanced Barrier Precautions:.b. Personal Protective Equipment (gown and gloves) for Enhanced Barrier Precautions are only necessary when performing high contact care activities.d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room .4. High contact resident care activities include:.h. Wound care. Record review of the facility's In-service named Infection Control-Hand Washing-PPE dated 05/08/2026, revealed staff received training on the following: 1. Handwashing must be performed before and after each procedure.2. Handwashing is performed prior to taking care of a resident3. Wash hands prior to donning PPE4. Wash hands after doffing PPE5. Wash hands at least 20 seconds6. PPE must be donned prior to going into isolation/EBP rooms7. All PPE must be doffed prior to leaving isolation/EBP rooms.The list of staff names who received the training included the Wound Care Nurse.

Based on observation, interview and record review, the facility failed to dispose of garbage and refused properly for trash bins A and B reviewed for garbage disposal. - The facility failed to ensure the dumpster doors were secured on trash bin. - The facility failed to ensure trash bags were off the ground and in dumpster trash bins. This failure could place residents at risk of infections, pests and rodents from improperly disposed garbage.Findings included: Observation on 05/12/2026 at 07:46 a.m., multiple trash bags were observed on the ground in front of the 2 dumpster trash bins located outside of the facility. One of 2 doors open were left open. During an interview on 05/12/2026 at 01:08 p.m., the Regional Director of dietary services stated the trash was normally not left in that condition. She stated it may have been a new staff member who left the trash bags in front of the bins. She stated the kitchen staff were aware that trash bags should not be left outside of the trash bins, however multiple departments utilized garbage disposal bins. She stated it was important to keep the trash bin lids closed to ensure trash was not left on the ground. She stated that leaving trash on the ground and trash bin lids open may attract pests and contribute to infection control risks due to soiled briefs and linen. She stated she is going to re-educate staff and conduct in-service to prevent this from happening again. During an interview on 05/14/2026 at 09:13 a.m., the Housekeeping Supervisor stated the housekeepers staff moved trash from residents' rooms, the nurse's station, and the main bathrooms each shift. She stated housekeeping staff do not remove briefs, chuck pads, PPE, or wipes. As nursing staff are responsible for disposing of those items. She stated the risks for trash being left on the ground include infection control concerns and attracting rodents, dogs, and cats. She stated animals could potentially tear into and spread the trash. She stated an in-service training was conducted with all staff on 05/12/2026 to ensure the issue does not re-occur. During an interview on 05/14/2026 at 11:33 am., the DON stated, she observed the trash on the ground while driving into the facility on this date and immediately texted the maintenance staff to have the trash removed. She stated it was her expectation that trash was to be taken out every shift. She stated the trash bin lids were to remain closed at all times and not to be left on the ground. She stated open trash bins could encourage pests and create an infection control concern if visitors and staff came into contact with the trash. She stated the staff received an in-service re-education to ensure trash bin lids remained closed at all times and no trash was left on the ground. She stated the in-service education would be ongoing to reinforce compliance. During an interview on 05/14/2026 at 12:36 pm, the ADM stated, his expectation was for the dumpster area to always remain free from trash and debris. He stated trash was to be taken out after each shift by each department and should never be left on the ground. He stated the garbage disposal company serviced the dumpsters every Monday evening. He stated that leaving trash on the ground could create environmental concerns, including attracting rodents and other animals. He stated daily trash rounds were conducted by maintenance and kitchen staff to monitor the trash disposal area. He stated staff would be re-educated regarding proper trash disposal procedures and expectations. Record Review of the in-service training titled Topic Dumpster: Keep Lid Closed and no Trash on the Ground, date completed on 05/12/2026, reflected: The contents or summary read in part. All staff are responsible for the dumpsters. The dumpster must remain closed at all times. No trash is allowed on the ground. Please ensure that when you take out trash, please ensure all trash is in the dumpster. Record review of policy tilted Garbage Receptacles and dated 2018, revised date June 2019, reflected, Policy Statement. The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Outdoor receptacles: outdoor storage for refuse shall be constructed of nonabsorbent material such as concrete or asphalt and shall be smooth, durable and sloped to drain. It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insects and rodents with doors/lids kept closed and no waste outside of the receptacle. All shall be maintained in good repair.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures to accurately administer medications to meet the needs of each resident 1 (Resident #1) of 6 reviewed for pharmacy services. -RN A instructed CNA B to administer Resident #1's medication Eliquis. This failure placed residents at risk for medication errors. Findings: Record review of Resident #1's face sheet dated 12/02/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted again on 09/08/25. Resident #1's diagnoses included the following: chronic kidney failure, colostomy (surgical procedure that creates a new way for waste to exit the body into a bag), sepsis (infection), type 2 diabetes mellitus (when the body does not utilize sugar efficiently in the body for energy), abnormalities of gait and mobility, and rhabdomyolysis (condition where damaged muscle tissue breaks down, releasing harmful proteins and electrolytes {tiny particles in the body that carry electrical charges to aide in keeping the muscles working, nerves sending signals, and keeping the body hydrated} into the blood stream that could lead to heart problems, kidney failure, seizures or death}). Record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 13 indicating that resident cognition was intact. Record review of Resident #1's Comprehensive Care Plan dated 10/27/25 reflected that Resident #1 was care planned for anticoagulant (medicine that helps prevent blood clots) therapy Eliquis. An intervention included administering anticoagulant medication as ordered by the physician and monitor for side effects and effectiveness Q shift. Record review of Resident #1's Physician Order Summary for the month of December 2025 included the following order: -Dated 11/10/25 Eliquis oral tablet give 1 tablet by mouth two times a day to prevent blood clot for 60 days. Record review of Resident #1's MAR for the month of November and December 2025 reflected that Resident #1 was receiving the medication Eliquis 5mg by mouth two time a day for the prevention of clots at 9:00AM and 5:00PM. Observation on 12/02/25 at 1:44PM revealed Resident #1 resting in bed on an air mattress with the call light in reach watching TV.[BR1] Interview on 12/02/25 at 1:50PM with Resident #1 said he was receiving the medication Eliquis. Resident #1 said one time RN A gave the medication Eliquis to a CNA to administer him on the evening shift. Resident #1 said he could not remember the CNA's name or the day that had happened. Interview on 12/02/25 at 3:56PM with RN A said he worked the evening shift full time on the 2:00PM-10PM shift. RN A said he had been working at the facility for 2 years. RN A said he had taken care of Resident #1 in the past but not at the present time. RN A said approximately 2 days ago or so he was preparing to administer Resident #1's evening medication Eliquis. Resident #1 told him that he did not want him to come in his room. RN A said he had already pulled the medication Eliquis. RN A said at the time, CNA B was entering Resident #1's room with his dinner tray. RN A said he told CNA B to just give the medication to Resident #1. RN A said he did not want to waste the medication and therefore gave the medication to CNA B to administer to Resident #1 while he stood at the doorway and watched. CNA B said he knew that CNAs were not supposed to administer medications due to a safety issue. RN A said he just wanted to make sure that Resident #1 received his medication. RN A said he should have called the DON, and he could have also called another nurse to administer the medication. The DON was asked for the facility policy on medication administration and CNAs scope of practice as well as CNA's B training. Interview on 12/02/25 at 4:30PM with the DON said RN A should have called another nurse to administer the medication to Resident #1 or just discard the medication. The DON said RN A could have had the medication aide to administer the medication while he observed at the doorway. The DON said CNAs could not administer medications. The DON said that would place the resident(s) at risk for medication error. The DON said she was never told about the incident. Interview on 12/02/25 at 4:45PM with CNA B said he worked at the facility full time on the 2:00PM-10PM shift. CNA B said he had been working at the facility for a little over month. CNA B said he had been a CNA since February of 2025. CNA B said he should not have administered the medication because he was not certified to administer medications. CNA B said he administered the medication because RN A instructed him to do so. CNA B said that occurred about 2 or 3 days ago but could not remember the exact day. CNA B said RN A was standing in the doorway watching. CNA B said by him administering the medication, he did not know what it placed Resident #1 at risk for. Record review of facility Job duties/ Primary Responsibilities/Essential Functions for CNA, not dated, reflected in part: . Assist resident in customary daily requirements and tasks in care and treatment such as bathing, feeding, dressing, observing intake of food, care of hair, nails, moving residents from area to area, responding to calls Carry out duties and responsibilities in accordance with resident care policy and procedure Measure and record vital signs as assigned by Charge Nurse Detect and report situations that may cause resident accidents or injuries Contributes knowledge of resident's conditions/needs to resident care plans Observe and report symptoms, reactions, and changes of conditions to residents to Charge Nurse. Record review of the facility policy on Medication Administration, dated 10/24/22, reflected in part: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and accordance with professional standards of practice.

Based on observation, interview and record review the facility failed to provide the necessary services to maintain personal care for one of seven residents (Resident #19) reviewed for ADL care in that: -Resident #19 waited over an hour to receive incontinent care. -The call light activator switch was placed out of reach. -During that hour, three staff entered and exited the room without assisting the resident with incontinent care. -One staff turned off the call light and left the room. The deficient practice could cause residents at risk of not receiving the care as needed and place them at higher risk for skin breakdown. Findings included: Record review of the Admission Record for Resident #19 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, quadriplegia (loss of use of all four extremities), anxiety disorder, and muscle wasting and atrophy. Record review of the MDS assessment dated [DATE] revealed Resident #19 scored 10/15 on the BIMS, indicative of moderately impaired cognition. The MDS reflected the resident was dependent for hygiene. The MDS reflected the resident had a suprapubic indwelling catheter for urine and was incontinent of bowel. The MDS reflected the resident had four Stage 4 pressure sores. Record review of the Care Plan (revised 07/05/2023) for Resident #19 revealed the resident had bowel incontinence. One Intervention read, in part, .Check resident at frequent hours and provide incontinent care as needed. Record review of the Care Plan (revised 07/23/2024) revealed Resident #19 had a Stage 4 pressure sore on his sacral area. Record review of the Care Plan (revised 09/08/2022) for Resident #19 revealed the resident was at risk for skin breakdown from bowel incontinence. One Intervention read, in part, .Provide timely incontinent care . Observation and interview on 03/04/2025 at 10:36 a.m. revealed Resident #19 lying in bed. He said the staff do not check on him very often, and do not answer call lights promptly. Observation revealed the call light activator (pressure-type) switch was placed on the over bed table, out of the resident's reach. The Surveyor activated the call light at that time (10:36 a.m.). Observation on 03/04/2025 at 10:43 a.m. revealed RN L enter Resident #19's room. RN L exited the room at 10:47 a.m. The call light remained on. Observation on 03/04/2025 at 11:02 a.m. revealed CNA K entered the day room area across from Resident #19's room. The call light in the hallway was on and visible. CNA K put lotion or hand sanitizer on his hands, got a drink of water, and left the area, walking past Resident #19's room. Observation and interview on 03/04/2025 at 11:08 a.m. revealed Resident #19 was in the same position. He said RN L adjusted the television and left. He said he told RN L that he needed to be cleaned up. Resident #19 said He told me he would get someone and he just left. Observation on 03/04/2025 at 11:11 a.m. revealed RN L walk to the day room area across from Resident #19's room and looked into the room. Resident #19's call light was still on and visible. RN L left the area. Observation on 03/04/2025 at 11:15 a.m. revealed a female staff entered Resident #19's room. She exited the room. Observation at that time revealed the call light was off. Observation on 03/04/2025 at 11:30 a.m. revealed the Maintenance Director entered Resident #19's room. The Surveyor was in the day room and heard the resident say something but could not hear clearly enough to understand. The Maintenance Director said I'll get somebody and left the room. Observation on 03/04/2025 at 11:38 a.m. revealed LVN T entered Resident #19's room briefly and exited. Observation on 03/04/25 at 11:42 a.m. revealed CNA K enter the day room across from Resident #19's room, drank some water, and left the area. Observation on 03/04/2025 at 11:44 a.m. revealed the Speech Therapist enter Resident #19's room. Observation on 03/04/2025 at 11:48 a.m. revealed LVN T propelled Resident #19's roommate into the room. In an interview on 03/04/2025 at 12:00 p.m. LVN T said the first time she checked on Resident #19 (11:38 a.m.) she was seeing if he needed to be repositioned. She said the second time she went in (11:48 a.m.) Resident #19 said he would wait until the Speech Therapist left. Observation and interview on 03/04/2025 at 12:02 p.m. revealed RN L was at the nurses' station. RN L said when he went in to Resident #19's room the resident said he needed the television fixed. RN L said Resident #19 also said he needed to be changed. RN L said he went to tell the CNA . Observation at that time revealed RN L approached CNA F in the hallway. The Surveyor could not hear what RN L said to CNA F, but CNA F responded, I'll change him this afternoon. At that time the Surveyor asked RN L what a reasonable time frame was for a resident to be changed after he requested it. RN L said Reasonable is thirty minutes. Maximum one hour. He said he had told CNA K earlier. In an interview on 03/04/2025 at 12:06 p.m., CNA F said she had checked on Resident #19 when she started her shift at 6:00 a.m. She said she asked him if he needed to be changed then, and he said not before breakfast. She said she had just gone back into the room, but the Speech Therapist was in there. She said RN L had not told her earlier that Resident #19 needed care. She said CNA K just told her. Observation on 03/04/2025 at 12:10 p.m. revealed RN L and CNA F enter Resident #19's room. In an interview on 03/04/2025 at 12:31 p.m., Resident #19 said he had been cleaned up. Observation revealed the call light activator switch was on the over bed table, out of reach. In an interview on 03/04/2025 at 12:33 p.m., CNA K said RN L had told him to tell CNA F that Resident #19 needed to be changed. He said he told CNA F sometime after 11 [11:00 a.m.]. In an interview on 03/06/25 at 11:25 a.m., the DON said a reasonable time for a resident to be changed after activating the call light was between five to twenty minutes. The DON stated if a nurse answered a residents call light, If the resident requires two persons, get help. Or they can change the resident. If they're in the middle of med pass or something they can attempt to get a CNA. The DON said waiting from 10:36a.m. to 12:10p.m. was not reasonable. She said RN L should have told the resident he would come back or find a CNA. She said the CNA does not need to be assigned to that hall to help a resident. She said the possible negative outcomes for the resident would be a decline in the resident's comfort level, including dignity, and skin breakdown. The facility policy Call Lights: Accessibility and Timely Response (10/13/2022) read, in part, .5. Staff will ensure the call light is within reach of resident and secured, as needed .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #19) of 7 residents reviewed for infeciton control. -Staff provided incontinent care for the resident and did not practice hand hygiene prior to repositioning the resident and arranging the linens. The deficient practice placed the residents at risk for infection. Findings included: Record review of the Admission Record for Resident #19 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, quadriplegia (loss of use of all four extremities), anxiety disorder, and muscle wasting and atrophy. Record review of the MDS assessment dated [DATE] revealed Resident #19 scored 10/15 on the BIMS, indicative of moderately impaired cognition. The MDS reflected the resident was dependent for hygiene. The MDS reflected the resident had a suprapubic indwelling catheter for urine and was incontinent of bowel. Record review of the Care Plan (revised 07/05/2023) for Resident #19 revealed hethe resident had bowel incontinence. One Intervention read, in part, .Check resident at frequent hours and provide incontinent care as needed. Record review of the Care Plan (revised 09/08/2022) for Resident #19 revealed the resident was at risk for skin breakdown from bowel incontinence. One Intervention read, in part, .Provide timely incontinent care . Observation and interview on 03/06/2025 revealed CNA A and CNA G provide incontinent care for Resident #19. Both staff washed their hands and donned gowns and gloves. CNA G loosened the resident's brief. CNA A used disposable wipes to wipe the right groin area. She then discarded the wipe. She repeated the sequence for the left groin. The resident was turned onto his right side. The resident had two wound dressings that were intact and appeared clean. CNA A used disposable wipes to clean a small amount of feces from the perineal area, and discarded the wipes. The staff turned Resident #19 onto his left side. CNA G removed the soiled brief and discarded it. CNA A cleaned the resident again. Both staff placed a new brief under the resident and secured it. CNA A and CNA G did not remove their gloves or practice hand hygiene before repositioning the resident. They then covered the resident with linens. CNA A then, while wearing the same gloves, moved Resident #19's motorized wheelchair. Both staff then removed their gowns and gloves. CNA A and CNA B stated they did not perform glove changes and hand hygiene, but should have. In an interview on 03/06/2025 at 4:05 p.m., the DON said when providing incontinent care, the staff should have changed gloves when going from dirty to clean. They should have practiced hand hygiene after removing the dirty brief and discarding it. She said a negative outcome would be an increased risk of infection. The facility policy Hand Hygiene (10/24/2022) read, in part, .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.

Based on interviews and records reviewed, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoteds maintenance or enhancement of his or her quality of life, for 1 (Resident #1) of 6 residents reviewed for resident rights. -The facility failed to allow Resident #1 to exercise his right to choose that CNA B not provide him care. This failure could place residents at risk for decreased feelings of self-worth and dignity. The findings included: Record review of Resident #1's Admission Record, dated 07/31/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows), intervertebral disc disorders with myelopathy (injury to the spinal cord caused by severe compression), spinal stenosis (condition in which the spaces in the spine narrow, compressing the spinal cord), muscle wasting and atrophy (loss of muscle mass and strength), and unspecified deformity of left finger(s). Record review of Resident #1's Quarterly MDS assessment, dated 06/06/2024, revealed a BIMS score of 12, indicating moderate cognitive impairment. Further review revealed the resident was dependent with toileting hygiene and showering/bathing. Record review of Resident #1's undated care plan revealed the resident had an ADL self-care performance deficit r/t limited range of motion and was totally dependent on 1 staff for bathing/showering, dressing, personal hygiene/oral care, and toilet use. Resident needed extensive assistance with bed mobility and required mechanical lift with 2 staff assistance for transfer. Observation and interview on 07/31/2024 at 7:50 a.m. revealed, Resident #1 was lying in bed watching television. He said he did not want CNA B proving care to him and that CNA B was aware. He said CNA B would go into his room and offer him care but he would refuse. He said when CNA B would offer him care after he told him he did not want care from him it made him feel uncomfortable, like he was being punished, and like CNA B had power over him. He said he told the previous DON that he did not want CNA B assisting him, and he was assigned another CNA. He said when that DON left, CNA B was assigned to him again. He said he reported this to CNA C but was told they were not his CNA, and CNA B would be providing his care. He said he only reported his concern to the previous DON. In an interview at 10:36 a.m., CNA B said Resident #1 told him approximately a month ago that he did not want him providing care to him. He said he let the ADON know, and she suggested for him to switch rooms with the other CNA on the hall. He said for the past couple of days he offered Resident #1 help with his care because his call light would be on, but the resident would refuse his help. He said he first let his coworker know that she was assigned to the resident, but she would give him attitude and deny the resident's room was assigned to her. He said he would find another CNA to assist the resident. He said the ADON told him yesterday not to go into the resident's room. He said he followed CNA C into the resident's room this morning, 07/31/24, to show CNA C that the resident did not want him proving care to him and CNA C was trying to persuade the resident to let him care for him. He said he told the ADON today, 07/31/24, at approximately 8:30 a.m. that CNA C was not cooperating. He said he found another CNA to assist the resident. He said CNA C has since started to provide care to the resident. He said Resident #1 had the right to say he did not want him to assist him with his care. He said it could potentially affect the resident emotionally because they could be afraid something negative could happen to them. In an interview at 11:39 a.m., CNA C said the ADON told her yesterday that CNA B could not work with Resident #1 but did not say why. She said she was assigned to Resident #1 today but was not assigned to him this morning. She said CNA B and her had a discussion in the hallway about who was to provide care to the resident this morning. She said yesterday no one told her about a swap until 11:29 a.m. She said she never refused to provide care to Resident #1 . In an interview on 07/31/2024 at 12:26 p.m., the ADON said Resident #1 had a lot of psych issues and one week he would not have a problem with an assigned aide and the following week he would say he had a problem with the aide. She said CNA B was not to provide care to Resident #1 because her understanding was a charger came up missing but was found. She said the previous interim DON said CNA B was not to provide care to Resident #1. She said she told CNA B not to go into the room because it could put him in a place that he should not even be in. She said CNA B knew he was not to provide care or go into Resident #1's room since at least 07/10/2024. She said it was the right of the resident to specify if they did not want a certain aide to assist them with their care. In an interview on 07/31/2024 at 12:50 p.m., the DON said she has been working at the facility since last Monday, 07/22/24. She said she did not know Resident #1 requested that CNA B not provide him care and said she found out today. She said she was not informed by any of the staff members that CNA B should not be providing care to him. She said residents had the right to say they did not want a particular CNA to provide them care. She said emotional harm could potentially result from receiving assistance from a CNA they did not want, and their BP could go up. She said to her knowledge CNA B went into the resident's room this morning to show CNA C that the resident did not want care from him. She said her expectation was for the CNAs to abide by a resident's request to not have a particular CNA assist them with their care. Record review of the facility's document titled Your Rights and Protections as a Nursing Home Resident, undated, read in part . You have the right to .be treated with dignity and respect .

Based on observations, interviews, and record review the facility failed to ensure residents received care, consistent with professional standards of practice to identify, prevent pressure ulcers from developing and promote healing for 1 (Resident CR# 1) of 9 residents reviewed for pressure ulcers. The facility failed to prevent, identify, and treat pressure sores on Resident CR#1's right buttock and right hip. CR #1 was sent to the hospital after family intervention, and there it was determined she had an unstageable wound to her buttocks and a stage 3 wound to her hip. The noncompliance was identified as Past Non-Compliant. The IJ began on 07/13/2024 and ended on 07/16/2024. The facility corrected the non-compliance before the survey began. This failure placed residents who were at risk of developing wounds of delayed identification, treatment, hospitalization , surgeries, infection, a decline in health, and pain. Findings included: Record review of Resident CR #1's admission face sheet undated revealed she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (general term for loss of memory, language, and thinking ability), Alzheimer's Disease ( progressive disease that destroys memory and important mental functioning) , malignant neoplasm of breast (cancerous tumor), cognitive communication deficit, chronic kidney disease, and dysphagia (difficulty swallowing). Record review of Resident CR#1's quarterly MDS dated [DATE] revealed her BIMS score was 99 which meant it was unable to be completed. The resident's cognitive skills for daily decision making were severely impaired. The resident was always incontinent of bowel and bladder. Resident CR #1 was dependent on staff for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, chair/bed-to-chair, and tub shower transfer. The resident was identified as having medically complex conditions. Review of Section M Skin Conditions revealed Resident CR#1 was at risk of developing pressure ulcers. The resident did not have any unhealed pressure ulcers. Record review of Resident CR#1's care plan date initiated 03/21/2024. Date revised 04/17/2024 revealed: Problem: Resident CR#1 was at risk for pressure ulcer development related to incontinence (trouble controlling elimination) and dependence on staff, cognitive deficit. Goal: The resident would have intact skin, free of redness, blisters, or discoloration through review date 09/01/2024. Interventions: Follow the facility policy and protocols for the prevention and treatment of skin breakdown. Inform the resident, family, caregivers of any new areas of skin breakdown. Monitor, document, report as needed any changes in skin status: appearance, color, wound healing, signs, and symptoms of infection, wound size, and stage (classification of pressure wound injury). Record review of Resident CR#1's Braden Scale for Predicting Pressure Ulcer Risk unsigned dated 06/04/2024 was scored 15 out of 23. The resident's category was at risk for the development of pressure ulcers. Record review of Resident CR#1's Weekly Skin Evaluation dated 07/06/2024 signed by RN A revealed the resident had no abnormal skin areas. Record review of Resident CR#1's Weekly Skin Evaluation dated 07/13/2024 signed by RN A revealed the resident had no abnormal skin areas. Record review of the facility Grievance Log dated 07/14/2024 revealed: Resident involved: Resident CR#1. Report person: RP. Main concern: Wounds. Resolution: Sent to hospital. Record review of the facility Nurse's Progress Notes by RN A dated 07/14/2024 at 2:13 AM revealed 11:42 PM Resident CR#1's Daughter D came to the nurse's station. The Resident CR#1's Daughter D reported she called 911. She wanted her to go to the hospital because she had a bad wound. 11:44 PM the 911 crew picked up the resident. 11:52 PM Resident CR#1 transferred to local hospital emergency room by 911 crew. Record review of local hospital ED Triage (process that prioritizes treatment) Notes dated 07/14/2024 revealed EMS was called for patient with a new wound on the buttocks. Record review of local hospital History and Physical dated 07/14/2024 revealed Resident CR#1 was brought to the ED from a nursing home with a pressure ulcer on the buttocks area. The patient had a stage II right buttock sacral ulcer going into stage III present on admission. Physical Examination revealed Wound: Pressure Injury Right Buttocks. Wound: Pressure Injury Right Hip. Record review of local hospital Wound Care Nurse Evaluation dated 07/15/2024: Wound Assessment revealed: 1.Wound 07/14/2024 Pressure Injury Right Buttocks: Unstageable pressure injury POA. Size 2.5 length cm X 2.5 width cm X 0 depth cm. No undermining (damaged tissue beneath the skin). No tunneling (a tunnel that extended from the wound into deeper tissue). Wound bed (base of wound) was covered with eschar (collection of dried dead tissue within a wound). Edges well defined (edges were flushed with wound base). 2. Wound 07/14/2024 Pressure Injury Right Hip: Stage III POA. Size 2.5 length cm X 2.0 width cm X 0.1 depth cm. No undermining. No tunneling. Wound bed was pink with minimal necrotic tissue (dead or dying tissue that cannot perform the normal function). Edges well defined. Record review of Hospital Wound care orders dated 07/15/2024 revealed the right buttock and the right hip cleanse with Vashe (wound cleaning solution). Pat dry. Apply Polymem dressing (a dressing that cleans the wound bed). Cover with Mepilex dressing (absorbent foam dressing) every other day . In an interview on 07/17/2024 at 12:53 PM the Interim DON stated the two wound care nurses RN A and LVN B were suspended pending an internal investigation brought to us by Resident CR#1's Daughter D. Resident CR#1's Daughter D reported the resident had a bad wound on her hip. The family member called 911 to have the resident taken to the hospital. She stated LVN B worked Monday through Friday. LVN B was also suspended due to putting a protective padded dressing on the resident's hip without an order. The weekend treatment nurse RN A reported to us she did a complete head to toe assessment on Resident CR#1 prior to her leaving on 07/13/2024. RN A stated the resident did not have any open area. RN A resigned . In a phone interview on 07/17/2024 at 2:00 PM LVN B stated she was not the wound care nurse for the 500 hall where Resident CR#1 was. The week-end nurse RN A was responsible for the 500 hall assessments. LVN B stated as the main treatment nurse she made random assessments of all residents on the 500 hall. LVN B stated Resident CR#1 laid on her right side a lot. The LVN stated she put a protective dressing to prevent breakdown. LVN B stated she did not have any open areas. On 07/06/2024 the resident's right hip was pink but blanched (redness that disappeared when pressure was applied but returned when the pressure was removed. Blood was still inside the vessels). LVN B stated she was aware that if there was a wound, she would notify the physician and family . In a phone interview on 07/17/2024 at 4:11 PM RN A stated she assessed Resident CR#1's skin weekly on the weekends. RN A stated she did a complete head to toe assessment on 07/13/2024 . RN A stated the resident did not have any open areas. RN A stated if she found something it would need to be reported for treatment to start. RN A stated she did not know how this occurred. Observation and interview at the local hospital on 07/18/2024 at 8:22AM revealed Resident CR#1 in bed on her left side. Resident CR#1 was nonverbal. Observation at this time revealed the resident's right hip with an open wound. The wound base was visible and pink. Continued observation revealed an open wound to the resident's right buttocks. The wound base was not visible due to eschar. Resident CR#1's family member was at the resident's bedside. In an interview at this time the family member stated she saw an open sore on her mother's hip. She stated she noticed an odor. In an interview at the local hospital on 07/18/2024 at 8:45AM the Hospital RN stated she was Resident CR#1's nurse for the day. RN C stated the resident was not verbal. The RN stated the resident was admitted for new pressure wounds. RN C stated the dressings were changed every other day. The Wounds were documented as POA which meant present on admission. In an interview on 07/18/2024 at 9:50AM the interim DON stated she began the position on 07/04/2024. The DON stated her expectations, and the facility policy was that all staff would assess the resident's skin. She stated if issues were found it wound be reported and documented in the computer. The DON stated the skin assessments were done weekly. All wounds were expected to be assessed and treated as ordered. The physician and resident's responsible party was to be notified of any skin changes. The DON stated it was the responsibility of the DON to monitor skin assessments and wound care weekly. The DON stated when we received the complaint, we had a QAPI meeting and implemented a plan. The two nurses were interviewed on how this occurred. Both nurses reported they assessed the resident they did not see any open wounds. In an interview on 07/19/2024 at 10:48AM the Regional Clinical Specialist stated the facility policy and expectations were for skin assessments to be done on admission, weekly, and as needed. She stated if something new was identified the nurse, physician, nurse practitioner, and resident's responsible party were notified immediately so treatment could start. She stated she was not sure how this occurred. On approximately 07/03/2024 LVN B was asked to look at the resident's right hip by a CNA. The nurse looked at the resident's hip but did not see a wound. LVN B put a protective dressing on the resident's hip due to her being at risk for wounds. As the interview continued, she stated it was the DON's responsibility for monitoring the skin assessment. The monitoring was to be done by making rounds weekly to follow up after the wound care nurse. In a phone interview on 07/19/2024 at 11:01 AM the facility wound care physician stated he was not caring for Resident CR#1. The wound care physician stated it wound not be possible to determine a shear wound from a pressure wound from a picture. He stated the wound would need to be assessed to determine if it was a sheer wound. He stated in general a stage III wound or a wound with eschar would take more than a few hours to have occurred . In an interview on 07/19/2024 at 11:37 AM the Administrator stated his expectations for skin assessments were done appropriately according to the facility policy. He stated he was not sure how this occurred. He understood wounds could occur quickly within a matter of hours. He stated LVN B put a protective dressing on the resident's hip but did not communicate with the clinical staff. It was RN A's responsibility to assess the residents on the 500 hall. The DON was responsible for monitoring the wound care and skin assessments, and they had weekly skin meetings. Any skin changes were discussed in the meeting. The Administrator stated to prevent this in the future both nurses were suspended and terminated. He stated We hired a new experienced treatment nurse. We were monitoring residents' skin daily. Record review of the facility's policy titled Skin assessment dated [DATE] read in part: . Policy: It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, weekly for three weeks, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . The noncompliance was identified as Past Non-Compliant. The IJ began on 07/13/2024 and ended on 07/16/2024. The facility corrected the non-compliance by: Suspended the two wound care nurses. 100% head-to-toe assessments on all residents. Facility self-reported to Health and Human Service Commission. Quality Assurance and Performance Improvement Impromptu meeting (done without planning) with the Administrator, the DON, and the Medical Director. Notified the resident's physician and nurse practitioner. The DON assessed the residents with wounds with the facility wound care physician. Educated all staff on abuse and neglect. Identifying, reporting, and documenting changes to include changes in skin condition. Measures to prevent pressure injuries and weekly skin assessment. Actions to take if notified of a change in a resident's skin condition. Staff will report changes in condition to include skin changes to charge nurse and the DON . On 07/18/2024 at 4:36 PM., facility administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the administrator via email.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal care for 1 of 5 residents (Resident #1) reviewed for ADL care. 1. The facility failed to ensure Resident #1 received proper grooming, including hair washing, three times a week (Monday, Wednesday and Friday) as per her bed bath and shower schedule. 2. The facility failed to address Resident#1's refusal to have her hair washed with FM on 3/6/2024. These failures could place Residents at risk for skin breakdown, infection, and loss of self-esteem. Findings Included: Record review of the undated Face Sheet for Resident#1 revealed, a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of apraxia (a motor speech disorder that makes it hard to speak), hemiplegia (paralysis on one side of the body), Cerebrovascular Disease (a group of conditions that affect the blood vessels of the brain, usually caused by having a stroke), Contracture (condition of hardening of the muscles, tendons or other tissue, often leading to deformity and rigidity of joints), Dysphagia following cerebral infarction (swallowing disorder caused by a stroke). Record Review of a Comprehensive MDS dated [DATE] for Resident #1, revealed she had a BIMS score of 3, which indicated severe cognitive impairment. Her functional abilities reflected she required substantial/maximal assistance for bed baths and showers. Record Review of the Care plan dated 6/29/2016 for Resident #1 revealed, she requires total assistance, by two staff, with showering as scheduled and as necessary; staff must anticipate and meet needs as she has a communication problem r/t aphasia (loss of ability to understand or express speech, caused by brain damage). Record Review of the Care plan meeting held on 3/6/2024 at 11:50am, by the SW, with the FM in the facility revealed discussion of code status, orders and plan of care; however, the meeting did not mention a concern with Resident #1 refusing to have her hair combed, matted hair or any need for a professional beautician. Record Review of the April 2024 ADL Schedule revealed Resident#1 received showers and/or bed baths Monday, Wednesday and Friday on the 2pm - 10pm shift. Record review of a facility shower schedule revealed Resident #1 was scheduled to receive a shower three times a week on Monday, Wednesday and Friday on the 2PM -10PM shift. Record Review of the PCC (electronic health record used to document information on each resident) notes for Resident#1 and dated 4/18/2024 at 3:37p) for a Change of Condition revealed, the Red Abrasion to back of scalp began on 4/18/2024. The NP was notified and new orders for clean site, apply Vaseline, LOTA Have TX Nurse Assess. Record review of Resident#1's physician's order dated 6/24/2016 revealed, Resident#1 had an order dated 4/18/2024 at 6:00pm to cleanse abrasion to back of scalp with wc; and on 4/19/2024 at 9:00am to cleanse abrasion to back of scalp w/ wc/pat dry, apply Vaseline, LOTA one time a day for abrasion until 4/19/2024 at 11:59pm. Record Review of PCC revealed, the wound care doctor rounded, assessed denuded (irritation) to the sacral area, new order to cleanse with normal saline/wound cleanser, pat dry, apply calcium alginate to wound bed, cover with bordered foam dressing daily and prn soiled or dislodged, well noted, order followed through, well tolerated. The FM was called to be updated on new orders, no response. Unable to leave a message due to no voicemail set up. During observation and on 4/24/2024 at 12:40pm, Resident#1 was laying in her bed and had a satin hair scarf. The Wound Nurse removed the scarf and Resident#1's hairstyle was in cornrows (braids). A small area on the back of her head was not braided. Unable to observe the open wounds on the scalp. Wound Nurse stated that Resident #1's scalp had an abrasion that appeared like someone may have scratched the back of her head in that area. During an interview on 4/24/2024 at 3:30pm with CNA A, revealed she has been caring for Resident#1 for some time now. She stated Resident #1 always scream; however, she can tell if the screams are for pain or other attention. She stated the Resident#1 is in a lot of pain due to her legs. She states both legs are contracted and sometimes it's difficult giving her a bath or shower and not being in pain. She states the resident can say yes or no. She states if the residents seem to be in a lot of pain and it is off the time of the medication schedule, she will contact the charge nurse. CNA A states she does comb resident's hair during bed baths; however, because her neck is stiff, she is unable to get to the bottom part of the back of her head. She states when she noticed the hair beginning to get matted at the back, she told the resident's FM to see if there may be someone, he knew that could come and do her hair. She stated when she returned to work after 2 days off, the resident hair was braided. In an interview on 4/24/2024 at 3:40pm interview with the Beautician revealed, on Saturday 4/13/2024 the FM came to the salon and said Resident #1 needed her hair done because her hair looked like it was matted. She told him she would be back at the facility on Thursday 4/18/2024 and would do her hair then. On 4/18/24 she did Resident#1's hair, which was extremely dirty and matted. In her professional opinion, the Beautician stated Resident #1's hair appeared it had not been combed or washed over a period time. She stated based on how dirty the Resident #1's hair was, in her professional opinion, it appeared her hair had not been washed in at least 3-4 months. It was completely matted to the hair tie on the back of her head used to maintain a ponytail. The Beautician further revealed the FM's were in the facility and she summoned them into the beauty shop where she informed them that Resident #1's hair would have to be cut because it was matted. She was given permission to do so. Afterwards, she began to wash her hair and observed Resident#1 crying and screaming. The Beautician stopped washing her hair and looked closer at her scalp. At that time, she observed the open wounds on the scalp. She stated the type of wounds Resident #1 had occurred was a result of her hair not being washed; being matted and the scalp not having air to breath. She stated this could infect the scalp, which is what has happened to the resident over a period. She stated she took a photo of it while the family was there. She stated the FM observed the same thing. She stated she sent the photo to the staff over the activity department. The Beautician also revealed she has a double State of Texas License, one as an instructor for cosmetology students and the other as a actual beautician. She states she has over [AGE] years in the hair care industry. In an Interview on 4/25/2024 at 11:20am with CNA B, he stated he has cared for Resident#1 for the 8 months he has worked in this facility. CNA B observed a rubber band in the back of Resident #1's hair, which is where her hair is matted. He has tried combing her hair, but it would be tangled, and Resident #1 would be in pain so he would stop. CNA B indicated he did not know why her hair was matted but it just got tangled up. In an Interview on 4/25/2024 at 1:40pm with the ADON it was revealed, she was aware of the issue with Resident#1's head. She stated the Activity Director informed her the resident had something in her head that the Beautician had found. The ADON stated she went to Resident #1's room and observed a round red area in the back of her scalp much like the scalp had been irritated. It did not have any depth to it or draining. The ADON believes the scalp was irritated because Resident #1 did not like her hair to be combed and as a result the scalp became irritated. The ADON stated she notified the NP and she gave an order to clean it and apply Vaseline and let the treatment nurse assess it. She stated she tried to call family member. Stated the FM were there; however, she never spoke with them. She stated she has never documented a resident not allowing staff to comb their hair. She Stated it should be care planned because it is more often than not that staff is allowed to comb her hair. The ADON stated Resident #1 receives her baths on Monday, Wednesday and Friday. She stated Resident #1 has refused bathing on occasion. When that happens, the CNAs are required to tell the nurses and the nurse should go in and speak with the resident. The ADON stated the hair washing and combing is a part of the bed bath and shower schedule; however, if a resident refused any part (ex., oral care or hair care) of the ADL there is no documentation. Interviewed on 4/25/2024 at 2:00pm with the DON, it was revealed she is aware of Resident #1's hair being matted. She believed it is matted because the Resident#1 will not allow the CNAs to comb her hair in the back. She stated it is not a wound, it was not open nor was it draining. She stated if it was a wound, then there would have been an order for triple biotics. She stated it appeared to only be an abrasion; it was not a wound and it is no longer on her scalp. She further stated the CNAs have tried to get the FM to pay for a beautician on previous occasions, but he just ignored the request. She states there is no documentation from staff regarding conversations with the FM regarding Resident #1's hair. She stated that washing hair is part of a CNA's responsibility when they give showers and some bed baths. The DON revealed, Vaseline was appropriate for Resident #1 because the skin on her scalp was not open. Stated she went to see Resident #1's head and there wasn't anything there. She stated Resident #1 was seen by the Wound Nurse as well. In a telephone interview on 4/26/24 at 12:40pm with Resident #1's PCP, it was revealed she was not notified of an issue with her head, so she did not complete an examination of head/scalp area. The PCP states Resident#1's health was on the decline, so she visits her weekly. In an interview with FM on 4/29/2024 at 11:52AM, FM stated he took the initiative to find a beautician for Resident #1's hair because it was matted and didn't look like it had been washed. During a telephone interview on 4/26/24 at 12:59pm with the NP revealed she received a call from the ADON regarding Resident#1's scalp but did not receive any pictures. She stated she was informed that Resident #1's scalp in the back was slightly red and there were no open wounds/open areas. Because there were no open wounds, she stated she may have told the ADON to put Vaseline on the area on the back of the head but can't recall saying anything about Vaseline. The NP stated if she was advised of any skin tear, small or large, she would have advised the ADON to apply an anti-biotic cream/ointment and not Vaseline. A record review of Resident #1's bed bath and shower schedule dated 3/27/2024 through 4/24/2024, revealed she received her bed bath and shower three times per week as per schedule and there are no indications of refusals. A record review of the facility's ADL policy dated 5/26/2023 revealed, care services of bathing, dressing, and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Abbreviations: ADMIN - Administrator ADON-Assistant Director of Nursing AS-Agency Staff BIMS-Brief Interview for Mental Status MA- Medical Aides CNA-Certified Nursing Assistant CR-Closed Record CW-Confidential Witness DON - Director of Nursing DORC - Director of Resident Care ED - Executive Director ERN - emergency room Nurse EMS-Emergency Medical Services EMT-Emergency Medical Technician FM-Family Member HHSC-Health and Human Services Commission IJ-Immediate Jeopardy IT-Immediate Threat LE-Law Enforcement LVN-Licensed Vocational Nurse PD- Police Dept MD-Medical Doctor MT - Resident Med Tech NP- Nurse Practitioner R-Resident RA-Resident Assistant RN-Registered Nurse RP-Responsible Party Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (CR#1) of 5 residents reviewed for abuse. The facility failed to ensure each resident was free from abuse when CR#1 was physically abused by CNA C on 2/20/2024 around 6:30am, which was the time CNA A started her morning shift and observed the bruising to CR#1's face. An Immediate Jeopardy (IJ) was identified on 02/25/2024 at 5:23 p.m. While the IJ was removed on 02/27/2024 at 6:00pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect. Findings Include: Record review of CR#1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE]. CR#1 has a diagnosis of Anoxic Brain Damage (lack of oxygen to the brain causing death of brain cells), Type 2 diabetes mellitus hypoglycemia w/o coma (low blood sugar levels), hypertension (high blood pressure), dysphagia (difficult swallowing), major depression disorder (low or depressed mood), chronic kidney disease (damaged kidneys and/or loss of kidney function), cognitive communication deficit (difficulty thinking and using language), anxiety disorder (pounding heart and sweating when responding to certain situations), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of CR#1's MDS assessment dated [DATE], revealed a BIMS score of 4 (severe cognitive impairment). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard, resident is able to recall prior questions after cueing, resident does not have any psychosis behaviors, which includes physical behaviors, verbal behavior, or any other behavior symptoms directed at others and the resident was able to participate in an activity preference interview of her interest while in the facility. Record Review of the Progress Notes for CR#1: There was only one progress note entered since 1/3/2024 and that was on 2/21/2024 at 16:17 (4:17pm), which was titled Admin Note and stated the Administrator notified FM of the HHSC investigation on 2/21/2024 with allegations of abuse. Record review of CR#1's care plan updated 03/31/2022 revealed, the resident has a communication problem r/t expressive Aphasia, Hearing deficit, Neurological symptoms. The goal was the resident will maintain current level of communication function by making sound, using appropriate gestures, responding to yes/no questions appropriately through the review date. The interventions are to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact. Ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. Resident is a one (1) person total assist and two (2) person transfer using a mechanical lift. Further review of Resident #1's care plan updated revealed no documentation regarding the facial injuries on 2/21/2024 or any plan initiated to keep her safe while in the facility going forward. Record Review of CR#1's orders dated 2/1/2024 - 2/29/2024 revealed calcium tablet-1 tablet by mouth for type 2 diabetes (last taken 2/21/24 at 2000 (8PM) hours); magnesium oxide (last taken 2/22/2024 at 0730 (7:30AM); sertraline (1 tablet daily for anxiety); vitamin D2 (1 tablet daily); Coreg oral tablet by mouth one time daily (hold if <110HR<60); Depakote capsule 2 times daily); Janumet oral tablet two times daily for mood disorder. Hold if drowsy; Janumet oral tablet by mouth two times daily (d/c date 2/6/2024); refresh tears solution (carboxymethylcellulose sodium) instilled one drop in both eyes two times a day for dry eye syndrome (start date 6/30/2022 1700 (5PM)). -The orders reflected a code 7 at 1700 hours, indicating the resident is sleeping and see progress notes (FM observed nurse putting eye drops in CR#1's eyes when she arrived during this time); Lorazepam 1 tablet by mouth three times daily; Accucheck one time a day related to diabetes (notify MD if bs <70 or >250); monitor vital signs every two weeks one time a day every 2 weeks on Mondays for Health monitoring (start 2/19/2024); Behavior monitoring for antianxiety from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts; Behavior monitoring for antidepressants from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts. Behavior monitoring for antipsychotic from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts and on 2/21/24; Behavior monitoring for Busplrone (anxiolytic medication to treat anxiety) from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 received a 1, which indicated mania (mental health marked by periods of great excitement or euphoria, delusions and overactivity); in the EVE2 and a 6-grandiosity (unrealistic sense of superiority in which someone believes themselves to be unique and better than others) in the NOC1; Assess pain on each shift; monitoring antianxiety received a 1 and 6 on 2/21/24; Monitoring side effects for antidepressants codes indicated none, but on 2/21/24 there is a 1 in evening and 6 NOC 1 Record Review of R#2's MDS assessment dated [DATE] revealed, BIMS score of 8 (moderate cognitive impairment). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was accurate when asked about the current month, resident is able to recall prior questions after cueing, able to recall a color without cueing. Resident has no symptoms of delirium, she is attentive, organized thinking and has a level of consciousness, resident has no symptoms of feeling down, depressed or hopeless; resident has no indicators of psychosis, hallucinations or delusions; Resident's active diagnoses are progressive neurological conditions, hypertension, anxiety disorder, depression (other than bipolar), psychotic disorder (other than schizophrenia). Record Review of R#2's psychological progress note dated 2/10/2024 revealed, improved coping. No issues. Record Review of R#2's psychological progress note dated 2/20/2024 revealed no change in mental status, specifically stressor or changes in mental status that may affect functioning. Noted during psychotherapy were improved coping skills, adjustment to illness-decline-loss. Resident noted she is hopeful that her family member will be taking her home soon, which she is looking forward to. No issues. The clinician will follow up with patient in 1-2 weeks to continue to address client's symptoms. Record Review of R#2's psychological progress note dated 2/26/2024 revealed, client's BIMS score was reduced from 8 to 4 (indicating cognitive decline); client reported year as 2020, could only recall 0 of the 3 words. Clinician explored with client what happened to her roommate, which client didn't want to discuss, but stated she has already told it too many times. Stated resident stated the night before she found out her roommate had a black eye, she heard the CNA C changing the roommate and heard a scuffle and the roommate said no and stop. She further stated she did not see anything and did not hear anyone being hit. Client stated she was shocked to learn her roommate had an injury the next day. States client was tearful and spoke of her roommate not coming back and that she will miss her as they were together for a long time. Record Review of L.E. report dated 2/21/2024 from PD. According to the police report, based on the age of the resident and the injury, Adult Protective Services was contacted. The report indicated that the resident did not inform the officers of the nature of her injuries but did report she had been assaulted to the EMS personnel. Record Review of EMS report FB. According to the EMS report, they arrived at the facility on 2/21/2024 at 10:34am. CR#1 was noted to have a periorbital hematoma to the right eye. CR#1 was noted to be warm to the touch. According to the EMS responder, R#2 mentioned, that yesterday evening CR#1 was yelling and she assumed that she was being changed as she usually yells when being changed. The EMS responder stated, CR#1 stated she was hit when he asked her what happened. She further states she was hit by a staff after he asked her if she was hit by another patient or staff. CR#1 was transported, non-emergency, to hospital. EMS Responder stated during transport he took her vitals and the right pupil was noted to be 2mm and the left pupil 4mm. Record Review of Progress note created on 2/21/2024 at 13:46 (1:36pm), effective 2/21/2024 at 10:41am revealed, CR#1 transferred to hospital for evaluation and CT scan per FM request. Resident left the facility via stretcher and two EMT in stable condition. On 2/22/2024 at 10:53am Interview with R#2 - Stated she was the room mate of CR#1. She stated she was in the room with CR#1 when CNA C came in the room to change them both. She stated she was changed first. She stated she heard CR#1 scream and tell CNA C that she was hurting her. She stated CR#1 continued to say, stop, stop you're hurting me. She stated the CNA C responded, Just be quiet its all your imagination! CR#2 stated that prior to Tuesday 2/20/2024, CR#1 did not have those bruises. She stated she was afraid that something may happen to her. She stated CR#1s FM came to the facility yesterday, 2/20/2024 and when she entered the room she asked R#2 if she had seen what happened to CR#1. At that time R#2 stated she was able to look at CR#1 face and saw those horrible bruises. According to R#2, this incident occurred the morning on 2/20/2024. She stated that the CNA comes in to change them right before her shift ends. She further stated that the morning shift CNA comes in to check and change both, CR#1 and R#2, at the beginning of their shift. She reiterated that the CNA that she heard CR#1 screaming at was the lady whose shift was ending. This, according to R#2 was the night shift CNA (CNA C). Observation and attempted interview with CR#1 on 02/22/2024 at 12:50 p.m. while in the hospital, revealed she was in bed eating lunch. CR #1 briefly looked up but she did not respond to any questions. The redness under CR#2's right eye was not as profound as the photos shown the day of FM's observation in the facility. The bruising on her right jaw still had a discoloration, while mild, still noticeable. Hospital Nursing staff came into to the room to change her and when they asked her to turn toward them, she responded by doing what they asked. On 02/22/2024 at 1:00p.m. 2/22/24 at 12:30pm- Interview with LE. stated he arrived at the facility on 2/21/2024 at 8:50am. and met with FM, another family member and CR #1. He stated FM requested for CR#1 to be transported to ER. He stated during the time of gathering information from all involved, the EMS worker informed him the resident stated she was assaulted. He stated when he questioned resident, she would not respond to him. He further stated that he spoke to the DON Wednesday, yesterday, after being contacted by the resident's family member. He stated that the timeline was on Friday the FM saw the resident and she had no bruises and when she arrived on Tuesday evening, the resident had bruises. On 2/22/24 at 1:00pm Interview with FM - FM stated she visited CR#1 on Friday 2/16/24, 4:00pm - 4:30pm and left that evening around 7:30pm and CR#1 had no bruises. She stated she returned Tuesday 2/20/24, between 5:00pm - 5:30pm and CR#1 was in the cafeteria. She stated at this time she noticed CR#1's bruised eye. She stated she left the cafeteria area and went into the ADON's office to inquire about what happened to CR#1 face. She stated both ADON's (A & B) were in the office. She stated she told them that CR#1 looked like she has been assaulted. She stated the ADON A responded, Now no one has hit CR#1. She may have hit her head on the wall area. FM felt the ADON A was being condescending, which angered her. FM responded, that analogy is not true and she asked why she wasn't notified CR#1 had marks and bruises on her face. FM stated at this time the ADON B got up and accompanied her to the cafeteria. She stated at that time the CR# 1 was asked who hit her. She stated a male. The ADON B stated at that time that there were no male CNA's working on the night shift. She stated the ADON B continued to tell her CR# 1 may have hit her head on the wall. FM told the ADON B that it was not possible to do that based on how her Geri Chair (padded reclining geriatric chair) was positioned. She stated she asked ADON B again why she was not notified (CR#1) had bruises. FM stated she did not get an answer. FM stated she spoke with the Admin who told her that he was doing an abuse investigation. He stated he did not know about the accusations of abuse or about the resident's eye. The Admin went to get the DON to ask what was going on. She stated the DON began saying CR#1 could be combative and this may be the reason for her injury. FM stated at this time she disagreed with them and left the facility. She stated CR#1 began to cry and beg her not to leave, but she had to leave at that time and made a decision to return in the morning with LE. FM stated she called LE on her way to the facility. FM stated she arrived at the facility on Wednesday 2/21/24, around 8:30am at which time CR# 1 was seated in her geri chair at the nurses' station. FM witnessed a nurse putting eye drops in CR#1s eyes. She spoke with the DON. She stated the DON initially told her that he had no idea and was not notified of the bruising. She stated after she told the DON she had contacted the police, the DON told her she received a photo while she was off of CR#1s eye and she was going to do an investigation. On 2/22/24 at 2:48pm Interview with CW - CW stated that on Monday evening CR #1 was in her room seated in a chair slumped over about to fall out. CW stated that there were two CNA's in another resident's room just talking and laughing. CW stated CW called the CNA's to go help CR#1 and they did. CW stated on Monday CW did not see bruising on CR#1s 's face. CW stated Tuesday morning around 8:30am CW observed the bruising on CR#1s face, her eye was swollen and really red and her jaw was black and blue and swollen going down towards her neck. CW stated the injuries were unbelievable and looked as if someone had beat her up. CW stated CW typically goes into CR#1s room and says hello because CW has gotten an opportunity to meet CR#1's FM and CW has told her CW is there with CW's own FM all the time and CW will check on her CR#1. CW stated each day CW arrives at the facility; CW will go to CR#1s room and kiss her on the forehead and tell her CW is just checking on her. On 2/22/24 at 5:05pm Interview with RN B- stated she works 2-10 shift and is familiar with CR# 1. LVN A stated CR#1's FM spoke to her about the redness around CR# 1's eyes. She stated she did not see anything on the face of CR #1. LVN A said she did not see the bruise prior to the 2/22/2024. She states she saw the redness on CR #1's eye and believes it was on the left eye. On 2/22/2024 at 5:17pm Interview with CNA B - stated she always work 2-10 shift. She did see CR #1 on Monday 2/19/24, and Tuesday 2/20/24, and did not notice any marks or bruises on resident face. She stated she was not assigned to CR #1 but saw her two days ago. CN A B said she did not notice marks or bruises on her face on Tuesday and CR#1 had a red eye. CNA B stated she reported her observation to the nurse in charge, LVN A. CNA B stated CR# 1 has never been combative when she worked with her. CNA B stated, If I see a resident with injury I will report to the nurse in charge. On 2/23/24 at 7:41am Telephone Interview with CNA A - Stated CR#1 was usually trying to fight while changing her, but she just tensed up her body. CNA A stated she was able to change her. CNA A stated she was training CNA L who had just started. CNA A stated she did noticed bruising on CR#1. CNA A stated her eye was swollen, and she believes it was the right eye. Did not ask what happened to her eye. She stated she informed the charge nurse, LVN B. CNA A stated CR#1 never screamed she was being hurt while changing her. She stated the last training on abuse and neglect was 2-3 weeks ago. She said she did not know why she was trained. The in-service was conducted by DON and Abuse coordinator. In an interview with CNA C on 2/23/24 at 4:28am revealed, she worked with CR#1 on Monday evening and did not notice bruises. CNA C said she changed her in the morning. She stated if her face looked like this it would have been noticed. CNA C stated resident does talk a little. She can say what she wants and if she wants to get in her chair and go to the nurse's station. CNA C will take her to the nursing station when she requests throughout her shift. She stated at no time did CR# 1 tell her to stop or she was hurting while changing her. In an interview with RN C on 2/23/24 at 4:58am revealed, he worked the weekend and did see CR# 1. RN C stated he did not observe CR #1 with any marks or bruises on her face. When shown a photo of resident's marks/bruises, RN C stated he has never seen her face like that and if he had he would have been alarmed and written an incident report. On 2/23/24 at 7:52am - Telephone Interview with LVN B - Stated during the earlier morning hours of her shift, 2/20/2024, around breakfast, the CNA A came to her and told her that CR#1's eye was red and swollen. She stated at this time CNA A had pushed CR#1 to the nursing area. She stated she observed the eye to be red and swollen and reported it to the LVN C.She again stated when CNA A told her about CR#1, she was already in her Geri Chair located in the hallway. She looked at CR#1 and then proceeded to speak with LVN C around 9:45am. She stated she attended the nursing morning meeting and told everyone (including both ADON's and Administrator that CR#1's eye appeared red and swollen. On 2/23/24 at 8:35am -Telephone interview with LVN C.- LVN C indicated that on Tuesday, 2/20/24, she was the treatment nurse. She said in the morning between 10 AM and 11 AM, LVN B came to her, while she was documenting on another resident in the office and told her that CR#1's eye was red and somewhat raised. She said that the LVN B was the charge nurse. She stated that she looked at the CR#1s eye while she was seated in her geri chair by the nurse's station. She stated that the eye was a little red but told LVN B to keep observing the eye LVN C stated that her last in-service for abuse and neglect was Wednesday with the Administrator, HR and DON. On 2/23/2024 at 9:50am Interview with Admin - Stated he is the coordinator for abuse and neglect at the facility. Stated on Wednesday, 2/21/24, CR#1's injuries appeared to have gotten worse. On 2/23/24 at 5:58pm Interview with DON. Stated CR#1 went to the hospital on Wednesday 2/21/24. She stated she had not worked on Tuesday 2/20/24, and had no idea what was going on until CR#1's FM came to the facility on [DATE] and told her she had called the police. She stated FM told her to look at CR#1's eye. She did. She stated she told FM that she would check on the issues and that she had not been informed of any type of injuries. The DON stated the resident was always rubbing her eyes and this may have caused bruising. FM brought the bruising to her attention and said CR#1 was abused. The DON stated she conducted an in-service for abuse. She stated the resident has a history of taking psychiatric medication because of her behavior problems. She indicated CR#1 has been combative lately. The DON stated the FM requested CR#1 be sent to the hospital, which the facility had no other option but to comply. She stated the bruises may have come from CR#1 vigorously rubbing her eyes. The DON was shown a photo of the CR#1's facial area and she stated the resident's bruises were not there when she left the facility. It was like a scratch when she left the facility. The DON brought in an in-service that was signed by some staff and not by others. She stated she completed the Abuse and Neglect and Exploitation in-service on Wednesday after the FM, brought it to her attention. The DON continued to deny the CR#1's face had those bruises when she left the facility. The DON stated, if FM was so upset about CR#1 why did she leave her on Tuesday? The DON stated if there is suspected abuse, protocol will be to ask all the residents if they feel safe. She stated she would call the police and make an incident report. In an interview with ERN on 2/24/24 at 9:35am. revealed she was the emergency room nurse that evaluated CR#1 upon her arrival by EMS. She stated per EMT, the FM requested that the resident be seen due to possible assault. The EMT said that family found CR# 1with unexplained bruising and the facility was dismissive. ERN stated the EMT further stated CR# 1 told him someone hit her, but there was not a lot of detail. ERN is also forensic interviewer. She stated she spoke with CR#1. She stated when speaking to CR#1, you have to wait and allow her time to process what you are saying for at least 30 seconds. CR#1 was asked her name and she responded accurately. She asked her if she knew where she was (ER) and after about 30 seconds responded in the affirmative and said where (ER) she was. ERN stated she has taken photos of CR#1 and completed a forensic report. She stated HHSC can send in a request and obtain all photos and other pertinent information. ERN stated that in her professional opinion, CR#1's facial injuries are consistent with someone who has been assaulted. Record review of In-service training dated 2/21/2024 by the Admin on Abuse and neglect and exploitation signed by some staff members. Record review of LVN B's timecard reflected she was suspended on 2/24/24. Record review of CNA C's counseling report reflected she was suspended on 2/25/2024. On 02/25/2024 at 5:43pm the Facility's Administrator and DON notified, via telephone, of the Immediate Jeopardy for Abuse (F-600). The Template was signed by the Bus Mgr and MDS. The POR was immediately requested at this time. The following plan of removal was accepted on 2/27/24 at 12:01 p.m. REMOVAL OF IMMEDIATE JEOPARDY On February 25, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: F- Tag 600: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility failed to ensure each resident was free from abuse when CR#1 was physically abused by CNA C on 2/20/24 around 6:30am resulting in bruising to CR#1's face. Done for those affected: Resident CR#1 was assessed by licensed nurse on 2/21/2024. MD was notified by licensed nurse on 2/21/2024. Resident CR#1 was transferred to the hospital for evaluation on 2/21/2024 and remains at the hospital. An Allegation of Abuse was reported to HHSC for Resident CR#1 on 2/21/2024. On 2/25/2024, the facility suspended the Certified Nurse Aide who worked with resident CR#1 on the 2/19/2024 10pm to 6am shift, pending investigation. If CNA C is found to be guilty of abusing CR#1, the facility will terminate employment immediately. Identify residents who could be affected: Beginning 2/21/2024, the Facility Social Worker(s) completed 100% of interviews of interviewable residents to assess for potential abuse. Date of completion is 2/23/2024. Findings: No additional concerns were identified. Effective 2/25/2024, Administrator and/or designee notified facility residents of abuse and neglect reporting. Reeducation included who the abuse coordinator is and how to report concerns and/ or allegation of abuse, neglect, mistreatment and/ or misappropriation to facility personnel. Date of completion is 2/26/2024. Effective 2/26/24, Administrator and/or designee notified families via alert media of the facility abuse and neglect reporting process. Reeducation included who the abuse coordinator is and how to report concerns and/ or allegation of abuse, neglect, mistreatment and/ or misappropriation to facility personnel. Date of Completion is 2/26/2024. On 2/23/2024, head to toe assessments were completed by the Licensed Nurse on all residents to identify any signs of injuries of unknown source. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Date of completion is 2/23/2024. Findings: No additional concerns were identified. On 2/23/2024, the DON/designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect were identified and an investigation initiated, and the incident reported to HHSC. Findings: No additional concerns were identified. On 2/23/2024, the DON/ Designee reviewed incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified. Systemic Process: On 2/23/2024, the Regional [NAME] President of Operations reeducated the Administrator (Abuse Coordinator) on Abuse and Neglect and Abuse Policy. Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse (with or without serious bodily injury); or neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury are reported immediately, but not later than two hours after the incident occurs or is suspected. Date of Completion is 2/23/2024. -On 2/23/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: *Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse (with or without serious bodily injury); or neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury are reported immediately, but not later than two hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury and involves neglect, exploitation, missing resident, misappropriation, drug theft, fire, emergency situations that pose a threat to resident health and safety, a death under unusual circumstances will be reported immediately, but not later than 24 hours after the incident occurs or is suspected. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. Date of completion is 2/23/2024. *Resident assessment to include head to toe assessments and documentation with each resident incident/accidents. Date of completion is 2/23/2024. -Effective 2/24/2024, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift. -The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. -To monitor, the Director of Nursing/ designee will review the 24-hour report and resident incidents in facility Stand-up Morning Meeting, attended Monday - Friday. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include to ensure investigation, resident assessments to include a head-to-toe assessments were completed and provided. Date of implementation is 2/23/2024. -The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided. Date of implementation is 2/23/2024. -Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. Date of Implementation is 2/23/2024. -The facility has the Wellsential Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety Monday through Friday. Findings will be reported during Morning Stand-up meetings to address and follow up on concerns/grievances. Date of Implementation is 2/23/2024. Monitoring: -An AdHoc (as needed) QAPI meeting was conducted on 2/25/2024, attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F- Tag 600 - the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 2/25/2024. The surveyor confirmed the facility implemented their plan of removal and Monitoring began on 2/26/2024 - 2/27/2024. Residents were interviewed regarding skin assessments, abuse and neglect and reporting. 8 residents interviewed indicated the DON and other nursing staff completed a skin assessment, the social worker spoke with each resident about abuse, neglect, exploitation and reporting. Each resident was asked who the abuse coordinator was and each resident stated the administrator. Each resident confirmed the assessments completed by nurses. Confirmed that the administrator alerted families, via alert media, of the facility's abuse, neglect and reporting process. The alert listed the Abuse Coordinator. I . Received and reviewed the completed weekly skin assessment evaluation form that was completed by the SW. Head to toe assessments were completed by LVN on all residents in the facility on 2/23/2024.< [TRUNCATED]

Based on Interview, and record review, the facility failed to implement abuse and neglect policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 (CR#1) of 5 residents reviewed for abuse by not implementing their abuse policy to prohibit and prevent abuse by conducting an investigation immediately; thus, failing to protect resident when there is a warranted suspicion of abuse and identifying staff responsible for the investigation. The facility failed to ensure each resident was free from abuse when CR#1 was physically abused by CNA C on 2/20/2024 around 6:30am, which was the time CNA A started her morning shift and observed the bruising to CR#1's face. These failures placed residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect. An Immediate Jeopardy (IJ) was identified on 02/23/2024 at 5:42 PM. While the IJ was removed on 02/24/2024 at 8:43PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. Findings Include: Record review of the ANE policy dated 8/12/2024 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, exploitation and misappropriation of resident property. V. Investigation of alleged abuse, neglect and exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation 2. Exercising caution and handling evidence that could be used in a criminal investigation; I 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. focusing the investigation on determining, if abuse, neglect, exploitation, and or mistreatment, has occurred, the extent, and calls; and 6. Providing complete and thorough documentation of the investigation Record Review of CR#1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE]. CR#1 has a diagnosis of Anoxic Brain Damage (lack of oxygen to the brain causing death of brain cells), Type 2 diabetes mellitus hypoglycemia w/o coma (low blood sugar levels), hypertension (high blood pressure), dysphagia (difficult swallowing), major depression disorder (low or depressed mood), chronic kidney disease (damaged kidney's and/or loss of kidney function), cognitive communication deficit (difficulty thinking and using language), anxiety disorder (pounding heart and sweating when responding to certain situations), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record Review of CR#1's MDS dated [DATE], revealed a BIMS score of 4 (Severe Cognitive Impairment). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard, resident is able to recall prior questions after cueing, resident does not have any psychosis behaviors, which includes physical behaviors, verbal behavior, or any other behavior symptoms directed at others and the resident was able to participate in an activity preference interview of her interest while in the facility. Record Review of CR#1's care plan updated 03/31/2022 revealed, the resident has a communication problem r/t expressive Aphasia, Hearing deficit, Neurological symptoms. The goal was the resident will maintain current level of communication function by making sound, using appropriated gestures, responding to yes/no questions appropriately through the review date. The interventions are to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact. Ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. Resident is a one (1) person total assist and two (2) person transfer using a mechanical lift. Further review of Resident #1's care plan updated revealed no documentation regarding the facial injuries on 2/21/2024 or any plan initiated to keep her safe while in the facility going forward. Record Review of CR#1'sVitals revealed the following: *CR#1's last weight taken was 2/1/2024 at 21:57. She weighed *150.6. *CR#1's last Blood Pressure taken at the following times: 2/19/2024 at 07:02 *133/70 2/19/2024 at 15:44 *129/64 2/20/2024 at 07:43 *132/71 2/20/2024 at 15:21 *122/101 2/21/2024 at 07:05 *130/72 *CR#1's pain levels: 2/19/2024 at 09:05 *0 value 2/21/2024 at 11:12 *0 value *CR#1's Temperature 2/18/2024 at 18:43 *97.6 2/19/2024 at 09:05 *97.6 *CR#1's Head Circumference None noted *CR#1's 02 sats 11/22/2023 10:05 at *96.0% 02/19/2024 09:05 at *97.0 *CR#1's Pulse 2/19/2024 at 07:02 *74 2/19/2024 at 09:05 *78 2/19/2024 at 15:44 *57 2/20/2024 at 07:43 *66 2/20/2024 at 15:21 *65 2/21/2024 at 07:05 *74 *CR#1's Respirations 11/22/2023 10:05 at 18 Breaths/min 02/19/2024 09:05 at 18 Breaths/min *CR#1's Blood Sugar 2/18/2024 110.0 mg/dl 2/19/2024 111.0 mg/dl 2/20/2024 148.0 mg/dl 2/21/2024 130.0 mg/dl Record review of CR#1's orders dated 2/1/2024 - 2/29/2024 revealed, calcium tablet-1 tablet by mouth for type 2 diabetes (last taken 2/21/24 at 2000 hours); magnesium oxide (last taken 2/22/2024 at 0730); sertraline (1 tablet daily for anxiety); vitamin D2 (1 tablet daily); Coreg oral tablet by mouth one time daily (hold if <110HR<60); Depakote capsule02 times daily); Janumet oral tablet9two times daily for mood disorder. Hold if drowsy; Janumet oral tablet by mouth two times daily (d/c date 2/6/2024); refresh tears solution (carboxymethylcellulose sodium) instill one drop in both eyes tow time a day for dry eye syndrome (start dated 6/30/2022 1700) - according to the orders, there is a code 7 at the 1700 hours with initials AMD-Code 7 according to the charts states the resident is sleeping and see progress notes (FM observed nurse putting eye drops in CR#1's eyes when she arrived during this time; Lorazepam 1 tablet by mouth three times daily; Accucheck one time a day related to diabetes (notify MD if bs <70 or >250); monitor vital sign every two weeks one time a day every 2 weeks on Mon for Health monitoring (start 2/19/2024); Behavior monitoring for antianxiety from 2/1/2024 until 2/21/2024 there is a code of 0, which according to staff CR#1 did not have any behaviors noted during all shifts; Behavior monitoring for antidepressants from 2/1/2024 until 2/21/2024 there is a code of 0, which according to staff cR#1 did not have any behaviors noted during all shifts. Behavior monitoring for antipsychotic from 2/1/2024 until 2/21/2024 there is a code of 0, which according to staff CR#1 did not have any behaviors noted during all shifts and on the February 21st; Behavior monitoring for Busplrone (anxiolytic medication to treat anxiety) from 2/1/2024 until 2/21/2024 there is a code of 0, which according to staff CR#1she received a 1-mania (mental health marked by periods of great excitement or euphoria, delusions and overactivity) in the EVE2 and a 6-grandiosity (unrealistic sense of superiority in which someone believes themselves to be unique and better than others) in the NOC1; Assess pain on each shift; monitoring antianxiety received a 1 and 6 on February 21, 2024; Monitoring side effects for antidepressants codes indicated none, but on February 21, 2024 there is a 1 in evening and 6 NOC 1; Record Review of the Progress Notes for CR#1: There was no only one progress note entered since 1/3/2024 and that was on 2/21/2024 at 16:17 (4:17pm), which was titled Admin Note and stated the Administrator notified FM of the HHSC investigation on 2/21/2024 with allegations of abuse. Record Review of R#2 MDS dated [DATE] revealed, BIMS score of 8 (moderate cognitive impaired). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was accurate when asked about the current month, resident is able to recall prior questions after cueing, able to recall a color without cueing. Resident has no symptoms of delirium, she is attentive, organized thinking and has a level of consciousness, resident has no symptoms of feeling down, depressed or hopeless; resident has no indicators of psychosis, hallucinations or delusions; Residents active diagnoses is progressive neurological conditions, hypertension, anxiety disorder, depression (other than bipolar), psychotic disorder (other than schizophrenia). Record Review of R#2's psychological progress note dated 2/10/2024 revealed, improved coping. No issues. Record Review of R#2's psychological progress note dated 2/20/2024 revealed no change in mental status, specifically stressor or changes in mental status that may affect functioning. Noted during psychotherapy were improved coping skills, adjustment to illness-decline-loss. Resident noted she is hopeful that her son will be taking her home soon, which she is looking forward to. No issues. The clinician will follow up with patient in 1-2 weeks to continue to address client's symptoms. Record Review of R#2's psychological progress note dated 2/26/2024 revealed, clients BIMS score was reduced from 8 (Moderate Cognitive Impairment) to 4 (Severe Cognitive Impairment); client reported year as 2020, could only recall 0 of the 3 words. Clinician explored with client what happened to her roommate, which client didn't want to discuss, but stated she has already told it too many times. Stated resident stated the night before she found out her roommate had a black eye, she heard the CAN changing the roommate and heard a scuffle and the roommate said no and stop. She further stated she did not see anything and did not hear anyone being hit. Client stated she was shocked to learn her roommate had an injury the next day. States client was tearful and spoke of her roommate not coming back and that she will miss her as they were together for a long time. Record Review of L.E. report dated 2/21/2024 from PD. According to the police report, based on the age of the resident and the injury, Adult Protective Services was contacted (Intake#485517). The report indicated that the resident did not inform the officers of the nature of her injuries but did report she had been assaulted to the EMS #608 personnel. Record Review of EMS report FB. According to the EMS report, they arrived at the facility on 2/21/2024 at 10:34am. CR#1 was noted to have a periorbital hematoma to the right eye. CR#1 was noted to be warm to the touch. According to the EMS responder, R#2 mentioned, that yesterday evening CR#1 was yelling and she assumed that she was being changed as she usually yells when being changed. The EMS responder stated, CR#1 stated she was hit when he asked her what happened. She further states she was hit by a staff after he asked her if she was hit by another patient or staff. CR#1 was transported, non-emergency, to hospital. EMS Responder stated during transport he took her vitals and the right pupil was noted to be 2mm and the left pupil 4mm. On 2/22/2024 at 10:53am Interview with R#2 - Revealed she is the room mate of CR#1. She states she was in the room with CR#1 when CNA C came in the room to change them both. She states she was changed first. She stated she heard CR#1 scream and tell CNA C that she was hurting her. She stated CR#1 continued to say, stop, stop you're hurting me. She stated the CNA C responded, Just be quiet its all your imagination! CR#2 stated that prior to Tuesday 2/20/2024, CR#1 did not have those bruising. She stated she was afraid that something may happen to her. She stated CR#1s FM came to the facility yesterday, 2/20/2024 and when she entered the room she asked R#2 if she had seen what happened to CR#1. At that time R#2 stated she was able to looked at CR#1 face and seen those horrible bruises. I asked R#2 if this incident occurred with the night shift or morning shift? According to R#2, this incident occurred the morning on 2/20/2024. She stated that the CNA comes in to change right before her shift ends. She further stated that the morning shift CNA comes in to check and change both, CR#1 and R#2, at the beginning of their shift. She reiterated that the CNA that she heard CR#1 screaming at was the lady whose shift was ending. This, according to R#2 is the night shift CNA (CNA C). Observation and attempted interview with CR#1 on 02/22/2022 at 12:50 p.m. while in the hospital. CR#1 was in bed eating lunch. CR #1 briefly looked up at me but did not respond to any questions. The redness under CR#1's right eye was not as profound as the photos shown the day of FM observation in the facility. The bruising on her right jaw still had a discoloration, while mild, still noticeable. Hospital Nursing staff came into to the room to change her and when they asked her to turn toward them, she responded by doing what they asked. In an interview with LE on 02/22/2024 at 12:30p.m. revealed he did not want to add anything to his report. He stated he arrived at the facility on 2/21/2024 at 8:50am. and met with FM, her granddaughter and CR #1. He stated FM requested for her sister to be transported to ER. He stated during the time of gathering information from all involved, the EMS worker informed him the resident stated she was assaulted. He stated when he questioned resident, she would not respond to him. He further stated that he spoke to the DON Wednesday, yesterday, after being contacted by the residence sister, Mrs. [NAME]. He stated that the timeline was on Friday the sister seen the resident and she had no bruises and when she arrived on Tuesday evening, the resident had bruises. He stated that he submitted the report to the CID unit who will investigate further. In an interview with FM on 2/22/24 at 1:00pm revealed she visited CR#1 on Friday February 16, 2024, 4:00pm - 4:30pm and left that evening around 7:30pm and CR#1 had no bruises. She states she returned Tuesday February 20, 2024, between 5:00pm - 5:30pm and CR#1 was in the cafeteria. She stated at this time she noticed CR#1s bruised eye. She stated she left the cafeteria area and went into the ADON's office to inquire about what happened to CR#1 face. She stated both ADON's (A & B) were in the office. She stated she told them that CR#1 looked like she has been assaulted. She stated the ADON A responded, Now no one has hit Ms. [NAME]. She may have hit her head on the wall area. FM member felt the ADON A was being condescending, which angered her. FM responded, that analogy is not true and she asked why she wasn't notified her sister had marks and bruises on her face. FM stated at this time the ADON B got up and accompanied her to the cafeteria. She states at that time the CR# 1 was asked who hit her. She stated a male. The ADON B stated at that time that there were no male CNA's working on the night shift. She stated the ADON B continued to tell her CR# 1 may have hit her head on the wall. FM told the ADON B that it was not possible to do that based on how her Geri Chair was positioned. She states she asked ADON B again why she wasn't notified her sister had bruises? FM stated she did not get an answer. FM stated she spoke with the Admin who told her that he was doing an abuse investigation. He stated he did not know about the accusations of abuse or about the residents' eye. The Admin went to get the DON to ask what is going on. She stated the DON began saying CR#1 could be combative and this may be the reason for her injury. FM states at this time she disagreed with them and left the facility. She stated her sister began to cry and beg her not to leave, but she had to leave at that time and made a decision to return in the morning with LE. FM stated she called LE on her way to the facility. FM stated she arrived at the facility on Wednesday February 21, 2024, around 8:30am at which time CR# 1 was seated in her geri chair at the nurses' station. FM witnessed a nurse putting eye drops in CR#1s eyes. She spoke with the DON. She stated the DON initially told her that he had no idea and was not notified of the bruising. She stated after she told the DON she had contacted the police, the DON told her she received a photo while she was off of CR#1s eye and she was going to do an investigation. In an interview with CW on 2/22/24 at 2:48pm revealed on Monday evening (during 2-10 shift) she did not see bruising on CR#1s 's face. She states Tuesday morning around 8:30am she observed the bruising on CR#1s face, her eye was swollen and red and her jaw was black and blue and swollen going down towards her neck. She states the injuries were unbelievable and looked as if someone had beat her up. CW stated she typically goes into CR#1s room and say hello because she has gotten an opportunity to meet FM and she has told her she's there with her own FM all the time and she will check on her CR#1. She states each day she arrives at the facility; she will go to CR#1s room and kiss her on the forehead and tell her she's just checking on her. In an interview with RN B on 2/22/24 at 5:05pm revealed, stated she works 2-10 shift and is familiar with CR# 1. States CR#1's FM spoke to her about the redness around CR# 1's eyes. She stated she did not see anything on the face of CR #1. RN B said she did not see the bruise prior to the 2/22/2024. She states she saw the redness on CR #1's eye and believes it was on the left eye. In an interview with CNA B on 2/22/2024 at 5:17pm revealed, she always work 2-10 shift. She did see CR #1 on Monday February 19, 2024, and Tuesday February 20, 2024 and did not notice and marks or bruises on resident face. She stated she was not assigned to CR #1 but saw her two days ago. Did not notice marks or bruises on her face on Tuesday and CR#1 had a red eye. States she reported her observation to the nurse in charge, RN B. I asked if the CR# 1 was combative when she seen her and she stated CR# 1 has never been combative when she worked with her. When asked what the policy on a change in condition is, CNA B stated, If I see a resident with injury I will report to the nurse in charge. In an interview with CNA A on 2/23/24 at 7:41am revealed, CR#1 was usually trying to fight while changing her, but she just tensed up her body. States she was able to change her. States she was training CNA L who had just started. States she did noticed bruising on CR#1. Stated her eye was swollen, believes it was the right eye. Did not ask what happened to her eye. She states she informed the charge nurse, LVN B. States CR#1 never screamed she was being hurt while changing her. States last training on abuse and neglect was 2-3 weeks ago. She doesn't know why she was trained. The in-service was conducted by DON and Abuse coordinator. In an interview with CNA C on 2/23/24 at 4:28am revealed, she worked with CR#1 on Monday evening and did not notice bruises. Changed her in the morning. States she did not inspect or assess; however, if her face looked like this it would have been noticed. States resident does talk a little. She can say what she wants and if she wants to get in her chair and go to the nurse's station. CNA C will take her to the nursing station when she requests throughout her shift. She stated at no time did CR# 1 tell her to stop or she was hurting while changing her. In an interview with LVN E on 2/23/22 at 4:58am revealed, he worked the weekend and did see CR# 1. States he did not observe CR #1 with any marks or bruises on her face. When shown a photo of resident's marks/bruises, LVN E stated he has never seen her face like that and if he had he would have been alarmed and written an incident report. LVN E was asked if the CNA's complete documentation of what they do for a resident, and he stated yes. I asked if he could show me. RN C attempted to gain access as to what CNA assisted CR #1 and it (point click care in computer) was locked. He stated this is unusual as the nurses have access to what the CNA has completed during their shift. He stated the only person that has access to the computer is the DON. In an interview with LVN B on 2/23/24 at 7:52am revealed, during the earlier morning hours of her shift, 2/20/2024, around breakfast, the CNA A came to her and told her that CR#1's eye was red and swollen. She stated at this time CNA A had pushed CR#1 to the nursing area. She states she observed the eye to be red and swollen and reported it to the LVN C. She stated there was no assessment completed. She stated she did not document in PCC even though she had access. She stated she felt it was enough just to relay the information to the LVN C. LVN B appeared to get agitated with me and began asking me my name and who did I work for. I again identified myself and suggested that she call her DON, who was in the facility, to confirm who she was talking to. I continued my questioning. When asked concerning Change of condition protocol, LVN B stated she is supposed to let her supervisor know concerning the resident and document in PCC. She stated there was not an issue with PCC and she confirmed that she did have access to PCC. She stated there was a lot going on during this time (breakfast, etc.). She again stated when CNA A told her about CR#1, she was already in her Geri Chair located in the hallway. She looked at CR#1 and then proceeded to speak with LVN C around 9:45am. She states she attended the nursing morning meeting and told everyone (both ADON's, Administrator, can't think of the other staff who were in attendance) that CR#1's eye appeared red and swollen. In an interview with LVN C on 2/23/24 at 8:35am revealed on Tuesday, February 20, 2024, she was the treatment nurse. She states she comes in early, and she leaves a little early. She said in the morning between 10 AM and 11 AM, LVN B came to her, while she was documenting on another resident in the office and told her that CR#1 eye was red and somewhat raised. She said that the LVN B was the charge nurse. She stated that she looked at the CR#1s eye while she was seated in her geri chair by the nurse's station. She stated that the eye was a little red but told LVN B to keep observing the eye. She stated that she did not complete any documentation, nor did she complete an assessment and the reason was because she was not the charge nurse. She stated if she was the charge nurse, she would have followed protocol. She states she would have completed a full assessment of the resident then, checking vitals, diagnosis, then call the MD. She states she would have completed the change of condition form and documented doctor's recommendation as per the change of condition policy. LVN C states that her last in-service for abuse and neglect was Wednesday with the Administrator, HR and DON. In an interview with Admin on 2/23/2024 at 9:50am revealed he is the coordinator for abuse and neglect at the facility. Stated on Wednesday, February 21, 2024, CR#1 injuries appeared to have gotten worse and at this time he instituted a facility investigation report and filed with health and human services. Administrator stated he is not done with his investigation, but he has begun to interview residents in the same hallway (100) as CR #1 resided by asking them if they felt safe in the facility if they were ever threatened by staff or other residents and if they were ever assaulted or misused. He stated CNA A Followed protocol when she informed LVN B of the change and condition. He states that the issue here appears to be a breakdown in communications and that there should have been more detailed documentation. States that there should've been an appropriate assessment of the resident and an incident report should have been filed. He stated he wasn't given the 5 days to complete the Provider Investigation. In an interview with DON on 2/23/24 at 5:58pm revealed, CR#1 went to the hospital on Wednesday February 21, 2024. She stated she had not worked on Tuesday February 20, 2024, and had no idea what was going on until Ms. [NAME] came to the facility on [DATE] and told her she had called the police. She stated FM told her to look at CR#1's eye. She did. She states she told Ms. [NAME] that she would check on the issues that she had not been informed of any type of injuries. The DON states the resident was always rubbing her eyes and this may have caused bruising. Ms. [NAME] brought the bruising to her attention and said her sister was abused. The DON stated she told Ms. [NAME] she was going to do an investigation, but that was too late because she has already called police. The DON stated the nurse practitioner checked the resident on Tuesday 2/20/24 morning and documented. I indicated that the documentation from the NP is not in PCC. The DON indicated she must not have uploaded her notes yet. The DON stated she conducted an in-service for abuse. Stated the resident has a history of psych medication because of her behavior problem. The DON indicated that resident was on psych meds and the facility was trying to reduce the medication. She indicated CR#1 has been combative lately but could not give any reason why this behavior hasn't been documented by nursing staff in PCC. The DON stated the FM requested CR#1 be sent to the hospital, which the facility had no other option but to comply. She stated the bruises may have come from CR#1 vigorously rubbing her eyes. The DON was shown a photo of the CR#1 facial area and she stated the resident bruises were not there when she left the facility. It was like a scratch when she left the facility. The DON brought in an in-service that was signed by some staff and not by others. She stated she completed the Abuse and Neglect and Exploitation on Wednesday after the FM, brought it to her attention. The DON continued to deny the CR#1s face had those bruises when she left the facility. During the conversation, the DON became angry and stated, if FM was so upset about CR#1 why did she leave her on Tuesday? I replied, I don't know that is a question that only FM could answer. The DON stated if there is suspected abuse, protocol will be to ask all the residents if they feel safe. She stated she would call the police and make an incident report. In a telephone interview with ERN on 2/24/24 at 9:35am. revealed she was the emergency room nurse that evaluated CR#1 upon her arrival by EMS. She states per EMT, the FM requested that the resident be seen due to possible assault. The EMT said that family found CR# 1with unexplained bruising and the facility was dismissive. ERN stated the EMT further stated CR# 1 told him someone hit her, but there was not a lot of detail. ERN is also forensic interviewer. She stated she spoke with CR#1. She stated when speaking to CR#1, you have to wait and allow her time to process what you are saying for at least 30 seconds. CR#1 was asked her name and she responded accurately. She asked her if she knew where she was (ER) and after about 30 seconds responded in the affirmative and said where (ER)she was. ERRN stated she has taken photos of CR#1 and completed a forensic report. She stated HHSC can send in a request and obtain all photos and other pertinent information. ERN stated that in her professional opinion, CR#1's facial injuries are consistent with someone who has been assaulted. On 2/29/2024 at 2:15pm an interview with ADON A revealed, FM was in her office. The FM asked what was going on with CR#1 eye. ADON A stated she told her that it could have been from FM leaning on rail from GERI Chair. ADON A stated ADON B walked in the office and told FM that he's responsible for the 100 hall. When asked what the protocol is when issues arise with residents having unknown injuries, the ADON A stated usually the charge nurse document in PCC and call the FM or RP. Depending how serious, the charge nurse will notify ADON, DON, Admin. On 2/29/2024 at 2:19pm an interview with ADON B revealed, FM was in the office on 2/20/2024 talking to ADON A, as he was entering the office. At this time, he stated ADON A introduced him to FM. Stated FM told him she did not believe CR#1's injury was from the rail. FM accompanied ADON B to CR# 1's room and showed the halo. The halo enabler is used for resident to pull herself up and reposition. FM suggested may be her sister laid her face on the halo enabler and that caused injury. ADON B stated the FM was not upset. On 02/23/2024 at 5:42pm the Facility's Administrator and DON notified of the Immediate Jeopardy for Abuse (F-607). The Template was signed.and the POR was immediately requested at this time. REMOVAL OF IMMEDIATE JEOPARDY On February 23, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: F- Tag 607: The facility must develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents a misappropriation of resident property, of residents and misappropriation of resident property Done for those affected: Resident CR#1 was assessed by licensed nurse on 2/21/2024. MD was notified by licensed nurse on 2/21/2024. Resident CR#1 was transferred to the hospital for evaluation on 2/21/2024 and remains at the hospital. An Allegation of Abuse was reported to HHSC for Resident CR#1 on 2/21/2024. Identify residents who could be affected: Beginning 2/21/2024, the Facility Social Worker(s) completed 100% of interviews of interviewable residents to assess for potential abuse. Date of completion is 2/23/2024. Findings: No additional concerns were identified. On 2/23/2024, head to toe assessments were completed by the Licensed Nurse on all residents to identify any signs of injuries of unknown source. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Date of completion is 2/23/2024. Findings: No additional concerns were identified. On 2/23/2024, the DON/designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect were identified and an investigation initiated, and the incident reported to HHSC. Findings: No additional concerns were identified. On 2/23/2024, the DON/ Designee reviewed incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified. Systemic Process: On 2/23/2024, the Regional [NAME] President of Operations reeducated the Administrator (Abuse Coordinator) on Abuse and Neglect and Abuse Policy. Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse (with or without serious bodily injury); or neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury are reported immediately, but not later than two hours after the incident occurs or is suspected. On 2/23/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: o Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse (with or without serious bodily injury); or neglec [TRUNCATED]

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated, to prevent further potential abuse or mistreatment while the investigation was in progress, and report the result of all investigations to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident for 1 of 5 residents (CR #1) reviewed for abuse. The facility failed to complete the investigation of the allegation of abuse, report the results of the investigation to HHSC within 5 days, and prevent further potential abuse while the investigation was in progress when CR #1 was found with suspicious injuries of unknown origin. An Immediate Jeopardy (IJ) was identified on 02/26/2024 at 1:48pm. While the IJ was lowered on 02/27/2024 at 6:00pm, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. These failures placed resident(s) involved in abuse incidents at risk of continued abuse, mistreatment, further injury, pain and physical and emotional distress contributing to further serious injuries. Findings Include: Record review of CR#1's undated face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE]. CR#1 has a diagnosis of Anoxic Brain Damage (lack of oxygen to the brain causing death of brain cells), Type 2 diabetes mellitus hypoglycemia w/o coma (low blood sugar levels), hypertension (high blood pressure), dysphagia (difficult swallowing), major depression disorder (low or depressed mood), chronic kidney disease (damaged kidneys and/or loss of kidney function), cognitive communication deficit (difficulty thinking and using language), anxiety disorder (pounding heart and sweating when responding to certain situations), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of CR#1's MDS assessment dated [DATE], revealed a BIMS score of 4 (severe cognitive impairment). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard, resident is able to recall prior questions after cueing, resident does not have any psychosis behaviors, which includes physical behaviors, verbal behavior, or any other behavior symptoms directed at others and the resident was able to participate in an activity preference interview of her interest while in the facility. Record review of CR#1's care plan updated 03/31/2022 revealed, the resident has a communication problem r/t expressive Aphasia, Hearing deficit, Neurological symptoms. The goal was the resident will maintain current level of communication function by making sound, using appropriate gestures, responding to yes/no questions appropriately through the review date. The interventions are to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact. Ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. Resident is a one (1) person total assist and two (2) person transfer using a mechanical lift. Further review of Resident #1's care plan updated revealed no documentation regarding the facial injuries on 2/21/2024 or any plan initiated to keep her safe while in the facility going forward. Record Review of CR#1's orders dated 2/1/2024 - 2/29/2024 revealed calcium tablet-1 tablet by mouth for type 2 diabetes (last taken 2/21/24 at 2000 (8PM) hours); magnesium oxide (last taken 2/22/2024 at 0730 (7:30AM); sertraline (1 tablet daily for anxiety); vitamin D2 (1 tablet daily); Coreg oral tablet by mouth one time daily (hold if <110HR<60); Depakote capsule 2 times daily); Janumet oral tablet two times daily for mood disorder. Hold if drowsy; Janumet oral tablet by mouth two times daily (d/c date 2/6/2024); refresh tears solution (carboxymethylcellulose sodium) instill one drop in both eyes two times a day for dry eye syndrome (start date 6/30/2022 1700 (5PM)). -The orders reflected a code 7 at 1700 hours, indicating the resident is sleeping and see progress notes (FM observed nurse putting eye drops in CR#1's eyes when she arrived during this time); Lorazepam 1 tablet by mouth three times daily; Accucheck one time a day related to diabetes (notify MD if bs <70 or >250); monitor vital signs every two weeks one time a day every 2 weeks on Mondays for Health monitoring (start 2/19/2024); Behavior monitoring for antianxiety from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts; Behavior monitoring for antidepressants from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts. Behavior monitoring for antipsychotic from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts and on 2/21/24; Behavior monitoring for Busplrone (anxiolytic medication to treat anxiety) from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 received a 1, which indicated mania (mental health marked by periods of great excitement or euphoria, delusions and overactivity); in the EVE2 and a 6-grandiosity (unrealistic sense of superiority in which someone believes themselves to be unique and better than others) in the NOC1; Assess pain on each shift; monitoring antianxiety received a 1 and 6 on 2/21/24; Monitoring side effects for antidepressants codes indicated none, but on 2/21/24 there is a 1 in evening and 6 NOC 1 Record Review of the Progress Notes for CR#1: There was no only one progress note entered since 1/3/2024 and that was on 2/21/2024 at 16:17 (4:17pm), which was titled Admin Note and stated the Administrator notified FM of the HHSC investigation on 2/21/2024 with allegations of abuse. Record Review of R#2's MDS assessment dated [DATE] revealed, BIMS score of 8 (moderate cognitive impairment). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard after first attempt, was accurate when asked about the current month, resident is able to recall prior questions after cueing, able to recall a color without cueing. Resident has no symptoms of delirium, she is attentive, organized thinking and has a level of consciousness, resident has no symptoms of feeling down, depressed or hopeless; resident has no indicators of psychosis, hallucinations or delusions; Resident's active diagnoses are progressive neurological conditions, hypertension, anxiety disorder, depression (other than bipolar), psychotic disorder (other than schizophrenia). Record Review of R#2's psychological progress note dated 2/10/2024 revealed, improved coping. No issues. Record Review of R#2's psychological progress note dated 2/20/2024 revealed no change in mental status, specifically stressor or changes in mental status that may affect functioning. Noted during psychotherapy were improved coping skills, adjustment to illness-decline-loss. Resident noted she is hopeful that her family member will be taking her home soon, which she is looking forward to. No issues. The clinician will follow up with patient in 1-2 weeks to continue to address client's symptoms. Record Review of R#2's psychological progress note dated 2/26/2024 revealed, client's BIMS score was reduced from 8 to 4 (indicating cognitive decline); client reported year as 2020, could only recall 0 of the 3 words. Clinician explored with client what happened to her roommate, which client didn't want to discuss, but stated she has already told it too many times. Stated resident stated the night before she found out her roommate had a black eye, she heard the CNA C changing the roommate and heard a scuffle and the roommate said no and stop. She further stated she did not see anything and did not hear anyone being hit. Client stated she was shocked to learn her roommate had an injury the next day. States client was tearful and spoke of her roommate not coming back and that she will miss her as they were together for a long time. Record Review of L.E. report dated 2/21/2024 from PD. According to the police report, based on the age of the resident and the injury, Adult Protective Services was contacted. The report indicated that the resident did not inform the officers of the nature of her injuries but did report she had been assaulted to the EMS personnel. Record Review of CNA C's timesheet reveal she last worked on 02/22/2024 9:46pm - 6:32am hours. She was suspended on 2/25/2024. On 2/22/2024 at 10:53am Interview with R#2 - Stated she was the room mate of CR#1. She stated she was in the room with CR#1 when CNA C came in the room to change them both. She stated she was changed first. She stated she heard CR#1 scream and tell CNA C that she was hurting her. She stated CR#1 continued to say, stop, stop you're hurting me. She stated the CNA C responded, Just be quiet its all your imagination! CR#2 stated that prior to Tuesday 2/20/2024, CR#1 did not have those bruises. She stated she was afraid that something may happen to her. She stated CR#1s FM came to the facility yesterday, 2/20/2024 and when she entered the room she asked R#2 if she had seen what happened to CR#1. At that time R#2 stated she was able to look at CR#1 face and saw those horrible bruises. According to R#2, this incident occurred the morning on 2/20/2024. She stated that the CNA comes in to change them right before her shift ends. She further stated that the morning shift CNA comes in to check and change both, CR#1 and R#2, at the beginning of their shift. She reiterated that the CNA that she heard CR#1 screaming at was the lady whose shift was ending. This, according to R#2 was the night shift CNA (CNA C). Observation and attempted interview with CR#1 on 02/22/2024 at 12:50 p.m. while in the hospital, revealed she was in bed eating lunch. CR #1 briefly looked up but she did not respond to any questions. The redness under CR#2's right eye was not as profound as the photos shown the day of FM's observation in the facility. The bruising on her right jaw still had a discoloration, while mild, still noticeable. Hospital Nursing staff came into to the room to change her and when they asked her to turn toward them, she responded by doing what they asked. On 02/22/2024 at 1:00p.m. 2/22/24 at 12:30pm- Interview with LE. stated he arrived at the facility on 2/21/2024 at 8:50am. and met with FM, another family member and CR #1. He stated FM requested for CR#1 to be transported to ER. He stated during the time of gathering information from all involved, the EMS worker informed him the resident stated she was assaulted. He stated when he questioned resident, she would not respond to him. He further stated that he spoke to the DON Wednesday, yesterday, after being contacted by the resident's family member. He stated that the timeline was on Friday the FM saw the resident and she had no bruises and when she arrived on Tuesday evening, the resident had bruises. On 2/22/24 at 1:00pm Interview with FM - FM stated she visited CR#1 on Friday 2/16/24, 4:00pm - 4:30pm and left that evening around 7:30pm and CR#1 had no bruises. She stated she returned Tuesday 2/20/24, between 5:00pm - 5:30pm and CR#1 was in the cafeteria. She stated at this time she noticed CR#1's bruised eye. She stated she left the cafeteria area and went into the ADON's office to inquire about what happened to CR#1 face. She stated both ADON's (A & B) were in the office. She stated she told them that CR#1 looked like she has been assaulted. She stated the ADON A responded, Now no one has hit CR#1. She may have hit her head on the wall area. FM felt the ADON A was being condescending, which angered her. FM responded, that analogy is not true and she asked why she wasn't notified CR#1 had marks and bruises on her face. FM stated at this time the ADON B got up and accompanied her to the cafeteria. She stated at that time the CR# 1 was asked who hit her. She stated a male. The ADON B stated at that time that there were no male CNA's working on the night shift. She stated the ADON B continued to tell her CR# 1 may have hit her head on the wall. FM told the ADON B that it was not possible to do that based on how her Geri Chair (padded reclining geriatric chair) was positioned. She stated she asked ADON B again why she was not notified (CR#1) had bruises. FM stated she did not get an answer. FM stated she spoke with the Admin who told her that he was doing an abuse investigation. He stated he did not know about the accusations of abuse or about the resident's eye. The Admin went to get the DON to ask what was going on. She stated the DON began saying CR#1 could be combative and this may be the reason for her injury. FM stated at this time she disagreed with them and left the facility. She stated CR#1 began to cry and beg her not to leave, but she had to leave at that time and decided to return in the morning with LE. FM stated she called LE on her way to the facility. FM stated she arrived at the facility on Wednesday 2/21/24, around 8:30am at which time CR# 1 was seated in her geri chair at the nurses' station. FM witnessed a nurse putting eye drops in CR#1s eyes. She spoke with the DON. She stated the DON initially told her that he had no idea and was not notified of the bruising. She stated after she told the DON she had contacted the police, the DON told her she received a photo while she was off of CR#1s eye and she was going to do an investigation. On 2/22/24 at 2:48pm Interview with CW - CW stated that on Monday evening CR #1 was in her room seated in a chair slumped over about to fall out. CW stated that there were two CNA's in another resident's room just talking and laughing. CW stated CW called the CNA's to go help CR#1 and they did. CW stated on Monday CW did not see bruising on CR#1s 's face. CW stated Tuesday morning around 8:30am CW observed the bruising on CR#1s face, her eye was swollen and really red and her jaw was black and blue and swollen going down towards her neck. CW stated the injuries were unbelievable and looked as if someone had beat her up. CW stated CW typically goes into CR#1s room and says hello because CW has gotten an opportunity to meet CR#1's FM and CW has told her CW is there with CW's own FM all the time and CW will check on her CR#1. CW stated each day CW arrives at the facility; CW will go to CR#1s room and kiss her on the forehead and tell her CW is just checking on her. On 2/22/24 at 5:05pm Interview with LVN A- stated she works 2-10 shift and is familiar with CR# 1. LVN A stated CR#1's FM spoke to her about the redness around CR# 1's eyes. She stated she did not see anything on the face of CR #1. LVN A said she did not see the bruise prior to the 2/22/2024. She states she saw the redness on CR #1's eye and believes it was on the left eye. On 2/22/2024 at 5:17pm Interview with CNA B - stated she always work 2-10 shift. She did see CR #1 on Monday 2/19/24, and Tuesday 2/20/24, and did not notice any marks or bruises on resident face. She stated she was not assigned to CR #1 but saw her two days ago. CN A B said she did not notice marks or bruises on her face on Tuesday and CR#1 had a red eye. CNA B stated she reported her observation to the nurse in charge, LVN A. CNA B stated CR# 1 has never been combative when she worked with her. CNA B stated, If I see a resident with injury I will report to the nurse in charge. On 2/23/24 at 7:41am Telephone Interview with CNA A - Stated CR#1 was usually trying to fight while changing her, but she just tensed up her body. CNA A stated she was able to change her. CNA A stated she was training CNA L who had just started. CNA A stated she did noticed bruising on CR#1. CNA A stated her eye was swollen, and she believes it was the right eye. Did not ask what happened to her eye. She stated she informed the charge nurse, LVN B. CNA A stated CR#1 never screamed she was being hurt while changing her. She stated the last training on abuse and neglect was 2-3 weeks ago. She said she did not know why she was trained. The in-service was conducted by DON and Abuse coordinator. In an interview with CNA C on 2/23/24 at 4:28am revealed, she worked with CR#1 on Monday evening and did not notice bruises. CNA C said she changed her in the morning. She stated if her face looked like this it would have been noticed. CNA C stated resident does talk a little. She can say what she wants and if she wants to get in her chair and go to the nurse's station. CNA C will take her to the nursing station when she requests throughout her shift. She stated at no time did CR# 1 tell her to stop or she was hurting while changing her. In an interview with RN C on 2/23/24 at 4:58am revealed, he worked the weekend and did see CR# 1. RN C stated he did not observe CR #1 with any marks or bruises on her face. When shown a photo of resident's marks/bruises, RN C stated he has never seen her face like that and if he had he would have been alarmed and written an incident report. On 2/23/24 at 7:52am - Telephone Interview with LVN B - Stated during the earlier morning hours of her shift, 2/20/2024, around breakfast, the CNA A came to her and told her that CR#1's eye was red and swollen. She stated at this time CNA A had pushed CR#1 to the nursing area. She stated she observed the eye to be red and swollen and reported it to the LVN C.She again stated when CNA A told her about CR#1, she was already in her Geri Chair located in the hallway. She looked at CR#1 and then proceeded to speak with LVN C around 9:45am. She stated she attended the nursing morning meeting and told everyone (including both ADON's and Administrator that CR#1's eye appeared red and swollen. On 2/23/24 at 8:35am -Telephone interview with LVN C.- LVN C indicated that on Tuesday, 2/20/24, she was the treatment nurse. She said in the morning between 10 AM and 11 AM, LVN B came to her, while she was documenting on another resident in the office and told her that CR#1's eye was red and somewhat raised. She said that the LVN B was the charge nurse. She stated that she looked at the CR#1s eye while she was seated in her geri chair by the nurse's station. She stated that the eye was a little red but told LVN B to keep observing the eye LVN C stated that her last in-service for abuse and neglect was Wednesday with the Administrator, HR and DON. On 2/23/2024 at 9:50am Interview with Admin - Stated he is the coordinator for abuse and neglect at the facility. He stated on Wednesday, 2/21/24, CR#1's injuries appeared to have gotten worse and at this time he completed a provider self-reporting of LTC incident report with health and human services. On 2/23/24 at 5:58pm Interview with DON. Stated CR#1 went to the hospital on Wednesday 2/21/24. She stated she had not worked on Tuesday 2/20/24 and had no idea what was going on until CR#1's FM came to the facility on [DATE] and told her she had called the police. She stated FM told her to look at CR#1's eye. She did. She stated she told FM that she would check on the issues and that she had not been informed of any type of injuries. The DON stated the resident was always rubbing her eyes and this may have caused bruising. FM brought the bruising to her attention and said CR#1 was abused. The DON stated she told FM she was going to do an investigation, but that was too late because she has already called police. The DON stated she conducted an in-service training to nursing staff for abuse and neglect. The DON stated the FM requested CR#1 be sent to the hospital, which the facility had no other option but to comply. She stated the bruises may have come from CR#1 vigorously rubbing her eyes. The DON was shown a photo of the CR#1's facial area and she stated the resident's bruises were not there when she left the facility. It was like a scratch when she left the facility. The DON continued to deny the CR#1's face had those bruises when she left the facility. During the interview the DON appeared irritated by my questions, she stated, if FM was so upset about CR#1 why did she (FM) leave her on Tuesday? The DON stated if there is suspected abuse, protocol will be to ask all the residents if they feel safe. She stated she would call the police and make an incident report. In an interview with ERN on 2/24/24 at 9:35am. revealed she was the emergency room nurse that evaluated CR#1 upon her arrival by EMS. She stated per EMT, the FM requested that the resident be seen due to possible assault. The EMT said that family found CR# 1with unexplained bruising and the facility was dismissive. ERN stated the EMT further stated CR# 1 told him someone hit her, but there was not a lot of detail. ERN is also forensic interviewer. She stated she spoke with CR#1. She stated when speaking to CR#1, you have to wait and allow her time to process what you are saying for at least 30 seconds. CR#1 was asked her name and she responded accurately. She asked her if she knew where she was (ER) and after about 30 seconds responded in the affirmative and said where (ER) she was. ERN stated she has taken photos of CR#1 and completed a forensic report. She stated HHSC can send in a request and obtain all photos and other pertinent information. ERN stated that in her professional opinion, CR#1's facial injuries are consistent with someone who has been assaulted. On 2/26/2024 at 6:00pm, A request to view the unfinished investigation currently. The Admin provided the following: oRecord review of the current investigation revealed, Employees who did not witness the incident concerning CR#1 to sign the form dated 2/21/2024 titled, EMPLOYEES IN INCIDENT AREA HAVING NO KNOWLEDGE OF INCIDENT. oRecord review revealed, a form employees signed titled, Interview Record dated 2/21/2024 in which the admin Interviewed the NP who stated CR#1 was observed by her with discoloration alongside of right eye on 2/20/24. The NP stated the impacted area appeared as CR#1 bumped the side orbital eye area against her bed halo rail or fell asleep in bed with side eye against the rail. NP stated impacted area was slightly discolored, no bruising along lower eye lid observed. Stated CR#1 likely did not sustain fall b/c she requires total assistance to get up. Record review of the unfinished investigation lacked any interviews of nursing staff that cared for CR#1, there was no immediate nursing staff in-service training for abuse and neglect. The DON brought in an in-service that was signed by some staff and not by others. She stated she completed the Abuse and Neglect and Exploitation in-service on Wednesday after the FM, brought it to her attention. Record review of electronic signed document dated 2/20/2024 and signed on 2/23/2024 by NP, revealed the NP conducted rounds on 2/20/24 and seen CR#1 sitting in her Geri Chair in nurses' station outside of the dining room. Stated CR#1 was seen with very slight discoloration to right lower orbital below eye and above cheek. Mild swelling present. CR#1 denies pain/discomfort. EOM Intact. Mild erythema presents on sclera of right eye. CR#1 states she wants to go to the dining room with activities. No distress noted. CR#1 vitals stable. Discussed findings with ADONs and treatment team. No fall occurred. CR#1 frequently in Geri-chair during the daytime hours found with head lying on right side. Discussed possibility of CR#1 hitting face on hand rale on the wall next to her chair. CR#1 has history of anxiety, cognitive impairment. CR#1 has history of dry eye syndrome requiring artificial tears scheduled twice daily. CR#1 mood and behavior at her baseline. Record review of interview record for LVN A without a time of interview and dated 2/21/24. The form was titled Injury of Unknown Origin and signed by Admin and DON. It revealed, LVN A stated CR#1 was in her Geri chair when she began her 2-10 shift. LVN A stated CR#2 right eye was slight red and swollen with no discoloration. LVN A stated eye drop was administered by CMA (unknown) as ordered. Record review of interview record for CNA A without a time of interview and dated 2/21/24. The form was titled Injury of Unknown Origin and signed by Admin and DON. It revealed, she worked with CR#1 on 2/20/24 6am-2pm shift. States she went into CR#1's room and observed resident right eye was red and a lot swollen. States she notified the charge nurse who observed CR#1's eye. Record review of interview record for CNA A without a time of interview and dated 2/21/24. The form was titled Injury of Unknown Origin and signed only by Admin. It revealed, he interviews with CNA, via phone. He was informed that CNA A observed CR#1's right eye at approximately 6:20-6:30 upon entering her room. CNA states the eye was red around the pupil. States CR#1 made on allegations to who the person who may have caused injury. States CNA stated she immediately reported it to LVN B. Record review revealed admin investigation was to interview staff who cared for and or interacted with CR#1 during the dates and shifts below (2/19/2024, 2/20/2024 and 2/21/2024) during day shift, evening shift and night shift on the 100 hall, which is where CR#1 room was. Record review of In-service training dated 2/21/2024 by the Admin on Abuse and neglect and exploitation lacked signatures for all nursing staff members. Record review of LVN B's timecard shows she was suspended on 2/24/24. Record review of CNA C's counseling report states she was suspended on 2/25/2024. On 02/26/2024 at 1:48pm the Facility's Administrator notified of the Immediate Jeopardy for Abuse (F-610). The Template was signed and POR was immediately requested at this time. The following plan of removal was accepted on 2/27/24 at 12:01 p.m. REMOVAL OF IMMEDIATE JEOPARDY On February 26, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: F- Tag 610: The facility failed to investigate, suspend suspected staff member accused of abuse after resident injuries were reported by FM, CNA A and LE. The facility is placing current residents at risk of abuse and neglect by CNA C's continuous access. The facility failed to immediately investigate, report, and protect the resident when CR#2 was found with suspicious injuries of unknown origin. Done for those affected: Resident CR#1 was assessed by licensed nurse on 2/21/2024. MD was notified by licensed nurse on 2/21/2024. Resident CR#1 was transferred to the hospital for evaluation on 2/21/2024 and remains at the hospital. An Allegation of Abuse was reported to HHSC for Resident CR#2 on 2/21/2024. On 2/25/2024, the facility suspended the Certified Nurse Aide who worked with resident CR#1 on the 2/19/2024 10pm to 6am shift, pending investigation. If CNA C is found to be guilty of abusing CR#1, the facility will terminate employment immediately. Identify residents who could be affected: Beginning 2/21/2024, the Facility Social Worker(s) completed 100% of interviews of interviewable residents to assess for potential abuse. Date of completion is 2/23/2024. Findings: No additional concerns were identified. Effective 2/25/2024, Administrator and/or designee notified facility residents of abuse and neglect reporting. Reeducation included who the abuse coordinator is and how to report concerns and/ or allegation of abuse, neglect, mistreatment and/ or misappropriation to facility personnel. Date of completion is 2/26/2024. oEffective 2/26/24, Administrator and/or designee notified families via alert media of the facility abuse and neglect reporting process. Reeducation included who the abuse coordinator is and how to report concerns and/ or allegation of abuse, neglect, mistreatment and/ or misappropriation to facility personnel. Date of Completion is 2/26/2024. oOn 2/23/2024, head to toe assessments were completed by the Licensed Nurse on all residents to identify any signs of injuries of unknown source. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Date of completion is 2/23/2024. Findings: No additional concerns were identified. oOn 2/23/2024, the DON/designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect were identified and an investigation initiated, and the incident reported to HHSC. Findings: No additional concerns were identified. oOn 2/23/2024, the DON/ Designee reviewed incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified. Systemic Process: On 2/23/2024, the Regional [NAME] President of Operations reeducated the Administrator (Abuse Coordinator) on Abuse and Neglect and Abuse Policy. Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse (with or without serious bodily injury); or neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury are reported immediately, but not later than two hours after the incident occurs or is suspected. Date of Completion is 2/23/2024. On 2/23/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse (with or without serious bodily injury); or neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury are reported immediately, but not later than two hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury and involves: neglect, exploitation, missing resident, misappropriation, drug theft, fire, emergency situations that pose a threat to resident health and safety, a death under unusual circumstances will be reported immediately, but not later than 24 hours after the incident occurs or is suspected. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. Date of completion is 2/23/2024. Resident assessment to include head to toe assessments and documentation with each resident incident/accident. Date of completion is 2/23/2024 Effective 2/24/2024, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift. The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. To monitor, the Director of Nursing/ designee will review the 24-hour report and resident incidents in facility Stand-up Morning Meeting, attended Monday - Friday. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include to ensure investigation, resident assessments to include head-to-toe assessments were completed and provided. Date of implementation is 2/23/2024. The Administrator will m [TRUNCATED]

Tag:842 S/S= D Surveyor Name(s): Najiyyah Shadee Immediate Supervisor: [NAME] Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 Residents (CR#1) reviewed for clinical records accuracy, there was only one progress note Record Review of the Progress Notes for CR#1: There was only one progress note entered since 1/3/2024; then, on 2/21/2024 at 16:17 (4:17pm), there was a note which was titled Admin Note and stated the Administrator notified FM of the HHSC investigation on 2/21/2024 with allegations of abuse. The facility failed to maintain an accurate record by indicating CR #1's unexplained or unknown eye injury, what medical staff did after observing the injury, who they called and the type of assessment completed. This deficient practice could affect residents whose records are maintained by the facility and could place resident(s) at risk for errors in care and treatment. Findings Include: Record review of CR#1's undated face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE]. CR#1 has a diagnosis of Anoxic Brain Damage (lack of oxygen to the brain causing death of brain cells), Type 2 diabetes mellitus hypoglycemia w/o coma (low blood sugar levels), hypertension (high blood pressure), dysphagia (difficult swallowing), major depression disorder (low or depressed mood), chronic kidney disease (damaged kidneys and/or loss of kidney function), cognitive communication deficit (difficulty thinking and using language), anxiety disorder (pounding heart and sweating when responding to certain situations), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of CR#1's MDS assessment dated [DATE], revealed a BIMS score of 4 (severe cognitive impairment). Cognitive skills for daily decision making further revealed, resident can repeat at least three words heard, resident is able to recall prior questions after cueing, resident does not have any psychosis behaviors, which includes physical behaviors, verbal behavior, or any other behavior symptoms directed at others and the resident was able to participate in an activity preference interview of her interest while in the facility. Record review of CR#1's care plan updated 03/31/2022 revealed, the resident has a communication problem r/t expressive Aphasia, Hearing deficit, Neurological symptoms. The goal was the resident will maintain current level of communication function by making sound, using appropriate gestures, responding to yes/no questions appropriately through the review date. The interventions are to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact. Ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. Resident is a one (1) person total assist and two (2) person transfer using a mechanical lift. Further review of Resident #1's care plan updated revealed no documentation regarding the facial injuries on 2/21/2024 or any plan initiated to keep her safe while in the facility going forward. Record Review of CR#1's orders dated 2/1/2024 - 2/29/2024 revealed calcium tablet-1 tablet by mouth for type 2 diabetes (last taken 2/21/24 at 2000 (8PM) hours); magnesium oxide (last taken 2/22/2024 at 0730 (7:30AM); sertraline (1 tablet daily for anxiety); vitamin D2 (1 tablet daily); Coreg oral tablet by mouth one time daily (hold if <110HR<60); Depakote capsule 2 times daily); Janumet oral tablet two times daily for mood disorder. Hold if drowsy; Janumet oral tablet by mouth two times daily (d/c date 2/6/2024); refresh tears solution (carboxymethylcellulose sodium) instill one drop in both eyes two times a day for dry eye syndrome (start date 6/30/2022 1700 (5PM)). -The orders reflected a code 7 at 1700 hours, indicating the resident is sleeping and see progress notes (FM observed nurse putting eye drops in CR#1's eyes when she arrived during this time); Lorazepam 1 tablet by mouth three times daily; Accucheck one time a day related to diabetes (notify MD if bs <70 or >250); monitor vital signs every two weeks one time a day every 2 weeks on Mondays for Health monitoring (start 2/19/2024); Behavior monitoring for antianxiety from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts; Behavior monitoring for antidepressants from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts. Behavior monitoring for antipsychotic from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 did not have any behaviors noted during all shifts and on 2/21/24; Behavior monitoring for Busplrone (anxiolytic medication to treat anxiety) from 2/1/2024 until 2/21/2024 reflected a code of 0, indicating CR#1 received a 1, which indicated mania (mental health marked by periods of great excitement or euphoria, delusions and overactivity); in the EVE2 and a 6-grandiosity (unrealistic sense of superiority in which someone believes themselves to be unique and better than others) in the NOC1; Assess pain on each shift; monitoring antianxiety received a 1 and 6 on 2/21/24; Monitoring side effects for antidepressants codes indicated none, but on 2/21/24 there is a 1 in evening and 6 NOC 1 On 2/22/24 at 1:00pm Interview with FM - FM stated she visited CR#1 on Friday 2/16/24, 4:00pm - 4:30pm and left that evening around 7:30pm and CR#1 had no bruises. She stated she returned Tuesday 2/20/24, between 5:00pm - 5:30pm and CR#1 was in the cafeteria. She stated at this time she noticed CR#1's bruised eye. She stated she left the cafeteria area and went into the ADON's office to inquire about what happened to CR#1 face. She stated both ADON's (A & B) were in the office. She stated she told them that CR#1 looked like she has been assaulted. She stated the ADON A responded, Now no one has hit CR#1. She may have hit her head on the wall area. FM felt the ADON A was being condescending, which angered her. FM responded, that analogy is not true and she asked why she wasn't notified CR#1 had marks and bruises on her face. FM stated at this time the ADON B got up and accompanied her to the cafeteria. She stated at that time the CR# 1 was asked who hit her. She stated a male. The ADON B stated at that time that there were no male CNA's working on the night shift. She stated the ADON B continued to tell her CR# 1 may have hit her head on the wall. FM told the ADON B that it was not possible to do that based on how her Geri Chair (padded reclining geriatric chair) was positioned. She stated she asked ADON B again why she was not notified (CR#1) had bruises. FM stated she did not get an answer. FM stated she spoke with the Admin who told her that he was doing an abuse investigation. He stated he did not know about the accusations of abuse or about the resident's eye. The Admin went to get the DON to ask what was going on. She stated the DON began saying CR#1 could be combative and this may be the reason for her injury. FM stated at this time she disagreed with them and left the facility. She stated CR#1 began to cry and beg her not to leave, but she had to leave at that time and made a decision to return in the morning with LE. FM stated she called LE on her way to the facility. FM stated she arrived at the facility on Wednesday 2/21/24, around 8:30am at which time CR# 1 was seated in her geri chair at the nurses' station. FM witnessed a nurse putting eye drops in CR#1s eyes. She spoke with the DON. She stated the DON initially told her that he had no idea and was not notified of the bruising. She stated after she told the DON she had contacted the police, the DON told her she received a photo while she was off of CR#1s eye and she was going to do an investigation. On 2/23/24 at 7:52am - Telephone Interview with LVN B - Stated during the earlier morning hours of her shift, 2/20/2024, around breakfast, the CNA A came to her and told her that CR#1's eye was red and swollen. She stated at this time CNA A had pushed CR#1 to the nursing area. She stated she observed the eye to be red and swollen and reported it to the LVN C. She again stated when CNA A told her about CR#1, she was already in her Geri Chair located in the hallway. She looked at CR#1 and then proceeded to speak with LVN C around 9:45am. She stated she attended the nursing morning meeting and told everyone (including both ADON's and Administrator that CR#1's eye appeared red and swollen. She states she did not complete any documentation regarding CR#1's unexplained injuries. On 2/23/24 at 8:35am -Telephone interview with LVN C.- LVN C indicated that on Tuesday, 2/20/24, she was the treatment nurse. She said in the morning between 10 AM and 11 AM, LVN B came to her, while she was documenting on another resident in the office and told her that CR#1's eye was red and somewhat raised. She said that the LVN B was the charge nurse. She stated that she looked at the CR#1s eye while she was seated in her geri chair by the nurse's station. She stated that the eye was a little red but told LVN B to keep observing the eye. LVN C stated that her last in-service for abuse and neglect was Wednesday with the Administrator, HR and DON. She stated she did not complete any documentation regarding CR#1's unexplained injuries. On 2/23/2024 at 9:50am Interview with Admin - Stated he is the coordinator for abuse and neglect at the facility. He stated on Wednesday, 2/21/24, CR#1's injuries appeared to have gotten worse and at this time he instituted a facility (Provider) investigation report and filed with HHSC. He did not complete any documentation regarding CR#1's unexplained injuries On 2/23/24 at 5:58pm Interview with DON. Stated CR#1 went to the hospital on Wednesday 2/21/24. She stated she had not worked on Tuesday 2/20/24 and had no idea what was going on until CR#1's FM came to the facility on [DATE] and told her she had called the police. She stated FM told her to look at CR#1's eye. She did. She stated she told FM that she would check on the issues and that she had not been informed of any type of injuries. The DON stated the resident was always rubbing her eyes and this may have caused bruising. FM brought the bruising to her attention and said CR#1 was abused. The DON stated she told FM she was going to do an investigation, but that was too late because she has already called police. She stated she did not complete documentation regarding CR#1's injuries. 2/26/2024 at 4:27pm Interview with ADON A-States the LVN [NAME] stated there was something going on with the resident's eye. She stated ADON B said he would look at the eye. Stated she believes ADON B called the DON. ADON A stated if she had seen her face like the photo shown on Investigator's computer, she would have immediately told Admin, DON, and NP. She would have completed documentation in PCC. However, she did not complete any documentation regarding CR#1's eye. 2/26/2024 at 4:46pm Interview with ADON B - States he was in the meeting when LVN [NAME] stated it was something going on with CR#1's eye. States he told the nurse to let the NP know and document. States he checked her face. He stated he didn't see much. States the LVN told him that the NP was on it and recommend monitoring. He stated he did not document in PCC because it is usually the nurse on duty who documents. States he called the DON and let her know. Told her the NP had seen the resident.

Based on interviews and record review the facility did not provide, in writing, a bed-hold notice upon transfer at the time of transfer of a resident to a hospital or for therapeutic leave, for 1 of 3 residents (CR#1) reviewed for transfers and discharge. -The facility failed to provide bed-hold notifications to CR#1 when she was transferred to the hospital. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred. Findings included: Record review of CR#1's Face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: spinal stenosis (a narrowing of the spinal canal), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid) and hypokalemia (a blood level that is below normal in potassium). CR#1 was transferred to an acute care hospital on [DATE]. Record review of CR#1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. She required extensive assistance from two persons, physical assist with bed mobility, dressing, personal care, and hygiene. Required total dependence with toilet use. CR#1 was frequently incontinent of bladder and bowel. Record review of CR#1's Discharge MDS assessment dated [DATE] revealed the resident's return was anticipated post discharge, and it was an unplanned discharge with no evidence of an acute change in mental status. Record review of CR#1's Care Plan initiated 04/13/2023 and updated on 04/26/2023 revealed the following: Focus- (CR#1) had an ADL self-care performance deficit r/t Spinal Stenosis. Goal: The resident will improve current level of function in ADLs through the review date. Interventions: Bathing/showering: The resident requires extensive assistance by (1) staff with bathing/showering as necessary. Toilet use: The resident is totally dependent on 1 staff for toilet use. Record review of CR#1's Progress Note dated 09/18/23 at 2:46am written by LVN A revealed, Resident transferred at 0210 in stable condition via [company name] EMS . Record review of CR#1's September 2023 EMR revealed no transfer or discharge plans documented. Record review of CR#1's paper/electronic chart revealed no notification of the facility's bed hold policy. In a telephone interview on 01/12/2024 at 9:14a.m., with the Ombudsman, he said on 8/21/23, had a fair hearing for an improper discharge and on 9/13/23, received notification CR#1 won the hearing. He said CR#1 was sent to the hospital in stable condition. The facility failed to provide a written bed hold policy to CR#1 upon transfer. Attempted telephone interview on 01/12/2024 at 9:34 a.m., with CR#1 was unsuccessful. In an interview on 01/12/2024 at 9:44a.m., the Administrator said the Social Worker was responsible for discharge planning. He said residents that were sent to the hospital for acute care had the right to return to the facility. The Administrator said the bed hold policy was not provided to the residents at admission. The Administrator said the facility's admission packet did not include the bed hold policy. He said it was a form that was given by nursing in the event of a transfer. In an interview on 01/12/2024 at 9:59 a.m., with the Administrator and the DON, the DON said CR#1 was not provided a written bed hold policy upon transfer. CR#1 was transferred sometime in September 2023. The DON said corporate created a bed hold form in the end of December 2023. She said residents that were transferred in January 2024 should have a bed hold form in their electronic medical records. In an interview on 01/12/2024 at 10:38a.m., the Social Worker said that she was responsible for the resident discharge process. She said when a resident was transferred to the hospital, they had the right to return but, she was not aware of the requirement to present the residents with a bed hold policy. In an interview on 01/12/2024 at 11:31a.m., with LVN A, he said he worked full time at this facility. He said CR#1 was transferred to the hospital in stable condition. He said he did not provide CR#1 with bed hold policy. LVN A said, I have heard of the bed hold at other facilities that I have worked at but not at this facility. In a telephone interview on 01/12/2024 at 1:15 p.m., with CR#1's Family Member, she said CR#1 was discharged to the hospital on [DATE]. She said CR#1 was not provided an explanation of the resident's rights to remain at the facility, the bed hold policy, or any discharge planning. Record review of the facility's Bed Hold Notice Upon Transfer policy dated 10/24/22 revealed read in part: . Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Definitions: Bed-Hold means the holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. Reserve Bed Payment refers to payments made by a State to the facility to hold a bed during a resident's temporary absence from a nursing facility. Therapeutic Leave refers to absences for purposes other than required hospitalization. Policy Explanation and Compliance Guidelines: Bed Hold Notice Upon Transfer 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility: o The resident requires the services which the facility provides; o The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 2. In the event of an emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan .

Based on observation, interview and record review the facility failed to ensure services were provided or arranged by the facility, as outlined by the comprehensive care plan, that met professional standards of for 2 of 20 residents (Resident #23 and Resident #91) reviewed for services that met professional standards. 1. The facility failed to administer BP medication to Resident #23 as ordered by administering outside of parameters. 2. The facility failed to administer BP medication to Resident #91 as ordered by administering outside of parameters. These failures could place residents at risk of not receiving the care and services identified on their care plan and ordered by their Physicians and could result in a decline in health status. Findings include: 1. Record review of Resident #23's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #23's care plan revised 09/28/2021, read in part: Problem: Resident #23 had hypertension; Goal: Resident #23 will remain free of complications related to hypertension; Interventions: Give anti-hypertensive medications as ordered. Record review of Resident #23's quarterly MDS assessment, dated 07/29/22, revealed a BIMS score of 10, which indicated his cognition was moderately impaired. The MDS revealed one of Resident #23's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #23's physician's order summary report, dated 10/16/22, revealed [MEDICATION(S)] 10 Mg one tablet at bedtime for hypertension. Hold for SBP <110. Record review of Resident #23's physician order summary report, dated 10/16/22, revealed [MEDICATION(S)] 50 Mg two times a day for hypertension. Hold for SBP <110, HR <60. Record review of Resident #23's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for SBP <110. Resident #23's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 10/02/22 at 8:00 PM BP was 106/77 by MA A. Record review of Resident #23's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for SBP <110, HR <60. Resident #23's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 10/09/22 at 5:00 PM BP was 100/67 by MA A. In an observation on 10/17/22 at 10:44 AM Resident #23 was in the hall self-propelling in his wheelchair. Attempted to interview but resident refused to be interviewed . In an interview on 10/17/22 at 12:00 PM, MA A stated the initials on Resident #23's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MA stated before she gave BP medications, she checked the resident's blood pressure to make sure it was within the parameters and if it was not, she would not give the medication she marked it as held and notified the nurse. The risk to the resident was the blood pressure could drop too much if the medication is given outside the ordered parameters. The MA refused to state why the medications were given on 10/02 and 10/09 and how to prevent it from occurring again . In an interview on 10/17/22 at 12:15 PM, the DON stated her expectations were the ordered parameters for blood pressure medications were followed. These medications were given outside the ordered parameters and should not have been given. The risk to the resident was the resident's blood pressure could drop too low. To prevent this from occurring again the staff would be in-serviced. In an interview on 10/18/22 at 10:01 AM, the Administrator stated he was not clinical, but his expectations were that medications were administered according to the nursing policies and to follow physician's orders. He stated the risk to the resident best to his knowledge was the blood pressure could go low. To prevent it from occurring again he would reeducate, In-service and monitor the staff. 2. Record review of Resident #91's face sheet, dated 10/16/22, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #91's Annual MDS, dated [DATE], revealed the resident had severely impaired vision, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, required extensive assistance to total dependence on most ADLs, wheelchair use, was always incontinent of both bladder and bowel and an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #91's Care Plan revealed: Problem- Resident #91 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor for side effects such as orthostatic [CONDITION(S)] and increased heart rate and effectiveness. Resident #91 was not care planned for [CONDITION(S)]. Record review of Resident #91's Physician Orders, dated 09/29/22, revealed, [MEDICATION(S)] 5 mg- Give 1 tablet by mouth two times a day for [CONDITION(S)]. Give for SBP <110 . Record review of Resident #91's October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] <100 on: 10/1/22 at 5:00 PM with BP 100/69 by DON 10/3/22 at 5:00 PM with BP 143/71 by MA E 10/4/22 at 9:00 AM with BP 100/68 by MA C 10/5/22 at 5:00 PM with BP 144/71 by MA E 10/7/22 at 9:00 AM with BP 101/63 by LVN A and 5:00 PM with BP 125/60 by MA A 10/8/22 at 9:00 AM with BP 112/66 by ADON 10/10/22 at 5:00 PM with BP 143/70 by MA E 10/11/22 at 9:00 AM with BP 100/65 by MA C and 5:00 PM with BP 141/70 by MA E 10/12/22 at 5:00 PM with BP 143/71 by MA E 10/13/22 at 9:00 AM with BP 124/70 by MA B and 5:00 PM with BP 143/70 by MA E 10/14/22 at 5:00 PM with BP 143/70 by MA E 10/15/22 at 9:00 AM with BP 100/69 by MA C and 5:00 PM with BP 127/59 by MA D In an interview on 10/17/22 at 12:31 PM, the DON said prior to medication administration nursing staff must verify the 10 rights first, ensuring administration involved the right person and right drug. Once verified nursing staff must introduce themselves to the patient and check for ordered parameters such as BP and if the patient was within parameters the medication was to be administered. She said if the patient was outside of parameters such as a SBP of 100 and above for Resident #91 the medication was not to be administered and documentation should be completed in the facility EMR. The DON said [MEDICATION(S)] should not be administered outside of parameters because administration could cause the resident's BP to sky rocket placing them at risk for side effects . In an observation and interview on 10/18/22 at 11:50 AM, Resident #91 in bed and receiving oxygen via nasal canula, she appeared well fed, well-groomed in no immediate distress. Resident #91 said she had problems with her BP sometimes and it had gone as high as 190 at which point she experienced headache, chest pain/SOB . She said her blood pressure normally went high prior to hospitalization , which she had a few, from worsening of her CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs and other organs) but she felt better ever since she was placed on a renal diet (diet low in sodium, phosphorous and protein) and fluid restriction. Record review of MA C's Medication Administration Observation Report, dated 01/21/22, revealed, 5- For meds with parameters, vital signs are taken prior to administration. Competency met. Record review of LVN A Medication Pass Worksheet, dated 04/20/22, revealed LVN A passed her medication administration assessment, and medications were administered in accordance with the patient's physician's orders. Record review of MA A's Medication Pass Audit, dated 04/22/22, revealed, 8- Medications are administered in accordance with current physician's orders?- competency met-yes. Record review of MA E's Medication Pass Audit, dated 05/13/22, revealed, 8- Medications are administered in accordance with current physician's orders?- competency met-yes. Record review of MA C's Medication Administration Observation Report, dated 10/15/22, revealed, 5- For meds with parameters, vital signs are taken prior to administration. Competency met. Record review of the facility policy titled Medication Administration revised, 10/01/19, revealed, 2- Administration . B- Medications are administered in accordance with written orders of the prescriber . Right Assessment/Response- Medications like blood pressure medications always warrant a quick blood pressure check before giving a blood pressure medication. Nurses must be aware of parameters for administration specific to a medication.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 6 residents (Resident #86) and 2 of 3 medication carts (100-300 Hall Medication Aide Cart and 200-400 Hall Nursing Cart) reviewed for pharmacy services. - The facility failed to discard an expired bottle of Pro-Stat, a protein supplement, located in the 100-300 Hall Medication Aide Cart. - The facility failed to discard an expired bottle of Pro-Stat located in the 100-300 Hall Medication Aide Cart. - The facility failed to discard expired Insulin prescribed for Resident #86 that was located in the 200-400 Hall Nursing Cart. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings include: 100-300 Medication Aide Cart In an observation and interview on 10/17/22 at 11:00 AM, inventory of the Medication Aide Cart with MA C revealed: - 10 full and 3 partial loose pills - An open and in use bottle of Pro-Stat, with an open date of 03/2022 with manufacturer's instructions to discard 3 months after opening. MA C said nursing staff were expected to check their carts weekly and while in use for loose pills and expired medications. She said once found loose pills should be discarded and she was not aware the Pro-Stat had a 3 month shelf life. MA C said she always used the expiration date under the bottle. She said once medication expired it could become less effective and if the Pro-Stat was administered to the resident it could cause GI upset. 200-400 Hall Nursing Cart In an observation and interview on 09/12/22 at 09:12 AM, inventory of the 100 Hall Nursing Cart with LVN A revealed: - An open and in use vial of Insulin [MEDICATION(S)] for Resident #86 with an open date of 09/07/22 with manufacturer's instructions to discard 28 days (10/5/22) after opening. - an open and in use bottle of Pro-Stat, with an open date of 03/29/2022 with manufacturer's instructions to discard 3 months after opening. LVN A said nursing staff were expected to check their carts while in use and daily for expired medications and supplements. She said Insulin [MEDICATION(S)] expired 28 days after it was opened and the insulin vial for Resident #86 was expired and should had been discarded previously. LVN A said after insulin expired it became less effective and if used it could place residents at risk of uncontrolled blood sugars. LVN A said she did not know Pro-Stat had a shelf life of 3 months and since it was expired it could not be used because it might be less effective and could cause GI upset. She said since both the Insulin and Pro-Stat were expired they could not be used and must be discarded in the drug disposal bin located in the medication storage room. In an interview on 10/17/22 at 11:38, the DON said nursing staff were to check their carts daily for loose pills and expired medications. She said the pharmacist consultant also did monthly cart audits while the chart nurses inspected the carts weekly. The DON said all loose pills should be tossed in the trash with the expectation that all trash cans were covered and inaccessible to residents. The DON said she did not know Pro-Stat expired 3 months after dating and all insulin should be used before their beyond use date because after that date there was a decreased efficacy and if used the insulin could fail to properly regulate a patient's blood sugar. She said expired medications should be discarded in the drug disposal bin located in the medication storage room. The DON said the facility did not have a policy that addressed medication storage. Record review of the manufacturer's Insulin [MEDICATION(S)] Injection Highlights of Prescribing Information revised 10/2019, revealed, After vials have been opened: throw away all Insulin [MEDICATION(S)] vials after 28 days, even if they still have insulin left in them .

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6 percent based on 2 errors out of 33 opportunities, which involved 2 of 7 residents (Resident #33 and Resident #77); and 2 of 4 staff (MA A and MA C) reviewed for medication errors. 1. MA C failed to administer Resident #33's Nasal Spray as ordered by administering 2 sprays in each nostril instead of 1. 2. MA A failed to administer Resident #77 [MEDICATION(S)] ER (extended release), a medication that should not be crushed, by crushing the medication. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Include: 1. Record review of Resident #33's face sheet, dated 10/17/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #33's Quarterly MDS, dated [DATE], revealed moderately impaired vision with use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 13 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #33's care plan, revised 09/07/22, revealed no related focus areas, goals or interventions. Record review of Resident #33's Physician's Orders, dated 07/01/21, revealed [MEDICATION(S)] Eyedrops- 1 drop in both eyes two times a day for dry eyes. Record review of Resident #33's Physician's Orders, dated 07/02/22, revealed [MEDICATION(S)] 50 mcg/act- 1 spray in both nostrils one time a day for allergies. An observation on 10/17/22 at 07:58 AM revealed, MA C prepared medication for administration for Resident #33. She retrieved the bottle of [MEDICATION(S)] eye drops and [MEDICATION(S)] nasal spray put on gloves, entered the resident's room and informed the resident she would be administering her eye drops. After administering 1 drop of [MEDICATION(S)] in each of Resident #33's eyes she told the resident she would need help to reposition the resident prior to administering the other medications. MA C exited the resident's room and returned with a CNA who helped move the resident up on the bed in order to elevate her head at a 45 angle. After removing her gloves and performing hand hygiene, MA C returned to the resident room while holding the nasal spray bottle with her bare hands, primed the nasal spray by squirting one spray into the air and then inserted the nasal spray into Resident #33's right nostril and administered 2 sprays followed by 2 sprays to the left nostril. MA C exited the resident room, placed the nasal spray back into the box, into her medication cart and then prepared oral medication for administration to Resident #33. 2. Record review of Resident #77's face sheet, dated 10/17/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #77's Quarterly MDS, dated [DATE], revealed moderately impaired vision with the use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, extensive assistance to total dependence with ADLs, frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #77's Care Plan, dated 08/30/22, revealed Focus- diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .Interventions- give anti-hypertensive medications as ordered. Record review of Resident #77's Physician's Orders, dated 01/26/22, revealed, may crush medications and/or open capsules PRN as per pharmacy guidelines. Record review of Resident #77's Physician's Orders, dated 02/15/22, revealed [MEDICATION(S)] ER Extended Release 24 hour 90 mg- give 1 tablet by mouth one time a day for hypertension hold if SBP less than 110, DBP less than 60, HR less than 60. An observation and interview on 10/17/22 at 09:00 AM revealed, MA A prepared oral medication for administration to Resident #77. She retrieved a blister pack of [MEDICATION(S)] ER 90 mg as well as other oral medications for the resident, the blister back of [MEDICATION(S)] ER did not have an assessor label (sticker) that stated Do not Crush. MA A crushed [MEDICATION(S)] ER 90 mg along with other oral formulations, mixed them with pudding and administered the crushed medications to Resident #77 at 09:07 AM. MA said the only medications that should not be crushed were [MEDICATION(S)] coated medications because crushing them would change their taste. She said extended release formulations could be crushed and administered at the resident's request. In an interview on 10/17/22 at 11:38 AM , the DON said medication should be administered as ordered and MA C said she administered 2 sprays instead of 1 spray into the nostril of Resident #33. She said EC and ER medications should not be crushed because it interrupted their delivery method and administering do not crush medications could result in resident's not receiving the right dose of the medication. Record review of MA A's Medication Pass Audit, dated 04/22/22, revealed, 8- Medications are administered in accordance with current physician's orders?- competency met-yes. 10- Medications are crushed appropriately per pharmacy recommendations or physician orders, competency met-no. Record review of MA C's Medication Administration Observation Report, dated 01/21/22, revealed 6- Correct medication verified by visual check of med, label & MAR Record review of the facility policy titled Medication Administration revised 10/01/19 revealed, (1) Preparation .G- Tablet Crushing/Capsule Crushing .a- Long-acting or [MEDICATION(S)] coated dosage forms should not be crushed; an alternative should be sought .e- For residents able to swallow or having difficulty swallowing, tablets which can be appropriately crushed may be ground coarsely and mixed with the appropriate vehicle such as applesauce so that the resident receives the entire dose ordered. Please consult with product literature or 'Do Not Crush' list which the facility may have or with the pharmacist if there is a question about medications to be crushed.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #33) reviewed for infection control. MA C failed to wear gloves when administering a nasal spray and failed to perform hand washing/sanitization after administering a nasal spray to Resident #33. This failure could place residents at risk for infections. Findings include: Record review of Resident #33's face sheet, dated 10/17/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #33's Quarterly MDS, dated [DATE], revealed moderately impaired vision with use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 13 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #33's care plan, revised 09/07/22, revealed no related focus areas, goals or interventions. Record review of Resident #33's Physician's Orders, dated 07/01/21, revealed [MEDICATION(S)] Eyedrops- 1 drop in both eyes two times a day for dry eyes. Record review of Resident #33's Physician's Orders, dated 07/02/22, revealed [MEDICATION(S)] 50 mcg/act- 1 spray in both nostrils one time a day for allergies. An observation on 10/17/22 at 07:58 AM revealed, MA C prepared medication for administration for Resident #33. She retrieved the bottle of [MEDICATION(S)] eye drops and [MEDICATION(S)] nasal spray put on gloves, entered the resident's room and informed the resident she would be administering her eye drops. After administering 1 drop of [MEDICATION(S)] in each of Resident #33's eyes she told the resident she would need help to reposition the resident prior to administering the other medications. MA C exited the resident's room and returned with a CNA who helped move the resident up on the bed in order to elevate her head at a 45 angle. After removing her gloves and performing hand hygiene, MA C returned to the resident room while holding the nasal spray bottle with her bare hands, primed the nasal spray by squirting one spray into the air and then inserted the nasal spray into Resident #33's right nostril and administered 2 sprays followed by 2 sprays to the left nostril. MA C exited the resident room, placed the nasal spray back into the box, into her medication cart and then prepared oral medication for administration to Resident #33. She did not perform hand hygiene after coming into direct contact with Resident #33 and touching the nasal spray that was inserted into the resident's nostril with her bare hands. In an interview on 10/17/22 at 11:38 AM, the DON said nursing staff were not expected to wear gloves when administering nasal sprays. She said MA C was not required to wash her hands after administering the nasal spray to Resident #33 since her hands were not visibly soiled but she was required to at least sanitize her hands using a hand sanitizer following administration of the nasal spray. She said hand hygiene (washing or sanitizing) was required after direct contact with residents and failure to sanitize/wash hands could lead to the potential to spread disease . Record review of MA C's Medication Administration Observation Report, dated 01/21/22, revealed 5- For meds with parameters, vital signs are taken prior to administration. Competency met. 17- Proper hand washing technique at appropriate times, competency met-yes. Record review of the facility policy titled Medication Administration, revised 10/01/19, revealed 1-Preparation .B- Handwashing and Sanitizing- The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal and parental preparations and medication given via enteral tubes. Examination gloves are worn when necessary. Hand sanitizing is done with an approved sanitizer between hand washings, when returning to the medication cart or preparation (assuming hands have not touched a resident or potentially contaminated surface) .Medication Administration Guidelines g- Wash your hands with soap and water or sanitize your hands before giving someone medicine. Record review of the facility policy titled Handwashing- Hand Hygiene, revised January 2018, revealed, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b- Before and after direct contact with residents . I- after contact with a resident's intact skin. Single use disposable gloves should be used: . when anticipating contact with blood and bodily fluids.

Based on interview and record review the facility failed to ensure residents had the right to receive visitors of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident for 96 of 96 residents reviewed for resident rights. The facility failed to ensure all residents had the right to unrestricted visitation hours inside the facility. This failure could place residents at risk for isolation, decreased emotional well-being and a diminished quality of life. Findings include: Resident #1 Record review Resident #1, undated, face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed a BIMS score was 10 out of 15, which indicated moderately impaired cognitively. Resident #1 required extensive assistance from staff for personal hygiene, dressing and transfers. In a telephone interview on 1/31/22 at 1:33 p.m. with the complainant, he said in the last two weeks, the CDC revised visitation guideline stating that visitors and residents should have unlimited visitations. The facility was allowing visits between 7:00 a.m.-7:00 p.m. He said many of the visitors work and were not able to attend early hours. He said the Administrator refused to comply. At first, the Administrator stated he was waiting for corporate, then he just said no he was not changing the visiting hours to unlimited. The complainant said, it is unfair for many residents to lose visits, because the administrator is of out compliance. In an interview on 2/1/22 at 10:40 a.m., with Resident #1's friend, she said the facility's visitation hours were from 7 a.m. to 7p.m. She said she and other family members had brought it to the Administrator's attention and he told them the facility was following instructions from the corporate office. She said it was hard for the family and friends to see the resident when they worked full time and had to rush and come and see the resident before the visitation hours ended. She said residents were not allowed to see their family for over a year due to COVID only window visits were allowed. She said, it was not fair to the residents. They felt isolated. In an interview on 2/1/22 at 10:49a.m. with LVN A, she said facility's visitation hours were from 7 a.m. to 7 p.m. She said staff did not encourage family to stay after 7 p.m. She said the receptionist made rounds and informed the family/friends that they had to leave and could not stay past 7p.m. In an interview on 2/1/22 at 11:00 a.m. with the Receptionist, she said visitation hours were from 7 a.m. to 7 p.m., 7 days a week. she said the facility did not allow family/friends to stay after 7 p.m. She said if a resident came from the hospital after 7 p.m. the facility allowed family to come and stay for little bit and then request ed the family to leave so the resident could adjust to the new environment. Resident #2 Record review Resident #2's, undated, face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Comprehensive MDS, dated [DATE], revealed a BIMS score was 09 out of 15, which indicated the resident was moderately impaired cognitively. Resident #2 required extensive assistance from staff for personal hygiene, dressing, and transfers. In an interview on 2/1/22 at 11:23 a.m., with Resident #2 and Resident #2's family member, the Resident's family member was at the residents bedside. Resident #2 said her family member was visiting her from out of state. She said due to COVID-19 he was not able to come see her that often. The family member said the facility had visitation hours until 7 p.m. or 8 p.m. He said he was not sure of the exact timing, but he remembered the receptionist telling him in the past. Resident #2 said this is where I live. The facility should consider changing their hours because she didn't get to see her son and he was visiting her from out of state, and the resident didn't feel he should not have to leave by certain time. In an interview on 2/1/22 at 12:10 p.m., with the Administrator and the DON, the Administrator said recommended visitation hours were from 7 a.m. to 7 p.m. because residents shared rooms. He said, so it does not affect resident quality of life there was limitation to visitation hours. But we are not really restricting any visitors. The Administrator said the facility was following the CMS guidelines for COVID visitation. The Administrator presented CMS Nursing Home Visitation-COVID-19 Memorandum Ref: QSO-20-39-NH revised 11/12/2021. Record review of CMS Nursing Home Visitation -COVID -19 (REVISED), dated 11/12/2021 read in part: .Indoor Visitation: Facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the PHE, facilities can no longer limit the frequency and length of visits for residents, the member of visitors, or require advance scheduling of visits . Record review of facility's, undated, Your Rights and Protections as a Nursing Home Resident policy read in part: .Spend Time with Visitors: You have the following rights: To have visitors at any time, as long as you wish to see them, as long as the visit does not interfere with the provision of care and privacy rights of other residents. To see any person who gives you help with your health, social, legal, or other services may at any time .

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to prevent development and worsening of pressure injuries to 2 of 13 residents (Resident #1 and CR #2) reviewed for pressure ulcers in that; -Resident #1 was not repositioned every two hours when she was very high risk for development of pressure ulcers. She developed one facility acquired stage IV left hip pressure ulcer that required debridement. She had one community acquired stage IV sacral PU and three community acquired stage III pressure ulcers. -The facility failed to ensure CR #2's Weekly Pressure Ulcer Evaluations and Weekly Skin Reports were completed and/or accurately reflected the progression of his community acquired Stage II sacral pressure ulcer which developed into a large necrotic septic decubitus wound requiring hospitalization . These failures could affect residents with wounds or who are at risk of developing wounds and placed them at risk of infection, a decline in health, pain, and hospitalization . Findings include: Resident #1 Record review of Resident #1's face sheet revealed, a [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed, a BIMS score of 5 indicating severe cognitive impairment. Resident #1 was totally dependent of two people, physical assistance for bed mobility. She was at risk for development of pressure ulcers/injuries, had three stage 3 pressure ulcers that were present on admission, and one stage 4 pressure ulcer that was present on admission. Record review of Resident #1's Nursing-Clinically Unavoidable Pressure Ulcer Form dated 11/12/20 read in part, . 1. Interventions in place prior to the development of a pressure ulcer: (select all that apply) .d. Turn Q2 hours . was checked. Record review of Resident #1's Nursing-Braden Scale for Predicting Pressure Sore Risk dated 11/17/20 revealed, a score of 8 indicating the resident is very high risk. Record review of Resident #1's Care plan revised 11/18/20 read in part, Problem: Resident #1 has pressure ulcers r/t Hx of ulcers, Immobility, dependent on staff Has pressure ulcer on sacrum, R elbow, and 2 open areas on the abdomen; 11/12/20 Blister filled with fluid on L heel, 11/17/20 DTI on L Trochanter; Goal: Resident #1 will Pressure ulcer will show signs of healing and remain free from infection by/through review date; Interventions: .Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #1's Physician Wound Care notes dated 11/18/20 revealed, a facility acquired left hip wound identified on 11/16/20, measuring 3.5 x 3 x 0.5; Area: (sq. cm) 10; Volume: (cm3) 2.1; Moderate serous exudate, 26-50% moist Yellow Slough. Other Orders read in part, Pressure Relief/Offloading: Reposition per facility protocol, off-load wound. Record review of the facility's Weekly Skin Report dated 11/19/20 revealed Resident #1 had a St III left hip FA PU measuring 3.5cm x 3.0cm x 0.2cm, identified on 11/16/20. Observation on 11/20/20 at 12:09pm of Resident #1 revealed, the resident asleep lying on her right side on an air mattress, her heels were offload with pillows. Observation on 11/20/20 at 1:26pm of Resident #1 revealed, the resident asleep lying on her right side. There was a white towel under her neck. Observation on 11/20/20 at 2:14pm of Resident #1 revealed, the resident asleep lying on her right side. Her brief was loose exposing her left buttock. The dressing to her left hip had fallen off exposing a St III PU. The white towel that was under her neck was no longer there. Observation and interview on 11/20/20 at 2:22pm of Resident #1 with the DON, when asked about Resident #1, the DON stated she turned the resident herself earlier, further stating the resident will pull the sheets off. The investigator informed the DON, the resident was observed lying in the same position in a soiled gown with her back and brief exposed for over two hours and there was no sheet covering her during these observations. The investigator further informed the DON someone had removed the soiled white towel that was previously observed under the residents' neck but had not changed her gown, covered her exposed areas, or repositioned her. The DON again stated the resident will pull off her sheets and stated she repositioned the resident herself earlier. She stated she would get someone to change the resident's gown and put a new dressing on the left hip and reposition her. Interview on 11/20/20 at 3:11pm with CNA #1, when asked what the facility's policy is to prevent the development and/or worsening of a PU on a resident, she stated if a resident was bedbound, she made sure they were turned every two hours. She further stated there were places where they could put pillows, or a wedge and reposition them every two hours. She said Resident #1 was required to be turned every two hours because she could not stay in one position too long, stating, That's why you have to turn her every two hours. Interview on 11/20/20 at 3:55pm with CNA #2, when asked what the facility's policy was to prevent the development and/or worsening of a PU she stated, We position the patient every two hours and make sure the patient is clean and rub cream on their butt every two hours and check on them for incontinence. When asked how to do you know if a resident required to be turned every two hours she said, If a patient can't do anything for themselves, then they turn them. Interview on 12/10/20 at 1:42am with CNA #3, she stated Resident #1 was not able to turn herself and was a two-person assist further stating she was supposed to be turned every two hours. She stated on 11/20/20 she turned the resident in the morning and believed she turned her around 12:00pm. She stated CNA #4 helped her turn the resident. She could not state if any other staff turned the resident after her, further stating sometimes the DON or Treatment nurse would turn residents. When asked if they document the times residents were turned, she stated no. Interview on 12/10/20 at 1:54pm with the Wound MD, he stated Resident #1 developed a FA left hip PU identified by the facility as a DTI on 11/16. He said he first saw and debrided the wound on 11/18 which had 50% slough. He said once he debrided the wound to viable subcutaneous tissue and it was a Stage III PU. He said a few weeks later the PU worsened and was now a Stage IV. Interview on 12/10/20 at 2:47pm with CNA #5, she stated the key element in pressure ulcer prevention was turning residents every two hours. She stated she also used wedges, pillows and other pressure relieving devices to off-load and prevent PUs. When asked how CNAs knew which residents needed to be repositioned every two hours, she stated it is on the Kardex, stating before she touched a resident, she would go to the Kardex to see what is required. Interview on 12/10/20 at 3:06pm with CNA #6, she stated to prevent PUs from developing or worsening, residents must be turned every two hours and must be clean and dry. When asked how CNAs know if a resident should be turned every two hours or PRN, she stated you go to the POC and look in the Kardex. Record review of the facility's Pressure Ulcer Care policy obtained from Lippincott Nursing Procedures Seventh Edition no date read in part, .Implementation .Turn and reposition the patient every 1 to 2 hours or more frequently as required unless contraindicated . CR #2 Record review of CR #2's face sheet revealed an [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #2's Discharge MDS dated [DATE] revealed, documentation indicating the resident had one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. Record review of CR #2's Nursing Braden Scale for Predicting Pressure Sore Risk dated 9/14/20 revealed, a score of 7 indicating, Very High Risk. Record review of CR #2's Care plan revised 7/25/20 read in part, Problem: CR #2 is at risk for impaired skin integrity/pressure ulcer development due to limited mobility and bowel/bladder incontinence; Goal: CR #2 will maintain clean and intact skin through review date; Interventions: .Administer treatments as ordered and monitor for effectiveness, Inform the resident/family/caregivers of any new area of skin breakdown .Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, Teach the residents/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Tx the sacral wound as per MD order date initiated 10/08 revised 10/21/20. Further record review of CR #2's Care plan revised 7/25/20 revealed, the interventions did not address completion of and/or updating the Weekly Pressure Ulcer and Skin evaluations and Weekly Skin Reports. Record review of CR #2's nursing progress notes dated 8/24/20 read in part, Resident got readmitted from hospital accompanied by 2 EMS staff arrived via stretcher with the admitting [DIAGNOSES REDACTED]. Resident is alert and responsive. Head to toe assessment done. Resident denies verbal and nonverbal signs of pain. Gtube site is intact, no signs of infection noted, no discoloration noted. ABT [MEDICATION NAME] 500mg x 5 days [MEDICAL CONDITION]. Called NP for reconcile the medications. Received new lab order for CBC, BMP for AM tomorrow. Order carried out. Further record review of CR #2's nursing progress notes dated 8/24/20 revealed, there was no documentation of the residents' skin condition. Record review of CR #2' physician orders [REDACTED]. Record review of CR #2's Weekly Pressure Ulcer Evaluations dated 8/26/20, 9/3/20, and 9/13/20 revealed, identical documentation of an admitted with St II sacral pressure ulcer measuring 2.5 x 2.0 x 0.2 with serous; thin watery, clear drainage, moderate exudate, granulation tissue (pink/beefy) wound bed, with normal surrounding skin color and normal for skin surrounding tissue wound edges; no tunneling, no undermining. Treatment start date 8/24/20. Further record review of CR #2's Weekly Pressure Ulcer Evaluations dated 8/26/20, 9/3/20, and 9/13/20 revealed, Specify specific treatment ordered: Apply zinc oxide cream, to sacral open skin excoriation as ordered. Response to treatment was documented on all evaluations as improved. Further record Review of the CR #2's Weekly Pressure Ulcer Evaluations revealed, there were no PU evaluations completed for the weeks of 9/06/20, 9/20/20, 9/27/20, and 10/04/20 documenting the progression and/or deterioration of CR #2's St II sacral wound. Interview on 11/20/20 at 1:48pm with the DON, when asked if there were Weekly Pressure ulcer reports completed on 9/06, 9/20, 9/27, and 10/4 for CR #2, she stated the only ones completed from what she understands are the ones in PCC. She stated there was a problem with the previous DON and the Treatment nurse stating there was an audit completed on residents when they realized the assessments were not being completed. She said those assessments should have been done because they are supposed to be completed weekly. She stated the Treatment nurse is responsible for completing the Weekly Skin Reports, Weekly Pressure Ulcer Evaluations, and Weekly Skin Evaluations, further stating the treatment nurse was not keeping up with it. Record review of the facility's Weekly Skin Report dated 8/27/20, 9/3/20, and 9/12/20 revealed, no documentation of CR #2's Community Acquired St II sacral PU. Record review of CR #2's physician orders [REDACTED]. every day shift. Record review of CR #2's Treatment Administration Record dated September 2020 revealed the facility staff were documenting the resident's sacral wound was treated as ordered. Record review of the facility's Weekly Skin Report dated 9/17/20 revealed, CR #2's Community Acquired St II sacral PU measuring 2.5 x 2.0 x 0.2, identified on 8/25/20. Treatment calcium: alginate, air mattress, and dietary supplement. Record review of the facility's Weekly Skin Report dated 9/24/20 revealed, CR #2's Community Acquired St II sacral PU measuring 3.0 x 5.0 x 0.2, identified on 8/25/20. Treatment calcium: alginate, air mattress, and dietary supplement. Record review of CR #2's nursing progress notes dated 9/24/20 read in part, Call placed to Resident RP to update her on wound updates and progress. Resident has a stage 2 sacral pressure injury. Treatment continues as ordered. Resident continue to be repositioned and continue on a low air loss mattress to reduce pressure on the wound. Further record review of CR #2's nursing progress notes revealed, this was the first documentation of CR#2's St II sacral PU in the nursing progress notes. Further interview on 11/20/20 at 1:48pm with the DON, she stated CR #2 was on the COVID unit from 8/24/20 to 9/23/20 stating the nurses on that hall were doing wound care because they did not want the Treatment nurse working the COVID hall. She said the Hospice nurse did not want CR #2 to have aggressive therapy, stating no labs, or x-rays, were ordered. She further stated the Wound MD was not seeing the resident stating Hospice does not allow the Wound MD to see the resident because they manage the wounds. She stated once they realized there were problems with the wound reports, the DON was let go on 10/30/20 stating she was now rounding with the Treatment nurse weekly and as needed. She said the Treatment nurse must let her know about any changes in wounds immediately, so she can fix it. She said the Wound MD was now involved and will let her know when he completed his rounds and if anything was going on. She further stated a performance improvement plan and in-services were completed once they identified the problem. Record review of CR #2's physician orders [REDACTED]. Record review of the facility's Weekly Skin Report dated 10/8/20 revealed, CR #2's Community Acquired St II sacral PU measuring 7.5 x 5.0 identified on 8/25. Treatment calcium: alginate, air mattress, and dietary supplement. Record review of CR #2's physician orders [REDACTED]. Record review of CR #2's Treatment Administration Record dated October 2020 revealed the facility staff were documenting the resident's sacral wound was treated as ordered. Record review of CR #2's nursing progress notes dated 10/12/20 read in part, Leaking [DEVICE] site noted by the writer New order from NP per RP request: Send resident to hospital for [DEVICE] site evaluation. RP notified. Further record review of CR #2's nursing progress notes revealed, from 9/24/20 through 10/12/20 there was no documentation of the progression and/or deterioration of CR #2's sacral PU. Record review of CR # 2's hospital records dated 10/13/20 read in part, Reason for Referral: Sacral decubitus wound. History of Present Illness .Upon emergency room patient noted to be [MEDICAL CONDITION] from large necrotic sacral decubitus wound. The patient is unable to give history. History is obtained from the patient's family and the chart Physical Examination .Vital Signs: temperature is 99.9%, blood pressure 113/64, heart rate 121, respiratory rate 22, saturating 100% on 2L on nasal cannula .Skin: Sacral region with necrotic area measuring approximately 9 cm x 7 cm with 1 cm opening draining pus and foul-smelling dark liquid. Further record review of CR #2's hospital notes Imaging Studies read in part, CT scan of the abdomen and pelvis demonstrates midline decubitus wound with abscess air-fluid level extensive soft tissue gas involving the subcutaneous fat and each gluteus muscle . Further record review of CR #2's hospital records dated 10/13/20 read in part, Assessment and Plan: the patient is an [AGE] year-old man with history of [MEDICAL CONDITION] and alcoholic [MEDICAL CONDITIONS] with EF of 20%, [MEDICAL CONDITION], post recent MI, hypertension and bedridden stated [MEDICAL CONDITION] presents [MEDICAL CONDITION] and necrotic sacral wound. I had a long discussion with the patient's (family member), who is the medical power of attorney in regards to the risks and benefits of proceeding with surgical intervention. The patient has very high risk from cardiac standpoint and hepatic function standpoint for perioperative complications including each death. Patient's daughter has decided to proceed with hospice and comfort measures .Assessment/Plan: 81 y/o 1. [MEDICAL CONDITION]: Ordered: [MEDICATION NAME] 1gm IVP duration: 7 days, ABX indication: Skin/soft tissue infection .[MEDICATION NAME] IV Duration 7 days abx indication: Skin/Soft tissue infection . 2. Abscess of Sacrum . Interview on 11/20/20 at 3:20pm with the Treatment Nurse, he stated he was made aware of the problems with the wound reports when the regional nurse came to him to let him know the Weekly Pressure Ulcer evaluations, Weekly Skin reports, and Weekly Skin Assessments were not being done. He said after they told him about the problems with the reports he was in-serviced and educated on it, stating moving forward he would get it done. He stated CR #2 had COVID and went to the hospital and when he came back to the facility, he was put on the COVID unit. He stated during that time he was not going to the COVID unit doing wound treatments on those residents stating he was working on the general population, further stating that was why he was missed those reports. When asked who was completing wound care on the COVID hall, he stated the nurses working the COVID hall were responsible for doing the treatments. Further interview on 11/20/20 at 3:20pm with the Treatment nurse, when asked if someone else was responsible for completing the reports when he worked on the COVID hall, he said he could not go over there to do it and he was not sure if anyone else was responsible for completing the reports. When asked if the previous DON ever mentioned that the reports weren't being done, he stated when CR #2 came to the general population, that's when he noticed the reports were not being done and that's when he had to complete in-services back in August. He said the in-services completed were on the topics of making sure skin assessments were being completed on every patient along with the admission and weekly PU reports. When asked if the nurses were responsible for completing wound measurements, he stated the Wound MD does the measurements. He said when they get a new admission they do the initial skin assessment and measurements, then going forward he does the weekly measurements during rounds with the Wound MD. Further interview on 11/20/20 at 3:20pm with the Treatment nurse, when asked if the Weekly Pressure Ulcer Evaluations should be copied from another evaluation, or should the documentation reflect what was observed by the nurse, he said most of the time the measurements may remain the same until debridement was done, until then, you may not notice changes in the wound depth, length and width. He further stated the drainage, or the surface of the wound may have dried up or there was not as much moisture, stating that should be documented on the evaluation. He stated the PU evaluation should not say improved if that was not known or if the wound has not improved again stating you should document what you observed. Further interview on 11/20/20 at 3:20pm with the Treatment nurse, when asked how wounds were monitored and assessed for progression and/or deterioration, he said we do the weekly skin and PU assessments. He said when he completed daily treatments, he looked to see how the wound was, so you can tell if it was deteriorating stating, We use the weekly skin and PU assessments to see if its improving. He again stated they use the reports to determine how the wound is progressing. When asked if the reports are not completed and/or are inaccurate, would you know how the wound is progressing, he stated no. Interview on 12/08/20 at 1:54pm with the DON, the DON clarified information provided to the Investigator by the Treatment nurse during a previous interview, she said CR #2 was never at the facility during the time he was COVID positive stating that was from July 2020 to 8/23/20. She said he was re-admitted to the facility on [DATE] and was placed on the quarantine hall from 8/24/20 to 9/08/20. She said at that time, the Treatment nurse was working on both the quarantine and cold halls, further stating the Treatment nurse was completing the residents wound care. She said the resident was transferred to the Cold unit on 9/8 until he was transferred to the hospital on 10/12. Interview on 12/08/20 at 1:54pm with the Treatment nurse, when asked if was completing wound care on CR #2, he stated yes, when asked if he was completing all Weekly Pressure Ulcer Evaluations and Weekly Skin Reports on CR #2, he stated no. Record review of the facility's Performance Improvement Plan for Skin Documentation read in part, Issue (s): A review of the closed record for the discharged resident CR #2 was identified that all forms associated with the process were not fully completed; Analysis: a review of the forms/documentation associated with the skin process for residents with existing wounds was completed . Record review of the facility's Quick Reference Guide Skin Management-A guide to assist the center in actions required in the prevention and/or healing of wounds no date read in part, .3. A Weekly Skin Evaluation must be completed the day of admission (including readmission), at least once every 7 days, any change in skin condition and prior to discharge or transfer of a Patient. 4. A Weekly Pressure Ulcer Evaluation must be completed upon any identification of pressure ulcers and updated at least every 7 days and as necessary with any significant change. All pressure ulcers must be staged according to the updated NPUAP guidelines .

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 5 (Resident #1) reviewed for pressure ulcers. -The facility failed to prevent Resident # 1 from developing facility acquired Stage 4 deep tissue injuries to left and right ankles. -The facility failed to identify and intervene when CNAs were applying Prevalon boots to Resident #1's feet without training, physician orders, monitoring, or assessment by nursing staff. These failures could place all residents who are at risk for pressure ulcer development at risk for developing pressure sores, pain, infection, and hospitalization and complications to include worsening of the pressure ulcer for residents with existing pressure sores. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's NURSING-Braden Scale for Predicting Pressure Sore Risk - V 2 dated 6/26/2020 read in part: .Score is 11- High risk. SENSORY PERCEPTION 1. Completely Limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body surface. MOISTURE 4. Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals. ACTIVITY 1. Bedfast: Confined to bed MOBILITY 1. Completely Immobile: Does not make even slight changes in body or extremity position without assistance. NUTRITION 3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs. FRICTION & SHEAR 1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction . Record review of Resident #1's annual MDS assessment dated [DATE] revealed the resident had a BIMS of 11 out of 15 indicating the resident had moderately impaired cognitive skills. He required two-person assist with bed mobility, transfer, and toileting. Resident #1 required one-person assist with in the areas of locomotion on unit, dressing, eating and personal hygiene. He was coded for a wheelchair and a catheter. He was not coded for oxygen treatment. Section M0100. Determination of pressure ulcer/injury risk. Resident has a pressure ulcer injury, a scar over bony prominence, or a non-removable dressing/device. C. Clinical assessment M0150. Resident was coded for risk of pressure ulcers and injuries. He was coded for heel pressure ulcer injuries; stage 3. Current number of unhealthy pressure ulcers/injuries at each stage was 1. Section M: Skin conditions. M1200. Skin an ulcer/injury treatments were pressure reducing device for chair; pressure reducing device for bed; and pressure ulcer injury care. Observation and interview on 9/2/20 at 12:38 pm revealed Resident #1 lying in his air mattress bed wearing Prevalon boots on both feet/legs with socks on. Resident #1 had both feet floating off pillows while wearing Prevalon Boots. Observation of the label on the boots read, Prevalon. Resident #1 was positioned on his side facing the door. His left foot was floating off one pillow that laid underneath his foot. He had his right foot over his left foot with a pillow in between (off floating on pillows). The resident said he got the sores on his ankles at the facility. He had contractures on both hands. He was receiving oxygen therapy at 3.0 liters. There was a sleep apnea mask on his end table in a bag. The bag was not dated. The resident's cannula was yellow in color. His call light was sitting on his end table beyond his reach. He said he knew how to use the call light. He said he used it when he needed nursing staff to assist. He had a catheter bag 1/3 full. Record review of Resident #1's order summary dated from 6/1 to 9/1/20 revealed no physician orders for Prevalon boots. Record review of Resident #1's care plan initiated on 7/13/18 and revised on 9/4/20 revealed Resident #1 was not care planned for Prevalon boots. Resident #1's care plan for skin integrity revealed in part: Focus: Resident #1 had potential for impairment to skin integrity related to fragile skin, impaired mobility and incontinence. Further review revealed an unstageable pressure ulcer going to the right and left lateral ankle. Goal: Resident #1 will not have any complications related to any skin injury type and to maintain clean and intact skin. Intervention: Avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short; keep skin clean and dry; use lotion on dry skin .(date initiated 7/13/18). Monitor and document location size and treatment of [REDACTED]. report to medical doctor; cleanse right lateral ankle wound with normal saline, pat dry, apply collagen powder and cover with dressing daily until resolved. Cleanse left outer ankle unstageable pressure injury with normal saline, pat dry, apply calcium alginate dressing; cover with dressing daily until resolved .(date initiated 7/13/18, revised on 9/1/20). Record review of Resident #1's NURSING-Weekly Skin Evaluation -V2 dated 8/31/20 read in part: 3. Are any of these wounds new since last skin assessment? a. Yes Site: 47)Right ankle (outer) Description: unstageable wound to left ankle, measuring 2.0 x 2.0. Site: 48) Left ankle (outer) Description: unstageable wound to left ankle, measuring 2.0 x 2.0. Record review of Resident #1's physician order's dated 8/31/20 revealed orders to Clean outer ankle unstageable pressure injury with normal saline, pat dry, apply calcium alginate dressing, cover with dressing daily every day shift for wound care. Record review of Resident #1's nurses notes dated 8/31/2020 written by the Wound Care Nurse read in part: .during skin assessment nurse noted an unstageble opening to left lateral ankle and right lateral ankle of patient. MD notified, and RP notified Treatment order received and noted. Clean wound with normal saline apply calcium alginate to wound bed daily . Record review of Resident #1's nurses notes dated 9/3/2020 written by the Wound Care Nurse read in part: .wound care doctor was here to see patient regarding pressure injury to left outer ankle, and right outer ankle. Patient has stage 4 pressure injury to his left outer ankle and right outer ankle. New treatment orders received and noted. Clean stage 4 pressure injury to left outer ankle with normal saline, pat dry ,apply calcium alginate then cover with dressing daily. Also clean right lateral ankle pressure injury stag 4 with normal saline, pat dry apply Santyl ointment plus calcium alginate and cover with dressing daily. RP, (name) was notified of the new treatment orders and updated on the wound status . Record review of Resident#1's wound Assessment Details written by the Wound Care Nurse dated 9/3/20 read in part: .Wound location: Left, Lateral Ankle. Wound type: Pressure ulcer. Dated acquired: 8/31/2020. Acquired at facility: Yes. Wound measurement: Length: 1cm, Width: 2cm, Depth: 0.3cm . Record review of Resident#1's wound Assessment Details written by the Wound Care Nurse dated 9/3/20 read in part: .Wound location: Right Ankle. Wound type: Pressure ulcer. Dated acquired: 8/31/2020. Acquired at facility: Yes. Wound measurement: Length: 0.9cm, Width: 1.7cm, Depth: 0.2cm . In an interview on 9/3/20 at 3:10 pm with CNA #3, she said Resident #1 received shower three times a week and bed baths in between. She said Resident wore boots on his legs to prevent pressure ulcer. She said CNAs would remove his boots, place him on a Hoyer lift and take him to the shower room. She said after CNAs were done giving him shower, CNAs would apply lotion and his boots back on. She said she did not receive any training on how to apply and remove those boots. She said CNAs can take off boots for bed baths and showers. Observation on 9/4/20 at 8:30 am revealed Wound Care Nurse performed wound care on Resident # 1 assisted by ADON A. Observation revealed the dressing that was adhered to the resident's right lateral ankle was dated 9/3/20. When the pressure sore wound dressing was removed from the right lateral ankle, observation revealed a stage 4 pressure ulcer to the right lateral ankle area approximately 1 cm in diameter with moderate drainage. Further observation revealed the dressing that was adhered to the resident's left outer ankle was dated 9/3/20. When the pressure sore wound dressing was removed from the left outer ankle area, observation revealed a stage 4 approximately 2 cm in diameter with moderate drainage. Record review of Resident #1's physician's orders dated 9/4/2020 revealed an order to clean right lateral ankle pressure injury with normal saline pat dry apply Santyl ointment plus calcium alginate and cover with dressing daily every day shift for wound care. Record review of Resident #1's physician's orders dated 9/4/2020 revealed an order to clean left outer ankle pressure injury with normal saline, pat dry apply calcium alginate dressing, cover with dressing daily every day shift for wound care. Record review of Resident #1's nurse notes from 6/26 to 9/3/20 revealed no nurse's notes for orders for Prevalon boots; applying and/or removing and assessing sites. Observation and interview on 9/2/20 at 1:50 pm revealed Resident #1 lying on his side on his air mattress bed wearing Prevalon boots on both feet/legs with socks on. Resident #1 had both feet floating on pillows while wearing Prevalon Boots. The label on the boots read, Prevalon. Resident #1 was positioned on his side facing the door. His left foot was floating on one pillow that laid underneath his foot. He had his right foot over his left foot with a pillow in between (off loading on pillows). He was receiving oxygen at 3.0 liters. He said he was doing fine. Observation and interview on 9/2/20 at 3:35 pm revealed Resident #1 lying in his air mattress bed wearing Prevalon boots on both feet/legs with socks on. Resident #1 had both feet floating on pillows while wearing Prevalon Boots. The label on the boots read, Prevalon. Resident #1 was positioned on his side facing the door. His left foot was floating off one pillow that laid underneath his foot. He had his right foot over his left foot with a pillow in between (off floating on pillows). He was receiving oxygen at 3.0 liters. He said he was doing fine. In an interview on 9/3/20 at 8:13 am with CNA #1, she said she worked in hallway 500 today, but she was a restorative aide so she goes wherever needed. She said Resident #1 was totally dependent. He required 2-person for changing, bathing, one person for feeding and personal hygiene. She said she repositioned the resident every two hours. She said she noticed a sore on his left ankle when he was on hallway 100. She said she notified the nurse verbally. She could not recall the date she saw the sore on Resident #1's ankle. When asked about the protocol for reporting, she said she did not know beyond her responsibility to notify the charge nurse. In an interview on 9/3/20 at 8:35 am with CNA #2, she said she had worked at the facility for 6 years. She said she worked on the 500 hallway. She said Resident #1 was total dependent. He required 2-person for changing, transfers and repositioning. He required 1-person bathing, feeding and personal hygiene. She said she repositioned the resident every two hours. She said she had seen the resident with a bandage on his ankles. She said she notified the ADON to ensure that they were aware that the resident had a bandage. They were unaware. She said the wound care had placed the bandage because they found out later that he had sores on his ankles. She said residents got facility acquired pressure sores when they were not repositioned at least every two hours throughout the day. In an interview on 9/3/20 at 9:40 am with RN, she said she worked at the facility for 3 years. She said resident's in hallway 500 get repositioned every two hours. She said the charge nurses were responsible for reminding CNA's of their roles and to reposition residents every two hours. She said the possibility of bed sores could occurred when residents were not repositioned every two hours. She said the charge nurse was responsible for ensuring that the CNA's meet the resident's ADL needs. She said CNA #2 brought to her attention that Resident #1 had sores on his ankles. She said she didn't know how he got them because he was new to her unit. She said the reason a resident might have gotten the bed sores because they were not being repositioned or he was not being properly assessed. She said Resident #1 wore booties and maybe heat and/or moisture may have caused the sores if they were not being properly assessed. In a follow-up interview on 9/3/20 at 1:40 pm with RN, she said Prevalon boots required a Physician's order. She said she did not see the boots when she changed Resident #1's oxygen tubing at 2:00 pm. She said the CNA was in touch with the RP and whatever the RP said the CNA did. This Surveyor asked if CNA's could apply and remove Prevalon boots and she said, No. She said, only the charge nurse and/or wound care nurse could do it. She said she was not monitoring for potential complications because Resident #1 was not supposed to be wearing Prevalon boots. In an interview on 9/3/20 at 11:40 pm with the DON, she said Resident #1's RP had instructed the facility not to get the resident up when he was in Hallway 100. She said on 9/1/20, CNA #2 told the ADON that she had seen a bandage on Resident #1's ankles. She said the ADON brought it to her attention. She said at the same time, it just happened that the Wound Care Nurse was doing his rounds and he noticed the pressure sores on Resident #1's ankles and assessed them same day. She said she began questioning the nursing staff to find out how Resident #1 acquired pressures sores on his ankles at the facility. She said the facility had not self-reported because she was getting statements from the nursing staff in Unit 100. She said there was several reasons for how residents could get pressure sores in the facility. She said it could have been from not repositioning residents; not conducting weekly skin assessments; and CNA's not conducting daily checks and reporting a change in condition, so that it could be addressed immediately. In an interview on 9/3/20 at 10:30 am with Wound Care Nurse, he said he had been at the facility since November of last year as the wound care nurse. He said his responsibility was treatment Monday through Friday. Does skin assessment. Does initial skin assessment on resident to see if they have any wounds on top of the wounds that are noted on admission. Updates the wound care doctor that comes every week and makes rounds with residents with PU's. They note changes. He does weekly pressure and non-pressure ulcers. The doctor measures the notes. He said prior to Resident #1 getting here (admitting to the facility), the resident had a wound on his sacrum and on his hip area in stage 2 or 3 that was healed. He said returned from the hospital on [DATE] with a PU stage 3 to the sacrum. He said today the PU on sacrum was healed. He said on Monday, 9/1/20 he conducted a skin assessment on the resident and notice pressure sore on both ankles. He said he could not stage it. Notified MD, DON and RP. He said the wound care doctor was here this morning and the doctor assessed the wounds at stage 4 and new treatment orders were in place. He said they had pillows to elevate his feet but, the RP wanted him to wear booties. He said the doctor said this morning to remove the Prevalon boots and have his feet floating. He said he tells nursing staff to reposition resident's that have sacrum sores as needed and for those that have pressure sores on their legs to floating the legs and put them on pillows. In an interview on 9/3/20 at 12:25 pm with the Facility Doctor, Regional Nurse, and DON. The facility doctor said Resident #1 got pressure sore wounds on both ankles because, while staff was repositioning him on his sides, it disposed the resident to pressure sores on his ankles. He said the facility noticed the wounds on Monday, 9/1/20. He said when residents have darker skin tones/pigmentation, the redness can be missed. He said a pressure ulcer can go from zero to eschar in a couple of days. He said whatever was seen on the skin could be more significant than what was under the skin. He said that was why the pressure sore was staged as unstageable. He said the Wound Care Doctor had to open the wound to stage it. He said today it was at a stage 4. He said the prognosis was good as there was indication of healing on both ankles. He said the left ankle was moving faster than the left ankle. The Regional Nurse said the staff had been making efforts to reposition Resident #1 due to his recent sacrum healing, so the alternative was to reposition the resident on his sides and offload his feet with pillows. She said sometimes ankles could rest on pillows when off loaded. The facility doctor said it was likely what happened. The regional nurse said Resident #1 did not have booties on his feet. She said Resident #1 did not have orders for booties. She said she would not have used Prevalon boots on Resident #1 anyway because he was already on an air mattress and the boots would have caused pressure. The Regional Nurse, DON and the doctor all said that booties were different from Prevalon boots. The Regional Manager and the DON said Resident #1 did not have physician orders for Prevalon boots. The DON said Resident #1 was being repositioned because if he was not being turned the RP had a camera in the room and she would have called already like she had already called three times this morning. In an interview on 9/3/20 at 2:05 pm with Wound Care Doctor, he said wounds were stage 4 and it's the first time he saw them and identified them on Monday, 9/1/20. He said he went to the facility every Thursdays. He said he knew Resident #1 had several wounds in the past. He said he had taken care of Resident #1 for years. He said he tended to get wounds on his tail bone. He said he would eventually resolved all of them. He said recently while at the hospital the pressure sore on his sacrum once healed, reopened, but, eventually sacrum healed. He said in the process of the facility having him side to side he developed the wounds on his ankles. He said when he treated the wounds, Resident #1 had Prevalon boots on. He said he told RP that the boots were not ideal because they were still causing pressure to ankles, but she could be very insistent. He said the RP could be very demanding and persistent. He said, If she wants those boots on she will tell staff to put them on, so I get that the CNA's put them on which makes the wounds worse. He said he told the RP the resident needed to float the legs up with a pillow. He said, Ideally if we could elevate him up in the air like a magician, but we can't do that. He said, the problem was that he had a wound on his tailbone but, turning him side to side was a no-win situation. He said the Prevalon boots could have contributed to the pressure sores because although the boots are soft, it's still creating pressure. In an interview on 9/3/20 at 2:45 pm RN, she said she worked 4-days on and 1 day off. She said when she changed Resident #1's oxygen tubing, the resident did not have boots on his feet. She said she checked his feet to make sure the dressings on his wounds were in-tact. She said she had never seen Prevalon boots on the resident's feet. She said the resident had only been in her unit (hallway 500) for about 4 days. She said CNA's were not supposed to put on or take off boots because there were wounds and it was a treatment that required assessing. She said Resident #1 did not have an order for [REDACTED]. Record review of Lippincott Nursing Procedures Seventh Edition (not dated) presented by the DON on 9/4/20 at 1:11 pm read in part: .Pressure Ulcer Care: pressure ulcers results when pressure-applied with great force for a short period or with less force over a long period- impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, resulting ischemic [MEDICAL CONDITION] can lead to serious infection. Most pressure ulcers develop over bony prominences, where friction and shearing force combine with pressure to break down skin and underlying tissues. Prevention is the key to avoiding extensive therapy. Preventive measures include off-loading pressure, maintaining adequate nourishment, and ensuring mobility to relieve pressure and promote circulation. Implementation: Turn and reposition the patient every 1 to 2 hours or more frequently, as required, unless contraindicated. Eliminate .

Based on observation, interview and record review, the facility failed to ensure that Residents received treatment and care in accordance with professional standards of practice, for 2 of 21 Residents (Resident #6 and Resident #94) reviewed for quality of care in that: - Resident #6 had an indwelling catheter that was improperly secured with a strap resulting in the resident sustaining a 3 cm split to his penis. -Resident #94's blood sugar reading was not assessed according to physician's order and her insulin was not administered according to physician orders. The failures affected two residents placing them at risk for trauma, pain, injury and a decline in their quality of care. Findings include: Resident #6: Record review of the Admission Record for Resident #6 revealed he was [AGE] years of age, and was originally admitted to the facility on [DATE]. He was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Care Plan for Resident #6, dated 06/18/19, revealed the catheter site was to be checked for infection and bleeding every shift. The Care Plan reflected the staff was to monitor and document for pain and/or discomfort every shift. Record review of a Nurse's note dated 08/17/19 at 2:12 p.m. revealed a new indwelling catheter was provided to the resident. Record review of the most recent MDS assessment, dated 09/09/19, revealed a BIMS score of '4', indicative of severely impaired cognitive skills for daily decision making. The MDS reflected Resident #6 required extensive assistance for bed mobility and toilet use. The MDS reflected he had an indwelling catheter. Record review of the (MONTH) 2019 MAR and TAR for Resident #6 revealed the catheter was to be checked every shift for placement, and a leg strap may be used to secure the catheter. Observation on 09/27/19 at 1:33 p.m. revealed CNA DD and CNA II provided catheter care for Resident #6. When the covers were lowered and the brief loosened, there was a leg strap around the resident's right leg. The catheter appeared to be streched and pulled tight. CNA DD lifted the resident's penis. The resident's penis appeared to have been split by the catheter, from the meatus to approximately 3 cm down the shaft of the penis. There was no visible bleeding, but the split appeared to have occurred recently, as it was raw. CNA DD continued cleaning the resident as he verbalized pain. Interview at that time of the observation, CNA II said she had worked with Resident #6 for 1.5 months, and she thought the split had been there. She said the nurses were responsible for the leg straps. Interview on 09/27/19 at 1:47 p.m. with RN F, the floor Charge Nurse, she said she looked at the catheter that morning and she observed a tear. She said that was the first time she noticed it. She said she did not work the previous day, but said there was no tear two days prior. She said she had not called the physician yet to inform him of the tear in Resident #6's penis. Interview and observation in Resident #6's room on 09/27/19 at 1:50 p.m. the DON was asked to observe the catheter for the resident. She said the catheter was pulled too tight. She acknowledged the penis was split. She verbalized it appeared to be split for 1 inch (2.5 cm). Interview on 09/27/19 at 2:24 p.m. RN F said the Charge Nurse was responsible for monitoring the leg strap. She said there was no strap this morning, so she applied one. She said there should be slack to allow movement. She said the tear was more or less 2 inches. She said she saw it two days ago, and it was torn. She said she did not call the doctor because it was not bleeding. She said she noticed that when males had catheters they always had some tearing of the urethra. She said she had informed the physician after talking with the surveyor at 1:47 p.m. Interview on 09/27/19 at 2:30 p.m. the DON said the nurses were responsible for the leg straps for residents with catheters. Interview on 09/27/19 at 2:40 p.m. RN K said she worked two days prior. She said The meatus was split, but not much. Interview on 09/27/19 at 2:50 p.m. Resident #6 said he was not in pain at that moment, but did experience pain when the care was being provided. Record review of a Nurses' note dated 09/27/19 at 3:58 p.m. revealed RN F reported a 3 cm slit on Resident #6's penis to the physician. The physician ordered a Urology consult. Resident #94: Record Review of Resident #94's face sheet revealed he was a [AGE] year-old-female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #94's quarterly MDS assessment, dated 8/26/19 reflected Resident #94 had a BIMS score of 13, which indicated no cognitive impairment. Further review of the quarterly MDS indicated Resident #94 received insulin injections 7 days during the last 7 days. Record review of the comprehensive care plan for Resident #94 revealed, in part Problem (date initiated 12/05/18): .Resident #94 has Diabetes Mellitus . Interventions: .Diabetes medication as ordered by doctor . Record review of Resident #94's physician orders revealed an order dated 11/06/18, to inject [MEDICATION NAME] Solution 100 UNIT/ML (Insulin [MEDICATION NAME]) per sliding scale: if 0 - 149 = 0 If BS <70, notify MD ; 150 - 200 = 2 UNITS; 201 - 300 = 6, UNITS; 301 - 350 = 8 UNITS BS>351, GIVE 10, UNITS AND CALL MD, subcutaneously before meals. Resident #94 also had an order for [REDACTED]. Further review of the physician 's order reflected an order dated 11/6/18 to check blood sugar before meals and at bedtime. Observation during initial tour on 09/24/19 at 8:19 a.m. revealed RN F preparing to complete Resident #94's blood sugar assessment. Observation and interview on 9/24/19 at 8:31 a.m. RN F said Resident #94's blood sugar was 320 mg/DL and the resident had eaten breakfast already that morning. She said she was preparing [MEDICATION NAME]- 8 units and [MEDICATION NAME] 20 units to be administered for Resident #94. RN F said [MEDICATION NAME] is ordered to be given at 7 a.m. and [MEDICATION NAME] is ordered to be given at 7:30 a.m. She said the resident does not wake up until 7:30 a.m. and it caused a delay in blood sugar assessment and insulin administration. During interview with CNA V on 9/27/19 at 8:24 a.m. she said Resident #94 usually woke up early. She described the resident as an early morning bird. She said she got up often before 6 a.m. She said she usually gathered her clothes and dressed herself. During a later interview on 9/27/19 at 8:29 a.m. RN F said today she assessed if Resident #94 wanted to wake up earlier and she administered the insulin per the physician's order. She said she usually gave the medication before Resident #94's meals. She said she did not assess the resident on 9/24/19 because the resident got frustrated in the mornings. She said she had not communicated that Resident #94 woke up late on 09/24/19 and the medication was administerd late to the Physician. During interview with the DON on 9/27/19 at 9:25 a.m. she said Resident #94's blood sugars should be assessed before meals. She said no staff had communicated Resident #94 wanting to get up late. Record review of the facility policy (Lippincott Nursing Procedures 7th Edition), page 397, revealed in part: .Secure the catheter using a catheter securement device .to prevent pressure on the urethra at the penoscrotal junction, which can lead to formation of urethrocutaneous fistulas . Record review of the facility's policy, Medication and Treatment orders (revised (MONTH) (YEAR)) read in part: .medications shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one resident (Resident #1) of two resident reviewed for accidents in that -Resident #1 was not properly secured in the facility van during transport. -Resident #1 experienced a fall during hard braking while riding in the facility van resulting in an abrasion to the forehead, a sore shoulder (unspecified side), pain in both hands, and pain in both knees. The failure affected one resident placing her at risk of injuries. Findings included: Record review of the Admission Record for Resident #1, dated 06/20/19, revealed the resident was [AGE] year old male, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE], revealed Resident #1 had a BIMS score of 15, indicative of intact cognition. The MDS reflected Resident #1 exhibited no adverse behaviors during the seven day look-back period. The MDS reflected Resident #1 was not able to walk, but was independent with transfers and locomotion. Record review of the Care Plan for Resident #1 dated 11/13/2018 revealed he had ADL selk care performance deficit due to bilateral [MEDICAL CONDITION]. Record review of the Nursing Change of Condition Communication Form dated 06/08/19 revealed Resident #1 had a fall with an abrasion on the right forehead, a sore shoulder (unspecified side), pain in both hands, and pain in both knees. The form reflected the resident was taken to the hospital. Record review of the progress note dated 06/08/19 at 8:45 a.m. revealed Resident #1 stated on the previous day (06/07/19) he fell in the wheelchair and hit his head on the floor of the van when the driver braked. The resident had an abrasion of 2 cm on the right side of his forehead. He complained of shoulder and bilateral knee pain. The resident was sent to the hospital. Record review of the progress note dated 06/08/19 at 8:41 p.m. revealed the resident returned from the hospital. No major injury was noted. Observation on 06/20/19 at 9:28 a.m. revealed Resident #1 was propelling himself in his wheelchair in his room. Observation and interview on 06/20/19 at 10:30 a.m. revealed Resident #1 was in his wheelchair in his room. He said he was in the van with Driver A, after Driver A dropped off another resident at the facility. He said the facility van had an area in the back for a wheelchair. He said he was not secured correctly in the van. He said that when Driver A stopped suddenly, he 'flew out' of his wheelchair to the floor. He said he hit his head. He said Driver A stopped the van and helped him back into his wheelchair. He said she still did not secure him correctly. He said the next day he was hurting and went to the hospital. Interview on 06/20/19 at 1:30 p.m. Driver A said she had taken Resident #1 to the store, and on the return trip a vehicle next to them went straight in a right-turn only lane, causing her to brake hard. She said the center row seat of the van was in the 'down' position. Driver A said she looked back and Resident #1 was leaning forward but not out of the wheelchair. She said she asked Resident #1 if he was alright and Resident #1 replied that he was. She said the ADON checked on the resident and the resident again said he was ok. She denied that the resident fell . Interview with the ADON was not possible during the investigation, as she was on leave. Observation and interview on 6/20/19 at 1:35 p.m. of the facility van revealed there was a ramp at the rear of the van and a place designed for one wheelchair to be secured, facing forward. The second row of seats was able to be tilted forward. There were security straps attached to the floor located on each corner of the wheelchair area. Observation at that time revealed Driver A demonstrate how she said Resident #1 had been secured in the van. Another resident was going to an appointment and verbally granted consent for the surveyor to observe. Continued observation revealed Driver A propel the wheelchair up the ramp and place it in the designated area. Driver A removed the footrests of the wheelchair and positioned it at the forward end of the wheelchair area. She locked the brakes of the wheelchair. Driver A placed the hooks of the front straps around the frame of the wheelchair, one above each wheel. Driver A placed the hooks of the rear straps around the frame of the wheelchair, one above each wheel. Continued observation revealed Driver A place a lap strap around the resident's lap. The strap was attached to the floor of the van on each side of the resident, rear of the wheelchair. Observation revealed a second strap that was attached to the inside of the van, near the top of the rear doorway, right of the rear door. Driver A showed the surveyor the end of the strap, which had a chromed metal latch piece with a hole. Approximately one half inch in diameter. She said the strap was the shoulder strap for the wheelchair resident harness. She said she did not know how to attach that strap until after the incident with Resident #1, when the Maintenance Director told her how to attach it to the lap strap. She acknowledged the shoulder strap had not been on Resident #1 at the time of the incident. Interview on 06/20/19 at 3:35 p.m. the Maintenance Director said he conducted training for new drivers each monthon the transportation van. He said another person provided training twice each year. He said he came to the facility on the Saturday following the incident with Resident #1 and provided an in-service for Driver A. He said he demonstrated the proper way to secure a resident in a wheelchair, then had Driver A return-demonstrate. He said during the return-demonstration, Driver A did not sufficiently tighten the straps, and that the wheelchair was not placed forward enough. He said he demonstrated the proper procedure. The Maintenance Director said he did not have a manual for the wheelchair section of the van. Record review of the vendor in-service training dated 03/31/19 revealed Driver A was provided training by the manufacturer representative. Record review of the facility transport policy revealed all passengers must wear seat belts and must be secured according to the manufacturer's recommendations.

Based on observation, interview and record review, the facility failed to consult with the physician when a resident experienced a change of condition and there was a need to alter treatment significantly was required for 1 of 6 residents (CR #2) reviewed for notification of changes. -The facility did not consult with CR #2's physician when a change in condition related to the presence of diffuse, black mold-like substance within the [DEVICE] was noted by several staff. CR #2 was admitted to the hospital intensive care unit on 12/17/18 with septic shock, [MEDICAL CONDITION] (low sodium levels), [MEDICAL CONDITION] (high levels of potassium), concern for fungemia (presence of yeast or fungi in the blood) secondary to mold growing in her PEG tube, UTI, and [DIAGNOSES REDACTED]. CR#2 passed away on 12/19/18. These failures resulted in an IJ on 12/19/18. The IJ was lowered on 12/21/18 but the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one CR and placed her at risk of infections, health complication, hospitalization and death. Findings include: CR #2: Record review of CR # 2's face sheet revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's quarterly MDS assessment, dated 11/30/18, revealed CR #2 had a BIMS of 5/15, indicating severely impaired decisions and cognitive skills. The MDS also identified CR #2 as having a feeding tube. CR#2 was totally dependent on (1) or more staff for bathing, dressing, eating, and personal hygiene. CR#2 required extensive assistance from (1) or more staff for bed mobility. Record review of the care plan for CR #2 revealed, in part: Problem (no date): CR #2 requires tube feeding [MEDICATION NAME] 1.2 bolus .Goal: the resident will remain free of side effects or complications related to tube feeding . Interventions: .monitor/document/report PRN any s/sx of: tube dysfunction or malfunction . Record review of CR#2's enteral feed orders revealed an order written [REDACTED]. CR#2 was also ordered on [DATE] to have the feeding tube flushed with 30cc's of water before and after medication administration. Record review of CR #2's physician orders revealed an order written [REDACTED]. Further review of the physician orders revealed an order for [REDACTED]. Record review of the nurse's notes from 12/15/18 to 12/17/18 revealed no documentation to support that the black substance in the [DEVICE] had been communicated to the physician. Record review of nurse's note for CR #2 dated 12/17/18 at 5:58 am revealed in part: .check g tube placement, check for residual and none noted .flushed with 30 cc before and after administering bolus feed .after 2 minutes resident projected a mass amount of vomit .looks like feeding .12:15 am blood pressure 155/69 with oxygen at 88% room air .administered 3 liters of oxygen .at 2:00 am blood sugar was 48 and 1 ml of [MEDICATION NAME] was administered .resident looked lethargic and was moaning .2:20 am nurse practitioner was called to inform of resident status .ordered to send to hospital . Record review of the Hospital History & Physical dated 12/17/18 revealed .the tube has black mold within the tube. Further review of the history and physical revealed her admitting [DIAGNOSES REDACTED]. Record review of the infectious disease doctor's consultation dated 12/17/18 revealed CR # 2 was admitted with septic shock and was being treated with [MEDICATION NAME] and micafungin. Review of additional hospital consultation reports dated 12/17/18, revealed .they also noticed that there was black material coming out from CR #2's pe[DEVICE] .this was noted to be mold upon examination .mold growing in PEG tube .concerns for fungemia .micafungin added and infectious disease consulted . Observation of the CR #2 in the hospital on [DATE], at 9:10 a.m. revealed her [DEVICE] had a diffuse, black substance within the tubing. The black substance was diffusely spread throughout the entire [DEVICE] had a mold-like appearance. Interview with the family on 12/18/18, at 9:10 a.m. revealed he had concerns with quality of care. He said he did not feel the nursing staff was knowledgeable in proving [DEVICE] feedings. He said he spoke with a nurse (no name provided) after the [DEVICE] was inserted because the calculation for the amount of water being provided was incorrect. He said they corrected the amount after he spoke with them. He said he would visit CR #2 and she would not be groomed. He said overall the facility was not providing consistent quality of care. He said he took pictures of CR #2's g tube when she was admitted to the hospital because there was what it seemed like mold in the tube. Record review of the pictures taken by a family member when the resident was in the hospital on [DATE] and 12/18/18 revealed CR #2's tube, insertion site part, mushroom catheter tip, and other parts of the PEG tube were covered in dark spots and black matter that had a mold-like appearance. Record review of hospital progress note dated 12/18/18 revealed in part: .PEG tube was replaced today appears to be severely contaminated by possible mold, based on appearance .antifungals have been started empirically .i have discussed the care with the patient's primary care physician in the nursing home . During interview with the attending physician on 12/18/18 at 12:20 p.m. she said CR #2 was transferred to the hospital secondary to low pulse and low O2 saturation. She said her nurse practitioner last assessed CR #2 on 12/3/18 and no complications with the [DEVICE] site were communicated. The attending physician stated that the staff did not report any issues with CR #2's feeding tube to her. During interview with CNA D on 12/18/18, at 3:52 p.m. she said she worked with CR #2 last weekend. She said, last week she was assisting a nurse administered the scheduled bolus feeding for CR #2 and noticed CR #2's peg tube tubing appeared dirty. She said she discussed the need for CR #2's tubing to be changed, but the nurse informed her the facility would have to transfer the Resident to the hospital for her peg tube to be changed. She said she could not recall the exact day this discussion occurred. During interview with Charge Nurse LVN A on 12/18/18, at 4:04 p.m. she said she had worked with CR #2 frequently. She said she noticed CR #2's [DEVICE] to be dark. She said it looked normal because it flushed good and was not clogged. She said since she started working with CR #2 approximately three weeks ago it has looked like that. She said she did not discuss the dark [DEVICE] with nursing staff or report the changes noted to the physician because it was not clogged. During interview with the DON on 12/19/18, at 10:21 a.m. she said CR #2 was transferred to the hospital for decreased heart rate, blood sugar control, and vomiting. She said no problems were assessed with [REDACTED]. She said CR #2's family called the facility and reported alleged neglect of the [DEVICE] site after CR #2 was admitted to the hospital. She said since the allegation, she started nursing education on generalized care of [DEVICE]s. She said the attending physician and nurse practitioner were not informed of the discoloration. Pictures of CR #2's g tube were showned to the DON. She said the black substance looked like discoloration from medication administration. She said after CR #2 was admitted to the hospital a nurse communicated to her [DEVICE] abnormalities. In another interview on 12/19/18 at 1:21 p.m. she said the resident was taking iron ([MEDICATION NAME] sulfate) and cranberry tablet that could cause discoloration in the [DEVICE]. In a phone interview with CR #2's family member on 12/19/18 at 10:30 am he said that CR #2 passed away at the hospital that morning. In an interview with LVN R on 12/19/18, at 11:02 a.m. he said he had worked with CR #2 and on 12/16/18 he assessed her [DEVICE] and noted the tubing was discolored. He said he did not communicate the assessment finding to the physician. He said he could not recall if the [DEVICE] had been discolored prior to 12/16/18. During a phone interview with the nurse practitioner on 12/19/18, at 11:12 a.m. she said she last assessed CR #2 on 12/3/18. She said she did not assess the pe[DEVICE] because nobody indicated issues with the pe[DEVICE]. She said nurses were supposed to complete skin assessments and check the peg tube and insertion site for any abnormalities and report those to her or the MD. In an interview with ADON A on 12/19/18, at 2:05 p.m. she said CR #2's [DEVICE] was inserted in (MONTH) (YEAR). She said she had seen [DEVICE]s that present with a mold like substance within the tubing. She said that on those cases normally the tube would be changed out. She said no staff communicated abnormalities noted in CR #2's [DEVICE] to her. In an interview with the Administrator on 12/19/18, at 1:34 p.m. she said no direct care staff or nurses communicated a mold like substance in CR #2's [DEVICE] site. She said she was not clear why CR #2 was transferred to the hospital. In a phone interview on 12/19/18 at 3:40 pm with a hospital nurse, she said that CR #2 passed away that morning. She said that the family had requested an autopsy due to the mold in the feeding tube. Record review of report sent by the hospital on [DATE] revealed in part: .hospital doctor suspect the mold was the cause of CR #2's death .mold in tube appeared to be at least two months old . In an interview with the Nurse Practitioner on 12/20/18, at 10:34 a.m. she said CR #2 had nothing alarming upon last assessment on 12/3/18. She said she last assessed the Peg Tub site on 3/5/18. She said the reason for not assessing the pe[DEVICE] more frequently was because no changes were communicated to her and the Resident was independently mobile in her wheelchair. During interview with ADON B on 12/20/18, at 11:26 a.m. she said if she saw the [DEVICE] with black mold-like substance, then she would have communicated the assessment to the physician. In an interview with the Medical Director on 12/21/18 at 11:15 AM, he said he assessed all residents with [DEVICE]s. He said he ordered 2 [DEVICE]s to be changed due to the tubing being opaque and the inability of nursing staff to be able to see if there is any discoloration of the tubing. He said nursing staff need to have a heightened awareness in regard to changes in condition and communicate those concerns to the physician. Record review of the facility policy, Change in Resident's condition (dated (MONTH) (YEAR)) reads in part, .our facility shall promptly notify the resident, the attending physician, and representative of changes in the Resident's status .prior to notifying the physician or healthcare provider, the nurse will make observations and gather pertinent information for the physician . The Administrator and DON were notified on 12/19/18, at 3:36 p.m. of the IJ situation due to the above failures and a POR was requested. The POR was received and after two revisions, it was accepted on 12/20/18 at 2:56 p.m. POR included in part: .Effective 12/19/18, the Registered Nurse will reassess resident's gastrostomy tubes and gastrostomy tube sites for the presence of abnormality. This will be completed by 12/19/18. Effective 12/19/18, the licensed nurse will review resident's gastrotomy tube orders for completeness. This will be completed by 12/19/18. Effective 12/19/18, the Director of Nursing and/ or designee will reeducate licensed nurses on evaluating and identifying gastrostomy tube abnormalities. Reeducation will include site care and Q-shift observation, as well as action to take in the event abnormality is noted. This will be completed by 12/20/18 and will continue for new hire/ re-hire fulltime or PRN licensed nurses. Effective 12/19/18, the Director of Nursing and/ or designee will reeducate licensed nurses on medication administration via the gastrostomy tube, bolus feeding and gastrostomy tube flushing. Reeducation will include physician orders for flushing before and after medication administration. Reeducation will be validated by the Registered Nurse with return demonstration. This will be completed by 12/20/18 and will continue for new hire/ re-hire fulltime or PRN licensed nurses. Effective 12/19/18, the Director of Nursing and/ or designee reeducated licensed nurses on identifying and evaluating residents with a change in condition. Reeducation included evaluation/assessment tools, MD/NP notification process and communication related to residents with a change in condition. This will be completed by 12/20/18 and will continue for new hire/ re-hire fulltime or PRN licensed nurses. Effective 12/19/18, the Director of Nursing and/ or designee reeducated facility staff on reporting/ communicating observations related to resident changes in condition. Reeducation included methods of communication related to a resident's change in condition. This will be completed by 12/20/18 and will continue for new hire/ re-hire fulltime or PRN staff. Effective 12/21/18, Director of Nursing and/ or designee will monitor gastrostomy tubes and gastrostomy tube sites for abnormality by observing residents with gastrostomy tubes weekly for four weeks; then monthly for two months . The facility was monitored between 12/20/18 and 12/21/18 with the following results: Record review of the forms revealed that in-services were conducted on all three shifts with the nursing staff attending. As of 12/21/18 most staff had been in-serviced. During the monitoring phase, interviews were conducted by the surveyors on different shifts with 4 licensed nurses, 2 nurse managers, 10 CNA's and 2 MA's. All interviewed staff verbalized up to date knowledge on monitoring [DEVICE]s and assessing for changes tubing, notifying the physician of changes in condition, abuse and neglect, and resident rights. Observations were conducted during the monitoring phase of the 6 remaining Residents identified with gastrostomy status and no concerns were noted on the appearance of the G tubes. The Medical Director assessed all 6 residents with [DEVICE]s, and ordered 2 tubes to be changed due to the tubing being opaque and the inability of nursing staff to be able to see if there is any discoloration of the tubing. During interview with the Administrator on 12/20/18 at 3:09 p.m. she said she thought the Immediate Jeopardy came about because of miscommunication. The Administrator said she was not aware of a situation until a family called and alleged neglect. The Administrator said she felt the former Medical Director did not provide the appropriate education and oversite. She said she feels the new Medical Director will be better. She said the former Medical Director was provided a termination letter on (MONTH) 30, (YEAR) and the new Medical Director started on 12/15/18. In an interview with the Administrator and the DON on 12/20/18, at 3:19 p.m. she said the facility staff had been instructed to call the DON when a change in condition was identified. The DON said the facility had instituted a process termed watchlist, where residents identified with a higher risk of changes in condition were listed and the list was provided to the weekend nursing supervisor for the staff to monitor for specific concerns related to resident's care needs. The DON said she could not recall an in-service conducted specifically related to bolus tube feedings. The Administrator and the DON were informed on 12/21/18 at 11:43 a.m. that the IJ was lowered; however, the facility remained out of compliance at an isolated level and a severity of actual harm due to the facility needing more time to train staff.

Based on observation, interview and record review, the facility failed to ensure that residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 2 of 6 residents (CR #2 and Resident #5) reviewed for feeding tubes, in that: -The facility staff failed to monitor CR #2's [DEVICE] for changes in appearance and condition. -The facility did not consult with CR #2's physician when a change in condition related to the presence of diffuse, black mold-like substance within the [DEVICE] was noted by several staff. -The facility licensed staff providing [DEVICE] failed to assess, identify, and document condition related to the presence of diffuse, black mold-like substance within CR #2's g tube. CR #2 was admitted to the hospital intensive care unit on 12/17/18 with septic shock, [MEDICAL CONDITION] (low sodium levels), [MEDICAL CONDITION] (high levels of potassium), concern for fungemia (presence of yeast or fungi in the blood) secondary to mold growing in her PEG tube, UTI, and [DIAGNOSES REDACTED]. CR#2 passed away on 12/19/18. - RN H did not flush Resident #5's [DEVICE] according to the physician's order These failures resulted in an IJ on 12/19/18. The IJ was lowered on 12/21/18 but the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. Findings include: CR #2: Record review of CR # 2's face sheet revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's quarterly MDS assessment, dated 11/30/18, revealed CR #2 had a BIMS of 5/15, indicating severely impaired decisions and cognitive skills. The MDS also identified CR #2 as having a feeding tube. CR#2 was totally dependent on (1) or more staff for bathing, dressing, eating, and personal hygiene. CR#2 required extensive assistance from (1) or more staff for bed mobility. Record review of the care plan for CR #2 revealed, in part: Problem (no date): CR #2 requires tube feeding [MEDICATION NAME] 1.2 bolus .Goal: the resident will remain free of side effects or complications related to tube feeding . Interventions: .monitor/document/report PRN any s/sx of: tube dysfunction or malfunction . Record review of CR#2's enteral feed orders revealed an order written [REDACTED]. CR#2 was also ordered on [DATE] to have the feeding tube flushed with 30cc's of water before and after medication administration. Record review of CR #2's physician orders revealed an order written [REDACTED]. Further review of the physician orders revealed an order for [REDACTED]. Record review of the nurse's notes from 12/15/18 to 12/17/18 revealed no documentation to support that the black substance in the [DEVICE] had been communicated to the physician. Record review of nurse's note for CR #2 dated 12/17/18 at 5:58 am revealed in part: .check g tube placement, check for residual and none noted .flushed with 30 cc before and after administering bolus feed .after 2 minutes resident projected a mass amount of vomit .looks like feeding .12:15 am blood pressure 155/69 with oxygen at 88% room air .administered 3 liters of oxygen .at 2:00 am blood sugar was 48 and 1 ml of [MEDICATION NAME] was administered .resident looked lethargic and was moaning .2:20 am nurse practitioner was called to inform of resident status .ordered to send to hospital . Record review of the Hospital History & Physical dated 12/17/18 revealed .the tube has black mold within the tube. Further review of the history and physical revealed her admitting [DIAGNOSES REDACTED]. Record review of the infectious disease doctor's consultation dated 12/17/18 revealed CR # 2 was admitted with septic shock and was being treated with [MEDICATION NAME] and micafungin. Record review of additional hospital consultation reports dated 12/17/18, revealed .they also noticed that there was black material coming out from CR #2's pe[DEVICE] .this was noted to be mold upon examination .mold growing in PEG tube .concerns for fungemia .micafungin added and infectious disease consulted . Observation of the CR #2 in the hospital on [DATE], at 9:10 a.m. revealed her [DEVICE] had a diffuse, black substance within the tubing. The black substance was diffusely spread throughout the entire [DEVICE] had a mold-like appearance. Interview with the family on 12/18/18, at 9:10 a.m. revealed he had concerns with quality of care. He said he did not feel the nursing staff was knowledgeable in proving [DEVICE] feedings. He said he spoke with a nurse (no name provided) after the [DEVICE] was inserted because the calculation for the amount of water being provided was incorrect. He said they corrected the amount after he spoke with them. He said he would visit CR #2 and she would not be groomed. He said overall the facility was not providing consistent quality of care. He said he took pictures of CR #2's g tube when she was admitted to the hospital because there was what it seemed like mold in the tube. Record review of the pictures taken by a family member when the resident was in the hospital on [DATE] and 12/18/18 revealed CR #2's tube, insertion site part, mushroom catheter tip, and other parts of the PEG tube were covered in dark spots and black matter that had a mold-like appearance. Record review of hospital progress note dated 12/18/18 revealed in part: .PEG tube was replaced today appears to be severely contaminated by possible mold, based on appearance .antifungals have been started empirically .i have discussed the care with the patient's primary care physician in the nursing home . During interview with the attending physician on 12/18/18 at 12:20 p.m. she said CR #2 was transferred to the hospital secondary to low pulse and low O2 saturation. She said her nurse practitioner last assessed CR #2 on 12/3/18 and no complications with the [DEVICE] site were communicated. The attending physician stated that the staff did not report any issues with CR #2's feeding tube to her. During interview with CNA D on 12/18/18, at 3:52 p.m. she said she worked with CR #2 last weekend. She said, last week she was assisting a nurse administered the scheduled bolus feeding for CR #2 and noticed CR #2's peg tube appeared dirty. She said she discussed the need for CR #2's tubing to be changed, but the nurse informed her the facility would have to transfer the Resident to the hospital for her peg tube to be changed. She said she could not recall the exact day this discussion occurred. During interview with Charge Nurse LVN A on 12/18/18, at 4:04 p.m. she said she had worked with CR #2 frequently. She said she noticed CR #2's [DEVICE] to be dark. She said since she started working with CR #2 approximately three weeks ago it has looked like that. She said she did not discuss the dark [DEVICE] with nursing staff or reported the changes noted to the physician because it was not clogged. During interview with the DON on 12/19/18, at 10:21 a.m. she said CR #2 was transferred to the hospital for decreased heart rate, blood sugar control, and vomiting. She said no problems were assessed with [REDACTED]. She said CR #2's family called the facility and reported alleged neglect of the [DEVICE] site after CR #2 was admitted to the hospital. She said since the allegation, she started nursing education on generalized care of [DEVICE]s. She said the attending physician and nurse practitioner where not informed of the discoloration. Pictures of CR #2's G tube were showed to the DON. She said the black substance looked like discoloration from medication administration. She said after CR #2 was admitted to the hospital a nurse communicated to her [DEVICE] abnormalities. In another interview on 12/119/18 at 1:21 p.m. she said the resident was taking iron ([MEDICATION NAME] sulfate) and cranberry tablet that could cause discoloration in the [DEVICE]. In a phone interview with CR #2's family member on 12/19/18 at 10:30 am he said that CR #2 passed away at the hospital that morning. In an interview with LVN R on 12/19/18, at 11:02 a.m. he said he had worked with CR #2 and on 12/16/18 he assessed her [DEVICE] and noted the tubing was discolored. He said he did not communicate the assessment finding to the physician. He said he could not recall if the [DEVICE] had been discolored prior to 12/16/18. During a phone interview with the Nurse Practitioner on 12/19/18, at 11:02 a.m. she said she last assessed CR #2 on 12/3/18. She said she did not assess the pe[DEVICE] because nobody indicated issues with the pe[DEVICE]. She said nurses were supposed to complete skin assessments and check the peg tube and insertion site for any abnormalities and report those to her or the MD. In an interview with ADON A on 12/19/18, at 2:05 p.m. she said CR #2's [DEVICE] was inserted in (MONTH) (YEAR). She said she had seen [DEVICE]s that present with a mold like substance within the tubing. She said that on those cases normally the tube would be changed out. She said no staff communicated abnormalities noted in CR #2's [DEVICE] to her. In an interview with the Administrator on 12/19/18, at 1:34 p.m. she said no direct care staff or nurses communicated a mold like substance in CR #2's [DEVICE] site. She said she was not clear why CR #2 was transferred to the hospital. In a phone interview on 12/19/18 at 3:40 pm with a hospital nurse, she said that CR #2 passed away that morning. She said that the family had requested an autopsy due to the mold in the feeding tube. Record review of report send by the hospital on [DATE] revealed in part: .hospital doctor suspect the mold was the cause of CR #2's death .mold in tube appeared to be at least two months old . In an interview with the Nurse Practitioner on 12/20/18, at 10:34 a.m. she said CR #2 had nothing alarming upon last assessment on 12/3/18. She said she last assessed the Peg Tub site on 3/5/18. She said the reason for not assessing the pe[DEVICE] more frequently was because no changes were communicated to her and the Resident was independently mobile in her wheelchair. During interview with ADON B on 12/20/18, at 11:26 a.m. she said if she saw the [DEVICE] with black mold-like substance, then she would have communicated the assessment to the physician. Resident #5: Record review of Resident # 5's face sheet revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]., dementia, and gastro-[MEDICAL CONDITION] reflux disease. Resident #5's quarterly MDS assessment, dated 10/30/18, revealed Resident # 5's had severely impaired cognitive skills. Further review of the MDS identified Resident #5 as having a feeding tube. Record review of the care plan for Resident #5 revealed, in part: Problem (date initiated 11/01/18): Resident #5 requires tube feeding [MEDICATION NAME] 1.5 55cc/hr .Goal: the resident will remain free of side effects or complications related to tube feeding . Interventions: .the resident needs total assist with tube feeding and water flushes .monitor/document/report PRN any s/sx of: tube dysfunction or malfunction . Record review of Resident #5's physician orders revealed an order written [REDACTED]. Further review of the physician orders for Resident #5 revealed an order, written on 10/24/18 for [MEDICATION NAME] capsule delayed release 20 mg, give 1 capsule via pe[DEVICE] one time a day. During observation of medication administration for Resident #5 on 12/18/18, at 1:03 p.m. RN H poured water into a plastic cup without measuring the amount of water. She poured water in the syringe and used 30 cc's to flush the [DEVICE] before [MEDICATION NAME] was administered. She used 5 cc's to 'rinse' the medication cup to ensure entire dose of [MEDICATION NAME] was administered. She then poured the remaining water without measuring to flush the [DEVICE] after the medication was administered. The amount used to flush the [DEVICE] after [MEDICATION NAME] administration was less than the 35cc's ordered by the physician. During interview after medication administration 12/18/18, at 1:08 p.m., RN H said she did not measure if she had enough water but assumed she had enough water to flush the [DEVICE] after she administer the medication per the physician's order. In an interview with the Medical Director on 12/21/18 at 11:15 AM, he said he assessed all residents with [DEVICE]s. He said he ordered 2 [DEVICE]s to be changed due to the tubing being opaque and the inability of nursing staff to be able to see if there is any discoloration of the tubing. He said nursing staff need to have a heightened awareness in regard to changes in condition and communicate those concerns to the physician. Record review of the policy Lippincott nursing procedures, no date revealed .after administering the appropriate amount of formula, add 30mL of water to the [MEDICATION NAME] bag or bulb syringe .flushing maintains the tube's patency by removing excess formula, which could occlude the tube .Flush the feeding tube with 30 mL of water before and after medication administration to help prevent tube occlusion . Record review of the facility policy, Change in Resident's condition (dated (MONTH) (YEAR)) reads in part, .our facility shall promptly notify the resident, the attending physician, and representative of changes in the Resident's status .prior to notifying the physician or healthcare provider, the nurse will make observations and gather pertinent information for the physician . The Administrator and DON were notified on 12/19/18, at 3:36 p.m. of the IJ situation due to the above failures and a POR was requested. The POR was received and after two revisions, it was accepted on 12/20/18 at 2:56 p.m. POR included in part: .Effective 12/19/18, the Registered Nurse will reassess resident's gastrostomy tubes and gastrostomy tube sites for the presence of abnormality. This will be completed by 12/19/18. Effective 12/19/18, the licensed nurse will review resident's gastrotomy tube orders for completeness. This will be completed by 12/19/18. Effective 12/19/18, the Director of Nursing and/ or designee will reeducate licensed nurses on evaluating and identifying gastrostomy tube abnormalities. Reeducation will include site care and Q-shift observation, as well as action to take in the event abnormality is noted. This will be completed by 12/20/18 and will continue for new hire/ re-hire fulltime or PRN licensed nurses. Effective 12/19/18, the Director of Nursing and/ or designee will reeducate licensed nurses on medication administration via the gastrostomy tube, bolus feeding and gastrostomy tube flushing. Reeducation will include physician orders for flushing before and after medication administration. Reeducation will be validated by the Registered Nurse with return demonstration. This will be completed by 12/20/18 and will continue for new hire/ re-hire fulltime or PRN licensed nurses. Effective 12/19/18, the Director of Nursing and/ or designee reeducated licensed nurses on identifying and evaluating residents with a change in condition. Reeducation included evaluation/assessment tools, MD/NP notification process and communication related to residents with a change in condition. This will be completed by 12/20/18 and will continue for new hire/ re-hire fulltime or PRN licensed nurses. Effective 12/19/18, the Director of Nursing and/ or designee reeducated facility staff on reporting/ communicating observations related to resident changes in condition. Reeducation included methods of communication related to a resident's change in condition. This will be completed by 12/20/18 and will continue for new hire/ re-hire fulltime or PRN staff. Effective 12/21/18, Director of Nursing and/ or designee will monitor gastrostomy tubes and gastrostomy tube sites for abnormality by observing residents with gastrostomy tubes weekly for four weeks; then monthly for two months . The facility was monitored between 12/20/18 and 12/21/18 with the following results: Record review of the forms revealed that in-services were conducted on all three shifts with the nursing staff attending. As of 12/21/18 most staff had been in-serviced. During the monitoring phase, interviews were conducted by the surveyors on different shifts with 4 licensed nurses, 2 nurse managers, 10 CNA's and 2 MA's. All interviewed staff verbalized up to date knowledge on monitoring [DEVICE]s and assessing for changes tubing, notifying the physician of changes in condition, abuse and neglect, and resident rights. Observations were conducted during the monitoring phase of the 6 remaining Residents identified with gastrostomy status and no concerns were noted on the tubing placement, and appearance. The Medical Director assessed all 6 residents with [DEVICE]s, and ordered 2 tubes to be changed due to the tubing being opaque and the inability of nursing staff to be able to see if there is any discoloration of the tubing. During interview with the Administrator on 12/20/18 at 3:09 p.m. she said she thought the Immediate Jeopardy came about because of miscommunication. She said she was not aware of a situation until a family called and alleged neglect. The Administrator said she felt the former Medical Director did not provide the appropriate education and oversite. She said she feels the new Medical director will be better. The Administrator said the former Medical director was provided a termination letter on (MONTH) 30, (YEAR) and the new Medical Director started on 12/15/18. In an interview with the Administrator and the DON on 12/20/18, at 3:19 p.m. she said the facility staff had been instructed to call the DON when a change in condition was identified. The DON said the facility had instituted a process termed watchlist, where residents identified with a higher risk of changes in condition were listed and the list was provided to the weekend nursing supervisor for the staff to monitor for specific concerns related to resident's care needs. The DON said she could not recall when was the last time an in-service was conducted specifically related to bolus tube feedings. She said she had to look back for in-services on generalized [DEVICE] care. No documentation was provided to support generalized [DEVICE] care or in-services on [DEVICE] management had been completed before exit. The Administrator and the DON were informed on 12/21/18 at 11:43 a.m. that the IJ was lowered; however, the facility remained out of compliance at an isolated level and a severity of actual harm due to the facility needing more time to train staff.

Based on interviews and record reviews, the facility failed to consult with the physician and resident's representative when there was a need to alter treatment or there was a significaint change in the residents condition for 4 of 15 residents reviewed for notification.(Resident #22, # 24, # 25, and # 26) - Resident #22's physician was not consulted when he experience increased pain in his left shoulder on 10/7/17. X-rays showed the resident had old fractures on the left hip and left shoulder with acute re-injuries. Resident # 24, # 25, and # 26 were receiving psychoactive medication without a signed consent. This failure affected 4 residents and placed residents at risk a decline in their health status and a delay in treatment. Findings include: Resident #22 Record review of Resident #22's face sheet revealed an [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed he was cognitively impaired with a BIMS score of 3 indicating severely cognitive impairment. He required extensive assistance from one staff for bed mobility and totally dependent on one staff for dressing, eating, toilet use, personal hygiene and bathing. He had no ROM impairments and no falls. Record review of Resident #22's care plan dated 09/08/17 revealed the following care plan: Problem- Risk for spontaneous fractures related to dx of [MEDICAL CONDITION]. Goal: Resident will have a few, if any complications related to immobility as disease condition progresses with the next 90 days (12/10/17) . Approaches: Use caution when assisting resident with transfer and ADLs to prevent injury and fractures . Record Review of Resident #22's Nurses notes dated 10/07/17 at 11:23pm read in part, The resident mentioned that he is experiencing left shoulder pain. He has limited range of motion and experienced pain when I tried to help him move his arm. Record Review of Resident #22's medical file revealed no documentation that the physician was informed of the pain. The physician was not notified until 10/8/17. Further review of Resident #22's Nurses notes revealed that the next documentation regarding his pain was on 10/08/17 at 11:14pm, The Resident's shoulder pain continued and the doctor was notified. An X-ray of his left shoulder, clavicle, scapula and humorous were ordered. A prescription for 50mg [MEDICATION NAME] was also ordered for pain starting 1 [MEDICATION NAME] via [DEVICE] BID for 2 days followed by PRN after the 2 days . Record Review of the X-Ray results done on 10/08/17 revealed: in part: .[MEDICAL CONDITION] humerus is demonstrated. Findings could represent an old fracture with acute re-injury. Acute fracture is not entirely excluded. Further evaluation is recommended . The resident was sent to the hospital for further treatment. Record Review of the facility's self-report (Incident # 9) for Resident #22 read in part, On October 9, 2017 at approximately 7:45am, DON made Administrator aware of X-ray results indicating a fracture to the left humorous (hip) and left humorous (shoulder). Both findings could represent and old fracture with acute re-injury. In an Interview with RN D on 10/12/17 at 2:35pm, he said that he worked on Saturday (10/7/17) on the 2-10 shift. He said that he was told by the CNA that Resident #22 was refusing to be repositioned due to pain so he went to look at the resident. He said that he asked the resident if he was in pain and resident said that he was and pointed to his left shoulder. He looked at the shoulder for any redness or bruising and there wasn't any. He then left the resident because the resident stated he just wanted to be left alone. When asked if he assessed the resident for his level of pain, he replied that he did not. When asked if he did any assessment at all on the resident on 10/7, he replied that he did not. He said that he did not call the Doctor or do any assessments until 10/8/17 when he came back to work for the 2-10 shift. He said that he should have assessed the resident on 10/7 and notified the physician. When asked if the resident usually complained of pain, he said that he did not and that it was unusual for him to complain of pain. In a phone Interview with LVN E on 10/13/17 at 8:52am, he said that he worked the 10pm-6am shift on 10/7/17. He said that when he was doing his initial rounds, he saw 2 CNA's in Resident #22's room trying to change him. The CNA's told him that the resident was complaining of pain to the left shoulder and left leg. They asked me to stand with them while doing care because they felt more comfortable. He was grimacing and verbalizing pain when they touched his left shoulder. When asked if he did any assessments on the resident he said that he checked with the 2-10 nurse to see if he was aware. The 2-10 nurse told him that he was aware and that he took care of everything so he felt he didn't have to do anything. He said he did check on the resident every 2 hours but there is no documentation. Observation and Interview with Resident #22 on 10/13/17 at 9:50am revealed resident in bed, laying comfortably. [DEVICE] in place. The resident said he was doing fine and that he had just gotten back from the hospital. The resident denied any pain and stated he was comfortable. The resident said he hurt his shoulder but does not know how. He denied any falls or being abuse. In an Interview with the DON on 10/13/17 at 10:15am, she said that when a resident complains of pain to a nurse the nurse should take vital signs, assess the pain level, assess the pain site, talk to the resident, give pain meds if they have PRN, and notify the physician. If there was a standing order for pain medication then administer it, if not get an order from the physician. The DON said that the RN should have assessed Resident #22 on Saturday 10/7/17 when resident verbalized pain initially. She said that the RN was new and that she did one on one coaching with him about protocols. She said that they should have monitored Resident #22 starting Saturday and done better documenting. Record Review of the facility's job description for charge nurse read in part, the charge nurse will assist in ensuring the provision of quality care that promotes the highest practicable physical, mental and psychological well-being of each resident .identify significant changes in the condition of residents and takes necessary action per facility policies and procedures. Resident # 24 Record review of Resident # 24 face sheet revealed an [AGE] year old originally admitted to the facility on [DATE] and again on 06/20/2017 with the following diagnoses; Gastrostomy Malfunction, [MEDICAL CONDITION], Hypertension, Dysphagia, [MEDICAL CONDITION], Urinary Tract Infection, Dementia, Gastro-[MEDICAL CONDITION] reflux Disease, [MEDICAL CONDITION], Major [MEDICAL CONDITION], and Muscle Wasting ant Atrophy. Record review of Resident #24 Physician order [REDACTED]. Record review of facility Consultant Pharmacist's Medication Regimen Review created between 10/7/2017 and 10/10/17 revealed to please obtain a signed consent for the use of: [MEDICATION NAME]. Record review of Resident # 24's clinical file revealed no consent for [MEDICATION NAME]. Record review of Resident # 24 Medication Administration Record [REDACTED]. Resident # 25: Record review of Resident # 25's face sheet revealed an [AGE] year old admitted to the facility on [DATE] and again on 11/23/17 with the following diagnoses; [MEDICAL CONDITION] following Cerebral Infarction, Hypertension, Dementia, [MEDICAL CONDITION], Dysphagia, [MEDICATION NAME] due to [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux Disease, and [MEDICAL CONDITION] Pectoris. Record review of Resident # 25's Physician orders [REDACTED]. Further record review revealed an order dated 03/03/17 to administer [MEDICATION NAME] 5mg 1 tablet before sleep for [DIAGNOSES REDACTED]. Record review of the facility Consultant Pharmacist's Medication Regimen Review created between 10/7/2017 and 10/10/17 revealed to please obtain a signed consent for the use of: [MEDICATION NAME] and [MEDICATION NAME]. Record review of the clinical file for Resident #25 revealed no signed consent for the use of [MEDICATION NAME] and [MEDICATION NAME]. Record review of Resident # 25's Medication Administration Record [REDACTED]. Resident # 26 Record review of Resident # 26's face sheet revealed an [AGE] year old admitted to the facility on [DATE] and again on 08/30/17 with the following diagnoses; Contracture Left Hand and Shoulder, Dysphagia, Pressure Ulcer of Sacral, [MEDICAL CONDITION], [DIAGNOSES REDACTED], Upper Respiratory Infection, Hypertension, Pneumonia, Urinary Tract Infection, [MEDICAL CONDITIONS], and [MEDICAL CONDITION] Bladder. Record review of Resident # 26's Physician orders [REDACTED]. Record review of facility Consultant Pharmacist's Medication Regimen Review created between 10/7/2017 and 10/10/17 revealed to obtain a signed consent for the use of: [MEDICATION NAME]. Record review of Resident #26's clinical file revealed no consent for the use of [MEDICATION NAME]. Record review of Resident # 26's Medication Administration Record [REDACTED]. Interview on 10/12/17 at 4:45pm ADON-B said she was in the process fo auditing the resident charts for consent for psychoactive medications. Interview on 10/13/17 at 12:50 pm the DON said that it only took one nurse to get a phone consent from the family. The DON said the facility was lacking leadership and management skills and she has now hired the right staff to fulfill those roles. The DON said she could not provide a policy on consent for psychoactive medications. According to the facility CMS 672 the census was 111.

Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals for 1 of 23 (Resident #22) residents reviewed for quality of care in that: -Resident #22 was not assessed for pain and did not effective pain management when he complained of pain to his left shoulder on 10/07/17. -X ray results revealed the resident had old fractures on the left hip and left shoulder with acute re-injuries. This failure affected one resident and placed 23 other residents on hall 1 at risk for increase pain and a decline in their quality of life. Findings include: Resident #22 Record review of Resident #22's face sheet revealed an [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed he was cognitively impaired with a BIMS score of 3 indicating severely cognitive impairment. He required extensive assistance from one staff for bed mobility and totally dependent on one staff for dressing, eating, toilet use, personal hygiene and bathing. He had no ROM impairments and no falls. Record review of Resident #22's care plan dated 09/08/17 revealed the following care plan: Problem- Risk for spontaneous fractures related to dx of [MEDICAL CONDITION]. Goal: Resident will have a few, if any complications related to immobility as disease condition progresses with the next 90 days (12/10/17) . Approaches: Use caution when assisting resident with transfer and ADLs to prevent injury and fractures . Record Review of Resident #22's Nurses notes dated 10/07/17 at 11:23pm read in part, The resident mentioned that he is experiencing left shoulder pain. He has limited range of motion and experienced pain when I tried to help him move his arm. Record Review of Resident #22's medical file revealed no documentation to reveal any interventions were put in place on 10/07/17 to relieve his pain. The SBAR, Pain Assessment and Pain medications were not completed until 10/08/17. Record Review of Resident #22's MAR/TAR for October 2017 revealed that he was not assessed for pain or given any pain medication on 10/07/17. Further review of Resident #22's Nurses notes revealed that the next documentation regarding his pain was on 10/08/17 at 11:14pm, The Resident's shoulder pain continued and the doctor was notified. An X-ray of his left shoulder, clavicle, scapula and humorous were ordered. A prescription for 50mg [MEDICATION NAME] was also ordered for pain starting 1 [MEDICATION NAME] via [DEVICE] BID for 2 days followed by PRN after the 2 days . Record Review of the X-Ray results done on 10/08/17 revealed: in part: .[MEDICAL CONDITION] humerus is demonstrated. Findings could represent an old fracture with acute re-injury. Acute fracture is not entirely excluded. Further evaluation is recommended . The resident was sent to the hospital for further treatment. Record Review of the facility's self-report (Incident # 9) for Resident #22 read in part, On October 9, 2017 at approximately 7:45am, DON made Administrator aware of X-ray results indicating a fracture to the left humorous (hip) and left humorous (shoulder). Both findings could represent and old fracture with acute re-injury. In an Interview with RN D on 10/12/17 at 2:35pm, he said that he worked on Saturday (10/7/17) on the 2-10 shift. He said that he was told by the CNA that Resident #22 was refusing to be repositioned due to pain so he went to look at the resident. He said that he asked the resident if he was in pain and resident said that he was and pointed to his left shoulder. He looked at the shoulder for any redness or bruising and there wasn't any. He then left the resident because the resident stated he just wanted to be left alone. When asked if he assessed the resident for his level of pain, he replied that he did not. When asked if he did any assessment at all on the resident on 10/7, he replied that he did not. He said that he did not call the Doctor or do any assessments until 10/8/17 when he came back to work for the 2-10 shift. He said that he should have assessed the resident on 10/7 and notified the physician. When asked if the resident usually complained of pain, he said that he did not and that it was unusual for him to complain of pain. In a phone Interview with LVN E on 10/13/17 at 8:52am, he said that he worked the 10pm-6am shift on 10/7/17. He said that when he was doing his initial rounds, he saw 2 CNA's in Resident #22's room trying to change him. The CNA's told him that the resident was complaining of pain to the left shoulder and left leg. They asked me to stand with them while doing care because they felt more comfortable. He was grimacing and verbalizing pain when they touched his left shoulder. When asked if he did any assessments on the resident he said that he checked with the 2-10 nurse to see if he was aware. The 2-10 nurse told him that he was aware and that he took care of everything so he felt he didn't have to do anything. He said he did check on the resident every 2 hours but there is no documentation. Observation and Interview with Resident #22 on 10/13/17 at 9:50am revealed resident in bed, laying comfortably. [DEVICE] in place. The resident said he was doing fine and that he had just gotten back from the hospital. The resident denied any pain and stated he was comfortable. The resident said he hurt his shoulder but does not know how. He denied any falls or being abused. In an Interview with the DON on 10/13/17 at 10:15am, she said that when a resident complains of pain to a nurse the nurse should take vital signs, assess the pain level, assess the pain site, talk to the resident, give pain meds if they have PRN, and notify the physician. If there was a standing order for pain medication then administer it, if not get an order from the physician. The DON said that the RN should have assessed Resident #22 on Saturday 10/7/17 when resident verbalized pain initially. She said that the RN was new and that she did one on one coaching with him about protocols. She said that they should have monitored Resident #22 starting Saturday and done better documenting. Record Review of the facility's job description for charge nurse read in part, the charge nurse will assist in ensuring the provision of quality care that promotes the highest practicable physical, mental and psychological well-being of each resident .identify significant changes in the condition of residents and takes necessary action per facility policies and procedures. A policy for Pain Management and Change in Condition was requested but per the VP of Operations they did not have a policy on those. Facility census dated 10/10/17 listed 24 residents resided on hall 1.