Every finding on record at Amarillo Center for Skilled Care

Based on observation, interview, and record review the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #1) of 8 residents reviewed for pressure ulcers.The facility failed to install an air mattress ordered as an option for Resident #1 on 06/26/26 until 07/20/26 when he was found to have a stage 3 pressure ulcer.This failure could place residents at risk of developing pressure ulcers and of not receiving accurate/necessary care/treatment.Findings Included:Record review of Resident #1's admission record dated 07/24/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, central cord syndrome at unspecified level of cervical spinal cord subsequent encounter (incomplete spinal cord injury resulting in greater motor impairment in the upper extremities than the lower extremities), type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), and quadriplegia C1-C4 incomplete (partial paralysis of all four limbs with some preserved motor or sensory function offering potential for recovery through rehabilitation). Resident #1 was discharged to an acute care hospital on [DATE] at 07:14 PM.Record review of Resident #1's admission MDS assessment completed on 07/03/26 revealed a BIMS score of 13 which indicated intact cognition. Section GG Functional Abilities revealed Resident #1 had impairment on both side of upper and lower extremities and utilized a wheelchair. He was dependent ( Helper does ALL of the effort.) across all ADLs except for lying to sitting, sitting to lying and rolling left to right. For these three ADLs Resident #1 required substantial/maximal assistance ( Helper does MORE THAN HALF the effort.). Section M Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers/injuries and had a Pressure reducing device for bed.Record review of Resident #1's care plan initiated on 06/29/26 revealed he had Hemiplegia/Hemiparesis (paralysis) and would remain free of complications or discomfort. He was noted to have bowel incontinence, and staff were to Apply barrier cream after every incontinent episode. Resident #1 required two staff assistance with bed mobility. Resident #1 was noted to be at risk of developing pressure ulcers and on 07/20/26 the care plan was revised to note he had a stage 3 pressure ulcer on his sacrum (tailbone). One of the interventions initiated on 06/29/26 was to Inform the resident/family/caregivers of any new area of skin breakdown. The care plan had no mention of a pressure relieving device for his bed.Record review of Resident #1's active order summary dated 07/24/26 revealed the following orders with corresponding order dates:06/26/26 May apply barrier cream as needed06/26/26 May have pressure relieving mattress07/20/26 W/C stage 3 sacrum: cleanse with wound cleanser, pat dry, apply medihoney, apply calcium alginate, cover with foam dressing daily and prnRecord review of Resident #1's progress notes from 06/26/26 to 07/24/26 revealed the following:A skin assessment note written by ADON A on 06/26/26 revealed no skin concerns except scabbed area to forehead from a fall at home.A skin assessment note written by WCN on 06/29/26 revealed no skin concerns except lacerations to side of faceA skin assessment note written by WCN on 07/03/26 revealed no skin concerns except the lacerations to side of face.A skin assessment note written by WCN on 07/14/26 revealed no skin concerns.A note written by LVN B on 07/20/26 at 10:30 AM Resident [family member] arrived to the facility, reporting to this nurse that resident stated he was told by the night nurse that he has a sore on his buttocks. This nurse advised upon rounding will look at area, as this nurse had not been given information in report by PM shift nurse. This nurse notified Wound care nurse immediately after assessing skin and noticing pressure injury to buttocks.A note written by WCN on 07/20/26 at 03:45 PM revealed no skin concerns.A weekly ulcer assessment note written by WCN on 07/20/26 at 03:47 PM revealed stage 3 pressure ulcer to Resident #1's sacrum which measured 6.5 cm wide by 6 cm long by .2 cm deep. MD/NP notified about the wound on 07/20/26 at 03:50 PM.A transfer notification written by LVN C on 07/20/26 at 06:46 PM revealed Resident #1 was transferred to the hospital due to a change in condition.Record review of Resident #1's hospital records revealed he was admitted to the hospital for sepsis due to unspecified organism the night of 07/20/26. His temperature at 07:50 PM was 99 degrees Fahrenheit. He had a chronic indwelling catheter and no complaints of pain. He was noted to have severe sepsis with septic shock and a catheter associated urinary tract infection. On 07/23/26 the hospital called Resident #1's pressure ulcer unstageable and noted the base of the ulcer was obscured by slough (dead tissue that accumulates on the surface of a wound) and/or eschar (dead tissues that forms firm dry covering over a wound).During an interview on 07/24/26 at 07:37 AM Resident #1's family member stated Resident #1 was supposed to have an air mattress and was not given the air mattress. She stated when he was admitted to the facility on [DATE] she told staff he needed to have an air mattress. She stated Resident #1 developed a pressure ulcer and she was not notified about the pressure ulcer until she arrived to visit Resident #1. She stated at that time Resident #1 told her the night nurse told him (Resident #1) about the pressure ulcer on the evening of 07/19/26. Resident #1's family member stated she was upset Resident #1 had not received an air mattress and was in the hallway outside of Resident #1's room expressing her frustration on 07/20/26 when DOR stated Resident #1 should have had an air mattress. She stated she returned to the facility the evening of 07/20/26 and as she was standing in Resident #1's room ADM and some other nurses entered the room, and she told them she was worried about Resident #1. ADM told her he could be sent to the hospital if she (Resident #1's family member) wanted him sent to the hospital. She stated she told ADM she did want him sent to the hospital.During an interview on 07/24/26 at 08:28 AM ADON D stated when a physician ordered an air mattress for a resident HSK was the person who installed the air mattress. She stated all of the facility's mattresses were convertible to air mattresses. HSK would install the portion that converted the mattress to an air mattress when nursing staff requested that she do so.During an observation and interview on 07/24/26 at 08:37 AM HSK pointed to a box hanging off the end of an empty bed. She stated that it was the part that converted a regular mattress to an air mattress. She stated the empty bed belonged to Resident #1. HSK stated she had documentation in a group chat indicating she was asked by management to install the air mattress component on Resident #1's bed on 07/20/26. She stated she installed the component on 07/20/26.During an interview on 07/24/26 at 08:43 AM DOR stated he remembered Resident #1's family member being upset about Resident #1 not receiving an air mattress at admission on [DATE]. He stated he did not say Resident #1 should have had an air mattress. DOR stated he said Resident #1 could benefit from having an air mattress. DOR stated he had worked Monday through Friday each week with Resident #1 on physical therapy and during those 2-4 hours Resident #1 had been sitting up in his wheelchair with an air cushion in the seat of his wheelchair to relieve pressure. DOR stated Resident #1 often complained of pain in his left hip but never of pain on his bottom.During an interview on 07/24/26 at 08:58 AM RN E stated he used to be the wound care nurse for the facility but had transitioned to charge nurse. He stated a possible negative outcome of not giving a resident an ordered air mattress was the resident could develop a pressure wound.During an interview on 07/24/26 at 10:01 AM ADON D stated WCN was not in the building as she was suspended. ADON D stated a possible negative outcome of not giving a resident an air mattress when ordered by the physician was the resident could develop a pressure injury. She stated the charge nurse on duty when a resident was admitted to the facility was responsible for entering physician's orders into the EHR and for ensuring the orders are followed. She stated in the case of Resident #1 the charge nurse should have alerted HSK to Resident #1's need for an air mattress. ADON D stated the charge nurse on duty when Resident #1 was admitted was LVN B. She stated if the charge nurse did not notify HSK of the need for the air mattress ADONs or DON should do so. ADON D stated she did not know why Resident #1 did not get an air mattress at admission as ordered by the physician.During an interview on 07/24/26 at 10:22 AM RN F stated she worked with Resident #1 often and trained SNAs on incontinent and catheter care with Resident #1. She stated the last time she worked with Resident #1 was 07/16/26 and she provided incontinent care for him on that date. She stated she had not noted any redness or skin breakdown to Resident #1's bottom. RN F stated Resident #1 had never complained of pain to her.During an interview on 07/24/26 at 10:36 AM LVN G stated a resident's skin could break down if they were ordered an air mattress and did not receive it for 3 weeks. She stated if she was the admitting nurse for a resident who had an order for an air mattress she would contact HSK and ask her to install the air mattress.During an interview on 07/24/26 at 10:28 AM LVN B stated she was the charge nurse when Resident #1 was admitted to the facility. She stated HSK or ADONs were responsible for getting an air mattress. She stated she did not alert any of them to Resident #1's order for an air mattress because she didn't notice they hadn't gotten it (air mattress) yet. LVN B stated she did not think Resident #1's pressure ulcer was a result of him not getting an air mattress as ordered. She stated there was a multitude of things that need to happen when somebody can't move themselves. LVN B stated staff needed to reposition the resident every 3 hours and place an air cushion in his wheelchair. She stated that would help take the pressure off of his bottom. LVN B stated an air mattress would do the same thing. She stated Resident #1 had labs drawn that indicated elevated white blood cell count and she was confused by the labs due to him having no signs or symptoms or change in condition. She stated NP saw Resident #1 on 07/20/26 and that is when she entered orders for wound care.During an interview on 07/24/26 at 11:39 AM CNA H stated when she provided care for Resident #1, she put barrier cream on his bottom with each brief change. She stated when she cared for him on 07/16/26 she noticed an area the size of a nickel where his butt cheeks met that was red and slightly peeling. She stated she and LVN C changed Resident #1's brief together and she reported the area to LVN C. CNA H stated she was not certain the area was not caused when they used the draw sheet to move Resident #1 side to side. CNA H stated she would reposition Resident #1 approximately 4 times per shift because sometimes when she asked to reposition him, he declined and stated he was comfortable as he was. During an interview on 07/24/26 at 11:54 AM SNA I stated he provided incontinent care for Resident #1 on 07/17/26 and 07/18/26. He stated he applied barrier cream to Resident #1's bottom after each incontinent episode and did not notice any redness or skin breakdown on Resident #1's bottom. He stated he would attempt to reposition Resident #1 every two hours but would only actually reposition him 3-4 times a shift because the other times Resident #1 refused to be repositioned.During an interview on 07/24/26 at 12:08 PM SNA J stated she helped SNA I provide incontinent care to Resident #1 on 07/17/26 and 07/18/26 and did not notice any skin breakdown or redness on his bottom. She stated they applied barrier cream to his bottom after each brief change.During an interview on 07/24/26 at 12:15 PM SNA K stated she bathed and provided incontinent care for Resident #1 on 07/15/26. SNA K stated she did not notice any skin redness or breakdown on his bottom. She stated she repositioned Resident #1 every hour and a half because he asked to be repositioned that often.During an interview on 07/24/26 at 12:42 PM LVN C stated she worked with Resident #1 on 07/15/26 and did not notice any redness or skin breakdown on his bottom. She stated she applied barrier cream each time she changed or helped to change his brief. LVN C stated she and the aides who worked with her repositioned Resident #1 at least every 2 hours.During an interview on 07/24/26 at 01:37 PM ADM stated WCN was not suspended for anything to do with Resident #1.During an interview on 07/24/26 at 01:42 PM SNA L stated she worked with Resident #1 and he complained of pain in his legs but not his bottom. She stated she did not notice any redness or breakdown of the skin on his bottom.During an interview on 07/24/26 at 02:53 PM NP stated a stage 3 pressure ulcer could happen in a day or two. She stated it was not likely but was possible. NP stated Resident #1 not having an air mattress as ordered for 3 weeks could have contributed to him developing a pressure ulcer because the mattress would help distribute the pressure. NP stated having the air mattress might not have prevented Resident #1 from developing a pressure ulcer because pressure ulcer development was a result of a combination of things.During an interview on 07/24/26 at 07:13 PM RN M stated he worked with Resident #1 the night of 07/19/26. He stated he told Resident #1 he was developing a pressure ulcer. RN M stated he thought he told the day shift nurse about the pressure ulcer. He stated a possible negative outcome of not documenting a developing pressure ulcer and not notifying the physician of the pressure ulcer was the resident can probably . get sicker. RN M stated Resident #1 not having an air mattress as ordered did not contribute to him developing a pressure ulcer because we were turning him.During an interview on 07/24/26 at 07:20 PM ADM stated a possible negative outcome of not documenting a developing pressure ulcer was, Negative resident outcomes and potential delays in treatment or care. She stated she did not think Resident #1 not having an air mattress as ordered for his first three weeks in the facility contributed to him developing a pressure injury.During an interview on 07/24/26 at 07:26 PM RN N stated staff would not know how to care for a resident if a developing pressure injury was not documented and the physician and family notified.During an interview on 07/24/26 at 07:29 PM LVN O stated if staff did not document a developing pressure ulcer it might not be cared for, could become infected, and could get worse. She added that family and physician would not be notified.During an interview on 07/24/26 at 07:30 PM ADON A stated an air mattress as ordered for Resident #1 could assist with pressure ulcer prevention but not having an air mattress does not cause a pressure ulcer.Record review of facility policy titled Pressure Injury: Prevention, Assessment and Treatment and dated 05/25/25 revealed the following: . 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. Residents identified at risk will have person centered care planned approaches to attempt to prevent pressure injuries from developing. 4. Causes of Pressure Injuries: . 3. Paralysis which results in the inability to move off of an area of prolonged pressure. 4. Loss of skin sensitivity with resulting loss of awareness of prolonged pressure.

Based on interviews and record reviews the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is a significant change in the resident's physical status and/or a need to alter treatment significantly for 1 (Resident #1) of 8 residents reviewed for notification.The facility failed to inform Resident #1's physician and family member immediately when a stage 3 pressure ulcer was noted on his tailbone the evening of 07/19/26.This failure could place residents at risk of not receiving timely, appropriate care.Findings Included:Record review of Resident #1's admission record dated 07/24/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, central cord syndrome at unspecified level of cervical spinal cord subsequent encounter (incomplete spinal cord injury resulting in greater motor impairment in the upper extremities than the lower extremities), type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), and quadriplegia C1-C4 incomplete (partial paralysis of all four limbs with some preserved motor or sensory function offering potential for recovery through rehabilitation). Resident #1 was discharged to an acute care hospital on [DATE] at 07:14 PM.Record review of Resident #1's admission MDS assessment completed on 07/03/26 revealed a BIMS score of 13 which indicated intact cognition. Section GG Functional Abilities revealed Resident #1 had impairment on both side of upper and lower extremities and utilized a wheelchair. He was dependent ( Helper does ALL of the effort.) across all ADLs except for lying to sitting, sitting to lying and rolling left to right. For these three ADLs Resident #1 required substantial/maximal assistance ( Helper does MORE THAN HALF the effort.). Section M Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers/injuries and had a Pressure reducing device for bed.Record review of Resident #1's care plan initiated on 06/29/26 revealed he had Hemiplegia/Hemiparesis (paralysis) and would remain free of complications or discomfort. He was noted to have bowel incontinence, and staff were to Apply barrier cream after every incontinent episode. Resident #1 required two staff assistance with bed mobility. Resident #1 was noted to be at risk of developing pressure ulcers and on 07/20/26 the care plan was revised to note he had a stage 3 pressure ulcer on his sacrum (tailbone). One of the interventions initiated on 06/29/26 was to Inform the resident/family/caregivers of any new area of skin breakdown. The care plan had no mention of a pressure relieving device for his bed.Record review of Resident #1's active order summary dated 07/24/26 revealed the following orders with corresponding order dates:06/26/26 May apply barrier cream as needed06/26/26 May have pressure relieving mattress07/20/26 W/C stage 3 sacrum: cleanse with wound cleanser, pat dry, apply medihoney, apply calcium alginate, cover with foam dressing daily and prnRecord review of Resident #1's progress notes from 06/26/26 to 07/24/26 revealed the following:A note written by LVN B on 07/20/26 at 10:30 AM Resident [family member] arrived to the facility, reporting to this nurse that resident stated he was told by the night nurse that he has a sore on his buttocks. This nurse advised upon rounding will look at area, as this nurse had not been given information in report by PM shift nurse. This nurse notified Wound care nurse immediately after assessing skin and noticing pressure injury to buttocks.A weekly ulcer assessment note written by WCN on 07/20/26 at 03:47 PM revealed stage 3 pressure ulcer to Resident #1's sacrum which measured 6.5 cm wide by 6 cm long by .2 cm deep. MD/NP notified about the wound on 07/20/26 at 03:50 PM.A transfer notification written by LVN C on 07/20/26 at 06:46 PM revealed Resident #1 was transferred to the hospital due to a change in condition.Record review of Resident #1's hospital records revealed he was admitted to the hospital for sepsis due to unspecified organism the night of 07/20/26. His temperature at 07:50 PM was 99 degrees Fahrenheit. He had a chronic indwelling catheter and no complaints of pain. He was noted to have severe sepsis with septic shock and a catheter associated urinary tract infection. On 07/23/26 the hospital called Resident #1's pressure ulcer unstageable and noted the base of the ulcer was obscured by slough (dead tissue that accumulates on the surface of a wound) and/or eschar (dead tissues that forms firm dry covering over a wound).During an interview on 07/24/26 at 07:37 AM Resident #1's family member stated Resident #1 was supposed to have an air mattress and was not given the air mattress. She stated when he was admitted to the facility on [DATE] she told staff he needed to have an air mattress. She stated Resident #1 developed a pressure ulcer and she was not notified about the pressure ulcer until she arrived to visit Resident #1 the morning of 07/20/26. She stated at that time Resident #1 told her the night nurse told him (Resident #1) about the pressure ulcer on the evening of 07/19/26. She stated she returned to the facility the evening of 07/20/26 and as she was standing in Resident #1's room ADM and some other nurses entered the room and she told them she was worried about Resident #1. ADM told her he could be sent to the hospital if she (Resident #1's family member) wanted him sent to the hospital. She stated she told ADM she did want him sent to the hospital.During an interview on 07/24/26 at 08:43 DOR stated Resident #1 often complained of pain in his left hip but never of pain on his bottom.During an interview on 07/24/26 at 10:28 AM LVN B stated she was the charge nurse for Resident #1 on 07/20/26. She stated RN M who worked the night before did not report to her or document in the EHR Resident #1's pressure ulcer. She stated she found out about the pressure ulcer when Resident #1's family member reported to her that Resident #1 was told by the night nurse he had a pressure ulcer. She stated Resident #1 had labs drawn that indicated elevated white blood cell count and she was confused by the labs due to him having no signs or symptoms or change in condition. She stated NP saw Resident #1 on 07/20/26 and that is when she entered orders for wound care.During an interview on 07/24/26 at 02:53 PM NP stated a stage 3 pressure ulcer could happen in a day or two. She stated it was not likely but was possible. NP stated Resident #1 not having an air mattress as ordered for 3 weeks could have contributed to him developing a pressure ulcer because the mattress would help distribute the pressure. NP stated having the air mattress might not have prevented Resident #1 from developing a pressure ulcer because pressure ulcer development was a result of a combination of things.During an interview on 07/24/26 at 07:13 PM RN M stated he noticed a pressure ulcer on Resident #1's bottom the evening of 07/19/26 and told Resident #1 about the pressure ulcer. He stated he did not think to notify the physician or family regarding the pressure ulcer. He stated a possible negative outcome of not documenting a developing pressure ulcer and not notifying the physician or family of the pressure ulcer was the resident can probably . get sicker.During an interview on 07/24/26 at 07:20 PM ADM stated a possible negative outcome of not documenting a developing pressure ulcer or notifying the family or physician was, Negative resident outcomes and potential delays in treatment or care. She stated Resident #1's family member was upset she was not notified of the pressure ulcer.During an interview on 07/24/26 at 07:26 PM RN N stated staff would not know how to care for a resident if a developing pressure injury was not documented and the physician and family notified.During an interview on 07/24/26 at 07:29 PM LVN O stated if staff did not document a developing pressure ulcer it might not be cared for, could become infected, and could get worse. She added that family and physician would not be notified.During an interview on 07/24/26 at 07:30 PM ADON A stated family members could be shocked if staff did not notify them of a developing pressure ulcer. She stated it was important to pass the information up the chain so the doctor would be notified.Record review of facility policy titled Pressure Injury: Prevention, Assessment and Treatment and dated 05/25/25 revealed the following: . 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document Notification .Record review of an undated facility policy titled Resident Rights revealed the following: . 14. Notification of changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is - . b. A significant change in the resident's physical .status 9that is a deterioration in health.) c. A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .Record review of an undated facility policy titled Notifying the Physician of Change in Status revealed the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 5. The resident's family member . should be notified of a significant change in resident's status unless the resident has specified otherwise.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure stored food was secured, dated and used or discarded before the expiration date.B. Ensure hairnets were worn by all staff while in the kitchen. These failures could place all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: Observations of the walk-in freezer on 2/18/26 at 8:40 AM revealed the following:A. opened box of peanut butter cookie dough, open to air and unsecuredB. opened box of corn, open to air and unsecuredC. opened box of frozen biscuits, open to air and unsecured Observation of the pantry on 2/18 /26 at 8:50 AM revealed the following:A. 3 cans [NAME] Chacherie creole seasoning, dented, with a best if used by date of 10/2024.B. 4 containers of Smucker's plate syrup with a best if used by date of 9/30/25. C. 4 Containers of Horseradish with a best if used by date of 7/20/25, Observation of the kitchen shelving holding spices on 2/18/26 at 9:00 am, revealed a container of Sesame Seeds with a best by date of June 2025, Cloves best by September 2025, Celery Seeds expired January 2025 and Thyme best by [DATE]. Observations of the pantry on 2/19/26 at 9:40 AM revealed the same conditions in the kitchen were present with no corrections. In an observation and interview on 2/19/26 at 2:00 pm, [NAME] A was observed in the kitchen with no hair net covering his hair. [NAME] A stated he should have had a hairnet on his head while in the kitchen. He stated hair could get in food and food borne illness could occur. In an interview on 2/20/26 at 10:00 am the DM stated she expected all employees to wear a hairnet while in the kitchen. The DM stated all foods should be closed to air and securely sealed. The DM stated all expired foods should have been thrown out and not used. The Dm stated all issues in the kitchen could cause food borne illness. The DM stated the dietician had trained her in the kitchen and she had trained the staff. Record Review of the facility policy titled Dietary Food Services Personnel Policy and Procedures dated 2012, revealed hairnets are worn at all times. Record Review of the facility policy titled Dry Storage and Supplies dated 2012, revealed: Opened packages of food are stored in closed containers with tight covers and dated as to when opened.

Based on interview and record review, the facility failed to consider the views of a resident group and act promptly upon the grievances of such groups concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response for 3 of 4 months of Resident Council meetings reviewed in that: Feedback and follow-up to concerns expressed during Resident Council Meetings was not provided for December 2025, January 2026, and February 2026. This deficient practice had the potential to affect residents participating in Resident Council meetings and placed them at risk for decreased quality of life and unresolved grievances.The findings were: Record review of Resident Council Minutes dated 12/04/2025 revealed concerns regarding the Nutrition Services, specifically incorrect menu tickets and meals not matching what was ordered. There was no documentation indicating resolution of these concerns. Record review of Resident Council Minutes dated 01/01/2026 revealed concerns regarding the Nutrition Services, specifically incorrect menu tickets and meals not matching what was ordered. There was no documentation indicating resolution of these concerns. Record review of Resident Council Minutes dated 02/06/2026 revealed concerns regarding the Nutrition Services, specifically incorrect menu tickets and meals not matching what was ordered. There was no documentation indicating resolution of these concerns. During an anonymous interview on 02/19/2026 at 10:30 AM, with residents, 5 of 5 residents stated they had ongoing concerns about not receiving the correct meal according to their tickets and reported feeling staff were not listening to their concerns because nothing has been done. One resident reported at times that she would order the alternative meal for that day but would not get it but would get the original meal for that day. During an interview with the AD on 02/19/2026 at 1:34 PM, The AD stated she took notes during the meetings as requested by residents. The AD stated she would provide the meeting notes to the ADM or the SW. The AD stated she did not believe it was her responsibility to follow up on concerns expressed during the meetings, as her role was limited to documenting the discussion.The AD acknowledged concerns were raised during the meetings; however, she stated she did not know what actions were taken to resolve the concerns after the meetings concluded. The AD stated she believed the ADM or SW were responsible for follow up. The AD was unable to explain how she verified that concerns raised during Resident Council were addressed or resolved. During an interview on 02/19/2026 at 2:00 PM, the SW, who had worked at the facility for two months stated she had not received the Resident Council meeting notes containing resident concerns. The SW stated had she received the notes, she would have followed up by addressing the concerns with the Resident council or the appropriate department. The SW acknowledged that the failure to follow up on Resident Council concerns could result in resident feeling they are not being heard. During an interview on 02/19/2026 at 2:04 PM, the ADM who began working at the facility approximately two weeks prior, stated he met with the Resident Council in February. The ADM acknowledged it was the ADM's responsibility to ensure residents' concerns were addressed and followed through to resolution. During an interview on 02/20/2026 at 8:28 AM, the DM stated she was not aware of the Resident Council meetings concerning any dietary issues, including incorrect menu items or meal tickets. The DM stated the only correspondence she would receive regarding Resident Council was the meal of the month. The DM stated if she had been informed of the concerns, she would have addressed them. The DM acknowledged residents should get the meal they ordered for that day, and their meal ticket should be accurate. Record review of facility's policy on grievances dated 1/12/2023 revealed the following:The resident has a right to organize and participate in resident groups in the facility. The facility must consider the views of a resident or family group and act promptly upon the grievance and recommendation of such groups concerning issues of resident care and life in the facility.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 6 of 6 medication carts reviewed to meet the needs of each resident. The Controlled Drugs Count Record on 6 medication carts for shift-to-shift narcotic counts had multiple blanks which indicated that the narcotic count was not completed at shift change. The Glucometer Quality Control Log High/Low Controls were not tested every night. This failure could result in narcotics being misappropriated from the facility which could result in ineffective treatment resulting in exacerbation of residents' disease processed. Findings include: Observations on 2/18/26 of the facility's shift-to-shift narcotic count books revealed the following: *Controlled Drugs-Count Record for February 2026 documented the following on every sheet:Signing below acknowledges that you have counted the controlled drugs on hand, have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug Administration Record. -At 1:50 p.m. - Hall 100 narcotic sheet for February revealed 5 blanks where nurse signatures should be. -At 1:55 p.m. - Hall 200 back narcotic sheet for February revealed 6 blanks where nurse signatures should be. -At 2:00 p.m. - Hall 200 front narcotic sheet for February revealed 2 blanks where nurse signatures should be. -At 2:04 p.m. - Hall 300 front narcotic sheet for February revealed 25 blanks where nurse signatures should be. -At 2:07 p.m. - Hall 400 narcotic sheet for February revealed 12 blanks where nurse signatures should be. -At 2:12 p.m. - Hall 300 Back narcotic sheet for February revealed 25 blanks where nurse signatures should be. During an observation on 2/19/26 of Glucometer Quality Control Log High/Low Controls for February 1st through 19th revealed the following: -At 8:30 a.m. - Hall 100 glucometer Quality Control Log revealed the glucometer was checked 3 out of 19 days. -At 9:05 a.m. - Hall 300 back glucometer Quality Control Log revealed the glucometer was checked 10 days out of 19 days. -At 9:18 a.m. - Hall 300 front glucometer Quality Control Log revealed the glucometer was checked 0 out of 19 days. -At 9:25 a.m. - Hall 200 back glucometer Quality Control Log revealed the glucometer was checked 10 out of 19 days. -At 9:45 a.m. - Hall 200 front glucometer Quality Control Log revealed the glucometer was checked 10 out of 19 days. -At 9:54 a.m. - Hall 400 glucometer Quality Control Log revealed the glucometer was checked 1 day out of 19 days. During an interview on 2/19/26 at 2:41 p.m., the Administrator stated he was aware that the nurses need to sign the shift-to-shift narcotic sheet to ensure all narcotics were accounted for. The Administrator stated he did not know anything about taking care of the glucometers. During an interview on 2/19/26 at 2:51 p.m., Corp RN stated she started an in-service on signing the narcotic sheets last night. The Corp RN stated the nurses sign the narcotic sheet at every shift change when they count the narcotic drawer. The Corp RN stated she already knew there was an issue with the glucometer checks as they should be conducted daily on the night shift. During an interview on 2/20/26 at 8:15 a.m., LVN B stated when she first comes on shift, the nurse going off shift and her would count the narcotics first thing and both nurses would sign the narcotic sheet. LVN B stated if the narcotic count was wrong, they would count the narcotic again and if the count was still off, they would call the DON to get further instructions. LVN B stated it was night shifts job duty to check the glucometers to ensure they were accurate. During an interview on 2/20/26 at 8:35 a.m., RN C stated both nurses would count the narcotics together and then both nurses sign the shift-to-shift narcotic sheet. RN C stated the count must be correct before she would take over the medication cart. RN C stated she always cleans the glucometers in between residents, and the night shift checks the glucometers to ensure they were properly working. During an interview on 2/20/26 at 8:42 a.m., LVN D stated they count narcotics with the nurse going off shift and they both make sure the count was correct and then both sign the shift-to-shift narcotic count sheet.LVN D stated the night shift checks the glucometers, so they are working properly. During an interview on 2/20/26 at 8:51 a.m., RN E stated the nurse coming on shift and the nurse going off shift count the narcotics and the blister packs and then both nurses sign the shift-to-shift narcotic count sheet. RN E stated checking the glucometers for accuracy was a night shift duty. Record review of the facility policy, Controlled Medications - Administration, undated, revealed the following:Policy:Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedure: At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit. Review of the facility policy Glucometer, undated, revealed the following: Quality Control TestingTesting will be done routinelyPerform quality control testing by using Control Solutions: High and Low every per manufacturer recommendations.Perform Check Strip TestCall toll-free number if test remains out of range.Report unresolved problems to DON/ ADON.Do not use meter until problem is resolved. Obtain meter from another station.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 of 16 residents (Resident #60) reviewed for accidents and hazards. The facility allowed Resident #60 to possess large sharp scissors in her room despite facility policy prohibiting sharp objects in resident's rooms. The facility failed to ensure the sharps storage compartment on the 200 Hall Front Medication cart was secured. The lock was broken and the compartment contained used sharps. This failure could affect the residents at the facility by placing them at risk of injury. Findings included:Record review of Resident #60's face sheet dated 02/18/2026 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #60 had diagnoses that included but not limited to depression (feeling sadness), anxiety disorder (feeling anxious), weakness and personal history of malignant neoplasm of thyroid (thyroid cancer).Record review of Resident #60's admission MDS assessment dated [DATE] revealed she had a BIMS of 14 out 15 indicating her cognition was intact. In Section J1700 it was noted Resident #60 had a history of falling prior to admission.Record review of Resident #60's care plan dated 02/04/2026 revealed Resident #60 was a risk for falls with interventions to have a safe environment.Record review of admission Packet for the facility revealed the following: Items not allowed in Residents rooms. Safety Hazards .Scissors or knives, only blunt edge scissors are permitted.During an Observation on 02/18/2026 at 9:10 AM, Resident #60 was sitting up in her bed. She had several papers on her bedside table and a pair of large cutting scissors with sharp edges.During an observation on 02/18/2026 at 2:32 PM, Resident #60 was not in her room. The door was slightly open, and the large cutting scissors were laying on her bed.During an interview and observation on 02/18/2026 at 4:15 PM, Resident #60 was sitting in her bed. Scissors were located on her lap. Resident #60 stated the scissors belonged to her and she used them to open packages because she was no longer able to tear items open. Resident #60 stated staff were aware she had the scissors and had allowed her to keep them.During an interview on 02/18/2026 at 4:18PM CNA G stated she was aware Resident #60 had scissors in her room. She stated Resident #60 wanted the scissors and staff allowed her to have them. CNA G acknowledged that allowing residents to possess sharp objects could result in resident injury.During an interview on 02/18/2026 at 4:19 CNA H stated she was aware Resident #60 had scissors in her room. CNA H stated she knew possession of sharp scissors was against facility policy. CNA H acknowledged a potential negative outcome of allowing the resident to have sharp scissors could include injury to herself or other residents. CNA H stated staff were responsible for ensuring resident safety.During an observation on 02/19/2026 at 9:43 AM, the 200 Hall front Medication Cart had a sharps container lock box located on the right side of the cart. The lock box was unlocked and appeared broken. The door was open, and the lock box contained several used sharps.During an interview and observation on 02/19/2026 at 9:45 AM, RN F stated the lock box for the sharps on the 200 Hall Front Medication Cart did not have a functioning lock. RN H stated that she reported this to DON and the ADON., RN F stated having the lock box open and unlocked could cause needlestick injury to residents.During an interview on 02/19/2026 at 1:45PM, the DON stated he was not aware Resident #60 possessed scissors and confirmed that sharp scissors were against facility policy. The DON stated staff were expected to follow facility protocol regarding prohibited items in resident rooms.During an interview on 02/19/2026 at 2:04PM, the ADM was not aware Resident #60 possessed sharp scissors. The ADM confirmed that sharp scissors were against facility policy and stated staff were expected to follow facility policies and procedures. The ADM acknowledged a potential negative outcome of allowing the resident to have sharp scissors could include falling while holding them or sustaining injury.During an observation on 02/20/2026 at 8:20 AM, the lockbox on the200 Hall Front Medication Cart was observed to be broken. Tape had been placed on the box in an attempt to keep it secure.During an interview on 02/20/2026 at 11:00am, the Corp RN stated that although Resident #60 was cognitively intact, she should have been educated regarding safe use of scissors. The Corp RN stated that if scissors were permitted for use, staff should have secured them at the nurses' station after each use. The Corp RN further stated the facility had blunt scissors available for resident use.During an interview on 02/20/2026 at 11:15 AM, the DON stated all staff were responsible for ensuring any safety hazards were addressed and he was responsible for overseeing staff compliance. The DON said a negative outcome for having a broken sharps lock box on the medication cart would be that a resident could get hurt.During an interview on 02/20/2026 at 1:20 PM, ADON I stated she was told by the staff the sharps lock box was broken on 200 Hall Front Medication Cart. She stated she reported it to the DON and believed it was being repaired. The ADON stated it was all staff's responsibility to ensure the safety of the residents; therefore, the lockbox should be secured to ensure safety of residents.On 02/19/2026, the Accidents and Hazards policy was requested; however, it was not provided.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided with such care consistent with professional standards of practice for 1 (Resident #85) of 22 residents reviewed for respiratory care. RN J started breathing treatment on Resident #85 and left the resident's room, so the resident was unsupervised. This failure could affect residents by placing them at risk for respiratory compromise by not receiving their full breathing treatment, and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings include: Record review of Resident #85's face sheet, dated 2/19/26, revealed a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses which included: acute respiratory failure with hypoxia (tissues are deprived of adequate oxygen leading to impaired cellular function and potential organ damage), chronic obstructive pulmonary disease (progressive, long-term long disease that makes it difficult to breathe due to damaged, inflamed airways and destroyed air sacs/ Record review of Resident #85's Medicare 5-day MDS resident assessment, dated 2/13/26, listed him with a BIMS of 13 indicating he was cognitive intact, he had a functionality of being dependent on staff formost of his activities of daily living and was listed as having shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat. Record review of Resident #85's care plan with admission date, 2/10/26, revealed the resident has emphysema/COPD with interventions/tasks - give aerosol or bronchodilators as ordered. Monitor/documented any side effects and effectiveness. The resident had oxygen therapy - if the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal. Record review of Resident # 85's order summary report printed 2/19/26 revealed the following: Oxygen 1 - 5 liters via nasal cannula every shift.Budesonide Inhalation suspension 1 mg/2ml - one inhalation treatment every 6 hours. During an observation on 2/18/26 at 11:15 a.m., RN J provided Resident #85 new tubing and a mask for breathing treatment. RN J started the breathing treatment and told Resident #85 that she would be back to check on him in 10 or 15 minutes. During an interview on 2/18/26 at 11:16 a.m., RN J stated that she usually did not stay in the room with the resident because the breathing treatment takes 10 to 15 minutes to complete. RN J stated she would come back in 10 to 15 minutes to check on Resident #85. During an interview on 2/19/26 at 2:41 p.m., the Administrator stated he was aware nurses needed to stay with residents when they are receiving breathing treatments. During an interview on 2/19/26 at 2:51 p.m., Corp RN stated she has talked to the nurse who did that and she will start an in-service covering the need for nurses to stay with a resident while they were getting a breathing treatment. During an interview on 2/19/26 at 3:22 p.m., the DON stated his expectations would be accountability and communication. Review of the facility policy, Aerosolized Hand-Held Nebulizer revealed the following: Purpose: To provide guidelines for administration of nebulized medication to patients.Instruct patient to close his/her lips tightly around the mouthpiece and breathe deeply, pause 2 - 3 seconds and then exhale slowly. This allows the medication time to distribute evenly throughout the lungs. Instruct the patient in diaphragmatic breathing techniques. Encourage and work with the patient throughout the treatment for use of the proper and most effective technique. (Refer to Deep Breathing and Cough Procedure). Continue treatment until all medication has been nebulized. Periodically tap the compressor and allow the patient to rest for a few minutes and then resume the treatment.

Based on observation, interview, and record review, the facility failed to ensure medication was labeled and stored in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed for medication storage.The Hall 200 front medication cart had loose medication in a clear plastic drinking cup 3/4 full of unidentified medication. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes. Findings include:During an observation on 2/19/26 at 9:48 a.m., of the Hall 200 front medication cart with RN F present, there was loose medication in a clear plastic drinking cup 3/4 full of unidentified medication. During an interview on 2/19/26 at 9:52 a.m., RN F stated the medication in the clear plastic cup was Colace and she did not know they were in her medication cart. During an interview on 2/19/26 at 2:51 p.m., the Corp RN stated the pills in the cup were docusate (a stool softener The Corp RN stated there was a large bottle in the bottom drawer of the medication cart. The Corp RN stated she has found that some nurses pour some pills in cups to use during medication pass and then throw the pills out when finished with the medication pass. During a follow-up interview on 2/19/26 at 3:13 p.m., RN F stated that the medication in the plastic drinking cup was not given by her and that she disposed of them. When asked what a negative outcome could be, RN F stated medications not in their original container cannot be properly identified by all staff and should never be given. RN F stated that a negative outcome to the resident would be that the resident could get the wrong medication and have adverse side effects because of that.Reviewed the facility policy Medication Administration and General Guidelines, undated, revealed the following:Medications are administered at the time they are prepared. Medications are not pre-poured.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA A) of 4 staff observed for infection control. -CNA A did not perform hand hygiene properly while performing incontinent care. This deficient practice has the potential to place residents at risk for infections, tissue breakdown, and feelings of isolation related to poor hygiene.Findings include: During an observation of incontinent care on 2/05/2026 at 12:13 PM CNA A performed hand hygiene then assisted to roll the resident on her side. CNA A used wipes to clean the resident's left buttocks area, use wipes to clean the resident's right buttocks area, and used wipes to clean the residents' rectal area. CNA A then placed a clean draw sheet and a new brief under the resident. CNA A removed her gloves, washed her hands, placed new gloves and rolled the resident to her back. CNA A then secured the new brief. During an interview on 2/05/2026 at 12:35 PM CNA A stated when I moved from the dirty to the clean area, I should have washed my hands. I was dirty after I wiped her. I probable cross-contaminated. CNA A reported a problem with no performing hand-hygiene properly was it could cause poop. CNA A reported she had been trained in hand-hygiene by the former DON. During a group interview on 2/06/2026 at 10:17 AM with the Corp RN and DON, the Corp RN reported she expected staff to perform hand hygiene before they begin incontinent care, when they move from any dirty to clean portion of the care, and when they complete the incontinent care. The Corp RN reported this was done to prevent infection and if a staff member does not complete proper hand hygiene, then they will cause cross contamination with their care. The DON reported he agreed with everything the Corp RN said but he would like to add he expects staff to use ABHR before entering the resident room. Record review of the facility provided training titled Hand Hygiene provided to staff on 12/02/2025 revealed CNA A was trained on the following: Hand HygieneYou may use alcohol-based hand cleaner or soap and water for the following:-upon and after coming into contact with a resident's intact skin.-after coming into contact with a resident's mucous membranes and body fluids or secretions.-after removing gloves or aprons. Record review of the facility provided policy titled Perineal Care effective 05/11/2022, revealed the following: Important Points - Always perform hand hygiene before and after glove use.

Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 4 of 6 staff (SNA A, SNA B, SNA C, SNA D) reviewed for nursing services. The facility failed to ensure the following: -SNA A failed to perform hand hygiene before, during, or after incontinent care for Resident #1. -SNA B failed to perform hand hygiene before assisting with incontinent care for Resident #1. -SNA C failed to perform hand hygiene before or after assisting with incontinent care for Resident #2. -SNA D failed to perform hand hygiene before, during, or after incontinent care for Resident #2. -SNA D wiped back to front during incontinent care for Resident #2 This failure placed residents at risk of receiving care that is performed by untrained staff which could result in increased risk of infection or skin breakdown. Findings included: During an observation on 05/13/2025 at 9:44 AM SNA A and SNA B started to perform incontinent care for Resident #1, but failed to perform hand hygiene before care was started. SNA A performed perineal care and cleaned Resident #1. No glove change or hand hygiene was performed after cleaning the dirty areas of Resident #1, before picking up a clean brief to put on Resident #1. SNA A proceeded to touch Resident #1 and her clothing, bedding, and items on night stand. During an interview on 05/13/2025 at 9:56 AM SNA A stated the negative outcome for not performing hand hygiene would be that the resident did not receive the correct care. During an interview on 05/13/2025 at 9:59 AM SNA B stated the negative outcome for not performing hand hygiene would be that we could spread germs from one resident to another. During an observation on 05/13/2025 at 11:29 AM 05/13/2025 at 11:29 AM SNA C and SNA D performed incontinent care on Resident #2. Neither SNA's performed hand hygiene before starting incontinent care for Resident #2. SNA D used one wipe more than once and wiped back to front and not front to back when performing perineal care. SNA D then proceeded to place a clean brief on Resident #2 while the dirty brief was still in place, the dirty brief touched the clean brief. No glove change or hand hygiene were performed at any time during the incontinent care of Resident #2. SNA C took soiled wipes from SNA D and would throw them in the trash for SNA D and then return to holding the resident on her side so that SNA D could perform incontinent care on the back side or Resident #2. SNA C then touch the clean brief, residents clothing, and the blankets of Resident #2 with no glove change or hand hygiene was performed. Neither SNA performed hand hygiene after care was completed. During an interview on 05/13/2025 at 11:41am SNA D stated that she used multiple wipes during incontinent care and that is how I was taught how to do it, that is how I was trained. SNA D could not provide a negative outcome for the resident. During an interview on 05/13/2025 at 11:46 AM SNA C stated she had not been taught how to perform perineal care for residents. SNA C was unable to provide a negative outcome for not performing hand hygiene during incontinent care. During an interview on 05/13/2025 at 4:28 PM with CO-RN stated that the previous ADON whose last day was last Friday was supposed to have trained 3 of the SNAs and has their documentation. The documentation cannot be found for SNA B, SNA C, and SNA D due to previous ADON having their documentation. During an interview on 05/13/2025 at 5:41 PM DON stated the negative outcome for having staff who do not have the appropriate qualifications could lead to abuse, neglect, and increased infections for the residents. DON stated the SNAs come in for orientation, and further training, which will include training on the floor in the facility. Then they will get clinical training on top of that which will equal 40 hours over a 6-8-week time frame with clinical educators. Record review of Texas Nurse Aide Performance Record for SNA A, training start date: 03/18/2025, training end date: 05/02/2025, revealed the following: .6. Hand washing was completed on 03/18/2025 with a satisfactory for her clinical check-off. . 21. Perineal care/incontinent care-Female (with or Without catheter) (l, P) was completed on 04/23/2025 with a satisfactory for her clinical check-off. No trainings were found for SNA C or SNA D Record review of the facility provided policy titled, Student Nurse Aide dated 2010, revealed: .Only perform patient care areas that the student has received training for . .Ability to comply with the patient [NAME] of Rights and the employee responsibilities. .Ability to comply with Company and departmental safety policies and procedures. .Accountable for personal care (i.e., grooming, bathing, catheter care, pericare, and dressing), and observation of residents within patient care policy guidelines.

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 3 of 3 resident care areas (Resident #1, #2 and Resident #3) and 5 of 6 facility staff (SNA A, SNA B, SNA C, SNA D, and SNA F) reviewed for infection control. The facility failed to ensure that facility staff performed hand hygiene appropriately during incontinent care. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. Findings included: During an observation on 05/13/2025 at 9:44 AM SNA A and SNA B started to perform incontinent care for Resident #1, but failed to perform hand hygiene before care was started. SNA A performed perineal care and cleaned Resident #1. No glove change or hand hygiene was performed after cleaning the dirty areas of Resident #1, and before picking up a clean brief to put on Resident #1. SNA A proceeded to touch Resident #1 and her clothing, bedding, and items on night stand. Neither SNA A nor SNA B performed hand hygiene after the conclusion of incontinent care of Resident #1. During an interview on 05/13/2025 at 9:56 AM SNA A stated the negative outcome for not performing hand hygiene would be that the resident did not receive the correct care. During an interview on 05/13/2025 at 9:59 AM SNA B stated the negative outcome for not performing hand hygiene would be that we could spread germs from one resident to another. During an observation on 05/13/2025 at 11:29 AM SNA C and SNA D performed incontinent care on Resident #2. Neither SNA's performed hand hygiene before starting incontinent care for Resident #2. SNA D used one wipe more than once and wiped back to front and not front to back when performing perineal care. NA D then proceeded to place a clean brief on Resident #2 while the dirty brief was still in place, the dirty brief touched the clean brief. No glove change or hand hygiene were performed at any time during the incontinent care of Resident #2. SNA C took soiled wipes from SNA D and would throw them in the trash for SNA D and then return to holding the resident on her side so that SNA D could perform incontinent care on the back side or Resident #2. SNA C then touch the clean brief, residents clothing, and the blankets of Resident #2 with no glove change or hand hygiene performed. Neither SNA performed hand hygiene after care was completed. During an interview on 05/13/2025 at 11:41am SNA D stated she used multiple wipes during incontinent care and that is how I was taught how to do it, that is how I was trained. SNA D could not provide a negative outcome for the resident for not performing hand hygiene during incontinent care. During an interview on 05/13/2025 at 11:46 AM SNA C stated she had not been taught how to perform perineal care for residents. SNA C was unable to provide a negative outcome for not performing hand hygiene during incontinent care. During an observation on 05/13/2025 at 2:34 PM SNA E and SNA F performed incontinent care for Resident #3. SNA F was complete with cleaning Resident #3 and doffed gloves but failed to perform hand hygiene before placing clean gloves on to place clean brief on Resident #3. During an interview on 05/13/2025 at 2:50 PM with SNA F stated that the negative outcome for residents would be cross contamination and an increased chance of infection. During an interview on 05/13/2025 at 5:41 PM DON stated the negative outcome for staff not performing hand hygiene during incontinent care for residents could lead to an increase of infections for the residents. Record review of the facility provided policy titled, Fundamentals of Infection Control Precautions undated, revealed: .1. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. . Before and after entering isolation precaution settings; . .Before and after assisting a resident with personal care (e.g., oral cre, bathing); . .After contact with a resident's mucous membranes and body fluids or excretions; . .After removing gloves or aprons; . Record review of the facility provided policy titled, Hand Washing dated 2012, revealed: We will ensure proper hand washing procedures are utilized. Record review of the facility provided policy titled, Perineal Care dated 05/11/2022, revealed: . Procedure content . .Start . .10) Perform hand hygiene . .17)Gently perform perineal care, wiping from clean, urethral area, to dirty rectal area to avoid contamination the urethral area - CLEAN to DIRTY!' Female resident: Working from front to back, . .BACK . . 21) Gently perform care to the buttocks and anal area, working form front to back without contamination the perineal area . .24) Doff gloves . .25) perform hand hygiene. .CONCLUDE . 26) provide resident comfort . .31) perform hand hygiene .

Based on observation, interview, and record review; it was determined the facility failed to ensure each resident was provided privacy during personal care, for 1 of 3 residents reviewed for Resident rights (Resident #2). Facility failed to provide dignity and respect for Resident #2 by providing privacy during incontinent care. The facility's failure could place residents at risk of not being treated with respect, dignity, and care in a manner that protects and promotes the rights of the residents. Findings include: Resident #2 Record review of Resident #2's clinical record, dated 05/13/2025, revealed Resident #2 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia)), atherosclerotic heart disease of native coronary artery without angina pectoris (a heart condition where atherosclerosis (buildup of plaque) in the heart's blood vessels (coronary arteries) is present, but the individual doesn't experience chest pain (angina)), history of transient ischemic attack (TIA) (a past episode of temporary neurological dysfunction caused by brief, localized blockage of blood flow to the brain), and cerebral infarctions without residual deficits (a past episode of a stroke (cerebral infarction) where the damage to the brain tissue resulted in permanent neurological deficits, but the individual has recovered from these deficits, leaving no lasting impairment), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), epilepsy (a chronic neurological condition characterized by recurrent, unprovoked seizures). Record review of Resident #2's most recent MDS assessment, dated 03/01/2025, indicated Resident #2 had a BIMS of 14, indicating no cognitive impairment and a functionality of total dependency or maximal assistance was required in all care areas except moderate assistance needed with upper body dressing. Resident required touch assistance with eating and oral hygiene. During an observation on 05/13/2025 at 11:29 AM SNA C and SNA D did not shut Resident #2's blinds to her room or shut the door to Resident #2's room to provide privacy during incontinent care. During the time incontinent care was being provided to Resident #2, unidentified person walked by Resident #2's bedroom window twice. During an interview on 05/13/2025 at 11:41 AM SNA D stated Resident #2 did not like for her window blinds to be closed during the day even during patient care. SNA D stated this is how I was trained. SNA D could not give a negative outcome for the resident by not providing privacy to the resident. During an interview on 05/13/2025 at 11:46 AM SNA C stated she had not been trained on how to perform incontinent care for a resident. SNA C could not give a negative outcome for the resident by not providing privacy to the resident. During an interview on 05/13/2025 at 11:50 AM Resident #2 stated the staff are supposed to close the blinds and door during resident cares. Resident #2 stated she did not want someone to walk by and see her naked. The trash and dirty laundry are taken out of those doors right there (Resident #2 pointed out the window to a door across the open area), and most of the time it is men who are doing that. I don't want them seeing me. During an interview on 05/13/2025 at 5:41 PM DON stated a negative outcome for not providing privacy to the residents could lead to embarrassment and there is a lack of dignity for the resident. Record review of the facility's policy titled Residents Rights, revised 11/28/2016, revealed: .The resident has a right to be treated with respect and dignity, . .The resident has a right to personal privacy . Record review of the facility provided policy titled, Perineal Care dated 05/11/2022, revealed: .7) Provide privacy and modesty by closing the door and/or curtain .

Based on observations, interviews, and record reviews the facility failed to treat each resident with respect, dignity, and care for each resident, in a manner and environment that promotes the maintenance or enhancement of his or her quality of life, while respecting each resident's individuality. The facility failed to protect and promote the rights of 3 of 8 residents (Residents #1, #2, and #3) reviewed for resident rights. The facility failed to ensure Resident #1 was served a meal with napkins, dinnerware and cutlery which were non-disposable. Resident #1 was served a meal with a Styrofoam plate and cup and plastic cutlery as a form a convenience for facility staff. The facility failed to ensure the full visual privacy of catheter bag contents for two residents (Residents #2 and #3) by using privacy covers. These failures could cause residents to feel uncomfortable, embarrassed and disrespected. Findings included: Record review of Resident #1's clinical record reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Mild Cognitive Impairment of Uncertain or Unknow Etiology (brain changes occurring in the very early stages of Alzheimer's or other neurodegenerative diseases that cause dementia), and Major Depressive Disorder, Single Episode, Mild (a mental health condition that causes a persistent feeling of sadness and loss of interest in activities that were once enjoyable). Resident #1 had a BIMS score of 15 indicating she was cognitively intact. An interview with Resident #1 on 04/01/2025 at 9:47AM revealed she had awoken the morning of 03/27/2025 to find her breakfast tray on her bedside table. Resident #1 stated she wanted some hot coffee and tried to locate her call light. Resident #1's call light had fallen off her bed in the night and she was unable to reach it to summon a CNA. Resident #1 is ambulatory but was experiencing hip pain the morning of 03/27/2025 and had chosen to stay in bed. Resident #1 stated she took the cover off her breakfast plate and used her knife to tap on the side of the plate to get someone's attention. CNA B came into the room and asked Resident #1 why she was banging on the plate and not using her call light, like she was supposed to. CNA B told Resident #1 she was going to break the plate and get glass in her eyes if she kept doing that. CNA B retrieved the call light and clipped it onto Resident #1's blanket and then proceeded to write on the dining slip on the breakfast tray that Resident #1 could no longer have regular plates, cups, and silverware. She was to have only Styrofoam and plastic. Resident #1 stated CNA B put the slip back on her tray and left the room to get her some coffee. When CNA B returned with the coffee, Resident #1 asked if she were being punished. CNA B told her eating on a foam plate and using plastic utensils was for her own safety. Resident #1 stated her RR came to visit her shortly after breakfast and her breakfast tray was still sitting on her bedside table. She told her RR what happened, and the RR immediately took the dining slip with the written request for Styrofoam and plastic dinnerware and told Resident #1 she would take care of the situation. Resident #1 thought her RR had spoken with LVN A after the incident. Resident #1 stated she had received all meals since the lunch meal on 03/27/2025 on regular China with regular utensils but felt embarrassed receiving her lunch on a Styrofoam plate with plastic utensils. An interview with LVN A on 04/01/2025 at 10:00AM reflected on 03/27/2025 CNA B had written on the breakfast dining slip that Resident #1 was to have only Styrofoam and plastic dinnerware. LVN A stated she questioned CNA B on who told her to request the foam and plastic dinnerware for Resident #1. CNA B told LVN A no one had told her to put in the request; she had done it on her own to keep Resident #1 from banging on her plate with her knife and possibly becoming injured. LVN A stated she told CNA B she should have come to her first as the Charge Nurse to discuss the incident, before deciding to make the request to the kitchen on her own. LVN A asked CNA B what she had done with the dining slip and CNA B told her she left it on Resident #1's tray so the kitchen staff would see it before lunch. LVN A stated she spoke with Resident #1's RR who was still visiting at that time, about the incident, and was asked by the RR if Resident #1 was being punished for some reason. Resident #1's RR asked LVN A not to say anything to administration and told LVN A she would take care of the situation on her own. An interview with the DON on 04/01/2025 at 11:00AM reflected she was unaware of the incident between CNA B and Resident #1. The DON stated she had not been at work on Thursday or Friday, March 27th and 28th of prior week and no one had come to talk to her about the incident. She stated she would call CNA B immediately to find out the details of the incident and what disciplinary steps needed to be taken against CNA B. She stated she would also speak with Resident #1, her RR and LVN A. An interview with Resident #1's RR on 04/01/2025 at 5:13PM revealed she felt as if Resident #1 had been embarrassed by CNA B. The RR verified CNA B had written on the breakfast slip from 03/27/2025 Resident #1 was to have only Styrofoam and plasticware. The RR stated Resident #1 was served the lunch meal on a Styrofoam plate with plastic utensils on 03/27/2025, but all other meals since that time had been served on regular China with regular utensils. The RR stated she spoke with LVN A about the situation and asked her not to say anything to administration for fear of pushing too hard and causing problems. Record review of Resident #2's clinical record revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (dementia which presents with behaviors which are more mild and less aggressive and can present a disconnect between actual life circumstances and the person's state of mind or feelings), Major Depressive Disorder, Recurrent, Severe without Psychotic Features (an episode of depression in which loss of self-esteem, worthlessness and guilt are present), Charcot's Joint, Right Ankle and Foot (a rare condition caused by complications of diabetes-related neuropathy which causes bone and joint fragmentation), and Type 2 Diabetes without Complications (a condition where the body cannot use insulin correctly and sugar builds up in the blood). Resident #2 had a BIMS score of 00, indicating she was severely cognitively impaired. An observation of Resident #2 on 04/01/2025 at 10:10AM revealed she was sitting in her wheelchair by the nurse's charting station while CNA C was charting. Resident #2's catheter bag contents were clearly visible, and no privacy cover was in place. An attempt to interview Resident #2 was not successful due to her level of cognition. Record review of Resident #2's physician orders dated 03/21/2024 revealed the following: Ensure foley bag is in privacy bag while in bed or wheelchair, every shift. An interview with CNA C on 04/01/2025 at 10:12AM reflected he was not sure if Resident #2 minded if her privacy bag was not covering her catheter bag contents, but stated, It must have fallen off! [Resident #2] had it at breakfast; I don't know what happened. CNA C immediately went to Central Supply to replace Resident #2's privacy bag. CNA C stated the negative outcome of not having a privacy bag would be Resident #2 might become embarrassed or feel bad about herself. Record review of Resident #3's clinical chart revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Sepsis, Unspecified Organism (a serious condition in which the body responds improperly to infection), Addison's Disease (a condition where the body doesn't make enough of the hormones cortisol and aldosterone), Multiple Sclerosis (a disease that causes breakdown of the protective covering of the nerves), [NAME] (an intestinal bleed involving black, tarry stools from the upper gastrointestinal tract), Systemic Lupus Erythematosus, Unspecified (an auto-immune disease where the body mistakenly attacks healthy tissue, skin, joints, kidney, brain and other organs), and Neuromuscular Dysfunction of Bladder, Unspecified (the nerves of the brain or spinal cord are damaged and the sphincter muscles of the bladder can no longer work correctly). An observation of Resident #3 on 04/01/2025 at 1:30PM revealed she was laying in her bed with her catheter bag clipped close to the end of the bed. There was no privacy cover, and the bag was able to be seen from the hallway, when the door to the room was open. An interview with Resident #3 was unsuccessful due to her unresponsiveness and end-of-life circumstances. An interview with Resident #3's RR on 04/01/2025 at 1:33PM reflected Resident #3 had not had a cover on her catheter bag since Friday, March 28th when she started Hospice services. The RR stated Resident #3 would be so embarrassed if she knew the bag was hanging from the bed with no covering. Resident #3's RR stated the communication in the facility had been less than helpful. She had asked 2 unnamed CNAs if they could get privacy covers for the bag over the weekend, but neither had returned with the covers. Record review of Resident #3's physician orders dated 03/16/2025 revealed the following: Resident to be bed bound due to pain/end-of-life, two times a day for Hospice/end-of-life related to Sepsis, Unspecified Organism. Ensure Foley bag is in privacy bag while in bed or wheelchair every shift related to Neuromuscular Dysfunction of Bladder, Unspecified. Record review of the facility's undated policy for Resident Rights did not reflect written policy for the use of regular China and utensils or privacy bags over catheter bags.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure all food in the dry pantry and cold storage areas were properly sealed, labeled and dated. These failures could place residents at risk of residents at risk of food-borne illness and a diminished quality of life. Findings included: On [DATE] at 7:08AM an initial observation of the kitchen was conducted, and the following was noted: Dry Pantry: (2) 1.57-pound of bags of cream soup base-best by date [DATE]. (5) 24-ounce containers of quick grits-best by date [DATE]. (1) partial food service bag of elbow macaroni-no date, open to air. (6) 24-ounce packages of pepper gravy mix-no date. (7) 28-ounce boxes of creamy wheat cereal-no date. Cold Storage Unit: (2) 3-count each packages of English cucumbers-no label, no date. (1) partial 3-pound bag of hot dogs-no label, out of freezer date [DATE]. (1) partial gallon container of lime juice-best by date [DATE]. (1) 1-gallon zip closure bag of sausage links-no label, date on bag [DATE]. (1) partial 5-pound bag of Queso Cotija cheese-open to air. (1) partial 5-pound bag of feta cheese-open to air. (3) 1-gallon bags of scrambled eggs-use by date [DATE]. An interview with the Dietary Manager [DATE] at 1:02PM revealed the negative outcome of residents eating foods which were not labeled and dated was they could become sick if they ate foods which were expired and the quality of foods might deteriorate, if not used by the use by date. She stated she in-serviced the kitchen employees immediately after this surveyor's initial visit to the kitchen, using the following undated, Proper Food Storage training from the American Association of Nutrition and Food Service Professionals: Reseal, label and date all products. Use products within the use by dates stated on the original package. Sealed fin an airtight manner. (Containers with tight fitting lids or Ziploc bags) All leftover foods or foods removed from their original containers require proper labeling when stored, including item identification, date of preparation, and date foods are to be used or discarded. When to date: At the time food is being removed from its original container and placed in another container. At time leftover foods are removed from either hot or cold handling and placed in a container. When foods are received/dated-check the manufacturer's expiration dates upon delivery. How to Avoid a Survey Tag: Clearly label food item. Date when received, prepared, and opened. Practice First In, First Out method. Routinely check storage for proper labeling and dating. What to do: Utilize a clearly marked label. Identification of item in container/bag. Refer to storage guidelines for safe storage timeframe. Discard items by manufacturer expiration or use by date.

Based on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #171) of 18 residents observed for accident hazards. -Resident #171 had an oxygen bottle/cylinder left unsecured in her room. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, and feeling of isolation. Findings include: Record review of the clinical record for Resident #171 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include aftercare following joint replacement surgery, malnutrition (lack of proper nutrition), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), hypertension, (a condition in which the force of the blood against the artery walls is too high), and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #171's clinical record revealed she had been in the facility 6 days and an MDS was not due to be completed. Record review of Resident #171's clinical record revealed a care plan with the following: admitted : 11-14-2024 Focus: The resident has oxygen therapy. Date initiated - 11-14-2024. Record review of Resident #171's clinical record revealed active orders as of 11-20-2024. Resident #171 had no orders for Oxygen therapy. Record review of Resident #171's clinical record revealed a Medication Administration Record for the month of November 2024 with no administration of oxygen therapy listed. During an observation on 11-20-2024 at 07:18 AM revealed Resident #171 was in her room laying on her bed (Bed B) under her covers and did not wake to knocking or introduction. Resident #171's room was noted to have an oxygen bottle lying at the foot of the mattress on the second bed (Bed A that was unoccupied due to Resident #171 did not have a roommate) that was not secured. During an observation and interview on 11-20-2024 at 10:56 AM revealed Resident #171 was in her room sitting in her chair. Observation revealed the unsecured oxygen bottle had been removed from the room. Resident #171 reported that she had never used oxygen, that she was aware that someone came into her room a day or two ago and placed the oxygen bottle on the extra bed, and that she was not aware of who the oxygen bottle belonged to. Resident #171 was unable to remember who placed the oxygen bottle on the second bed. During an interview on 11-21-2024 at 10:48 AM CNA E (CNA for the hall Resident #171 was on this shift) reported that an oxygen bottle should not be left unsecured on a resident's bed because it could fall and explode and that could result in an injury to a resident. CNA E verified that she had been trained through the facility online training system on oxygen safety and that she was not the one who placed the oxygen bottle on the bed. During an interview on 11-21-2024 at 01:26 PM LVN A (a nurse from a different hall that Resident 171 was on) reported that an oxygen bottle should be stored upright and secured in the oxygen room away from any flames. LVN A reported that an oxygen bottle should never be placed unsecured on a resident's bed and that if it was the oxygen bottle could fall off the resident's bed resulting in an injury to a resident or staff. LVN A verified that he had been trained through the facility online training system on oxygen safety and that he had not worked on Resident #171's hall. During an interview on 11-21-2024 at 01:47 PM the DON reported that all oxygen tanks should be stored in a carrier either on the resident's wheelchair or in a secured carrier when transported, that if an oxygen tank was not secured such as with placing on a resident bed, then the tank could fall and explode resulting in an injury to either a resident, family, or a staff member. The DON reported that she suspected that either a hospice staff member had placed the oxygen bottle on the mattress or when the resident was admitted she entered the facility on oxygen and whoever brought her in left it on the bed. The DON stated that she could not be sure of who put the oxygen bottle on the bed. Record review of the facility provided policy titled Compressed Gas, Safe Handling of reviewed 12-10-2015, revealed the following: 11. When tanks are stored, all tanks and cylinders should be stored in a cylinder cart or securely chained in a secure storage area. Never leave cylinders free-standing. All cylinders must be individually secured.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #4) of 4 residents reviewed for respiratory care. The facility failed to administer oxygen at the correct dose for Resident #4. This failure could affect all resident on oxygen therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Record review of Resident #4's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 5-8-2017 and readmitted on [DATE] with diagnoses to include chronic respiratory failure (a long-term condition that occurs when the body's respiratory system can't exchange oxygen and carbon dioxide properly) with hypoxia (low level of oxygen in your body tissue), pneumonia (lung inflammation caused by a bacterial or viral infection), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), diabetes, (a chronic condition that affects the way the body processes blood sugar (glucose), and history of pulmonary embolism (clot blocking blood flow to lungs). Record review of Resident #4's clinical record revealed her last MDS was a quarterly completed 10-4-2024 listing her with a BIMS of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring partial/moderate assistance with most of her activities of daily living. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #4 was marked as having oxygen While a Resident. Record review of Resident #4's Order Summary Report with Active Orders as of 11-20-2024 revealed the following order: -Oxygen @__3__l/m via nasal canula PRN as needed for Shortness of Breath related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA - Active 06-18-2021 Record review of Resident #4's clinical record revealed a care plan with the admitted [DATE], last review date of 10-8-2024 revealed the following: Focus: Resident has Oxygen Therapy R/T CHRONIC RESPIRATORY FAILURE W/ HYPOXIA, RESIDENT EXPERIENCES SOB at times Date Initiated: 07-25-2017 Revision on: 08-03-2022 Goals: The resident will have no s/sx of poor oxygen absorption through the review date. Date Initiated: 07-25-2017 Revision on: 04-28-2023 Target Date: 12-09-2024 Procedure: Apply O2 as ordered. Date Initiated: 07-25-2017 During an observation and interview on 11-20-2024 at 07:52 AM revealed Resident #4 was in her room eating her breakfast. Resident #4 was wearing oxygen via a nasal cannula (NC) at 5L/min. Resident #4 reported that staff provided all her oxygen care, and that she had no concerns. During an observation on 11-20-2024 at 11:39 AM revealed Resident #4 was sleeping in her bed with her oxygen on via NC at 5L/min. During an observation on 11-21-2024 at 07:25 AM revealed Resident #4 was sleeping in her bed with her oxygen on via NC at 5L/min. During an observation on 11-21-2024 at 09:48 AM revealed Resident #4 was sleeping in her bed with her oxygen on via NC at 5L/min. During an observation and interview on 11-21-2024 at 10:19 AM revealed LVN A (the nurse responsible for Resident #4 this shift) entered Resident #4's room and checked her oxygen. LVN A reported that Resident #4's oxygen was currently at 5L/min via her nasal canula which Resident #4 was wearing and that to his knowledge that was too high. LVN A then turned the Oxygen level/dose down. LVN A reported he was going to verify the correct oxygen dose that Resident #4 was ordered to be on. LVN A checked Resident #4's chart and verified the current orders were for Resident #4's oxygen to be at 3L/min and reported that he would immediately ensure that Resident #4's oxygen dose was corrected. LVN A reported that oxygen that was administered at too high of a dose was a medication error and that giving a resident to much oxygen could affect a resident negatively, that it could compromise the resident's ability to breath. During an interview on 11-21-2024 at 01:49 PM the DON reported that she expects her staff to follow all physician's orders in a timely manner. The DON stated that if a staff member questions a physician order, then she expected them to call and clarify that order before implementing the order. The DON reported that she expected all orders to be checked every shift and ensure that they were accurate and implemented correctly. The DON verified that not following an oxygen order was considered a medication error and that administering too much oxygen could result in hyperinflation or O2 toxicity for a resident. Record review of the facility provided policy titled Oxygen Administration reviewed 2-13-2007, revealed the following: Goals: 1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.

46534 Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #45 and Resident #221) of 18 residents reviewed for infection prevention and control. 1. The facility failed to keep Resident #45's nasal cannula off the floor. 2. The facility failed to keep Resident #221's catheter bag off the floor. These failures could place residents at risk of infections, secondary infections, tissue breakdown, and communicable diseases. Findings Included: 1. Record review of Resident #45's admission record dated 11/22/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but were not limited to Alzheimer's, heart failure, and major depressive disorder. Record review of Resident #45's significant change MDS completed on 11/15/24 revealed the following: Section C: Resident #45 had a BIMS of 4 which indicated severely impaired cognition. Section O: Resident #45 was receiving oxygen therapy while a resident. Record review of Resident #45's care plan revealed a completion date of 09/18/24 and no mention of oxygen therapy. Record review of Resident #45's active orders dated 11/22/24 revealed an order with start date of 11/07/24 for oxygen use via nasal cannula as needed at 2-3 liters per minute to maintain blood oxygen saturation above 90 % and an order with start date of 11/14/24 for oxygen use at 2 liters per minute twice a day as needed for shortness of breath and anxiety. During an observation and interview on 11/20/24 at 07:35 AM Resident #45 was in her room lying in her bed with an oxygen concentrator on and sitting next to the bed. The nasal cannula was rolled up on the floor under her bed with the nasal prongs in direct contact with the floor. Brownish discoloration noted to the nasal cannula. Resident #45 stated she did not need or wear oxygen. During an observation on 11/20/24 at 09:01 AM Resident #45 was observed lying in her bed receiving oxygen via nasal cannula. During an interview on 11/21/24 at 01:24 PM LVN A stated nasal cannulas used for oxygen therapy should be stored in a plastic bag off the floor, so the nasal cannula did not touch the floor. He stated if the nasal cannula did touch the floor, it would become contaminated and put the resident at risk of developing an infection. During an interview on 11/21/24 at 01:45 PM DON stated oxygen tubing and nasal cannulas were to be stored in a bag if not on the resident. She stated if the nasal cannula came into contact with the floor, then it would become contaminated and would need to be replaced. DON stated if a nasal cannula that came into contact with the floor was not replaced, the resident would be at risk for contamination and infection. 2. Record review of Resident #221's admission record dated 11/21/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, encounter for surgical aftercare following surgery on the circulatory system, cancer of tongue, gum, lung, and lymph nodes, and retention of urine. Record review of Resident #221's MDS tab in his EHR revealed an Admission MDS in process. Record review of Resident #221's care plan initiated on 11/07/24 revealed a focus area regarding enhanced barrier precautions for catheter care initiated on 11/07/24 and resolved on 11/21/24. The goal was There will not be any transmission of infection from or to the resident. Record review of Resident #221's completed orders revealed the following: An order with end date of 11/20/24 to change his Foley catheter once a month. An order with an end date of 11/20/24 for foley catheter to gravity drainage. An order with an end date of 11/20/24 to ensure the catheter strap (holds tubing for catheter to leg of resident) was in place and holding. An order with an end date of 11/20/24 to empty the catheter drainage bag. An order with an end date of 11/20/24 to monitor the catheter once a shift for leakage, blockage, sediment buildup, and low output. An order with an end date of 11/20/24 to ensure the catheter bag was in a privacy bag. During an observation and interview on 11/20/24 at 07:17 AM Resident #221 was seated in his wheelchair next to his bed and his catheter bag and approximately 1.5 feet of catheter tubing were lying on the floor next to him. He stated no one told him it was not okay to keep his catheter bag on the floor. During an observation and interview on 11/21/24 at 02:34 PM Resident #221 was lying on his back in bed. He said of his catheter, They (staff) took it out yesterday morning, thank the LORD. Stated staff had not educated him on keeping his catheter bag off the floor at any time since he had been in the facility. During an interview on 11/21/24 at 02:35 PM CNAs B and C stated their duties as CNAs with catheters were to empty the bag and to provide perineal care. Both CNAs stated it was never okay for the catheter bag to be on the floor. CNA B stated a catheter bag on the floor could be contaminated, resident could step on it and pull it out. During an interview on 11/21/24 at 02:38 PM DON stated nurses were responsible to insert and discontinue catheters and CNAs were responsible to empty the bag and do perineal care. She stated a possible negative outcome of a catheter bag on the floor was infection control is [the] biggest one or it could leak and [create a] risk of falls, or [the catheter could] get pulled out and cause trauma. During an interview on 11/21/24 at 02:43 PM ADM stated a possible negative outcome of a catheter bag on the floor was bacteria and infection control. During an interview on 11/22/24 at 09:00 AM ADON stated there was not a possible negative outcome for a resident if their catheter bag was on the floor. She said it would not affect infection control for a catheter bag to be lying on the floor. During an interview on 11/22/24 at 09:10 AM LVN D stated she worked on Resident #221's hall. She stated since he had been in the facility she had not noticed his catheter bag on the floor. She stated a possible negative outcome of a catheter bag on the floor was, It can get a leak and it is an infection control problem. During an interview on 11/22/24 at 09:14 AM LVN D stated after she thought about the question more she remembered Resident #221 placing his catheter bag on the floor and she remembered educating him not to do so. Record review of facility policy titled Infection Control Plan: Overview and dated 03/2024 revealed the following: . The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The intent of this policy is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control to the extent possible, the onset and spread of infection within the facility. Record review of facility policy titled Catheter Care and dated February 13, 2007 revealed the following: . 5. Check the resident frequently . Keep tubing off floor . 10. Be sure the catheter tubing and drainage bag are kept off the floor. Record review of facility policy titled Oxygen Administration and dated February 13, 2007 revealed the following: . Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l min) by cannula . The policy did not address oxygen tubing storage or infection control.

Based on interview and record review, the facility failed to report an alleged violation of injury of unknow origin immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation resulted in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for one (Resident #1) of 8 residents reviewed for injury of unknow origin. The facility failed to report that resident #1 had a fall on 2-27-2024 resulting in a right intertrochanteric fracture (right hip fracture) for 38 days after the fracture occurred. This failure could affect residents by resulting in a delay of identification of injuries and lack of timely follow-up on recommended interventions to prevent serious bodily harm, or lasting physical impairment. Findings include: Record review of Resident #1 face sheet dated 4-17-2024 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include displaced intertrochanteric (extracapsular (outside a capsule or capsular thing) fractures of the proximal femur) fracture of the right femur (onset 2-28-2024), malnutrition(lack of proper nutrition), anxiety disorder(a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Alzheimer's(a progressive disease that destroys memory and other important mental functions), hypertension(a condition in which the force of the blood against the artery walls is too high), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and displaced intertrochanteric (extracapsular (outside a capsule or capsular thing) fractures of the proximal femur) fracture of the left femur (onset 2-20-2024). Record Review of Resident #1's last MDS was an admission completed 2-23-2024 with a BIMS of 4 indicating she was severely cognitively impaired, and she had a functionality of requiring partial/moderate assistance with most activities of daily living. Section C-Cognitive Patterns: C0400 Recall Resident #1 was listed 0 - No-could not recall. Record review of the facility provided Hospital Discharge Summary with date of service 2-29-2024 revealed the following: admitted : 2-27-2024 Admission Diagnoses: Fall, Right Intertrochanteric Fracture Record review of Resident #1's Progress Notes dated 2-27-2024 3:13 AM revealed the following: Per LVN A - Note Text: CNA notified this nurse that resident was on the floor. Upon entering the room resident was on the floor laying on her right-side. Her upper body and head laying on a pile of blankets. resident was near the bottom of the bed. Assessed ROM and c/o pain to Right upper thigh. Denies no other pain. resident denies hitting head. No other injuries noted at this time. x 2 assist to bed. Educated resident to use call light. Notified RP and DON. Also notified NP new order for Xray to right femur and right hip 2 view. Record review of neuro assessments (completed by LVN A) for Resident #1 with effective dates 2-27-2024 at 02:45 AM, 3:00 AM, 3:30 AM, 4:00 AM, and 4:30 AM revealed the following: b. Best Verbal Response 4) Confused - not oriented, but communication is coherent. During an interview on 4-16-2024 at 09:50 AM a family member reported that her mother did have dementia and would often become confused, that on the night of the fall Resident #1 was confused and thought that she had an appointment to get her teeth looked at and that her mother got out of bed thinking that she had an appointment. During an interview on 4-17-2024 at 08:07 AM the Administrator reported that the DON was not in the facility today, would not be available, and did not give a reason why. During an interview on 4-17-2024 at 08:27 AM the administrator reported that the incident with Resident #1 did not become an issue until the resident was discharged and, on the way, out of the facility a family member reported to a staff member that she was going to sue the facility for letting her mother fall resulting in her fracturing her hip. The Administrator reported that the incident/fall occurred on 2-27-2024 and that the CNA (who no longer works for the facility) found Resident #1 on the floor. Resident #1 was assessed, x-rays were ordered, and the original x-rays did not indicate a fracture but due to the residents continued pain Resident #1 was sent to the hospital were a second x-ray did find the fracture and surgery was completed to correct the fracture. The Administrator reported that the staff fallowed protocol and the resident's condition was addressed timely, all staff have been trained on ANE and have been retrained with this new report. When asked why the fall with fracture was not reported the Administrator reported that due to the resident making a specific statement that she was returning from the bathroom and that she would no longer wear socks because she fell , the facility felt the resident was able to explain what occurred and therefore the incident was not and injury of unknow origin. The Administrator stated, If there is any question or if the resident appears confused in any way, then we will report it but if the resident is clear then we determine that the resident is oriented and able to report what happened. During an interview on 4-17-2024 at 12:33 PM MDS C verified that she completed all section of Resident #1's 2-23-2024 MDS. MDS C verified that Resident #1 did have a BIMS of 4 and a 0 on all short-term memory questions, that Resident #1pretty much did not have any short term recall every time Resident #1 was interview meaning that Resident #1's short-term memory was poor. MDS C reported that Resident #1 often refused care to include therapy due to poor short-term memory leading to not being able to achieve any of her goals and not qualifying for skilled care because Resident #1 could not remember any of the tasks. When asked if Resident #1 could remember why she fell on [DATE] MDS C stated, Probably not. Her short-term memory was so poor she could be standing on the end of the bed or coming from the bathroom, and she would not remember. During an interview on 4-17-2024 at 1:04 PM the SW reported that Resident #1 had poor short-term memory and that she did agree with the MDS Coordinator that Resident #1 did not have the memory capability to recall why she fell on [DATE]. The SW reported that she interviewed Resident #1 on another incident that occurred on 3-9-2024 and she interviewed the Resident #1 again on 3-11-2024 and Resident #1 had no memory of that incident. During an interview on 4-17-2024 at 1:37 PM LVN C (nurse who assessed Resident #1 post the fall on 2-27-2024) confirmed that the CNA found the resident on the floor with the blankets under her head and reported that Resident #1 had a poor memory and history of forgetting immediately instructions that Resident #1 had been given by staff such as using the call light, where to put her laundry, or meal delivery. LVN A reported that she notified the Dr, family, and the DON, that reporting the fall and fracture were definitely something the facility needed to follow protocols and that is why she notified the Dr, family, and DON. During an interview on 4-17-2024 at 1:55 PM the Administrator (the Abuse/Neglect Coordinator) reported that due to Resident #1 making a very specific statement concerning not wearing socks and her fall the facility felt like the resident explained why she fell and that is why they determined that the fall was not an injury of unknown origin and therefore was not reportable. The Administrator reported that she felt like there were no negative consequences because they fallowed their facility ANE policy reporting guidelines. Record review of the facility provided policy titled Abuse/Neglect revised 3-29-2018, revealed the following: E Reporting 3. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, injury of unknown origin to the facility administrator. The facility administrator or designed will report to HHSC . a. If the allegations involve abuse or result in serious bodily harm, the report is to be made within 2 hours of allegation.

Based on observations, interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 7 residents (Resident #1) reviewed for care provided. The facility failed to ensure Resident #1's surgical incision on his ankle was properly assessed and received physician ordered daily dressing changes. The facility failed to ensure a physician ordered wound vac, gently pulls fluid from a wound over time, was placed on Resident #1's surgical incision to help with healing. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/19/23 at 2:24 p.m. While the IJ was lowered on 10/20/23 at 10:42 a.m., the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This facility failure led to Resident #1 being sent to the hospital with his left leg red, swollen and warm to touch which resulted in the resident being admitted to ICU for sepsis and left ankle wound with tendons exposed and mild swelling of the entire area with redness up to the knee. Findings Included: Record review of Resident #1's face sheet in his clinical record revealed the resident admitted to the facility on [DATE], was [AGE] years old with the following diagnoses: cellulitis of left lower limb (bacterial skin infection), dementia without behaviors, psychotic and mood disturbances, anxiety, atrial fibrillation (irregular, often fast heart rate), peripheral vascular disease (narrow blood vessels reduce blood flow to the limbs), COPD (airflow limitation), MRSA (severe staph infection), depressed mood, varicose veins (twisted, rough, enlarged veins), Chronic Kidney disease, cardiac pacemaker (prevents the heart from beating too slow), angina pectoris (chest pain), glaucoma (can cause vision loss), hypothyroidism (deficiency of thyroid hormones), diabetes (too much sugar in the blood), hearing loss, reflux, hypertension (high blood pressure), osteoporosis (weak and brittle bones), history of prostate cancer. Record review of Resident #1's face sheet indicated that his family member was his responsible party and medical power of attorney. Record Review of Resident #1's care plan, dated 9/8/23, documented the resident had cellulitis infection and was being treated with antibiotics and the facility should have monitored the incision/wound for increased signs of infection: swelling, drainage, redness, pain and warmth. The care plan documented the resident was resistive to care and did not want to change clothes when visibly soiled despite education, call family member if resident continues to refuse, educate resident/family /caregivers of the possible outcome(s) of not complying with treatment or care. Record review of Resident #1's quarterly/Medicare 5-day MDS resident assessment, dated 9/13/23, documented the resident had a BIMS score of 4 of 15, indicating severe cognitive impairment. The MDS assessment indicated that Resident #1 required limited assistance from staff for ADLs and had limited range of motion of one lower extremity. Record review of Resident #1's clinical record revealed that on 10/5/23, Resident #1 had surgery at Hospital A to remove a cancerous lesion on his left ankle. The surgical incision was left open and packed. Resident #1 returned to the facility with wound care orders for daily dressing changes. The orders sent to the facility with Resident #1 stated: daily dressing change left ankle: flush with NS or wound cleanser, lightly pack with iodoform gauze covered with gauze secured with kerlex and ace bandage as tolerated; keep left lower extremity elevated as much as possible. Record review of Resident #1's clinical record revealed the following physician orders for wound care: 10/5/23 -left ankle - clean with wound cleaner/normal saline, lightly pack with iodoform gauze then cover with gauze then wrap with Kerlex and ace bandage/coban as tolerated. Change daily. Keep left foot elevated as much as possible. 10/10/23 - continue with current orders until wound vac arrives then begin wound vac to lower left medial aspect. Cleanse with wound cleanser, apply wound vac at 125 mmhg continuous. Record review of Resident #1's clinical record revealed the following weekly skin assessments: 9/15/23 - completed by RN I - Resident's lower legs are wrapped. He did not want them messed with at this time. 9/21/23 - completed by RN I - Resident said he just went to the wound care doctor and did not need his dressing changed at this time so I could not unwrap his legs. 9/28/23 - no skin assessment documentation was found in Resident #1's clinical record for this date 10/5/23 - completed by WCN - wounds to bilateral feet 10/11/23 - Left lower dressing clean, dry and intact, bilateral lower extremities multiple scabs dry Record review of nurses notes in Resident #1's clinical record documented the following: 10/12/23 at 2:17 p.m. - Resident stated that the VA just did it (dressing change), left messaged {sic}for physician to be notified about Veteran's refusal of wound care at facility. Awaiting return call for new orders. Documented by WCN. 10/13/23 at 11:08 a.m. - tramadol oral tablet 50 mg - give one tablet by mouth every 8 hours as needed for pain. Resident complaining of pain in foot, nurse is aware - documented by WCN 10/13/23 at 4:07 p.m. - After getting Veteran to his room and agreeing to place wound vac, Veteran then changed his mind and would not let this nurse even removed old bandages. Attempted three times, will reapproach tomorrow.- documented by WCN 10/13/23 at 4:09 p.m. - would not let this nurse remove old bandages after agreeing and getting to his room. Attempted three times. Will reapproach tomorrow. - documented by WCN 10/13/23 at 6:19 p.m. - resident complained of pain to left foot, when asked it foot could be assessed, resident refused and stated. It's all bandaged up and we will have to take everything off and rewrap it again and it will just be a hassle. This nurse told resident we would need to make sure there was not an infection. Resident refused again on letting this nurse remove and assess wound. Pain medication was administered and follow up was assessed. - documented by LVN A 10/14/23 at 4:20 p.m. - refused three times - documented by the WCN 10/15/23 at 7:51 a.m. - resident was discovered on the floor. This nurse assessed resident, no injury noted and vital signs are within normal limits. Resident denies any pain, resident stated the he lost his balance from the recliner to the wheelchair. This nurse assessed resident to the wheelchair, This nurse informed the ADON, NP and POA. Documented by LVN B 10/15 23 at 8:41 a.m. - Resident #1 was transferred to a hospital on 10/15/23 at 8:43 a.m. related to per {family member's} request since resident #1 does not have a wound vac and has increased confusion. Documented by LVN B Record review of Hospital records concerning Resident #1's History and Physical dated 10/15/23 revealed the resident came to the emergency room as a transfer from the Hospital A due to elevated troponin levels (a protein that's released into the bloodstream during a heart attack). The resident presented to Hospital A with lethargy and weakness. The resident has dementia and was unable to provide a history. The family member was present to help provide the history. The family member states that the resident was recently found to have an ankle wound of his left lower extremity that was discovered to have squamous cell cancer. The resident had excision of the cancer and has been at the skilled nursing home for treatment. The resident was supposed to have a wound vac in place and it was ordered for the resident but the family member says that the staff lost it and the resident has been without the wound vac or treatment of the ankle wound. The family member saw the resident on Thursday (12th) and he was doing fine but upon seeing him today, she noticed that there was some redness around the ankle extending all the way up to the knee that she did not see before. While at Hospital A, the resident was found to have a troponin of 1900 (considered elevated level about 40 ng/L). A PICC line was placed and patient sent to Hospital B. Prior to this evaluation, his blood pressure dropped as low as 64/51. Physical Examination: Extremities: left ankle wound with tendons exposed. Mild swelling of the entire area with redness changes spreading up to the knee. During a confidential interview on 10/17/23 at 12:19 p.m., CI stated the facility had orders to change the dressings on Resident #1's left foot every day and to have a wound vac placed on his foot. CI stated Resident #1 was in ICU at that time with severe dehydration and a bad urinary tract infection. CI stated she went to the facility on Sunday (10/15/23) and as soon as she saw Resident #1, she knew something was not right. CI stated Resident #1's leg was swollen, puffy and it was warm to touch. CI stated his eyes were glassed over and he was not talking correctly. In addition, CI noticed the dressing on Resident #1's leg was dated 10/10/23 when the podiatrist changed the dressing. CI stated the nurse that was working on Sunday called her on Sunday after Resident #1 fell and the nurse told her that he had not seen a wound vac and there was not one on Resident #1's leg. CI stated, if Resident #1 was refusing care, why in the world did staff not call Resident #1's POA so the POA could talk to Resident #1 so he would get the care he needed? During an interview on 10/17/23 at 2:05 p.m., the DON stated the Wound Care Nurse who was out of the building right now but would be back shortly. The DON stated she knew that the nurses were doing really good documentation on Resident #1 refusing care and Resident #1 did not let the girls touch his leg at all. The DON stated Resident #1 was very non-compliant with receiving care. During an interview on 10/17/23 at 4:40 p.m., LVN C stated Resident #1 was his own person and if he told you he was not going to something, he was not going to do it. LVN C stated Resident #1 had been seeing a wound care doctor at Hospital A once a week, and he had a reaction to the antibiotic so they had to change the antibiotic. LVN C stated Resident #1 had poor circulation in his legs and always hasdtrouble with wounds on his legs but the wound care orders were daily but he always refused care. During an interview on 10/18/23 at 8:35 a.m., ADON D stated she took care of Resident #1. ADON D stated Resident #1 was a very sweet man but if he did not want to do something, he was not going to do it. ADON D stated she had not taken care of Resident #1 during the day but one night, she did and his bandages were clean, dry and intact. During an interview on 10/18/23 at 9:30 a.m., MA E stated Resident #1 was on her hall and always refused showers but they did their best to get him in the shower. MA E stated she has never helped with Resident #1's wound care. MA E stated if Resident #1 refused dressing changes, she would have reported that to the DON and put it in the computer. MA E stated if Resident #1 refused to do something, the nurse should have called his family member so she could talk to him and they also should be reporting it in the computer. During an interview on 10/18/23 at 9:45 a.m., RN F stated she had taken care of Resident #1 and he was in his 90's and he followed commands but he really did not want anyone to help him. RN F stated she had not done any wound care for Resident #1 after he had the procedure. RN F stated they had a wound care nurse and she was supposed to be changing his dressing and on the weekends, the nurse was responsible to do dressing changes. RN F stated she remembered seeing an order for a wound vac but after that she had not taken care of him. During an interview on 10/18/23 at 10:00 a.m., CS G stated Hospital A ordered the wound vac for Resident #1 and it came in last Thursday 10-12-23. CS G stated she told the WCN later that day that the wound vac came in and it was kept in her office. CS G stated she felt WCN tried to put the wound vac on Resident #1 that day and she brought it back in her office because she did not want to leave it at the nurses station. During an interview on 10/18/23 at 10:15 a.m., the DON stated Resident #1 was one of the projects that she took on and COVID did a number on his mental capacity. The DON stated Resident #1 got even more standoffish and he did not like to come out of his room. The DON stated Resident #1 was allergic to several medications and they had to send him to the hospital due to a reaction. The DON stated a new order came from the VA on the 10th for a wound vac and the WCN went down to Resident #1's room to put his wound vac on and he refused. The DON stated she thought the WCN went down to Resident #1's room four times wanting to look at his legs and Resident #1 refused and he fell on Sunday and was sent out to the hospital. The DON stated Resident #1 was always refusing dressing changes but he gets his dressing changed at the VA every week. The DON stated if a resident refused dressing changes for a few days, they would send the resident to the hospital. The DON stated the family should have been called and notified of Resident #1 refusing the wound vac and dressing changes. During an interview on 10/18/23 at 3:25 p.m., the WCN stated she had taken care of Resident #1. The WCN stated Resident #1 refused care because his ankle hurt him too bad. The WCN stated she had changed Resident #1's dressing two or three times after his procedure on the 5th. The WCN stated Resident #1's wound care order was changed to daily dressing changes on 10/5/23. The WCN stated she would call the doctor if there was a change of condition but Resident #1 did not have a change of condition. The WCN stated she called the VA and left a message for the doctor because Resident #1 was refusing dressing changes but she never received a call back. The WCN stated she looked back in the record and he had refused dressing changes frequently. The WCN stated she was Resident #1's wound care nurse on Friday and Saturday, she was Resident #1's actual nurse that day. The WCN stated Resident #1 was not complaining about any pain on Friday or Saturday. The WCN stated it was Resident #1's right to refuse care and dressing changes and she could not force Resident #1 to have his dressing changed. During an interview on 10/18/23 at 4:00 p.m. LVN H stated if she had a resident that kept refusing dressing changes, she would call the doctor and the family member and tell them about the resident's refusal. LVN H stated, How can you do a good skin assessment if you don't look under the dressing and see what was going on with the wound. LVN H stated if she had a resident with a bandage, she was going to look under it to see what the wound was doing. During an interview on 10/18/23 at 4:35 p.m., LVN A stated she attempted to change Resident #1's dressing on Friday (13th) because his foot was hurting and she needed to check on the wound but he refused. LVN A stated Resident #1 said changing his bandage would be a hassle. LVN A stated she remembered calling Resident #1's family member when he refused a shower but she finally got him to take a shower. LVN A stated if she had a resident who was refusing to have dressings changed, she would notify the ADON of the refusal. LVN A stated she did give Resident #1 a PRN pain medication for the pain he was having in his foot. An observation on 10/19/23 at 8:20 a.m. at Hospital B revealed Resident #1 lying in bed. Resident #1 was sitting up in bed, eyes blinking but seemed blurry, wearing glasses, wound vac on left foot and it was covered with a grippy sock and his left foot was twice the size of his other foot and there was a lot of yellowish fluid in the container on the wound vac and he had and IV fluids running continuously. During an interview on 10/19/23 at 11:25 a.m., when asked what her expectations when a resident refused dressing changes, the DON stated the nurse should have contacted the physician and family about the refusal and the sent the resident to the hospital. During an interview on 10/19/23 at 11:52 a.m., the Administrator stated the facility did not have a specific policy for when a resident refuses care or if they have a low BIMs score or are incompetent , they just follow the Resident Rights. During an interview on 10/19/23 at 12:15 p.m., Resident #1's primary physician stated apparently Resident #1 was refusing his dressing changes. Resident #1's primary physician stated the last time he saw Resident #1, he had some edema so he started him on Lasix (diuretic). When asked if he should have been notified of Resident #1 refusing dressing changes, the physician stated his expectation would be for the nurse to contact him if a resident was refusing dressing changes. During a call back on 10/19/23 at 12:25 p.m., Resident #1's primary physician stated he had just reviewed Resident #1's nurses notes and found where they had attempted to contact the doctor at Hospital A but they never reached out to him. During an interview on 10/19/23 at 12:35 p.m., Hospital A NP stated she honestly only assisted when Resident #1 has surgery on his ankle. Hospital A NP stated they should have called someone when Resident #1 was refusing dressing changes. During a follow-up interview on 10/19/23 at 12:45 p.m., Hospital A NP called back and stated she found documentation on 10/10/23 when Resident #1 came to Hospital A for a dressing change, the doctor had ordered a wound vac and documented the wound was worse. During an interview on 10/19/23 at 1:20 p.m., LVN B stated he did not usually take care of Resident #1 but the aide that morning (Sunday) informed him that Resident #1 was not eating and not feeling well and said his chest was hurting. LVN B stated Resident #1 had fallen that morning and he assessed him and notified Resident #1's family member of the fall. LVN B stated when Resident #1's family member arrived at the facility, she immediately asked about dressing changes and wanted to know where the wound vac was because it was not on his ankle. LVN B stated he checked the medication room and the main lobby and the mail room and he could not find a wound vac anywhere. LVN B stated Resident #1's leg was very red, swollen and warm to touch and he was very confused. LVN B stated he called the NP and informed her that Resident #1 did not have a wound vac in place and his ankle was very painful. LVN B stated Resident #1's family member said to send him to the hospital but he called the NP back and informed her of the need and the NP said to send Resident #1 out so he sent him to the hospital. LVN B stated he did not know that Resident #1 was refusing dressing changes. LVN B stated if a resident refused dressing changes, he would notify the family and the physician to see what needs to be done next. LVN B stated the resident does have the right to refuse but there was a risk when they do that and usually when staff or family talk to the resident, the resident will comply. Record review of Wound Treatment Management Policy, copyright 2021, documented the following: Policy: To promote wound [NAME] of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 5. Treatment decisions will be based on: a. Etiology of the wound: i. pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma calciphylaxis). b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size - including shape, depth and presence of tunneling and /or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. c. Location of the wound. d. Goals and preferences of he resident/representative. 6.c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound On 10/19/23 at 2:24 p.m., the Administrator was notified that an Immediate Jeopardy (IJ) had been identified. IJ templates were provided and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on 10/19/23 at 5:14 p.m. Plan of Removal Problem: Failed to Provide dressing changes Interventions: - 100 % skin rounds completed by 5 pm today on 10/19/23 by Administrative Nurses and Corporate Compliance Nurses. No additional skin issues noted. - The following in-services were initiated by Regional Compliance Nurse on 10/19/23: Any nurse not present or in-serviced on 10/19/23 will not be allowed to assume their duties until in-serviced. All newly hired staff will be in-serviced prior to taking an assignment. Licensed Nurse: - Wound prevention and treatment including providing treatment as ordered (wound vac) and initialing/dating dressing. - Documentation and accurate assessment of wounds. Including wound vac use and functioning. - Notification of Physician with change of condition or refusal of care immediately and if physician does not respond timely, notify Medical Director. - Refusal of care for residents who have decreased BIMs score or continued refusal of care. - Negotiated risk assessment and family notification - SBAR completion for physician and family notification of refusals - Social services will be notified of residents with continual refusal of care to address any psychosocial or cognitive issues. NA/CNA - Who to notify for refusal of care - Where to document refusal and notification of charge nurse The Medical Director was notified of the potential immediate jeopardy situation on 10/19/23 at 10:53 a.m. and off cycle QAPI was completed. Monitoring -The DON/designee will conduct wound rounds each wound weekly x 4 weeks. Monitoring will start 10/19/23. -The DON/designee will audit 10 skin assessments weekly to ensure all assessments match the resident's currently condition weekly x 4 weeks. Monitoring will start 10/19/23. -DON/designee will validate all wounds have treatment orders in place weekly x 4 weeks. Monitoring will start 10/19/23. -DON/designee will monitor for refusals of care using SBAR and follow up with family and physician 5 x weekly x 4 weeks. Monitoring will start 10/19/23. -Regional Compliance Nurse will monitor DON/Designee for monitoring compliance weekly x 4 weeks. Monitoring will start 10/19/23. -The QA committee will review the findings and make changes as needed monthly. Monitoring of the Plan of Removal included: On 10/20/23 at 8:10 a.m., the Administrator and DON were at the front door in-servicing staff who were not contacted prior to that day. The Administrator stated all staff who were working on the floor were in-serviced before starting their day. During interviews with facility staff conducted on 10/20/23 from 8:10 a.m. to 10:05 a.m., 42 of 52 nursing staff members verified that they had received in-service training covering change of condition, refusing care and reporting findings. All staff interviewed acknowledged and demonstrated understanding of the topics covered in the inservice training. The following staff were interviewed: DON, 6 LVNs, 2 ADONs, 2 Medication Aides, 1 Regional Nurse, 1 VP of the company, 3 Hospitality Aides, 2 CNAs, 1 RN, 1 SW and 1 COTA. An observation on 10/20/23 at 8:20 a.m., on a laptop on the 200 hallway had documented; Refusal of care of Change of condition: Did you notify the provider, did you receive a response, did you notify family and did you start an SBAR. An observation on 10/20/23 at 9:20 a.m., revealed on each hallway by the CNAs station and on every lap top, there was a posting that documented the following: Refusal of Care or Change in Condition: 1. Did you notify the Provider? 2. Did you receive a response? 3. Did you notify family? 4. Did you start a SBAR? Record review and an interview with the administrator on 10/20/23 at 10:15 a.m. Reviewed the binder the Administrator provided with all the in-serviced conducted so far. The Administrator stated staff that come into work at 2:00 p.m. and 11:00 p.m. today will be in-serviced as the arrive for work and will not clock in until they have been in-serviced. 1. The first section was labeled Plan of Removal and contained the accepted POR and the IJ Templets. 2. The second section was labeled In-Services which covered the following areas: a. Negotiated risk agreement - education a resident/family would be provided for refusals or negative behavior. 40 staff signatures b. Wound Prevention Strategies - 39 staff signatures c. Physician and family communication of condition change - 32 staff signatures d. Abuse/Neglect - 41 staff signatures 3. Follow up questions for staff concerning the in-serviced - 42 staff signatures 4. Skin assessments - 73 resident assessments 5. Posted notification - refusal of care or change in condition Monitoring sheets - will be used for monitoring by the facility On 10/20/23 at 10:42 a.m., the Administrator was informed the IJ was lifted as of 10:42 a.m. While the IJ was lowered, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (Resident #20) of 17 residents. -Over flow medication cart left unlocked and unattended on Hall 300 -Medication discovered on bedside table for Resident #20 These failures could place all residents at risk for obtaining medications that could cause adverse reactions that could lead to death. Findings included: Observed on 09/27/2023 5:01am revealed medication cart was unlocked, LVN A left cart to administer medication to resident. Medication cart not within eyesight Observed on 09/27/2023 5:05am revealed medication cart was unlocked, LVN A left cart to administer medication to resident. Medication cart not within eyesight. Observed on 09/27/2023 5:17am revealed medication cart unlocked, LVN A left cart to administer medication to resident. Medication cart not within eyesight. Interview on 09/27/23 05:17 AM with LVN A stated that the cart was the overflow cart, it holds the extra medications for the residents. LVN A stated that she was pulling Levothyroxine for residents since they were always out of it. LVN A stated that she would lock it when she is finished passing meds and proceeded to lock cart at this time. Observation on 09/27/23 05:42 AM revealed Resident # 20 lying in bed. Observed Trelegy Ellipta inhaler on beside table, when I asked the resident if this was his medication, Resident #20 stated that it was his, but don't worry it only has 1 puff left in it. Record review of Resident #20's medical records indicated that Resident #20 was a [AGE] year-old male with a BIMS of 15. Resident #20 has the following diagnosis, but not limited to: -CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION -CHRONIC RESPIRATORY FAILURE WITH HYPOXIA -PSORIASIS VULGARIS Medication orders are as follows: Start date of 06/30/2022 Trelegy Ellipta Aerosol Powder Breath Activated 100- 62.5-25 MCG/INH (Fluticasone-Umeclidin-Vilant) 1 puff inhale orally one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION; CHRONIC RESPIRATORY FAILURE WITH HYPOXIA Start date of 05/08/2023 Triamcinolone Acetonide Cream 0.1 % Apply to legs topically every 12 hours as needed for psoriasis Attempted interview with LVN A on 09/27/23 06:06 AM, She stated that her shift ended at 6am, and she walked off without answering any further questions. Interview on 09/27/23 06:18 AM with LVN D, stated the carts should be locked at all times, LVN D stated that there was a resident that does wander around facility and does try to open the medication carts. LVN D stated that the resident could take a medication and it could lead to a negative outcome, it could even be very bad, such as an adverse reaction to the medication, allergic reaction and even death, depending on the med. Interview on 09/27/23 6:51 AM with MA E, stated that medication carts should be always locked. MA E stated that it is not supposed to happen no matter what. Nurses and med aids were to wait until medication is consumed and then leave the room, under no circumstances do you leave a medication with a resident. Interview on 09/27/23 9:26 AM with ADON stated that carts need to be always locked. No matter the circumstances. Medications should not be left in resident's room, and under no circumstances were medications to be left on bedside tables. ADON stated that she would in-service her staff regarding this concern. Interview on 09/27/23 9:34 AM with DON stated that carts need to be always locked, no matter what. Medications should not be left in resident's room, and under no circumstances were medications to be left on bedside tables. DON was asked what a negative outcome could be, she stated an adverse reaction for the resident. Observation on 09/28/23 12:37 PM of Resident #20's bedside table revealed his Triamcinolone cream was left out on bedside table. Resident was asked if the medication was his, Resident #20 confirmed the cream was his for his skin. Interview on 09/29/23 11:00 AM with RN F stated that the policies that were provided were the policy that she has regarding medication being left out and not being locked up. Policy on locking the medication cart was provided, along with medication administration. No other policy provided by facility. Record review of policy provided by facility named Medication Carts, dated 2003 states but not limited to the following: 1. The medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use of under the direct supervision of the designated nurse. 3. Carts not in use are to be stored in a designated area not blocking egress in the building. 4. Carts must be secured. 5. Carts should be clean. 6. Should said equipment be found unsuitable for use or in need of general maintenance. This equipment includes medication carts, administration records, notebooks, and Emergency Kits facility or designee will repair/replace. Record review of policy provided by facility named Medication Administration Procedures, dated 2003 does not have any recommendations for medications being left at bedside of resident.

Based on observation, interview and record review; it was determined the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives the necessary treatment and services to promote healing and prevent infection for 1 of 2 residents (Resident #4) reviewed for pressure sores. The facility failed to ensure weekly skin assessments were completed on Resident #4 which lead to Resident #4, acquiring a Stage 3 pressure ulcer. This failure could place 58 residents receiving preventive skin care at risk for worsening of existing pressure ulcers or developing new pressure ulcers. Findings included: While reviewing the chart for Resident #4, it stated: Resident #4 is [AGE] years old; Resident #4 admitted to the facility on [DATE]; Resident #4 has [DIAGNOSES REDACTED]. MDS dated [DATE] reflected a Brief Interview for Mental Status of 11, reflecting moderate cognitive impairment. While reviewing Resident's #4's MDS, dated [DATE], it stated: Resident requires the extensive assistance of at least one person for all transfers, bed mobility, hygiene, bathing and dressing. Resident #4 has limited range of motion to the upper and lower extremities. Resident #4 has a [MEDICAL CONDITION] and a Foley catheter. While reviewing the plan of care for Resident #4, updated 06/27/2016, it stated: Resident #4 has a Foley catheter and a [MEDICAL CONDITION]. She is a high risk for falls. She requires [MEDICATION NAME] for depression and has some difficulty adjusting to the change in lifestyle to a nursing facility. She has some mild cognitive loss and is dependent on facility staff for all her needs due to her disease process. She requires assistance with position in bed due to her disease process. She requires some pain management. She is at risk of developing a pressure sore due to decreased mobility, and is care planned to follow the facility policy for the prevention of skin breakdown. While reviewing the weekly skin assessment for Resident #4, last updated 08/08/2016, it stated: Abrasion to the right posterior thigh. While reviewing the physician orders [REDACTED]. 08/11/2016 at 2:00 p.m.: Shearing to right posterior lateral thigh-clean with wound cleanser, apply TAO to wound bed, cover with 4x4 adhesive island dressing. Change daily. 08/16/2016: DC previous wound care orders to right posterior lateral thigh. New wound care orders as follows: cleanse with wound cleanser and pat dry with gauze. Apply calcium alginate AG and cover with [MEDICATION NAME] with adhesive borders. Change daily until healed. 08/22/2016: Wound culture to right buttock skin shear. While reviewing the nurses' progress notes for Resident #4, it stated: 08/11/2016 at 2:17 p.m.: Shearing to right posterior lateral thigh - 4cm X 7.5cm X 0.1cm - clean with wound cleanser, apply TAO to wound bed, cover with 4x4 adhesive island dressing. Change daily. (E-signed LVN F). 08/15/2016 at 6:46 p.m.: Wound care performed to right thigh per MD orders using aseptic technique. Pt tolerated well. NO signs/symptoms of infection noted at this time. Pt denies any complaints currently. (E-signed LVN G). 08/16/2016 at 6:35 p.m.: DC previous wound care orders to right thigh. New orders written as follows: cleanse with wound cleanser and pat dry with gauze, apply calcium alginate AG to area and cover with [MEDICATION NAME]. Change dressing daily until healed. Wound care performed per new orders using aseptic technique. Pt tolerated well. No signs/symptoms of infection noted. Pt has small amount of serous (clear) drainage noted. Pt denies any concerns at this time. (E-signed LVN G). 08/17/2016 - 08/19/2016: No nurses' notes were available; however, daily treatment log indicate daily wound care was performed. 08/20/2016 at 3:45 p.m.: Wound care performed per MD orders to right thigh using aseptic technique. Pt tolerated well. No signs/symptoms of infection noted. Pt had minimal serosanguineous (clear fluid and some blood) drainage to dressing. Pt has brown eschar noted to edges of wound. No other changes noted. Pt denies any pain or other concerns at this time. (E-signed LVN G). 08/21/2016 at 4:09 p.m.: Wound care performed per MD orders to right thigh using aseptic technique. Pt tolerated well. No signs/symptoms of infection noted. Pt has minimal pink drainage to dressing. Pt denies any concerns at this time. Pillow placed under right hip to relieve pressure to area. (E-signed LVN G). The treatment administration record (TAR) dated August 2016 indicated dressing changes to the right posterior thigh were being done daily for Resident #4 by LVN F, LVN G and RN H. During an observation of wound care on 08/22/2016 at 2:10 p.m., Resident #4 was lying in bed with a pressure relieving mattress in place. LVN F performed wound care as per the physician orders. During wound care, LVN F removed the dressing dated 08/21/2016. When he removed the dressing, the dressing was saturated with a foul smelling, tan exudate. The wound bed had foul smelling, serosanguineous (clear, blood-tinged) drainage and blackened, rolled wound edges. Adipose (fat) was visible. Fascia (membrane covering muscle tissue) was visible but not exposed. No tunneling or undermining was noted. Redness was noted for several inches surrounding the wound bed on all sides. In the interview immediately following the wound care, LVN F confirmed he should have measured the wound, and would measure it tomorrow. During an interview on 08/22/2016 at 2:45 p.m., LVN F confirmed the wound had deteriorated since he last saw it on 08/19/2016. He confirmed the wound originally was a skin shear, but it was larger and had redness and a foul smell now. He confirmed changes in wound status should be reported to the physician. He confirmed signs and symptoms of infection and worsening of the wound would be redness to the surrounding area, a foul smell, and an increase in wound size. He confirmed he would notify the physician after the wound care. During an interview on 08/22/2016 at 3:30 p.m., LVN F confirmed there are no other nurses' progress notes (except as stated previously). LVN F confirmed there was no weekly skin assessment for 08/15/2016. During an interview on 08/22/16 at 03:40 p.m., DON confirmed the facility did not have a wound care nurse because she had been terminated for poor documentation. She confirmed the last skin assessment was 08/08/2016 for Resident #4. She confirmed the only nurses' notes regarding the wound for Resident #4 were documented on 08/11/2016, 08/15/2016, 08/16/2016, 08/20/2016 and 08/21/2016. She confirmed the last physician correspondence regarding the wound (prior to the surveyor-observed wound care) was 08/16/2016. She confirmed nursing staff is responsible for checking the wound on at least a daily basis. She confirmed a skin shear is basically a stage 2 pressure ulcer. During an interview on 08/23/2016 at 08:50 a.m., LVN G confirmed she was the wound care nurse and had treated Resident #4. She stated, the original order was keeping the wound to moist .I wrote the order changing the treatment. She confirmed the original wound care nurse for the facility was no longer there, and she and LVN F took over wound care. She stated, the wound was originally a shear and the skin was still intact. She confirmed the wound was now open and had deteriorated since treatment had begun. During an interview on 08/23/16 at 09:40 a.m., RN H confirmed the previous wound care nurse performed all wound care prior to termination. She stated, (LVN G or LVN F) do the wound care for Resident #4. She confirmed if either wound care nurses are off, the nurse for the hall is responsible for the wound care. She confirmed she had performed wound care for Resident #4, but was unable to recall characteristics of the wound or care provided. During an interview on 08/23/2016 at 09:55 a.m., LVN F confirmed he and LVN G are the wound care nurses for the facility. He confirmed the wound was already there when they called me to consult on 08/11/2016. He confirmed the wound was a skin shear about the same size, but not as deep. He confirmed the skin was not intact the first time he saw the wound. He confirmed the wound had not improved, and the physician was contacted on 08/16/2016 for new orders. He confirmed that he and LVN G provide wound care. He confirmed when they are off, the nurse for that hall is responsible for the wound care. He confirmed the wound has progressed to a Stage 3 pressure sore. During observation of wound care on 08/23/2016 at 3:10 p.m., the Stage 3 pressure ulcer on right posterior thigh measured 9.4cm X 7.4cm X 0.1cm in depth (compared to 4cm X 7.5cm X 0.1cm on 08/11/2016) with no tunneling or undermining. Adipose (fat) was visible. Fascia was visible but not exposed. The foul smell and redness had decreased markedly since the observation of the wound care on 08/22/2016. During an interview on 08/23/2016 at 03:40 p.m., Resident #4 denied being repositioned every two hours; however, she confirmed she is able to reposition herself. During an interview on 08/24/2016 at 10:30 a.m., DON confirmed LVN F and LVN G have taken over wound care, and the ADON would ensure skin assessments, dietary consults, and treatments were being performed as indicated. While reviewing the National Pressure Ulcer Advisory Panel website at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (accessed 08/26/16), it stated: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin. The wound bed is visible, pink or red, moist, and may also be present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of the tissue damage varies by anatomical location; areas of significant adiposity (fat) can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. While reviewing the undated, facility-provided Resident Wound Spreadsheet, it stated: Resident #4 has a Stage 2, facility-acquired shearing to the right thigh, and separate resident has a non-facility acquired Stage 2 pressure ulcer. While reviewing the facility's policy for Pressure Injury: Prevention, Assessment and Treatment, dated 0812/2016, it stated: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury and infection. 2. Early prevention and/or treatment is essential . 4. Causes of Pressure Injuries: 2. Shearing of tissue against bone causing tissue and vessel destruction. 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. 2. Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages. Staging definitions are per the guidelines of the National Pressure Injury Advisory Panel February 2016 definitions. Review of the CMS Form 672 Resident Census and Conditions of Residents, dated 08/22/2016, documented 58 residents receiving preventive skin care. During observation of wound care on 08/23/2016 at 3:10 p.m., the Stage 3 pressure ulcer on right posterior thigh measured 9.4cm X 7.4cm X 0.1cm in depth (compared to 4cm X 7.5cm X 0.1cm on 08/11/2016) with no tunneling or undermining. Adipose (fat) was visible. Fascia was visible but not exposed. The foul smell and redness had decreased markedly since the observation of the wound care on 08/22/2016. During an interview on 08/23/2016 at 03:40 p.m., Resident #4 denied being repositioned every two hours. During an interview on 08/24/2016 at 10:30 a.m., DON confirmed LVN F and LVN G have taken over wound care, and the ADON would ensure skin assessments, dietary consults, and treatments were being performed as indicated. While reviewing the National Pressure Ulcer Advisory Panel website at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (accessed 08/26/16), it stated: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin. The wound bed is visible, pink or red, moist, and may also be present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of the tissue damage varies by anatomical location; areas of significant adiposity (fat) can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. While reviewing the undated, facility-provided Resident Wound Spreadsheet, it stated: Resident #4 has a Stage 2, facility-acquired shearing to the right thigh, and separate resident has a non-facility acquired Stage 2 pressure ulcer. While reviewing the facility's policy for Pressure Injury: Prevention, Assessment and Treatment, dated 0812/2016, it stated: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury and infection. 2. Early prevention and/or treatment is essential . 4. Causes of Pressure Injuries: 2. Shearing of tissue against bone causing tissue and vessel destruction. 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. 2. Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages. Staging definitions are per the guidelines of the National Pressure Injury Advisory Panel February 2016 definitions. Review of the CMS Form 672 Resident Census and Conditions of Residents, dated 08/22/2016, documented 58 residents receiving preventive skin care.